How Did Convulsive Therapy Originate?

In the second half of the nineteenth century, European neuropsychiatrists had identified three mental illnesses that dominated the clinical scene: neurosyphilis (described as dementia paralytica), dementia praecox (schizophrenia today), and manic-depressive insanity (now known as the two disorders of major depression and bipolar disorder). These diseases were devastating, often fatal, and no effective treatments were known. Caretakers of the mentally ill commonly resorted to chains, restraining chairs, cold and hot baths, and seclusion to control aggressive behavior. Morphine and other sedative chemicals kept patients asleep but did little to heal their illnesses. The mentally ill who were dangerous to themselves or to others were housed in large state-supported hospitals managed by hospital superintendents with full authority to treat the inmates. Lacking effective remedies, they permitted many experimental and unsafe interventions. Prolonged sleep was an experimental treatment that seemed to relieve severe depressive and agitated states. Agitated patients were kept in a stupor for days with continuing high doses of barbiturates, with periods of alertness for feeding and toileting. While some died of pneumonia, the few who recovered their senses encouraged these trials. Body infections were once thought to cause mental disorders, so to cure mental disease, the teeth, tonsils, gallbladder, and large sections of the colon were often removed even though there was no credible evidence to justify the procedures. Many patients died. The patients suffered further humiliation when hospitals did not provide false teeth to help them chew their food. Surgical removal of sexual organs was another “treatment.” Eugenicists argued for sterilization of the mentally ill, especially those who had become burdens on society. It is estimated that more than 18,000 people in psychiatric institutions were surgically sterilized during the first half of the twentieth century. The discovery of bacteria as the cause of infectious febrile illnesses was a great accomplishment of medical research in the nineteenth century. The French chemist Louis Pasteur’s demonstration that high temperatures would destroy bacteria, an observation that led to the pasteurization of foods, also suggested that fevers could have a therapeutic benefit in bodily infections. This theory was supported by improvement of psychosis in patients who survived infections with smallpox or typhoid fever.

Manic Mood Disorders

Patients suffering from mania are overactive, intrusive, excited, and belligerent. They may believe that they have special powers, are related to public figures, and can read the minds of others. They spend money lavishly. Voices on the radio or television are sometimes understood as personal communications. They speak rapidly, with illogical and confused thoughts, move constantly, and write page after page of nonsense. They typically sleep and eat poorly, have little interest in work, friends, or family, and often require restraint or seclusion. Suicide is a perpetual threat. Some manic patients are likable, while others are angry and frightening. Psychosis is a frequent feature. Manic patients believe that their parents are not their real parents, asserting that they have royal blood. They believe that they can predict the future. They know that others are watching or talking about them, and they hear voices when no one is present. Delusional mania requires more intensive treatment and almost always hospital care. In older classifications of psychiatric illnesses, these patients were considered to be suffering from a manic-depressive illness. In modern classification, this term has been discarded and the illness is now conceived as bipolar disorder for patients with manic and depressive features and major depression for those with depressive symptoms only. Bipolar disorders, ranging from mild to severe, are divided into numerous subtypes. The variety of symptoms that admit the diagnosis of bipolar disorder has led to a virtual epidemic of diagnoses of the condition. Many patients so labeled do not exhibit the sleep difficulty, loss of appetite, and loss of weight, or the severity of illness, that were the criteria for manic-depressive illness. In manic-depressive illness, the manic episode persists for hours, days, weeks, or months and interferes with normal living. Once the episode resolves, it may suddenly recur; or manic episodes may alternate with periods of depression, or occur as simultaneous mixed episodes of depression and mania. When the shift in mood from mania to depression takes place within one or a few days, the condition is labeled rapid cycling, a particularly malignant form of the illness. In manic-depressive illness, the manic episode persists for hours, days, weeks, or months and interferes with normal living.

The Patient’s Experience

The popular images of electroshock presented in the media reflect practices that were discarded more than 40 years ago. The films One Flew Over the Cuckoo’s Nest and A Beautiful Mind portray imaginative Hollywood images—not reality. The dramatic scene of a pleading patient dragged to a treatment room, forcibly administered electric currents as his jaw clenches, his back arches, and his body shakes while being held down by burly attendants or by foot and wrist restraints, is false. Patients are not coerced into treatment. They may be anxious and reluctant, but they come willingly to the treatment room. They have been told why the treatment is recommended, the procedures have been explained, and many have seen DVD or video images of the procedures. Each patient has consented to the treatment in writing, and in many instances, family members have also agreed. Understandably, the patient may be hesitant about the first treatment. He has seen those movies, so the procedures are explained again, and, except for feeling a needle placed in his vein and electrodes and measuring devices attached to his body, the patient is unaware of the treatment as it occurs. One patient described his treatment this way: “It is a nonentity, a nothing. You go to sleep, and when you wake up, it is all over. It is easier to take than going to the dentist.” Many patients ask to be treated early in the morning so that they can return to the day’s activities as soon as possible. It is not uncommon for patients to reassure family members about the procedure. Doctors frequently ask an experienced patient to explain the procedures and the discomforts to a candidate; patients undergoing ECT have proved to be its best advocates. A consent form, voluntarily signed by each patient, is a necessary part of electroconvulsive treatment in the United States. Such a consent procedure is uncommon in psychiatric practice, and was developed to address concerns about abuse at a time when public distrust of governmental authority was widespread and had affected the physician-patient relationship. In most venues, doctors accept the patient’s cooperation with medication treatment and psychotherapy as consent.

What Is Electroconvulsive Therapy?

Electroconvulsive therapy (ECT) is an effective medical treatment for severe and persistent psychiatric disorders. It relieves de pressed mood and thoughts of suicide, as well as mania, acute psychosis, delirium, and stupor. It is usually applied when medications have given limited relief or their side effects are intolerable. Electroconvulsive therapy is similar to a surgical treatment. It requires the specialized skills of a psychiatrist, an anesthesiologist, and nurses. The patient receives a short-acting anesthetic. While the patient is asleep, the physician, following a prescribed procedure, induces an epileptic seizure in the brain. By making sure that the patient’s lungs are filled with oxygen, the physician precludes the gasping and difficult breathing that accompany a spontaneous epileptic fit. By relaxing the patient’s muscles with chemicals and by inserting a mouth guard (not unlike those used in sports), the physician prevents the tongue biting, fractures, and injuries that occasionally occur in epilepsy. The patient is asleep, and so experiences neither the painful effects of the stimulus nor the discomforts of the seizure. The physiological functions of the body, such as breathing, heart rate, blood pressure, blood oxygen concentration, and degree of motor relaxation, are monitored, and anything out of the ordinary is immediately treated. Electroconvulsive therapy relieves symptoms more quickly than do psychotropic drugs. A common course of ECT consists of two or three treatments a week for two to seven weeks. To sustain the recovery, weekly or biweekly continuation treatments, either ECT or medications, are often administered for four to six months. If the illness recurs, ECT is prescribed for longer periods. The duration and course of ECT are similar to those of the psychotropic medicines frequently used for the same conditions. Electroconvulsive therapy has been used safely to treat emotional disorders in patients of all ages, from children to the elderly, in people with debilitating physical illnesses, and in pregnant women. Emotional disorders may be of short or long duration; they may be manifest as a single episode or as a recurring event. Electroconvulsive treatment is an option when the emotional disorder is acute in onset; when changes in mood, thought, and motor activities are pronounced; when the cause is believed to be biochemical or physiological; when the condition is so severe that it interferes with the patient’s daily life; or when other treatments have failed.

Pediatric ECT

The role of ECT in the treatment of adolescents and children is not well understood. The experience is limited and poorly documented, especially in pre-pubescent children. For much of the twentieth century, child and adolescent psychiatrists believed that the mental disorders of children and adolescents are psychologically, not biologically, determined. Psychological attitudes and family interactions were considered the cause of the pathology of the disorders. In the past two decades interest has shifted to biological causes and treatments. Depression and mania, autism, anorexia nervosa, and attention deficit hyperactivity disorder (ADHD) are now recognized in children and adolescents with increasing frequency. These shifts in attitude encourage greater interest in medication trials, and with these, increasing tolerance for trials with ECT. The renewed interest in the role of ECT in pediatric patients was shown at a 1994 conference when experts reported an additional 62 case reports beyond the 94 that had been described in publications. Patients between 14 and 20 years of age with major depressive syndromes, delirious mania, catatonia, or acute delusional psychoses had been successfully treated with ECT, usually after other treatments had failed. No reports of harm to age-related faculties, such as impaired maturation, growth, and the capacity to learn, were presented. On the contrary, the resolution of their mental disorders encouraged the young people to complete school and continue their education. No adjustments to the adult ECT protocol were required except that close attention was given to energy dosing. Adolescents require very little energy to induce an effective seizure. No reporter described instances of uncontrolled seizures. Some clinicians, faced with seriously ill adolescents with features that would encourage ECT if the features were seen in adults, now recommend ECT. Examples of the successful treatment of melancholia, psychosis, mania, and catatonia dot the literature. Efficacy is reported in patients with severe mental retardation and in those with self-injurious repetitive behavior and catatonia grafted onto various forms of autism. These reports are sufficiently encouraging to loosen the usual injunctions against the use of ECT in adolescents. In 2004, the American Academy of Child and Adolescent Psychiatry offered official practice guidelines for the use of ECT in adolescents that closely follow the guidelines for treatment in adults.

Depressive Mood Disorders

Electroconvulsive therapy is most often used to treat disorders of mood. The internally experienced feeling is the emotional state reflected in the way we present ourselves to others and in the ways we react to them. Mood varies with daily circumstances and is sensitive to the conditions of the body, particularly physical health, fatigue, hunger, and hormonal activity. Moods are experienced internally and fluctuate widely. Two disorders are recognized. Depression, or depressive mood disorder, is dominated by sadness, hopelessness, fear of the future, and the persistent thought that life is not worth living. Mania, or manic mood disorder, is a state of excitement, grandiosity, expansiveness, and feelings of increased power and energy. In the present psychiatric classification, mania is labeled bipolar disorder and the depressed phase is labeled major depression. In a depressive mood disorder, body functions are disrupted. Patients are sleepless, appetite is poor, and weight loss may be pronounced, at times amounting to 20% of the body weight within a few weeks. Work, sexual activity, and family may be disregarded. The future appears hopeless, patients believe they are helpless to affect it, and their thoughts are filled with gloom. Threats of suicide reflect their distress. They are often agitated and restless. Many meet the criteria for the malignant syndrome of melancholia. Overwhelmed by feelings of helplessness, hopelessness, and worthlessness, the depressed patient dwells on thoughts of suicide. He may believe that others are watching or talking about him; voices are heard when no one is present; and concerns that his spouse is unfaithful dominate his thought. At times, the events depicted on the television or movie screen seem to apply directly to him. Such strange thoughts are delusions, and this severe state of depressed mood and disorder in thought is labeled delusional depression or psychotic depression. These disorders require intensive treatment and almost always hospital care. A depressed patient is commonly unaware of the day’s events, registers little of what happens around her, and has a compromised memory. This form of depression can be difficult to distinguish from an Alzheimer-type dementia. When the symptoms of dementia are brought about by depression, however, they can be reversed with treatment.

The Treatment Technique

The decision to recommend ECT is difficult, much like the decision for a surgical operation. A physician seeking the source of the patient’s symptoms goes through an intellectual process similar to that of a detective solving a mystery. The doctor listens to the patient’s story, finding some conditions to be likely and others not. Physical signs of illness are sought, and tests and special examinations that narrow the probability to a specific illness are considered. When the doctor is able to put the history, symptoms, signs, and test results together, a diagnosis is offered: a solution to the mystery. In many cases, doctors are able to recommend specific treatments that are effective and predict a good outcome. When effective treatment is lacking, symptom relief is offered. For the psychiatric symptoms caused by syphilis, diabetes, thyroid disease, and other medical illnesses, doctors verify the diagnosis with specific tests and offer effective treatments. But for most psychiatric conditions we do not understand the cause, nor do we have laboratory tests to narrow the diagnoses. In the past half century, the classification of psychiatric disorders has grown to more than 300 conditions described mainly by clusters of symptoms. For only a few disorders can we assure effective treatment. At their best, the psychotherapies and medications relieve symptoms, but none cure the disease. The same is true for ECT. It eases identifiable syndromes, or clusters of symptoms. The relief is provisional, however, requiring continued treatment to sustain the benefit. Our abilities have progressively improved in selecting and administering anesthesia, in selecting the amount of electrical energy and the location of the electrodes for stimulation, and in monitoring bodily effects for safer treatments. The following descriptions are meant to answer questions about the techniques of treatment. Bone fractures were a principal risk of the treatments of the late 1930s and 1940s. Physical restraint by a sheet over the chest and abdomen was effective, but chemical relaxation of the muscles that inhibited the convulsion was better. By 1953, the synthetic chemical Anectine was shown to block muscle contractions quickly and safely. Given intravenously, it acts within a minute.

Is ECT Practice Ethical?

Electroconvulsive therapy is widely considered a controversial treatment in psychiatry. Many cite it as the most controversial treatment in medicine. It is not its efficacy that is controversial, however; as we’ve seen, it offers effective relief for severe psychiatric illnesses even when other interventions have failed. Nor is the controversy about the immediate risks of the treatment, for the risks and death rates are extremely low—almost certainly lower than the risks acknowledged for the psychoactive agents that are the core of modern pharmacotherapy. No systemic illness or medical condition limits its use. The controversy is based on the belief that inducing seizures by electricity permanently damages the brain, causing such severe losses of personal memory that the patient is no longer recognizable as the person known before. This belief is unfounded, and any effects on memory and cognition have been shown to be limited to the time during and directly before treatment. The roots of the controversial image are many, not the least of which is the unfortunate conflation of ECT with lobotomy and insulin coma. The poor portrayal of the treatments by the media inflames viewers’ perception. Conflicts between believers in the biological basis of mental illness and those with the psychological interests of psychoanalysis and clinical psychology roiled psychiatry throughout the twentieth century. As a result, governmental regulations for ECT, especially those limiting its use in children and adolescents, and requirements for written consent (in some venues for each treatment), have restricted its use. Ethical guidelines for the relationship between physician and patient have a long history, the Hippocratic Oath developed by the ancient Greeks being the most widely acknowledged guide. The shameful evidence of medical experimentation on unwilling prisoners by physicians in Germany and the Soviet Union during the Second World War incited a worldwide reassessment of the patient-doctor relationship. Until the 1970s, no limitation on experimental intervention with psychiatric patients was envisioned. Treatments without a scientific basis were lauded and then discredited when the adverse consequences were shown to be greater than the benefits. Treatments were applied in institutions where the patients had an utterly dependent role, and assigned treatments were mandated at the discretion of the institution director.

Is Brain Stimulation an Alternative to ECT?

Interest in electricity in medicine, especially in psychiatric conditions, is as old as our knowledge of electricity as a controllable phenomenon. At the end of the eighteenth and the beginning of the nineteenth centuries, Benjamin Franklin and Anton Mesmer were among many students who used electric currents to stimulate paralyzed limbs and to relieve hysterical states. Giovanni Aldini, the nephew of Luigi Galvani, a principal early student of electricity, applied electric currents to mentally ill patients. In the original Aldini publication, the figures show one electrode applied to the top of the head and a second to the hand. The text states that the electrodes were connected to earrings. Much of Aldini’s work was done on fresh cadavers to show that electricity stimulated motor movements. There is no evidence that he produced seizures for therapeutic purposes. From the onset of the introduction of ECT, the importance of the grand mal seizure to the treatment has been questioned. Many people followed popular science beliefs in the potency of electricity alone and administered low-energy electric currents without inducing a seizure. When scientists compared sham treatments to real ECT in seeking benefits for patients, they found the sham currents to be ineffective. Low-energy electric currents delivered from a battery with electrodes on the scalp to either alert or sleeping subjects (electrosleep) were without benefit. Some applications of electricity in medicine have been truly innovative. At the end of every grand mal seizure, brain waves (measured by the EEG) flatten out, with markedly reduced rhythmic activity. Such activity can be simulated by anesthesia using a chemical called isoflurane. Isoelectric narcotherapy (isoflurane anesthesia therapy) is a brain-stimulation technique that seeks to induce long periods of electro-cerebral silence or markedly decreased electrical activity in the brain. An hour of isoelectric brain electrical activity under anesthesia was once thought to relieve depression in a fashion similar to ECT, but an attempt at replication in six subjects failed. Without independent confirmation, the technique has been abandoned. In the past two decades, three physical interventions have been enthusiastically promoted as replacements for ECT, that is, as ways to induce the same benefits without seizures.

How Does ECT Work?

The major puzzle in ECT is its mechanism of action. How do seizures, which can be dangerous and damaging when they occur spontaneously, change a dysfunctional brain into one that performs normally? Why do repeated epileptic seizures relieve psychiatric disorders? The originator of the therapy, Ladislas Meduna, believed in a biological antagonism between mental illness and seizures, an antagonism we no longer consider credible. But though we may smile at this belief, we acknowledge that it led Meduna to devise methods to induce seizures safely, select patients who were likely to benefit, develop a plan for a successful course of treatments, demonstrate the safety of inducing seizures, evaluate the merits and risks of seizures as treatment, and convince others to continue his work. His observations have been repeatedly verified, leaving little doubt about the effectiveness of ECT in treating mental illnesses. We know a great deal about the essential features of a successful course of ECT. The generalized brain seizure is the central therapeutic event. The biochemical and physiological consequences of the seizure are the basis for the behavioral effects; neither anesthesia nor electric current alone is useful, nor, except rarely, is a single seizure. To be of benefit, seizures must be repeated two or three times a week for many weeks. The more recent the mood, thought, or movement disorder, the more fully it can be relieved. Illnesses involving lifelong problems, character pathology, neuroses, and the mood disorders secondary to the abuse of drugs are not amenable to this treatment. We know how to avoid the risks of anoxia, unmodified convulsions, and prolonged seizures, and we recognize that these aspects of the treatment course do not explain how ECT works. Two aspects of the brain seizure have been extensively studied. The EEG records electrical activity of the brain under electrodes that are symmetrically placed over the scalp. Immediately after the stimulus, the “seizure” EEG is recorded on a moving strip. The electrical waves show a sharp buildup of frequencies and amplitudes, then the frequencies slow, mixtures of slow brain waves and sharp spike-like waves appear, with ever higher amplitudes and slower waves in runs and bursts.