The electrical current throbs from one side of the skull to the other, scrambling circuits along the way, inducing a brief seizure. When it's over and the anesthesia wears off, patients often are subdued, confused, sometimes unsure of where they are or why. Then, sometimes, the remarkable happens: Severely depressed people find that the darkness has lifted; they feel better than they have in years.
Others are left distraught. They've been shocked — and feel
no better than before.
In recent decades, electroconvulsive
therapy, or ECT, has undergone a transformation, many psychiatrists say.
The body no longer thrashes violently, as depicted in movies a generation
ago; it lies still, under medication, with the thrashing confined to the
mind. Techniques are more precise, they say; the brain better
Although exact numbers are not available on how many
people get modern ECT — estimates have ranged from 30,000
to more than 50,000 a year since the early 1990s — scientific interest in
the treatment has surged, in part because of the acknowledgment that drugs
don't help many deeply depressed people, particularly older adults, a
growing and hard-to-treat population. The government is funding some 20
ECT studies to see how different techniques and treatment combinations
researchers have looked directly at how the bolts of current alter
biology, by studying the brains of shocked rodents. And in June, a leading
medical journal published the results of a broad survey detailing what
former ECT patients think about the treatment.
Yet far from
proving the effectiveness of ECT, the emerging research has only
accentuated its unknowns and shortcomings. After more than 60 years of
experience, doctors still don't know exactly how the shocks affect the
brain, whether they cause permanent damage, or why they affect depression.
Although the techniques and technology have improved, ECT itself appears
no more effective than it ever was, studies show.
When it comes to
treating older people in particular, doctors have no scientifically
rigorous evidence establishing the treatment's safety or effectiveness,
according to an exhaustive review of the literature published last month.
"Proponents have been saying it's safe and effective, but their statements
go beyond what we know for elderly people," said John Bola, a mental
health researcher at USC who studies treatment effectiveness. "It starts
to sound more like an advertisement than a statement of fact."
reputation of shock therapy has alternately risen and fallen since 1938,
when an Italian psychiatrist named Ugo Cerletti decided to try shocking
one of his patients, a 39-year-old man, after watching slaughterhouse
workers subdue pigs with bolts of current delivered to the brain, and
after first experimenting on animals. Cerletti reported that the man
improved after repeated shocks, and the idea soon caught on among doctors
desperate for some way to manage disturbed, often aggressive, patients.
Use of the treatment then declined through the 1960s and 1970s, due to the
introduction of new psychiatric drugs and the public stigma attached to
That decline stopped in the 1980s, researchers say,
because psychiatrists refined their techniques and continued to report
recoveries in severely depressed people who didn't respond to any other
treatment. By 1990, an American Psychiatric Assn. task force report on ECT
concluded that the treatment was highly effective, "with 80% to 90% of
those treated showing improvement." The association also set precise
guidelines for treatment, specifying the amounts of electricity and
placement of electrodes that seemed to produce the best
"You're talking about people who are desperate, who are
often suicidal, who have just about lost it all," said psychologist Harold
Sackeim, chief of biological psychiatry at the New York State Psychiatric
Institute and a professor at Columbia and Cornell universities in New
York. "This is a treatment that we know can help them turn it around, and
it is very satisfying to see that happen."
Psychiatrists acknowledge that the
mood-altering effect of ECT is usually very short-lived: Those who do feel
better after a series of shocks almost always plunge back into depression
within a few weeks, or months. Aggressively treating these people with
drugs can help; but it is hardly a guarantee that the depression will
lift, or that a person will agree to endure such treatment in the first
"It must be thought of as a stopgap measure in
life-threatening situations," said Dr. Jeffrey Schwartz, a research
psychiatrist at UCLA's Neuropsychiatric Institute. "All you're doing is
buying more time to get to a place where drugs, or cognitive therapy, can
have some effect."
In an article in the March 14, 2001, Journal of
the American Medical Assn., researchers at Columbia University in New York
reported that a combination of ECT and aggressive drug treatment
successfully vanquished depression in 14 of 23 people (61%) for at least
six months. This is a significant improvement, and far more effective than
ECT alone, which helped only four of 25 people in the study (16%) for six
But the researchers also reported that more than half of
the 316 people originally enrolled and given shock therapy dropped out of
the study, or were excluded. Most of these people didn't feel at all
better after the shocks; others refused further treatment; and some
suffered medical complications. The success rate of the treatments is
based only on the fraction of the people who both responded well to the
shock and had no adverse reactions or second thoughts. Without continual
therapy of some kind, the authors conclude, "almost universal relapse
should be expected."
Some psychiatrists believe that the solution
for this is more ECT. Continuation-ECT, or C-ETC, as it's known, involves
"maintenance" shock sessions every every three to six months, or whatever
seems best suited to the patient. Some psychiatrists have been providing
C-ECT for years, and hundreds of people are already on this steady
regimen, experts estimate.
Yet there's no scientifically rigorous
evidence that continually shocking a person is safe, and it could cause
damage, some doctors say.
In several recent studies in rats,
scientists have reported some of the first direct evidence of biological
changes from the treatments that might be related to changes in behavior.
They report that ECT accelerates the production of new brain cells in
these animals and spurs the growth of neural connections called mossy
fibers. Some ECT doctors say new neurons are probably helpful and that new
nerve connections may enhance brain function.
"These changes could
help explain how it is that these severely depressed patients recover,"
said Dr. Sarah Lisanby, a Columbia University psychiatrist who heads the
American Psychiatric Assn.'s ECT Committee.
though, that doctors aren't sure whether the brain changes are good or
bad. The studies purporting to show brain cell proliferation due to ECT
may in fact be showing evidence of brain cell damage, according to Richard
Nowakowski, a neuroscientist at the Robert Wood Johnson School of Medicine
in Piscataway, N.J., who pioneered the use of the cellular techniques used
in the experiments. "It's not clear in these studies whether they're
seeing proliferation or something else," he said. As far as what the
changes actually mean, he said, "anyone who tells you they know
Nor is it clear what the growth of these new neural
connections means. Neuroscientists say that the brain's nerve networks are
laid down over years, as the brain develops and responds to the outside
world. The chances that an instantaneous, shock-induced fiber would make
exactly the right connections to enhance function, they say, are extremely
remote. Moreover, the kind of neural sprouting, or mossy fiber
proliferation, observed in shocked animals also turns up in the brains of
people who have epilepsy, a neurological disease in which the body suffers
periodic, unexplained seizures. "In this area, there's a debate over
whether the epilepsy causes the fibers, or the fibers cause the epilepsy,"
The men and women on the receiving end of the electrodes
vary widely in their judgment of the effect. Some are grateful for the
treatment, and insist that the shocks both relieved their illness and
improved their cognitive function. Others are outraged. Over the years,
the practice of ECT has spawned a large and vocal group of critics who say
the shocks harmed them, mainly by erasing memory.
thousands of people out there who feel they weren't told the whole story
before getting the treatment," said Juli Lawrence, 44, a St. Louis-based
freelance writer who started the Web site ect.org after a series of shock
treatments failed to lift her depression and obliterated about two years
In the first large-scale effort to learn from ECT
patients themselves, researchers in England reviewed 35 studies of patient
attitudes. All told, the studies involved more than 2,000 men and women
who got ECT treatment in the last two decades or earlier. Depending on the
study, 30% to 80% of former patients reported lasting memory loss. In one
survey, a third of patients agreed with the statement, "Electroconvulsive
therapy permanently wipes out large parts of memory." The proportion of
people who considered the treatment ultimately helpful varied just as
widely — from about one-third, when patients helped design or conduct
surveys; to about three-fourths, when doctors did.
"This is what
happens when you ask patients what they think," said patient turned
prominent ECT critic Linda Andre, who has questioned ECT research and
practice. "You get a completely different story from the one psychiatrists
Weighing benefits, risks
LOREN MOSHER, former director of schizophrenia research at the National
Institute of Mental Health and now a clinical professor of psychiatry at
UC San Diego, said the issue comes down to a "cost-benefit" analysis.
"Does it make sense to expose people to something which not only isn't
very effective but also has serious inherent danger? In my view, the cost
to the person is greater than the potential benefit."
find an answer for severe depression whose costs are not so steep, the
controversy is not likely to diminish. Drug companies have been working to
find better antidepressants for years, so far without significantly
improving on what's been available for the last 10 years or so. Now,
Lisanby and other researchers are investigating the possibility of using
magnetically induced convulsions as an alternative to electricity. A
strong magnetic field near the head can also induce a brief seizure. The
hope is that the magnetic stimulation might "break" the depression in the
same way ECT does, but for longer than a few months or weeks and without
the memory loss.
"ECT is an important treatment, and has helped to
save the lives of many patients, many of my own patients, but we need to
do better, to find treatments that are more tolerable and accessible,"
In order to determine safety and side effects,
doctors at Columbia and the New York State Psychiatric Institute induced
brain seizures in 10 severely depressed men and women with bursts of
magnetic stimulation. They report that these shocks induced fewer memory
problems than ECT.
As for the effect on depression, psychiatrists
in Europe have reported on one person who got a full treatment course of
magnetic shocks. A 20-year-old woman, she felt an almost immediate lifting
of her mood, according to psychological measures done after the
But to prevent relapse, doctors decided she needed
further treatment — with ECT.