- The Ethics of Electroconvulsive Therapy
- Why ECT Is Becoming a Preferred Depression Treatment
- Depression Isn’t Just Feeling Sad
- Using ECT to Treat Depression
- Finding Relief
- Stigma as a Barrier to Care
- Using TMS
- ECT Is Not a Last Resort
- Visions Journal
- What is “Modern” ECT?
- Is ECT Painful?
- Does ECT Cause Brain Damage?
- Is ECT Risky for the Elderly?
- How Were the Guidelines Developed?
- Concluding Remarks
- Electroconvulsive Therapy: A History of Controversy, but Also of Help
- ECT’s origins in the 1930s
- ECT used as a threat in hospitals in 1950s
- The rise of the anti-psychiatry movement
The Ethics of Electroconvulsive Therapy
«First, do no harm» is the healing profession's best-known ethical precept because in the actual practice of medicine doctors may unwittingly do harm [1,2]. However, is it ethical for physicians to give harmful treatments knowingly?
Such a course of action might be considered proper if no alternative treatments are available, if the treatment is not only effective but ly to be life-saving, if no coercion is involved, and if true informed consent is obtained for the procedure.
Unfortunately, electroconvulsive therapy (ECT) meets none of these conditions.
In fact, to the horror of truly ethical physicians, there are several recent instances in the United States of the involuntary administration of ECT, over the expressed repeated wishes of the patient .
The issue is rather simple. The defining feature of ECT (modified or unmodified, bilateral or unilateral)—that which distinguishes it from any other treatment and is indicated in its name—consists in the electrical induction of a generalized seizure. This frequently leads to an acute organic brain syndrome characterized by amnesia, apathy, and euphoria .
Administering ECT to depressed or severely depressed patients shows an «effectiveness» (evaluated by rating scales including many items that would respond to any nonspecific sedative intervention) lasting no more than 4 to 6 weeks . Within 6 months of receiving ECT, 84 percent of patients relapse . ECT is not life saving: no decrease in suicide results from its use , and some increase in suicide may follow .
ECT is not safe: it produces varying amounts of memory loss and other adverse effects on cognition in nearly everyone who receives it, typically lasting weeks or months after the last treatment (as well as many other adverse consequences, from ocular effects to postictal psychosis).
ECT is not necessary: numerous alternative, less harmful interventions—that work with the patient's consciousness, strengths, and social network—are available .
ECT is too often given as the treatment of next resort (not, as some of its supporters would insist, last resort) when drug treatment has seemingly failed, as drug treatment often does , especially for the modal ECT patient today, an elderly woman.
Less harmful options are not considered for reasons having very little to do with the patient's «condition» and very much to do with psychiatrists' increasing unfamiliarity with nonbiological interventions, professionals' frustration that patients are not recovering «quickly enough,» and some institutions' reliance on the procedure as a revenue source.
Needed: A Study of Consent Forms
Finally, we suggest that true informed consent is almost never obtained, because practically no one would sign a truthful consent form for ECT (if any exists) unless coerced—grossly or subtly—to do so.
Defenders of ECT might claim that informed consent is scrupulously obtained, but it is at present impossible to evaluate this claim properly.
Indeed, despite the importance of divulging the risks of this most controversial treatment in psychiatry, no study describing actual ECT consent forms used in different institutions (even a small sample of 2 forms) has ever been published.
Unless a harmful treatment is life-saving, unavoidable, uncoerced, and its risks are fully divulged, knowingly administering it is unethical.
Here are the words of 3 individuals who received ECT and described publicly what they view as ethical violations involved in their experience of this procedure.
Leonard Roy Frank said, «I have concluded that ECT is a brutal, dehumanizing, memory-destroying, intelligence-lowering, brain-damaging, brainwashing, life-threatening technique. ECT robs people of their memories, their personality, and their lives. It crushes their spirit.
Put simply, electroshock is a method for gutting the brain in order to control and punish people who fall or step line and intimidate others who are on the verge of doing so» .
Thomas Hsu wrote, «My ECT's were in 1998. Overall I feel violated and very emphatically wish I had never consented to the treatments and would caution others.
While I was not coerced into receiving the 'treatment,' I do feel I was misled and at the very least not suitably informed about the potential negative effects and lack of efficacy in treating depression.
I would never consent to receiving ECT again» .
Jackie Mishra said, «One moment that I remember clearly from my hospital stay for ECT in 1996 is the horror I felt when after one of my treatments I couldn't remember how old my children were.
Not only did the ECT not work for me, but my suffering was compounded when I realized that approximately 2 years of my life prior to the ECT had been erased. My retention of new information is also severely impaired.
If anyone had told me that this could happen, even a remote chance, I never would have consented to ECT. I would much rather have lost a limb or 2 than to have lost my memory—my 'self'» .
Sharpe VA, Faden AI. Medical Harm. Cambridge, England: Cambridge University Press: Cambridge, United Kingdom; 1998.
Biller J. Iatrogenic Neurology. Butterworth-Heinemann Medical: Philadelphia; 1998.
See MindFreedom Support Coalition International's Web site. Accessed September 26, 2003. See also ECT.org. Accessed September 26, 2003.
- Cohen D. Electroconvulsive treatment, neurology, and psychiatry. Ethical Human Sciences & Services. 2001;3(2):127-129.
Banken R. The use of electroconvulsive therapy in Québec. Agence d'évaluation des technologies et modes d'intervention en santé: Montreal; 2003. Accessed September 26, 2003.
- Sackeim HA, Haskett RF, Mulsant BH, et al. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial. JAMA. 2001;285(10):1299-1307.
Black D, Winokur G, Mohandoss E, et al. Does treatment influence mortality in depressives? A follow-up of 1076 patients with major affective disorder. Ann Clin Psychiatry. 1989;1:165-173.
- Brodarty H, Hickie J, Mason C, et al. A prospective follow-up study of ECT outcome in older depressed patients. J Affect Disord. 2000;60(2):101-111.
Kirsch I, Moore T, Scoboria A, Nicholls SS. The emperor's new drugs: an analysis of antidepressant medication data submitted to the US Food and Drug Administration. Prevention & Treatment. 2002;5. Accessed September 26, 2003.
As only one example of several sources describing practical brief approaches with «chronic,» «resistant,» and «difficult» patients, see: Miller SD, Hubble M, Duncan BL. Handbook of Solution-focused Brief Therapy. San Francisco: Jossey-Bass;1996.
MindFreedom Journal. Winter 2002-2003;45:51.
Hsu T. Quoted by: Support Coalition International Response to the March 1998 Electroconvulsive Therapy Background Paper by Research-able Inc, Prepared for the US Dept. of Health and Human Services. MindFreedom Support Coalition International. Eugene, Oregon;1999:6.
Mishra J. Quoted by: Support Coalition International Response to Electroconvulsive Therapy Background Paper. Research-able Inc, Prepared for the US Dept. of Health and Human Services. March 1998. MindFreedom Support Coalition International: Eugene, Oregon; 1999:8-9.
ECT has remained a controversial treatment in psychiatry since its introduction more than six decades ago. The two pieces below illustrate some of the current ethical arguments offered by proponents and opponents of ECT. This is the first of two commentaries.
Virtual Mentor. 2003;5(10):349-351.
The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
Why ECT Is Becoming a Preferred Depression Treatment
Brian Neville had a good life. A one-time bodybuilder, he was 43, a successful businessman in the tanning industry, with a home in Massachusetts and a vacation condo in Florida.
Then one morning in 2006 he woke up with the blues. It developed into a persistent darkness that just would not go away. After about six months, he sought treatment. He received prescription medications that he was assured would help counter a listless feeling that made even simple tasks cleaning a room feel climbing Mt. Everest while wearing nothing but his shoes.
Except that it didn’t.
Neville, now 54, realized what was troubling him was not what he calls “situation sadness,” a temporary state that can come from the loss of a job or a loved one.
“Everybody knows what it’s to feel sad,” said Stephen J. Seiner, MD, medical director of the Electroconvulsive Therapy (ECT) Service at McLean Hospital. “And I think most people even know sadness to the point where it can temporarily incapacitate you.”
Depression Isn’t Just Feeling Sad
But depression goes far beyond mild anxiety or a passing dark moment. It is a physical illness, one the World Health Organization places as the leading cause of disability worldwide.
An estimated 16 million American adults, or about 6.
7% of the United States population age 18 and over, are diagnosed with major depressive disorder, according to the Anxiety and Depression Association of America.
Depression often accompanies other behavioral health diagnoses, including psychosis, bipolar disorder, or catatonia. It can often be triggered by everyday life stresses or changes.
Left untreated, major depressive disorder triggers a cycle that can produce significant life changes, which may include the loss of the ability to work or function normally. It can lead to the deterioration of relationships and result in social isolation.
The causes can be varied, including biological, environmental, and genetic factors.
355 million people are affected by depression, making it one of the most common disorders in the world
“There can be a biological predisposition, but there is often a trigger, and we just don’t always know what that trigger is,” explained Seiner.
“Very often in patients who experience depression there may be a psychosocial stress that somehow sets off a cascade of neuronal connections in the brain that then leads to an episode of depression.
Where most people would be able to bounce back from the stressor, patients who have a predisposition towards depression often continue to spiral down.”
In the most severe cases, depression can make it impossible for a person to function. “It affects you so that sometimes you can’t think straight,” said Seiner. “Your brain plays tricks on you. You can’t eat. You can’t sleep. The smallest task can seem completely overwhelming”
“The worst thing in my day was when my first eye opened in the morning,” Neville recalled. “The second worst thing in my day was when my second eye opened. It meant I had to get up and put on an act, trying to please people and fake everything. I got sick of faking my day.”
He would escape by driving town. “I would go to Starbucks and hang out, as far away as Connecticut or Rhode Island. I needed somewhere to kill the day. To get the day going. To get the day over with.”
Using ECT to Treat Depression
Effective treatments for depression include counseling, psychotherapy, and prescription medications. However, for an estimated 100,000 people a year in the United States, Neville, these options fall short. And for them, ECT is safe, reliable, and effective.
The treatment has evolved since the 1930s, when psychiatrists hypothesized that grand mal seizures could help treat schizophrenia, the observation that some nerve cells in the brains of people with schizophrenia appeared to be arranged in a way that was the opposite of people with epilepsy. However, it turned out that the seizures were most effective in treating depression and other mood disorders.
Dr. Stephen Seiner talks with an ECT patient
Scientists know seizures can reset brain function. And because brain activity involves electrical signals passing through neurons, ECT “is when you reboot your computer when something has gone awry,” said Paula Bolton, MS, APRN-BC, program director of McLean’s Psychiatric Neurotherapeutics Program. “Although there are a lot of theories, no one is really quite sure why it works.”
The mystery of how to treat depression goes beyond ECT. Psychiatrists are also hard-pressed to explain exactly how medication or psychotherapy affects the synapses.
“We know a lot about what medications do, what they are designed to do, but how that translates into treating a complex human emotion depression is still not fully understood, just with ECT,” said Seiner.
“We know there are a lot of things ECT does in the brain—we can show that with modern imaging or other scientific techniques—but how that correlates to lifting depression or rebooting is not entirely clear.
What is clear is that for severe illness, such as psychotic depression or catatonia, where patients can lose 40-50 pounds and can be at some risk of death, ECT has been shown to be 80-95% effective.
Brian Neville recalls once spending 19 days curled up in a ball in bed, unable to do simple tasks and finding no enjoyment in anything he did. Then he was referred to McLean.
“I would walk in every Tuesday, and if someone had come up with a gun to the back of my head and pulled the trigger, I would have been happy,” said Neville. “Four hours later, I would walk out a totally different person.”
However, thanks to many ECT treatments in two courses over several years—combined with good nutrition and exercise—that all changed.
“In November of 2011, I got up at around 2:30 in the morning to get something to eat, and it was a switch went off, literally,” he explained. “I went ‘whoa, I can feel things.’ I went back to bed, and for the first time in five years, I was excited to get bed. I felt I can enjoy today.” He has been well since and has not needed to return to ECT.
Stigma as a Barrier to Care
Despite that track record, ECT has been shrouded in stigma, particularly in popular culture through movies such as “One Flew Over the Cuckoo’s Nest,” a 1975 film that portrayed a punitive, painful treatment of a patient transferred to a hospital from a prison farm.
Today’s treatment is a far cry from the film version. It’s usually done on an outpatient basis. Patients receive general anesthesia and a muscle relaxant that puts them to sleep for five minutes and relaxes the body so there is little, if any, movement.
Electrodes are placed on the scalp, usually on the right temple and on the top of the head, and low-intensity electrical pulses are administered to trigger a grand mal seizure.
Treatments generally are given two or three times a week until the symptoms are in remission.
Doctors and nurses work together to deliver safe and effective ECT treatments to patients
Seiner noted that today’s treatment reflects “a lot better understanding of how much stimulus is needed and the best places in the brain to induce a seizure to minimize side effects.
The patients are completely asleep, so there is little to no movement when the seizure is induced. We also have better monitoring to make it safer. We have better medications to make it more comfortable.
And now it’s done more often on an outpatient basis, and patients tend to tolerate it pretty well.”
Despite these changes, several fictions linger around ECT.
“Fiction number one is that it’s painful,” stated Seiner. “The only mildly painful part for people is when we put a tiny IV in. And occasionally, most often after the first treatment, people have a mild headache.”
Another lingering misconception is ECT will change your personality. “Depression changes people’s personalities,” Seiner said, explaining ECT brings people back to their baseline traits.
Another fiction is the fear of brain damage.
“While ECT can sometimes cause people to lose some past memories, we’ve become much better at mitigating that, and it’s less common and much less severe,” said Seiner, explaining unilateral placements of electrodes and the use of “ultra-brief pulses” better emulate how the brain works, so clinicians can induce seizures with less electricity and fewer side effects.
“There’s no evidence ECT causes any long-term effect on your ability to learn, on your cognition, or on your ability to make new memories. The research indicates that if you wait two months after ECT, or six months, after the ‘dust’ of the ECT has settled, most people do much better on neuropsychological testing than they did before ECT.
That’s because when people aren’t depressed, they think better and test better.”
Certain patients can be treated with transcranial magnetic stimulation (TMS), which induces an electric field in the brain using a magnetic pulse, rather than applying an electrical field directly through ECT.
Seiner explained that TMS specifically targets the depression center of the brain, while ECT is “a more general treatment. TMS doesn’t require anesthesia and has no cognitive side effects. It is a daily treatment for 4-6 weeks, and since it is milder, it is better for more standard depressions, rather than psychotic depression or catatonia.
Clinicians are also turning to “deep TMS,” which penetrates deeper into the brain, and there is now experimental magnetic seizure therapy to induce seizures under anesthesia.
“ECT is getting gentler and gentler, and TMS is trying to find ways to get stronger and stronger,” said Seiner.
Those changes also mean ECT should not be viewed as a last resort.
ECT Is Not a Last Resort
For patients with psychotic depression and catatonia, and an accompanying high risk of complications such as self-harm, ECT should be considered as a first-line treatment.
“We often don’t see a patient until after they have lost their job, isolated themselves, and maybe even made a suicide attempt and ended up on the inpatient unit,” said Seiner. “We’d rather see them earlier and prevent all those things because it’s a lot easier to put your life back together when you don’t have to start all over.
“It’s not something someone would typically choose to do right away, but I think it also depends on the severity of their illness,” added Bolton, noting some patients “are so severely depressed or suicidal that ECT is necessary to get them better quicker.”
No matter the course of treatment, the most important step any patient or family member should take is to learn the pros and cons. Bolton said they should meet with clinicians to review risks and benefits.
Though currently considered one of the best options for severe and treatment-resistant depression, ECT has a long history of misconceptions and stigma
Equally important is to speak directly with other patients. McLean offers monthly support groups with nurses and patients, open to people before and after treatment.
“The more we talk about ECT and real-life stories and what a difference it makes in people’s lives, the better, because it helps to develop strategies to help people cope during treatment,” said Bolton.
What’s also needed is a better understanding about the nature of the illness, an area where Charles Welch, MD, another McLean ECT physician, believes the United States trails many other countries.
“Depression is a physical illness,” said Welch. “It’s not clear exactly what structures of the brain are involved in what ways, but it’s very clear this is a physiologic illness that’s very responsive to treatment.
In the United States, the stigma that goes along with depression is very unfortunate.
Too often, people are ashamed of their symptoms, afraid to let people know of their symptoms, and they struggle for years with these debilitating symptoms of depression that are, ironically, completely treatable.”
Welch believes medical schools have an important role to play in the education of patients and the public.
“We tend to be too conservative in the use of ECT in this country,” said Welch, adding it should be considered earlier in the treatment cycle.
“We see so many patients who come to us with this kind of history of having struggled for decades with inadequately treated depression. This is a worldwide problem.
We are simply not being aggressive enough in intervening therapeutically in the lives of people with depression.”
Ultimately, Seiner said, two things are true generally about every patient who seeks treatment with ECT.
“One is that they’re really struggling, and two, they’re terrified about what we do. It’s important to get them better, but our job is to walk them through it, to be there with them. This is what we’re committed to. We understand. And that makes a huge difference.”
Today Neville has the same goal.
“I want to get out there and educate people, to bring comfort to the people with depression.”
For more information or to make a referral to McLean’s ECT Service, please call 617.855.2355.
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Electroconvulsive therapy (ECT) was first introduced in 1938 by Cerlitti and Bini in Italy. Since then, there have been numerous changes with regards to ECT devices, techniques, reasons to consider ECT, and anaesthetic procedures.
ECT practice guidelines have been developed in Canada (1992), Great Britain (1995), Australia (2000), and the United States (2000), which update standards for delivering ECT. The recentlypublished BC Guidelines for ECT (2002), soon available online at www.healthservices. gov.bc.
ca/mhd, attempt to set the standards for ECT in BC. Despite the stigma and media controversy surrounding ECT, “modern” ECT is safe and ly the most effective single treatment for certain psychiatric conditions.
It can be life saving in some of those with suicidal behaviour, and in those with malnourishment and dehydration. The following attempts to dispel some of the myths surrounding “shock” therapy.
What is “Modern” ECT?
ECT involves the passage of electricity through the skull and into the brain in order to produce a brief convulsion. A typical successful course constitutes 6-12 treatments.
Despite many hypotheses, the mechanism of action is unknown, but ECT effectively treats a number of psychiatric conditions, (most commonly for depression, sometimes for mania, and occasionally for schizophrenia), and medical conditions (e.g. Parkinson’s Disease).
Some will benefit from outpatient, less frequent continuation of ECT in order to maintain improvement. “Modern” ECT over the past 25 years incorporates the mandatory use of modern ECT devices, general anaesthesia, and muscle relaxation. Heart monitoring and oxygenation are essential during and after ECT.
“Modern” ECT looks at the best available techniques in order to minimize side effects, and is stringently applied only for certain conditions deemed treatable by ECT, but not for individuals considered strictly “antisocial” or “criminal.”
Is ECT Painful?
ECT is performed under general anesthesia and no discomfort is experienced during treatment. Properly applied ECT does not lead to burns to the skin or hair. On occasion, headaches and muscle aches are side effects, which are not incapacitating and last less than a day.
Does ECT Cause Brain Damage?
There is no evidence that, in the era of “modern” ECT, it causes “brain damage,” (i.e. structural changes to the brain). ECT does not change a person’s personality, nor is it designed to treat those with just primary “personality disorders.
” ECT can cause transient short-term memory — or new learning — impairment during a course of ECT, which fully reverses usually within one to four weeks after an acute course is stopped. Whether ECT can rarely cause memory loss for certain (but not all) types of remote events is controversial and is an area of active research.
Adjusting the dose of energy delivered and the ECT technique employed can minimize the risk of memory impairments.
Is ECT Risky for the Elderly?
In general, being elderly does not mean there is an increased risk for complications related to ECT. In fact, studies indicate the elderly respond to a higher degree to ECT than younger adults. Being elderly means the increased lihood of having medical conditions and dementia.
Having certain medical conditions can increase the risk when undergoing ECT, and need to be considered in light of potential benefits.
It is generally safe to administer ECT in those with dementia, and could be considered in these individuals who may also have depression (though the evidence is less clear regarding its use for people with dementia without depression).
How Were the Guidelines Developed?
The guidelines were developed by several UBC-affiliated psychiatrists, a nurse clinician, and an anaesthetist. Dr. Martha Donnelly, Head of the Division of Geriatric Psychiatry, chaired the group.
An advisory committee was also formed that was comprised of representatives from the UBC Department of Psychiatry based in Vancouver and Prince George, from the BC Ministry of Health, from the Mood Disorders Association, and from the Department of Psychiatry at the University of Toronto.
The guidelines establish contemporary standards for delivering ECT throughout the province, and deem each local health authority as the organization responsible for implementation and monitoring.
The guidelines incorporate how consent for ECT should be obtained in the light of the recent Health Care Consent Legislation and Facilities Care Act (HCCFCA) of BC encompassing competency issues, and in light of the Provincial Mental Health Act governing voluntary/involuntary patient status and treatment.
Those with dementia may not be competent to provide consent, and the guidelines have special sections dealing with these individuals who require ECT. In the HCCFCA, there is also a provision to automatically involve the Community Legal Assistance Society to advocate for such individuals deemed “incompetent to consent for ECT” under this piece of legislation.
ECT is a safe and effective procedure for a variety of conditions in younger and older adults. Negative depictions of ECT in the press and cinema have contributed to misperceptions surrounding current ECT practice. This is unfortunate, as ECT remains an important tool in combating the devastating consequences of certain mental illnesses.
Dr. Chan is Head of the ECT Program at Vancouver General Hospital
Electroconvulsive Therapy: A History of Controversy, but Also of Help
The following essay is reprinted with permission from The Conversation, an online publication covering the latest research.
Carrie Fisher’s ashes are in an urn designed to look a Prozac pill. It’s fitting that in death she continues to be both brash and wryly funny about a treatment for depression.
The public grief over Carrie Fisher’s death was not only for an actress who played one of the most iconic roles in film history. It was also for one who spoke with wit and courage about her struggle with mental illness. In a way, the fearless General Leia Organa on screen was not much of an act.
Fisher’s bravery, though, was not just in fighting the stigma of her illness, but also in declaring in her memoir “Shockaholic” her voluntary use of a stigmatized treatment: electroconvulsive therapy (ECT), often known as shock treatment.
Many critics have portrayed ECT as a form of medical abuse, and depictions in film and television are usually scary. Yet many psychiatrists, and more importantly, patients, consider it to be a safe and effective treatment for severe depression and bipolar disorder. Few medical treatments have such disparate images.
I am a historian of psychiatry, and I have published a book on the history of ECT. I had, many people, been exposed only to the frightening images of ECT, and I grew interested in the history of the treatment after learning how many clinicians and patients consider it a valuable treatment. My book asks the question: Why has this treatment been so controversial?
ECT’s origins in the 1930s
ECT works by using electricity to induce seizures. This is certainly a counterintuitive way of treating illness. But many medical treatments, such as chemotherapy for cancer, require us to undergo terrible physical experiences for therapeutic purposes. The conflicts over ECT have other sources.
Electroconvulsive Therapy Machine 1945-60. Credit: Science Museum, London Wellcome Images (CC BY 4.0)
ECT was invented in Italy in the late 1930s. Psychiatrists had already discovered that inducing seizures could relieve symptoms of mental illness. Before ECT, this was done with the use of chemicals, usually one called Metrazol.
By many reports, patients experienced a feeling of terror after taking Metrazol, just before the seizure started.
A Cleveland psychiatrist who was active then once told me that the doctors and nurses used to chase the patients around the room to get them to take Metrazol.
Ironically, given that ECT would become iconic as a frightening treatment, the Italian researchers who proposed using electricity instead were searching for a safer, more humane and less fearsome method of inducing the seizures. Their colleagues, internationally, believed they had succeeded. Within only a few years of its invention, ECT was widely used in mental hospitals all over the world.
ECT used as a threat in hospitals in 1950s
Many depictions of ECT in film and television have portrayed the therapy as an abusive form of control. Most famous is the film “One Flew Over the Cuckoo’s Nest,” in which an unruly patient is subjected to the procedure as a punishment. There is probably no fictional story that so haunts our consciousness of a medical treatment.
“Cuckoo’s Nest,” and many other depictions, are sensational, but we cannot grasp the historical background to the stigma around ECT if we do not acknowledge that “Cuckoo’s Nest,” while released as a movie in 1975, was not completely unrealistic for the era it depicts, the 1950s.
A scene from ‘One Flew Over the Cuckoo’s Nest.’
There is no question that ECT was benefiting patients then, but there is also a lot of evidence from that period showing that ECT, and the threat of it, were used in mental hospitals to control difficult patients and to maintain order on wards.
ECT was also physically dangerous when first developed. Now there are ways to mitigate those dangers.
Current practice, known as modified ECT, uses muscle relaxants to avoid the physical dangers of a seizure and anesthesia to avoid pain from the electricity.
These modifications were learned early, but it took a while for them to become standard practice.
Ken Kesey, who wrote the original novel of “One Flew Over the Cuckoo’s Nest,” released in 1962, worked in a mental hospital in the 1950s. He would have been able to witness all of this.
Kesey, though, would also have known about ECT’s power to relieve symptoms of mental illness, and one of the characters in the book attests to this.
At that time, ECT was also used as a “treatment” for homosexuality, then considered by psychiatrists to be an illness. This was not a major part of ECT practice, but this is not a comfort to gay people who received the treatment, for whom it could be traumatizing.
The psychiatrists who used ECT in this way sincerely believed they were trying to help sick people, which serves as a warning against “medicalizing” behavior, and assuming that this will reduce stigma. This use of ECT did not last, in part because there was no evidence it did alter anyone’s sexuality.
But it survived in the social memory of the therapy.
The rise of the anti-psychiatry movement
By the 1960s, the evidence that ECT was very effective for treating depression was robust. But there were also good reasons for patients to fear ECT. These reasons, combined with widespread revolts against authority and conformity that flourished in the 1960s, also gave rise to a revolt against medical authority – the anti-psychiatry movement.
In its most extreme versions, the anti-psychiatry movement rejected the very idea of mental illness. But physical treatments, and most especially ECT, aroused its strongest rejections. Most advocates of anti-psychiatry – even those who questioned the very reality of mental illness – were supportive of talk therapy.
This provides another clue about why ECT occasions such deep divides. By acting so directly on the body, without any delving into the life history of the patient, ECT’s powerful effects raise questions about what mental illness is, and what kind of psychiatry is best. It evens raises questions about who we are, and what a person is.
ECT use declined in the 1960s and 1970s, but revived starting in the early 1980s. During the years since, there have been a growing number of positive portrayals, often in patient memoirs Fisher’s. Writers such as Norman Endler and Martha Manning wrote moving accounts of how ECT brought them back from very bleak depression.
Increasingly, ECT came to be provided with consent, and the use of modified ECT became standard. Now, psychiatrists estimate that about 100,000 Americans receive ECT.
With the rise of the age of Prozac, our culture became more comfortable with physical fixes for those illnesses we continue to call “mental.” According to psychiatrists who provide the treatment, many patients often go back for voluntary repeat ECT treatments, as Fisher did.
That is hard to square with a stereotyped view of ECT as a form of abusive social control. ECT continues to have many critics, often people who received the treatment unwillingly, or who felt pressured into receiving it.
For example, Wendy Funk wrote about this in her book “What Difference Does it Make?”
The main source of continuing controversy concerns a possible adverse effect: memory loss.
There is no question that ECT causes some memory loss, particularly of events near the time of the treatment. These memories often return, however. And there is also little doubt that many patients get potent therapeutic results, and many patients say they have little, if any, permanent memory loss.
But permanent long-term memory loss does occur, and it is uncertain how common it is. Many clinicians believe it to be exceedingly rare, their experience treating many patients over the years.
The scientific studies are not very conclusive, however, and serious and permanent memory loss is everywhere in patient memoirs – not least in those patients who have written positive accounts of ECT’s therapeutic effects.
In her book “Shockaholic,” Fisher was emphatic about the power of ECT to reverse stubborn depression, but added, “the truly negative thing about ECT is that it’s incredibly hungry and the only thing it has a taste for is memory.
ECT can be an invaluable treatment for many people. Many providers lament that that it is a stigmatized treatment. Dispelling the stigma, though, will require more than just testimony to its therapeutic effect, but also a full reckoning with its costs, both past and present.
This article was originally published on The Conversation. Read the original article.