Weighing the Risks and Benefits of Shock Therapy Nearly 100,000 Americans sign up for electro-shock therapy every year to treat severe depression. Many patients call it life-saving, yet scientists still struggle to explain why it is effective. Critics say the procedure is barbaric and that doctors underplay the risk of post-therapy memory loss.
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Weighing the Risks and Benefits of Shock Therapy

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LYNN NEARY, host:

This is TALK OF THE NATION. I'm Lynn Neary in Washington. Neal Conan is away.

Some 100,000 Americans undergo electroconvulsive therapy every year. In the treatment, psychiatrists use a controlled electrical current to induce small seizures in the brain. Though no one knows exactly how it works, it is effective for many patients - and in many cases - where prescription drugs have not helped.

Critics of the procedure say that electroconvulsive therapy has been overprescribed, the doctors have underplayed the risk of post-therapy memory loss, and that the procedure is barbaric.

Have you or has someone you know undergone electroconvulsive therapy? Did it work? Were you happy with the results? Or, have you suffered from memory loss or other unexpected complications? Our number here in Washington is 800-989-8255. That's 800-989-TALK. And our e-mail address is talk@npr.org. And you can comment on our blog at npr.org/blogofthenation.

Later in the program, can the U.S. military take lessons from Madison Avenue to help win over the Iraqi and Afghan people?

But first, electroconvulsive therapy. We're joined by Kitty Dukakis, the wife of former Massachusetts governor and presidential candidate Michael Dukakis. She first underwent electroconvulsive therapy in 2001 and she continues to use the procedure to treat her depression. Kitty Dukakis has written about her treatment in "Shock: The Healing Power of Electroconvulsive Therapy." She joins us now by phone from her home in Massachusetts. Kitty Dukakis, welcome to TALK OF THE NATION.

Ms. KITTY DUKAKIS (Co-author, "Shock: The Healing Power of Electroconvulsive Therapy"): Thank you so much. It's good to be with you.

NEARY: What made you decide to undergo electroconvulsive therapy? What led up to that decision?

Ms. DUKAKIS: I had suffered for close to 17 years with clinical depressions. And they had been cyclical and came about every nine or 10 months, and were unbearable, really. They lasted for four months, and antidepressants just didn't work. They - if they did work at all, it was for very brief periods of time. And so I was really looking for an alternative, something that would work to heal these periods of frightful depression.

NEARY: What had you heard about this treatment? Did you have negative ideas about it?

Ms. DUKAKIS: Oh, I had, very initially. I certainly did. I had seen the movie "One Flew Over the Cuckoos Nest" and had pictures of that with Jack Lemmon in my own mind. Fortunately, I had a wonderful doctor who was able to describe what in fact happened with the ECT, with electroconvulsive therapy, and was able to view a film and then did a great deal of reading about it.

And at that particular point in my life, my depression happened to lift, and I said if it came back again, I certainly would try it. And it did come back about a year later. And six years ago, in June, I had my first treatment.

NEARY: When you say you did a lot of research and, obviously, relied upon your doctor, what assurances did you get from him and that made you go ahead, and in your own research that made you go ahead? What…

Ms. DUKAKIS: Right. That it worked in a good 75 to 85 percent of the cases in which it was used. That the side effect of some memory loss was different with every individual, that I might suffer with some of that. And I was willing to take that risk. And I have had some memory loss. It is - I consider it minor, though I have some periods in my life that are at total blank right now. But cognitively and in every other way, intellectually, my memory has not affected my life.

And I consider it a tradeoff, a very fair tradeoff. And I have my life back again. And it works for me. When depression hits, I know that this particular therapy is going to work.

NEARY: Let me - did you know it immediately after the first treatment?

Ms. DUKAKIS: Well, I was one of those unusual cases. Normally, it takes people several treatments. There are usually six treatments in a series. And most people would take two or three treatments before they begin to notice the difference. I felt it off immediately and I was very fortunate. I happen to have - for my very first treatment, I happen to have ECT on Michael and my anniversary, and had told him before I went in for a treatment that I was sure I wouldn't feel like going out to celebrate.

And on the way home from treatment, in the car, I turned to him and said I'm ready, I want to go out for dinner tonight. And he noticed the difference as I woke up from the treatment that I had a smile on my face. I didn't ever have a smile on my face during those periods of depression.

NEARY: But you have to continue these treatments. It's not like you get one round of it and it's done.

Ms. DUKAKIS: Right. It depends on the individual. There are people who are fortunate enough to have one series of treatments. And I've met many of them when my book was published. And they never have to have them again. They've, in a way, just have been cured of their depression or bipolar disease or whatever else is a problem. I'm not one of those people. I usually cycle every nine or 10 months.

The beauty of this treatment is that I know it works. And I don't worry about the other shoe dropping. I know that there is a treatment that is going to make me feel better.

NEARY: Let me ask you a little bit more about the memory loss because this is, of course, in the minds of many people, a huge drawback to this treatment. And yet, you said that you think it's a fair tradeoff and that it's kind of minor. But what kinds of things have you forgotten?

Ms. DUKAKIS: Well, we had - soon after my first treatment, we had - I had been with Michael to Paris for the first time many weeks before my first treatment. And I have no memory of that first trip. We went back again. We stayed at the same hotel - I have no memory of the first trip. I saw a movie a year ago, and it was at the time of treatment, which just happens very often that one's memory is disturbed. And I saw the movie a second time a year later - I had no memory of the first time I've seen that movie.

NEARY: I have to say, I don't think I'd forget a trip to Paris, but I might forget a movie I had seen.

Ms. DUKAKIS: Well, the trip to Paris, you know, it's one of those things. I just - it's gone. We went back. I was fortunate in having a husband who was - so he could still go back with me and to go back to the same hotel. I tell the story about my sister being with me on the second trip and knocking on the door and saying - greeting me and saying, how could you have come back to this crummy hotel?

And I said - looked at her and said, I don't remember. So I didn't remember going the first time. And the hotel was very - the rooms were very tiny. And we have joked about this as being a part of the memory that just wasn't there.

NEARY: Yeah. One other thing, in preparing for the procedure - it means do you have to get ready for this procedure? Is there anything…

Ms. DUKAKIS: I mean, one should never drink and one doesn't eat the day of, you know, right before going under because there is anesthetic, so that most treatments take place in the morning. And I, usually, am the first patient and I go in very early at 7:30 in the morning or 7 o'clock, I guess it is. And I am out usually by 8:30, and I'm my way home. And sometimes, I'm tired that first day and I'll take a nap, and other times, I have spoken in the evening of the day I've had surgery.

NEARY: And one other thing, do you follow this up with other kinds of therapy or other medications as well? Or…

Ms. DUKAKIS: Many people do. I had such unpleasant experiences with antidepressant's side effects. And I continued for a very short period of time, and some of those side effects came back. And a decision was made in concert with my doctor that I would not continue with them. So I have not been on antidepressants since, basically since I started ECT.

NEARY: Your struggles with depression and your addiction to alcohol has become very public. But did you have any hesitation about going public with this? Was this…

Ms. DUKAKIS: Not at all. I tell you, I felt so strongly that one - that the stigma needed to be removed from this treatment that is so successful with so many people - that so many were out there suffering; that there were huge numbers of suicides that could have been helped with this treatment; that women, who are pregnant, who don't wish to take antidepressants, can use this treatment; that elderly, who are having difficult times with depression and not able to get out of bed, find this treatment very successful.

So that I wanted to talk about this, and was fortunate in having a superb co-writer in Larry Tye, who was able to talk about the history and all of the technical sides to the treatment, and wanted very much to write the book.

NEARY: Well, thanks so much for being with us, Mrs. Dukakis.

Ms. DUKAKIS: Thank you.

NEARY: Kitty Dukakis is the wife of former Massachusetts governor and former presidential candidate Michael Dukakis. She joined us by telephone from her home in Massachusetts.

And joining us now is Larry Tye. He's a medical journalist and the co-author, with Kitty Dukakis, of "Shock: The Healing Power of Electroconvulsive Therapy." And he joins us by phone from Boston. Welcome to the show.

Mr. LARRY TYE (Co-Author, "Shock: The Healing Power of Electroconvulsive Therapy"): Nice to be with you.

NEARY: All right. We just have a couple of minutes before we go on a brief break. We're going to hold you over after that break. But quickly, if you can, just give us a little sense the early days of electroconvulsive therapy, when it was known as electroshock therapy. Who came up with this idea?

Mr. TYE: It was originated in Rome by a physician there who had tried it. He had noticed an effect when they were analyzing the brains of schizophrenics, and have noticed that schizophrenics who had had convulsive - convulsions, naturally occurring epileptic convulsions, it seemed to have an effect on alleviating schizophrenia. And it was first tried in Italy in the late 1930s.

Throughout the 1940s and '50s, it became the treatment of choice in psychiatric hospitals all around the world. And it was largely because there was nothing else available. It was used widely. It was used - probably overused in more hospitals than not, at too many dozes, too high a frequency. That was the only things that was available then. This is in the days before psycho-pharmaceuticals. So throughout the 1940s and '50s, it was the most widely used psychiatric treatment around the world.

NEARY: And it was thought to be a cure-all of…

Mr. TYE: It was thought to be a cure. Today, we're much - we do it in a different way and with a far greater sense of its potential possibilities and limits.

NEARY: We're talking about electroconvulsive therapy. And we're going to continue our discussion with Larry Tye after a short break. We'll get a view from inside the medical community as well. You can join us at 800-989-TALK and you can send us an e-mail, the address is talk@npr.org.

I'm Lynn Neary. It's TALK OF THE NATION from NPR News.

(Soundbite of music)

NEARY: This is TALK OF THE NATION. I'm Lynn Neary in Washington, filling in for Neal Conan. We're talking today about shock therapy, known medically as electroconvulsive therapy. The treatment has come a long way from the days of "One Flew Over of the Cuckoo's Nest," but there are still critics. They say it's used too often or the risks aren't made clear to patients. We'll talk with a psychiatrist about that in a moment.

Right now, Larry Tye is with us. He's co-author of the book "Shock: The Healing Power of Electroconvulsive Therapy." If you or someone you know has undergone electroconvulsive therapy, we'd like to hear from you. Let us know, did it work? Were there any side effects? Give us a call at 800-989-8255.

Larry Tye, at some point - you were describing before the break that at a certain point, this was thought to be a cure-all. It was the most widely used psychiatric treatment. But the tide turned. What happened? Why did the tide go against this? People really started to think of it as a bad thing after a certain point.

Mr. TYE: Sure. Two things happened. One is that psycho-pharmaceuticals - all the antidepressants and the anti-psychotic drugs - came out, so much easier for anybody to contemplate popping a pill than going in and getting a surgical procedure of having electricity zapped into their brain. So much more appealing and easier process with drugs - the other thing that happened was, partly because of actual overuse and misuse of the procedure, and partly because of the way the media and more importantly books and movies portrayed it, it came to be seen as a brutal form of torture.

And the movie that most captured that image was "One Flew Over the Cuckoo's Nest," based on Ken Kesey's book. And the movie, starring Jack Nicholson, showed a very dramatic image of people being levitated off of the table and really given some sort of brain damage by having electroconvulsive therapy.

NEARY: Pretty much stigmatized it for many, many years.

Mr. TYE: Did stigmatize it. There's an irony, though, about the movie. First, the fact that Ken Kesey - if anybody should have known what ECT was really all about, then it was Ken Kesey, who wrote the book that the movie was based on, and had worked in a California psychiatric hospital, and had helped - as an orderly - had helped administer ECT. So he knew that even at that early phase, it was being administered with muscle relaxant that would prevent the kind of body jolting procedure that was portrayed in the book and the movie, and it was not being done with anesthesia and with oxygen to protect the brain against damage. So it was being done in a more benign way even at the time that the movie was portraying a torturous form of treatment.

NEARY: Larry, I know you have to catch a plane. Do you have some time to stay with us a little bit and take some calls?

Mr. TYE: I do.

NEARY: Okay. I'm going to bring in Sarah Lisanby into the conversation now, Dr. Sarah Lisanby. She is the chief of the Brain Stimulation and Neuromodulation Division at Columbia University. She is also the chairperson of the American Psychiatric Association's Committee on ECT and Related Electromagnetic Therapies. Dr. Lisanby is with us from a studio at New York Presbyterian Hospital. Thanks so much for being with us, Dr. Lisanby.

Dr. SARAH LISANBY (Brain Stimulation and Neuromodulation Division Chief, Columbia University): Thank you for having me.

NEARY: Let me ask, is this procedure for everybody or should it be used as an absolute last resort?

Dr. LISANBY: Well, there are particular indications that we look for in deciding whether ECT is right for each particular person, so I would say it's not for everybody, but it is a treatment that does help a significant proportion of people as even when other treatments like psychotherapy or medications may be failing. One of the great excitements about ECT, that it can offer hope when these other less invasive treatments fail.

NEARY: Did this treatment go through something similar within the medical community, as happened in the larger culture, that is it fell out of favor and is now being looked on slightly differently again, or?

Dr. LISANBY: Well, I think that's a good parallel. I mean, the medical community is part of the larger culture, isn't it? And so there's a bit of a parallel process when psychotropic medications became available, as Larry Tye mentioned. The medical community began to realize that actually, antipsychotic medications are much more effective for schizophrenia than ECT is.

And in the case of schizophrenia, ECT is really used later on in the course of illness when the condition is refractory to most medications. But it was discovered in the medical community that depression responded much more readily to ECT than did schizophrenia. And that took several decades to figure out and that helped to refine what we now consider the indications for ECT. And now, the leading indication for ECT is depression.

NEARY: We're talking about electroconvulsive therapy. If you'd like to join the discussion, our number is 800-989-8255. Let's go to a call now from Jenny. She is in Grand Rapids, Michigan. Hi, Jenny.

JENNY (Caller): Hi.

NEARY: Go ahead.

JENNY: I just wanted to comment. I started having ECT back in October of '06 and it did worked really well for me. It really helped. I was at a point where I had to check myself into a hospital. And - but now, I'm to a point I go once a month and the recovery process has just become so exhausting that I don't feel that I can keep it up.

NEARY: What do you mean by that? Maybe you could explain what…

JENNY: I don't wake up from it well. Coming out of the anesthesia, my mom will hear me screaming quite a bit in recovery. And I have to be given additional, like Ativan, something to calm me down.

NEARY: So it started to work, but now it's not working? I wonder, Dr. Lisanby, if you can comment on that? Or, if you - if this is a common kind of thing to happen?

Dr. LISANBY: Well, what you seem to be describing might be called postictal agitation, which is a phenomenon that we occasionally see when a person is waking up from the anesthesia, right after the ECT. And before you're fully awake, there may be some disorientation or agitation, and we call that postictal agitation. And that is usually treated by giving Ativan or some medication at that immediate recovery period. But that doesn't necessarily mean that the treatment isn't working. I think the question is whether the treatment is helping keep the depression at bay, and what your describing is…

JENNY: It is doing that. It's just I'm getting to a point where it seems the side effects are greater than the effects of not having the depression.

NEARY: So we heard earlier - we heard from Kitty Dukakis earlier saying, for instance, with the memory loss that it was - what she got from ECT seemed to benefit her more, so that she was willing to take on the side effects of memory loss. It wasn't - didn't seem so bad. But you're saying it seems to be going in the other direction for you.

JENNY: Right, right. And I've kind of been seeking out some more alternative means, looking at some more holistic approaches.

NEARY: Okay. Well, thank you for your comments, Jenny. And I don't know if there's anything more you can say about that, Dr. Lisanby, while Jenny is still on the line.

Dr. LISANBY: Well, you know, it's difficult to know without knowing the exact medical details. But I can say that in cases that we've seen with postictal agitation, sometimes this can be effectively treated by changing the dosages of the anesthesia so that the recovery period is more smooth, and so that you wake up more smoothly without having that period of agitation. But again, it's hard to comment without knowing the details for each individual person.

NEARY: All right. Thanks so much for your call, Jenny.

JENNY: Thank you.

NEARY: Appreciate it. Larry Tye, we were talking earlier with you about sort of this sort of cultural attitudes towards this. I'm curious - what got you interested in this, and looking at it again, perhaps, from a different perspective yourself?

Mr. TYE: Sure. Lynn, I think that journalists assume - particularly, if they have a specialty like medicine - that they know the trends going on in the medical world. And I was really surprised when Kitty came to me and was looking for a partner, and bring the book. I wasn't interested originally. And then, I started looking into some things about ECT and found that it had made this extraordinary, subterranean comeback.

ECT today is as common as a hysterectomy and twice as common as knee replacement(ph) in America. And yet, as somebody who was covering medicine fulltime at that time for the Boston Globe, I had no idea that it was back and was being used as widely. I also had no idea that all the leading medical authorities, from the surgeon general to the American Psychiatric Association, seem to be saying that this was the singly most effective treatment in psychiatry.

And my image of it was as a brutal form of treatment that had gone out with the "Cuckoo's Nest." When I found out that it wasn't, I wanted to know why and why a stigma remained that caused the treatment to be underused.

And of course, most importantly, we're not - we didn't write the book, saying that people should be getting ECT. We said that it ought to be available if they wanted it and it shouldn't be a treatment where the stigma of the treatment was even worse than the stigma of the disease that was underlying it. So that people - what Kitty is coming out and doing is saying, if you're getting it and if it's working for you, you shouldn't be embarrassed to acknowledge that you're getting it. And it will work to some people. It has side effects that seem overwhelming for others, and everybody who's got to make the personal decision of whether to use it or not. But the idea that it is out there and available and being used by people, to me, was intriguing.

NEARY: All right. Well, thanks so much for being with us today, Larry.

Mr. TYE: Thank you.

NEARY: Larry Tye is the co-author of "Shock: The Healing Power of Electroconvulsive Therapy." And Dr. Lisanby, we've talked about memory loss being one of the side effects. We just heard a caller talk about the fact that she has some problems when she comes out of the actual procedure. Are there other medical risks associated with this?

Dr. LISANBY: Yes. The risks can be divided into those that come from the anesthesia itself and those that come from the seizure that's induced by the ECT. And - going under general anesthesia has risks that are well known and they're the same as for brief surgical procedure.

But the parts of the risks that are specific for ECT have to do with the seizure. And the seizure can cause the heart rate to go up. It can increase the blood pressure. These effects are short lived. But if a person had serious heart disease such as having heart attack or myocardial infarction within a few weeks prior to the procedure, that would be an issue.

So before anyone goes through ECT, they receive a full medical evaluation to look and find out if they have any medical risk factors for complications from the treatment - and cardiac is one of the areas that we pay a close attention, too.

Common side effects from ECT besides memory loss can include headache. You can get some muscle soreness after the treatment. You can feel fatigued. You can have some nausea, which often happens after you have anesthesia. Most of those are short-lived side effects, but the side effect that seems to be most concerning for people receiving ECT is the memory loss.

NEARY: Let's take another call now from Robin(ph). She is calling from Oakland, California. Hi, Robin. Go ahead.

ROBIN (Caller): Hi. How are you?

NEARY: Good.

ROBIN: Thank you very much for letting me contribute to this discussion. I'm really thankful that somebody like Kitty Dukakis has come forward and talked about her experience with ECT. I, myself, am 45 years old and have had major depressions for the last 20 years of my life. I went through about three major depressions. And on the last one, the antidepressants that I had been taking no longer worked. And I really was up against what was going to be next.

And the only option that seems like it would work would be ECT. Then, it was an agonizing decision to make because I was scared and had only had, you know, the - sort of the description of it from a movie like "One Flew Over the Cuckoo's Nest." But I finally decided to make it and it was something that works very well for me.

NEARY: And do you still - are you continuing with the treatments now?

ROBIN: No. No. I only had it once. And thankfully, I've not had to revisit that. It doesn't mean that I won't. You know, you're always sort of vigilant about those things. But I do want to say that I think, probably, the people who are most vehemently opposed to ECT are people who have never in their life experienced the kind of sadness and the kind of hopelessness that clinical depression brings upon someone. And without having experienced that, I don't think you can really be in the position to say people shouldn't…

NEARY: Yeah. And I think that we heard the same thing from Kitty Dukakis that this is a lifelong problem she was dealing with, and that finding something that could help her made it possible to do something that she was afraid of. And maybe Dr. Lisanby, you can talk a little bit about that. Who best - is it only people who are suffering from depression that this can be useful for or are there other mental illnesses or emotional illnesses as well? And Robin, I want to thank you, by the way, for participating in, for your call.

ROBIN: Thank you very much.

NEARY: Okay. And I just want to remind our listeners that you are listening to TALK OF THE NATION from NPR News. Dr. Lisanby?

Dr. LISANBY: So to answer your question, depression is the primary indication for ECT, but it can also be used in other conditions and is used on other conditions. For example, bipolar disorder also called manic depression, when a person has periods of depression, but also has periods of mania where their mood is very elevated. They have excessive energy. And ECT can be effective in treating the depressive episodes in bipolar disorder. And also, if the manic episodes don't respond to medications, ECT can be effective there as well.

We talked about schizophrenia earlier, and ECT is still used in schizophrenia, though, less commonly. It's more used when most of the medications are not working for severe schizophrenia. But it can be helpful there.

ECT is even used in other conditions on occasion, for example, Parkinson's disease. The neurological disorder that causes tremor sometimes is not effectively treated with medications alone. And ECT can induce pretty dramatic improvements in the tremor of Parkinson's disease. Sometimes, people with Parkinson's also are susceptible to depression. And in those cases, ECT can be helpful with both conditions.

NEARY: Is this covered by insurance, by the way?

Dr. LISANBY: Most insurances do cover ECT. Medicare does cover ECT.

NEARY: Okay. And I was also wondering - are you still there, Doctor?

Dr. LISANBY: Yes.

NEARY: Okay. I was also wondering, Dr. Lisanby, I was curious about in terms of the memory loss, can it affect you later in life when you're older? Can that memory loss become worse? I mean, we know that older people have problems with short-term memory, things like that. If you have ECT when you're younger, could it come back to haunt you later on in some way?

Dr. LISANBY: Well, that's a very interesting question. The pattern of memory loss and recovery from memory goes on the opposite direction from what you're suggesting. So, let's say someone has ECT when they're 25. Then, in the weeks to months to years after their course of ECT, the memory tends to improve, so it doesn't go in the opposite direction. It doesn't get worse with time. It tends to improve the further you are out from when the ECT was given.

I think your question is whether having it earlier in life could affect later life risk for memory disorders. There is no evidence of that. But I would say that if you receive ECT later in life in the presence of an already existing memory problem such as dementia, or age-related memory loss, evidence suggests that if you already have some memory loss from dementia, you may be more at risk for some of these cognitive side effects of ECT.

That being said, however, later in life, depression does occur and it can happen in people with dementia. And in some cases, if medications aren't effective, ECT can be used in those situations.

NEARY: Thanks very much, Dr. Lisanby. Dr. Sarah Lisanby is the chairperson of the American Psychiatric Association's Committee on ECT and Related Electromagnetic Therapies.

You're listening to TALK OF THE NATION from NPR News. I'm Lynn Neary.

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