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Wednesday, August 06, 2008

Shock therapy makes a quiet comeback

Dr. Kenneth Melman says that ECT is "the definitive treatment for depression," adding that "There aren't any other treatments for depression that have been found to be superior to ECT."

Dr. Melman is so very wrong but then he and a few of his colleagues with whom I've worked at Farifax Hospital in Kirkland, WA, a Seattle suburb, during the early
1990s, have been reviving this difficult and not always effective modality therapy.

Problems with ECT
ECT has been modified to maximize the benefit and minimize the side effects. The amount of electricity has been decreased, patients are asleep during the process, and muscle relaxants prevent muscle convulsions.

Electroconvulsive Therapy is a shock treatment that induces a grand mal seizure in the brain. These seizures are similar to epileptic convulsions where basically the brain’s electrical pathways all fire at the same time. The seizure alters many chemical aspects of the brain during and after the seizure activity.

For ECT to be effective a series of treatments are required and a seizure must occur with each treatment. The patient typically receives Electroconvulsive Therapy three times a week for two to four weeks (at which time the depression should be gone). After several treatments, changes build up in the brain that relieves the depression. However, the changes in the brain are generally not permanent; CT scans and MRI scans taken before and after ECT show no structural changes in patient brains.

The electricity induces the brain seizure, which lasts from 30 to 120 seconds. After the seizure ends, patients are allowed to wake up in a recovery room, and later go home until the next treatment.

Side effects during Electroconvulsive Therapy include increased blood pressure and pulse as well as irregular heartbeat. As with any procedure that requires anesthesia, there is a small risk of death (about 1 in 100,000). If the patient aspirates (breathes in) saliva or vomit they could develop pneumonia. In about 1 in 2,000 treatments the patient has spontaneous seizures after the end of the treatment.

When the patient wakes up after ECT, they may feel groggy, confused, nauseous, and have a headache and muscle aches. ECT also results in short-term memory loss and an impaired ability to retain new information. For most patients memory problems usually ends a few weeks after treatment ends. However, in some cases long-term memory loss can occur.

ECT may end episodes of depression in about 80% of patients that finish the therapy. However, since the brain changes that occur with Electroconvulsive Therapy are not permanent, there is a strong chance that depression will return. In fact, with no further treatment, 90% of patients relapse in one year. Therefore, patients need further treatments.

What mainstream psychiatrists generally fail to investigate are other approaches to care such as nutrition, orthomolecular therapy or the use of natural treatments such as Leitzin.

see also

This is certainly a real consideration because of the recent story about the move to pills and such treatments like ECT by psychiatrists who are abandoning traditional interactive therapies or psychoanalysis because there is more money and less time involved in a drug based practice. Much of this has been pressure from HOMs and managed behavioral medicine companies.

When Bill Russell tells people that his severe depression was relieved by shock therapy, the most common response he gets is: "They're still doing that?"

Most people might be quicker to associate electroshock therapy with torture rather than healing. But since the 1980s, the practice has been quietly making a comeback. The number of patients undergoing electroconvulsive therapy, as it's formally called, has tripled to 100,000 a year, according to the National Mental Health Association.

During an ECT treatment, doctors jolt the unconscious patient's brain with an electrical charge, which triggers a grand mal seizure. It's considered by many psychiatrists to be the most effective way to treat depression especially in patients who haven't responded to antidepressants. One 2006 study at Wake Forest University School of Medicine in North Carolina found that ECT improved the quality of life for nearly 80 percent of patients.

"It's the definitive treatment for depression," says Dr. Kenneth Melman, a psychiatrist at Swedish Medical Center in Seattle who practices ECT. "There aren't any other treatments for depression that have been found to be superior to ECT."

In fact, antidepressants - the most widely used method for treating depression - don't work at all for 30 percent of patients.

But some doctors and past patients say that the risks of shock therapy, such as memory loss, are too high a price to pay for the temporary benefits.

Despite convulsive therapy's 70-year history, doctors still aren't sure exactly how ECT works to ease depression. What they do know is that ECT works very quickly, with many patients reporting their depression lifting after just a few sessions - and in patients with severe depression, a fast-acting treatment is considered imperative to prevent a suicide attempt.

MSNBC:August 6, 2008
MSN © 2008 Microsoft

In era of pills, fewer shrinks doing talk therapy

The Associated Press - Monday, August 4, 2008
CHICAGO: Cartoons about the psychiatrist's couch were recently the subject of a museum exhibition. Now, the couch itself may be headed for a museum.

A new study finds a significant decline in psychotherapy practiced by U.S. psychiatrists.

The expanded use of pills and insurance policies that favor short office visits are among the reasons, said lead author Dr. Ramin Mojtabai of Johns Hopkins Bloomberg School of Public Health in Baltimore.

"The 'couch,' or, more generally, long-term psychoanalytic psychotherapy, was for so long a hallmark of the practice of psychiatry. It no longer is," Mojtabai said.

Today's psychiatrists get reimbursed by insurance companies at a lower rate for a 45-minute psychotherapy visit than for three 15-minute medication visits, he explained.

His study found that the percentage of patients' visits to psychiatrists for psychotherapy, or talk therapy, fell from an average of 44 percent over the 1996-1997 two-year period to an average of 29 percent for the years 2004-2005. The percentage of psychiatrists using psychotherapy with all their patients also dropped, from about 19 percent to 11 percent.

Psychiatrists who provided talk therapy to everyone had more patients who paid out of pocket compared to those doctors who provided talk therapy less often. And they prescribed fewer pills.

As talk therapy declined, TV ads contributed to an "aura of invincibility" around drugs for depression and anxiety, said Charles Barber, a lecturer in psychiatry at Yale University and author of "Comfortably Numb: How Psychiatry is Medicating a Nation."

"By contrast, there's almost no marketing for psychotherapy, which has comparable if not better outcomes," said Barber, who was not involved in the study.

The findings, published in Monday's Archives of General Psychiatry, are based on an annual survey of office visits to U.S. doctors. Of more than 246,000 visits sampled during the 10 years, more than 14,000 were to psychiatrists. The researchers analyzed those psychiatrist visits.

The study did not survey visits to psychologists or other mental health counselors who are not medical doctors, but who also practice talk therapy.

Psychotherapy uses verbal methods to get patients to explore their emotional life, thoughts or behavior. The goal is to ease symptoms, sometimes through getting the patient to change behavior or mental habits.

Its benefits can be seen in brain imaging studies, said Dr. Eric Plakun, who leads an American Psychiatric Association committee working to restore interest in psychotherapy by psychiatrists.

"The couch is far from dead," Plakun said. "The couch turns out to be an effective 21st century treatment."

Talk therapy can be done by psychiatrists less expensively than split treatment, where a patient sees a doctor for pills and a counselor for talk therapy, Plakun said, citing two prior studies.

It also works better than drugs for some patients, such as those with chronic major depression and a history of childhood trauma, he said.

Accreditation requirements for psychiatric residency programs are putting more emphasis on talk therapy, Plakun said. That may slow the decline of the couch.

The new study doesn't answer an important question: whether other professionals are picking up the slack, said psychologist David Mohr of Northwestern University's Feinberg School of Medicine. Psychologists and social workers provide counseling but most cannot prescribe drugs, so it's possible that for patients who require both talk and pills, some coordination in care may be lost, Mohr said.

1 comment:

Eric Plakun, MD said...

Since I am quoted in the article on psychotherapy that you mention in your 8/6 posting, I thought I would respond. Your 2 psychiatry postings today seem related. ECT is one of the biological treatments for depression that psychiatrists think of readily for people who don’t respond to usual medication treatments—while psychotherapy often is not thought of. ECT can be a potent and lifesaving treatment when used for the proper indications. The worry is, as you probably know, that many people suffering from depression do not have simply an uncomplicated biologic illness, but are also struggling with the aftermath of trauma or with the way their identity and sense of self have been shaped by life events or with multiple simultaneous disorders or with having already failed biological treatments that do not address the loss of meaning in their lives. For these people psychotherapy may be the preferred treatment. See more about our treatment program at to get a sense of the way we try to integrate intensive individual, group and family therapy into state of the art general psychiatry—without using ECT.