You win.

The f irst time she came in my office, she asked if she could lie on the floor. She was already slumped down in her chair as far as possiblewithout falling out of it. Shewas Bso tired[ that sitting upright seemed like a chore. She had no makeup and looked like she had just risen from bed, although it was late afternoon. Eye contact was nonexistent. Her husband was with her, as was the Bsitter. [ The husband had arranged a sitter to be with the patient, so that he could occasionally get out of the house. The patient could not, or would not, cook or perform basic household duties without companionship. She had failed all reasonable medication options and was clearly miserable and functionally impaired. We discussed electroconvulsive therapy (ECT), she consented, and thus, we commenced a course of outpatient, high-dose right unilateral ECT. The course was uncomplicated, side effects were unremarkable, and clinical result was very successful. She and her husband flew out of state to a large family function 1week after her ninth acute ECT session. Her husband said that she took care of all her own personal needs while on the trip, fully participated in the family activities, and generally appeared well. No cognitive problems of any kind were noted. The patient returned to my office after her trip, now 2 weeks since the end of acute ECT. She no longer needed a sitter to stay with her. Her hair was styled; makeup was tastefully applied. She sat straight up right across from me and looked at me intensely declaring BECT is not helpingme. [ In the background, her husband silentlymouthed thewords Bit is helping her. [ Given the severityof this episodeof illness and thehigh risk for relapse, I recommended that she begin a time-limited course of outpatient continuation ECT to protect the gains she had made. BI hate ECT; I do not like it,[ she said. I said, BI am not asking you to like it, I am asking you to do it for health reasons. [ She turned to her husband and said Byou win,[ and agreed to come to her first continuation treatment, which was today. This case is unremarkable in many respects, yet contains a few useful lessons. First, patients are usually the last to appreciate the benef its of ECT, long after the family, health care providers, and friends note improvement. This presents a challenge in how to frame the results of the treatment to the patient. It would be foolish to tell the patients that they feel great when they say they feel bad. The only solution is to acknowledge that both facts are true at the same timeVthat she feels bad, yet looks so much better to everyone else, and is functioning at a much higher level. The patient must be convinced of the value of the family’s and doctor’s judgment, even if it contradicts her self-assessment. The doctor walks a clinical tightrope that bridges respect for the patient’s experience, while emphasizing the reality of the observable improvement in affect and behavior. The second lesson is the need to acknowledge that patients do not like ECT. This is no more cause for alarm that a patient who expresses dislike for colonoscopies, dialysis, or any other medical or surgical procedure. Indeed, I would be worried about a patient who said they liked ECT! It is best to tell the patient, Bof course you don’t like it, and I am not asking you to like it, but this is what you have to do to be well, and to stay well. [ The third lesson is the importance of family or other support in the successful completion of ECT. As I have noted elsewhere, family can play a key role in consent to treatment and completion of a course of ECT. Although it is true that the patient suffers and is the one who signs the consent form, all families suffer when onemember is experiencing depression. In this respect, consent and completion of ECT ideally are a family process.Whenmy patient mouthed the words Byou won[ to her husband, in actuality she was showing the good judgment of a person who knows that disease and its treatment involve decision making that is bigger than she is and acknowledges her role as a member of a family unit.