Shocked Out Of Depression
While it remains a controversial medical practice, electroconvulsive therapy is giving severely depressed patients and their families a new lease on life
By Alice Keesing
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Dr. Celia Ona
cause brain damage,” she says, pointing out that untreated depression itself can actually damage the brain.
And sometimes, ECT may be the only therapy that helps.
“People who suffer from severe depression are being tortured (by their illness),” says Hawaii Mental Health Association executive director Marya Grambs. “Severe depression is severe mental anguish and can be truly unbearable, so sometimes, when medications haven’t worked, people try ECT.”
One of the biggest criticisms of ECT is that it can cause memory loss.
The experts say this is exceedingly rare and is usually limited to the time surrounding the treatment itself. Ona, who says she has treated “hundreds and hundreds” of patients since she began practicing in New York, cannot remember anyone she has treated suffering serious memory loss.
But there are exceptions. Honolulu resident Ruth Lee says she received ECT at Queen’s Medical Center in 2004.
“I still have a lot of problems with my memory and it seems to be permanent,” she says.
“I can’t remember what I’m doing, I’ll go to do something and I can’t remember why I’m there. My memory isn’t coming back, and it’s been well over a year.”
Lee says she had no problems with her memory prior to her treatment. But these days, she cannot remember what she needs when she gets to the grocery store; she cannot find her way to places that she used to know well, like her girlfriend’s home. Lee can’t even return to work, because her memory is no longer reliable.
“I’m just not the same person I used to be,” she says. “I mostly just stay at home.”
Lee’s case also raises another difficult issue surrounding ECT - the issue of consent. She never wanted to receive the treatment.
“When I was 26 I was diagnosed as bipolar,” she says. “For a long time I couldn’t watch (One Flew over the Cuckoo’s Nest), I was so afraid that someone would do that to me.”
For Lee, the truth of what happened to her is shrouded by her memory loss. She recalls nothing of being admitted to the hospital - the only hint she has of that day is a photograph of a dinner with her family for her 60th birthday. She has been told she was catatonic and non-responsive. A family member, who was appointed her guardian, gave the approval for the ECT. Since then, Lee has had that guardianship dissolved and has drafted an advance directive stipulating that she not be given ECT again.
One of the biggest concerns about the old form of shock treatment was that it was given to people against their will. And today there are times when ECT is given without the patient’s specific consent. If a patient is too ill to make decisions for themselves, doctors turn to family members to make the decisions for them, using a court-granted power of guardianship.
And, in the case of patients with criminal convictions, doctors do go to court to obtain an “order to treat.”
Hospitals are not required to report ECT treatments, so there are no statistics on how often it is used in Hawaii and how often it is done without the patient’s specific consent.
“I don’t think people out there would be abusing this intentionally,” says consumer advocate Mike Pablin. But he says there could be concern if people are not well-educated on the role of a guardian or on the pros and cons of different treatments, whether it be ECT or psychotropic medications.
“It is a complex issue when you have people who sometimes lose their capacity to make healthcare decisions and then regain it, and who’s going to determine when that happens,” Pablin says. “The court’s role is in balancing the need of the patient with the rights of the patient.”
Queen’s Medical Center did not respond to requests for an interview on ECT.
For her part, Ona says she rarely gives ECT that has been court-ordered.
“It’s not very often,” she says. “In the last year, two or three.
“An order to treat is obtained on very stiff criteria,” she adds. “Someone has to have really injured someone, or be of imminent risk or danger to themselves or to others.”
And often it is the case that patients who have received court-ordered ECT are very willing to continue the treatment once they get better, Ona says.
“Ideally, I always want it to be voluntary, so that the patient understands the risks, the benefits,” Ona says.
Mark Mitchell
Despite the lingering debate over ECT, the not-for-profit Kahi Mohala opened its ECT suite one year ago, signaling its belief that there is a need and demand for the procedure in Hawaii. It’s estimated that 20 percent of the population suffers from depression. Those who are severely depressed make up 5 percent. Do the math on Oahu, and that equates to 50,000 people.
“(ECT) has been around for a long time, it just hasn’t been used much in Hawaii,” says Kahi Mohala executive director Mark Mitchell. “One of the things we wanted to do was make sure it was offered in a convenient way that was easy for people to access.”
Typically, a patient will receive three treatments a week for four weeks. After that, monthly maintenance treatments are common. Right now, Kahi Mohala treats between two and five patients a day on Mondays, Wednesdays and Fridays, and they expect that to grow.
Kahi Mohala staff tout the convenience of their ECT suite, which is located on the hospital’s bucolic grounds in Ewa Beach. Parking is available right outside, they say. Patients can come in the morning and be out in time for lunch. There are some Neighbor Island patients who fly over in the morning for their treatment and go home the same day. They’ve even had Mainland vacationers come in for their maintenance treatments while they enjoy the other pleasures of a holiday in paradise.
Patients range in age from 20 to 80, and there are slightly more women than men. They have treated everyone from a university professor to a physician to a homeless person.
“They’re from all walks of life,”
Mitchell says.
The ECT waiting room is much like any doctor’s waiting room. There is a water cooler and flowers, and magazines such as Ladies Home Journal to flip through. When it’s time for their treatment, patients walk down the hallway to the treatment room. After donning a gown, they lie down on a white-sheeted gurney, their head on a soft pillow. Classical music is playing. The walls are painted in soothing tones of blue and gray. The staff, who take pride in the personal care they offer, wear aloha shirts and look like guys you might see at the beach or mall.
They place monitors that will track the patient’s heart rate, pulse and oxygen saturation. A cuff is wrapped around the right ankle - preventing the muscle relaxant reaching that foot, providing one way to monitor the seizure.
An IV is started in the arm; this delivers the anesthesia, muscle relaxant and any other drugs the patient needs. A bite block is put in the mouth. An oxygen mask is placed over the face. Electrodes are attached on each temple.
“They can refuse at any time, even up to the last second,”
says the recovery nurse Ben Nelson. And that has happened.
When the patient is anesthetized, Ona lifts a safety cover and presses the square, yellow button that delivers the shock.
Fifty joules - about one-quarter of the lowest setting on a defibrillator - travels through the electrodes into the patient’s brain. The shock lasts between 5 and 10 seconds, sending the body into a convulsion that can last as long as one minute.
For the staff in the room, there is no overt reaction in the patient. The right foot might tense or twitch, and occasionally they see some subtle movement in other parts of the body.
“Nothing.” That’s how Karin - who has been receiving monthly maintenance treatments at Kahi Mohala - describes the experience. “You feel absolutely nothing.”
Despite her initial fears about being treated with electricity - “Running an electric shock through your body just seems really crazy,” she says - she is totally at ease with the procedure and knows it has given her back her life.
Ona says there is joy in seeing the patients “before and after.”
She describes one patient, a 70-year-old woman, who had stopped eating, drinking, talking and taking care of herself.
“She was just sitting, staring at the wall,” Ona says.
“They want to die, but once you give them ECT, you see them blossom, they start feeling better and after the end of treatment they put on makeup, they take care of themselves, they’re smiling. It’s actually so dramatic, they start smiling in the recovery room.”
The last testimony in this controversial issue comes from Nira Estrella. In April 2003, her husband of 35 years, Ernest, began to change.
“He could not sleep. He lost his appetite. He started feeling sad. He would pace the floor from sunrise to sunset without sitting down. He would have to hold the walls to balance himself. He just couldn’t rest he was so anxious.” The strain of those difficult times still lingers in Nira’s voice.
Her search for help eventually led to Kahi Mohala where she met Ona, who suggested that ECT could help her husband.
“I refused,” says Nira, who read all the pros and cons of the treatment on the Internet. But as Ernest’s condition worsened, she and her family agreed to try.
“After his very first ECT treatment, he responded very well,” Nira Estrella says. “It was a miracle. He was back to his old self, but better than ever.”
The Estrellas seized onto life again with renewed vigor. They went on cruises. And they learned ballroom dancing, even performing the East Coast Swing jitterbug before an audience of 800 at the Sheraton Hotel.
“It was fun!” Nira Estrella says. Sadly, Ernest Estrella died on Sept. 2, 2005, from bone marrow disease. But Nira is grateful for those last memories.
“If I had not chosen to try ECT, I would not have had those last happy 23 months that I had with my husband,” she says.
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