We do not fully understand how it works, but electroconvulsive therapy (ECT) helps patients get rid of the symptoms of the disease in more than 80% of cases. That brand, which is attached to it, prevents use of this method for the benefit of sick people, the author of popular scientific articles and books is convinced.
80 years ago in one of the oldest universities in the world, the University of Rome "Sapienza", doctors let through a head of the 39-year-old man a current with a voltage of 100 volts.
A week ago this man was detained by the police. He wandered the streets, muttering words that no one understood.
"He was absolutely unemotional, he did not react to anything. He was like a tree that does not bear fruit", wrote a young psychiatrist, Ferdinando Accornero, at the time.
It was impossible to establish the identity of the man, no one was looking for him. He was diagnosed with schizophrenia in a difficult stage.
"The prognosis was bad, “Accorero wrote. – We concluded that we are dealing with a completely destroyed psyche and there is no hope even for a partial recovery".
However, it so happened that after a few weeks the mysterious patient was already talking normally, returned home to his wife, and even again began working as an engineer in Milan.
The patient designated as "E.S.", became the first person for whose treatment the electric shock method was applied. And although the symptoms a few months later, by the time the man himself and the doctors already knew – E.S. it is quite possible to treat.
Today, electroconvulsive (electroconvulsive) therapy, formerly known as electroshock or electroshock therapy, is often seen as something barbaric, as a tool of torture, with which the brain is destroyed and which has no place in modern medicine.
And yet, ECT remains the most effective method of treating a small group of mental illnesses.
Although no one fully understands how this method works, with the help of ECT one can get rid of the symptoms of severe depression, catatonia and various mania
No one fully understands how this works. But in more than 80% of cases, ECT helps to get rid of the symptoms of various mania, catatonia or severe cases of depression, often ending with suicide.
The method of electroconvulsive therapy is far from perfect. For example, it can not completely cure a patient, ECT should be applied every few months to prevent the return of initial symptoms. In addition, there is a risk of memory loss (although often – only temporary), headaches and pains in the jaws.
But do these side effects justify the stigma that accompanies this method of treatment? Chemotherapy, for example, is also a dangerous thing, it causes suffering to the patient and often does not bring success – nevertheless it continues to be considered one of the main methods of cancer treatment.
For many people, electroconvulsive therapy could save lives.
Suicide (often associated with a mental illness) is the main cause of death in British men between the ages of 20 and 49 years. In the world, this is the second leading cause of death in people aged 15 to 29 years.
And depression is the main global cause of incapacity, surpassing in this any other disease.
What is the truth about electroconvulsive therapy?
American novelist William Styron was one of many thousands of people who suffered and suffer from depression and who are visited by thoughts of suicide
Every morning, at 9 o’clock, the alarm on my phone reminds me that it’s time to take antidepressants. Unlike the previous ones, these pills seem to work.
Combined with regular counseling from a therapist and two courses of cognitive-behavioral psychotherapy (CPT), this gave me nearly four months of life without a single bout of depression. Prior to this, such attacks occurred with a frequency of every two weeks, at best – once a month.
I have not recovered yet, I just have remission. Depression will return – it would be naive for me to think otherwise.
The loss of interest in things that used to bring joy, the inability to love your loved ones, the thoughts of suicide that haunt you, will all return.
However, even those few months (and maybe more), during which I am free from the shackles of depression, are priceless for me.
For several decades, the main method of treating depression was placing a person in a psychiatric hospital
I often think: how would my depression be treated if I lived at another time? At the beginning of the 20th century, I would probably be placed in one of those psychiatric hospitals that were scattered around the countryside of Britain.
In the 1930s, I would have been prescribed amphetamines (a class of medicines that includes ecstasy), which were advertised as the first antidepressants.
In the 1940s (the decade when my parents were at my present age, 25-35 years old), I would be tried to treat with electric shock.
Electroconvulsive therapy at that time was so popular that it was often used in polyclinics – about the same way as people went to the dentist, they went on an electric shock procedure and then returned home. (In one study in 1980 it was found that 50% of the respondents feared a visit to the dentist more than ECT procedures.)
The idea of using convulsions (cramps) for the treatment of mental illness belongs to the neurologist from Budapest University Laszlo Medun.
Like other doctors working in psychiatric hospitals, he noticed that schizophrenic patients became noticeably better after convulsions (which were the result of taking strong medications). They got rid of hallucinations, incoherence speech and delirium.
And although the symptoms returned with time, Meduna thought about how to use the cramps most effectively to treat patients in his area.
In the 1940s, electric shock treatment was so popular and common that it was performed in polyclinics
In 1934, he began to use a drug called cardiazol (or metrazole in the US), which provoked seizures within seconds or a couple of minutes after the injection in the muscle.
Having recovered, the patients who had suffered from catatonia began to walk on their own, to dress, and in some cases for the first time in several years they spoke.
The new method caused an explosion of enthusiasm. Is it now possible to cure previously incurable?
Hearing about cardiuzzole, Hugo Cherletti, dean of the Faculty of Psychic and Nervous Diseases of the University of Rome "Sapienza", I thought that I knew a much better way to get cramps.
He had used short and strong discharges of electricity for many years during animal experiments. This led to seizures similar to epileptic ones.
The method of Cherletti looked affordable, cheap and highly manageable. Unlike cardiazole, which could act differently, the impact of electricity had two main variables – the number of volts and the length of time (fractions of a second).
Based on these two parameters, one of the students of Cherchetti, Lucio Bini, designed and built an apparatus on which it was possible to raise and lower the voltage, and using an automatic stopwatch to limit the discharge time by one tenth of a second.
"Apparatus of Cherletti Bini" sent electric discharge on two electrodes (wrapped in a cloth impregnated with saline solution), fixed on both sides of the patient’s head, over the temples.
Doctors at the hospital in the Canadian city of Toronto strengthen the electrodes on the patient’s head during the simulation of the ECT procedure (1976)
What happened to the patient then, could not be called pleasant. All the muscles at once contracted, the patient’s body arching, as if in a grotesque yoga posture, the air whistled from the lungs, legs and arms made chaotic movements, because of the contraction and tension of all tendons, the body began to get rid of urine and feces, and in men – even from seminal fluid.
Bones cracked – although these were microscopic cracks, visible only on the x-ray and rapidly growing together, it was quite frightening.
There was also reported a loss of memory. After coming to consciousness after the procedure, some patients did not understand where they were, how they got here and who their immediate relatives were.
Although in most cases memory was restored within a few days or weeks, to some it never returned.
Responding to critics of electroconvulsive therapy, Lothar Kalinowski, one of Cherletti’s former colleagues, wrote in 1946: "The surgeon does not refuse the necessary operation because it is risky … Mental disorders are as destructive as a malignant tumor, and bear more terrible suffering. Thus, the risk is justified".
Indeed, with all its shortcomings, ECT was unusually effective in the treatment of some of the most difficult mental illnesses to cure – especially, as it soon turned out, severe depression.
In 1945, a study conducted by psychiatrists at the McLean Hospital in Massachusetts showed that ECT helped to get rid of a severe depression episode of 80% of patients. At least two of them were in this state from 10 to 15 years – after six or seven procedures conducted within a few weeks, the depression left them.
As a forest fire releases seeds from cones of coniferous trees, so electric discharge – or more precisely, convulsions, which it generates, – frees the patient from the psychic shell, in which he is chained by the disease.
As once, in the 1950s, Peter Cranford, a psychiatrist from the state of Georgia, wrote in his diary, "Today he is in a catatonic stupor, and tomorrow he plays basketball".
From the very first days the method of electroconvulsive therapy was often misused, and at times they were simply abused. In 1944, when the Second World War was coming to an end, Emil Gelni, a doctor who worked in two psychiatric hospitals in Austria and a member of the Nazi Party, perfected the ECT apparatus so that it could be used to kill patients with mental illness.
He added four more electrodes, and the device gave a discharge for not milliseconds, but several minutes. Thus, 149 patients were killed whose life "did not represent value".
And although far more people died from lethal injections and hunger, it is understandable why "Job" Gelney cast a dark shadow on the future of ECT.
Often this therapy was used where she simply could not help. In 1946, two Italian psychiatrists from Siena wrote: "Today there is no such mental illness that would not be tried with ECT".
Including homosexuality, which for many years was officially considered a form of mental illness – in particular, in the directory of the American Psychiatric Association.
Such widespread use of ECT – often without the patient’s consent – was a way to control uncontrolled patients. After the procedure, they were in a drowsy state, with a clouded consciousness, so it was easier to cope with them. So this was not a cure, but a deprivation of liberty.
Film "flying over Cuckoo’s Nest" with Jack Nicholson in the title role (where the hero was repeatedly punished with electric shock) helped form a negative image of electroconvulsive therapy
With words "electroconvulsive therapy" comes to mind to anyone who watched the movie "flying over Cuckoo’s Nest" with Jack Nicholson as McMurphy, for which the actor received an Oscar? Forced treatment without pain as a punishment.
However, the production of Hollywood does not necessarily relate to real life. Already in the 1940s, ECT was used with anesthesia and medications to relax the muscles, to rid the body of convulsive contractions, to prevent cracks in the bones. The patient just slept during the procedure.
As an anesthetic, curare extract was used in combination with strong sedatives. However, this led to an increase in the number of deaths (four by 11 thousand patients by 1943), because drugs could stop and breathing.
In the 1950s, instead of curare, succinylcholine was used in combination with conventional anesthesia.
And today this procedure looks completely different from the one that frightens. All cramps occur only in the patient in the brain, which is confirmed by an electroencephalogram.
Before ECT, the patient is given pain medication – by the middle of the 20th century this has become a common practice
Such a "modified electroconvulsive therapy" much safer. It reduced the death rate to about one case per 10,000 patients – this is lower than that of normal anesthesia.
As one physician in Chicago wrote in 1977, "ECT is about 10 times safer than childbirth".
Despite all the improvements, after the 1960s, ECT fell into disgrace, they tried to forget about it. Although, as the medical historians Edward Shorter and David Healy wrote in 2007, forgetting about it is about the same as forgetting penicillin.
This was partly due to the fact that doctors began to prescribe drugs for the treatment of depression – although they were often much less effective in severe cases. And partly because of what the image of ECT has developed.
In the 1970s, Shorter and Healy wrote in his book "Shock therapy", the growing anti-psychiatric sentiment was directed by the Church of Scientology, which proclaimed that ECT destroys the brain.
Demonstration of 1977 for passing a law obliging to warn patients about the risk of ECT
There is no convincing evidence for this. In 1991, after performing the ECT procedure for 35 patients with depression, Edward Coffey and his colleagues from Duke University concluded: "Our results confirm (…) that there is no connection between ECT and brain damage".
The loss of memory, however, is a problem with which both scientists and Scientologists agree, at least to a certain extent.
Although memory is usually returned a few weeks after ECT, there is evidence of a complete loss.
As in the case of other diseases or operations, physicians must be weighed in each case, which will be more profitable for ECT – harm or benefit.
The most important issue here is not whether the evil or good electroconvulsive therapy is, but whether it helps those people who need it.
There is sufficient evidence that ECT is not just an effective method of treatment, it is in some cases the best method available.
"The truth is that this is an unusually good method, “says Vikram Patel, a professor at the Harvard School of Medicine. – This is a method that saves lives of people, one of the few in psychiatry".
"In fact, I have never seen methods of treatment in psychiatry that would work as phenomenally as ECT".
A patient with severe depression is preparing for an ECT procedure at a North Carolina hospital (2008)
In 2004, a study funded by the National Institute of Mental Health (USA) found that of the 253 patients with severe and psychotic depression, 238 (94%) experienced significant symptom reduction after ECT.
189 (75%) patients achieved complete remission after an average of seven ECT procedures for three weeks. 10 people (4%) stopped their course due to problems with memory or confusion.
In comparison, antidepressants, similar to those that I take, are usually effective in only two out of three people (66%) with depression, and remission occurs in one of three (33%).
Regarding the potential of ECT, George Kirov, a clinical professor at Cardiff University in Britain, wrote in 2017 that "If a patient with psychotic depression does not improve during the course of ECT, then we must figure out what we are doing wrong".
An excellent prognosis is even for such susceptible people who are often not able to take antidepressants, like pregnant women and elderly people.
When I was collecting material for this article, I discussed ECT with a few friends and family members. And every time the conversation began with a similar reaction: "What, it still do ?!" Distrust, horror and even shock.
And this is understandable. Even those who did not look "flying over Cuckoo’s Nest", the use of an electric discharge in relation to a person is more likely to be torture than treatment.
But this image of electroconvulsive therapy as a barbaric, painful, brain-destroying method hinders to help those people who are in great need of it.
Because of this image, not only in hospitals, reluctantly resort to ECT, but people who can help the method perfectly do not see it as a treatment option.
Stigma, lying on ECT, is not just harmful, it interferes with healing and saving people from death.
But interest in ECT is coming back. According to the latest data, the number of people who decide to turn to it is growing.
For example, in Britain in 2015-2016. 22600 ECT procedures were performed – this is 11% more than a year earlier.
Together with ECT, more selective forms of electrotherapy have been used, such as deep brain electrical stimulation and transcranial magnetic stimulation (both are increasingly being used to treat depression, Parkinson’s disease and other mental disorders).
As for me, it calms the fact that if suddenly my antidepressants stop working and my condition worsens, there is a promising alternative.
Although we do not understand how ECT works, it is often compared to rebooting a computer.
Perhaps, it is also time to restart our outdated ideas about electroconvulsive therapy.
Alex Riley lives in Bristol and writes articles on scientific topics. Now he is working on a popular science book on how depression is treated in different countries.
You can read the original of this article in English at BBC Future.