Electroconvulsive Therapy

The Return of Electroshock Therapy Can Sarah Lisanby help an infamous form of depression treatment shed its brutal reputation? John Cuneo DAN HURLEY DECEMBER 2015 ISSUE | HEALTH Like The Atlantic? Subscribe to The Atlantic Daily, our free weekday email newsletter. Email SIGN UP NE MORNING in early October, on her final day as the chair of the O psychiatry and behavioral-sciences department at the Duke University School of Medicine, Sarah Hollingsworth Lisanby ushered me over to a display case in one of the department’s conference rooms. There, behind glass, sits the world’s only museum, such as it is, of electroconvulsive therapy (ECT), or what most people still call “shock therapy.” The oldest artifacts on display, some of which are made of polished wood and brass, date to the late 19th century, when electrical stimulation was promoted as a cure for a host of ailments. A mid-20th- century relic labeled ELECTRO SHOCK THERAPY EQUIPMENT features a red button in the center helpfully marked START SHOCK. In the popular imagination, ECT—the application to the scalp of an electrical current strong enough to induce a brief seizure—is an archaic practice that might as well be relegated to a museum collection. But according to Lisanby and other leading researchers, the modern version of ECT, far from outmoded, is the most effective therapy available for severe, treatment-resistant depression and bipolar disorder (and even sometimes, when deployed early enough, schizophrenia). No one knows exactly why ECT works—there are many theories—but numerous studies have established that it does work: The vast majority of severely depressed, even suicidal, patients feel much better after a course of treatment. Many experience a total remission. Refinements over the past few decades, moreover, have dramatically reduced the temporary memory loss once associated with ECT. And yet, due largely to the stigma surrounding the treatment, only a tiny fraction of the millions of Americans with depression unresponsive to psychotherapy or medication ever receive it. Lisanby, who was recently named the director of the National Institute of Mental Health’s division of translational research, has devoted her career to what you might call a kinder, gentler form of ECT. At 50, she has green eyes that convey the intensity of an adolescent science nerd—albeit one who happens to be nearly 6 feet tall, and wearing knee-high boots and a wool lab coat. As we talked, she told me that she blames ECT’s nasty reputation partly on movies like One Flew Over the Cuckoo’s Nest. Set in a psychiatric hospital, the 1975 film includes a harrowing scene in which Jack Nicholson’s character is held down by orderlies while he suffers violent convulsions as a result of a shock. “When you see modern ECT done,” Lisanby said, “it’s nothing like the negative portrayals in the movies.” She ticks off some of the differences: “We use anesthesia and muscle relaxants, so there’s actually no motor convulsions. It’s like any other medical procedure.” In the manner of someone used to testifying before panels and speaking at scientific meetings, Lisanby has a ready command of the statistics: Some 35,000 Americans commit suicide every year. Depression is a leading cause of disability —the leading cause, according to the World Health Organization. But still, ECT’s dismal reputation persists, not just among the public but among medical professionals, too. “Stigma,” Lisanby told me, “is something that even doctors are not immune to.” S A MEDICAL STUDENT at Duke in the late 1980s, Lisanby witnessed A firsthand the effects of electroconvulsive therapy on a woman whose depression had advanced to catatonia. “She was mute, had stopped eating, was just wasting away, and was going to die from her depression, it was so severe,” Lisanby recounted in an oral history. “She got ECT and the afternoon of her first treatment she started talking, and I thought, This is a miracle.” Following her residency, Lisanby took a fellowship under Harold Sackeim, the chief of biological psychiatry at the New York State Psychiatric Institute. Sackeim had been developing a method to reduce the memory loss associated with ECT by modifying the way electricity was delivered to patients. In 1994, the year before Lisanby joined his lab, Sackeim published a paper proposing that side effects could be reduced further by replacing electricity with magnets. Whereas electricity is blunted and dispersed by the scalp and skull, magnets generate an electromagnetic field unimpeded by either one. Sackeim supposed that they might therefore be used to induce seizures in specific regions of the brain—thereby avoiding the hippocampus, which plays an essential role in memory formation. He asked Lisanby to work on turning his idea into a functional prototype. In the popular imagination, ECT is an archaic practice that might as well be relegated to a museum collection. After several years of collaboration with researchers around the world, Lisanby had put together a magnetic device that she believed would be capable of inducing seizures in humans; all she needed was a person to test it on. A 20-year-old Swiss woman whose depression had not responded to standard treatments volunteered, and in April 2000, Lisanby shipped her heavy, one-of-a-kind equipment to the University of Bern. She was about to fly over herself when one of her Swiss collaborators, Thomas Schlaepfer, called. “I have good news and bad news,” he told her. “The device arrived, but it’s in a thousand pieces.” With just days to go before the procedure, Lisanby had to lug some of the replacement parts in her baggage. “Luckily it was before 9/11,” Lisanby recalled, “so the oscilloscope went right through security.” Schlaepfer told me that he and Lisanby were nervous before the procedure. “There was still an edge in me saying, It might be dangerous. Did we calculate everything correctly?” he confessed. “But it went absolutely fine.” The patient had four sessions of magnetic seizure therapy and eight regular ECT sessions, then went into full remission. Multiple studies later, magnetic seizure therapy appears to be about as effective as ECT in relieving depression, while causing almost no discernible memory loss. Even so, the treatment remains unapproved for use in Europe and the U.S. The problem is that the small companies that build magnetic-seizure-therapy devices have not undertaken the kind of large, randomized trial the FDA would require before approving them for use outside of studies. Lisanby, however, has recently completed a new trial that she hopes will keep the ball moving. In 2005, Lisanby became the founding director of Columbia’s division for brain stimulation and neuromodulation. By the time she moved to Duke in 2010, she had co-authored some 150 scientific papers and book chapters and served as president of two international professional organizations on brain stimulation. When the FDA held a hearing in 2011 to consider reclassifying ECT from Class III, its highest risk designation, to Class II, Lisanby testified as the chair of an American Psychiatric Association task force on ECT. “I’m here to deliver one critical point,” she told the panel. “Depression kills, while ECT saves lives.” She rattled off statistics. She reviewed decades of data. And, on a more personal note, she added, “I’m also the family member of a person whose life was saved by ECT.” Each time Lisanby walked in and out of the room that day, an anti-ECT advocate in the audience made a buzzing noise, in an effort to imitate an ECT device. (In fact, the devices make no such sound.) In the end, despite all the testimony from Lisanby and many others, and despite the evidence from randomized trials involving hundreds of patients, the panel did not recommend reclassification. O BE FAIR, the reality of ECT early on—when stronger, less targeted jolts of T electricity were given without the benefit of anesthesia—was brutal. But today, Lisanby and other leading practitioners insist, memory loss tends to be relatively mild. The treatment’s chief drawback, for now, is that without maintenance therapy (whether drugs or more ECT), its benefits last many patients only about six months to a year. So why aren’t more doctors prescribing ECT? “Why indeed,” says Thomas Insel, the recently departed director of NIMH who recruited Lisanby. (He is headed to Google Life Sciences, which is looking to expand into mental-health care.) “If we were talking about Alzheimer’s, and I had a treatment that would largely resolve the major symptoms within six weeks 80 percent of the time, and then I told you this treatment is not accessible in many parts of the country and rarely used where it is available, you would say that can’t be.” Insel hired Lisanby, he told me, in part because she has “a modern view of mental illness.” Through the 1970s, mental illness was seen as resulting primarily from early trauma and adverse experiences; the treatment was psychotherapy. Beginning in the 1980s, it was regarded as an imbalance of neurotransmitters, best treated with medication. “Depression kills, while ECT saves lives.” Lisanby, he continued, “brings the contemporary approach: It’s a disorder involving changes in brain circuitry.” This understanding points to the limits of drug-centered therapy; medications cannot target discrete brain circuits. Moreover, Insel said, Big Pharma presently has little appetite for developing new psychiatric drugs. The excitement he sees in the field these days is around brain stimulation. Thanks to Lisanby and others who have focused attention on this “third option,” Insel explained, “we’re in a new era.” As her final day at Duke wound to a close, Lisanby sat at a conference table, surrounded by students, faculty, and staff, listening to one of them present some new data.

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