WINSTON-SALEM, NC ( Ivanhoe Newswire) - One in 10 adults suffers from some type of depression. Medications and psychotherapy are common treatments, but for many, they just don't work. Now, a treatment considered barbaric decades ago is making a big comeback.
The past six years have been anything but easy for Jim and Amy Adkins. Jim suffers from severe depression that started when his dad committed suicide.
"I basically would get up and sit on the couch and stare at the wall," Jim Adkins, told Ivanhoe.
It got so bad this father of three nearly followed in his dad's footsteps.
"I attempted suicide twice. I was just at the end of my rope," Jim said.
Drugs and therapy didn't work, so Jim's doctor told him about shock therapy, now known as ECT.
"I was a little reluctant, skeptical, and scared," Jim said.
Duke psychiatrist Richard Weiner says ECT has been used since the 1930s, but Hollywood gave it a bad rap.
"For a lot of the public, what they know about ECT is what they saw on one flew over the cuckoo's nest. The treatments don't look anything like they used to look," Richard Weiner, M.D., PhD, a professor of psychiatry at Duke University School of Medicine, explained.
Jim's on his thirteenth treatment. Doctors first give him general anesthesia and a muscle relaxer. Once Jim's asleep, doctors deliver a quick electrical current that causes a seizure in the brain. The seizure produces chemical changes in the brain that reduce the depressive symptoms.
"The same kind of neurotransmitter changes that occur with antidepressants also occur with ETC," Dr. Weiner said. "It's just that ECT does it more powerfully."
There's no pain, and studies show for those who are good candidates, ECT works between 80 and 90 percent of the time. There are risks including headache, muscle pain, nausea and temporary memory problems, still, Jim's happy he gave it a try. Since starting ECT, he hasn't had any thoughts of suicide.
"Now, there's hope," Jim said. "I see a future."
The number of patients using ECT has tripled since the 1980s. Most patients will need follow-up treatments or other drug therapies after ECT. The shock therapy is mainly used for patients with severe, debilitating depression.
BACKGROUND: Depression is a medical illness that involves the brain. It affects more than 20 million Americans. Symptoms can include sadness, loss of interest or pleasure, changes in weight, difficulty sleeping or sleeping too much, a loss of energy, feelings of worthlessness, and thoughts of death or suicide. Researchers believe there are a variety of causes including genetic, environmental, psychological and biochemical factors. Depression usually starts between ages 15 and 30 and is much more common in women. Typical treatments include antidepressant drugs and talk therapy. (SOURCE: National Institute of Mental Health)
WHAT IS ECT? Electroconvulsive therapy (ECT) is used to treat severe depression. It involves using electricity to induce a seizure. Doctors believe the seizure in the brain produces a host of chemical and physiologic changes in the brain. When ECT was first introduced in the 1940s, it was performed without anesthesia. The treatments were often portrayed as painful and punitive in movie scenes. "The treatments don't look anything like they used to look," Richard Weiner, M.D., Professor of Psychiatry, Medical Director of the Duke ECT Program, told Ivanhoe. "The type of electricity that we use now is very different from the type of electricity that used to be used. What we use now is actually modeled after the type of electricity that the brain itself uses." Today, patients also receive muscle relaxers prior to having the procedure, and they are put under general anesthesia. About 100,000 people undergo ECT treatments each year. It is recommended for those with severe depression who fail to respond to other therapies such as medications and psychotherapy. (SOURCE: www.doctoroz.com, Ivanhoe interview with Dr. Weiner)
HOW SUCCESSFUL IS IT? Several studies show ECT therapy works between 80 percent and 90 percent of the time for those who are good candidates. "The results can be extraordinarily dramatic," Dr. Weiner said.
RISKS: There are risks and side effects of ECT therapy. These include headache, muscle pain, nausea, and memory problems. Many patients who undergo ECT treatments continue taking their antidepressant medications, which also pose side effects. "Any treatment has risks and not treating also has risks," Dr. Weiner said. While there has been some concern about ECT causing permanent changes in the brain, Dr. Weiner says: "What's been found is ECT doesn't cause any pathological, structural changes in the brain. Interestingly, what has been found is depression itself causes pathological changes in certain parts of the brain, so in a sense, ECT may end up being better for their [patients'] brain rather than bad for their brain." (SOURCE: Ivanhoe interview with Dr. Weiner)
Dr. Richard Weiner, MD, PhD, a Professor of Psychiatry at Duke University School of Medicine, talks about a treatment once thought of as torture that may have saved a man's life.
Who is a candidate for the ECT treatment?
Dr. Richard Weiner: The great majority of patients that we treat with ECT have what we call severe major depression. These are episodes where the person is not only depressed, but their lives have been terribly disrupted. They have no energy. They have no interest in things. Usually they can't work. They're more or less totally incapacitated by the illness. It's unfortunate because it is a treatable disorder. Usually people are treated with medications or psychotherapy or both first, but when either those don't work or if the condition is so gravely severe, they may need ECT.
How does the treatment work?
Dr. Richard Weiner: Before the treatment, the patient is evaluated carefully by a psychiatrist who does ECT. There are certain lab tests that are done. An anesthesiologist will examine them to make sure that everything is safe. On the day of the treatment the patient comes in early in the morning; they're checked in by one of our nurses who put an IV catheter in their arm, take their vital signs-blood pressure, heart rate and so on. Then we'll go over some educational information with them and see how they're doing. The psychiatrist who's doing the ECT treatment will come in and talk with them for 5 or 10 minutes to see how they've been doing since the initial ECT consult or the last treatment and determine whether there's been any medical issues that have come up. Based on that discussion, we will decide not only if it is a good idea to go ahead with the treatment that day, but also when the next treatment should be. People in an acute episode of illness receive what we call an "index" ECT course, which is generally-3 times a week, for 6-12 treatments, depending on how quickly they respond. After the psychiatrist talks with them, they are brought into the treatment room where they lie down on a bed. All sorts of monitoring equipment is hooked up to them, not just EKG, which is heart wave monitoring, but the oxygen saturation in the blood, blood pressure, heart rate even the brain waves (EEG) are monitored during ECT. After that's all set up, a fast acting general anesthetic medication is injected into their IV line, and within a minute they're asleep. The next thing they know is they're waking up 5 or 10 minutes later in another room. While they're asleep they're an intravenous muscle relaxant medication, which relaxes their muscles. Once that's done, two stimulus electrodes are put on the head and an electrical current is applied for usually a few seconds, which immediately produces seizure activity within the brain, Because of the muscle relaxant medication, very little observable body movement takes place during the seizure, so that the EEG monitor is necessary to ensure that the seizure has occurred. . The seizure usually lasts a minute or less and then the treatment is done. Within usually 5 minutes after leaving the treatment room people are breathing on their own and starting to wake up. They stay in the recovery room for maybe another ½ hour – 45 minutes and then they're ready to leave to go home if they are an outpatient or to go back to the Ward if they are an inpatient.
What type of electricity is used?
Dr. Richard Weiner: The type of electricity that we use with ECT now is very different from the type of electricity that used to be applied. This is just one of the innovations that have occurred over the years to make the treatment not just more effective, but safer. The electricity that we use now is actually modeled after the type of electricity that the brain itself uses. Many people don't realize that the brain itself operates electrically, and that that's how the nerve cells communicate with one another. In addition to the type of electrical signals we now use to stimulate the brain to produce a seizure being modeled after the natural type of electricity used by the brain, we have a way of determining what level of electrical dose is necessary for a particular patient. We have ways to match the amount of electricity to what is needed to produce a seizure in a particular person so that nobody gets more electricity or less electricity than is necessary to produce the desired response. That's something that allows the treatment to be given in a safer and more efficient fashion.
Does the treatment need to be repeated?
Dr. Richard Weiner: As mentioned, formost people, an index course of ECT involves takes anywhere between 6 to 12 treatments, usually administered 3 times a week, but for some people it takes more and for some people it takes less. There's no way to predict in advance how many treatments it will take. It's like a medication; in that one can't predict exactly how long it will take an anti-depressant medication to work, except that generally ECT has a more rapid action. We monitor very closely the response of the person to the treatment so that we know at the time of every treatment how they're doing compared to when they started the ECT. We have ways of quantitatively measuring this response so that we know when the ECT series should be ended. In other words, when received a maximum effect, usually when they're back to their baseline, the treatment course is stopped. Then we begin the patient on some sort of maintenance treatment which is usually medications or psychotherapy or both, but it can include relatively infrequent ECT treatments, ranging from once a week to start, going out to once a month or even once every 2 months. The need for such maintenance treatment is because there's a high risk of relapse after a course of ECT just like with getting antibiotics for an infection. If you get a course of antibiotics for an infection and it treats that infection successfully, but you're susceptible to getting infections, then having had an antibiotic in the past is not going to prevent you from getting a recurrence of the infection. It's a similar situation with ECT. Major depression is a recurrent illness. For the most part it tends to recur anywhere from multiple times a year to once every 20 to 30 years. The recurrence rate varies from person to person.
How is the electricity helping them?
Dr. Richard Weiner: We don't believe it's the electricity. The electricity is just the means to produce the seizure within the brain, and the seizure within the brain produces a whole host of chemical, neuroendocrine, and neurophysiological changes. For example, the same kind of neurotransmitter changes that occur with antidepressant medications also occur with ECT. It's just that ECT does it more powerfully than the medications do.
Has ECT been around for a while?
Dr. Richard Weiner: Yes. ECT was first utilized in the 1930's and has been used continually since that time. The amount of ECT used has gone down over the years because of the development of antidepressants and antipsychotic medications. But what we find now is that those medications don't always work, and that the likelihood of another medication or even medication combination working goes down quite dramatically with the number of medication trials. ECT, because it is such a powerful antidepressant treatment, will often work when the medications have not been able to work.
Do people have misconceptions about the therapy when they first hear about it?
Dr. Richard Weiner: There are many misconceptions about ECT. For a lot of the public, what they know about ECT is what they saw on One flew Over the Cuckoo's Nest, the movie with Jack Nicholson. That movie portrays ECT as a punitive treatment given against a person's will, and given without any anesthesia or muscle relaxation. That's just not the way it's given anymore. The ECT recipient, or their legal guardian, provides consent to ECT. They can stop anytime they want. The treatments don't look anything like what they used to look like in that regard. They are much safer and they are not painful. A general anesthetic medication is used and the person is asleep throughout the whole time when the electricity is applied and the seizure occurs. They're not aware of that at all, and again there isn't any pain. Another kind of misconception is that ECT is quote "bad for your brain". Although induced seizures are associated with memory impairment, much of which is temporary, a lot of studies, particularly in recent years, have looked at the issue of whether ECT produces harmful structural changes in the brain. What's been found is that ECT doesn't produce any such brain changes. Interestingly, however, what has been found is that depression itself causes some abnormal changes in certain parts of the brain, and that antidepressant treatments tend to reverse those changes. In a sense, ECT may actually end up being better for a person's brain rather than be bad for it.
What kind of results have you seen?
Dr. Richard Weiner: The results of ECT vary. Some patients don't improve, but most do, and the amount of improvement is usually substantial. It's not just the psychiatrist observing that there has been improvement, but the patient and the family as well. We've had a number of our patients tell us that they haven't felt this good in years, and we've had situations where the family may say it's hard for them even to recognize that it's the same person that they were dealing with before. It's been that dramatic. We've had situations where ECT has even saved patients' lives. For example, some people on medical wards, even in intensive care units, become so debilitated from their medical diseases, when they're not eating, they're not moving, and they just don't care whether they live or die. In some such cases, ECT is able to pull them out of that life-threatening state to the point where their medical condition can be effectively treated, and they can get better and leave the hospital.
How rewarding are these results to you?
Dr. Richard Weiner: If a large improvement in a major depressive episode can happen in 2 or 3 weeks, that's extraordinary. We don't see a lot of treatments like that, not just in psychiatry but even elsewhere in medicine.
Is ECT offered nationwide?
Dr. Richard Weiner: ECT is available throughout the United States. It's not hard to find some place that gives ECT, except if one lives in a very rural area, even though a minority of psychiatrists actually administers the treatment, because it requires a lot of extra training.
How effective is it?
Dr. Richard Weiner: Many research studies, both a long time ago and more recently, have looked at the efficacy of ECT. If one is what we call a good candidate, which means that they don't have multiple mental disorders, and the episode has not been going on for t many years, then the likelihood of improvement, and I mean substantial improvement, is in the 80 to 90% range, which is very high for a psychiatric treatment. If their situation is more complicated by concurrent psychiatric disorders other than major depression, or if they've had a highly treatment resistant and long episode of illness, then the likelihood of substantial may be somewhere between 50 and 75%. Unfortunately, for these latter kinds of patients, the likelihood of another trial of medication, even multiple medications, being effective is much lower than 50%.
Are there any risks that people should know about before they consider ECT?
Dr. Richard Weiner: Any treatment has risks; however, not treating the illness itself has risks which may sometimes be even greater. We know, for example, that having major depression is associated with a much higher mortality and morbidity from a variety of medical disorders. The most common side effects with ECT are things like headache; muscle pain, nausea, and memory problems. The headache, muscle pain, nausea tend to last only minutes to hours and tend to be easily managed. The memory problems typically build up over an index course of ECT. When such effects are detected, the psychiatrist providing the ECT can sometimes modify the treatments to make the memory problems less. For that matter the kind of electricity and the way we apply the electricity to the patients head now is associated with fewer problems with memory, although because some persons receiving ECT have reported more long lasting memory difficulties, we go over all of the possibilities with patients before they agree to have the ECT and give persons considering the treatment information about ECT that details the risks so that they're able to make a truly informed decision on whether to have the treatment.
FOR MORE INFORMATION, PLEASE CONTACT:
Sarah Avery Senior Media Relations Specialist Duke Medicine News and Communications (919) 660-1306 firstname.lastname@example.org
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