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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. It’s not too pleasant of an image to think about while you’re 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 Cuckoo’s 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. "Cuckoo’s 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 patient’s 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 1950’s 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 patient’s 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, stabilizing mood.

* 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 I’ve 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. ECT’s 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. ECT’s 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.

Informed Consent

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. It’s 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.

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