The electrical current throbs from one side of the skull to the other, scrambling circuits along the way, inducing a brief seizure. When it's over and the anesthesia wears off, patients often are subdued, confused, sometimes unsure of where they are or why. Then, sometimes, the remarkable happens: Severely depressed people find that the darkness has lifted; they feel better than they have in years.
Others are left distraught. They've been shocked -- and feel no better than before.
In recent decades, electroconvulsive therapy, or ECT, has undergone a transformation, many psychiatrists say. The body no longer thrashes violently, as depicted in movies a generation ago; it lies still, under medication, with the thrashing confined to the mind. Techniques are more precise, they say; the brain better understood.
Although exact numbers are not available on how many people get modern ECT -- estimates have ranged from 30,000 to more than 50,000 a year since the early 1990s -- scientific interest in the treatment has surged, in part because of the acknowledgment that drugs don't help many deeply depressed people, particularly older adults, a growing and hard-to-treat population. The government is funding some 20 ECT studies to see how different techniques and treatment combinations affect behavior.
Recently, researchers have looked directly at how the bolts of current alter biology, by studying the brains of shocked rodents. And in June, a leading medical journal published the results of a broad survey detailing what former ECT patients think about the treatment.
Yet far from proving the effectiveness of ECT, the emerging research has only accentuated its unknowns and shortcomings. After more than 60 years of experience, doctors still don't know exactly how the shocks affect the brain, whether they cause permanent damage, or why they affect depression. Although the techniques and technology have improved, ECT itself appears no more effective than it ever was, studies show.
When it comes to treating older people in particular, doctors have no scientifically rigorous evidence establishing the treatment's safety or effectiveness, according to an exhaustive review of the literature published last month. "Proponents have been saying it's safe and effective, but their statements go beyond what we know for elderly people," said John Bola, a mental health researcher at USC who studies treatment effectiveness. "It starts to sound more like an advertisement than a statement of fact."
The reputation of shock therapy has alternately risen and fallen since 1938, when an Italian psychiatrist named Ugo Cerletti decided to try shocking one of his patients, a 39-year-old man, after watching slaughterhouse workers subdue pigs with bolts of current delivered to the brain, and after first experimenting on animals. Cerletti reported that the man improved after repeated shocks, and the idea soon caught on among doctors desperate for some way to manage disturbed, often aggressive, patients. Use of the treatment then declined through the 1960s and 1970s, due to the introduction of new psychiatric drugs and the public stigma attached to the therapy.
That decline stopped in the 1980s, researchers say, because psychiatrists refined their techniques and continued to report recoveries in severely depressed people who didn't respond to any other treatment. By 1990, an American Psychiatric Assn. task force report on ECT concluded that the treatment was highly effective, "with 80% to 90% of those treated showing improvement." The association also set precise guidelines for treatment, specifying the amounts of electricity and placement of electrodes that seemed to produce the best results.
"You're talking about people who are desperate, who are often suicidal, who have just about lost it all," said psychologist Harold Sackeim, chief of biological psychiatry at the New York State Psychiatric Institute and a professor at Columbia and Cornell universities in New York. "This is a treatment that we know can help them turn it around, and it is very satisfying to see that happen."
Relief usually temporary
Psychiatrists acknowledge that the mood-altering effect of ECT is usually very short-lived: Those who do feel better after a series of shocks almost always plunge back into depression within a few weeks, or months. Aggressively treating these people with drugs can help; but it is hardly a guarantee that the depression will lift, or that a person will agree to endure such treatment in the first place.
"It must be thought of as a stopgap measure in life-threatening situations," said Dr. Jeffrey Schwartz, a research psychiatrist at UCLA's Neuropsychiatric Institute. "All you're doing is buying more time to get to a place where drugs, or cognitive therapy, can have some effect."