Electroconvulsive therapy

A 1960s-era ECT machine

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Electroconvulsive therapy (ECT), also known by the now-disfavored terms electroshock therapy or shock treatment, is one of the most controversial aspects of 20^th and 21^st century psychiatry. The idea that strapping a distressed patient to a bed and artificially inducing seizures via shocks to the brain can have a worthwhile, safe, and therapeutic effect for mood is as ridiculous as it sounds.

ECT has had a roller-coaster ride in reputation: once viewed as a miracle cure, it became (along with the equally maligned practice of lobotomy) a symbol of the evils and undeniable ethical failures of psychiatry in the 1960s to today. ECT has been "applied in clinical practice for over 70 years", and today is mainly used on severe and vulnerable depressives, such as those who did not respond to drug interventions and could not or would not escape psychiatry altogether. ECT is performed involuntarily on many such patients, including today, against United Nations advice. A Neuropsychopharmacology Journal study found that ECT produces slow reaction time as well as severe and persistent retrograde amnesia. A separate study concludes that up to half of ECT patients report persistent memory loss. A metastudy of 91 studies found no evidence that ECT performs better than placebo.

According to the US FDA, "The long-term safety and effectiveness of ECT treatment has not been demonstrated."

History

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It is sometimes claimed that the idea behind ECT comes from a doctor visiting a slaughterhouse, seeing a pig being electrically stunned before death, and noticing its surprising appearance of calm. Actually, the idea behind ECT is very old, and goes back to early observations of epilepsy patients, who often appeared calm and peaceful after a seizure. Although the mechanisms of mental illness or mental function were largely uncomprehended, chemically-induced seizures were sometimes used for 'therapeutic' purposes as far back as the 16^th century, and were a common part of the therapeutic arsenal from the 18^th century. Admittedly, this was not a terribly effective 'therapeutic' arsenal, with 18^th and 19^th century fashions ranging from fresh air, sunshine, and exercise (moral treatment) to corporal punishment, bloodletting, bizarre devices involving spinning chairs, and use of restraints.

Almost as soon as electricity began to be studied scientifically, people wondered about the effects it would have on the human body and on animals. Some of the earliest research took place in Alessandro Volta's experiments with frogs. This led to wide use of electrical shock therapy by the 19^th century for applications including weight loss, toothache, and neuralgia. This early use was generally quackery, as science-based medicine was just beginning to catch on.

The modern application of induced seizures in psychiatry goes back to the 1930s. Hungarian psychiatrist Ladislas J. Meduna experimented with chemically-induced seizures as a treatment for schizophrenia, using camphor and metrazol (cardiazol). Ugo Cerletti and Lucio Bini in Italy began to experiment with electric shocks in the late 1930s. At the time there were few other options for treating serious mental illness. By the mid-1940s, ECT was widespread in western Europe and North America.

Past criticism

Starting in the late 1950s hostility began to grow in some sectors of society towards psychiatry, broadly labeled as the anti-psychiatry movement. Psychiatry was seen as an instrument to impose conformity on the population and turn creative individuals into automatons. Ken Kesey's novel One Flew Over the Cuckoo's Nest and its 1975 film adaptation cemented ECT's reputation in the popular mind as a brutal implement of social control akin to torture. Psychiatrist Alan Stone suggested in the 1960s that the book's portrayal of institutional malpractice was not far from the truth, describing his experience as an army doctor: "The Colonel in charge of the psychiatric unit prescribed a course of 20 to 25 unmodified ECT’s for virtually every soldier requiring admission to the inpatient unit." ECT is still portrayed to this day in media as a dire terror, such as in the TV drama Homeland.

ECT, particularly in its earlier years, was sometimes done with little care and minimal pain relief or anaesthesia. It can potentially have serious side effects. These include retrograde amnesia (although this was often seen as a positive side effect if the patient could not remember the traumatic treatment). Patients are often confused and disoriented after therapy, and can also experience anterograde amnesia (memory loss for a short time after treatment). There is also a serious risk of physical trauma, including broken bones, from convulsions if the patient is not sedated. There are also risks of hypoxia or anoxia causing brain damage, particularly if the patient is heavily sedated and not monitored properly. Thus, although ECT worked on some patients, the negatives were significant. A particular issue was that of informed consent. ECT was sometimes forcibly administered, as Stone described, and even patients who opted for the treatment were not made aware of the risks. It is still involuntarily administered today.

While psychiatry makes mistakes and many patients' rights are still not respected, the anti-psychiatry critique omits the fact that without a harmful placebo, many people would be unable to lead any kind of normal life, or would be dead.^{[citation needed]} In the 1940s, there were few other effective options for treatment for serious mental illness. Apart from ECT, other traumatic or potentially dangerous treatments were also used in the 1950s and 1960s, such as the insulin subcoma therapy, which was administered to John Nash (as depicted in the film A Beautiful Mind). The decline in popularity of ECT coincided with the development and introduction of many psychiatric medications.

Efficacy and safety

Today, ECT is broadly accepted in psychiatry as a treatment for severe depression. It is not routinely used for schizophrenia or mild or moderate depression. The American Psychiatric Association says, "ECT is an effective antidepressant in all subtypes of major depressive disorder". Perrin calls it "the most potent treatment in severe depression". Charles H Kellner says, "ECT is the only 'somatic' treatment from the early 20^th century that has survived. It has done so because of its unparalleled efficacy and safety. ECT is the most effective antidepressant treatment we have; response rates are typically in the 60% to 90% range." A 2008 study found it "highly effective in severely treatment-resistant patients with major depressive disorder". In severe depression it has been shown to be superior to placebo ECT, where the patient is anaesthetised and otherwise treated as if they would be getting ECT, but does not receive a shock.

The exact mechanism of action is still not fully understood, but the same is true of many, many accepted medical treatments, including many widely-used drugs. Research shows that ECT affects blood flow in the brain and brain chemistry, and may promote the growth of new neurons and neuron pathways. It is hypothesized that the therapeutic effect is not a direct result of the electric shocks, but rather of the resulting seizures.

Headaches, amnesia, memory loss, and confusion are common effects. Issues of informed consent have improved greatly; Kelner says "because ECT is so closely scrutinized, more attention is paid to the process of informed consent with ECT than for most other medical procedures. Patients are given detailed information about the medical and cognitive risks of ECT; when balanced against the risks of remaining seriously depressed, many patients choose to have the treatment."

Other side effects may include tooth damage and other damage to the mouth. Longer-term memory impairment has been reported, although this may also be caused by the depressive illness itself.

Adverse cognitive effects due to ECT treatment were found as late as 6 months after acute ECT treatment. Such effects could last longer, however the relevant study did not track these symptoms after 6 months.

Clinical use today

Throughout its history there have been improvements in ECT, to make it more effective and reduce side effects. These include changes to reduce the electrical current received by the patient, by moving from sine wave sources to brief pulses, and precautions to protect the patient from physical convulsions. Both bilateral and unilateral ECT may be used; the former passes a current across the entire brain while the latter is administered to only one brain hemisphere, which can reduce side effects but also may be less effective.

In modern practice, general anaesthesia and muscle relaxants are administered before therapy. The patient is unconscious for the procedure, which lasts around 30 minutes. It commonly takes 4 or 5 treatments over 2-3 weeks before improvement; up to 12 treatments may be given at 2 a week. Patient Lucy Tallon described the modern experience as quite unlike the media depictions of patients strapped down and electrocuted against their will: "You go in, have your blood pressure taken, sign a form, lie down, go to sleep, wake up with a slight headache and go home. And often, you feel instantly better."

ECT is used either in situations where other therapies have failed, or where very rapid improvement is important. In the UK it is used primarily for severe depression after the failure of medication and talking therapies; also as a potentially rapid solution for postnatal depression where it is important to allow the mother to bond with her baby as soon as possible; and more rarely for extreme manic episodes or catatonia.

Modern opposition

As well as a general public suspicion based on old ideas of what treatment involves (brain-frying), there is more some fundamental opposition to ECT. This is mainly from modern anti-psychiatry campaigners who oppose all psychiatry.

This includes the British group Speak Out Against Psychiatry. SOAP opposes virtually all psychiatric treatment other than talk therapy, believing (incorrectly) that most schizophrenia is caused by child sexual abuse, psychiatric medications have no effect even on severe depression, ADHD has no scientific basis, and ECT is "just about useless".

Scientology, and its front organisation the Citizens Commission on Human Rights, condemns all psychiatric treatment from drugs to ECT (or "electro–convulsive therapy that caused broken teeth and bones, not to mention loss of memory and regression into a vegetable state") for "negating the spirit itself — claiming that all is physical and only so much matter and chemicals." Despite the large body of evidence supporting ECT, Scientology in the US has called for arduous and expensive re-testing of ECT equipment.

Notable recipients

A number of famous people have received ECT, with variable results. This is no more than anecdotal evidence.

• Sylvia Plath, who suffered from mental illness from her teens and made a number of suicide attempts before her 1963 death, received it in the early 1950s.
• Lou Reed, who went on to write "Kill Your Sons" about his experience.
• Ernest Hemingway received ECT in the early 1960s.
• Peter Green of Fleetwood Mac, who suffered from schizophrenia, received it in the 1970s.
• Carrie Fisher, who had a long history of bipolar disorder, described receiving ECT in her autobiographical writings such as Shockaholic. She wrote that it had "done me a lot of good".
• David Foster Wallace received it in the years prior to his 2008 suicide.