A Brief History of Electroshock Therapy (ECT)
Almost everyone who I know who has undergone electroshock therapy and every
doctor associated with mental illness treatment seems to know the same horrible
story of Ugo Cerletti, the Italian psychiatrist, who in 1938 came up with the
idea for treating human beings with electroshock therapy. Cerletti was observing
the barbaric act of slaughterhouse pigs being electrocuted into unconsciousness
to make it less difficult for workers to slit their throats and thought that it
could be applied to the treatment of mental illnesses in human beings. Its
not too pleasant of an image to think about while youre laying on a gurney
about to go into the operating room for your first treatment.
The concept of having electricity pass through your brain is daunting enough
to frighten even the most educated of people. The reputation of electroshock -
- also referred to as electroconvulsive therapy or ECT by proponents - - has suffered.
Not more than a year after Cerletti got his brilliant idea, the New York State
Psychiatric Institute introduced ECT into the United States.
For the next thirty years, hundred of thousands of patients of all ages, received
electroshock treatments for every type of disorder including depression,
mania, schizophrenia and even homosexuality and truancy.
But by the end of the 1960s, electroshock had almost vanished from the psychiatric
scene. The film One Flew Over the Cuckoos Nest was released
in 1975. Jack Nicholson played the unforgettable character who is given unwanted
and unnecessary electroshock treatments and his fellow patients on the ward were
portrayed as lobotomized-looking, hollowed-out souls who had trouble recognizing
friends and family. Their capacity for speech and language had been damaged and
they often ended up needing to be institutionalized. "Cuckoos Nest"
played a major role in discrediting ECT.
It was the great leap in creating psychotropic medications, especially antidepressants,
which were able to do what electroshock therapy was supposed to do but even more
efficiently, that slowed down the use of ECT. Soon, ECT was put on hold
- - it was performed less frequently. These new psychotropic medications were
not nearly as barbaric as jolting a patient with an electrical current and inducing
a grand-mal seizure.
The Procedure of ECT
ECT is usually administered to patients in a series of treatments, ranging
from six to twelve treatments over a two week period. Most of these patients have
had no success on antidepressants or mood stabilizing medications.
The patients heart rate is monitored throughout the procedure, which
actually lasts no more than ten minutes in the operating room. He receives an
IV of an anesthetic (i.e. Brevital) in his arm and usually is asked to count (I
was asked to count backwards) until he becomes unconscious. Then an IV of succinylcholine
is put in the arm (relaxing the muscles to prevent broken bones and cracked vertebrae),
a rubber block is inserted in the mouth to prevent biting on the tongue, a mask
is placed over the mouth so the brain is not deprived of oxygen and conducting
jelly is rubbed on the temples and electrodes connected. The doctor presses a
button and electric current shoots through the brain, causing a grand-mal seizure
for 20 seconds. Usually, the patient wakes up in about 30 minutes. I remember
waking up completely confused and not knowing where I was or what had happened.
My jaw ached, my limbs were sore and I had a horrible headache, almost as if I
had downed a Margarita too quickly!
Different 50 Years Ago
Patients in the 1950s sometimes received more than 100 treatments. The
amount of electricity used was also greater, and the waveform and the stimulus
was different. Anesthetics and muscle relaxants were not used (patients were shackled
to the gurney but there were still broken bones and vertebrae) and they were not
closely monitored. ECT today is different than it was fifty years ago. How ECT
works, with minimal damage to the patient, has a lot to do with how it is currently
administered. There are two advances that have improved the procedure. The first
is nondominant unilateral ECT, which is the use of electrodes only to the right
side of the patients head (as opposed to bilateral), protecting the left
side of the brain, the site of language and auditory memory. The other advance
has been the introduction of brief-pulse stimulus - - a quick jolt of electricity
instead of a steady stream, making it less likely that the patient will later
suffer serious problems with memory.
Side Effects of Electroshock Therapy
It is well established and documented that memory impairment is the worst side
effect and is the one most frequently cited by patients. Most ECT specialists
say that memory loss is transient and concerns principally the time immediately
after electroshock treatment. The other most common side effects are headaches,
nausea, confusion and muscle ache or soreness. Over the course of ECT, patients
may have difficulty remembering newly learned information. Some patients report
memory loss for events that occurred during the day, weeks, and months preceding
ECT. I have memory loss from the period six months before my first treatment through
the period ending six months after my last treatment (a total of thirty months).
Most of these memories return, but some patients have reported longer-lasting
problems with recall of some of these memories and some patients have claimed
they have permanent brain damage. I still am unable to recall all
my memories and the events from this period. Researchers have yet to find evidence
that ECT damages the brain. They have established that the amount of electricity
which actually enters the brain is much lower in intensity and shorter in duration
than that which would be necessary to damage the brain. But there are cases of
patients who have reported improved memory ability following ECT because of its
ability to remove the amnesia that is sometimes associated with severe depression.
How Electroshock Therapy Might Work
What is most incredible is that doctors do not know why ECT actually works
to fight mental illnesses, which often makes making a decision to have ECT even
more difficult for a patient. It seems so unscientific and remains a mystery.
But here are the major theories:
* Neurotransmitter theory. Shock works like antidepressant medication,
changing the way brain receptors receive important mood-related chemicals, such
as serotonin and dopamine and norepinephrine.
* Anti-convulsant theory. Shock-induced seizures teach the brain to resist
seizures. This effort to inhibit seizures dampens abnormally active brain circuits,
* Neuroendocrine theory. The seizure causes the hypothalamus, part of the
brain that regulates water balance and body temperature, to release chemicals
that cause changes throughout the body. The seizure may release a neuropeptide
that regulates mood.
* Brain damage theory. Shock damages the brain, causing memory loss and
disorientation that creates a temporary illusion that problems are gone. Shock
supporters strongly dispute the theory, advanced by psychiatrist Peter Breggin
and other shock critics.
ECT and the Debate
ECT has undergone a complete image makeover in the last twenty years. It has
regained respectability. Many psychiatrists now consider it an efficient way to
relieve severe depression or to break a manic cycle for the manic depressive.
Its success rate, according to the American Psychiatric Association (APA), is
80%, considerably higher than the 50% to 60% success rate of most antidepressant
medications. And according to ECT advocates, it can restore a severely depressed
or manic patient to health in half the time it takes medication - - sometimes
as little as three weeks to reach a therapeutic level.
When I tell people that Ive had nineteen electroshock treatments, they
seem surprised that it is still being used as a treatment in this country. But
ECT has made a big comeback and is thought of as being kinder and gentler today.
Only thirty years ago, it was still being used to punish and subdue patients in
psychiatric hospitals. In the last fifteen years, the tremendous increase in treating
mental illness with medication has allowed ECT to come out of the closet.
But critics of ECT (and there are many who are quite organized and started
their own anti-ECT groups) argue that it is primitive and outdated. They also
believe that positive results are short-term and that patients who undergo ECT
suffer cognitive problems, including significant memory loss and learning. They
think that what looks like relief is really just the slap-happy
effect of a head trauma. ECTs opponents have even been so vocal and powerful
that they helped pass ordinances prohibiting the use of the treatment in some
cities - - including Berkeley, California (although the court later overturned
the ban). There are also others who argue that it is overused and point to the
fact that it is quite a lucrative treatment, usually covered by insurance.
Only five states - - California, Colorado, Illinois, Massachusetts and Texas
- - require its hospitals to keep hard statistics on electroshock treatments.
The most recent year for which the National Institute of Mental Health (NIMH)
has any ECT data is 1980, when it reported that 33,384 patients underwent shock
treatments in the United States. By 1996, that number jumped to an estimated 55,000.
And by 1998 it had doubled to 100,000. Approximately twice as many shock treatments
as tonsillectomies were performed in this country in 1998. ECTs opponents,
to prove its overuse, tend to exaggerate this number; its proponents, to demonstrate
its underuse, minimize them.
NIMH is currently studying the effects of ECT on patients who are simultaneously
taking anti-depressant medication. Their results are expected in early 2006.
Many patient advocacy groups agree that modern day ECT has come along way.
The National Depressive and Manic Depressive Association (NDMDA), the National
Alliance for the Mentally Ill (NAMI) and the National Mental Health Association
(NMHA) all recognize the value of ECT. The most recent American Psychiatric Association
task force report - - from 1990 - - calls ECT often the safest, fastest
and most effective treatment for severe depression.
Both camps are at different ends of the pole, much like the abortion issue.
The leading opponent of ECT, Peter Breggin, a psychiatrist and author, feels that
the price is too high. Taking a chance at electroshock is like playing Russian
roulette with your brain, he says. He thinks it is no more sophisticated
than hitting someone over the head with a two by four. He believes that for
a time, people become silly, shallow and giggly, like a teenager who has sniffed
glue - - or a person who has just had shock treatment. There also exist
groups around the country of unhappy former ECT patients, like the Committee for
Truth in Psychiatry, which believe that patients are inadequately informed about
the potential dangers of ECT, and lobby state and federal legislators on the issue.
Under informed consent protocol, permission to administer ECT comes
after a careful review of the treatment with the person providing consent. The
psychiatrist explains what ECT involves, what other treatments might be available,
and the benefits and risks of treatment. The person consenting to the procedure
is kept informed of progress and may withdraw consent at any time. A psychiatrist
may not force a patient to have ECT or decide for the patient that it is the appropriate
treatment. He or she must obtain written consent from the patient, or if the patient
is too ill to make decisions for him or herself, from a court-appointed guardian.
Anyone who is considering ECT should not rely only on the available information
offered by either the pro-ECT or anti-ECT camps, because both are skewed by various
agendas. You might do yourself a disservice by trying to make a decision based
on the literature. Its a difficult and personal decision.
Celebrities and ECT
In the past sixty years, a number of well-known artists, writers, actors and
politicians have undergone ECT. For some, the experience was traumatic and devastating,
while for others, it was a blessing and a salvation. Some of these celebrities
include Vivien Leigh, Tammy Wynette, Dick Cavett, Ken Kesey, Ernest Hemingway,
Michael Moriarity, Lou Reed and Yves Saint Laurent.