Thursday, September 2, 2010

Kitty Dukakis on ECT

Following is an edited excerpt from a much longer piece on ECT, from mcmanweb:

In 2006, Kitty Dukakis (with journalist Larry Tye) published "Shock: The Healing Power of Electroconvulsive Therapy." Ms Dukakis is the wife of 1988 Democratic Presidential candidate Michael Dukakis. From the time she was old enough to worry about her body image, diet pills were a constant in her life. Ms Dukakis describes her quarter-century love affair with amphetamines as an addiction, though these pills almost certainly did more for her depression than the antidepressants she later took (readers, please don’t get any ideas).

The cure turned out to be worse than her addiction. Once she was off the pills, her depression manifested in full measure, together with a new dependency on the bottle. A steady round of rehabs followed, plus failed trials on antidepressants and mood stabilizers. In a state of emotional unraveling and desperate for a solution, in 2001 Ms Dukakis turned to ECT.

The very fact that Ms Dukakis had the option to choose electroconvulsive therapy is something of a miracle. As she and Larry Tye describe in their book, had events played out according to expectations, the plug would have been pulled from ECT years before.

Ironically, ECT's worst enemy has been the psychiatric profession. The over-use of the treatment during the forties and fifties and sixties, often against the patient’s will, under primitive conditions, and on populations upon whom the procedure conferred no benefit, gave rise to strong opposition. Part of the backlash came from the new antipsychiatry movement which got its start from patients who had been abused by ECT and inhumane institution-based practices. The movement found ready allies in other sixties-era groups pressing for political and social reform.

At around the same time, new psychiatric meds, with marketing campaigns heavily bankrolled by the drug industry, promised a new day. The death knell was the release of the 1975 movie, "One Flew Over the Cuckoo’s Nest," that portrayed head nurse Ratchett as Torquemada and ECT as a torture rack with voltage.

According to the authors of "Shock," Max Fink MD of New York State University, Stonybrook, helped save ECT from extinction. Essentially, he led with the facts – that for depression the response rates were exceptionally high (even in treatment-resistant populations) and offered immediate relief. For most depressed patients, the treatment worked better than antidepressants, and without their troubling side effects. The treatment also worked for mania and for depressive symptoms in schizophrenia.

But there was still the persistent problem of memory loss to contend with. Psychiatry did not help its own cause by repeatedly down-playing and even denying this disturbing invasion to the brain’s hard drive. Ludicrously, psychiatrists picked fights with patients who uncooperatively reported they could no longer remember their own kids’ birthdays. Clinical evidence, anecdotal or otherwise, was difficult to come by, as few clinicians even bothered to follow up on their patients.

Ironically, the authors report, during ECT’s golden era, its champions cited memory loss as an advantage of the treatment. (Economists would call this creative destruction.)

If Dr Fink saved ECT, it was Harold Sackeim who restored its credibility. To the horror of Dr Fink and others, Dr Sackeim freely acknowledged the memory loss. What the old guard saw as giving aid and comfort to the enemy, Dr Sackeim saw as a chance to improve upon technology and technique. Thanks in large part to his efforts, a more sophisticated generation of machines has been introduced and "unilateral" placement (to only one side of the brain) is replacing bilateral placement (though there still may be scope for the latter).

The authors cite Dr Sackeim for the observation that new generation ECT can target specific regions of the brain, thus reducing side effects and memory loss. By contrast, clinicians lack control for how meds are diffused throughout the brain.

During the early nineties, the media began observing that ECT was making a quiet comeback. Lately, the psychiatric profession has been more vocal in advocating ECT as an early treatment option, a development that may frighten some people otherwise prepared to accept the procedure as a last ditch or desperation measure.

The debate is by no means settled, and moderates tend to get assailed on all fronts by psychiatry and antipsychiatry zealots alike, who unfortunately tend to dominate the discussion (such as it is). As Kitty Dukakis and Larry Tye freely acknowledge, memory loss is still a legitimate concern and needs to be weighed against the promised benefits of treatment. Indeed, Ms Dukakis confesses to not being able to remember important events in her life and to having difficulty recalling names and other details. But she also writes, in relation to her first treatment:

Next thing I know I am waking up. I am back on the upper floor of Massachusetts General Hospital, in the unit where I slept last night … I am not sure I got the treatment. One clue is a slight headache … Another is the goo on my hair, where they must have attached the electrodes. There is one more sign that I did have my first session of seizure therapy: I feel good – I feel alive.

Yes, Ms Dukakis acknowledges, "I still can’t remember Paris," and that ECT may not be for everyone, but, "as my counselor Corky says, the choice is simple: Would I rather be depressed or be forgetful?"

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