stanford medicine


No longer shocking


No longer shocking

Electroconvulsive therapy is a lifesaver

To this day, he does not know what drove him to the railing of the Golden Gate Bridge.

He had just exhausted all hope and energy to continue. He left a goodbye note for his family, saying that he was sorry.

He was, by all external measures, a man in the fullness of life. He had his thriving medical practice in the Bay Area, a loving wife and three wonderful kids. He enjoyed economic security, abundant friends and a vibrant social life. But by some weird twist in his brain chemistry, he had become trapped in a prison of despair.

“I was sailing along, and literally one day this world that looked great was black as midnight. Everything just shut down,” says Henry, an ophthalmologist in his late 50s who asked that his real name not be used. “I was so shocked by the impact. It was as if someone had turned a switch, and it just got worse from there.”

He had a strong family history of depression — his mother had suffered from the condition — but he had only the barest hint of the disease earlier in his life. While an undergraduate at Stanford, he had suffered an “identity crisis,” a feeling of temporarily being lost. But nothing like this darkness.

“It’s a sensation as if you’re already dead,” he says. “There is no color. It’s absolutely inconceivable that you’ll ever get better again. You have no reason to be alive.”

So he stood at the edge of the bridge, contemplating his demise. He saw a police car approach.

“I remember that moment well. The officer came and stopped 5 feet away. He said, ‘I think I know why you’re here.’ It was disarming. He said, ‘Why don’t you get in the car.’”

Though it seemed too painful for life to go on, Henry said he realized it would have been a terrible thing to do to his children if he ended it there. “That was the battle going on. I think I would have jumped immediately if it weren’t for them,” he said. He was taken first to Marin General Hospital, then transferred by ambulance to Stanford Hospital, as he had longstanding ties to Stanford. There, he incessantly paced the courtyard of the locked psychiatric ward. It was the fall of 2008. In his troubled mind, he would never practice medicine again or return to anything that resembled a normal life.

Pale green curtains separated patients in the third-floor ambulatory care center at Stanford, where four people lay calmly, awaiting a treatment that they desperately hoped would lift them out of the shadows. Each had a history of profound depression; some had attempted suicide more than once. One had been admitted to the hospital a month before in a catatonic state, mute and completely unresponsive.

Their treatment, known as electroconvulsive therapy, or simply ECT, uses a device that outwardly resembles an ordinary stereo receiver. Henry, hospitalized by now for a month, was among the group of patients prepared for the treatment. He had small pads on his temples to deliver an electric current and recording patches attached to his head to track the resulting seizure. He received anesthesia through an IV, enough to put him to sleep for five or 10 minutes. Then he was given a drug, succinylcholine, that left him temporarily paralyzed.

The anesthesiologist placed a black rubber bite block in his mouth to prevent him from biting his tongue or cracking a tooth and then positioned a clear plastic dome over his nose and mouth, providing oxygen to his brain as he slumbered. Then psychiatrist Brent Solvason, MD, PhD, pressed a preprogrammed button on the box. Henry’s arms clenched a bit as a blood pressure cuff on his arm kept the succinylcholine from paralyzing it. This allowed doctors to monitor the seizure by following the movement in the arm as well. Within 20 to 60 seconds, it was all over.

“There’s still a stigma associated with it that can dissuade psychiatrists and psychologists from recommending this treatment.”

Henry’s brain had just been jolted by an electrical current less than that used to power a light bulb. It produced an organized firing of brain cells, thought to affect structures deep within the brain. The ECT seizure is unlike an epileptic seizure, which is confused and disorganized across the entire brain, Solvason says.

Within 10 minutes, Henry was awake, though still foggy from the procedure. He remembered being wheeled into the outpatient center, the nurse starting the IV, even what Solvason was wearing that day. After that, his recollection fades. He was taken back to his hospital room with the hope that this somewhat daunting treatment somehow would release him from his anguish.

Solvason admits that ECT, commonly known as electroshock therapy, seemed like a strange procedure when he first observed it as a fellow in 1998. “But after I began to treat people, I was stunned at how effective it was,” says Solvason, an associate professor of psychiatry and behavioral sciences who directs the Psychiatric Neuromodulation Service at Stanford. The program is part of the Stanford Mood Disorders Center, one of 15 centers in a national depression treatment network.

Since then, he has treated many hundreds of patients with the technique, with results that he says can’t be matched by any other form of treatment. All patients who receive ECT at Stanford have failed many rounds of medication treatments and therapy, says Solvason. These patients suffer a sadness so profound that they find themselves struggling on a minute-to-minute basis with a desire to die and are so disabled by depression that they can no longer care for themselves, he says.

With ECT, “People get better faster, and more of them improve than with any other treatment, which is gratifying to see,” he says.

About 100,000 patients undergo the treatment every year in the United States, where ECT is enjoying a quiet renaissance of sorts. Typically these are patients with major depressive disorder, or with bipolar depression, which is characterized by manic highs and depressive lows, or with psychotic depression, in which patients also lose touch with reality. ECT is widely recognized as the most effective, acute therapy for these serious mood disorders.

Though the therapy remains imperfect, with some disquieting effects on memory and cognition, it has improved dramatically from its early days and incorporates strong safeguards for patients. Still, it remains dogged by a tortuous history.

“There’s still a stigma associated with it that can dissuade psychiatrists and psychologists from recommending this treatment,” Solvason says. Because of that stigma, millions of patients who don’t respond to medication and could benefit from ECT don’t receive the treatment, says Sarah Lisanby, MD, professor of clinical psychiatry at Columbia University and an expert in the field.

ECT originated in the 1930s after scientists observed that people with mental illness who suffered convulsions made surprising recoveries from their mental disabilities. Ugo Cerletti, a renowned Italian neurologist, was the first to test it in a patient, a delusional engineer from Milan found wandering the city’s train station. Using a crude shock device invented by fellow physician Lucio Bini, Cerletti delivered 100 volts of electricity to the head of the schizophrenic man, jolting him back into reality and into a normal state of mind.

The results ignited excitement in the psychiatric community, for it was the first treatment that was found to help in managing psychiatric illness. The practice soon spread throughout the world and for the next three decades, it would dominate psychiatric treatment as the preferred method of therapy.

In the early days, however, patients were not anesthetized while being treated, and some reported the experience as a kind of torture. Nor were muscle relaxants used, resulting in cracked vertebrae and fractured limbs, as patients flailed wildly during seizure. The procedure also suffered from abuses, as institutionalized patients were sometimes coerced into treatment against their will.

These inglorious practices were immortalized in the 1975 Academy Award-winning film, One Flew Over the Cuckoo’s Nest, in which institutionalized patients thrash violently about after being herded into shock therapy by Nurse Ratched, who resembles a sadistic prison guard.

ECT’s popularity was further eroded with the introduction of the first antidepressant medications, the so-called tricyclic drugs, in the late 1950s and early 1960s. These were followed by even safer drugs, the SSRIs (selective serotonin reuptake inhibitors), such as Prozac, Zoloft and Lexapro. Soon we were a nation on medication, and ECT seemed altogether less attractive than popping a pill.

But there are an estimated 14 million adults in this country with major depression, and only about a third respond to medication, Lisanby notes. As the drawbacks of medication became apparent over time, psychiatrists slowly turned their attention back to ECT, primarily as a last-resort option for patients who were otherwise beyond help.

Henry languished in the locked psychiatric ward after his brush with suicide, still out of reach. He had tried multiple drugs — Prozac, Elavil, Zyprexa — but he never ceased to despair. He went on suicide watch. His suffering was so acute that Solvason says he was deeply concerned for his safety. Henry’s doctors suggested ECT.

Henry was terrified of the treatment but at the same time relieved to have an option, because he could see no other way out. “There was nothing in my life that I felt needed working out in psychotherapy, where I could say, ‘Let’s talk this out.’ And I was afraid I would just get worse,” he says.

Friends and colleagues did not respond well to the idea of shock therapy. “There was a lot of negative reaction,” Henry says.

It is not known how ECT works, though it is believed to mobilize a number of different systems in the brain, says Alan Schatzberg, MD, professor and chair of psychiatry and a depression expert. It is likely to cause release of neurotransmitters, mood stabilizers such as serotonin, he says. It also is thought to help regulate cortisol, a stress-related hormone, and stabilize the so-called stress axis — the link between the hypothalamus, pituitary and adrenal glands — which can affect mood and brain function.

“It’s hard to know which is the key, but it is causing a really profound effect,” Schatzberg says.

Henry sees it as a method for resuscitating a failed organ.

“There are some people whose brains and psychological makeup just fail them,” he says. “Some systems go haywire. It’s analogous to the kidney shutting down. I think the drugs available are good at helping people who are very sad, but they may not help people with comprehensive failure of the chemical system in the brain. It’s like having to take your computer and reboot it.”

Initially, Henry was treated three times a week with ECT over a month, the typical course of therapy. He would suffer the usual side effects: nausea, headache, muscle aches and confusion, but these soon disappeared. What did linger was a profound loss of memory. He read voraciously while in the hospital, about a book a day, but to this day he does not remember a single word of what lay between those pages. His knowledge of medicine — the decades spent in training and practice — seemed to evaporate from his mind overnight.

“It was pretty frightening not to be able to think or remember,” he says.

He went home Christmas Eve, stable but not recovered. He would go to parties with his wife and have her secretly whisper people’s names or give him other clues about who they were. One day he set off to go to the neighborhood bookstore, one of his favorite haunts, but couldn’t remember where it was or how to get there. He had always been an organized person, a man with a long to-do list, so to lose this organizational capacity was devastating, he says.

Cognitive difficulties, including memory loss, may occur with ECT, with these problems sometimes persisting six months after treatment, according to a 2006 study led by researchers at Columbia University. These side effects vary from one treatment center to another, depending on different practices, such as the dosage and waveforms of electricity and the placement of electrodes.

“There is memory loss, but that risk has been significantly reduced by modifications in how the treatment is used,” Lisanby, the Columbia professor, says. For instance, giving ECT with ultra-brief electrical pulses, just a few milliseconds each, can reduce side effects, as can placing the electrodes on one side of the head rather than both, she says. Physicians also are investigating the possibility of pretreating patients with certain drugs to minimize memory loss, Schatzberg says.

For Henry, the memory problems were unusually severe. If he were ever going to work again, he realized he would have to retrieve everything he had learned in his medical training — a daunting task. He decided to start by rereading the textbooks he had used 25 years before in his residency.

Even the most basic aspects of ophthalmology seemed faint and distant at first, he says. He read journals, watched surgical videos and studied his own previous notes. He sat in on colleagues’ surgeries and recorded his observations. Two months out of the hospital, he decided to try his hand again at surgery.

That day, “I awoke feeling like I did as an early resident, a sense of concern approaching dread at the possibility that I would fail to perform well,” he recalls. He asked a colleague to assist him at every step.

He decided to leave a textbook open in his office at all times so he could quickly retrieve information that had been wiped from his brain. His first week back at work, he was visited by a patient with herpes zoster infection in the eye, a serious syndrome that can cause blindness. Henry recognized the problem but says he “had no clue what to do.”

“It was so striking because I started reading in the textbook, and all of a sudden, the whole thing came back,” he says. “The memory comes in these little pockets. Some of those pockets you may lose forever, and some are accessible.”

Gradually, he returned to the surgeries he had done before — cataract operations, LASIK, intraocular lens implants and a wide range of laser procedures.

“Surgically, I believe I’m noticeably better than I was because I had to go back and rethink everything,” he says. He is also a more empathic physician, he says, often taking extra time to talk to patients about their general health and personal lives.

“I had the sense that it reprogrammed my brain — the empathy center, the friendship center, the ‘feeling hassled’ center. I don’t feel hassled anymore,” he says.

While he was regaining his medical skills, his mood very gradually improved. Still, it would be months before he could look at a flower and appreciate its beauty. He returned to the hospital for periodic ECT treatments to make sure his recovery stayed on track.

That is important, Solvason says, because of the risk of relapse. If patients get no follow-up treatment at all, the relapse rate is 80 percent, Lisanby says. With maintenance ECT treatments or a combination of ECT and medication, the likelihood a patient will remain healthy is about 50-50, she says. Recently, she launched a clinical trial in older patients to try to improve these odds.

“It’s hard to keep people well,” Solvason says. “You have to work very hard to keep the symptoms from creeping back. With depression, the brain is prone to disregulate even when there is nothing stressful happening in your life. So we do everything to help keep people well in the hope that the brain will be able to stay in a normal pattern of functioning that ECT has been able to re-establish.”

Henry had his last ECT treatment in April 2008 and has been depression-free since, though he continues taking medication. “In that year and a half, I have not had a second of a worrisome mood,” he says.

Recently, he’s been preoccupied by a serious illness in the family and has had to work at keeping his equilibrium intact.

But, he notes, “There is some kind of inner strength that came out of this experience that is helping me,” he says. Indeed, the procedure did far more than that, he and Solvason agree. It saved his life.


E-mail Ruthann Richter






©2010 Stanford University  |  Terms of Use  |  About Us