Zapping Depression

"A little dab'll do ya," quips Jack Nicholson, as his character, McMurphy, accepts a dose of gel to his temples in preparation for a jolt of electricity. Without administering anesthesia or muscle relaxants, the sanitized staff restrain his limbs and let the sparks fly. He writhes -- we watch.This 1975 description of electro-convulsive therapy (ECT) in Milos Forman's film One Flew Over the Cuckoo's Nest shaped at least one generation's opinions on this procedure, as well as their opinions on the entire psychiatric enterprise. Two decades later, many of us have retained this image of electro-convulsive therapy as a symbol of the worst of institutional power left unchecked: cold, hard cruelty. Are our Hollywood-influenced notions justified? What is the current use of ECT and how does it affect people's lives? These questions led me to a small surgery room in Boise's Veterans' Administration Medical Center, where I watched Barry Frost (not his real name) receive 104 joules of electricity -- an amount that would momentarily light a 60-watt light bulb -- through his temples.Barry Frost's appearance is that of an average, middle-aged man. There seems to be a slight nervous, scattered quality to his speech and demeanor, but he is quite warm and friendly and he tells his story with earnest animation.It is difficult to picture him as he must have appeared three years ago when he showed up at Boise's Veterans' Administration at the lowest point in a severe clinical depression. He can't picture it either: he has no memory of how he got to Boise or the VA from his home in Oregon, nor does he remember the entire year preceding his arrival.What he does remember is 17 years as a state worker in Oregon, followed by three years of graduate studies in preparation for the Catholic priesthood. He enjoyed his studies and excelled at them, but Barry had to leave school prematurely because of psychological problems.He also remembers serving as a medic in Vietnam during the war. This part of his past he has tried, unsuccessfully, to forget. His most difficult memories involve the bloodied remains of Vietnamese children and their mothers' aggrieved and desperate cries. These memories were certainly a strong contributing factor toward his decline into depression, a depression that resulted in the deterioration of his cognitive functions, disruption of his normal sleeping and eating patterns and a strong desire to kill himself. "ECT saved my life," Barry asserts. "The anti-depressive drugs they tried on me didn't work. If I hadn't had the ECT, I'd be dead." Upon his arrival to the VA, three years ago, Barry had several series of 12 ECT treatments. He then transitioned to a maintenance therapy of one ECT treatment every two weeks. Difficulties with concentration and the time involved in receiving regular treatments prevent him from holding down a job, but he is an avid reader and is an active member of his Catholic church. He is also able to live independently in an apartment which he shares with a student at BSU. Barry, probably drawing upon his background as a student cleric, serves as an unofficial counselor and advisor to other VA patients who are fighting depression. "Everyone I have talked to at the VA who has received ECT says the same thing I do: it saved my life," Barry contends. "I've never talked to any patient who has claimed anything different."Barry's positive sentiments are echoed in a new book, Undercurrents, by therapist Martha Manning. Manning's own challenge with depression was ultimately met with ECT. As much as she wanted to avoid the treatment, which she considered horrific, she had exhausted other medical and counseling options. She is currently on anti-depressant medication, but attributes her ability to function and enjoy life to the ECT treatments. One Boise man was suddenly forced into making a decision about ECT when his 80-year-old father was diagnosed with depression three years ago. "Mike," a professor at BSU, anguished long-distance as his father in New York battled the mental illness that caused him to stay in bed most of the day and avoid activities he had always loved."My father no longer showed interest in life," Mike reports. "Prozac and other anti-depressant medications weren't effective, but when his psychiatrist suggested ECT as an option, I freaked."Mike questioned nursing and psychology staff at Boise State as part of his investigation that ultimately led to his father receiving the treatment last fall. As a result of pre-existing heart problems, Mike's father received only a shortened series of four treatments out of the standard regimen of 10 to 12. Even so, the procedure seems to have proved effective. "Since receiving ECT, my father has had a much better outlook on life, his appetite has increased, he is participating in outside activities again and his short-term memory has improved," says Mike. "He is not 100 percent of what he was before the depression, but at the age of 83 he is 'recharged'."How did someone first get the idea of jolting depressed people's brains with electricity? And how, exactly, does it work? The first question is easier to answer than the second. The roots of ECT lie in an early 20th-century misconception that epileptics could never get schizophrenia.This myth led Hungarian neuropsychiatrist Lazlo Meduna, in 1935, to inject schizophrenics with camphor oil to elicit epileptic-like seizures. The process resulted in a marked improvement in the mood of Meduna's patients. Other physicians experimented with insulin shock in order to bring about seizures.Several years later, two Italian doctors began to administer electrodes to patients' heads as a more reliable technique for inducing seizures. By 1940, "electroshock therapy," as it was then called, had become a dominant form of psychiatric treatment for major mental disorders.The stigma attached to this therapy most certainly has roots in its early history. During these experimental years, no anesthesia or muscle relaxants were used before inducing grand mal seizures (the most severe form of brain seizure).The pain, muscle trauma and broken bones which resulted made the Cuckoo's Nest depiction look like a picnic. Even after the use of medications made the procedure humane and virtually pain-free, it was used indiscriminately to treat all kinds of mental illnesses, as well as aggression and general non-conformity. This ugly slice of ECT history adds to the negative perceptions that linger to this day. So exactly how does zapping one's brain cure depression? The answer: no one knows.One current theory, according to the Boise VA's Dr. Gary Falk, is that the seizure increases the sensitivity of the brain's nerve cells to the chemicals which travel throughout the brain, impacting moods and thoughts. He compares the brain's function to that of a heating or cooling system. "Most of us have something like a thermostat circuit that regulates our moods.It keeps our ups and downs from getting too extreme," explains Falk. "It keeps us in balance. For some reason, some people's thermostat mechanisms don't kick in to regulate their moods. ECT resets the thermostat."Today, ECT use is clinically approved for severe depression, mania (the extreme opposite of depression) and catatonia (which can manifest as unceasing physical and mental agitation or as an unresponsive stupor). The treatment is occasionally used for those with severe Parkinson's disease and schizophrenics who do not respond to medication.According to physicians at the Boise VA, its effectiveness rate for depression is 90 percent, as compared with medication's effectiveness of 70 percent. ECT's depression-lifting results are immediate: a fact that is vitally important for those who are suicidal. Patients generally need to wait two to three weeks before anti-depressant drugs begin to work.It's 7:30 a.m. on a recent morning. I sit tiredly on a stool next to Barry Frost. He is lying on a gurney waiting for his turn in the surgery room. We chat about religion and about the doctors. He talks a little about what happens before the procedure. "You'll have to tell me what it looks like when I get the treatment," Barry requests. "I've never seen it." We both smile.Finally, the door opens and we are ushered into the small room. Inside are two doctors, the anesthesiologist, an assistant, an observing pharmacy student, Barry and me. Everyone is quite genial -- the tone is professional but relaxed. I notice that if Barry looks at the ceiling, he sees a poster of actor Tim Allen carrying a giant screwdriver; it reads, "Warning: Man Wielding a Large Tool."The presiding psychiatrist is Dr. Kenneth Khatain, who has been at the VA since last September, 1994. The anesthesiologist cleans Barry's temples with rubbing alcohol to remove oil and applies the clear gel which will increase conductivity. "A little dab'll do ya," I am tempted to quip. I refrain. What happens next is something relatively new in Barry's case. Barry is injected with 1,000 milligrams of caffeine, the equivalent of 8-10 cups of coffee.Barry says that this is his least favorite part of the treatment. A few seconds later he looks, not surprisingly, like someone who has just drunk 8-10§ cups of coffee. He is slightly flushed and wears a nervous expression. He rubs his eyes and forehead.Caffeine lowers one's seizure threshold by readying the nerves for intense firing. As people age, it becomes more difficult to induce a substantial seizure, and men have a higher seizure threshold than women. The caffeine injections have helped enhance the therapeutic value of Barry's treatments by giving him longer seizures.About five minutes later, it is time to administer anesthesia and muscle relaxant through the IV. The muscle relaxant prevents the muscles of his body from flailing in rhythm with his brain's contractions: the absence of muscle relaxant could cause pulled muscles and broken bones. Several seconds later, Barry is out cold. A mask is placed over his nose and mouth. He is briefly hyperventilated with oxygen: this extra oxygen boost protects the heart from oxygen deprivation and helps to lessen confusion -- an inevitable aftereffect of ECT.A rubber bite block is inserted between his upper and lower teeth. It's show-time. The assisting physician places the two electrodes, looking exactly like bicycle handlebars, on each side of Barry's forehead. The machine is flipped on. Barry's jaw clamps shut on the bite block and his expression tightens into a grimace. 1-2-3-4-5. Off. His face relaxes.Dr. Khatain now monitors the seizure in two ways. He watches Barry's foot shake for about 10 seconds. The muscle relaxant has been prevented from entering Barry's foot by a tightly wrapped blood pressure cuff. This offers physical confirmation of an induced seizure. The primary indicator of the seizure is the print-out on the electro-encephalograph (EEG). The machine needs to detect a seizure of at least 25 seconds for the treatment to be therapeutic. 33 seconds.Good. We're done.A few minutes later, Barry is awake and I speak with him in the recovery room. He knows who everyone is, and is able to carry on a conversation with the nurse and me. He asks me what I saw and I tell him. I ask if he remembers what we were discussing in the hallway before his treatment and he seems confused. I also notice, in his conversation with the nurse, that he can't remember his roommate's major at BSU. (Two days later, when I ask him to recall the major, he does easily. However, he has no memory of me being in the recovery room with him.) He is pain-free, having received low-level pain medication to prevent headaches -- a common side-effect of ECT. Half an hour later he is ready to go home.Why isn't everyone swayed by the success of Barry and others? Why, when I mention ECT to people, do they always respond so viscerally: "Yuck! Do they really still do that? How horrible!"One major source of criticism on the national scene is the Church of Scientology's Citizens Commission on Human Rights. How strong is their position on ECT? Well, their information letter on the topic includes insights such as the following: "These shock doctors with their slaughterhouse mentalities are filling the streets and back rooms of America's cities with the shells of devastated human souls, injured beyond repair, and condemned to lives of brain-damaged oblivion, foraging our garbage cans for their daily bread." Yup, them's fightin' words.But among the ideological rhetoric are concerns which had been on my mind since my first meeting with Barry Frost: charges that ECT causes permanent memory loss, long-lasting confusion and cognitive dysfunction. Why did Barry forget the entire year preceding his first series of treatments? Why is a man who excelled in graduate studies unable to focus enough to hold down a job or drive a car?The concerns about irreparable damage caused by ECT are shared by Judy, a Boise woman, who as a young adult in 1971 was involuntarily committed to the psychiatric ward of a hospital in Ogden, Utah. She had taken psychedelic drugs and her parents were worried about her emerging rebellion. Against her will, says Judy, the chief psychiatrist administered a series of ECT treatments over the course of several weeks. As a result, she has permanently lost memories of events that transpired immediately before the procedure, including a vacation she took with her brother.She reports that during the few weeks she received the ECT and medications, she experienced the sensation of coming in and out of awareness while carrying on conversations and going about her day. She also says she did not "feel like herself" until she finally escaped from the hospital by fleeing out a bathroom window and hitching a ride out of state. Judy reports that the chief psychiatrist was eventually fired.The physicians I spoke to at the Boise VA assert that they have not personally witnessed the use of ECT for anything other than severe depression or otherwise untreatable schizophrenia. They also doubt that ECT can cause permanent memory damage.In the case of Barry's memory and concentration problems, his physician, Dr. Khatain, asserts that there are several contributing factors. During Barry's forgotten year, he was on a number of anti-depressant drugs which, although not clearing his depression, did make him lethargic and unable to concentrate. "He probably didn't store information into his memory properly during that time," says Khatain, "and that's why he can't remember it now." Barry is still taking some strong anti-depressant medication, which has a side-effect of making him feel "spacey." His doctors are going to try him on a new medication which they hope will relieve this problem. Dr. Khatain is also concerned about the frequency of Barry's maintenance treatments. "Every two weeks is too often," says Khatain. "His memory is not able to return to baseline before he gets another treatment." Khatain is working toward weaning Barry to one treatment every four weeks. This would relieve some of the short-term memory problems. The problem is that as soon as the depression returns, Barry once again becomes suicidal. "We walk a fine line," posits Khatain. "On one side is the negative side effects of the frequent treatments, on the other is severe depression. We try to find that balance."Dr. Larry Dewey is Chief of Psychiatry at the Boise VA. He has just returned from an intensive week-long ECT training session at Duke University in Durham, North Carolina. After 11 years practicing psychiatry at the local facility, and after years of supervising others' performance of ECT, he finally decided to learn how to perform it himself."The idea of putting electricity through people's brains to treat depression is an abomination. But over and over again I've seen that it works. We'd be in desperate shape without it," says Dewey. His observations of positive results from the procedure led him to the training at Duke, where leading psychiatrists from around the country shared the latest information on research and technique."I learned some very subtle improvements in technique that I will share with the staff here at the VA," he reports. "I brought up Barry's case at the training and I learned a few things that might alleviate some of his problems." Dr. Dewey concurs with Khatain about Barry needing to lengthen the time that elapses between treatments. "These frequent maintenance treatments are causing an ongoing problem with memory," he says.However, Dr. Dewey doubts that ECT is responsible for Barry's lost memories from before his first series of treatments. "It is most likely the severe depression he was suffering at the time that caused the gap in memory," Dewey contends. "It is extremely unlikely that ECT is responsible for such a long-term memory loss."A drawback of ECT, according to Dr. Dewey, is that it can vary greatly in its length of effectiveness. It can alleviate depression for years, or sometimes only weeks. Another problem is that it can be prohibitively expensive.Dr. David Kent, one of a handful of psychiatrists in private practice who perform ECT at St. Alphonsus, laments the fact that the costs are prohibitive for many potential beneficiaries."Idahoans are basically uninsured for mental health," says Kent. "Many policies have a lifetime mental health benefit cap of $5,000. This would not even cover one series of ECT treatments. I've had to do a number of treatments for people for free. I just don't know how long I can realistically continue."Ultimately, after all the research, issues of health care costs, state-of-the-art technology, criticisms and concerns are reviewed and considered, it comes down to the individual -- in one case, what benefits Barry Frost."My own guess is that my memory loss is due to a combination of depression and the ECT," speculates Barry. "It's frustrating. People come up to me and talk to me like they know me, but I don't remember them. I've taken the attitude that what I don't remember wasn't worth remembering."Barry says he doesn't focus on any negative side effects that may relate to his treatment, and that he holds his physicians at the VA in the highest regard."They look at me as a whole person. They have encouraged me to help myself, particularly through my strong love of spirituality and the Catholic Church," he says. "Whatever the biochemical reactions, ECT did help me. When I first went to the Medical Center my major problem was my strong desire to commit suicide. I'll go back and talk to some of the staff and they say to me: 'We had given up on you. We figured you were definitely going to kill yourself.' Now whenever I go up to the ward they always ask me, 'Are you suicidal?' With ECT I can honestly say, 'Not at this time.' Perhaps it's not a perfect solution, but what choice do I have?"