News from the Johns Hopkins Department of Psychiatry and Behavioral Sciences
Lorrie Nottingham and Jack Nicholson have little in common, fortunately, aside from the topic of electroconvulsive therapy (ECT).
As a man pushed into “shock treatment” in One Flew Over the Cuckoo’s Nest, Nicholson brought his too convincing acting to what was a bogus take on the therapy as it had existed in the 1930s. That, plus the film’s showing a lapse of medical ethics so staggering that you pray it’s fiction, planted the thought in a generation of Americans: Avoid ECT, no matter what.
Patient Nottingham, however, is the reality. Last May, the soon-to-be-grandmother became one of the 130 or so each year to undergo ECT at Hopkins Hospital. Unlike the movie portrayal, she was neither in pain nor made a zombie.
“We’re well aware of public perceptions,” says psychiatrist Irving Reti, who directs Hopkins’ ECT service. “But what we see is a therapy that works amazingly well for selected patients.” Roughly 85 percent of resistant depressions lift with ECT, making it psychiatry’s most effective treatment for the illness. “It’s not without considerations,” he says—like memory loss that’s temporary in most—“but, still, ECT is overwhelmingly safe.”
For the better part of 20 years, Nottingham has lived with deep depression. “I’ve had so many different antidepressants. They work a while, then stop,” she says. And her recent downturn was especially grim; when she came to Hopkins, she lay in bed, tearful, knees drawn in: a human knot of sadness. “I have no future,” she’d whisper.
At each treatment session, with both psychiatrist and anesthesiologist present, Nottingham experienced short, barbiturate-induced anesthesia, received a muscle relaxant and then the brief pulse of electricity that induces a seizure. Time asleep: less than five minutes. By the fifth session—most patients have six to 12 over several weeks—she’d become both engaged and engaging. “I’m much more social,” she said, perched on the side of her bed. “I talk to people at dinner. I’m feeling good. I can’t describe how, but I am.”
Reti and his colleagues share Nottingham’s puzzlement at how, exactly, a seizure lightens mood. The going idea is that it turns on specific genes that sculpt brain synapses, and clinician/neuroscientist Reti has spent a decade investigating what regulates this rapid synaptic remodeling. Though much of Reti’s work applies to addiction, he says it’s not hard to imagine that repeated ECT might tap some of the same genes and share brain circuits. “Also, we know that antidepressants and antipsychotics activate those genes, though with ECT, they’re expressed far more robustly.” Perhaps that’s why the latter acts faster than antidepressants—in two to three weeks or less.
It’s still a mystery why ECT’s benefits fade in a few months without additional antidepressant therapy or maintenance ECT. Nor is it clear why a drug that had little effect before ECT is one that can keep mood on track afterward. “We’d love to find out,” says Reti.
Nottingham, however, is untroubled by thoughts on the mechanism: “I just know it works.”
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