The rise and reform of shock therapy

AUSTIN (KXAN) - The police officer’s radio crackled to life as he reported Mary Anne Dale’s faint pulse to the paramedics. Relieved, Dale’s son, David Clemons ran up the stairs of his mother’s house.

Dale’s body was motionless and chilled - sprawled on the carpeted floor of her bedroom. Her skin was drained of color. Desperate, un-oxygenated tissue in parts of her body had already withered and died.

The previous Saturday, Dale, 70, could not decide what to pack. She had agreed to attend the Contemporary Forum’s conference on nursing with a colleague. But now, the mounting depression from an unwanted divorce, an isolating private practice as a psychiatric nurse, the recent death of her best friend and festering childhood traumas immobilized her.

Instead of packing, Dale wrote out a lengthy note to her grown children and swallowed 60 pills of benzodiazepine. Her son, escorted by police, discovered her two days later, when she was rushed by an ambulance to University Medical Center Brackenridge in Austin, Texas. Doctors pronounced a 50% chance of death.

Dale survived - barely. Within seven days, she was released from the intensive care unit of this hospital, wheelchair bound with uninterrupted symptoms of depression. After psychological counseling and anti-depressant medications failed, Clemons, who had grown up enduring his mother’s recurrent suicide attempts, talked to Dale’s psychiatrist about administering electroconvulsive therapy.

Better known as its stigma-shrouded alter ego: shock therapy.

During this treatment, electrodes are placed on the patients’ head and currents are fired through their brains, inducing seizures to relieve major depressive disorders. For decades, the early version of this treatment as a bone-snapping memory-shredder would be its claim to controversy. Throughout the 1950’s, the use of ECT declined with the advent of early psychiatric medications, allowing researchers to improve upon this treatment. Today, as a refined version of electroconvulsive therapy bears new promise in the medical field, the number of people who seek this treatment nationwide swells.

'A quiet comeback'

In the United States, an estimated 100,000 people receive electroconvulsive therapy every year, according to the National Mental Health Association .

In 2008, MSNBC.com reported that this treatment was making a “quiet comeback,” as the number of people who use it yearly has tripled since the 1980’s. Dr. Mustafa Husain, a psychiatrist and researcher from UT Southwestern in Dallas , says that the current, modified version of ECT is unmatched in effectiveness for psychotic, melancholic, catatonic, and acutely suicidal patients.

“The surge that you see in the late 90’s, early 2000’s, was because all these anti-depressant medications, their combinations, were not as effective in patients with major depressive disorders,” Dr. Husain says. “ECT is probably the best treatment in this sub-patient population.”

Opponents of ECT refute the “comeback” of electroconvulsive therapy in its new, shiny outfit. They contest it as a cruel treatment that erases the memories of its unsuspecting patients and point to the high relapse rates of depression in ECT patients. Dr. Michelle Magid, ECT director at Seton Shoal Creek Hospital, acknowledges that “the biggest thing that people still complain about is the cognitive side effects, and it’s real. People are really confused during that month of ECT and probably a few weeks afterwards, sometimes up to six months afterwards.”

Clemons remembers how this treatment had rescued his mother from depression once before. In 1986, Dale, who had recently recovered from alcoholism and lost her job, slid into a catatonic stupor. Her gait was sluggish, her stance – hunched.

She was a vortex that sucked the happiness out of a room, says Clemons.

After anti-depressant medication and talk therapy had failed, she received electroconvulsive therapy to treat her depression at Seton Shoal Creek. Clemons remembers a frightening, child-like version of his mother when he went to visit her in the hospital after the first treatment – himself, a confused 23-year-old.

“I just remember that though she seemed relieved and not so depressed, she was also… out of it,” he says. “She really wasn’t fully oriented and so, it was rather disturbing.”

Dale received bilateral ECT during that treatment, in which the electrodes are placed on opposite sides of the front of the head. Dr. Magid says that this form of convulsive therapy causes the most severe side effects, including disorientation and memory loss. But, she says, it’s also the effective.

Two weeks after her first treatment, Dale rose like the phoenix from her own ashes: a content version of herself who continued to monitor her mental health, attend her AA meetings, and take on several jobs at once – until the evening of March 29, 2009, when she reminded her children of her financial assets in her suicide note.

Now, Clemons gripped the delicate reigns of his mother’s

life as she lay in the intensive care unit, and together with her psychiatrist, convinced his mom to undergo this procedure that had already once saved her life. Initially Dale refused.

“When a person is in that type of depression, they will sometimes work against you for the very thing that would help them,” Clemons says.

On Mother’s Day of 2009, his mother relented, and started her second treatment of electroconvulsive therapy.

An ongoing debate

The treatment was born in 1938 out of Ladislaus von Meduna’s experiments to treat schizophrenic patients. Since then, the original treatment has been cast in the media as a Frankenstein incarnate due to its adverse side effects. Looming large in the public imagination is the 1975 movie, One Flew Over the Cuckoo’s Nest, in which actor Jack Nicholson as mental patient Randle McMurphy is seen writhing painfully from a medically induced seizure to cure his behavioral problems.

Moreover, former ECT patients decry this treatment. Before writer Ernest Hemingway shoved a shotgun against his throat in 1961, he offered: “What is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business?” Likewise, in 1996, former Baywatch actress and Playboy model Melissa Holliday told the Houston Chronicle : "I've been through a rape, and electroshock therapy is worse.”

According to Dr. Husain, modified electroconvulsive therapy has greatly improved this treatment’s safety. With the use of anesthesia and muscle relaxants, ECT patients are no longer wide-eyed and thrashing during the procedure – rather, they are given bite blocks and oxygen after falling into an anesthetized sleep. Doctors report only a mild twitching of their feet throughout the 20-minute treatment.

Modified, unilateral ECT targets a single, non-dominant part of the brain to decrease the memory loss associated with the previous, bilateral method. In addition, patients are now given an ultra-brief pulse of electricity, shortening the duration of the seizure-inducing electric current.

“There are people (patients) who claim that their memories are wiped out forever... So that’s what the field is truly trying to address,” Dr. Husain says.

Supporters within the medical field acknowledge the ongoing limitations of this procedure: memory loss and high relapse rates. But as research continues, and improvements become clear, doctors feel more confident about using ECT. Dr. Harold Sackeim, chief of biological psychiatry at the New York State Psychiatric Institute , says:

“It has a much greater scientific respectability. It’s no longer just thought of as sort of blindly kicking a box, you know, resetting a machine. We have a much finer understanding of the treatment and so that engenders greater confidence in it.”

Opponents of shock therapy emphasize that science cannot pinpoint exactly how this procedure works. They also argue that ECT causes brain damage, and that controlled clinical trials show no advantages in receiving the actual treatment, as psychiatrist Dr. Peter Breggin contends in his book Brain Disabling Treatments in Psychiatry . Dr. Breggin also refers to a study from 2007 of permanent ECT-induced memory loss in patients to be consistent with dementia.

Others argue that ECT is not “back” – it never went away.

Neurologist John Friedberg, author of Shock Treatment is Not Good for your Brain , attributes the surge in patient numbers to forced treatments. He says: “What has happened is that its advocates have grown more arrogant and the number of patients forced to undergo ECT against their will is increasing.”

Similarly, former ECT patient Linda Andre argues against the concept of “modified” ECT. In her book, Doctors of Deception , Andre argues that updates such as anesthesia have increased the patient’s risk of death during the procedure.

“The use of anesthesia in and of itself is associated with a small risk of death; with ECT, since the anesthesia is repeated on a dozen or more occasions, this risk is additive,” she writes.

In 2009, Seton Shoal Creek was the scene of 834 electroconvulsive therapy treatments on 83 patients.

“We have an 80% success rate,” Dr. Magid says. “We get the sickest patients for whom everything has failed: medication has failed, talk therapy has failed. Of those patients, 80% of them get better with ECT.”

Dr. John Breeding, an Austin psychologist, leads the group Coalition for the Abolition of Electroshock in Texas . In 2006, his organization rallied against Seton Hospital’s use of electroconvulsive therapy to treat patients.

“ ‘Side effects’ to me is a euphemism,” Breeding says.

Moments before, a radio interview he had done for "Free Radio" streamed from his computer at his home office. Ever cognizant of campaigns, Breeding spins his own.

“Drugs and treatments have effects. The ones that are desired are called ‘good effects’ and the others are called ‘side-effects.’ (Electroconvulsive therapy) is very damaging, and it doesn’t even really

work, even by the standards of those who believe in it.”

The Texas Legislature agreed that ECT was unfit for children under the age of 16, and banned the treatment for this population in 1993. The state also endorsed strict laws to monitor the use of this procedure in the adult population, including annual reports that are submitted to the governor and members of the Legislature.

When state records revealed an elevated death count of ECT patients in 1995, Rep. Senfronia Thompson, D-Houston , sponsored a bill in the House that would ban electroshock therapy in Texas. The committee hearing included testimony from 150 shock patients – split evenly between advocates and opponents of the treatment. The bill died in committee in 1995, but was reintroduced in 1997 by a persistent Thompson and Republican Sen. Jerry Patterson , now the Texas Land Commissioner. The legislation failed again.

Thirteen years later, Texas has yet to approve a statewide ban on this treatment. But the medical field still bears the weight of legal restrictions enacted in 1993. Some ECT doctors believe the laws are too limiting and should be re-evaluated.

Dr. Magid acknowledges that the legislation came about due to past abuses in the medical field – not just in psychiatry.

But she still contends: “To globally say, ‘absolutely nobody under 16 should get ECT,’ you’re missing a few patients (for which) it really could be life saving.”

Dr. Husain, who acknowledges that he is a scientist and not a politician, believes that research supports the selective use of this treatment for children, and asks: if 48 other states approve this treatment for children under the age of 16, why not Texas?

An old monster

During her lobbying years in Austin, she was known as Dianna Loper, The Founding Mother for the Ban on Shock.

She bourgeoned as a lobbyist under the guidance of the former Texas Speaker of the House, Billy Clayton. In 1993,when she found out doctors were using ECT to treat children, her lobbying firm, Legislative Advocates, organized groups including the World Association of Electric Shock Survivors and the Church of Scientology to successfully ban this procedure on children. Her firm would continue lobby for the ban of ECT in Texas for more than five years.

In the spring of 2010, a remarried Dianna Posthauer was gearing up to visit her old friends at the State Capitol in Austin for round three of trying to ban electroshock therapy in Texas.

“You know the one thing that they can’t figure out is the brain. That’s the one thing they don’t get. So we are shooting electricity through something we don’t get, hoping and praying it works,” she said.

Her former life as a firecracker lobbyist was re-claiming its hold on her as she discussed her extreme disapproval of ECT – a treatment that snipped her life in half: Pre and Post-shock.

But a few weeks later, Posthauer is spent. Age, like an unwanted filibuster, has worn her down.

“Shock treatment, literally took over my life,” recognizes the former ECT patient. “But I’m 64, and I’ve already given literally my whole life for this issue, and I just can’t take anymore. I don’t have the strength physically or mentally to do it.”

As a young mother suffering from post-pardum depression in 1972, Posthauer was forced by her husband and psychiatrist to undergo a “new, experimental” procedure – electroshock therapy.

“I remember being put in the straight jacket and being put forcibly on that table,” she says. In her Houston home, Posthauer reclines on an oversized couch – behind her, a small stone plaque bears a Bible inscription: “I know the plans I have for you, declares the Lord.”

“I remember them jabbing something in my mouth, and then putting these things here,” she says, pointing to each side of her head.

She paused.

“Well, it’s this bolt. This bolt that goes through you … your whole body just convulses.”

Posthauer’s description of the treatment refers to bilateral ECT, the same treatment that Mary Anne Dale received in 1980. Posthauer says that she did not receive any form of anesthesia before or during the procedure, consistent with an earlier, unmodified version of ECT.

Immediately after the treatment, she could not remember how to tie her shoes or drive a car, and was stunned when her mom showed her how to use a washcloth. She also could not recall giving birth to her son or getting married several years prior to the young, evangelical preacher who forced her to get shock therapy.

Dr. Sackeim acknowledges that as with any other medical procedure, a “minority” of patients may experience the side effects from this treatment more extensively than others, “and that’s very unfortunate.”

Forty years after her own treatment, Posthauer continues to bear the effects. Some are "unfortunate”: violent, thrashing seizures and job-destroying dyslexia.

Her short-term memory is held up by thin crutches placed discreetly throughout her house: small, typed labels in her kitchen cabinet that remind her where the cups and plates

live, a sticker on her dryer that reads: ”close dryer door,” Office Depot note cards, on which she measures out in neat, capital letters her daily schedule.

But, as Posthauer acknowledges, her story has been questioned by everyone from her own husband to Oprah Winfrey, when she was a guest on that show in 1993. They argue that the clarity with which Posthauer recounts her past political scrapes, marriages, and even, her ECT procedure is inconsistent with the memory handicaps she describes.

Ex-husband and lifelong friend Bob Loper, who admits to her “scary” seizures and dyslexia, says: “Well, it was really not as extreme as she’d have you think. She still functioned well.” He admits that she would have to write notes to herself and have memory crutches, but that she still “functioned.”

Posthauer recalls her own ECT treatment with empathy for all of the confused, three-dimensional characters involved – most of whom she has forgiven. She offers this emphatic defense about trying to ban the treatment: “I’m not fighting them just to fight them. I’m not destroying every marriage I ever had… just to be out doing that. I’m doing it because it’s wrong.”

Texas laws about ECT still bear the imprint of her lobbying efforts. But for all the years she dedicated to banning shock, large gaps perforate Posthauer’s personal life: an unformed dialogue with her son – with whom she is estranged, the irreparable finality of her past several marriages, an unshakable distrust of men.

In retrospect, she says about the years of fighting against this treatment: “I would leave my Lord, my family, my husbands, and every time I would get ready to come up there (the Capitol), I never had peace about it… I can let down now. It’s okay to let down.”

Before Posthauer clicks off her phone and retreats into seclusion, she says: “Everyone thinks they have the right answer. I’m not sure I have the right answer. But until they show that it’s totally safe without any damage, period, then don’t do it. Period.”

'Waiting for the big breakthrough'

Research is ongoing in the field of electroconvulsive therapy with the intent of developing methods of the treatment that are more effective.

The next step in the trajectory of ECT is to develop ways of inducing the seizure in the patients that target more specific areas of the brain. To that end, researchers are experimenting with a magnetic stimulus, as opposed to an electrical one, which Dr. Mustafa Husain refers to as Magnetic Seizure Therapy (MST).

Dr. Husain admits that MST is in an early, experimental phase and that it has not been FDA approved. But, he says, “the most exciting part of MST is that it does not seem to cause the type of memory problems that are associated with ECT - that demonized ECT. All of these are being studied. Why? Because neuro-stimulation seems to help these severely depressed patients.”

Still, Dr. Sackeim admits that research in this hot area of development will be continuing over the next decade or so.

“Those approaches may be somewhat incremental,” he says. “So I think we’re all waiting for a big breakthrough.”

Meanwhile, Dr. Magid contends that a middle ground must exist between advocates and opponents of the current treatment. She stresses that the existing procedure is only effective in pre-screened patients who match the appropriate diagnosis for the procedure. Magid also emphasized what ECT does not treat: substance abuse, personality disorders, mental retardation or autism.

“We can’t deny that ECT is a very safe and effective treatment, but it’s not for everyone. If you can get the right person to ECT, it can be a life-saving treatment.”

  Life after near-death

On a breezy spring day in Austin, Mary Anne Dale chomps on a healthy lunch of chicken salad and fruit. Jason’s Deli is unusually noisy this afternoon, but she doesn’t mind the break from filing her taxes. The former psychiatric nurse, who has worked multiple jobs at once, spends her days in retirement waking up when she pleases, having relaxed lunches, enjoying her friends, and playing with her grandchildren.

“I mean, the thing is that once you’ve gotten so desperate as I did and you’ve actually tried to kill yourself, you’re not afraid of dying,” Dale says in reference to her 2009 suicide attempt. “What you’re afraid of is living that way. Living as such a miserable human being is just the worst thing that I can possibly think of. “

Dale is a tiny creature whose frequent, full-bodied laughter belies her 70 years of simultaneously engaging in and struggling with mental health. Age touches kindly upon Dale. From the back, she is an athletic 20-something in a fitted leather jacket and jeans. From the front, light creases feather the skin around her eyes and mouth.

“Depression is like your saddest day that you can imagine, multiplied by about 100 times and lasting all the time,” she says in between bites. “Where you never feel happy, you can’t laugh, you see nothing getting better for you. It’s like a big dark hole.