Contents | February 2001
In This Issue (Contributors)
More on technology and science from The Atlantic Monthly.
From the archives:
"Listening to St. John's Wort" (May 1998)
Medical science meets the "natural Prozac." By Edison Miyawaki
"Suffering Children and the Christian Science Church" (April 1995)
The unwillingness of many Christian Science parents to seek help from physicians for their critically ill children has led to many painful and unnecessary deaths and, increasingly, to legal actions that have become burdensome to the Church and its members. By Caroline Fraser
From Atlantic Unbound:
Web Citation: "Psychotherapy on the Net" (September 16, 1998)
Boldly going where Freud never went. By Toby Lester
Elsewhere on the Web
Links to related material on other Web sites.
"Electroconvulsive Therapy. NIH Consens Statement Online" (June 1985)
A statement summarizing the consensus of a panel (representing psychiatry, psychology, neurology, psychopharmacology, epidemiology, law, and the general public) with respect to issues surrounding electroconvulsive therapy. The panel was convened for the 1985 National Institutes of Health conference on Electroconvulsive Therapy.
The History of Shock Therapy in Psychiatry
An overview of the development of shock therapy and related treatments since the nineteenth century, including a description of the backlash against electroconvulsive therapy, and a guide to electroconvulsive therapy resources on the internet. Posted by a neuroscientist at the University of São Paulo.
"Electroconvulsive Therapy (ECT)"
An introduction to electroconvulsive therapy for patients by the American Psychiatric Association. Includes information about side effects, patient rights, and costs, along with an extensive bibliography.
Citizens Commission on Human Rights
A branch of the Church of Scientology devoted to demonstrating that psychiatry—and epecially electroconvulsive therapy—is counterproductive and abusive.
The Committee for Truth in Psychiatry: What You Should Know About ECT
"The Committee for Truth in Psychiatry, or CTIP, is a national organization of over 500 former electric shock patients. None of us was truthfully informed about the nature or consequences of this treatment before consenting to it, and we have pooled our experience-gained knowledge to provide truthful information about it for future psychiatric patients."
The Atlantic Monthly | February 2001
n the cover of a pamphlet I was sent recently appears a photograph of an elderly man with bright bolts of electricity shooting outward from his temples. His teeth are clenched. His eyes are squeezed shut. His hair is standing on end. Holding the man's head secure is a leather strap that resembles the restraint on a prisoner in the electric chair.
Shock and Disbelief
Electroconvulsive therapy was once psychiatry's most terrifying tool—blunt, painful, and widely abused. It is now a safe and effective treatment for a wide range of mental illnesses. But an unlikely trio of activist groups stands against it
by Daniel Smith
This is electroconvulsive therapy (ECT)—the psychiatric use of an electric current to stimulate a grand mal seizure—as seen through the eyes of the Citizens Commission on Human Rights, a lobbying group founded by the Church of Scientology and the most active and well-organized anti-ECT group in existence. It is a grim view, invoking coercion, barbarity, anguish—everything negative that has ever been associated with psychiatry. It is also the common view.
Last fall I saw a patient receive ECT at McLean Hospital, a private psychiatric facility in Belmont, Massachusetts. There, in a well-lit treatment room, attended by a nurse, a psychiatrist, and an anesthesiologist, a middle-aged man suffering from hallucinations and depression lay unconscious on his back while two electrode paddles were placed on his head. A button was pressed, and the patient's right foot twitched lightly. Shortly afterward the patient awoke and was given a snack before being escorted back to his room.
The contrast between image and reality is surprising. The procedure I saw at McLean reflects the way ECT has been administered for years, as cautiously and as formally as any other medical procedure—perhaps even more so, because of the awareness psychiatrists have of ECT's reputation as savage. Yet the popular image of ECT has persisted, sustained almost single-handedly, it sometimes seems, by the 1975 movie One Flew Over the Cuckoo's Nest, the release of which coincided with a decline in the use of ECT. In 1980 less than three percent of all psychiatric inpatients were being treated with the procedure, and by 1983, thirty-three states were in some way regulating it.
Although the public seemed willing to let ECT fall into obsolescence, many psychiatrists felt that they were losing a valuable and irreplaceable treatment. In 1985 the National Institutes of Health, in Bethesda, Maryland, called a three-day conference on electroconvulsive therapy. The first day of the conference passed without incident, as experts delivered lectures. On the second day, however, during an open discussion period, anger erupted on the floor of the conference hall. Former patients and even a few clinicians began protesting loudly. One of those present was Max Fink, then a professor of psychiatry at the State University of New York at Stony Brook and a pioneer in modern ECT research. As Fink remembers it, "They were shouting, 'How dare you even consider electroshock as a possibility! It has no place in the world! Everybody who does electroshock should be in jail!'"
When the conference resumed, a panel of "nonadvocate" experts forged a consensus statement in which they observed, with standoffish delicacy,
Electroconvulsive therapy is the most controversial treatment in psychiatry. The nature of the treatment itself, its history of abuse, unfavorable media presentations, compelling testimony of former patients, special attention by the legal system, uneven distribution of ECT use among practitioners and facilities, and uneven access by patients all contribute to the controversial context in which the consensus panel has approached its task.
oday ECT has strengthened its position in the profession. Many psychiatrists, whether or not they actively administer the treatment, have come to appreciate its ability to ameliorate a range of mental illnesses, from depression to some forms of schizophrenia and catatonia. A 1993 commentary in The New England Journal of Medicine stated, "Electroconvulsive therapy is more firmly established than ever as an important method of treating certain severe forms of depression." The first phase of a National Institute of Mental Health-supported study, to be published this spring, found that ECT produced a greater than 95 percent remission rate in psychotically depressed patients—vastly higher than the rate for any drug on the market. When I talked with Fink recently, he told me, "ECT is the most effective antidepressant, antipsychotic, anticatatonic we have today." Other psychiatrists have been even more enthusiastic. One, T. George Bidder, has written that ECT is "one of the most effective treatments in all of medicine—with a therapeutic efficacy, in properly selected cases, comparable to some of the most potent and specific treatments available, such as penicillin in pneumonococcal pneumonia." Such endorsements have led to what looks like a renaissance for ECT: it is estimated that 100,000 patients are treated with it each year—nearly triple the number cited for 1980 by the NIMH.
Yet the attacks on the treatment are as virulent as ever. Activists continue to push for prohibitive legislation. In 1997 a bill that would effectively have made administering ECT a criminal act, punishable by a fine of up to $10,000 and/or up to six months in jail, was narrowly defeated in Texas. ECT has virtually disappeared from state-run psychiatric facilities, owing in large part to government regulation. To be treated, patients must almost always gain access to a private or academic hospital. This means that ECT is very rarely an option for poor patients—those without adequate insurance or access to information, or without the means to travel, for example, to a distant, well-equipped university hospital. A 1995 article in the American Journal of Psychiatry found that ECT was unavailable in more than a third of the 317 metropolitan areas nationwide that it surveyed. "The situation has reversed itself from where it was decades ago," says Richard Weiner, a professor of psychiatry at Duke University and the head of the American Psychiatric Association's Committee on ECT. "Many ECT patients used to be asylum patients. Now it's very hard to get ECT in such places, and its use has shifted to general hospitals and private psychiatric hospitals."
The stigma attached to ECT is in some ways a holdover from less scrupulous days of psychiatry. But one of the main reasons many people still consider ECT to be archaic and even destructive is that it continues to be painted as such by an unlikely trio of activist groups: a handful of former ECT patients, some dissenting psychiatrists, and the Church of Scientology. These groups have agitated for the complete elimination of ECT. They have pushed legislative attempts to limit or ban ECT. They have initiated and supported lawsuits against psychiatrists, hospitals, and ECT-device manufacturers. They claim that ECT is authoritarian, violent, and representative of everything that is wrong with the profession of psychiatry. And despite all medical evidence to the contrary, people are listening to them.
"A Crack of Electricity"
lectroconvulsive therapy emerged during a bleak period for psychiatry. In the first third of the twentieth century not much could be done for the mentally ill. Psychoanalysis, the dominant method of treatment, proved helpful to some wealthy patients complaining of the so-called "minor illnesses": melancholy and neurosis. But it didn't do much for patients with more-systemic afflictions, such as schizophrenia and manic-depressive illness. These patients were merely warehoused in vast state asylums, where conditions were appalling. Patients were abused, shackled, even surgically sterilized. Psychiatry's job seemed to be no more than brutal custodianship; psychiatrists could do no more than hope that their patients would recover spontaneously from their illnesses. Under these desperate circumstances some psychiatrists began experimenting with radical treatments: insulin coma, transorbital lobotomy, malarial fever.
One of these "somatic therapies"—Metrazol shock—seemed particularly promising, given the theory (now known to be untrue) that a "biological antagonism" existed between epilepsy and schizophrenia. A schizophrenic patient was injected with Metrazol, a drug similar to camphor. After a few minutes the patient would undergo a full-blown seizure: all the muscles in his body would convulse violently, his back would arch, his limbs would flail, his breathing would become shallow. Often he would vomit. It was a gruesome ordeal. The historian Edward Shorter, in A History of Psychiatry (1997), reported that a Swiss psychiatrist stopped using the treatment because it caused "agonizing fears of dying and crumbling away," and that a British doctor spoke of "the unseemly and tragic farce of an unwilling patient being pursued by a posse of nurses with me, a fully charged syringe in my hand, bringing up the rear." And yet, strangely, Metrazol shock worked pretty well. "Convulsive therapy," as it came to be called, opened wide vistas of possibility.
But no one really understood why inducing seizures made patients better. Even today there are only educated guesses. Some subscribe to the neuroendocrine hypothesis, which states that seizures cause a shift in the body's hormonal system. Others subscribe to what has been called the anticonvulsant view, which holds that, paradoxically, the whole purpose of causing a seizure is to tap into the brain's ability to stop that seizure naturally. In other words, the brain's anticonvulsant mechanism may alter the brain's neurochemistry, acting as a built-in antidepressant. Still others believe that it is the seizures themselves that change the level of chemicals in the brain. In 1990 a group of articles in the journal Neuropsychopharmacology examined all three possibilities without drawing any conclusions.
Regardless, from the beginning convulsive therapy proved promising. Ugo Cerletti, in the 1930s the chief of the Clinic for Nervous and Mental Diseases at the University of Rome, was among those who were impressed. But he considered that electricity might cause seizures more quickly, and thus in a less harrowing manner, than Metrazol. Earlier Cerletti had tested the neurological effects of electricity by conducting experiments on dogs. His first attempts were inauspicious: because he put one electrode in the dog's mouth and one in its anus, the bulk of the current passed through the dog's heart; half the dogs died of cardiac arrest. Lucio Bini, one of Cerletti's assistants, solved this problem by transferring the electrodes to the dogs' temples. Cerletti and his staff worked tirelessly, experimenting on animals that were brought to them each week by dog catchers. The results supported their hopes: it seemed that using electricity was an effective way to produce an epileptic fit. Before applying it to a human being, Cerletti's assistants visited a Rome slaughterhouse to observe an electrical device that was being used to incapacitate pigs prior to slaughter. They discovered that there was a wide margin between the amount of electricity that would create a seizure and the amount that would kill.
In the spring of 1938 "electroshock," as Cerletti called it, was ready to be tested on a human being. The subject was a Milanese man the Roman police had found wandering in the train station without a ticket, mumbling gibberish to himself. Shorter described the inaugural treatment.
The patient, his head shaved, seemed quite indifferent to what was going on. A nurse placed the electrodes on his temples while an orderly put a rubber tube between his teeth to prevent him from biting his tongue ... There was a crack of electricity. The patient's muscles jolted once ...
Despite the primitive application, the patient responded quite well. He had ten more treatments and was released, "in good condition and well-oriented." After a year he had not relapsed significantly. This was no small feat; no one could remember any experiment that had shown nearly such promising results. Thereafter ECT spread quickly to European hospitals. By 1940 it had appeared in the United States. Psychiatrists were enthusiastic. One, whom Shorter quoted, wrote in the British Journal of Psychiatry, "Without ECT I would not have lasted out in psychiatry, as I would not have been able to tolerate the sadness and hopelessness of most mental illnesses."
"Let's step it up to 90," said Cerletti.
Another electrical crack. Another spasm. The patient lay motionless for a minute, then began to sing.
"We'll try it one last time at a higher voltage," said Cerletti, "poi basta [and then enough]."
At this point, the patient said, in a perfectly calm and reasonable voice, as though answering an exam question, "Look out! The first is pestiferous, the second mortiferous." The residents looked at each other puzzled.
ECT was a great step up. Patients did not vomit, as they did in the course of Metrazol shock, and they did not experience as much psychological trauma. But they did still have to suffer the effects of muscular convulsions, which were frequently excruciating, and which have contributed to the persistent image of ECT as a brutal form of treatment. Thrashing around on the treatment table, many patients bit their tongues and cheeks. Many suffered broken bones or serious spinal injuries. Sometimes a gang of orderlies and nurses was needed to prevent the patient from tossing himself off the table altogether. In addition, patients suffered memory loss. They would awake confused, unsure of where they were or what had happened, often forgetting events of the preceding weeks or months.
ECT was also drastically overused. Doctors in some hospitals would treat dozens of patients in one giant room, wheeling the device on a cart from bed to bed; patients were forced to watch the ordeal of those who came before them. One doctor in England treated some of his patients more than a thousand times each. In the 1950s Ewen Cameron, a psychiatrist at McGill University, in Montreal, "depatterned" his patients by giving them twelve treatments daily. Milledgeville State Hospital, in Georgia, for a time the largest asylum in the United States, had perhaps the worst history of abuse: it used what was known as the Georgia Power Cocktail to punish uncooperative patients.
Elsewhere on the Web
Links to related material on other Web sites.
U.S. Senator Thomas F. Eagleton withdraws his nomination for the vice presidency
A recording of Eagleton's withdrawal speech, posted by the History Channel.
The publicized experiences of famous patients treated privately with ECT bolstered the evidence against the treatment. The poet Sylvia Plath was subjected to ECT and wrote about it in her autobiographical novel The Bell Jar: "Then something bent 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." (Later in the novel the narrator had a less unpleasant ECT experience.) Ernest Hemingway underwent a course of ECT at the Mayo Clinic, in Rochester, Minnesota, and wrote to his biographer, A. E. Hotchner: "What is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure, but we lost the patient." Soon afterward Hemingway shot himself. In 1972 Senator Thomas Eagleton had to withdraw as the presidential candidate George McGovern's running mate after it was revealed that he had been treated with ECT. And, of course, One Flew Over the Cuckoo's Nest bundled all the public's negative associations into the disturbing image of Jack Nicholson, mocking and playful one moment, writhing on a table the next, and finally catatonic—the result, in actuality, not of the ECT he received but of an off-camera lobotomy.
ECT all but disappeared in the 1970s, eclipsed by psychiatric drugs, which brought about, as Shorter called it, the "triumph of the biological." More and more drugs came on the market, offering a sophisticated biochemical arsenal for treating mental illness. In the 1980s, owing to more-advanced neuro-imaging techniques, physiological sources were found for schizophrenia and manic-depressive illness. As is by now well known, psychiatry and neurology edged toward a permanent intimacy. Electroconvulsive therapy seemed more than a little outmoded.
But drugs have not been the complete answer to mental illness. They were and still are a frustratingly inexact method of treatment—with a long wait between the first pill and any sign of relief. Often they don't work at all. This can be fatal for a patient who is suicidally depressed. Moreover, some patients prove resistant to medication.
The psychiatric community set out to modernize ECT and improve its image. Researchers worked with manufacturers to modernize ECT devices, outfitting them with equipment to monitor heart rate and brain activity and upgrading the electricity used. The 1985 NIH conference was followed by a 1990 report by the American Psychiatric Association committee charged with introducing better standards for treatment. The problem of physical injuries had been solved by the administration of fast-acting anesthesia and muscle relaxants, which confine the effects of a seizure to the brain. Clinicians implemented an informed-consent procedure that detailed every aspect of ECT along with its benefits and risks—including the (slim) possibility of death. (According to the most recent report of the APA Committee on ECT, published this year, one death occurs for every 80,000 treatments.) ECT became safer and more exact, and psychiatrists used it more selectively. Today ECT is frequently used to treat the elderly, a population highly susceptible to mental illness and sensitive to the side effects of medication. Because drugs can cause birth defects, ECT is also often the preferred psychiatric treatment for women during the early stages of pregnancy.
Some side effects do remain. Memory loss is the most prevalent and is the primary reason that ECT is not used more often. Patients may have gaps in their memory affecting several months preceding treatment, and may also have trouble "laying down" new memories for a couple of weeks following treatment. In a small number of patients these problems can persist for a much longer period of time. But to some people, the fact that ECT causes any memory loss at all is unacceptable. ECT's detractors focus their objections on this side effect.
Photograph by Arthur Tress.
Copyright © 2001 by The Atlantic Monthly Group. All rights reserved.
The Atlantic Monthly; February 2001; Shock and Disbelief - 01.02; Volume 287, No. 2; page 79-90.