At 7 a.m. this past Monday morning, my friend Angela (not her real name) walked into the University Health Network on University Avenue in Toronto and took the elevator up to the second floor surgical admissions desk, where she was registered for her first Electroconvulsive Therapy treatment.
Because she has joined a long-term, multi-site Toronto study to examine the hotly debated issue of memory loss and ECT, last week she signed consent papers (routine for anyone choosing to have ECT), had blood work, four hours of tests, including a two-hour MRI of her brain, and a consultation with an anesthesiologist.
She also met with the doctor who will administer her treatments that will be unilateral, twice weekly and last between eight and 12 weeks.
After years of fighting simply to get up in the morning with her deadening depression, unable to work and struggling against constant suicidal thoughts, Angela had concluded that ECT was her last chance. Her doctors have prescribed eight different antidepressants, alone and in combination with a number of anti-psychotics. To sleep, she needs sleeping pills.
None of these medications have helped her. Her melancholy persists. She feels desolate, as if a psychic blankness is blanketing her and killing her spirit. Now, working with her psychiatrist who agreed that ECT was a viable option, when Angela suggested it, she was feeling more upbeat in anticipation of her first treatment.
She had researched ECT meticulously, besides discussing it with her psychiatrist and with me. She knew that I had had several courses of bilateral ECT in the 1960s and 1970s with no memory loss or any other side effect. I told her that it had helped me when I was psychotic. So now, with more optimism than she's felt in years, Angela was looking forward to the relief of this storied, controversial, much maligned and misunderstood procedure with its long and curious history.
"I read so many reports about its effectiveness," she told me last week. "I'm not worried."
After registering, she was taken to a small waiting room, called after a few minutes, and taken to another room where she was instructed to change into two hospital gowns and slippers. Then, Angela was led to a larger room where she laid on a bed and was covered with warm flannel blankets. A nurse attached three small electrodes to her upper right and left chest and lower down over her left rib cage for an electrocardiogram. She was then hooked up to a machine that monitored all her vital signs – blood pressure, heart rate, oxygen saturation, respiratory rate, temperature and pulse.
Her anesthesiologist came by to check her weight and told her that he was preparing two medications that would be infused intravenously – a short-acting anesthetic called sodium pentathol and a muscle relaxant called succinylcholine.
These medications were not used in the early days of modern ECT, and certainly not in the most iconic of Hollywood's depictions of ECT – the 1975 Milos Forman film One Flew Over The Cuckoo's Nest adapted from Ken Kesey's 1962 novel. In that film, a drama, ECT appears to be cruelly administered for social control without anesthetics and muscle relaxants.
The methodology has "absolutely" changed since then, said my friend and mentor Dr. Ron Pies, clinical professor of psychiatry at Boston's Tufts University and psychiatry professor and lecturer on Bioethics and Humanities at SUNY Upstate Medical University in Syracuse. He is also author of Everything Has Two Handles: The Stoic's Guide to the Art of Living as well as a book of poetry, a play and several psychiatric texts.
"In the early days of ECT, it was given without benefit of anesthetics or muscle relaxants – this is the origin of the horror-movie scenes often still shown in popular depictions of ECT," he explained. "The role of ECT is often confused with psychiatry's record of frankly unethical and deplorable treatment (during the 1930's-1960's) known as lobotomy which many people confuse with ECT. For example, here's a quote from a review of the movie One Flew Over the Cuckoo's Nest:
"Seeing people taken from the ward to another place and only returning to be even less than what they were when they left caused McMurphy to want to play hero. They were being taken to a room and being given electroshock therapy. In others words, lobotomy."
Pies added, "Of course, lobotomy has absolutely nothing to do with ECT, and is no longer performed in the U.S. or other advanced countries. This began to change in the 1950s and 1960s, at least in the west. In more recent years, refinements in electrode placement and in the amount and nature of the electrical stimulus have led to a procedure with far fewer side effects than in the early days. The actual medical risks of the ECT procedure itself acutely are comparable to those involved in having your tonsils taken out."
Angela admitted that nothing hurt her in the least. Even when the anesthesiologist inserted the IV needle into the left radical vein of her left hand, "down the line of my thumb," she said. A few minutes later, an oxygen mask was placed on her face and the doctor who was going to administer the ECT came in wheeling the ECT machine with her on a cart. She introduced herself and said she would be giving her the ECT treatments for the next two weeks.
"Like everyone else there, she was very nice and respectful," Angela said.
While the psychiatrist was getting the equipment ready, a nurse put gel on Angela's head and right temple and she was hooked up to an electroencephalogram machine to monitor her brain waves.
When the anesthesiologist announced he was ready to give her the medications, Angela remembers saying to the psychiatrist, "While you're in there, can you help me with my math skills."
The doctor laughed and said, "I don't know. I think I'll have to have a consult with your psychiatrist."
When the medications were started, the anethesiologist said, "Try to keep your eyes open. Most people say the medication tastes like garlic."
Angela thought it tasted like gasoline.
"Then I was out," she said.
Her next memory was waking up in the recovery room. The nurse told her she came out of the anesthetic very quickly and offered her more warm flannel blankets.
"I was monitored the whole time, from the moment I woke up from the anesthesia," Angela said.
After a while, she was wheeled into the Medical Day Unit.
"A nurse asked me how I felt," Angela said. "I told her I had a headache and they gave me something for the pain through the IV."
After another assessment of my vital signs, the nurses asked her if she wanted anything to drink. (She hadn't eaten or drank anything since 12 midnight the night before the procedure.)
"I said, 'No, I feel ready to leave.' But they kept me for another 15 minutes. Finally, I left at 9:15 a.m."
We spoke on Monday afternoon at 12:55 p.m.
Angela said she felt like she had had dental surgery and it was hard for her to open her jaw.
"It's probably because my muscles were clenched," she said. "But really, it was nothing. The whole procedure was nothing."
I asked her how her memory was.
"No problem," she said. "I remember everything, except I feel like I was hit on the side of the head with a baseball bat. But you know what? I would have done this two years ago, if I had had a psychiatrist. I've had more memory loss from smoking pot. I just feel a little tired."
At 8:43 p.m. Monday evening, she reported that her headache was much better. She had taken some Advil.
"My body feels a little achy, like I'd just done a work out. But I don't feel suicidal. I know that. And the repetitive thoughts about my childhood trauma seem dulled."
On Tuesday afternoon, she said her headache was gone, though she still felt a little achy.
"I think I'm going to give sculpting a try," she said. She hadn't sculpted in months.
"I feel a little guarded because I want this to work, but I slept well with my sleeping medication, though I was up too early, at 5:30 a.m. At least, I had no dreams."
She added, "I feel not bad at all. So far. So good"