When most people think of electroconvulsive therapy (ECT), the first thing that comes to mind may be a scene in the 1975 film “One flew over the Cuckoo’s nest,” where Jack Nicholson undergoes the treatment, in a way more akin to torture than medical care. There are people holding him down, he is not under anesthetics, and the shocks cause him terrible pain.

Though a scene like this may have been plausible in a not so distant past, ECT has seen many advances, with new techniques reducing several of its many side effects. Moreover, the traumatic experience portrayed in the Milos Forman movie is also a thing of the past, as anesthetics are always in order today.

As popular belief would have it, ECT can make people “less smart” by destroying brain cells, as well as making them “forget things.” In fact, it is also common belief that shock therapy is no longer in use, and that science has advanced so much, that such “inhumane” treatments are no longer necessary. Needless to say, there is much that is inaccurate about all of these general assumptions.

A little history

ECT has been used to treat major depression, mania in bipolar patients, catatonia, and schizophrenia, among other disorders, ever since it was discovered by the Italian neurologist Ugo Cerletti in 1937. While the possibilities of the discovery were extremely promising, and ECT spread fast all over the world, its abuse in the psychiatric wards up to the 1970’s lead Medical Historian David J. Rothman to say, in a 1985 conference:

ECT stands practically alone among the medical/surgical interventions in that misuse was not the goal of curing but of controlling the patients for the benefits of the hospital staff.

It was the subduing effects of ECT on difficult patients that lead to this widespread abuse, which started giving it a bad press during the 60’s and 70’s, peaking in the Milos Forman movie, which was based on an autobiographical book by someone who had been a victim of the kind of ECT practices that were common at the time.

When a medical treatment is demonized the way ECT was, it is very difficult for it to make a comeback. However, scientific advances as to the kinds of electricity applied, and the application techniques, alongside the strict regulations for the practice of ECT, helped it slowly regain some of the terrain it had lost; the word “popularity” would be out of place here, as that is something ECT may never achieve.

ECT today

The devices used for ECT today have come a long way from Cerletti’s instruments, which had been inspired by the ones used at pig slaughterhouses in Italy. The brief-pulse currents used today, as well as unilateral electrode placement greatly reduce the risks of memory loss and verbal memory disturbances.

The fact is that shock therapy was used on over one million patients worldwide in 2007 (2) , and the number is not going down. When ECT was partially abandoned; it was not only due to bad press. There had also been great advances in the development of new medication and drugs; some of which had a positive effect on the treatment of certain stages and symptoms in psychiatric patients, for which nothing but ECT would work before. But the fact remains that there are certain cases of major depression and manic states in bipolar disorder, for example, where medication either doesn’t work or takes too long to work. In these cases, ECT is commonly prescribed.

Patients who ask for ECT?

Faced with the prospect of months, and maybe years, of going in and out of clinics and being unable to continue with their normal lives due to one of these crises, certain patients willingly undergo ECT, which is, still today, the fastest way out of, for example, a crisis in a bipolar patient with heights of aggressiveness and lows of suicidal tendencies.

I once heard a prominent psychiatrist describing shock therapy to a bipolar patient as a method akin to the resetting of a computer. The patient hadn’t been through shock therapy since the late eighties, and it was his way of talking her into trying it again, as she had been experiencing harsher and longer crises since trading the old-fashioned lithium for Sodium valproate. Ever since she agreed to undergo ECT again to try and stop the course of a crisis, and switched back to lithium, the patient’s crises became much less frequent and shorter.

I mention this example in order to show how, however outmoded or regardless of whatever contraindications there may be, the choice of a treatment depends on several factors, and psychiatrists have to consider all of the possibilities available to them, in order to ensure that their patients may enjoy the best quality of life possible, with the minimum of time spent in psychiatric wards, and the maximum spent living a normal, healthy life.

“Destroying lives”

Of course, one must also consider the available literature as regards the effects of ECT on memory loss and especially long-term effects on general cognition. In this respect, there is a long-standing controversy in the medical community. In 2007, in a section of one of his papers entitled “Destroying Lives,” Peter Breggin wrote:

Even when these injured people can continue to function on a superficial social basis, they nonetheless suffer devastation of their identities due to the obliteration of key aspects of their personal lives. The loss of the ability to retain and learn new material is not only humiliating and depressing but also disabling. Even when relatively subtle, these activities can disrupt routine activities of living.

On the other hand, to quote just one of several papers written to the same effect that have been published around the world, in 2009, Portuguese researchers stated, in a paper entitled Electroconvulsive Therapy: Myths and Evidences:

[ECT is an] efficient, safe and even life saving treatment for several psychiatric disorders.

Conclusions

Personally, I have met several people who have undergone shock therapy many times along their lives. While I had initially disagreed with the prescription most of the times, I have to say that while the techniques used many decades ago did have the effect of leaving patients to walk around like zombies without the slightest trace of purpose or personality; in the long run, none of those people seem to have lost their identities, as some researchers claim that they should. Besides, with modern techniques, patients can be fully functional even on the same day of having undergone ECT, only experiencing, as directly observable adverse effects, a short-term memory loss that quickly wears off.

To illustrate, I would like to refer to the case of P. (female, 38), a brilliant South American scientist and researcher with medication-resistant bipolar disorder. After roughly 10 ECT treatments experienced over a span of 20 years, P. is currently finishing her Ph.D. and working as part of the research team of a prominent University. Cases like this call for further studies as to the consequences of ECT on the brain, which are extremely complex and tend to be over-simplified by both detractors and advocates alike.

The subject of ECT is and will ever remain controversial until science discovers an alternative that is less aggressive and has a lesser charge of adverse effects. Until then, it seems that it will continue to be used by psychiatrists all over the world as a last resort, when nothing else seems to have the ability to restore patients to a state of sanity. In the case of chronic patients, which is where ECT is most commonly used, the quest of psychiatric science should always be to try to grant patients the possibility of enjoying the longest time without experiencing the disabling symptoms of chronic disorders. When ECT seems to be the only path to a healthy psyche, at least one million times a year in the world and 100,000 times a year in the US, psychiatrists have agreed that it shouldn’t be ruled out.

References

Rothman DJ. ECT: The historical, social and professional sources of the controversy. Psychopharmcology Bulletin 1986; 22(2):459-63.

“Electroconvulsive therapy discussion hosted at the MGH”. Retrieved 2010-09-15.

Breggin, P. (2007). ECT Damages the Brain: Disturbing News for Patients and Shock Doctors Alike Ethical Human Psychology and Psychiatry, 9 (2), 83-86 DOI: 10.1891/152315007782021196

Coentre R, Barrocas D, Chendo I, Abreu M, Levy P, Maltez J, & Figueira ML (2009). [Electroconvulsive therapy: myths and evidences] Acta medica portuguesa, 22 (3), 275-80 PMID: 19686628