Email | Print

Each fall the Columbia University College of Physicians and Surgeons holds a Saturday seminar about the latest medical approaches to depression. The New York Psychiatric Institute and the National Alliance for the Mentally Ill are co-sponsors. This year's event on November 17 attracted some 200 people, mostly professionals and family members. (By comparison, this year's seminar on schizophrenia garnered 400 attendees.)

Why do so few consumers attend these presentations? Although I found at least half the information in the morning lectures over my head, all the authors answered questions in afternoon workshops where the atmosphere was less intimidating. This approach of doubling up on subjects is commendable.

Perhaps the atmosphere of the place remains alienating. Not only is West 168th Street a long way from anyplace else in New York City (it took me two hours by subway from Brooklyn), but its mainly ancient skyscrapers reminded me of the fortresses where the mentally ill have been "imprisoned" in the past.

Or perhaps the main reason consumers stay away is that most people come to the conference to get the latest "dope" on medications. This is not an academic matter for us. It is clear that the Columbia physicians are trying to expand their audience by discussing how physical illness can cause depression and vice versa. There was even a workshop on "The Role of Psychotherapy in Treatment." Psychotherapy has been so neglected with the advent of the new medications that apparently its practitioners must now reintroduce the discipline to some professionals and the public.

Most unusual was a report on Electro Convulsive Therapy (ECT) and possible alternatives with fewer side effects. Sarah H. Lisanby, MD, is Associate Professor of Clinical Psychiatry and Director of the Columbia Transcranial Magnetic Stimulation Laboratory. In spite of the bad press ECT has received, Lisanby became convinced of the technology's usefulness when she was a medical student at Duke; she saw many people there recover from severe depression. Some were so catatonic they neither spoke, ate, nor slept. ECT's bad rep goes back at least to the 1940s and 50s when ECT was often administered without anesthesia or oxygen. The excessive power of the electrical current was also damaging. Even if you believe as Lisanby does that short-term memory loss is the only significant side effect these days, the jury is still out on the key question of how long the benefits of ECT last.

The doctor cited various studies that 85% of ECT users relapse in six months if they do not take anti-depressants immediately following treatment. That figure drops to 35% with drugs or with "maintenance" ECT applications. Lisanby claimed the number would be smaller if the medications were administered during the procedure as well. However, she admitted that patient refusal to take the medication is a long-term obstacle to the success of this program. The more ECT a consumer undergoes, the more likely that despair interferes with their compliance. Still, some people do benefit from ECT. For these folks, it should not be banned as some psychiatric survivors advocate. I asked the doctor whether her search for alternatives to ECT is motivated as much by the desire to reduce the side effects so feared by consumers as by her desire to find a more effective therapy. She agreed on both counts.

Transcranial Magnetic Stimulation uses a magnetic pulse that lasts less than a millisecond. No anesthesia is required and no seizure is induced; the pulse does not affect the deep brain. Its direction is radial rather than tangential. At low frequency, the device is not as "effective" as ECT but at higher doses side effects begin to appear. Magnetic Seizure Therapy does indeed create a seizure but a less severe one than with ECT.

Vagus Nerve Stimulation has already been approved for epilepsy that is resistant to drugs. Like time-release medication, this implanted technology regularly stimulates the vagus nerve to increase blood flow to the brain. The Psychiatric Institute is also experimenting with shorter electrical impulses on both sides of the head as a means of reducing memory loss. Normally ECT is directed to the right hemisphere to minimize language loss.

Thus far the size of the studies has been too small to justify these techniques. The fact that the Psychiatric Institute is engaged in this research may be significant because the Institute has been criticized for its role in the state's policy on ECT, especially in the case of individuals who have been forced to undergo ECT. This shows that protests are having an effect, if not the effect they desired. Only eight people attended the workshop after Dr. Lisanby's morning lecture and two of the attendees were her colleagues. This shows that either the public is not vigilant about ECT and its variants or, just as the doctors, claim it really is a last resort for a small group of people.