Shock Preface

There is no treatment in psychiatry more frightening than electroconvulsive therapy. It works like this: two electrodes are strapped to the patient’s skull. The doctor presses a button that unleashes a burst of electricity powerful enough to set off an epileptic-like convulsion. The sheer strength of the seizure shocks the brain back into balance.

There also is no treatment in psychiatry more effective than ECT.

Ask any psychiatrist about it and he is likely to rave — provided no one is listening. Even more certain is that he will recommend ECT only as a last resort, if then, and will barely refer to it when training the next generation of psychiatrists.

Mention it to someone on the street and the first reaction is: “Shock treatment! They aren’t still doing that, are they? Often followed by, “My Aunt Agnes had that a long time ago and it made her better.

How is it that a therapy nearly 70 years old still provokes such passionate and paradoxical responses? No remedy in medicine is more entangled in polemics than ECT. This book sifts through the controversy and unravels the contradictions. It separates scare from promise, real complications from lurid headlines. In the process it offers practical guidance to prospective patients and their families on whether ECT can help them battle depression, bipolar disorder, and other disabling mental diseases. ECT stirs fears and hopes that intrigue everyone, but that mystify most. This text is an exercise in demystification.

It does that in two voices, one personal and narrative, the other dispassionate and explanatory. The narrative is Kitty Dukakis’s experience with ECT, presented in every other chapter in the first person. Kitty knows about mental illness. For two decades she has suffered a depression that at times she has been able to outrun and at other times has marooned her in bed, unable to think of anything but the next mouthful of vodka. She also knows about the addictions that frequently accompany psychiatric sickness. Her unlucky romance with diet pills started at age nineteen and lasted twenty-six years. Her drinking began later and persisted nearly as long, although she has been sober for five years. Such dependencies and disease would be tormenting for anyone; for Kitty they were aggravated by her husband Michael’s three terms as governor of Massachusetts, his 1988 run for the presidency, and her high-profile roles in all of them.

The explanatory chapters are mine. I am a former medical writer at the Boston Globe. I first heard Kitty’s story when she and Michael told it to participants in the Boston-based training program that I run for health care journalists. My fellow reporters and I sat transfixed by the tale of a treatment we were supposed to know about but did not, and by storytellers we thought we knew but had never heard speak so movingly. Their presentation had special resonance for me: a journalist friend had recently considered ECT when nothing else could lift him out of despair, but he was scared away by lingering images from Jack Nicholson’s One Flew Over the Cuckoo’s Nest. A favorite aunt had the procedure when I was a boy, and she was depressed and desperate.

Kitty and I began a negotiation en route to a collaboration. She already had shared her experience with friends of friends, along with total strangers, who had heard about her treatment and were searching for something to subdue their demons. Now she wanted my help bringing her story to a wider audience. I was reluctant to wade into the controversy, but became mesmerized by a treatment that some condemn as torture and others lionize as life-saving. I said I would join in, on two conditions: that I could tell the broader story of ECT to fill out her individual angle, and that I have the freedom to go anywhere the facts led me, for better and worse. She enthusiastically agreed.

Kitty’s tale is more than just hers. It is the story she remembers, with recollections and reactions woven in from her children and husband, her sister and brother-in-law, and friends who, as always with a disease like depression, played roles in her illness and her recoveries. It is her struggle with alcohol and with diet pills, which both masked and exacerbated her despair. Her doctors contributed to this retelling, opening her hospital and therapy records to her and to me, adding perspective, and letting me observe as she got convulsive treatments over the course of more than a year.

My chapters probe ECT’s history, its effects, and its prospects. They are based on interviews with leading ECT researchers and practitioners in the United States and overseas, some fifty in all. I talked to passionate critics, along with historians of medicine and others familiar with the procedure as it has evolved over the last half century. I visited ECT clinics across America. I pored through 60 books on electroshock and related procedures, and read about 600 articles. Most importantly, I talked to people who had received ECT, more than 100 of them, for illnesses ranging from depression to schizophrenia and with results that ranged from life-sustaining to personality-obliterating. Some were referred to me by their doctors. Others were sent by anti-ECT activists. Most came my way thanks to ads posted and emails sent by support groups like the National Alliance on Mental Illness and the Depression and Bipolar Support Alliance. While some asked not to be named, or to have us use just their first name, most spoke at length and for attribution.

My subjects were people everyone has heard of, like Pulitzer Prize-winning author William Styron, and anonymous ones like Carrie DeLoach and Christine Elvidge. DeLoach, a 31-year-old English teacher who lives in Spain, got ECT twice for deep depression and once for a manic high like I’d never experienced. Each time the therapy restored her equilibrium, immediately and without a single complication. Elvidge opted for shock treatment after nearly 100 medications failed to calm alternating bouts of mania and depression — and after she tried slitting her throat with a broken mayonnaise jar. ECT made her forget everything from her daughter’s recent birthday party to whether she had a husband. “At the time I said I would never, ever want to have ECT again,” says Elvidge, who is 41 now and a mental health counselor in Illinois. “Later I saw how it had helped me get my life back. ECT is not easy . . . but I believe it’s better than taking your own life.

Each person I interviewed had a story that was slightly different. Yet after hearing 100 of them, patterns started to form. Their stories, together with Kitty’s, are the grains of sand that reveal the broader landscape of electroconvulsive therapy.

Our book begins filling in that landscape in Chapter 2, which explores the dramatic yet subterranean comeback of ECT, then zeroes in on what the treatment looks like today from the United States to the British Isles and Indian subcontinent. Chapter 4 looks back at electroshock’s birth and growth from the late 1930s through the 1950s, when it was the psychiatric profession’s treatment of choice. Chapter 6 documents how, after thirty years on the rise, it fell from grace and from most psychiatrists’ tool bags. ECT rose again starting in the mid-1980s, and chapter 8 looks at the scientific evidence of effectiveness that fueled the rebound. Not all its effects are good, of course. Chapter 10 considers memory loss and other complications that have kept ECT under a cloud of controversy, along with ways to minimize that loss if not defuse the controversy. Chapter 12 reviews the mechanisms underlying electroshock, ones we know and others we guess at, and previews new brain-stimulation therapies.

Woven between are six chapters of Kitty’s up-close experience with ECT. Her struggles and triumphs help bring alive my history, medicine, and science. We conclude with an Epilogue of simple advice to would-be ECT recipients.

The picture of electroconvulsive therapy that emerges is of a treatment with enormous promise, especially for depression, the most omnipresent mental illness in the world. The U.S. surgeon general, the National Institutes of Health, and much of the psychiatric establishment agree that ECT presents a better prospect for relieving severe depression than even the best antidepressants or the sagest psychotherapist. It goes to work faster, which is essential for patients determined to kill themselves. It also is accessible to the elderly, pregnant women, the physically ill, and others who cannot tolerate psychotropic drugs. And it is not just depression: ECT has an enviable success rate for a series of other debilitating mental conditions. All of which explains why a treatment that nearly vanished along with the lobotomy and insulin coma is here once more.

But the stigma has not gone away. That is partly because it was planted so effectively by books and movies like Cuckoo’s Nest and The Snake Pit, and because any therapy that sends a current coursing through the brain is bound to be contentious. It also is because ECT can cause memories to melt away, in rare cases going back years and never coming back. Like chemotherapy, ECT is a toxic treatment for a crippling disease. Like any surgery requiring anesthesia, it carries risks. And like the electric paddles that cardiologists use to shock back into rhythm a fibrillating heart, ECT is not a cure but can offer relief and even remission.

No one is sure just how it accomplishes that. Or, more precisely, researchers have endless theories and little consensus. The seizure could be key, or shutting off the process that produces seizures. It could center around the electricity, or the same biochemical reactions that make antidepressants work. Many patients prefer to think of ECT as somehow resetting the brain when it gets out of balance, the same way rebooting a balky computer sometimes fixes it.

These pages also steer readers through the claims and counterclaims surrounding ECT. We agree with doctors who say the treatment is dramatically more forgiving today than during its bone-breaking primordial days. We concur with critics who say ECT can and should be made even better by facing and redressing complications like memory loss. Yet we surely will draw the ire of true believers in both camps — proponents for pointing out ECT’s adverse effects, opponents for strongly disagreeing with their call to ban a treatment that is helping millions worldwide. Our real audience is current and prospective patients. For them we compare electroshock to drugs, talk therapy, and other treatment alternatives, knowing the latter are less intrusive but less likely to provide fast, effective relief. We also calibrate ECT’s potentially onerous side effects alongside the often more onerous prospect of bearing a debilitating disease like depression. ECT, it turns out, is neither a panacea nor a scourge, but a serious option for treating severe ailments.

Wading through such minefields, we realize that even our choice of a name for this procedure is sure to be explosive, the way it has always been. Its founders toyed with electroshake and electric shock, finally settling on electroshock. The press and public preferred the simpler and more evocative electric shock treatment, trimmed to shock treatment, then to shock. As part of its recent renaissance, promoters opted for the scientific-sounding electroconvulsive therapy. Even better, the laconic and vanilla ECT. Kitty and I made different decisions on what to call it in our respective chapters. She largely avoids the phrase shock treatment, which she feels is inflammatory and not descriptive of a procedure that for her has been benign. I generally refer to it as shock treatment when that was the name it was known by, ECT when that came into wider use, and throughout as electroshock, the title Ugo Cerletti chose when he launched the therapy at his Rome clinic in 1938. We agreed to use shock in our title because that is the name by which most people recognize the treatment.

Whatever it is called, the story of ECT is, in the end, a lens into how psychiatry and medicine work in America. It is a world where analysts argue with psychopharmacologists, social workers split hairs with psychologists and psychiatrists, and consumers wrangle among themselves and with practitioners. Those fault lines run especially deep when it comes to the profession’s most controversial treatment, electroconvulsive therapy. Nowhere is there a clearer demarcation of the debate between medical and therapeutic models of mental illness. It is counterintuitive to see a treatment as time-consuming and tangled as ECT catch on in this era of Prozac and the quick fix. Most surprising of all, ECT is the only remedy in mainstream medicine that is expanding in use, receiving increased attention in research, and offering life-saving hope to tens of thousands of people, even as much of the public believes it is extinct.