ECT, Depression, & Conflicting Psychological Adaptations
Harold Sackheim, of Columbia University, also spoke recently at the Mood Disorders Symposium at Johns Hopkins. He offered a summary of data on electroconvulsive therapy, still the most effective treatment for major depression. He unintentionally gave us a study on conflicting Psychological Adaptations.
Frans De Waal (1996, Good Natured, Harvard Univ Press) gives convincing examples of succorant and sympathetic behavior in apes. Succorant behaviors include those associated with caring for an injured peer, youngster, or senior chimp. The many examples even include one of a chimp picking a scab from the back of De Waal's hand! Sympathetic behaviors (not only "knowing" how a victim feels but also acting to prevent further harm) include vocalizations and protective, and comforting routines toward the bullied or injured. It appears that there is a set of behaviors (fixing the problem) and emotional reactions (feeling bad for the victim).
Both sets of behaviors ought to compliment each other and may share a common foundation. Yet, with ECT we can observe succorant behavior (relieving depression) in conflict with sympathetic behavior (consoling the victim of depression and protecting them from an effective treatment).
A. ECT, given to one hemisphere rather than across the entire head: 1) Is effective 80% of the time, more so than any medication. 2) Has greater impact with the same procedures that REDUCE physical discomfort and psychological side effects. 3) Results in immediate improvements (3 days) in attention, initiative, mood, and even I.Q. 4) Is praised by the patients themselves. 5) Produces no demonstrable brain damage. (There is, however, some loss of memories with no demonstrated impact on the ability to form new memories. The amount of cognitive loss appears to vary with other conditions such as preexisting organicity.) Fixing the problem (succorance) should reign. 6) The patient is commonly oriented within 4 minutes of unilateral treatment.
B. ECT is: 1) Given generally only after medication failures 2) Rarely given in "maintenance" treatments even though less effective medications are. Indeed, ineffective medications are commonly given again after ECT; the medicine often fails again with the exception of lithium which is associated with a 34% relapse. Nortriptylene is little different from placebo. 3) Given almost exclusively to wealthy, white patients. 4) Under consideration as a possible criminal offense by the Texas legislature.
I do remember the earlier days of ECT. I was a psychiatric aide in a university psychiatric teaching hospital; the treatments were not pleasant and neither staff nor patients liked them. It was given through the temples, a grand mal seizure was thought essential for its effectiveness, and muscle relaxants were or were not used as a function of availability or treatment hypotheses. Disorientation and confusion were more marked; sometimes bones broke during the convulsions.
Reactions to ECT have been so strong that research about milder, more effective procedural variations was inhibited. Still, with other medical procedures we do things that are generally approved even though no one really stands in line for such treatments. My bypass is 8 years old; I appreciate being alive but also eat in a fashion that should keep me out of more operating rooms. I will not go back. Sometimes resolving the dissonance between our Psychological Adaptations, particularly when they have been institutionalized or highly personal, is difficult, expensive, and prolonged.