Hoboken hospital shocks seniors
Hoboken got mentioned in yesterday’s Wall Street Journal.
A story about how Electroconvulsive Therapy (ECT) is being used to treat many people for depression, mainly senior citizens. Treatment at Hoboken University Medical Center helped one woman who was previously a lost cause.
The Graying of Shock Therapy
By SHIRLEY S. WANG
Ida Galvanoni, 93, was living alone in Union City, N.J., when she fell in July and broke her hip and shoulder. After months of hospitalizations, she became profoundly depressed. “I didn’t care if I died or got better,” she says.
Medicine failed. Then her doctor, Robert Greenberg, described another option: electroconvulsive therapy, or ECT, often referred to as shock therapy. “I had qualms about it,” Ms. Galvanoni says, but starting in October, she decided to be wheeled three times a week into the ECT room at Hoboken University Medical Center, where doctors used an electrical current to induce a seizure.
“I’m smiling more now; I can see it in myself. I don’t get so distraught,” Ms. Galvanoni said after the first three sessions. Ultimately, she received seven sessions before being discharged last month.
The use of ECT to treat depression has been on the rise in recent years — and elderly patients like Ms. Galvanoni make up a significant portion of the patients. Over the past five years, people over 65 have accounted for as much as 40% of ECT treatments conducted in Texas and California, two of the few states that require reporting of ECT sessions. In some clinics, such as the Duke University Medical Center, more than half of the patients are in this age range, according to David Steffens, head of Duke’s geriatric-psychiatry department.
Read the rest of this story after the jump.
But while use among the elderly is generally well-accepted within psychiatry, some mental-health experts say that it creates a unique set of concerns. For one, some worry about the memory impairment that shock therapy can cause. “When you consider ECT for an older person, who might have age-related memory loss, obviously you would be especially concerned,” says Sarah Lisanby of Columbia University, an expert in brain-stimulation techniques.
Doctors also must be careful to ascertain that an elderly person has the capacity to consent to such treatment, and that the patient isn’t actually suffering from dementia that was misdiagnosed as depression.
Nevertheless, proponents say modern shock therapy is among the most effective short-term treatments available for severe depression. And, they say, it can be especially valuable in older depressed patients — some of whom don’t respond well to medication or its side effects, or take other medications that interact with antidepressants, which can take weeks to have an effect.
“One of the big challenges with elderly people who suffer from severe depression is you just don’t have the time,” says James Tew, an assistant professor at the University of Pittsburgh School of Medicine who has studied the use of ECT on older patients. “If they’re not eating and drinking, you don’t have that luxury of time.”
Electroconvulsive therapy involves jolting the brain with an electric current to induce a brief seizure, which somehow resets faulty brain connections much like a computer is rebooted. No one knows exactly why, but it has proved effective in ameliorating symptoms in several psychiatric illnesses.
Decades ago, the treatment developed a bad reputation, in part because it was applied liberally in patients for whom it may not have been warranted. Patients were also sometimes injured by the procedure. Today, the use of anesthesia and muscle relaxants have helped eliminate many of the more dangerous side effects once associated with ECT — such as fractured disks from the seizures.
Used mainly to treat severe depression, ECT seems particularly effective in stemming “psychotic” depression featuring symptoms such as delusions or paranoia. ECT is also used for people with bipolar disorder, and to a much lesser extent in those with schizophrenia.
ECT has demonstrated short-term effectiveness for severe depression — relapse of symptoms remains a big concern — and may work particularly well for older people. A study published in 1999 by Dr. Tew in the American Journal of Psychiatry found that adults ages 60 to 74 have a greater response rate to ECT (73%) than adults 59 and younger (54%). Patients 75 and older had a response rate of 67% in the study, which included 268 patients.
Rates of depression among the elderly are comparable with those of adults in general — anywhere from 8% to 20% — but older people are often more debilitated by a major depression because they may stop taking care of themselves, geriatric-depression experts say. Loss of appetite and trouble sleeping, two common symptoms of depression, can lead to malnutrition, confusion and failure to take important medications. And the percentage of those over 65 who die by suicide, who often have depression, is higher than in the general population.
Seventy-year-old Verna Swauger fit the profile when she first received ECT for a deep depression five years ago. Over the course of two months, she lost 20 pounds and stopped showering, while her sleep diminished to just two to three hours a night. The depression “changed my personality,” says Ms. Swauger, of Homestead, Pa. Medications failed, so she turned to ECT. She received about 30 sessions — the typical number is 6 to 12 but varies tremendously among patients — over six months.
Ms. Swauger’s daughter, Cindy DeFerrari, says she really pushed her mother to get the ECT, and began to see improvement after just the third session. “It surprised me how quickly she responded to them,” Ms. DeFerrari says. Her mother’s appetite and sleep improved, and she “seemed more up.” A few months after the end of treatment, Ms. Swauger began to live on her own again.
Ms. Swauger denies having any memory problems following ECT, though she says she doesn’t remember many details from her time in the hospital. Ms. DeFerrari says her mother did forget details about trips they took, mostly around that time, but says, “When you weigh the odds, it’s better to be healthy.”
Memory loss remains a significant concern. Because cognitive impairment is more common as people age, doctors say that it is important to determine whether any pre-existing impairment decreases patients’ understanding of what ECT entails.
While most patients’ memory loss is limited to events around the weeks to months before the treatment, there is growing recognition in the field that a subset of people seems to have more widespread impairment, says Harold Sackeim, professor of psychiatry and radiology at Columbia University who has done extensive ECT research. “I think one of the real advances we’ve made in the field is that the American Psychiatric Association has stated there are permanent memory deficits,” says Dr. Sackeim, who nevertheless believes that the treatment can be beneficial.
Improvements in recent years have helped to reduce side effects. Using “ultrabrief” pulses of current and administering it through electrodes on the same side of the head instead of both seems to reduce cognitive side effects without compromising efficacy in many people. Practitioners should also figure out the lowest effective dose of current necessary to induce seizure, according to Dr. Greenberg of Hoboken University. And there are other forms of experimental electrical-stimulation techniques that researchers hope will affect only specific regions of the brain — and perhaps one day replace ECT.
Another concern is the risk of shocking someone who is actually suffering from dementia rather than depression. Depression can cause memory and concentration problems, and it can be difficult to figure out whether cognitive symptoms are due to depression, which can benefit from ECT, or a decline into dementia, which may actually be made worse. Doctors say that impending dementia like Alzheimer’s tends to be a gradual decline, whereas depression-related impairment has a more sudden onset, and it is helpful to know this history before deciding upon treatment.
Elderly patients should be carefully monitored for confusion after treatment, and sessions may need to be spread out, perhaps two times a week instead of three, says Benoit Mulsant, physician chief at the University of Toronto and an ECT practitioner.
Dr. Steffens at Duke says that he has seen cases in which the “the person appeared to get more confused” after ECT than before it. ECT is stopped immediately with these patients, he says.