Shock Treatment

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Read anything good lately? We have, and that’s why we’re pumped to publish this occasional series inspired by our favorite recent reads. This week Mary’s inspiration was the Pulitzer Prize winning Trust by Hernan Diaz. 

By Mary Carpenter

“CONVULSIVE therapy”—using chemicals to induce epileptic seizures—appears near the end of Diaz’s novel, one of this summer’s top book-group reads, a late-1930s treatment for one character’s depression. By the 1940s, seizures produced by chemicals—including insulin and the drug Metrazol—gave way to electrical stimulation (electroconvulsive therapy or ECT), now increasingly used as a “first-line” treatment in cases of severe depression.

Psychedelic drug therapy (notably MDMA) for depression related to PTSD is also receiving recent attention—from veterans speaking up about their experiences. In response, members of Congress have increased support—up from 91 votes in 2019 to 140 in 2021—for what they dubbed Alexandria Ocasio-Cortez’s “little shrooms bill” that proposes to lift federal prohibitions making it difficult to study psychedelic drugs, specifically referring to the psilocybin in “magic mushrooms.” In early July, a similar version, calling for clinical studies of psychedelics in military treatment facilities, made it into the National Defense Authorization Act.

Casting a dramatic recent spotlight on treatments for severe depression —in this case in-patient care and antidepressant drugs— is newly elected Pennsylvania Senator John Fetterman’s openness about taking more than six weeks’ leave from his new Senate job. Arriving at Walter Reed Hospital “gaunt, listless, barely able to function,” Fetterman told Time, “I didn’t think I could be fixed.”

“It was a powerful and a helpful thing that he did,” said Vermont Senator Peter Welch, who noted that “the COVID-19 pandemic and its aftermath triggered a widespread mental-health crisis that the nation is struggling to address.” In a recent survey of Americans, 18% said they have depression—a rate that has nearly doubled in the past decade—with fewer than 10% of sufferers receiving psychiatric treatment.

“Depression to the public connotes sadness [but] the cardinal feature of the medical illness of depression is slowed speech, movement, and a lack of drive or initiative,” explained Walter Reed inpatient Neuropsychiatry Director David Williamson.  “[Fetterman] was very passive, very flat, very unemotional, almost mute, although he did talk. Just a lack of responsiveness and a flatness, a lack of that spark or passion you would expect to see in humans.”

“A medical condition rooted in brain chemistry” is how Williamson characterizes depression, although he was able to convince the Senator only after persuading him to read Understanding Depression, by Raymond ­DePaulo (currently out of print, audio is available).  Said Williamson, Fetterman’s openness about his struggles has the power to help countless others.

“There can be a biological predisposition, but there is often a trigger, and we just don’t always know what that trigger is,” explained McLean Hospital Director of ECT Services Stephen Seiner. “Very often in patients who experience depression there may be a psychosocial stress that somehow sets off a cascade of neuronal connections in the brain that then leads to an episode of depression. Where most people would be able to bounce back from the stressor, patients who have a predisposition towards depression often continue to spiral down.”

Depressive episodes “characterized by persistently depressed mood or loss of interest in activities [cause] significant impairment in daily life,” according to CMS (Centers for Medicare and Medicaid). Of those with a diagnosis of major depressive disorder (MDD)— about 16 million U.S. adults in 2015—around 70% do not recover completely, which puts their illness in the category of “treatment-resistant depression” (TRD).

With psychedelic drugs, significant improvement can come after just one experience in a therapeutic setting. MDMA, or ecstasy, works specifically to block or extinguish “fear memory,” according to a recent study of 91 patients with severe PTSD. A major motivation to study psychedelic drugs, according to Veteran Affairs: “nearly 17 veterans dying by suicide each day.”  The FDA appears “expected to approve MDMA for PTSD and psilocybin for depression within two years,” according to New York Times opinion writer Maia Szalavitz, writing about the psychedelic drug, ketamine. Szalavitz describes testimony by two survivors of the cult Nxivm, actress Catherine Oxenberg and her daughter India, about their “new foundation that plans to offer ketamine in a therapeutic setting to other female survivors of cult and sexual violence.”

“Plant medicines like psilocybin…give you exactly what you need, even if you don’t know what it is you need,” notes Veronica Duron, chief of staff to New Jersey Senator Corey Booker, co-sponsor of Senate legislation similar to the “little shrooms bill.”  The subjective experience of tripping while taking psychedelics appears to be part of the therapeutic effect—and biochemical changes in the brain appear related to the same serotonin neurotransmitters targeted by antidepressants.

While psychedelics, antidepressants and talk therapy help many people with depression, these options “fall short” for an estimated 100,000 people a year in the United States who may respond better and more quickly to ECT, according to McLean’s Seiner. While no one is certain why ECT works, the observations that seizures reset brain functions—and that brain activity involves electrical signals passing through neurons—has led some to compare ECT to rebooting a computer.

For many, including Seiner, ECT should become the first-line treatment in severe cases of depression, especially when suicide is a possibility—although concern about side effects, including headaches, muscle aches and temporary memory loss, means many continue to use it only as a last resort. Based on a five-year review of ECT studies, however, Chinese researchers write that it “should be a first-line therapy for depression due to its profound effects in relieving desperation in certain situations.”

ECT is “the most valuable option in case of treatment resistance and severe and life-threatening mental conditions, especially depression and schizophrenia,” write German researchers based on their three-year analysis of ECT. They found “excellent remission rates of up to 75% even in treatment resistance, improving health-related quality of life [also] a significant anti-suicidal effect.”

In Trust, chemical seizures helped at first but ultimately killed the character. For me, however, two friends who underwent ECT for overwhelming, long-lasting depression said the side-effects, even memory loss, didn’t persist long enough to affect their conclusions—that ECT worked when nothing else had.

—Mary Carpenter regularly reports on topical subjects in health and medicine.

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