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Electroconvulsive therapy

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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 20th century psychiatry, a potentially useful treatment for mental illness that nonetheless inspires enormous fear. The idea that electric shocks to the brain can have a positive effect seems ridiculous, especially in view of other applications of electricity, such as killing elephants and convicted felons, and its use in torture. But these days, we hopefully base medicine on evidence, not fear or novelty.

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 perceived evils and undeniable ethical failures of psychiatry in the 1960s. Although the mechanism of action isn't entirely understood, there is evidence that ECT is effective in treating certain psychiatric disorders. ECT has been "successfully applied in clinical practice for over 70 years",[1] and today is mainly used for serious depression where other treatments have failed. Despite some side effects it is generally believed to be safe in the long term, and far preferable to suffering from severe depression.

History[edit]

Victor Frankenstein stands in his lab, waiting for a lightning bolt to surge through his experimental apparatus and spark his hideous collection of dismembered corpse-pieces back into life…

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.[2] 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 16th century, and were a common part of the therapeutic arsenal from the 18th century.[3] Admittedly, this was not a terribly effective therapeutic arsenal, with 18th and 19th century fashions ranging from fresh air, sunshine, and exercise (moral treatmentWikipedia's W.svg) 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 19th century for applications including weight loss, toothache, and neuralgia.[4][5] 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. MedunaWikipedia's W.svg experimented with chemically-induced seizures as a treatment for schizophrenia, using camphor and metrazol (cardiazol). Ugo CerlettiWikipedia's W.svg 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[edit]

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,[6] 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."[7] ECT is still portrayed to this day in media as a dire terror, such as in the TV drama Homeland.[8]

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. Today even mentally-ill patients are expected to make a rational decision about their own treatment; back then, ECT was sometimes forcibly administered, as Stone described, and even patients who opted for the treatment were not made aware of the risks.[9]

While psychiatry did certainly make mistakes and patients' rights were not always respected, the anti-psychiatry critique omits the fact that without it many people would be unable to lead any kind of normal life, or would be dead. 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).[6] Fortunately, the decline in popularity of ECT coincided with the development and introduction of many effective psychiatric medications.

Efficacy and safety[edit]

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.[10] The American Psychiatric Association says, "ECT is an effective antidepressant in all subtypes of major depressive disorder".[11] Perrin calls it "the most potent treatment in severe depression".[1] Charles H Kellner says, "ECT is the only 'somatic' treatment from the early 20th 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."[9] A 2008 study found it "highly effective in severely treatment-resistant patients with major depressive disorder".[12] 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.[10]

The exact mechanism of action is still not fully understood,[1] 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.[10]

Although headaches, amnesia and confusion are still common side-effects,[10] the medical consensus is that ECT does not typically cause brain damage or lasting cognitive impairment.[13] 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."[9]

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.[10]

Clinical use today[edit]

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.[10]

In modern practice, general anaesthesia and muscle relaxants are administered before therapy. The patient is unconscious for the procedure, which lasts around 30 minutes.[10] It commonly takes 4 or 5 treatments over 2-3 weeks before improvement; up to 12 treatments may be given at 2 a week.[10] 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."[8]

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.[14]

Modern opposition[edit]

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.[15] 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".[16]

Scientology, and its front organisation the Citizens Commission on Human Rights[17], 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."[18] Despite the large body of evidence supporting ECT, Scientology in the US has called for arduous and expensive re-testing of ECT equipment.[11]

Notable recipients[edit]

A number of famous people have received ECT, with variable results.[19] 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.
  • 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".[20]
  • David Foster Wallace received it in the years prior to his 2008 suicide.

External links[edit]

References[edit]

  1. 1.0 1.1 1.2 Electroconvulsive therapy reduces frontal cortical connectivity in severe depressive disorder, Jennifer S. Perrin et al, PNAS, vol. 109 no. 14, 5464–5468
  2. Ugo Cerletti: A Brief Biography, Cerebromente
  3. See the Wikipedia article on Electroconvulsive therapy.
  4. Victorian electric shock therapy machine, Antiques Atlas
  5. Electric Shock Therapy Machine, St Andrews Preservation Trust
  6. 6.0 6.1 Electroconvulsive and Neuromodulation Therapies, Conrad M. Swartz, pp 210-211
  7. Quoted in Some Reflections on Electroconvulsive Therapy, Past and Present, History of Psychiatry blog, 15 Sep 2010
  8. 8.0 8.1 What is Having ECT Like?, Lucy Tallon, The Guardian, 13 May 2012
  9. 9.0 9.1 9.2 ECT Today: The Good It Can Do, Charles H Kellner, Psychiatric Times, September 14, 2010
  10. 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 Information about ECT (Electro-convulsive therapy), Royal College of Psychiatrists
  11. 11.0 11.1 FDA Considers Caving to Scientology and Making Mental Illness Treatment Illegal, Huffington Post, 18 March 2010
  12. "The effectiveness of electroconvulsive therapy in treatment-resistant depression: a naturalistic study", Khalid N, Atkins M, Tredget J, Giles M, Champney-Smith K, Kirov G., J ECT. 2008 Jun;24(2):141-5. doi: 10.1097/YCT.0b013e318157ac58.
  13. Electroconvulsive therapyWikipedia's W.svg
  14. About ECT, Mind website (British mental health charity)
  15. Crusade for Better Mental Health: 7,000 shock treatments on NHS condemned for brain damage, Lucy Johnston, Daily Express, 6 May 2012
  16. Mainstream psychiatry is failing – but there is another way, John Hoggett, The Guardian, 25 July 2011
  17. Scientology and psychiatryWikipedia's W.svg
  18. Scientology's basic objection to psychiatry, Scientology.org.au
  19. List of people who have undergone electroconvulsive therapyWikipedia's W.svg
  20. Quoted in MedPage Today