Fort Myers, Florida (News-Press) -- The patients are rolled on gurneys into a small screened-off area at Park Royal Hospital every 15 minutes with assembly line regularity.
One is a woman in her 60s, who, like the others, gets a momentary jolt of electricity sent through her head, causing a brain seizure and her body to tense for several seconds. The hope: That this treatment - the electroconvulsive, or "electro-shock," therapy - will ease the symptoms of her bipolar disorder that has so far not responded well to drugs.
The procedure, one of thousands performed at Park Royal since the 76-bed hospital opened last year, has worked on the woman in the past, says Dr. Ivan Mazzorana, who performs all of them on patients here. And, he said, it's likely to do so again.
These days, the treatment goes by its more clinical-sounding acronym, "ECT."
"When you bring it up, most people say, 'Oh my God! Not ECT, that's something from the past,'" Mazzorana said. "It's a very simple procedure, safer, and it's a lot quicker than the medication."
Electroconvulsive therapy today is a procedure widely accepted by the medical community and one, absent a rare court order, that is done with patient consent. But it is also a treatment that lingers in the public imagination as a crude medical holdover almost as dated as bloodletting. Many outside of psychiatry are surprised to learn that the procedure still exists at all.
Despite that, ECT has seen a resurgence at many U.S. health centers in recent decades, experts say, and is now doing a brisk business here in Southwest Florida.
Park Royal, the only inpatient psychiatric hospital in Lee County, has already treated nearly 200 people with ECT, most receiving multiple treatments. The number represents roughly 10 percent of all Park Royal's admissions since it opened in early 2012.
The hospital is a for-profit facility owned by the Tennessee-based Acadia Healthcare Co.
ECT had been widely available before Lee County's last inpatient psychiatric hospital, Charter Glade, closed in 2000. Separately, one physician had provided ECT services in Collier County before retiring several years ago.
Otherwise in Southwest Florida, Riverside Behavioral Health in Punta Gorda offers the treatment, though it performs far fewer than Park Royal. Riverside's Dr. Bernardo Arias estimates his facility performs 150 treatments a year. Park Royal estimates it has performed more than 2,000 in the last year.
Most of those who have received ECT at Park Royal - patient ages have ranged from 18 years to those in their 90s - suffer from severe depression or bi-polar disorders. About 90 percent are inpatients. Others are referred from other parts of Florida, according to the hospital. A few are snowbirds who come in for ETC "maintenance" treatments.
The Mayo Clinic calls the treatment, which has a reported success rate of 70 percent to 80 percent, the "gold standard" treatment for severe depression. The most common side effect, according to proponents, is temporary short-term memory loss.
"I was afraid, to be honest with you," said Ron Spesia, a 71-year-old Fort Myers Beach retiree who suffered a deep, multi-year depression that did not respond to medication. He had 12 treatments and said he started feeling better after the third. "Then one day I decided, 'Hey, you know what? It's time to put the big boy pants on and pursue this.' Smartest move I ever made."
Still, ECT has its critics. Some, including patients of decades past and anti-ECT groups, say it is little more than intentional brain damage. This, despite the psychiatric community's endorsement of it and positive testimonials from many of the estimated 100,000 Americans who get the treatment each year.
A News-Press reporter was recently allowed to witness about a half dozen such procedures at Park Royal.
But even hospital administrators remain sensitive to the ECT stigma. Though a patient agreed to be photographed during one such procedure, and to have it recorded on video, the hospital overruled that consent.
The hospital also prohibited patient interviews inside the building, though other medical facilities routinely allow such interactions if patients are willing. David Edson, the Park Royal's director of business development, cited concerns about privacy and "the very delicate nature of the ECT treatment."
Despite that, Mazzorana said he wants to demystify the treatment and those who get it.
"It seems like an extreme, dramatic treatment," Mazzorana said. "It's a matter of really educating the psychiatric community, so then we can educate patients."
Mundane process
The treatments at Park Royal begin at 7 a.m. Mondays, Wednesdays and Fridays, and continue throughout the mornings. Staff usually see up to 10 ECT patients on these days.
The process bears little resemblance to its horrific depictions in popular culture. At Park Royal, it starts when patients come to a medical preparation area adjacent to the ECT treatment room, where staff hook them up to IVs - they will eventually get medication to paralyze their muscles during the treatment - as well as heart and brain monitors attached to their skin.
After a quick chat with medical staff, who assess their conditions, patients bite down on foam "bite blocks" before they are put fully under.
Flashlight-shaped paddles coated with a blue conductive gel are placed on each temple (bilateral treatment) or one goes on the right temple and the top of their heads (unilateral treatment), depending on the type of ECT the patients need. Bilateral ECT is recommended in more severe cases of mental illness and may produce more memory loss, experts say.
Following a quick buzzing sound, patients' bodies tense for about five seconds. Patients typically wake a minute or so after the procedure and are sent off to a recovery area until the anesthesia fully wears off. They remember nothing of the treatment itself.
New patients must typically stay in the hospital for the first half of the standard dozen ECT treatments.
Spesia, the former ECT patient, said the IV injection was the most painful part of the process. The most unpleasant, he said was the hospital stay. Now, months after the process, he said the only lingering side effect has been some short-term memory loss.
"All I can remember is them giving me the rubber bite block and then them putting the (anesthesia) mask on and telling me to breathe deeply." he said. "Absolutely painless."
Nancy Kish, a 74-year-old Fort Myers resident who has received dozens of treatments over the years, said her memory of treatments from years past is fuzzy but that her mind is otherwise as sharp as it has ever been. She said the treatment is a better alternative to the high doses of medication she otherwise took, drugs that largely left her bed-ridden.
"I feel pretty good," said Kish. "I get upset easy, and I get anxiety attacks. But other than that, I'm better than what I was."
Much like therapeutic mystery behind anti-depressant medication experts are not exactly sure why ECT works for some patients.
Mazzorana said two theories dominate: One says that electroconvulsive therapy enhances certain beneficial brain chemicals that are lacking in different parts of the brain. Another states that it causes the release of hormones that have a beneficial effect on mood and promote the growth of healthy brain cells, he said. Other recent research suggests that ECT works by reducing "hyper-connectivity" in the minds of severely depressed patients.
Endorsements
Whatever the exact mechanism, ECT's endorsements include the American Psychiatric Association, the American Medical Association, and the U.S. Surgeon General.
"When you raise ECT, people's eyes always roll up in their heads and their family says, 'Oh my God, you're a monster!'" said Fort Myers psychiatrist Steve Machlin, who performed the procedure more than a decade ago for Lee County's last inpatient psychiatric hospital, the now-shuttered Charter Glade Hospital. "There's always going to be people on the outside who say it's not proven but, if you've looked at the science, it's been proven to be effective."
Another Southwest Florida psychiatrist and researcher, Fred Schaerf, said opposition to the treatment is largely anti-psychiatry bias and from the treatment's early days, when it was performed without anesthesia.
"I think there is a misconception about the treatment - that it's barbaric, cruel," Schaerf said. "It has to do with that stigma and people's belief system with psychiatry."
Dr. Arias, the Riverside Behavioral Center physician, said the treatment was hard to find a decade ago in Southwest Florida, but largely for economic reasons.
Most insurance, including Medicare, covers the treatment. But most physicians didn't want to offer it in years past because of the low payments for it and the cost of malpractice coverage, he said. Those rates have improved in recent years, he said.
Edson, the Park Royal Hospital business development director, said the health center generally charge insurers $500 a treatment, though that does not include the costs of the anesthesiologist and hospital stay. Mazzorana said the total cost is about $1,000.
Arias, who is not connected to Park Royal or familiar with its operation, estimates that a physician generally earns $100 per treatment; the anesthesiologists earns about $300; and hospitals earn about $700.
Opposition
Medical and patient endorsements aside, some patient groups believe it does little more than cause brain damage. A quick Internet search turns up a long list of anti-ECT websites, many of which include testimonials from people claiming to have suffered negative effects from the treatments.
Among the most vocal opponents is the Philadelphia-based National Mental Health Consumers' Self Help Clearinghouse, which urged the U.S. Food and Drug Administration in 2011 not to reduce federal oversight of ECT devices. It also sharply criticized the Surgeon General's endorsement of ECT in 1999.
The group points to published studies suggesting that ECT leads to memory loss and may be far more dangerous for the elderly than medication alone. Susan Rogers, the organization's director, said patients aren't warned enough about the risks.
"People are not given the opportunity for truly informed consent," said Rogers, who has not had the procedure herself. "People are not advised of the enormous risks as well as the benefits. They're given a whitewashed version of the facts. They're not told it might cause permanent cognitive impairment, and I think that's wrong."
She said she is not opposed to the treatment itself.
"Apparently about 100,000 people a year receive ECT in the United States and, I'm sure for many of those people, they're satisfied with those results," she said. "There are also many people who feel that ECT has destroyed their lives."
The psychiatric community commonly uses the 1 in 10,000 patients mortality figure (or 1 per 80,000 treatments), figures anti-ECT groups say dramatically under-estimates the risk, particularly among older patients. A 1995 USA Today investigation found that it may have been as high as 1 in 200 among elderly patients, based on some state reports at the time and some earlier studies.
A recent Veterans Administration review of ECT between 1999 and 2010 found no ECT deaths at VA hospitals during that period. It placed the mortality risk at 1 per 14,000 patients, or 1 per 73,400 treatments.
Florida does not closely track ECT usage. But Texas, which does, reported that none of the 2,079 patients receiving ECT last year died during the procedure. Two died shortly after treatment in 2012, the state report noted, but neither case was related to the treatment.
Five years of reports show that roughly 2 percent of patients experience some level of memory loss shortly after treatment.
None of Park Royal's ECT patients have died during the procedure, said Christina Brownwood, the hospital's ECT coordinator. Nor have any needed emergency medical care immediately after a treatment, she said. Mazzorana said treatment is immediately stopped for patients showing any signs of significant memory loss.
"In reality, the procedure is not really that dangerous," said Arias, the Charlotte County physician who has performed the treatments since 1995. "At least what I've seen in my practice. We haven't seen any complications."
Fort Myers News-Press
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