A shock to the system: Electroconvulsive Therapy shows mood disorder-specific therapeutic benefits

The oldest well-established procedure for somatic treatment of unipolar and bipolar disorders, electroconvulsive therapy (ECT) has, at best, a variegated reputation – and not just in its reputation for being a “barbaric” treatment modality (which, as it turns out, it is not). The scientific, clinical, and ethical controversy extends to unanswered questions about its precise mechanism of action – that is, how major electrical discharge over half the brain shows efficacy in recovery from a range of sometimes quite distinct psychological and psychiatric disorders. Recently, however, scientists at Université de Lausanne, Lausanne, Switzerland and Charité University Medicine, Berlin, Germany found local but not general anatomical brain changes following electroconvulsive therapy that are differently distributed in each disease, and are actually the areas believed to be abnormal in each disorder. Since interaction between ECT and specific pathology appears to be therapeutically causal, the researchers state that their results have implications for deep brain stimulation, transcranial magnetic stimulation and other electrically-based brain treatments.

Prof. Bogdan Draganski discussed the paper that he, Dr. Juergen Dukart and their co-authors published in Proceedings of the National Academy of Sciences.

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Researchers find ECT can rid the mind of selected memory

A team of researchers working in the Netherlands has found that partial selective memory deletion can be achieved using Electroconvulsive Therapy (ECT). In their paper published in the journal Nature Neuroscience, the team describes a memory experiment they conducted with the assistance of severely depressed people who had already consented to undergoing ECT and found that such treatment could be used to at least partially erase memories of a specified event.

Scientists have known since 1968 (thanks to experiments conducted by psychologist Donald Lewis) that applying a shock to the brain of a rat can cause it to forget something unpleasant it had remembered. Subsequent experiments have found that memories can be blunted using repetitive type therapies or by injecting drugs such as propranolol into the brain. The one element all such findings have in common is that they must be applied during a time when a person is attempting to recall a certain event. Scientists hope that such research may lead to new ways to treat PTSD and other memory related mental ailments. In this new effort the researchers explored the idea of erasing specific memories using ECT.

Currently, people with severe depression who don’t respond to any other type of treatment are offered ECT as a last resort. It has a remarkably good success rate (approximately 86 percent rate of remission) but causes some degree of memory loss. In the Netherlands study, the team enlisted the assistance of 39 such patients who had already agreed to undergo ECT. Instead of receiving just the standard treatment, however, the volunteers were asked to watch two slide shows (along with narration) —both of which contained unsettling content. A week later the participants were divided into three groups—two to get the shock treatment and one to serve as a control group—all were asked to remember and describe one of the traumatic events described in the slide shows. Afterwards, one of the groups was given ECT and then the next day was asked to recount both stores. The other non-control group was given ECT and then were asked right afterwards to recount the unpleasant stories. The control group was asked to try to recount both stories as well.

In comparing the results between the groups, the researchers found that the first group that had been quizzed a day after receiving ECT had difficulty recalling the first story, which they had recounted prior to ECT, but remembered most of second. The second group that received ECT were able to recall both stories equally well, and the third—the control group—were able to remember both stories better than either of the groups that had received ECT.

The experiment suggests that it is possible to selectively erase short term memory in a controlled environment. Much more research will have to be conducted to determine if it would work in real world situations.

Electro-shock therapy sees a resurgence

The procedure is widely accepted by the medical community, although it lingers in the public imagination as a crude medical holdover.

The patients are rolled on gurneys into a small screened-off area at Park Royal Hospital every 15 minutes with assembly line regularity.

One is a woman in her 60s, who, like the others, gets a momentary jolt of electricity sent through her head, causing a brain seizure and her body to tense for several seconds. The hope: That this treatment — the electroconvulsive, or “electro-shock,” therapy — will ease the symptoms of her bipolar disorder that has so far not responded well to drugs.

The procedure, one of thousands performed at Park Royal since the 76-bed hospital opened last year, has worked on the woman in the past, says Dr. Ivan Mazzorana, who performs all of them on patients here. And, he said, it’s likely to do so again.

These days, the treatment goes by its more clinical-sounding acronym, “ECT.”

"When you bring it up, most people say, ‘Oh my God! Not ECT, that’s something from the past,’" Mazzorana said. "It’s a very simple procedure, safer, and it’s a lot quicker than the medication."

Electroconvulsive therapy today is a procedure widely accepted by the medical community and one, absent a rare court order, that is done with patient consent. But it is also a treatment that lingers in the public imagination as a crude medical holdover almost as dated as bloodletting. Many outside of psychiatry are surprised to learn that the procedure still exists at all.

Despite that, ECT has seen a resurgence at many health centers in recent decades, experts say.

Park Royal, the only inpatient psychiatric hospital in Lee County, Fla., has already treated nearly 200 people with ECT, most receiving multiple treatments. The number represents roughly 10 percent of all of Park Royal’s admissions since it opened in early 2012.

The hospital is a for-profit facility owned by the Tennessee-based Acadia Healthcare Co.

Most of those who have received ECT at Park Royal — patient ages have ranged from 18 years to those in their 90s — suffer from severe depression or bi-polar disorders. About 90 percent are inpatients. Others are referred from other parts of Florida, according to the hospital. A few are snowbirds who come in for ETC “maintenance” treatments.

The Mayo Clinic calls the treatment, which has a reported success rate of 70 percent to 80 percent, the “gold standard” treatment for severe depression. The most common side effect, according to proponents, is temporary short-term memory loss.

"I was afraid, to be honest with you," said Ron Spesia, a 71-year-old Fort Myers Beach retiree who suffered a deep, multiyear depression that did not respond to medication. He had 12 treatments and said he started feeling better after the third. "Then one day I decided, ‘Hey, you know what? It’s time to put the big boy pants on and pursue this.’ Smartest move I ever made."

Still, ECT has its critics. Some, including patients of decades past and anti-ECT groups, say it is little more than intentional brain damage. This, despite the psychiatric community’s endorsement of it and positive testimonials from many of the estimated 100,000 Americans who get the treatment each year.

A Fort Myers News-Press reporter was recently allowed to witness about a half dozen such procedures at Park Royal.

But even hospital administrators remain sensitive to the ECT stigma. Though a patient agreed to be photographed during one such procedure, and to have it recorded on video, the hospital overruled that consent.

The hospital also prohibited patient interviews inside the building, though other medical facilities routinely allow such interactions if patients are willing. David Edson, Park Royal’s director of business development, cited concerns about privacy and “the very delicate nature of the ECT treatment.”

Despite that, Mazzorana said he wants to demystify the treatment and those who get it.

"It seems like an extreme, dramatic treatment," Mazzorana said. "It’s a matter of really educating the psychiatric community, so then we can educate patients."

Mundane process

The treatments at Park Royal begin at 7 a.m. Mondays, Wednesdays and Fridays, and continue throughout the mornings. Staff usually see up to 10 ECT patients on these days.

The process bears little resemblance to its horrific depictions in popular culture. At Park Royal, it starts when patients come to a medical preparation area adjacent to the ECT treatment room, where staff hook them up to IVs — they will eventually get medication to paralyze their muscles during the treatment — as well as heart and brain monitors attached to their skin.

After a quick chat with medical staff, who assess their conditions, patients bite down on foam “bite blocks” before they are put fully under.

Flashlight-shaped paddles coated with a blue conductive gel are placed on each temple (bilateral treatment) or one goes on the right temple and one on the top of the head (unilateral treatment), depending on the type of ECT the patients need. Bilateral ECT is recommended in more severe cases of mental illness and may produce more memory loss, experts say.

Following a quick buzzing sound, patients’ bodies tense for about five seconds. Patients typically wake a minute or so after the procedure and are sent off to a recovery area until the anesthesia fully wears off. They remember nothing of the treatment itself.

New patients must typically stay in the hospital for the first half of the standard dozen ECT treatments.

Spesia, the former ECT patient, said the IV injection was the most painful part of the process. The most unpleasant, he said was the hospital stay. Now, months after the process, he said the only lingering side effect has been some short-term memory loss.

"All I can remember is them giving me the rubber bite block and then them putting the (anesthesia) mask on and telling me to breathe deeply." he said. "Absolutely painless."

Nancy Kish, a 74-year-old Fort Myers resident who has received dozens of treatments over the years, said her memory of treatments from years past is fuzzy but her mind is otherwise as sharp as it has ever been. She said the treatment is a better alternative to the high doses of medication she otherwise took, drugs that largely left her bed-ridden.

"I feel pretty good," said Kish. "I get upset easy, and I get anxiety attacks. But other than that, I’m better than what I was."

Much like the therapeutic mystery behind anti-depressant medication experts are not exactly sure why ECT works for some patients.

Mazzorana said two theories dominate: One says that electroconvulsive therapy enhances certain beneficial brain chemicals that are lacking in different parts of the brain. Another states that it causes the release of hormones that have a beneficial effect on mood and promote the growth of healthy brain cells, he said. Other recent research suggests that ECT works by reducing “hyper-connectivity” in the minds of severely depressed patients.

Endorsements

Whatever the exact mechanism, ECT’s endorsements include the American Psychiatric Association, the American Medical Association, and the U.S. Surgeon General.

"When you raise ECT, people’s eyes always roll up in their heads and their family says, ‘Oh my God, you’re a monster!’" said Fort Myers psychiatrist Steve Machlin, who performed the procedure more than a decade ago. "There’s always going to be people on the outside who say it’s not proven but, if you’ve looked at the science, it’s been proven to be effective."

Another Southwest Florida psychiatrist and researcher, Fred Schaerf, said opposition to the treatment is largely anti-psychiatry bias and from the treatment’s early days, when it was performed without anesthesia.

"I think there is a misconception about the treatment — that it’s barbaric, cruel," Schaerf said. "It has to do with that stigma and people’s belief system with psychiatry."

Most insurance, including Medicare, covers the treatment.

Edson, the Park Royal Hospital business development director, said the health center generally charge insurers $500 a treatment, though that does not include the costs of the anesthesiologist and hospital stay. Mazzorana said the total cost is about $1,000.

Opposition

Medical and patient endorsements aside, some patient groups believe it does little more than cause brain damage. A quick Internet search turns up a long list of anti-ECT websites, many of which include testimonials from people claiming to have suffered negative effects from the treatments.

Among the most vocal opponents is the Philadelphia-based National Mental Health Consumers’ Self Help Clearinghouse, which urged the U.S. Food and Drug Administration in 2011 not to reduce federal oversight of ECT devices. It also sharply criticized the Surgeon General’s endorsement of ECT in 1999.

The group points to published studies suggesting that ECT leads to memory loss and may be far more dangerous for the elderly than medication alone. Susan Rogers, the organization’s director, said patients aren’t warned enough about the risks.

"People are not given the opportunity for truly informed consent," said Rogers, who has not had the procedure herself. "People are not advised of the enormous risks as well as the benefits. They’re given a whitewashed version of the facts. They’re not told it might cause permanent cognitive impairment, and I think that’s wrong."

She said she is not opposed to the treatment itself.

"Apparently about 100,000 people a year receive ECT in the United States and, I’m sure for many of those people, they’re satisfied with those results," she said. "There are also many people who feel that ECT has destroyed their lives."

The psychiatric community commonly uses the one in 10,000 patients mortality figure (or one per 80,000 treatments), figures anti-ECT groups say dramatically under-estimate the risk, particularly among older patients. A 1995 USA TODAY investigation found that it may have been as high as one in 200 among elderly patients, based on some state reports at the time and some earlier studies.

A recent Department of Veterans Affairs review of ECT between 1999 and 2010 found no ECT deaths at VA hospitals during that period. It placed the mortality risk at one per 14,000 patients, or one per 73,400 treatments.

Florida does not closely track ECT usage. But Texas, which does, reported that none of the 2,079 patients receiving ECT last year died during the procedure. Two died shortly after treatment in 2012, the state report noted, but neither case was related to the treatment.

Five years of reports show that roughly 2 percent of patients experience some level of memory loss shortly after treatment.

None of Park Royal’s ECT patients have died during the procedure, said Christina Brownwood, the hospital’s ECT coordinator. Nor have any needed emergency medical care immediately after a treatment, she said.

Hopkins Researchers Uncover Key to Antidepressant Response

Through a series of investigations in mice and humans, Johns Hopkins researchers have identified a protein that appears to be the target of both antidepressant drugs and electroconvulsive therapy. Results of their experiments explain how these therapies likely work to relieve depression by stimulating stem cells in the brain to grow and mature. In addition, the researchers say, these experiments raise the possibility of predicting individual people’s response to depression therapy, and fine-tuning treatment accordingly. Reports on separate aspects of the research were published in December on the Molecular Psychiatry website, and will also appear in the Feb. 7 issue of Cell Stem Cell.

Researchers find decline in availability and use of key treatment for depression

Electroconvulsive therapy (ECT) is considered the most effective treatment option for patients with severe depression who cannot find symptom relief through antidepressant medications or psychotherapy. In a new study, researchers at Butler Hospital and Bradley Hospital in Rhode Island found a sharp decline in the availability and use of ECT in general hospitals across the U.S. The findings were published online in the journal Biological Psychiatry on October 10, 2012.

The researchers analyzed data from a nationally representative survey of US general hospitals, the Nationwide Inpatient Sample (NIS), conducted annually by the Agency for Healthcare Research and Quality (AHRQ). They took information from between five and eight million patient discharge records at 1,000 hospitals nationwide between the years 1993 through 2009 and found that the annual number of hospital stays in which ECT was administered fell 43 percent over the 17 year period, from more than 1.2 million to 720,000. Researchers also found a dramatic decline in the percentage of hospitals conducting ECT, from 55 percent to 35 percent of facilities with a psychiatric unit. The percentage of inpatients with severe, recurrent major depression treated in hospitals conducting ECT fell from 71 to 45 percent. But for depressed patients treated in hospitals that conduct ECT, the proportion who received the procedure remained stable.

"The data strongly support the impression that psychiatric units in general hospitals are discontinuing use of ECT and that this is driving the decline in the number of severely depressed inpatients receiving the procedure," said Brady Case, MD, an assistant professor of psychiatry and human behavior at Brown University and director of the Health Services Research Program at Bradley Hospital. "Growing pressures to avoid the inpatient treatment costs and length of stay associated with ECT may be one factor associated with this trend. We didn’t have information on provider and patient attitudes, but as facilities cease conducting ECT, we can expect that fewer clinicians and inpatients are exposed to the option, reinforcing the turn away from ECT." Researchers also note the FDA approval of new treatment alternatives, like vagus nerve stimulation and transcranial magnetic stimulation, as possible influences.