The Positives and Negatives of Shock Therapy

Medically Reviewed by Cynthia Dennison Haines, MD on September 16, 2004
From the WebMD Archives

In the sometimes bitter battles over electroconvulsive therapy, also called ECT or shock therapy, 41-year-old Lynn Swan, of Cleveland, is a noncombatant. Neither a staunch advocate nor a foe, Swan -- who has bipolar depression -- says the treatment can work, depending on the illness and the individual patient.

After more than 50 treatments, in which electrodes were attached to her skull to electrically induce a seizure, Swan has earned her right to an opinion.

"Even in the minds of good psychiatrists, it's still controversial," she admits. "But I know it works for some people."

But Swan herself reports only mixed success. Over a four-year period, she received ECT treatments at hospitals in Florida and Ohio, typically two or three times a week, followed by termination of therapy for as long as several months. Invariably, she would relapse and need the treatments again.

Today, she no longer receives ECT but instead takes a combination of five and six drugs at a time, including lithium. She continues to experience debilitating amnesia -- a potential side effect of ECT -- and although she says the procedure worked to relieve her bipolar symptoms in the short term, she believes it did not have a lasting effect.

Her experience would appear to crystallize the promise and pitfalls of ECT: rapid, sometimes startling recovery, followed by relapse.

A 2001 study in The Journal of the American Medical Association confirms that when ECT is abruptly halted without follow-up therapy, relapse is only too predictable. Conversely, the study shows, when ECT is followed by aggressive antidepressant drug therapy, patients are much more likely to stay well.

And experts say that for all the controversy the procedure engenders, it is time for ECT to come "out of the shadows."

"Stigma against ECT is a problem," says Richard Glass, MD, deputy editor of The Journal of the American Medical Association. "It's understandable because it does seem like a strange way to treat an illness -- by causing a seizure. But the most important thing is that it works, and it works in patients who don't respond to anything else."

"While it is not a trivial procedure, what people don't understand is that the procedure is done under general anesthesia, and patients are unconscious," he says. "They are given muscle relaxants, so it can be hard to tell a patient is even having a seizure."

Glass says the study shows the importance of prescribing drug therapy after ECT and how it contributes to the overall effectiveness of the procedure.

"What the study shows is that in people who receive ECT, almost everyone will relapse unless they receive aggressive drug therapy," says lead researcher Harold A. Sackeim, PhD, chief of the department of biologic psychiatry at the New York State Psychiatric Institute in New York City.

In the study, 290 patients who completed ECT treatment received either the tricyclic antidepressant Pamelor, a combination of Pamelor and lithium, or an inactive placebo pill. Eighty-four percent of the patients who received the placebo had a recurrence of depression, while 60% of the patients on Pamelor alone had a recurrence. Only 39% of patients who received the lithium/Pamelor combo had a return of severe depression, according to the study.

Sackeim believes relapse after ECT can be cut even further by continuing ECT treatments beyond the standard three-week cycle, tapering the treatments as time goes on. Starting patients on medication at the time of ECT can also help, though he notes that patients should not receive lithium simultaneously with ECT.

ECT practitioners who reviewed the JAMA article say the recommendation makes sense.

"ECT is the only treatment in psychiatry that we give until the patient stops showing symptoms, even though we have known for 65 years that that doesn't work very well," says Max Fink, MD, professor emeritus of psychiatry and neurology at the State University of New York in Stony Brook.

It is reasonable for patients to continue to receive ECT once a week for as long as six months, Fink tells WebMD, in combination with antidepressant medication.

Today, Swan counts herself lucky to be receiving aggressive drug therapy for her bipolar disorder. A volunteer for the National Alliance for the Mentally Ill in Cuyahoga County, Ohio, Swan urges patients to know as much about ECT as possible -- especially side effects like amnesia -- and to consult more than one physician before undergoing the treatment.

"It's a very important decision and not something you jump into because you feel like it," she tells WebMD. "You need to be an educated consumer."