Patrice was misery incarnate. Unlike some of my depressed patients, who lived the proverbial life of quiet desperation, Patrice did not hide her suffering. She wept. She moaned. She regaled our walk-in clinic with a kind of biblical keening, which, understandably, attracted the attention of our clinic director. He took me aside one day and said, as gently as possible, “You really need to do something with that lady.” He was right, of course, and thus far I had done little to help Patrice, despite months of treatment.
Aside from being poor and dealing with some physical limitations, Patrice had no discernible cause for her chronic depression. Her marriage was good, and despite her straitened
circumstances, Patrice lived in a modest but comfortable home. Unlike many depressed patients, Patrice herself had no “narrative”— no internalized account of how she came to be depressed. Her mood disorder was as much a puzzle to her as to me — the kind of illness that, in the 1960s, would have been called “endogenous depression”— arising, rather mysteriously, from within.
Patrice had the usual symptoms of major depression — lack of energy, poor concentration, inability to experience pleasure, suicidal thoughts, etc.— but there was another layer to her pathology. She had a quality textbooks describe as “importuning,” and which most people would call “clingy” and “demanding.” When I listened to Patrice ’s complaints, it was as if my pant leg were being tugged by someone groveling piteously on the ground. When I examined my emotional reaction to Patrice, I could see that on some level, her “neediness” angered me—perhaps because it left me feeling helpless. This, generally, is not a feeling those in the medical field handle well.
Patrice had been on several of the most robust antidepressant regimens I knew of, to little avail. She was too uncomfortable to sit through an “exploratory” or psychoanalytically-oriented therapy, so I used a supportive approach. Contrary to popular belief, “supportive psychotherapy” does not consist of patting the patient on the shoulder and saying, “There, there!;” rather, it is aimed at shoring up the patient’s more mature coping mechanisms and helping him acquire new problem-solving skills.
But after many months, Patrice was no better. I began to conclude that underneath her depression, Patrice suffered from a personality disorder—what the textbooks describe as “a lifelong pattern of maladaptive behavior.” Indeed, Patrice fit quite nicely into what was once termed “Passive-Dependent Personality Disorder” and what later became “Dependent Personality Disorder” in the current DSM-IV classification. Individuals with DPD are described as having a long-standing need to be “taken care of;” “clinging” behavior; a fear of being abandoned and difficulty making everyday decisions without excessive reassurance from others. Patrice fit the bill, all right. And yet, she had apparently functioned adequately in her life, marriage, and career, until about ten years prior to my seeing her, when her mood inexplicably began to plummet.
One day, I received a call from the emergency room. Patrice had been admitted after a “moderate overdose” on the medications I had prescribed. After speaking with the inpatient service, which quickly agreed to admit her, I felt myself foundering in the waters of guilt, anger and denial. Rather than admit to myself how badly my treatment had failed, I felt that Patrice had failed me—by “acting out” in this “passive-aggressive” manner. After discussing my patient’s voluminous treatment history with the inpatient unit director, I was surprised to hear her say, “Maybe it’s time for electricity.” This, of course, was “shop talk” for electroconvulsive therapy, or ECT—one of the most controversial treatments in psychiatry, and the stuff of innumerable myths and misunderstandings. “She’s been tried on everything,” the unit director pointed out, “and I think we owe her our best treatment.”
Indeed, there is no question that ECT is the most effective treatment available for severe, intractable major depression. Remission rates with ECT are in the range of 60-90%—much higher than rates with initial antidepressant treatment, which hover around 25%. ECT is also known to decrease suicidal ideation during the course of treatment. Yet this valuable intervention is often used as a “last resort,” even by experienced psychiatrists, frequently as a result of misconceptions on the part of clinician, patient, or both.
I recently heard a talk by Mrs. Kitty Dukakis—whose own ECT treatment was clearly lifesaving—in which she implored the audience of psychiatrists to use ECT earlier in treatment. Contrary to the myth fostered by Ken Kesey’s movie, “One Flew Over the Cuckoo’s Nest”—in which Jack Nicholson’s character, McMurphy, receives punitive ECT without a muscle relaxant –modern ECT methods do not cause convulsions. Neither does ECT cause detectable damage to brain tissue, based on several biological measures. (Many viewers of “Cuckoo’s Nest” seem to confuse ECT with lobotomy, which is no surprise, since McMurphy is later forced to undergo this barbaric neurosurgical procedure!). In fact, some preliminary evidence suggests that ECT actually increases certain “nerve growth factors” that enhance connections between brain cells. The beneficial effects of ECT treatment may last for many months, but some patients require occasional “maintenance” treatments, once a month or so, in order to stay in remission.
The biggest concern — memory loss — is usually mild, transient, and circumscribed, using the latest technical modifications of ECT technique. Recent data suggest that ECT’s effects on memory are comparable to those associated with long-term pharmacotherapy. While a small percentage of patients may report significant and enduring memory problems after ECT*, the vast majority do not, when the most advanced and “conservative” ECT methods are used. Most studies find that, six months after a course of ECT, neuropsychological testing reveals no substantial mental impairment in patients whose depression is in remission. Furthermore, cognitive risks must be weighed against the enormous degree of suffering, incapacity, and mortality—i.e., at least a 4% rate of suicide—associated with severe major depressive disorder. Nonetheless, candidates for ECT must receive detailed “risk-benefit” information as part of the informed consent process, and consultation with family members is often an important part of that process. It should go without saying—but I will say it!—that nobody should be coerced into accepting ECT, or undergo the procedure without having provided informed consent.
Somewhat to my surprise, Patrice did consent to the ECT, and I fully concurred. When I saw her a month later, as an outpatient, she had undergone a routine course of unilateral ECT, in which the electrical stimulus was administered to the “non-dominant” side of her brain. This method is known to minimize cognitive side effects, all other factors being equal. I was impressed, but not entirely surprised, that Patrice’s depression had been knocked back on its heels—she was clearly in remission. Her mood, energy, and zest for life had returned. She did not complain of any significant memory problems. What I found absolutely jaw-dropping was Patrice’s profound change in personality: she seemed, in every meaningful sense, a “new woman.”
The piteous and needy demeanor that I had attributed to a personality disorder had been completely transformed. The radiant woman who now sat before me wore the confident, beaming and assertive face of her youth. Patrice began spouting off on plans, projects, and long-postponed pleasures—without a hint of dependency or neediness.
The “real Patrice” had emerged, butterfly-like, from the cocoon of inadequately-treated depression. And I had learned two valuable lessons: first, patients don’t fail treatments; treatments fail patients. And second: what appears to be etched in the hard stone of personality is sometimes merely scratched in the shifting sand of treatable illness.
Note: “Patrice” is not the patient’s actual name.
Sources for Further Reading:
An Overview of Electroconvulsive Therapy (ECT) – Psych Central
Electroconvulsive therapy (ECT) – Mayo Clinic
Electroconvulsive therapy (ECT) – McLean Hospital
Smith GE, Rasmussen KG Jr, Cullum CM et al: A randomized controlled trial comparing the memory effects of continuation electroconvulsive therapy versus continuation pharmacotherapy: results from the Consortium for Research in ECT (CORE) study. J Clin Psychiatry. 2010 Feb;71(2):185-93.
Bocchio-Chiavetto L, Zanardini R, Bortolomasi M et al: Electroconvulsive Therapy (ECT) increases serum Brain Derived Neurotrophic Factor (BDNF) in drug resistant depressed patients. Eur Neuropsychopharmacol. 2006 Dec;16(8):620-4.
Shock: The Healing Power of Electroconvulsive Therapy, by Kitty Dukakis and Larry Tye; New York, Avery, 2006.
*For one patient’s personal perspective on her memory loss associated with ECT, see:
Donahue AB: Electroconvulsive therapy and memory loss: a personal journey. J ECT. 2000 Jun;16(2):133-43. [The PDF is available on line. This patient reported substantial and enduring problems with her memory, yet says she probably owes her life to her ECT treatment—RP]
Acknowledgment: I wish to thank Psychcentral’s Sandy Naiman for her careful reading of this article; however, the opinions expressed herein are solely mine.