Time to Abandon Electroconvulsion as a Treatment in Modern Psychiatry
Advances In Therapy
Volume 16 No. 1
Hanafy A. Youssef, D.M. D.P.M., FRC Psych.
Fatma A. Youssef, D.NSc, M.P.H, R.N.
This review examines the evidence for the current use of electroconvulsive therapy (ECT) in psychiatry. The history of ECT is discussed because ECT emerged with no scientific evidence, and the absence of other suitable therapy for psychiatric illness was decisive in its adoption as a treatment. Evidence for the current recommendation of ECT in psychiatry is reconsidered. We suggest that ECT is an unscientific treatment and a symbol of authority of the old psychiatry. ECT is not necessary as a treatment modality in the modern practice of psychiatry.
Berrios (1) has thoroughly documented the history of electroconvulsive therapy (ECT). We suggest that in both the 19th and 20th centuries the social context in which ECT emerged, rather than the quality of the scientific evidence, was decisive in determining its adoption as a treatment.
The medical literature is a virtual graveyard for inadequately tested preparations that die ignominiously after a brief moment of glory. Egas Moniz won a Nobel Prize in medicine for the prefrontal lobotomy, targeted at patients in whom ECT had failed. Clearly, psychiatrists abandoned all forms of shock treatment except ECT because of the empiric nature of such therapy and the lack of a credible explanation why it should work.
The prime bases of validation for ECT are vague statements about "clinical experience." Since the introduction of antipsychotics and antidepressants, the number of people subjected to ECT has undoubtedly declined, yet it is still used by some psychiatrists as the ultimate weapon. The proponents of ECT have to preserve the integrity of its use by having more training and better technology and claiming that ECT has proved its worth in clinical "experience." Thomas Szasz wrote that electricity as a form of treatment is "based on force and fraud and justified by 'medical necessity'." "The cost of this fictionalization runs high," he continued. "It requires the sacrifice of the patient as a person, of the psychiatrist as a clinical thinker and moral agent." Some people who have had ECT believe that they were cured by it; this fact indicates that they have so little self-control over the conditions of their lives that they must be shocked by an electric current to discharge their responsibilities.
When ECT became an emotional issue in psychiatry because of pressure groups, various bills were introduced by legislators in the United States. Professional societies and colleges “ the task force of the American Psychiatric Association (3) and the Royal College of Psychiatrists memoranda (4-6) “ have tried to study the subject and survey ECT use. Despite these efforts, ECT is and will remain controversial.
SHOCK AND TERROR AS THERAPY
Terror as a therapy for insanity has been used since antiquity, and as late as the 19th century, the insane were submerged in cold water to terrify them with the prospect of inevitable death.
While using insulin as a sedative in Viennese drug addicts, Sakel (8) observed that accidental overdose resulted in coma or epileptic fits. In a burst of nonscientific theorizing, he wrote: "I began with the addict. I observed improvements after severe epileptic fits.... Those patients who had previously been excited and irritable suddenly became contented and quiet after this shock.... The success I had achieved in treating addicts and neurotics encouraged me to use it in the treatment of schizophrenia or major psychoses."
Meduna used camphor-induced fits on psychiatric patients in a Hungarian state mental hospital after unsuccessful attempts by Nyiro, his superior, to treat schizophrenia by injections of blood from epileptics. Meduna later employed Cardiazol-induced shock. Nyiro's and Meduna's convulsive therapies were based on the view that a neurobiologic opposition existed between epilepsy and schizophrenia. Meduna abandoned his theory of schizophrenia and epilepsy and later wrote "We are undertaking a violent onslaught...because at present nothing less than a shock to the organism is powerful enough to break the chain of noxious processes that lead to schizophrenia."
Psychiatrists of that era who used this form of shock therapy believed that the fear and terror produced were therapeutic because the "feeling of horror" before the onset of convulsion following injection of camphor, pentetrazol, triazole, picrotoxin, or ammonium chloride rendered the patients different after the experience. (10)
ELECTRICITY AS THERAPY
Extensive literature is available on the use of electricity as a therapy and the induction of epilepsy by electric current. (11) In ancient Rome, Scriborus Largus tried to cure the emperor's headache with an electric eel. In the 16th century, a Catholic missionary reported that the Abyssinians used a similar method to "expel devils out of human body." Aldini treated two cases of melancholia in 1804 by passing galvanic current through the brain. In 1872, Clifford Allbutt in England applied electric current to the head for treatment of mania, dementia, and melancholia.
In 1938, Ugo Cerletti obtained permission to experiment with electricity on pigs in a slaughterhouse. "Except for the fortuitous and fortunate circumstances of pigs' pseudo-butchery," he wrote, electroshock would not have been born." (12) Cerletti did not bother to obtain permission to experiment on the first human subject, a schizophrenic who after the initial shock said "Non una seconda! Mortifere." (not again; it will kill me). Cerletti nevertheless proceeded to a higher level and a longer time, and so ECT was born. Cerletti admitted that he was frightened at first and thought that ECT should be abolished, but later he started to use it indiscriminately.
In 1942, Cerletti and his colleague Bini advocated the method of "annihilation," which consisted of a series of (unmodified) ECTs many times a day for many days. They claimed good results in obsessive and paranoid states and in psychogenic depression. In fact, Cerletti had discovered nothing, as both electricity and fits were already known. No scientist, he believed that he discovered a panacea, reporting success with ECT in toxemia, progressive paralysis, parkinsonism, asthma, multiple sclerosis, itch, alopecia, and psoriasis. (12) By the time of his death in 1963, neither Cerletti nor his contemporaries had learned how ECT worked. The inheritors of ECT continue the same lack of understanding today.
Insulin coma and pentetrazol-induced fits, heretofore treatments of choice for schizophrenia, are not therapies any longer, and ECT is not a treatment for schizophrenia. The fact of the matter is that the pioneers of all these shock treatments contributed nothing to the understanding of mental illness, which contemporary psychiatrists are still trying to comprehend and treat on a scientific basis.
ELECTRICITY, CONVULSIONS, THE BODY, AND THE BRAIN
For its proponents, ECT is a relatively simple procedure. Electrodes are attached to the subject's head, either at the temples (bilateral ECT) or at the front and back of one side (unilateral ECT). When the current is turned on for 1 second, at 70 to 150 volts and 500 to 900 milliamperes, the power produced is roughly that required to light a 100-watt bulb. In a human being, the consequence of this electricity is an artificially induced epileptic fit. Modified ECT was introduced as a humane improvement on earlier versions of convulsive therapy to eliminate the elements of fear and terror. In modified ECT, muscle relaxant and general anesthesia are supposed to make the patient less fearful and feel nothing. Nonetheless, 39% of patients thought it was a frightening treatment. (13) These induced fits are associated with many physiologic events, including electroencephalographic (EEG) changes, increased cerebral blood flow, bradycardia followed by tachycardia and hypertension, and throbbing headache. Many patients report temporary or prolonged loss of memory, a sign of acute brain syndrome.
Since early in the history of ECT, we have known that insulin coma or pentetrazol shock can cause brain damage. (14) Bini reported severe and widespread brain damage in experimental animals treated with electroshock. (15) EEG studies showed generalized slowing following ECT that takes weeks to disappear and may persist even longer in rare cases. (16) Calloway and Dolan raised the issue of frontal lobe atrophy in patients previously treated with ECT. (17) The memory deficits after ECT may persist in some patients. (18)
Fink, an advocate of ECT, argues that the risks of ECT amnesia and organic brain syndrome are "trivial" (19) and can be reduced by hyperoxygenation, unilateral ECT over the nondominant hemisphere, and the use of minimal induction currents. (20) Earlier, Fink had indicated that post-ECT amnesia and organic brain syndrome were "not trivial." ECT advocates blame the modification for decreasing the efficacy of the treatment. (21) In the United States, the issue of unilateral ECT reflected class differences. In Massachusetts in 1980, ECT was bilateral in 90% of patients in public hospitals and in only 39% of patients in private hospitals. (22)
Templer compared the issue of ECT brain damage to that of boxing. He wrote that "ECT is not the only domain in which change to the human brain is denied or de-emphasised on the grounds that this damage is minor, occurs in a very small percentage of cases or is primarily a matter of the past." (23)
There has been less scientific investigation into the effect of ECT on other body functions and morbidity. Various animal studies showed significant results that may be important in psychoimmunology“an area of investigation that is more neglected in psychiatry than in any other field of medicine. Although it is difficult to move from an animal model to the human system, animal models frequently demonstrate the role of a range of variables in disease onset. Rats subjected to electrical stress showed significant diminution in the strength of their lymphocyte response that could not be explained by an elevation in adrenal corticosteroids. Even adrenalectomized rats had a similar decrease in lymphocyte response after electric shock (24) ; other studies have confirmed immunologic change following electric shock in animals.
Initial claims that cardiazol convulsions and insulin coma were successful in the treatment of schizophrenia were not universally shared. Some researchers found that these interventions were worse than no treatment. (26)
For more than 50 years, psychiatrists used ECT as therapy for schizophrenia, even though there is no evidence that ECT alters the schizophrenic process. (27) In the 1950s, ECT was reported to be no better than hospitalization alone (28) or anesthesia alone. (29) At the beginning of the 1960s, the era of ECT in schizophrenia was fast drawing to a close as ECT abuses were brought to light by patients and pressure groups. In 1967, however, Cotter described symptomatic improvement in 130 schizophrenic Vietnamese men who refused to work in a psychiatric hospital and received ECT at a rate of three shocks per week. (30) Cotter concluded that "the result may simply be due to patients' dislike and fear of ECT," but he further claimed that "the objective of motivating these patients to work was achieved." (30)
Most contemporary psychiatrists consider the use of ECT in schizophrenia as inappropriate, but some believe that ECT is at least equal to other therapies in this illness. (31)
ECT in Depression
In the 1960s, advocates of ECT were not able to provide evidence that it is therapeutic in schizophrenia but were nevertheless convinced that electricity and fits are therapeutic in mental illness and vigorously defended the use of ECT in depression. Their rationale came from studies in the United States (32) and Britain. (33)
In the US study, 32 patients were pooled from three hospitals. In hospitals A and C, ECT was as good as imipramine; in hospitals B and C, ECT equaled placebo. The results showed that ECT was universally effective in depression, regardless of type: 70% to 80% of depressed patients improved. The study also showed, however, a 69% improvement rate after 8 weeks of placebo. Indeed, Lowinger and Dobie (34) reported that improvement rates as high as 70% to 80% can be expected with placebo alone.
In the British study, (33) hospitalized patients separated into four treatment groups: ECT, phenelzine, imipramine, and placebos. No differences were observed in male patients at the end of 5 weeks, and more men who received placebo were discharged from the hospital than those treated with ECT. Skrabanek (35) commented about this most quoted study: "One wonders how many psychiatrists read more than the abstract of these studies."
The Royal College of Psychiatrists memorandum mentioned earlier was in response to a report of ECT abuse in depression. The memorandum declared that ECT is effective in depressive illness and that in "depressed patients" there is suggestive, if not yet unequivocal, evidence that the convulsion is a necessary element of the therapeutic effect. Crow, (36) on the other hand, questioned this widely held view.
In the late 1970s and in the 1980s, with uncertainty continuing and further work needed, seven controlled trials were carried out in Britain.
Lambourn and Gill (37) used unilateral simulated ECT and unilateral real ECT in depressed patients and found no significant difference between the two.
Freeman and associates (38) used ECT in 20 patients and achieved a satisfactory response in 6; a control group of 20 patients received the first two of six ECT treatments as simulated ECT, and 2 patients responded satisfactorily. (38)
The Northwick Park Trial showed no difference between real and simulated ECT. (39)
Gangadhar and coworkers (40) compared ECT and placebo with simulated ECT and imipramine; both treatments produced equally significant improvements over 6 months follow-up.
In a double-blind controlled trial, West (41) showed that real ECT was superior to simulated ECT, but it is not clear how a single author carried out a double-blinding procedure.
Brandon et al (42) demonstrated significant improvements in depression with both simulated and real ECT. More important, at the end of 4 weeks of ECT, consultants were unable to guess who received real or simulated treatment. The initial differences with real ECT disappeared at 12 and 28 weeks.
Finally, Gregory and colleagues (43) compared simulated ECT with actual unilateral or bilateral ECT. Real ECT produced faster improvement but no difference between the treatments was apparent 1, 3, and 6 months after the trial. Only 64% of patients completed this study; 16% of the patients withdrew from bilateral ECT and 17% from simulated ECT.
From the West and the Northwick Park trials, it appears that only delusional depression responded more to real ECT, and this view is held by ECT proponents today. A study by Spiker et al, showed that in delusional depression amitriptyline and perphenazine were at least as good as ECT. After a series of ECT for his depression and just before committing suicide, Ernest Hemingway said, "Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business." His biographer remarked that "it was a brilliant cure but we lost the patient." (45)
ECT AS AN ANTISUICIDAL
Despite the lack of an acceptable theory as to how it works, Avery and Winokur (46) regard ECT as a suicide preventive, although Fernando and Storm (47) later found no significant difference in suicide rates between patients who received ECT and those who did not. Babigian and Guttmacher (48) found that the mortality risk after ECT was higher soon after hospitalization than in patients who did not receive ECT. Our own study (49) of 30 Irish suicides from 1980 to 1989 showed that 22 patients (73%) had received a mean of 5.6 ECTs in the past. The explanation that "ECT induces a transient form of death and thus perhaps satisfies an unconscious desire on the part of the patient, but this has no preventative effect on suicide; indeed it reinforces suicide in the future." (49) Many psychiatrists today concur that ECT as a suicide preventive does not hold up.
THE PSYCHIATRIST'S DILEMMA: TO USE OR NOT USE ECT
Some psychiatrists jusitify the use of ECT on "humanistic grounds and as a means of controlling behaviour" against the wishes of the patient and family. (50) Even Fink admits that the catalogue of ECT misuses is depressing but suggests that the guilt lies with the abusers and not the instrument. (51) The editor of the British Journal of Psychiatry considered it "inhuman" to administer ECT without asking the patient or the relative, even though Pippard and Ellam showed that this was common practice in Britain. Not long ago, ECT administration in Great Britain was described as "deeply disturbing" by a Lancet editorial writer, who commented that "it is not ECT which brought psychiatry into disrepute; psychiatry has done just that for ECT". (53) Despite efforts to preserve the integrity of the treatment, in Great Britain and in most public hospitals worldwide consultant psychiatrists order ECT and a junior doctor administers it. This maintains the belief of institutional psychiatry that electricity is a form of treatment and prevents the junior psychiatrist from being a clinical thinker.
Levenson and Willett (54) explain that to the therapist using ECT it may seem unconsciously like an overwhelming assault, which may resonate with the therapist's aggressive and libidinal conflict."
Studies that examined attitudes of psychiatrists toward ECT found marked disagreement among clinicians about the value of this procedure. (55,56) Thompson et al (57) reported that ECT use decreased 46% between 1975 to 1980 in the United States, with no significant changes between 1980 to 1986. Fewer than 8% of all US psychiatrists use ECT, however. (58) A very recent study (59) on the characteristics of psychiatrists who use ECT found that female practitioners were only one-third as likely to administer it as were their male counterparts. (59) The proportion of female psychiatrists has been rising steadily and if the gender gap continues, this could hasten the end of ECT.
When ECT was introduced in 1938, psychiatry was ripe for a new therapy. Psychopharmacology offered two approaches to the pathogenesis of mental disorders: to investigate the mechanism of action of drugs that ameliorate the disorder and to examine the actions of drugs that reduce or mimic the disorder. In the case of ECT, both approaches have been pursued without success. Chemically or electrically induced fits have profound but short-lived effects on brain function, ie, acute organic brain syndrome. Shocking the brain causes increases in levels of dopamine, cortisol, and corticotropin for 1 to 2 hours after the convulsion. These findings are pseudoscientific, as there is no evidence that these biochemical changes, specifically or fundamentally, affect the underlying psychopathology of depression or other psychoses. Much of the improvement attributed to ECT is an effect of placebo or, possibly, anesthesia.
From the earliest uses of convulsive therapy, it was recognized that the treatment is unspecific and only shortens the duration of psychiatric illness rather than improves the outcome. (60) Convulsive therapy based on the old belief of shocking the patient into sanity is primitive and unspecific. The claim that ECT has proved its usefulness, despite the lack of an acceptable theory as to how it works, has also been made for all the unproven therapies of the past, such as bloodletting, which are reported to produce great cures until they are abandoned as useless. Insulin coma, cardiazol shock, and ECT were treatments of choice in schizophrenia, until they, too, were abandoned. For ECT to remain as an option in other psychoses transcends clinical and common sense.
When an electrical current is applied to the body by tyrannical rulers, we call this electrical torture; however, an electrical current applied to the brain in public and private hospitals by professional psychiatrists is called therapy. Modifying the ECT machine to reduce memory loss and giving muscle relaxants and anesthesia to make the fit less painful and more humane only dehumanize users of ECT.
Even if ECT were relatively safe, it is not absolutely so, and it has not been shown to be superior to drugs. This history of ECT, its abuse, and resultant public pressure are responsible for its increasingly lower use.
Is ECT necessary as a treatment modality in psychiatry? The answer is absolutely not. In the United States, 92% of psychiatrists do not use it despite the existence of an established journal entirely devoted to the subject to give it scientific respectability. ECT is and always will be a controversial treatment and an example of shameful science. Even though some 60 years have been spent defending the treatment, ECT remains a revered symbol of authority in psychiatry. By promoting ECT, the new psychiatry reveals its ties to the old psychiatry and sanctions this assault on the patient's brain. Modern psychiatry has no need of an instrument that allows the operator to zap a patient by pressing a button. Before inducing a fit in a fellow human being, the psychiatrist as clinician and moral thinker needs to recall the writings of a fellow psychiatrist, Frantz Fanon (61) : "Have I not, because of what I have done or failed to do, contributed to an impoverishment of human reality?"