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Electroconvulsive therapy: Considered a safe, effective treatment for patients, despite its persistent stigma

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COLUMBIA — Two years ago, Alexis Katchuk circled a date in her planner. May 8: It was the day she intended to kill herself.

Katchuk, a former MU student diagnosed with Bipolar Disorder Type I in 1999, was experiencing a severe depressive episode when she started having suicidal thoughts. In response, her doctor admitted her to University Hospital and increased the frequency of her treatment — a therapy where seizures are electrically induced in patients to provide relief from psychiatric illnesses.

The treatment, known as "ECT" or electroconvulsive therapy to mental health professionals, but “electroshock therapy” to the general public, has been practiced in the United States for more than 80 years.

There is still a stigma around electroconvulsive therapy, rooted in depictions such as a scene in the film “One Flew Over the Cuckoo’s Nest,” when a character played by Jack Nicholson has the treatment while strapped to a bed. But a number of physicians have returned to it, calling it a safe, effective treatment for many psychiatric patients.  

University Hospital is one of a number of academic hospitals in the United States that offer the treatment. It is now successfully used for severe, persistent cases of mental illnesses such as major depressive disorder, and psychiatrists at Johns Hopkins Hospital have adopted the electroconvulsive therapy to treat adolescents with severe autism.

An FDA executive summary for Neurological Devices Panel in 2011 pointed out the resurgence of interest in electroconvulsive therapy. According to the summary, "ECT use in the U.S. has been estimated at 100,000 individuals receiving this treatment annually.”.

Max Fink, a neurologist and psychiatrist in New York, has spent 60 years using the therapy, despite its controversial history. He has written a number of books to enlighten the medical profession about the value of the treatment for patients who have severe psychiatric illness where medication is not an option.

His 2008 book, “Electroconvulsive Therapy: A Guide for Professionals and Their Patients,” describes the surgical procedure, which involves nurses, an anesthesiologist and a psychiatrist. Patients are first given a short-acting anesthetic; then, while unconscious, the psychiatrist induces a grand mal seizure in the brain using an electrical current.

Early history

The procedure was first developed by Hungarian neuropathologist Ladislas Meduna in 1934. After World War II, when thousands of soldiers were left with psychiatric illnesses that couldn't be effectively treated, ECT gained considerable popularity as an alternative, though anesthesia or muscle relaxers weren't used until 1953. In some instances, Fink said, the electrical currents were powerful enough to cause bone fractures.

After that, he said, both the science and technology involved in the treatment developed significantly. ECT became a vital tool for psychiatrists, social workers and other professionals in the mental health field before the development of psychotropic drugs in the early 1960s. Then, because many professionals believed that the drugs would replace ECT, it declined in popularity. 

Meanwhile, groups such as the Church of Scientology began a campaign against it. In fact, the Scientologists' campaign was effective enough to persuade the California legislature to prohibit the therapy for those younger than 12 in 1974.

According to a 2012 report by the American Academy of Child and Adolescent Psychiatry, ECT is now legal in every state, with some parameters. In addition to restrictions in California, it is illegal to administer the treatment to children younger than 16 in Colorado and Texas and those younger than 14 in Tennessee.

In 2013, however, the Mayo Clinic in Rochester, Minnesota, called it a "safe, reasonably well-tolerated, and effective treatment, especially for the most severely ill patients who have shown resistance to both pharmacotherapy and psychotherapy."

Today, doctors such as Fink have complete faith in the treatment.

“At the present moment, ECT turns out to be one of the safest treatments we know,” he said. “Death does not occur anymore, fractures don’t occur anymore, and memory losses are minimal and temporary.”

At Johns Hopkins Hospital in Maryland, Dr. Irving M. Reti has been studying the effects of ECT on teenagers with severe autism since 2006. These adolescents come from the Kennedy Krieger Institute, a Johns Hopkins affiliate that treats young people with developmental disabilities.

The patients all have a severe form of autism that causes them to experience self-injurious behavior, which is connected to catatonia, a behavioral disorder that causes abnormal movements. The doctors at Kennedy Krieger Institute use ECT to specifically treat these catatonic symptoms of autism, Reti said.

Reti said most of the patients have an excellent response to ECT, which typically stops their self-injurious behaviors. In some cases, he said, the behaviors markedly suppress after just a few treatments.

Getting over the stigma

Yet the stigma persists. Although Katchuk was told electroconvulsive therapy could be an effective treatment for her, she said she was initially terrified.

“All I had in my mind were those stereotypical movies from the '60s and '70s that show people going into seizures on the table and walking around kind of like they were zombies afterward," she said. "I was terrified that my personality was going to disappear.”

Katchuk’s history with ECT began in 1998 when she received her first treatment. After being diagnosed with major depressive disorder in 1997 and trying a series of different medications without results, her hometown doctor recommended electroconvulsive therapy at a general psychiatric unit for depression in Pennsylvania.

Katchuk can’t recall much from this period, partially because memory loss is a potential side effect of ECT, but she said she knows she received ECT three times a week for three weeks. In 1999, when her diagnosis was changed to bipolar disorder, she was no longer undergoing ECT. It wasn’t until she moved to Columbia in 2008 that she began the treatment again, after other health problems intervened.

Katchuk had been diagnosed with anorexia nervosa in December 1999, and she said she was in and out of five different hospitals with “no intention of getting better” until 2005. After enduring the cycle of rehabilitation and relapse for six years, she decided to make a change.

“I was told that I could either get better or die,” she says. “I chose to get better.”

Katchuk said her eating disorder affected her bipolar disorder when she lost so much weight that her body had insufficient energy to “try and stabilize moods.” This made it difficult for doctors to decide what to do because her body did not respond well to bipolar disorder medication.

She earned a degree in English from East Stroudsburg University in 2005 and a master's degree from American University in 2008, but she continued to struggle with both anorexia and bipolar disorder. She said she was at her absolute lowest weight during the winter of 2006, when she was also the most depressed.

In the fall of 2008, Katchuk arrived at MU and started working toward a Ph.D. in creative nonfiction writing. That winter, she started struggling with the pressure put on doctoral students and began seeing a psychiatrist at University Hospital. An MU physician recommended she talk to a therapist as well, so Katchuk began working with one at the MU Counseling Center.

When neither medication nor counseling were sufficient, Katchuk was admitted to the MU Psychiatric Center. At that point she was put in touch with the two doctors in Columbia who were licensed to perform ECT — Muaid Ithman and Howard Houghton.

In December 2009, Katchuk was hospitalized again, and that's when she said Houghton persuaded her to give ECT another try. She had left Pennsylvania unhappy about the first attempt and said she wasn’t confident it would work.

Yet, she decided to give ECT another shot because, for the first time, she said she had a doctor who was willing to answer her questions. Electroconvulsive therapy might be a real solution, she thought.

“I was really scared that I was going to live the rest of my life being depressed all the time,” Katchuk said. “I had given up hope on medication because it didn’t seem to be helping me at all.”

After beginning treatments with Houghton, Katchuk said it took about a year for her to see significant improvement.

Beneficial treatment

Experts such as Fink, a professor of psychiatry and neurology emeritus at the Stony Brook University School of Medicine, said multiple patients find ECT just as beneficial as Katchuk did.

Katchuk is one of an estimated 100,000 people who, according to Mental Health America, undergo electroconvulsive therapy every year. “Star Wars” actress Carrie Fisher went public about her use of ECT to help symptoms of depression on the “The Oprah Winfrey Show” in 2011.

At 92, Fink is one of the few medical professionals who has been alive throughout the evolution of electroconvulsive therapy.

In addition to his 2008 book about the subject, he has written hundreds of academic articles regarding the therapy and founded The Journal of ECT.

Fink said he learned how to administer the therapy in 1952 during his residency at Hillside Hospital in New York. He moved to St Louis in 1962 to establish the Missouri Institute of Psychiatry and was on the faculty at MU from 1963 to 1966.

“Electroconvulsive is a remarkably effective treatment for severe mental illnesses,” Fink said in one article titled “Prejudice Against Electroconvulsive: Competition with Psychological Philosophies as a Contribution to its Stigma.”

“It is safely administered. It is more effective than alternate therapies for the cases for which its use is now recommended... Yet, electroconvulsive is persistently denigrated, legally restricted, and haphazardly applied.”

Katchuk describes the procedure this way: After a nurse inserts an IV line, she gets her blood pressure and heart rate checked, answers questions from her doctor and is led to the treatment room. There, she is hooked up to monitors that track her heartbeat and breathing patterns during the therapy. Finally, the doctor administers the shock waves to her brain while she is anesthetized.

“I wish people knew that it doesn't hurt, that you don’t feel anything during the treatment; you’re not aware during the treatment, and that you wake up and you are still the same person,” Katchuk said. “And I wish people would know that ECT can be an extremely effective treatment.”

Recovering her passions

Katchuk said she began contemplating suicide in 2014. When she revealed her suicide plan, her doctor admitted her to University Hospital’s general psychiatric ward for a month. Although she had been undergoing maintenance ECT once every five weeks, her doctor decided to increase the frequency of the treatments to once a week.

Katchuk said she knew the electroconvulsive treatments were working when she started reading and writing again. She had gotten to the point where she couldn't enjoy any of her favorite activities, she said. She had dropped out of the doctoral program and had stopped teaching English at Moberly Area Community College.

“It’s kind of what I lived for," she said. "I couldn’t sit down with a piece of paper and come up with anything. I just stared at it.”

Ultimately, it was decided that moving back to New York to live with her parents would be best for her. She had been referred to a doctor there who would continue to administer ECT. Within a few months, she started noticing a difference.

Today, Katchuk teaches English at SUNY Broome Community College in Binghamton, New York. She said she tries to be honest with her students because she believes many of them may have struggles similar to her own.

“I want them to know that they aren’t the only person that is experiencing what they are,” Katchuk said. “I think it’s really important to know that you’re not alone.”

Despite the potentially alienating stigma that surrounds electroconvulsive therapy and mental illness in general, Katchuk doesn’t think twice before explaining the improvements the treatment has brought to her life.

“Depression really stole my identity away from me,” Katchuk said. “I was just a shell of a person.

"After my journey toward recovery — and I owe a great deal of that to ECT — I feel like myself. I feel like an individual with passions and a desire to live ... I have dreams and goals, and the energy to actually work toward them again.”

Supervising editor is Jeanne Abbott.

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