Article written in English by John Read, professor of clinical psychology at the University of East London and published in .
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In the early 1970s, I was a naive 21-year-old, enamored of my first job as a nursing assistant in a New York psychiatric ward. Three times a week, several older women sat in a row against the hallway wall. Some collapsed motionless in their chairs. Others seemed scared and agitated. From time to time, one would try to run away and the friendly but firm staff would lead her to the chair. When I found out that they were waiting for an electroconvulsive therapy session, I volunteered for the job of sitting with them when they came out of general anesthesia, after the electric shocks and seizures. They asked me: “Where am I?” “Who I am?” “Why does my head hurt?” and “What did they do to me?” I remember not being able to answer the old woman who asked me, through tears, “Why would they do such a thing to me?”
He Royal College of Psychiatristsin its latest public information document (2020), stated:
- Electroconvulsive therapy (ECT) is a treatment for some types of serious mental illnesses that have not responded to other treatments.
- An anesthetic and a muscle relaxant are given, and then an electrical current is passed through the head. This causes a controlled adjustment, which typically lasts less than 90 seconds.
- When using anesthesia, the person is asleep while this happens. The muscle relaxant reduces the movement of the fit.
- It is administered as a twice-weekly treatment course, usually for 3-8 weeks.
The most common response I get when I mention electroconvulsive therapy outside of mental health circles is, “Are we really still doing that?”
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It is necessary to go back in time to understand the persistence of this treatment. ECT is part of a long tradition of applying extreme physical procedures to people with mental health problems: strong laxatives, bleeding, forehead blisters, swivel chairs, baths, forced inhalation of chimney soot, and, briefly at the turn of the century XX in the United States, surgical removal of teeth, testicles, ovaries, gallbladders, and colon. The 20th century saw malaria-induced fevers, insulin-induced comas, and a variety of “psychosurgery” procedures that included hammering an ice-pick-shaped instrument into the brain through the eye socket (“prefrontal leucotomy”). and insertion of radioactive yttrium (Y90) into the brain (“subcaudate tractotomy”). All of these “treatments” were administered by professionals who, at the time, genuinely believed they were helping people.
The seizures per se, of course, were always considered the symptom of a disease rather than a cure. So why, in the 1930s, did some Italian psychiatrists come up with the idea that it would be useful to cause seizures in people considered insane? The key is a theory of the time that postulates that epilepsy could not exist alongside the symptoms of schizophrenia. So while some doctors began treating epilepsy by injecting blood from people diagnosed with schizophrenia, other psychiatrists were exploring ways to induce epilepsy, or at least epileptic seizures, in schizophrenic patients.
In Hungary in 1934, the psychiatrist induced seizures in patients by injecting camphor and metrazol. After administering his first injection, Meduna “was so distraught that nurses had to take him to his room,” according to investigators. Meanwhile in Italy, the neurologist was trying electricity. He first experimented on dogs, placing electrodes in the mouth and rectum. Many died. But he discovered, in the slaughterhouse, a way to not affect the heart:
The pigs had their temples clamped with large metal tongs that were connected to an electrical current (125 volts)… They fell unconscious, stiffened, then, after a few seconds, were shaken by convulsions in the same way as our experimental dogs. … I believed that we could venture to experiment with humans.
Their first human subject was a 39-year-old engineer from Milan, whom police found wandering around a Rome train station in a state of confusion. When the first electric shock did not produce the desired seizure, Cerletti and his assistant discussed whether they should administer a more powerful shock. Cerletti reported:
Suddenly, the patient, who had evidently been following our conversation, said clearly and solemnly, without his usual hubbub: “Not another one! He is mortal!”
Cerletti proceeded anyway, it was the first of the millions of cases that followed, and continue today, of people receiving this treatment despite having clearly stated that they do not want it. After another, stronger electric shock caused him to have a seizure, the engineer did not remember receiving the electric shocks. It also became the first of millions of cases of people who lost short-term memory due to this treatment.
Like Meduna before him, Cerletti was not insensitive to the effects of what was causing the person in front of him:
When I saw the patient’s reaction I thought: this should be abolished! Since then, I have looked forward to the time when another treatment replaces electroshocks.
I had a reaction similar to that of Meduna and Cerletti when, in that hospital in New York, I witnessed, along with other medical students, my first electroconvulsive therapy. When the psychiatrist asked, “Does anyone want to press the button?” the other five students were enthusiastic. After having seen the woman convulse and go completely limp, I carried her unconscious body down the hallway, which was not a very reassuring sight for the other people waiting for her turn. I ended up in the parking lot, vomiting. . Even before I knew what the research said about ECT, I had literally had a gut reaction that something was terribly wrong. But to understand why ECT is still used today, it is necessary to remember the five medical students who did not share my revulsion, or, perhaps, chose to hide it from the professor.
The acceptance in the 1940s of Cerletti’s strange invention is better understood if we remember that the medical model of psychiatry had not developed effective treatments until then. There were hundreds of mental institutions, filled with thousands of “chronic,” “incurable” patients and, presumably, a rather demoralized and pessimistic medical staff.
I see what happened as a grand naturalistic experiment demonstrating the power of placebo, including creating positive expectations in staff and, ultimately, patients. Certainly, the 1940s and 1950s saw many people discharged from hospital after ECT, sometimes after being hospitalized for many years, or even decades. This was a very important development, given the devastating effects of institutionalization and the belief that recovery was impossible. But the people who decided to discharge were probably the same people who decided to apply ECT. The first two studies from the 1950s that compared patients who received ECT with others who did not find lower recovery rates or no recovery for people who received ECT. While some critics cited this work, the fact is that it was impossible to eliminate the treatment because there were no placebo control groups. This was a common treatment error at the time, but ECT researchers had a valid excuse because at that time placebo studies could not be done due to the frequent spinal fractures and other injuries that the control group could suffer.
In the early 1950s, muscle relaxants and general anesthesia were introduced, making it possible to evaluate this new “modified ECT” by comparing it to control groups who were unconscious from general anesthesia but who did not receive ECT (sham ECT). ). The first such study, in 1953, in which neither psychiatrists nor patients were expected to know who received ECT, found no difference in outcomes between the two groups. By now, “antipsychotic” drugs were replacing ECT as the treatment of choice for “schizophrenia,” and proponents of electroconvulsive therapy were turning their attention to depression. In 1959, the first placebo-controlled trial involving depressed patients found no significant difference between ECT and sham ECT for depression or “schizophrenia.”
Meanwhile, investigators were documenting the damage they caused. In 1946, a review titled “Brain changes associated with electric shock treatment” published in The Lancet, reported that people suffered extensive hemorrhages in multiple parts of the brain. Although the review author was not prepared to conclude that all the changes were related to ECT, he did cite autopsy findings of a 57-year-old man who had died 90 minutes after his 13th shock: “in the lobes frontal and temporal there were several small devastated areas, completely devoid of ganglion cells… Diffuse degeneration of nerve cells was present in the cortex.”
A review of the first 20 years of autopsies concluded: “damage to the brain, sometimes reversible but often irreversible, occurred during electric shock treatments.” Already in 1956, a “controlled study” of people over 65 years of age had established that ECT accelerates senile dementia. As one early commenter noted: “given the extraordinarily sensitive electrochemical nature of the human brain, it is not difficult to realize the enormous destruction of ECT…Electrical damage and destruction to some degree cannot be avoided.”
The idea that ECT causes brain damage was so obvious to early proponents that they incorporated it into an explanation of how ECT worked. In 1941, the American doctor, best known for advocating lobotomies, wrote about ECT:
The greater the damage, the more likely the remission of psychotic symptoms… Perhaps it will be shown that a…