Eighty years ago at the University of Rome La Sapienza, doctors sent 100 volts of electricity through the head of a 39-year-old man. A week earlier, he had been found by the municipal police wandering the streets and muttering words that no one could understand. “He was unemotional, living passively, like a tree that does not give fruit,” wrote Ferdinando Accornero, a young psychiatrist at the university. Nonsensical, unknown, and unclaimed, the man was diagnosed with severe and advanced schizophrenia. “The illness had a poor prognosis,” Accornero added. “We concluded that we were dealing with a mentality that was completely unravelled, and gave little hope, even for partial recovery.” In just a few weeks, however, this mysterious patient would be talking again, living in his home, and sleeping in a bed next to his wife. He returned to his work as an engineer in Milan. Referred to as “E.S.”, he was the first patient to receive what would become known as electroshock or electroconvulsive therapy (ECT). Although his symptoms would return in a few months, by then he – and the doctors – knew they were treatable.
Today, ECT often is viewed as a barbaric, brain-damaging tool of torture with no place in modern medicine. And yet it remains the most effective treatment for a small subset of mental illnesses. No-one knows how it works. But in more than 80% of cases, ECT can help shed the most harmful symptoms of mania, catatonia (a mental condition that leaves patients withdrawn, mute, and unresponsive), or severe depression that can slide into suicide. ECT is far from perfect. It can’t cure a patient, for example, and has to be performed every few months to prevent the original symptoms from returning. And there are risks of memory loss (often temporary), headaches, and jaw pain. But do these side effects warrant the continuing stigma attached to this treatment? Chemotherapy, for example, comes with a litany of pains and dangers, and often isn’t successful – but it continues to be a staple of cancer treatments. For many people, ECT could be a life-saver. Suicide – often associated with mental illness – is the leading cause of death in men aged between 20 and 49 in the UK. Around the world, it is the second leading cause of death in 15 to 29-year-olds. And depression is the number one cause of disability globally, sapping more healthy years out of our collective lifetimes than any other illness.
So, what’s the truth about electroconvulsive therapy? Every morning at 09:00, the alarm on my phone reminds me to take my antidepressants. Unlike my previous prescription, these pills seem to be working. Combined with regular counselling sessions and two courses of cognitive behavioural therapy (CBT), I haven’t had a bout of depression for nearly four months. Before this, I would have a couple of weeks to a month between one spell of depression and another. I’m not cured; I’m just in remission. The depression will return – it would be naive of me to think otherwise. The lack of interest in once enjoyable activities, the inability to love my loved ones, the haunting thoughts of suicide: they will all be back. But whether it lasts for months or years, freedom from these shackles is a priceless gift. I often wonder what treatment I would receive for my depression if I had been born into a different generation. At the turn of the 20th Century, I might have been institutionalised in one of the many mental hospitals that dotted the British countryside. In the 1930s, I would have been prescribed amphetamines, the class of drugs that includes ecstasy and were marketed as the first antidepressants. And in the 1940s – the decade when my grandparents would have been my age, in their late 20s or early 30s – I would have received electroconvulsive therapy. At this time, shock therapy was so popular that it was often performed on an out-patient basis. Like a visit to the dentist, people could book an appointment with their doctor, receive a session of ECT at so-called ‘shock shop’ and return home the same day. (One 1980 survey found that 50% of respondents feared the dentist more than ECT.)
The idea to induce convulsions to treat mental illness originated with Ladislas von Meduna, a neurologist at the University of Budapest. Like other doctors working in mental hospitals, he had noted how patients with schizophrenia who suffered from a convulsion – which was normally a result of the powerful drugs they were taking – seemed to recover. Their hallucinations, nonsensical speech, and delusions appeared to vanish. Although the symptoms would, in time, return, his observation opened a new vista of possibility for psychiatric treatments. Find a way to induce convulsions, Meduna thought, and perhaps the most stubborn forms of mental illness would vanish in their wake. In 1934, Meduna used a drug called cardiazol (marketed as Metrazol in the US) that induced convulsions within seconds or a couple of minutes after its injection into a muscle. After regaining consciousness, once-catatonic patients began to get out of bed, dressing, and – in some cases – talking for the first time in years. This new therapy created a buzz of excitement. Were once incurable conditions soon to be cured? After hearing about cardiazol, Ugo Cerletti, the chair of the Department of Mental and Neurological Diseases at the University of Rome La Sapienza, thought he knew of a better way to induce convulsions. He had been using short, sharp bursts of electricity to induce epileptic-like fits in his study animals for years. It was instantaneous, cheap, and highly controllable. Unlike cardiazol, which varied in its potency, electricity was split into two basic variables: number of volts and fractions of a second. Cerletti’s student Lucio Bini designed and built a machine based on these two parameters. A dial controlled the voltage, while an automatic stopwatch could reduce the shock to a tenth of a second. Connected to the electrical wiring of a light switch, the ‘Cerletti-Bini electroshock machine’ sent a burst of electrical current through two electrodes – each wrapped in a cloth soaked in a salt solution – that were placed on each side of a patient’s head, above the temples.
What happened next wasn’t pretty. With all muscles contracting at once, the patient’s body would arc back on itself like the death pose seen in dinosaur fossils or a grotesque yoga position. Teeth would clamp down on a piece of pipe as air hissed out of the lungs. Legs and arms might thrash wildly, and faeces, urine, and for men, even semen could be ejected from the body as a result of straining every sinew. Bones could be fractured, especially those in the spine and around the shoulders and hips. (These were hairline fractures often only seen in X-rays and which healed quickly, but still undesirable). Then there were reports of memory loss. After regaining consciousness, some patients wondered where they were, how they got there, even to whom they were married. Although their memories would normally return days or weeks after the treatment, some patients seemed to lose memories forever. Responding to critics of ECT, Lothar Kalinowsky, one of Cerletti’s former colleagues, wrote in 1946, “The surgeon does not refuse a necessary operation because of its impending risks… Mental disorders are as destructive as a malignant growth and far more terrible in the suffering they may cause. Risks are therefore justified.” Indeed, for all its drawbacks, ECT was incredibly effective at treating some of the most stubborn mental illnesses – especially, as it soon turned out, severe depression. In 1945, a study from two psychiatrists from McLean Hospital in Massachusetts showed that ECT rid 80% of patients with a severe bout of depression. At least two of their patients had suffered from their condition for 10 or 15 years, only to find it lift for the first time after six or seven sessions of ECT performed over a few weeks. Like a forest fire vital in liberating the seeds from inside tough pinecones, a quick burst of electricity – and, more importantly, the convulsion that it caused – seemed to reanimate a person from the thick psychological armour in which they were encased. Or as Peter Cranford, a psychiatrist working at Milledgeville State Hospital in Georgia, noted in his diary in the 1950s, “Catatonic stupor one day, play basketball the next.”
From its earliest days, ECT was misused and sometimes abused. In 1944, Emil Gelny, a psychiatrist at two mental hospitals in Lower Austria and a member of the Nazi Party, modified an ECT machine for use in the T4 euthanasia programme of the mentally ill. As World War Two was coming to a close, he added four more electrodes to an ECT machine, allowed the current to flow for minutes (not milliseconds), and murdered 149 patients whose lives were regarded as “not worth living”. Although far more people died from lethal doses of drugs or by malnutrition, Gelny’s work would cast an understandably dark shadow over ECT’s future. More commonly, ECT was indiscriminately used on people it would never help. In 1946, two psychiatrists from Siena, Italy wrote, “Today there is no mental illness where [ECT] has not been tried.” This included homosexuality, which the first three volumes Diagnostic and Statistical Manual of Mental Disorders (published between the 1950s and 1980s) categorised as a form of mental illness. Such widespread use – often without the patient’s consent – was a way to control uncontrollable patients. After a session, patients were in a dazed, sleepy, and therefore more manageable, state. It was custodial, not curative. In her 1963 book The Bell Jar, the novelist Sylvia Plath wrote about her destructive experience with ECT a decade earlier. “Something went down and took hold of me and shook me like the end of the world. Whee-ee-ee-ee–ee, it shrilled, through an air crackling with blue light, and with each flash, a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant. I wondered what terrible thing I had done.” This is the image of ECT that would flow through the minds of the public for decades. It featured in an Academy Award-winning performance by Jack Nicholson in One Flew Over the Cuckoo’s Nest in 1975. His boisterous character Randle McMurphy later was given a prefrontal lobotomy.
But Hollywood is fiction, not fact. As early as the 1940s, ECT had been combined with an anaesthetic and a muscle relaxant that stopped the body from convulsing prevented any fractures or ejections and ensured that the patient was asleep throughout. The first came from an extract from an Amazonian climbing vine called curare, combined with strong sedatives. But this led to an increase in the number of deaths – four in 11,000 patients by 1943 – as breathing also could be paralysed. In the 1950s, succinylcholine chloride, or ‘sux’, was used instead of curare and combined with a general anaesthetic. Today, the treatment looks far different than what Plath once described. “If the [founders of ECT] were to see what happens in a clinic today,” says Max Fink, a retired psychiatrist who used ECT from the early 1950s, “they would see the patient lying on a table, electrodes applied, current supplied, and some movements of the patient’s foot… And that’s it.” The convulsion only occurs in a person’s brain, as revealed by an electroencephalogram (EEG) that records brain activity. This ‘modified ECT’, as it became known, was much safer. It reduced the mortality rate to around 1 in 10,000 patients – a probability lower than that of general anaesthetic itself. As one doctor from Chicago Medical School wrote in 1997, “To put the mortal risk with ECT in proper perspective, it is only necessary to note that ECT is about ten times safer than childbirth.”
Despite such advances, ECT would fall out of favour after the 1960s. “It was as if penicillin had somehow vanished from the medical armamentarium and a generation’s memory of its very existence had been somehow erased,” wrote Edward Shorter and David Healy, two medical historians, in 2007. This was partly due to the rise in prescription drugs – though these were often less effective in severe depression – and partly due to the bad press ECT received in books, films, and the mass media. In the 1970s, historians David Healy and Edward Shorter write in their book Shock Therapy, a growing anti-psychiatry movement spearheaded by the Church of Scientology claimed that ECT ‘destroys minds.’ There is no conclusive evidence of this. In 1991, after performing ECT on 35 depressed patients, Edward Coffey and his colleagues at Duke University concluded, “Our results confirm and extend previous imaging studies that also found no relationship between ECT and brain damage.” Memory loss, however, is an issue that many scientists agree on, at least to a degree. Although memories lost to ECT usually return within a few weeks, there are reports of permanent losses. Like treating any other disease or operation, the possibility of health has to be weighed against that of harm.
The important question here isn’t whether ECT is good or bad – a miracle or an evil – but whether it can help people who truly need it. And there is ample evidence showing that it isn’t just an effective treatment but, in some cases, the best we currently have. “The truth remains [that] it’s an incredibly good treatment,” says Vikram Patel, a professor at Harvard Medical School. “It’s a life-saving treatment, one of the few we have in psychiatry. “I have never seen any treatment in psychiatry work as phenomenally as ECT has.” In 2004, a study from the Consortium for Research in ECT (CORE), a programme funded by the National Institute of Mental Health, found that out of 253 patients with severe and psychotic depression, 238 (94%) responded with a significant reduction in their depressive symptoms as gauged by a standard questionnaire. In total, 189 (75%) of patients achieved full remission after an average of seven sessions of ECT spread over three weeks. Ten people (4%) dropped out because of memory problems or confusion. In comparison, antidepressants such as those I take are usually only effective in two out of three people (66%) with depression, and remission only occurs in one in three (33%). About ECT’s potential, George Kirov, clinical professor at Cardiff University, wrote in 2017 that “if a patient with psychotic depression is not improving during an ECT course”, he tries “to find out what we are doing wrong.” It has even shown great promise for pregnant women and the elderly, two populations that are at high risk of depression but often can’t take antidepressants.
While I was researching this article, I discussed ECT with a few of my friends and family. Each time, I received a similar response: “Do they still do that?!” The reaction shows disbelief, horror, and (dare I say it) shock. And it is understandable. Even for those who haven’t watched One Flew Over the Cuckoo’s Nest or read Sylvia Plath’s biography, shocking someone with electricity can seem as likely to kill as to cure. But this image of ECT as a barbaric, painful, and brain-washing treatment discourages those instances where it could bring someone back from a life-threatening illness. Because of it, not only are hospitals less likely to administer ECT, but people who have a high chance of benefiting from it wouldn’t even consider it an option. The stigma isn’t just harmful; it can also prevent recovery. As suicide and depression become leading causes of death and disability around the world, we need all the support we can get. Interest in ECT is returning. According to a recent report, a growing number of people are deciding to undergo the treatment. Between 2015 and 2016 in the UK, 22,600 sessions of ECT were performed, an 11% increase over the previous year. And ECT has been joined by more selective forms of electric therapy such as Deep Brain Stimulation (DBS) and Transcranial Magnetic Stimulation (TMS), both of which are growing in support and popularity in the treatment of depression, Parkinson’s disease, and other mental disorders. In my case, I am comforted by the fact that there are promising alternatives if my antidepressants start to fail and my condition deteriorates. Although how it works is little understood, ECT often is likened to the rebooting of a computer. The wiring of the brain is refreshed. Perhaps it’s time for the image of ECT to undergo a similar transformation.
Credit: Alex Riley for The BBC, 3 May 2018.