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Shocking Development

Photo by Erin N. Calmes

Shock Discipline: Local resident Kathy received electroshock at age 13 as punishment for her strong-headedness and believes she still suffers from its effects. Kathy believes doctors who give ECT should provide full details about ECT's risks, which critics say is rare, despite laws that require it.

To the chagrin of its opponents and the delight of many psychiatrists, shock therapy has made a strong, silent comeback

By Michael Mechanic

On a sunny afternoon last May, a small group of protesters waved signs in front of psychiatrist David Hoban's office in downtown Santa Cruz. The demonstrators, mostly current or former patients and advocates in the mental health system, were angry with the doctor for recommending to a judge that a severely depressed 84-year-old woman receive shock therapy against her will.

The protest was merely symbolic. The woman was transported--by court order--to Community Hospital in Monterey to receive her treatments, since no hospital in Santa Cruz County offers electroshock.

Forced electroshock is rare nowadays, but the treatment itself appears to be making a strong comeback despite widespread criticism by former patients, advocates and a small number of outspoken psychiatrists.

Critics of Electro Convulsive Therapy--so named because the electricity causes convulsions similar to an epileptic seizure--argue that the procedure is dangerous, that it is largely ineffective in the long term and that, despite laws in many states requiring doctors to give patients detailed information on the risks, recipients of the procedure are seldom fully informed. "Mostly people are cajoled," says Bethesda-based psychiatrist Peter Breggin, a leading critic of ECT. "They're depressed. They're in no position to resist and very often they're toxic on drugs at the time."

John Gillette, chief psychiatrist for Santa Cruz County Mental Health Services, says the elderly woman in this case had stopped eating and caring for herself and that he believes she responded well to the treatments. "This was a lady who already had mild dementia and depression," Gillette says. "She was elderly and required lengthy hospitalization and received several months worth of medications and remained miserable throughout. If they're not eating or caring for themselves or they are talking about suicide [then ECT is appropriate]."

Introduced in 1938 by two Italian doctors, Cerletti and Bini, electroshock has gone in and out of vogue as a treatment for severe depression and, by some psychiatrists, for mania (the "up" phase of so-called manic-depressive illness), catatonia (in which a person is unresponsive) and some forms of schizophrenia.

The procedure requires anesthetizing a patient, paralyzing the muscles with a drug called Anectine and passing electricity directly through a patient's brain to induce convulsions. The patient remains hospitalized while shocks are given--usually three treatments a week--in series that can range from a handful to dozens of shocks.

It seems primitive, but most psychiatrists believe in its efficacy for certain psychiatric conditions as a "last resort." Dr. Gillette admits that the analogy of hitting a television to improve the reception is "probably a good one" for ECT. Nevertheless, Gillette says he recommends the procedure for patients who have severe depression and are unresponsive to drugs or cannot take them because of severe side effects.

Nobody really understands how ECT works, Gillette says, but he uses it because it seems to be effective. Gillette estimates that about half of his patients who have undergone ECT have responded to the treatments.

Like Being Kicked in The Head by a Mule

For her part, Santa Cruz resident Rose Dabbs describes ECT as the most frightening experience of her life. The year was 1964, and Dabbs, then 21, was a student at San Jose State University who suffered from depression. She told school psychologists she couldn't continue to care for herself and the doctors checked her into Agnews State Hospital in San Jose, where she would undergo the first in a series of 26 shock treatments.

Now in her 50s, Dabbs says the treatments did nothing to ease her depression. "It's just awful," she says. "They put conductive grease on your temples and put these things that look like ice tongs on your head, and put a rubber bit in your mouth. When they throw the switch, it knocks you unconscious. They give you Anectine, which makes it impossible to move your muscles. You feel like you're drowning in your own spit and suffocating and you can't breathe. You can't talk. The fear is just overwhelming.

"ECT," she concludes, "was like being kicked in the head by a mule."

Most psychiatrists would publicly agree with Ira Glick, a professor of psychiatry at Stanford Medical School. Glick says the procedure is far safer than it used to be. "Overuse and inappropriate use has been diminished and appropriate use has been increased," he says. "For major depression, patients who are acutely suicidal or have medical contraindications to drug therapy--in those situations, it's a lifesaving treatment with minimal side effects, the worst of which is short-term memory loss."

Breggin, a Harvard-trained psychiatrist whose anti-ECT writings have made him a pariah in the community of psychiatrists, strongly disagrees with Glick. In his books, Toxic Psychiatry and Electroshock: Its Mind-Disabling Effects, the psychiatrist claims ECT's proponents have ignored or greatly misrepresented the risks involved and argues that the procedure is no safer today than in the past.

Certainly, many who have undergone ECT experience problems that the psychiatric community tends to drape in euphemism. Risks include temporary and, in many cases, permanent memory loss. In a study published in the British Journal of Psychiatry in 1980, researchers reported that 74 percent of patients complained of memory impairment and 30 percent felt their memory had been permanently affected. In a 1990 Task Force Report, the American Psychiatric Association (APA) cited the same study, understating that "a small minority of patients" report persistent memory deficits.

Many who have undergone ECT complain of impaired cognitive ability, seizures and other physical and emotional problems they believe resulted from the treatment. Local resident Madelyn Keller described changes in her aunt, who underwent an ECT series in New York. "She became like a shadow of her former self, very insecure," Keller says. "Where she used to be feisty and argumentative, she became fearful and withdrawn."

Damage, Treatment And Discipline

Although it is hotly disputed, considerable evidence indicates that ECT may cause some brain damage. Indeed, as Breggin and other opponents point out, many early proponents of ECT openly suggested that brain damage is key to the efficacy of ECT, a view few psychiatrists embrace today.

In a 1994 article in The Journal of Mind and Behavior, ECT opponent Doug Cameron follows the progression of thought on the mechanism of ECT. He cites research with various types of shock machines and suggests that the electrically induced convulsions are not what is responsible for ECT's "efficacy."

Breggin and other opponents believe brain damage is the culprit. "It's bizarre my colleagues say they don't know how ECT works," Breggin says. "When you create an organic brain syndrome you get apathy or euphoria-- it's obvious how it works."

Mainstream psychiatrists view Breggin as a maverick. Glick compares him to Peter Duesberg, the UC-Berkeley virologist who has been essentially ostracized for questioning the belief that human immunodeficiency virus causes AIDS. But while they dismiss the critics, ECT proponents can provide little solid evidence showing how else ECT might work.

Although rarely reported, ECT has been implicated in the deaths of some patients. Following recent enactment of a disclosure law in Texas, the Houston Chronicle reported in March that eight individuals had died over the previous 15 months, all within two weeks of receiving ECT. Health officials admitted a direct link to ECT in only "one or two cases," but critics grasped upon the report as further evidence that ECT is dangerous.

Psychiatrists agree that ECT--a procedure that seems linked in the public's mind with leeches and bloodletting--suffers in the public relations department. "The image is an important one," Glick says. "The problem has been the One Flew Over the Cuckoo's Nest image that has grabbed the public and is difficult to dispel. Fortunately, psychiatry is now emerging from the stigma."

During the 1940s, 1950s and 1960s, shock was used liberally and routinely both as a psychiatric treatment and as a disciplinary measure for unruly patients in mental institutions.

Kathy, a 48-year-old Santa Cruz resident, was just 13 when she received ECT as a disciplinary measure. She was a rebellious teenager, who first ran into trouble by challenging the canons of her church.

Kathy didn't want to tell her sins to a priest. She communicated with God on her own, she told the dismayed nuns. She was equally obstinate with officials at her junior high school, refusing to take an American history test the school required for graduation. Kathy says she had good grades and found it ridiculous that such a test should be a deciding factor.

School and church officials recommended that she spend some time in a juvenile facility. Kathy's mother opted for what she believed to be the lesser of two evils and her parents instead checked her into Agnews State Hospital.

For a while Kathy did as told by hospital staff, taking unidentified pills and spending much of her day in a large, empty common room with sedated older patients, she says. She soon grew restless from lack of activities and began bickering with the nurses over the hospital rules. That was when the shocks began. "I remember having sets of these shock treatments. I remember it being like Novocain after it wears off. My body hurt and my muscles hurt. The top half of my head was whirling."

Kathy doesn't recall having any problems with her mental health prior to her hospitalization. Nowadays, she depends on anti-psychotic medications and sees a therapist. "Absolutely my experience in the hospital has affected my mental health," she says. "The treatments are bad. I think people should be made much more aware of what it entails."


Photo by Hillary Schalit

Treading Lightly: Santa Cruz County Chief Psychiatrist John Gillette believes ECT is appropriate for severe depression as a last resort.

Cleansing the Treatment Of Controversy

ECT's decline during the late 1960s and 1970s was due, in part, to the insurgence of anti-depressant drugs, which psychiatrists began to favor over electroshock. At the same time, news of abuses in the locked facilities found the limelight and consumer groups and advocates began to protest the abusive practices. Some states, including California, passed laws requiring doctors to fully disclose the risks of ECT to their patients.

But the decline ended in the 1980s, according to a study published in the American Journal of Psychiatry last November. The authors reported that 58,667 patients received shock treatments in 1975, which dropped to 31,514 by 1980. By 1986, however, the number had increased again by 16 percent. Most recipients were white, they found, and three-quarters were women. People over 65, they reported, received ECT "out of proportion to their numbers in inpatient care." Breggin puts the number of patients now receiving ECT at more than 100,000 per year, a figure he claims has been accepted by ECT supporters.

"Most teaching hospitals, including virtually all West Coast teaching hospitals--UCLA Medical School, Stanford University, University of Washington--and virtually all East Coast teaching hospitals all have ECT services, so it's a fairly common procedure that has gained significant resurgence in the past 20 years," concurs Dr. Charles Debattista, head of Stanford's Mood Disorders Clinic and a strong believer in the efficacy of ECT.

The resurgence, according to Debattista, was boosted by consensus reports from the American Psychiatric Association and National Institutes of Heath in 1986, which suggested the procedure was safe and effective for treating major depression and other conditions.

Opponents of ECT have tried to counter the APA's claims, which they view as pro-shock propaganda. In a 1992 paper, Breggin attacks the APA's 1990 Task Force Report on ECT. He points out that three of the six task force members are "among the nation's most zealous defenders of the treatment." He assails the organization for attempting to "cleanse the treatment of controversy" in order to preempt strict regulation by the FDA.

In his paper, Breggin offers examples of how the APA misrepresented the findings of some researchers and ignored those whose research pointed toward damaging effects of ECT. Concluding that the psychiatric community was unwilling to fully disclose the true facts about electroshock to its patients, Breggin ended his paper with a call for an outright ban on the procedure.

Berkeley "shock survivor" Ted Chabasinski, now ombudsman for City of Berkeley Mental Health, led a successful ballot drive in 1982 to ban ECT within Berkeley city limits. The measure, however, was immediately challenged by the Northern California Psychiatric Society and was overturned in court on the grounds that municipalities cannot regulate a medical procedure.

"They don't like the idea that mental patients put this crazy idea on the ballot and all these crazy people voted 2-to-1 to ban electroshock," Chabasinski says. "This whole thing is like the medical profession rising up to protect this handful of incompetents. Doctors have too much power--psychiatrists especially so. The people that I've known who have had ECT, the doctors have just told them, 'You should have shock treatment, it would really help.' It wasn't any last resort."

Despite the controversial nature of ECT, its proponents continue as before, insisting that the treatments are safe and effective. "The reason virtually every university center has gone back to ECT is that clearly a large number of patients are benefiting," contends Dr. Debattista. "Studies thus far indicate ECT could be the single most effective treatment for serious depressive episodes."

That rationale isn't sufficient for Breggin. "The issue isn't whether the treatment helps some people," he says. "That a treatment can help some people is not a justification for its existence. It simply does much more harm than good and nobody is given informed consent."

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