When electroconvulsive therapy is the right choice

At the end of medical school, when it was time to choose my specialty, I was torn between psychiatry and internal medicine. Psychiatry seemed most suited to my interests and aptitudes. Focusing on the mind and mental illness bridged my interest in the big questions of human existence and the practice of medicine. On the other hand, it was hard to see how being a psychiatrist would fit with the vision of being a medical missionary that motivated me to become a doctor in the first place. I, therefore, chose to receive the broader training that internal medicine would provide.

As an internist, I manage a variety of health issues from gout and hypertension to diabetes and dementia. But perhaps because of my long-standing interest in psychiatry, treating depression is one of the most absorbing and fulfilling parts of my practice. It provides the chance to hear people’s stories, to encounter the complex interplay between the mind and the body, and to quite often offer a helpful treatment. In fact, my experience is that with regular exercise, therapy, medication, or combination thereof, most people successfully recover from depression in a relatively short amount of time.

Unfortunately, there are some patients with depression in whom these initial treatments don’t work. They require the expertise of a psychiatrist and sometimes the combination of multiple medications. And even with the best efforts of a skilled psychiatrist, certain people with severe depression fail to respond to medications and therapy. In such cases of treatment-resistant depression, the sufferer descends into a more miserable and hopeless place. Lacking the motivation to engage in any activities, they may become bed-bound, so that physical weakness begins to accompany their mental lethargy. And the mental lethargy can become so profound that a previously sharp-witted person comes to appear like somebody with end-stage Alzheimer’s Disease, unable to retain information or put their thoughts together. All the while, friends and family watch impotently as their loved one tragically slips away.

In such situations, a treatment called electroconvulsive therapy (ECT) can sometimes be quite effective. The idea of causing somebody to experience seizures by applying electricity to their brain evokes an understandably negative reaction. But before quickly dismissing it as barbaric or inhumane it is important to consider the awful, hopeless situations in which ECT is applied and the transforming results it can provide.

In his book, How We Age, geriatric psychiatrist Marc Agronin presents a case from his practice that provides a good deal of insight into ECT. Over a year’s time, a Cuban man named Leonardo had seen his “once bright, loving mother Rosa turn cold, confused, and compulsively agitated.” She was “full of mental confusion, irritability, anxiety, odors of incontinence, and fits of crying and panic that quickly gave way to screaming, kicking, and flailing at any attempts to redirect or soothe her.”

Agronin describes the “almost violent grief” that overtook Rosa’s husband Alberto as his witnessed his wife’s decline. When Alberto spoke, “his entire body seemed to convulse with each phrase, and he vacillated between expressing devastation over the loss of his partner and exaltation over his enduring love for her. His face would twist and spasm as he coughed and choked on his words of concern: ‘She … needs more … help … now!’”

Agronin writes that “I always knew when they arrived for appointments because I could hear Rosa’s yelps grow increasingly louder as they approached the door of my office.” At home, “peaceful hours for Alberto with his wife alternated with crises: She fell; she hit him; she urinated on the living room floor.”

When Rosa was ultimately transferred to a nursing home, “every effort to care for her was met with fits of panic and screaming.” Agronin tried to address Rosa’s destructive behavior with medications, but each one he tried had produced intolerable side effects. He writes,

I tried every psychopharmacologic trick in my bag, to but to no avail. In concert with her internist and neurologist, I ran every possible diagnostic test, hoping that I was missing some hidden organic cause. Nothing revealed itself and nothing worked. Alberto and Leonardo were initially patient with my attempts at treatment, but with time they lost faith. Eventually, I too lost faith in my ability to understand and heal her condition. It would have been easiest to simply call in hospice and wash my hands of the case, but something in me resisted.

After much discussion with Leondardo and Alberto, Agronin decided to hospitalize Rosa and try ECT. Agronin writes that,

despite many misconceptions about ECT, it is actually one of the safest and most effective treatments for severe depression, even in older individuals. A course of ECT typically involves eight to twelve sessions spaced out over several weeks. During each session the individual is briefly anesthetized and paralyzed with medications and then administered an electric shock to the forehead to induced a seizure. We still have no idea how ECT changes brain chemistry to improve depression and other mood disorders, but its effects are impressive. Nevertheless, it’s usually a treatment of last resort. ECT is used even more rarely to treat agitation associated with dementia, but with Rosa I felt we had run out of choices other than massive doses of sedating medications … Over the course of three weeks Rosa received 8 rounds of ECT. Her memory impairment held steady, and she seemed to tolerate ECT well for the first two weeks, but without response. During the third week, however, Rosa’s storm began to subside as she grew quieter and less frenetic … Actually, the treatment worked beyond our wildest expectations, and a completely different woman emerged from the hospital. She was generally calm, pleasant, and cooperative. I could actually have a conversation with her.

Her husband Alberto and son Leonardo were overjoyed by the change. To them, “Rosa, even in her relatively severe state of cognitive impairment, seemed like a rose. It was as if an exile had returned, changed from the experience and not quite the same person, but good enough.”

The story of the surgeon and author Sherwin Nuland provides another revealing look into ECT. Nuland describes suffering from a depression so severe and resistant to medication that during his hospitalization, psychiatrists came close to performing a lobotomy. At that point in the 1970s, ECT had fallen out of favor, and it was only because a resident-in-training advocated for its use in Nuland’s case that he received it. As Nuland shares in his lecture, ECT worked and he was able to ultimately go back to being a productive surgeon and later a writer who won the National Book Award.