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Editor’s note: This story focuses on suicide, self harm and other topics related to psychiatric distress. If you or a loved one is in crisis, resources are available here.
During the pandemic, Dr. Anna Borisovskaya was treating a man who was so severely depressed that he required hospitalization.
Most available treatments hadn’t succeeded. So Borisovskaya suggested electroconvulsive therapy (ECT), which works by inducing seizures. It’s usually the last in a long line of treatments for people who are resistant to other therapy options and are severely ill with conditions such as catatonia, major depressive or bipolar disorder.
The man left the hospital after undergoing six ECT treatments. He needed more.
But the pandemic was raging. And Borisovskaya, who at the time practiced at the VA Puget Sound Health Care System, found her ability to treat patients was constrained. Like many other medical procedures, the VA cut the number of ECT treatments Borisovskaya could perform in half, in part because patients who undergo ECT could expose health care workers to COVID-19. There was also a staff shortage, Borisovskaya said, and the U.S. Surgeon General had advised hospitals to postpone elective procedures. At many hospitals, ECT was among them.
Borisovskaya asked the man to schedule another treatment in a month; she’d decided to prioritize patients who were suicidal, and as far as she knew, the man wasn’t. “I thought he would be OK,” she said.
But before he was due for his next appointment, Borisovskaya said, the man killed himself.
“The decisions I’m making are like I’m in a war where you decide between two people who are actively dying,” Borisovskaya said. “Who do you save?”
Scientific studies suggest ECT is a lifesaving procedure for those who need it, and it results in a 40%-80% response rate in patients, depending on their diagnosis. But the treatment’s long history of stigma has created significant barriers to getting care. And Washington psychiatrists and ECT patients say the pandemic only further limited access.
ECT, colloquially called “shock therapy,” is still stigmatized outside the medical community, and to some degree, inside it. Its controversial history is shadowed by scary depictions in films like “One Flew Over the Cuckoo’s Nest,” where Jack Nicholson’s character is shocked against his will. It doesn’t help that scientists still don’t fully understand why ECT works: It’s unclear why inducing a seizure relieves symptoms of serious depression, suicidality and other mental illnesses.
Psychiatrists interviewed for this story acknowledge that ECT can be scary for the person receiving it, and that short- and long-term memory problems are a consistent side effect. But there’s little scientific evidence that ECT damages the brain: Studies hint that ECT is associated with certain changes, like growth to the brain’s learning and memory center, the hippocampus — but not that it results in scarring or lesions typically associated with brain damage.
It’s an imperfect, but important stopgap, many experts say.
“I’d be delighted if we made all of our treatments we had today obsolete because we have better things than that,” said Dr. Michael Henry, director of somatic therapy (ECT) at Massachusetts General Hospital. ”Given the kinds of advances in science, that will eventually come … But today, ECT clearly has a role.”
Borisovskaya and several other psychiatrists interviewed for this story say they knew ECT was essential — not elective — for their patients. Now, emerging scientific evidence suggests they were right.
The pandemic “was a horrible opportunity to test the hypothesis that it is necessary in certain patients to continue the treatments,” said Dr. Nele Van de Velde, a psychiatrist at Ghent University Hospital in Belgium, whose December research suggests a high relapse rate among people with depression who discontinued ECT during the pandemic.
Concern about ECT access was so profound that the American Psychiatric Association put out guidance during the pandemic that reiterated the treatment is “highly effective.” “Not allowing this urgent use of this rapidly and powerfully effective treatment modality will lead to harm to the patient over the short term,” the guidance reads.
The morning of Mira Gandhi’s ECT appointment, a friend picks her up at her First Hill home and drives her to Swedish Medical Center in Ballard, where she navigates her way to the same-day surgery center.
Gandhi puts on a gown. Medical staff talk with her about medications and her mood, take her vitals and place an intravenous line into her arm. They wheel her into an operating room, and make sure she’s hooked up to monitors that track her vital signs. An anesthesiologist arrives — ECT is performed while patients are unconscious — and Gandhi receives anesthesia and a muscle relaxant that calm her body and puts her to sleep.
Staff place electrodes on her head to measure brain activity and an oxygen mask over her mouth. Her psychiatrist, Borisovskaya, holds paddles to her temples and presses a button that delivers a brief electrical current to Gandhi’s brain.
It triggers a seizure.
Sometimes, Gandhi’s toes curl or her fingers twitch. But after about a minute, the seizure has ended. Gandhi comes to a few minutes later, and an hour after that, she’s ready to go home.
The whole process, from the time Gandhi gets an IV, to when she awakes, takes 20-30 minutes.
“It’s a very civil procedure,” says Gandhi. There’s “nothing barbaric” about it.
But getting access to the treatment — that’s another story, patients and psychiatrists say.
Before the pandemic, Borisovskaya said, new patients typically waited two to four weeks for their first outpatient ECT appointment, wait times she called “fairly OK.” It now takes much longer: Patients interviewed for this story reported waiting two to four months before landing their first ECT treatment during the pandemic.
Gandhi, 30, is a lab technician who studies rare genetic diseases. She started experiencing severe symptoms of depression around the time her family emigrated from Canada to Texas just after the September 11 attacks in 2001. As a 10-year-old with brown skin and an Indian name, she said, she was suddenly the target of racism from classmates and some adults; she was also thousands of miles from everything she knew. Her stress worsened as she got older. She started to frequently have thoughts of wanting to hurt herself, or to end her life.
She tried antidepressants, mood stabilizers, anxiety medications. After struggling with rough side effects, she asked her psychiatrist about ECT. Still in Texas at the time, she started the therapy without hesitation. “I have a lot of faith in medicine and science,” she said. Like many other ECT patients interviewed for this story, she also said she was so depressed that she “didn’t even care what happened.”
The effects were fast, and “life changing,” she said. But when she took a new job in Washington during the pandemic, she had to start all over again. Find a therapist. Find a psychiatrist. Find someone who performs ECT.
She hadn’t yet found a provider when, in May 2021, she hurt herself. It was a major turning point that caused her to reach out to SeattleNTC, an ECT provider where Borisovskaya is now employed. The next available appointment wasn’t until September — more than a year after her last ECT treatment.
Borisovskaya acknowledges that wait times are long at SeattleNTC, which is one of just a handful of providers statewide that specialize in ECT and other brain stimulation therapies. But she said it was worse at the VA; she left her job there in April 2021 after becoming increasingly demoralized and having no option but to continue rationing care.
Lack of access to ECT even before the pandemic is largely rooted in long-standing societal and professional stigma against the treatment, psychiatrists say. When ECT was invented more than 80 years ago, psychiatrists didn’t use sedatives or anesthesia, and patients often thrashed around so violently that they hurt themselves. That version of ECT is long gone, but robust ECT training still isn’t always included in medical residency programs.
Few psychiatrists in Washington offer the service. A 2019 Washington State Psychiatric Association directory lists the names of 17 ECT practitioners statewide, all but three of whom practice in the Seattle metro area. This fits with a nationwide trend: Research suggests the availability of ECT has declined by one-third since the early 1990s.
In general, Borisovskaya said, ECT is more widely available in Washington than it is in other nearby states; patients regularly traveled from Alaska and Oregon for treatment at VA Puget Sound, she said.
But the pandemic changed access everywhere: According to a 2020 survey of 20 ECT treatment sites across the U.S., a vast majority had to cut their appointments by at least 50%. “What I’ve heard is, some places never restarted,” ECT treatments, said Dr. Daniel Maixner, who led the research and is director of the ECT program at the University of Michigan.
In Washington, legal barriers also prevent access for certain patients, like those who are experiencing catatonia due to a psychiatric concern and can’t make decisions about their own medical care. Unlike in most other medical emergencies, family members are barred from consenting to ECT on a loved one’s behalf. Instead, a judge must sign off on the treatment, which can delay access for weeks while the person continues to decline physically and cognitively.
During the 2019-20 legislative session, state Sen. Reuven Carlyle, D-Seattle, introduced legislation that would give family members decision-making power when ECT is recommended by at least two medical professionals. But the bill faced pushback from some patient advocates, who argued a law change could result in involuntary ECT and violate patients’ human rights. The bill died in committee.
“I wanted to be responsive to the medical best practices,” said Carlyle, whose wife is an anesthesiologist. Current law, he said, is “just completely out of date and disconnected from reality.”
The gap in ECT availability has unintended consequences, patients like Autumn Davis say.
Davis, 28, started looking for an ECT appointment at the same time as Gandhi — it was May 2021, and Davis couldn’t shake the suicidal thoughts or overwhelming feelings of exhaustion that were creeping in.
Davis, who lives in Sand Point and had been diagnosed with bipolar II disorder, said a cocktail of five prescription medications wasn’t working. Her insurance covered ECT treatment through SeattleNTC, but like Gandhi, she had to wait until September for her first appointment. “I had to wait a really long time which is really difficult to do when you are already at the end of your rope,” she said.
To keep her mind busy, she trained for and completed a 50K running race, took long bike rides, and swam. She also spoke with an uncle, who told her that her grandmother had received a few ECT treatments in the 1970s. That knowledge gave her some peace of mind that it might work.
And it did.
But the experience was so chaotic — even scary at times, she said — that she made the difficult decision to end her treatments. During her first session, the nurse placing her IV made a mistake. When she woke up, the right side of her face was in severe pain. And she says she wasn’t given discharge paperwork or information about the medications she’d received during the therapy. During another session, she said, medical staff mistakenly gave her the wrong medication.
“It just felt like they had to rush through the patients in order to treat everyone because there’s a lot of people who need it, and not a lot of doctors doing it,” she said. Davis and others said they experienced memory loss, a common and sometimes serious side effect of ECT.
Dr. Joshua Bess, medical director at SeattleNTC, said he and his colleagues heard Davis’ feedback and have since thought about how they could improve care when their schedules get tight. “We really try to not make it feel like an assembly line,” he said. But, “the pandemic, since there were fewer sites and we were getting more referrals, did really test that system.”
Several ECT patients said the benefits outweigh the costs. And many other patients described smoother experiences during their ECT treatments.
Idamay Curtis, who lives in Edmonds, said that before the treatments, she felt she didn’t deserve to be alive. After undergoing ECT in 2021, she lost all memories of a winter trip with her husband to Yellowstone. But Curtis, 60, said the feelings of being “underwater” that weighed her down physically and emotionally were eased immensely by ECT.
“The memory and cognitive issues are disturbing,” she said. “But I’m still glad that I did ECT because I do feel better.”