A Shocking Method: Electro-Convulsive Therapy
What comes to your mind when you hear "Electro-Convulsive Therapy"? Do you directly think about electro-shock and remember a movie scene? Maybe "One Flew Over Cuckoo's Nest"? If you say yes (I did), you are not alone. Electro-convulsive therapy (ECT) has a lot of stigma against it, and the media has a major role in it. ECT has a very long and complicated history. But before dwelling on its origins, what is ECT?
ECT is an effective treatment for a wide range of mental disorders, especially for severe depression (1,2). It involves applying a short-duration electrical pulse to the brain with two electrodes to induce a grand mal seizure of 20-30 seconds (1,2). ECT treatments generally consist of 6-12 sessions, distributed two to three times per week (1–3). ECT is commonly applied to treatment-resistant patients or those requiring urgent treatment (3). After the ECT treatment, follow-up treatment is generally needed, either pharmacological, tempering off ECT, or both (1,3,4). After 80 years since its invention, ECT is still being used today (5).
ECT is considered a safe and effective procedure and is included in the line of treatment by many health agencies worldwide (1,3,6–11). ECT is so successful that the advocates claim it shouldn't be the last resort but needs to be put further up in the line of treatment (3,12). Despite the high efficacy, why is ECT not as commonly used as the advocates suggest? The history of ECT helps us answer this question.
ECT was developed in the first half of the 20th century when there was frustration in psychiatric medicine, and doctors were using bold approaches (12). From using Malarial fever to treat psychotic symptoms to surgically disconnecting the frontal lobe from the rest of the brain (a procedure called lobotomy) to prevent obsessive thinking, many treatments that would be considered unethical today were used in that era (12–14). What is more striking is that both of the above treatments, which are not used today, earned their inventors a Nobel Prize (4,15,16).
During this period, there was an observation that the co-existence of epilepsy and schizophrenia was rare and that these two illnesses do not occur simultaneously (12). Even when they occur in the same patient, the symptoms alternate. This mutual exclusivity turned out to be false; however, it created the question: can epileptic seizures cure schizophrenic symptoms?
Ladislas Meduna, the inventor of convulsive therapy, started giving patients convulsions chemically, using camphor and later a drug called Metrazol (12,17,18). Drug-induced convulsion treatment was highly effective; however, it was causing serious side effects. The risk of vertebral fractures during the convulsions was high (12). It caused a lot of anxiety in the patients and the medical crew while waiting for the drugs to take effect (12). This high level of anxiety sometimes caused violence in patients and made the follow-up treatments difficult for both the crew and the patients (18).
The first ECT machine is displayed at the Museum of History of Medicine in Italy. https://commons.wikimedia.org/w/index.php?curid=24290197
Ugo Cerletti and Lucio Bini from Italy introduced the idea of using electricity for convulsion (12). Using electricity lowered the anxiety as ECT was causing instant unconsciousness in the patient (18). Their first patient, Enrico X, was treated in April 1938 and released after 11 treatments after showing good recovery (6,12,18) (†). In the mid-'40s, metrazol-induced convulsion therapy and ECT came to be used worldwide because they were very effective (12). With time, due to its fast effectiveness, ECT largely took over. It was so widely used that by 1947, 90% of US mental hospitals used some type of convulsion therapy, mostly ECT (12). The treatment also started to be improved. To prevent the fractures, the patients were given muscle relaxants (18). This "modified" form of ECT was done under anesthesia, not because the process is painful (the patient loses consciousness immediately), but because the muscle relaxants caused anxiety in the patients as they feel they cannot breathe. With these improvements, ECT was so easy to apply that it was also done as an outpatient. In fact, most ECT between 1938-1970 was done as an outpatient (12).
Psychoanalysis and the discovery of various antidepressants changed how psychiatry treatments worked during the '60s and '70s (1,18). A big backslash started against ECT. Psychoanalysts claimed ECT to be inhumane and not a solution as psychoanalysis would provide (12). There was also a big stigma against ECT, mostly because of how it was shown in the media. Movies or novels used the unmodified version of ECT (without muscle relaxants and anesthesia) for its dramatic impact (12). Patients were scared to get the treatment. The patients' families were dead against the treatment if their patient was in no condition to make a decision. The stigma was so high that even those who got the therapy were highly criticized. A VP candidate in the 1972 presidential race in the USA had to leave the campaign after it became public that he received the treatment (18).
Due to the negative pressure, the number of ECT treatments drastically decreased by the end of the century. Still, psychoanalysis and drugs alone didn't lower the number of institutionalizations. ECT slowly returned to the treatment timeline to help the seriously ill (13). Today, every year, there are almost 1.5 million patients around the world receiving ECT(5). However, debates and controversies on the effectiveness and safety of ECT continue to this day, as well as the stigma (5,6,19–23). And not only in the general public! An interesting study from Croatia showed that watching a live ECT session positively changed the perception of 4th-year medical students (24). The majority of the students' prior knowledge was coming from movies.
There are valid concerns about the safety of ECT, which are generally short-term and can be minimized by different measures. The severity of the side effects depends on the patient, the frequency of the application, and the dosage (3). There is a risk of cardiopulmonary events in less than 1% of the patients (3). There is pre-assessment and continuous observation of the vital signs to minimize the impact of these types of events (1). The most notorious side effect attached to ECT is memory loss. There can be, mostly temporary, anterograde and retrograde amnesia (3). Anterograde amnesia, which is the ability to make new memories, generally disappears within weeks, whereas retrograde amnesia, the loss of memory for previous events, can take months (3). Pre-oxygenation of the patient is now used as part of ECT treatments to minimize the risk of memory loss.
ECT works, but its mechanism is still unknown today (4,17). Interestingly, whatever measure the researchers suspect may be related to its effectiveness, they see a difference before and after ECT (3). It is accepted that ECT has a larger effect on the brain than any other method (12). It impacts many neurotransmitter metabolisms and the endocrine hormones under the control of the hypothalamus (12,17). In animal studies, it is found that ECT increases neurogenesis, the generation of new neurons, in the hippocampus, which is an important part of the brain for learning and memory (25). Studies also show increased hippocampal volume after ECT in humans (26). From increased connectivity of different brain regions to increased growth factors, many studies are trying to explain the mechanism behind ECT (3,17,27,28). However, these studies do not show whether a certain measure is the cause of the effectiveness. It is also not known whether the impact of ECT on various conditions is the same or different from patient to patient. Regardless, ECT plays a major role in treating patients with serious mental illnesses, and researchers continue to try to solve the puzzle.
While doing literature research for this post, I learned a lot about psychiatric medicine's striking history. The fact that such a successful treatment had to take a back seat, mainly due to its representation in the media, made me appreciate the hard work of all the researchers who clung to the treatment's potential and fought for its usage for decades. To be fair, the idea of having gaps in one's memory is a scary concept; however, the side effects of the mental illnesses the ECT is treating can be far more serious (12). If the ECT treatment can lower the suicidal tendencies of a patient and let them live a healthier life, there would be more time for them to make new memories. What we do not know about the brain still far exceeds what we know. Hopefully, researchers will find more clues on the effectiveness of ECT that will help many more patients.
† I tried to find out what happened to Enrico X afterwards. I found only one source indicating that he was admitted to another hospital two years later, based on a letter written by his wife (12). However, I could not find a scientific paper discussing the follow-up of the first-ever ECT patient.
Blog by Emine Topcu
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