Shock therapy rebounds at HCMC

  • Article by: ABBY SIMONS
  • Star Tribune
  • August 5, 2012 - 9:42 AM

Electroconvulsive therapy, once branded a barbaric relic of primitive psychotherapy, has made a major comeback and is being administered to patients thousands of times a year at Hennepin County Medical Center in Minneapolis.

Doctors at HCMC administered ECT 2,206 times in 2011, twice the number of procedures they employed as recently as 2009.

Many of those sessions have taken place with judicial approval to treat patients under civil commitment by the county's Mental Health Court.

Psychiatrists say unequivocally that the treatment -- which became infamous as the "electroshock'' depicted in "One Flew Over the Cuckoo's Nest'' and other films -- saves lives.

"We've had some horrific self-injurious behaviors -- people so psychotic they've done unbelievable things to themselves -- who have had terrific responses to ECT," said Dr. Ian Heath, inpatient medical director for psychiatry at HCMC.

Advocates say the side effects -- headaches and some memory loss -- are a small price to pay for a success rate that can be as high as 70 to 80 percent for cases of uncomplicated but severe depression that fail to respond to other treatment.

Critics contend ECT is still dangerous, under-researched and capable of causing significant memory loss.

"I don't want to dignify it by calling it a treatment; I'll call it a radical procedure," said Lauren Spiro, director of the National Coalition for Mental Health Recovery.

Rebooting the brain

First developed in the 1930s, the therapy is used to treat serious depression, bipolar disorders and schizophrenia. It sends an electrical current to the brain, inducing a brief seizure. Exactly how it works remains unknown, Heath said, but the seizure's therapeutic effect may stem from the release of the same chemicals targeted by medications and has been likened to a reboot of the brain.

Patients generally receive six to 12 treatments at a cost of $800 to $1,200 each, with maintenance treatments afterward. Placed under general anesthesia and given muscle relaxants and mouth guards to prevent injury from the seizure, patients typically wake up a few minutes after the session is complete.

Most of the ECT treatments at HCMC are voluntary. Heath said the increase is due to the growing numbers of severely mentally ill people referred to HCMC, the success rate of ECT and increased advocacy by physicians and psychiatrists. There's a movement in the psychiatric community to no longer consider the treatment only as a last resort, he said.

Dr. Lori Suvalsky, an inpatient psychiatrist at the Minneapolis Veterans Medical Center, administers about 80 treatments per year after a careful screening process.

"By only doing ECT on patients it's best suited for, we have really good results," she said. "Since there are side effects, it's pretty important not to do ECT on people for whom the risk-benefit ratio is not all that positive."

That opinion is shared elsewhere nationally, with use of ECT having grown from about 33,000 patients in 1980 to an estimated 100,000 now.

"I think about it as a very valuable treatment with noteworthy risks that is appropriate for selected people," said Dr. Ken Duckworth, a psychiatrist and medical director for the National Alliance on Mental Illness, the nation's largest nonprofit advocacy group for the mentally ill.

One patient's experience

Joanne Ericksen has experienced ECT from both sides. The retired psychiatric nurse-practitioner at Mayo Clinic taught patients about the procedure, and after battling depression herself since the 1980s, received her first treatments in 1992. After years of occasional relapse and follow-up, she hasn't undergone ECT in five years and relies on medications.

While it brought memory loss she calls "frustrating," she would use ECT again if she returned to the throes of depression. "No question," she said. "I don't have a choice if I want to get better."

Stigma hard to shake

Bill Nieman heads the Adult Services Division in the Hennepin County attorney's office. His staff is responsible for about 1,300 commitments of mentally ill and chemically dependent people annually.

Petitions for court-ordered ECT treatment increased in Mental Health Court from 40 in 2006 to 51 last year, with 32 so far this year.

"Attitudes have changed over the past 20 years," he said of the increase. "There was more reluctance to use it by the entire legal system, partly because of the way the public viewed it and, historically, how it had developed."

He recalled a patient so severely depressed that she refused food and fluids for nearly a week. She awoke from her second treatment and asked for something to eat. "It can happen miraculously," he said.

As head of the county's Mental Health Court, District Judge Jay Quam is responsible for signing off on the treatments for civilly committed patients. "It's hard to imagine they're the same person that came in before," he said. "They'll talk about ECT as the thing that really did save their life."

Quam will issue a decision early next week whether to approve ECT for Davis Gullickson, who has paranoid schizophrenia and has been committed to the Minnesota Security Hospital in St. Peter. Gullickson, 59, who is delusional and sometimes violent, wasn't responding to medications. Psychiatrists recommended 20 ECT treatments over 10 weeks, with follow-up. It worked in the past for Gullickson, who stopped treatments because he was concerned that the memory loss would land him in a nursing home.

At a hearing last week, Quam asked Gullickson's psychiatrist if any other treatment would help.

"In my opinion, no," Dr. Andrei Nemoianu replied.

'Where's the research?'

Although widely accepted by the psychiatric community, ECT's side effects, including short-term memory loss, can be disconcerting. Last year, the Food and Drug Administration's independent Neurological Devices Panel recommended that the FDA continue to classify most ECT devices as high-risk, meaning most new equipment must go through clinical trials. The panel recommended that patients' cognitive function be monitored throughout treatment and that doctor and patient sign an additional checklist to acknowledge the risks.

Spiro said the lack of data about ECT's long-term effects should give doctors pause about its use, even for desperately sick patients.

"Where's the research? If this were any other medical procedure, there would be studies or data," she said.

A 2007 study funded in part by the National Institute of Mental Health said that some forms of ECT can cause "adverse cognitive effects [that] can persist for an extended period."

Heath doesn't deny some memory loss as a side effect but points out that some medications have their own harmful side effects, and the success rates for ECT create a "far superior" option for taking on life-threatening mental illnesses.

"People think of it as the electrical lobotomy, that it'll erase their memories," he said, adding that he's actually had patients who were disappointed that he can't erase painful childhood images.

The next step, he said, is to help ECT overcome popular stigma.

"It wouldn't make good movies if they showed it the way it actually was."

Abby Simons • 612-673-4921

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