I had to read the nurse’s note twice. “Patient complains he is dead,” it said.
I looked over at room 4B, the emergency room’s psychiatry unit, where an elderly man in a terry-cloth robe was sitting, head down, shoulders hunched. He looked depressed and toothpick thin but clearly alive.
I walked into the room, flipping through his medical records. The patient was an 82-year-old widower who resided in a South Carolina assisted-living facility nearby. He had a history of hypertension, mild senile dementia, and depression. He was taking several medications, including an antidepressant. His wife had died three years ago. His health had been stable until three months ago, when he began losing weight. During that time, he had lost more than 10 pounds. Aside from the recent depression, he had no history of psychiatric illness.
“Hi,” I said to the man. “How are you doing?”
“Leave me alone,” he said irritably, massaging one hand with the other. “I’m dead.”
I didn’t know what to say next, so I said what I usually say: “How long has this been going on?”
He kept wringing his hands. “Since about 7:30.”
“Yeah. Just after breakfast.”
“Oh,” I paused to find the right words. “How do you feel now?”
He lifted his head to look at me, clearly irritated. “I’m dead. How do you expect me to feel? Just look around. Can’t you see? Evil and death. It’s everywhere. It’s coming out of the walls. It’s all over. Evil has taken over the world.”
I didn’t know how to categorize the chief complaint. Was it physical? Psychiatric? The patient was delusional, technically a psychiatric complaint, but delusions in the elderly often result from organic disease. The patient could think he was dead for such reasons as simple pneumonia, increased pressure in the brain, or an abnormal accumulation of copper. All of these conditions can cause delusions.
I ordered a number of tests for organic imbalances that can affect mental function. But an hour later, I was no further along. All the results proved normal, and the patient only looked worse. He sat rocking steadily, back and forth, in anguish.
Severe depression is a soul-wrenching, psychic black hole. Hippocrates described it first: “The patient feels something like a thorn stinging his innards. He flees from light and from people, loves the dark, and he is caught by panic. He is terrified and sees frightening visions, dreadful nightmares, and sometimes dead people.”
Doctors once called this condition involutional melancholia—the deep, deep despair of old age. Modern medicine has folded the diagnosis into the disorder known as major depressive episodes with psychotic features. But keeping the ancient view of involutional melancholia as a distinct entity is useful because it underscores that the elderly are particularly vulnerable. Among this group, depression can be punishingly severe and, in some cases, nearly impossible to treat successfully. This patient’s prognosis was not good.
The social worker had a different take. After interviewing the patient, she chirped, “Well, he’s a bizarre little guy.”
“I think he’s very depressed.”
“Well, whatever . . . I think he can go home, and we’ll send a social worker.”
“That man,” I told her, “needs to be admitted to the hospital.”
“Because he’s depressed? But he’s not suicidal or homicidal.” Impulses to kill oneself or others are the two main symptoms that mandate hospitalization.
“Of course he’s not suicidal,” I shot back. “He doesn’t need to be suicidal. He’s already dead.”
“I don’t think he’s depressed,” she said. “I think he’s just senile.”
Rather than answer her, I sat in silence, my head in my hands. Depression in the elderly can mimic many conditions, including Alzheimer’s disease. I had learned this firsthand when my father entered his worst stage of Alzheimer’s. In addition to being confused, he became very despondent. “I’m watching myself die, aren’t I?” he once asked. I thought his despair was just a normal reaction to the trauma of losing one’s bearings. He tried an antidepressant, though, and after six weeks of treatment, his mood markedly improved. He remained as confused as ever but somehow not as miserable. Despite the disease, he became somehow more like my dad. Depression seemed to take more away from him than Alzheimer’s did.
We finally did admit the patient. I forgot about him until a few days later, when I visited the psychiatry ward for another reason. The patient was seated in the day-room, looking even thinner than when I last saw him. He was still wearing the same bathrobe. His hand-washing gestures were gone. He sat immobile.
His middle-aged son was visiting, and he motioned me to a corner. “He’s even worse than he was before,” he told me. “And what’s more,” he dropped his voice to a whisper, his face stricken, “the doctor says he wants to shock him.”
Shock him. Electroconvulsive therapy. ECT. The term shock therapy conjures up an image of Frankenstein’s monster: Someone strapped to a table while the doctor pulls a huge switch. Decades after its introduction, ECT remains shrouded in controversy. Even these days, when failing hearts are routinely sparked with defibrillators, shocking the brain carries the distant echo of Soviet psychiatric wards and the 1948 film The Snake Pit. Yet in certain situations, ECT is the most effective therapy available. For some patients, it is their only hope.
“I’m not surprised,” I told the son.
For centuries, electricity has been exploited for medical uses. The Romans touched electric eels to treat headaches, and Ethiopians touched electric catfish to cast devils out of the body. In the 16th century, the physician Paracelsus treated insane patients with inhalations of large amounts of camphor, which induced seizures and a subsequent period of calm.
By the early 20th century, physicians began exploring seizures experimentally. Two doctors in Italy—Ugo Cerletti and Lucio Bini—developed a means of safely and reliably inducing seizures in dogs by attaching electrodes to their scalps. The first person to receive this new form of therapy was a 39-year-old man found wandering about a train station in 1938. He was clearly insane—disoriented and delusional, with periods of incomprehensible speech alternating with periods of mutism. Cerletti and Bini administered a single shock of 110 volts for a fraction of a second and produced a grand mal seizure. Following the treatment, the patient awoke, sat up, and looked around calmly. The investigators asked him, “What happened to you?” The man answered, “I don’t know. Perhaps I have been asleep.” The physicians reported a full recovery after 11 treatments.
Unfortunately, the story then turns ugly. When ECT was first introduced, the treatment was brutal. The patient was strapped, usually unwillingly, to a cot, and a rubber dam was inserted between the teeth. Patients were fully conscious when they received the shock, which was intensely painful. (The man from the railway station pronounced the experience “murderous.”) The electric current induced muscular contractions severe enough to break bones. But the results were so beneficial that electroconvulsive therapy began to be used for many types of psychiatric illness. Doctors would sometimes move down a row of beds in a psychiatric ward, administering shocks to one patient after another.
Today the treatment is different. Since 1951, patients receive general anesthesia so that they are unconscious and paralyzed throughout the procedure. Electrodes can be placed on one or both sides of the brain. Often only the nondominant side of the brain, the side that is not related to language, is stimulated. This practice seems to lessen memory loss, which is the treatment’s most significant side effect. A patient who is severely depressed and has not responded to other therapies generally receives 6 to 12 treatments. Unfortunately, the relief can be relatively short-lived, so some elderly patients are scheduled for bimonthly shock treatment. In most cases, the age of a patient is not a safety issue.
How does shock therapy work? Nobody knows. Some evidence suggests that it changes the cerebral blood flow and the metabolic activity in certain parts of the brain. Methods of imaging the brain should give us more information over the coming decade.
I never had a chance to speak to the patient or his son about what electroshock therapy may or may not have done. But I did catch a glimpse of the patient after he had begun his treatments, and they seemed to be working. It was about a week after I had talked with his son. The patient sat alone in the corner of the cafeteria. He wore street clothes that hung loosely on his gaunt frame. But what impressed me wasn’t the street clothes or the interest with which he surveyed the room. I was most impressed by what he was doing. The patient had a big plate of food, and he was eating with relish.
Pamela Grim is an emergency room physician in Beaufort, South Carolina,
and the author of Just Here Trying to Save a Few Lives. The cases described in Vital Signs are true stories, but the authors have changed some details
about the patients to protect their privacy.