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Electroconvulsive therapy: a retrospective

Electroconvulsive Therapy (ECT), formerly known as shock therapy, is ‘ a psychiatric treatment in which seizures are electrically induced in patients to provide relief from mental disorders’, Rudorfer, Henry, and Sackeim (2003). It is a treatment that has attracted sharply conflicting views since its conception and popularisation in the 1930s and 1940s by Italian neurologist Cerletti, and remains a polarising treatment to this day.

Among ECT’s most outspoken critics are Friedberg (1977) and Breggin (2007), who claim that it is ‘ no more than an anachronistic relic of a barbarous psychiatric past’, reminding readers of the negative association ECT shares with the lunatic asylums of the early 19 th century. Conversely, the American Psychological Association (1990) have supported the treatment, citing it as ‘ safe, effective and often life-saving, with a better side effect profile than drugs’.

Before exploring ECT further, it must be acknowledged that it was used indiscriminately in the past (Leechuy, Abrams & Kohlhaas 1988) and therefore has a legitimate bases for it’s poor reputation; during the 1940s and 1950s, it was used without proper consideration, and was extremely frightening to patients (Sabbatini, 1997). Difficult patients have been documented to have received several shocks a day, many times without proper restraint or sedation. Medical historian Rothman (1985) summarised this dark period of psychiatric history by saying that ‘ ECT stands practically alone among the medical and surgical interventions, in that misuse was not [performed with] the goal of curing, but of controlling the patients for the benefits of the hospital staff’.

From the historical beginnings of the old armamentarium in the 19 th century when moral treatment and non-restraint were encouraged by asylum doctors, sometimes questionable methods were still used to pacify patients. Some of these, such as purging and ECT, appalled the public both historically and contemporaneously, and have contributed towards the negative stigmatisation of mental illness.

Shock therapy had its beginnings with convulsants such as cardiazol and metrazol, as it was thought this would counteract the effects of schizophrenia by effectively jolting the brain to its ‘ default’ setting (Fink, 1984). ECT took this further and was popularised in the 1930s by Cerletti, with experimentation on animal subjects initially, then once the process was refined, human subjects suffering acute schizophrenia were tested. Surprising changes to patients included the development of retrograde amnesia, or a loss of all memory of events immediately before the shock (Fink, 1984); this meant that patients had no memory of discomfort, and therefore, no negative feelings towards the therapy. Furthermore, ECT was more reliable, controllable, and less dangerous than the drug-induced seizures of the past.

In the 1940s, further research on Cerletti’s methods uncovered positive effects on affective disorders; according to Thienhaus, Margletta, and Bennett’s clinical study (1990) 90% of cases of severe depression which were resistant to drug treatments disappeared after three or four weeks of ECT, displaying the great efficacy of what was judged to be a barbaric practice. It was then that ECT began to be viewed as the shock therapy of choice in the majority of hospitals and asylums around the world, replacing the use of often dangerous drugs.

ECT has become more refined in the modern day, including the use of synthetic muscle relaxants and the anaesthesia of patients to ease any potential discomfort. Despite these advances, the popularity of ECT dramatically declined in the 1960s and 1970s due to the use of more effective drug treatments and as a reaction to the strong anti-ECT movement of the time (Sabbatini, 1997).

This counter-culture mentality took root against institutionalized psychiatry as a whole, beginning largely in Europe and the USA. Together with popularised psychosurgery such as frontal lobotomies, ECT was denounced by both the mass media and the public as a cruel and unnecessary practice (Goodie, 1991). Perhaps one of the most famous examples of the cultural rejection of ECT comes in the form of Kesey’s (1962) novel One Flew Over the Cuckoo’s Nest, within which is depicted an extremely grim telling of the use of ECT in an American institution. These negative views presented in the media led to a series of legal actions involving the abuses of shock therapy, which in turn led to the therapy falling into disrepute among the public.

In the face of such criticism, it is perhaps no surprise that the use of ECT declined in the 1960s and 1970s with the psychotropic revolution that brought somatic drug treatments, such as antipsychotics, to the foreground for treating mental health conditions. It would be several years before psychological research once again took up the mantle of ECT and sought to gain evidence in support of its efficacy.

ECT is the only somatic treatment from the 1930s that remains in use today, with between 100, 000 and 150, 000 patients receiving it every year in the USA (Satcher, 2000). It is clear that lessons of responsibility and patient dignity have been learned from the backlash of ECT’s somewhat chequered past; modern use is subject to strict regulations and a very specific target population of individuals suffering from severe depression (Weiner & Prudic, 2013). Furthermore, the issue of informed consent was addressed in 1978 when The American Psychiatric Association released its first task force report in order to assure ethical standards.

Testimonies of former patients, questionnaires around public opinion, legal restrictions on use, and disputes as to the efficacy of ECT indicate that its use remains controversial (Fisher, 2012; Whitaker, 2010). While the bleak beginnings of this therapy and the unnecessary suffering it caused to asylum patients cannot be ignored, neither can the recent explorations suggesting its effectiveness. Psychiatry as a whole has largely cast off the negative connotations from the time of lunatic asylums, however ECT remains harshly judged by memories of that period. It is still a controversial treatment approach, however there seems to be strong evidence in support of its usage, and perhaps it is time to re-examine the predominantly negative view that is still perpetuated by the mass media.

Reference List

Breggin, P. R. (2007). ECT Damages the Brain: Disturbing News for Patient’s and Shock Doctors Alike. Ethical Human Psychology and Psychiatry , 9 (2), 83.

Fink, M. (1985) Convulsive Therapy. New York: Raven Press.

Fisher, P. (2012). Psychological factors related to the experience of and reaction to electroconvulsive therapy. Journal of Mental Health , 21 (6), 589-599.

Frankel, F. H. (1990). The 1978 and 1990 APA Task Force Reports.

Friedberg, J. (1977). Shock treatment, brain damage, and memory loss: a neurological perspective. Am J Psychiatry, 134(9), 1010-1014.

Goode, E. (1999). Federal report praising electroshock stirs uproar. New York: New York Times.

Kesey, K. (1962) One flew over the cuckoo’s nest. Oregon: Penguin Publishers.

Leechuy, I., Abrams, R., & Kohlhaas, J. (1988). ECT-induced postictal delirium and electrode placement. Am J Psychiatry , 145 (7), 880-881.

Paterson, A. Spencer. “ UGO CERLETTI 1877-1963.” The British Journal of Psychiatry 110, no. 467 (1964): 599-600.

Rothman, D., J. (1985) Electroconvulsive Therapy. NIH Consens Statement, 5 (11), 1-23.

Rudorfer, M. V., Henry, M. E., & Sackeim, H. A. (2003). Electroconvulsive therapy. Psychiatry , 2 , 1865-1901.

Sabbatini, R. M. (1997). The history of shock therapy in psychiatry. Brain Mind Electron Mag Neurosci , 4 .

Satcher, D. (2000). Mental health: A report of the Surgeon General–Executive summary. Professional Psychology: Research and Practice , 31 (1), 5.

Thienhaus, O. J., Margletta, S., & Bennett, J. A. (1990). A study of the clinical efficacy of maintenance ECT. The Journal of clinical psychiatry .

Weiner, R. D., & Prudic, J. (2013). Electroconvulsive therapy in the United States: How often is it used?. Biological psychiatry , 73 (2), 105-106.

Whitaker, R. (2010). Mad in America : bad science, bad medicine, and the enduring mistreatment of the mentally ill. New York: Basic Books.

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