• The Misunderstood Consequences of Electroconvulsive Therapy

    Mary Cregan on Doing Whatever It Takes to Deal with Depression

    During the 1980s, in the aftermath of One Flew Over the Cuckoo’s Nest, clinicians were reluctant to suggest electroconvulsive therapy and more likely to face opposition by the patient’s family if they did. Most medical schools, and even most psychiatry residency programs, didn’t include ECT in their curricula. In the hospitals that still did provide ECT, it was often used only after a long drug trial had failed.

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    Take, for example, a young psychiatrist in 1984, whose female patient remained suicidal after four weeks on an antidepressant. Having seen One Flew Over the Cuckoo’s Nest, her husband was alarmed when the doctor suggested ECT. But he acquiesced when told that if he resisted, the hospital would seek a court order to overrule him. So the psychiatrist jotted down the new plan: “In this acutely suicidal patient, bilateral ECT is felt to be the modality of choice with the highest potential for rapid clinical improvement. Projected number of ECT treatments is 7–10 with hope of response evidencing around 4th-5th treatment.”

    I was that patient. When I first stepped into the treatment room, the use of ECT was in the trough of its long decline, while in the wider culture it carried a powerful stigma. The antipsychiatry backlash meant that progress in refining the techniques had drastically slowed. In the trial-and-error approach that my hospital record reflects, certain aspects of the treatment were not so distant from the experimental early days of Meduna and Cerletti, despite the four and a half decades that had passed.

    It was late morning when one of the aides came for me, and we walked through long, polished corridors to another part of the hospital. A nurse and two doctors—an anesthesiologist and the resident who would perform the procedure—were waiting in a large tiled room. They were kind and reassuring, and although I was anxious about what was now going to happen, I felt that I had nothing to lose. I lay down on a gurney and the nurse started an IV for the anesthetic. Behind me was the ECT machine, a small electrical box with knobs and switches. The nurse placed an oxygen mask over my face and told me to count backwards from 100. I don’t think I ever got further than 97. The next thing I remember, someone helped me off the table and walked me back up to my room.

    There was more going on before and during the treatment than these few details that I recall. Bilateral ECT means that the current passes between electrodes placed on both sides of the head, and the resulting seizure affects both sides of the brain. This was considered the most effective treatment for someone in the terrible shape that I was in. It causes greater temporary cognitive deficits than unilateral placement because the current passes through the brain’s speech and memory centers, but is more efficient in bringing about a recovery. The memory loss is usually temporary, though this is a matter of contention and an issue that still gives pause to potential patients. The electrodes would have been moistened with conductant gel, positioned over my temples, and held in place with a rubber headband. My pulse, blood pressure, and brain waves would have been monitored. The muscle relaxant succinylcholine was given through the IV to keep my body from moving during the seizure. Because the diaphragm is temporarily paralyzed by the muscle relaxant and cannot expand and contract the lungs, oxygen is necessary.

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    Today, a nurse or doctor manually ventilates the lungs because the anesthetized body’s inability to actively take in oxygen means the brain is not getting enough, and this increases the cognitive side effects. According to the record, they also gave me atropine. Seizures can cause a temporary interruption or slowing of the heart’s rhythm, and atropine was used to prevent that. The fast-acting sedative that sent me to sleep in three seconds was pentobarbital. ECT is a simple procedure, but many precautionary measures must be taken before the pulse of electricity can be given to produce the seizure.

    For the first few treatments, given the settings he marked down, it seems that the doctor was working with the variables of current and voltage in order to induce a seizure of adequate strength and duration. Seizure thresholds vary according to the patient’s age, gender, medications, and other factors, and the current can be impeded by faulty contact of the electrodes and other issues. He would have needed to begin with a setting based on given parameters and modify according to the results.

    It was late morning when one of the aides came for me, and we walked through long, polished corridors to another part of the hospital.

    ECT seizures should end without intervention, but my first two seizures lasted more than two minutes, and the doctor stopped them with additional pentobarbital. After the third treatment he seems to have arrived at the result he was seeking, and from then on most seizures were in the range of 45 to 65 seconds. Because I knew he would have been familiar with the treatment protocols of the mid-1980s, I consulted ECT expert Max Fink, who told me that notations on my treatment record indicate the use of a then recently introduced machine that delivered a brief-pulse current, as opposed to the sine-wave current of earlier machines. Since the early 1980s, brief-pulse machines have replaced the earlier sine-wave ones. After the fourth session a nurse reported, “Patient talks about feeling like she is cured, that she would never hurt herself again, is in good spirits and talking to patients and staff.” (I found this hospital euphemism “to hurt oneself” annoying, since I had never been interested in hurting myself. I had only been interested in dying, as quickly as possible.) Dr. Young, too, noted my brighter mood. He raised my observation status so that I was no longer being watched 24 hours a day.

    Side effects were troublesome. In the aftermath of anesthesia came headache, nausea, and vomiting, sometimes into the next day. Another problem appears in the notes: they suspected that one of the drugs used during ECT was exacerbating a rash I’d had for several weeks. It began as a reaction to the antidepressant imipramine, which gave me hives. Although that drug had been tapered quickly before the ECT began, a very itchy, angry rash was now spreading up my back and neck. I was taken to a medical clinic in another wing of the hospital, where a blood test indicated a strong allergic reaction. They discontinued the atropine, which can cause a rash in some people, and gave me Benadryl, which eventually solved the problem. Much of the physical discomfort I had with ECT treatment resulted from complications of drug sensitivity, and these diminished with adjustments in the first couple of weeks.

    Immediately after each treatment I had some loss of memory, which cleared as the hours passed. As the number of treatments mounted, the amnesia increased. This aspect of the bilateral ECT I was receiving was very strange, since it separated me from the feelings that had brought me to the hospital. On the day of the third session Dr. Young wrote, “Patient has been disoriented and confused with treatments. As yet this pseudo-dementia is transient though will become a more persistent feature with bilateral treatments. Patient showing some early improvement but unable to recognize this herself as her cognitive features of depression persist and are severe.”

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    “Pseudo-dementia” was a term then used in psychiatry to refer to problems with memory, concentration, and attention that are reversible but similar to those of dementia. Prolonged severe depression causes cognitive symptoms too, which result from a loss of neural connections in the brain. That day, I couldn’t remember why I was in the hospital. A nurse wrote in my chart, “She says something happened to her although she doesn’t know what it is. Confused after ECT and not really understanding what has happened to her or what she is doing here.” I had forgotten about my daughter Anna’s death and all that followed. I was still having melancholia’s variation in mood, feeling very dark in the morning and better as the day wore on. Dr. Young commented on how this diurnal mood shift made it hard for me to hold on to feeling better: “It is difficult for her to experience subjective improvements and be confronted soon after with these renewed feelings of hopelessness.”

    Whatever mild improvement Dr. Young had noticed then reversed itself, and I entered a state of true depressive psychosis. He put me back on 24-hour surveillance. Now I was talking freely about my terrible thoughts: “Patient had a talk with nursing staff member and explained her problem as a ‘moral illness.’ She feels disloyal to husband and family in wanting to kill herself. She has been suicidal for a long time and has prayed but her prayers were not answered so she feels she’s evil and full of sin and can’t change. She feels suicide is inevitable and has no desire to live.” The next day I was begging to be allowed to go home, since I believed that there was nothing more they could do to help me. Dr. Young noted my “significant loss of reality testing,” and added the antipsychotic Haldol to my regimen. The next day he wrote, “Patient currently firmly believes that she is ‘not human,’ is not depressed but rather ‘depraved,’ ‘evil,’ and would like ‘a brain transplant.’ ” I could feel and express nothing but guilt, hopelessness, and self-condemnation. He increased the dose of Haldol.

    How much more disastrous could things get? My parents, too, had had enough: during visiting hours one day, a nurse wrote, they were asking me to “snap out of it.” It was unbearably frightening for them. Jake was bringing books from the library and reading to me about patients having the same delusional thoughts I was having. But I continued to believe, he says, that I was evil, not depressed. In psychiatry there is a term for this: I lacked “insight” into my state of mind. Like so many people in the state of what used to be called madness, I believed in the truth of my delusions.

    On the day of the eighth ECT treatment Dr. Young wrote, “Patient continues to be markedly delusional—today unhappily is her birthday, and she is involved with the fact that it is Friday the 13th, as it was on her actual day of birth.” Recent events had proven that I was very unlucky indeed, and I now believed it was no coincidence that I’d been born on that particular day. Dr. Young noted that the treatment plan was to be re-evaluated, since the ECT didn’t appear to be making any difference in my condition. They had abandoned the antidepressant trial, and now they were considering abandoning ECT for a new medication trial combining an antipsychotic and an antidepressant. Jake remembers feeling that the doctors were “grasping at straws,” since none of their proposed treatments were helping. He worried that I was having too much shock treatment: “Your short term memory got bad and you continued to be depressed. . . .  The ECT continued well beyond the half dozen sessions that had been proposed. It was spring and getting quite nice out. You weren’t allowed out of the ward. I wanted them to take you outside.”

    I had been indoors continuously for over three weeks. So many aspects of our life had become very strange, and to Jake my situation seemed too much like imprisonment. The doctors then decided to press on with more ECT: “Patient continues not to show any clinical improvement with this treatment but nonetheless a full course of ECT will be pursued.” They added a drug called Cogentin, which was supposed to protect against the neurological side effects, like rigidity and muscle spasms, that could result from prolonged exposure to the anti-psychotic Haldol.

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    Over the next ten days or so my condition continued unchanged as the number of ECT treatments mounted. The cognitive side effects of the shock treatment were taking a toll. A nurse asked me to recite my home phone number one day, and I couldn’t. I had been writing occasionally in a notebook, and Dr. Young suggested that given the increasing short-term memory loss, I record what feeling better was like so that I could read it when I felt hopeless. In one such lucid moment I wrote, “Feeling hopeful again today that there must be some way to recover from this and return to my old, better self. There is so much to live for, if only I can convince the doctors here that I’m capable of it.” At other times, Dr. Young observed, I seemed detached, lethargic, “generally blunted affectively”—possibly Haldol side effects—and worried about what would happen when they finally realized that they couldn’t help me.

    The cognitive side effects of the shock treatment were taking a toll. A nurse asked me to recite my home phone number one day, and I couldn’t.

    In my guilty frame of mind, the anxiety was overwhelming. I was tormented by the seeming inevitability of suicide. I was unable to reverse the mental process that had brought me so low, and now the experts, too, were stymied in their efforts to reverse it. I worried about how my suicide would affect Jake and my family. I felt responsible for the crime of not being able to carry the burden of my own life, and thereby transferring the burden of my death to the people who loved me. My trouble seemed to me unnatural and perverse: everyone should be able to stay alive, at the very least. I couldn’t see that illness was driving me to suicide, and not my own moral failing or weakness of character.

    By the third week of April I’d been in the hospital for a month, and Dr. Young put in a transfer request to longer term care. He was ready to give up on ECT, noting that after the twelfth treatment I would be considered “ECT nonresponsive,” and they’d have to try another plan. After the twelfth treatment, the nurse noted that I was “extremely confused, disoriented, babbling.” She did neurological checks throughout the evening as these cognitive and speech disturbances gradually cleared. But cumulative exposure to bilateral treatments and a daily antipsychotic grew more and more debilitating.

    Instead of switching to an antipsychotic/antidepressant combination for the next phase of treatment, they again decided to press on with ECT. Today the number of treatments in an effective sequence can range from four up to twenty or so, but because these are usually unilateral— given on the right side of the head only—or with ultrabrief pulses of current, they don’t cause the degree of memory loss that I experienced. They took me off the antipsychotic and switched to an older-style ECT machine that used sine-wave current (the kind of current in wall outlets). For whatever reason, my recovery began with the use of this more primitive machine. It may be a coincidence, but within two treatments there was noticeable improvement. According to a National Institutes of Health study on ECT from 2007, the treatment I had would not now be recommended because of its heavy toll in cognitive side effects: “Sine wave stimulation, for the use of which there is no justification at this point, and bilateral electrode placement, produced the most persistent long-term deficits.”

    I did lose memories, but most of what I forgot I eventually remembered. Episodes from my childhood and my more recent past were inaccessible for quite a while, though after the treatments were over I had no trouble retaining new information, and I started graduate school the following year. What happened while the treatments were ongoing remains mostly a blank. My older brother visited and gave me a dress for my birthday, but when I got home I had no idea where the dress came from. Friends wrote letters I have no memory of receiving. What I do remember about the time during treatments, I’ve been able to retrieve because the hospital record jogged the memory, or because I wrote it down in the notebook at the time.

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    The problem of memory loss remains the most contentious issue with ECT. Some people refuse treatment for fear of it, while others agree to treatment despite the chance of it. It all depends on what you’re willing to lose: your memory or your life. Ernest Hemingway protested, shortly before his suicide, that shock treatment had destroyed him: “What these shock doctors don’t know is about writers . . .  What is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient.” Hemingway’s alcoholism and his very severe depression could also have impaired his memory, but it was simpler to blame ECT.

    A very different perspective on ECT and writers comes from David Foster Wallace, whose friend Donald Antrim was in the depths of a suicidal depression. Antrim’s doctor told him, “You’re very sick, and you’re very psychotic, and we can take care of you.” They told him he should have ECT. Antrim was terrified, “because he believed it would mean the end of him as a writer. That his talent would be scattered. His brains scrambled. The mechanism disassembled.” Wallace, having been in these circumstances himself, called Antrim at the hospital. He said, speaking writer to writer, “I’m calling to tell you that if they offer you ECT, you should do it. You’ll be all right.” For the great majority of people, any lingering amnesia clears as the brain heals in the months after treatment, but a small and vocal group claims that important moments in their lives—the birth of a child, a wedding, the death of a parent—are lost forever.

    By the end of April, after 17 treatments over a period of 6 weeks, the worst was over. The nursing notes are studded with a new, positive language: “Patient seems brighter, alert and motivated, interacting with staff and peers”; “Status raised to CS. This made her very happy”; “Patient able to concentrate long enough to play chess”; “Patient continues in great spirits, smiling and verbal”; “Patient socializing with peers. In good spirits. Affect brighter. Pleasant.” Dr. Young wrote, “Affect is bright and full-range. Patient continues to have euthymic mood, punctuated with mild persistence of diurnal mood variation. Denies suicidal ideation, no longer expressing hopelessness and worthlessness, no evidence of psychotic thought process”; “Patient to receive 14th ECT today. Plan is to administer additional 2–3 more ECT treatments to consolidate response”; “Socializing appropriately with other patients. Went outside to courtyard and played volleyball.” Volleyball? Chess? Great spirits? Even now I can feel the relief and happiness conveyed by these words and what they meant for me, for my family, and for my doctor, who had been expecting improvement much earlier.

    The problem of memory loss remains the most contentious issue with ECT. Some people refuse treatment for fear of it, while others agree to treatment despite the chance of it.

    Suicidal depression is difficult to treat, and I imagine it can be nearly as distressing for the doctor as for the patient. For some reason, I didn’t get better as quickly as Dr. Young’s optimistic projection suggested I would. I assume that psychiatrists will think it unfair of me to look back and question the technique or the experience of the resident who performed the ECT, and to wonder whether it might have been more quickly effective with another person in charge. The truth is, I just don’t know whether the treatment could have, or should have, gone better at the time. Certainly it is much better for the majority of people having ECT today.

    The American Psychiatric Association claims that ECT can bring about a dramatic improvement in 80 to 90 percent of patients with mood disorders. The improvement is not necessarily permanent; these are relapsing and recurrent illnesses. But because of continuing stigma and fear, ECT is often not suggested until a lengthy course of medication has failed to bring relief. Some people kill themselves in this interim. In my case it’s easy to recognize some of what went wrong: the belated realization that I was ill and not merely grief-stricken, the belated diagnosis and prescription of medication, the switch from medication to ECT only after a nearly lethal suicide attempt. Lithium could have been given as soon as I arrived in the hospital, since it has a proven record of reducing suicidal impulses.

    Despite the discomfort and the temporary memory loss it caused, I would have ECT again without hesitation. People voluntarily undergo much more invasive and damaging medical interventions to save or to prolong their lives—chemotherapy, radiation, open-heart surgery, blood transfusions, bone marrow transplants—and speak freely about those experiences, but continue to think about cancer and heart disease differently from mood disorders that can be equally deadly. In telling my own less than ideal story 30 years after the fact, I don’t want to discourage anyone from having this potentially life-saving treatment. What was difficult in my experience would now be unusual because the treatment protocol has improved over the years to greatly reduce the side effects. And my situation was extreme not only because of the perilous condition of my mind, but because my body was already hypersensitive and aggravated by drug allergies.

    But now ECT was behind me. The serious work of returning to life could begin.


    Reprinted from The Scar. Copyright (c) 2019 by Mary Cregan. Used with permission of the publisher, W.W. Norton & Company, Inc. All rights reserved.

    Mary Cregan
    Mary Cregan
    Mary Cregan attended Middlebury College and received her PhD from Columbia University. Her writing has appeared in the Chronicle of Higher Education and in the Financial Times. A lecturer in English literature at Barnard College, she lives in New York.

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