Electro Convulsive Therapy
When we look back a couple
of hundred years we are very critical about the way that the mentally ill were
treated. At the Bethlem Royal Hospital in London in 1770 you could have paid a
penny to watch the depressed and the manic being bled, beaten, soaked in cold
water and blasted with electricity.
We may no longer deliberately beat
or bleed the mentally ill (not officially at least) but we do still blast them
Doctors have been using electricity as a therapy for
centuries. In ancient Rome, Scriborus Largus, tried to cure the emperor's
headache with an electric eel. But it was in 1938 that the use of electricity
for the `treatment' of mental illness was `rediscovered'. Two Italians, called
Cerletti and Bini, decided to try pumping fairly large amounts of electricity
into the human brain to treat schizophrenia. They developed Electroconvulsive
Therapy (ECT) because they believed that epilepsy and schizophrenia could not
exist together. ECT is, of course, a sort of artificially induced epileptic
In a standard ECT session electrodes are attached to one or both
sides of the patient's head and something like 80 to 100 volts are applied to
the head for up to a second at a time. That amount of electricity provides a big
enough current to light up a 100 watt light bulb. Not surprisingly, perhaps, in
a human being it causes a brain seizure which can be traced on an
While being given the treatment patients are
usually anaesthetised and given a muscle relaxant. Without the muscle relaxant
contractions can be so severe that bones can be fractured or teeth chipped. An
electrocardiogram is sometimes used to monitor the beating of the heart and some
doctors give oxygen to reduce the risk of brain damage.
electric shock has been given, patients slowly regain consciousness but usually
remain groggy and confused for a while. Sometimes patients complain that their
ability to remember events from the past disappeared. Author Ernest Hemingway
was convinced that ECT erased his personal experiences and ruined his career as
For thirty years or so after Cerletti and Bini introduced ECT
psychiatrists all around the world continued to use the `therapy', apparently
without worrying too much about such minor inconveniences as the lack of
evidence to show that it worked. Psychiatry is very much a black art and ECT is
surely the blackest of the black art therapies.
By the 1960s there was
growing disquiet about this type of treatment. Despite a lack of convincing
evidence showing that pumping electricity into the brain did any good, a number
of experts had decided that it could do harm. Many patients told how they had
been held down or tied down and given huge doses of electricity which had sent
them into violent convulsions. It all sounded terribly barbaric - more like
something from a mediaeval torture chamber than a twentieth century hospital.
Then, in 1975 the film `One Flew Over The Cuckoo's Nest' was released.
In the book, based on Ken Kesey's book, actor Jack Nicholson was seen receiving
electric shock treatment. This reinforced the idea that electric shock therapy
was cruel, barbaric and outdated. The amount of public pressure on doctors to
stop giving electric shocks to psychiatric patients increased for a while. But
then psychiatrists started to argue that they had nothing else to offer in the
place of ECT. And the popularity of the technique began to rise once more.
However, there was still confusion and controversy about just how ECT
should be applied and which patients it might help. Numerous experiments had
been done - including some at Buchenwald during the Second World War - but there
was still no agreement on how to get the best out of the alleged treatment.
The controversy and confusion was, I feel, summarised well in a paper
entitled `Indications for Electric-Convulsive Therapy and Its Use by Senior
Psychiatrists' that was written by two psychiatrists, Gill and Lambourn, and
published in the British Medical Journal in May 1979.
Gill and Lambourn
sent a questionnaire to a number of senior psychiatrists and, as a result,
showed that there was a considerable difference of opinion among psychiatrists
about how best the treatment could be used.
First, there were great
differences in the frequency with which psychiatrists used ECT. Some referred
ten to twenty patients a month for ECT. One said he never used it.
Second, the survey also showed that there were significant differences
between the reasons given for using ECT. Some psychiatrists said they thought it
was useful in the treatment of depression. Some said they used it for
schizophrenia. Some said they found it useful for mania.
researchers found that more than a third of the consultants believed that
temporary memory loss was invariably associated with clinically effective ECT.
Despite this - and other risks associated with the treatment - less than 20% of
the consultants personally administered ECT. Most preferred to leave the
unpleasant work to junior members of their staffs.
But the most
startling conclusion was that psychiatrists still did not agree about how to
apply ECT. Some consultants said that they preferred to give four treatments.
Others preferred a series of twelve treatments. Some of the consultants placed
the electrodes on one side of the head. Other consultants placed the electrodes
on both sides of the head.
It seemed to me, when I first read it, that
this startling survey strongly suggested that psychiatrists applying ECT didn't
have the faintest idea what they are doing.
The disquiet produced by
this study led to a major report on ECT published by the UKs Royal College of
Psychiatrists (RCP) in 1981. This report was based on 2,755 questionnaires
completed by doctors using ECT. The RCP report pointed out that of the 100
clinics where the researchers watched ECT being given not one satisfied the
standards that the RCP had outlined.
The RCP report also claimed that
obsolete machinery was being used. As a result the UK Secretary of State for
Social Services set up a working group which concluded that although over 20,000
ECT treatments were being given every year in the UK there was `no agreed
theoretical basis for the use of particular wave forms, frequencies, energy,
rate of delivery of energy, etc' and so there were `no minimal performance
requirements for the effective and safe use of ECT equipment to guide ECT
equipment manufacturers'. In other words, it seemed that after well over four
decades of use, doctors did not know how ECT worked, they did not know which
patients it should be given to, they did not know how it should be applied and
they did not know how best to make the equipment to give the electric shocks.
Hardly a rousing vote of confidence for ECT or psychiatry.
psychiatrists who used ECT claimed that it was most useful in the treatment of
severe depression. Some said it was appropriate for schizophrenia. Some said it
wasn't. Some were probably in two minds about it.
The survey done by the
Royal College of Psychiatrists showed that very few doctors seemed to know where
the electrodes should be applied and in three quarters of the clinics visited by
the doctors organising the survey for the RCP the settings on the machines used
to give ECT were never altered even though ECT machines are made so that the
strength and pulse of the current given can be varied according to the illness
and particular needs of each individual patient. (The snag, of course, was that
although these things could be altered no one seemed to know how they should be
Some machines available had no automatic timer so that the
control of the dose of electricity given depended entirely on the operator.
(Despite the fact that too much ECT is known to lead to prolonged memory
impairment). It was even found that only about half the ECT equipment in regular
use received any regular maintenance.
I have been vehemently critical of
ECT for decades. It has always seemed to me to be a primitive, barbaric and
crude form of `therapy'. As a medical student I once had to watch it being
administered. I remember feeling deeply ashamed of the profession I was
preparing to enter.
In 1988, in my book `The Health Scandal' I wrote
that: `Every year tens of thousands of patients receive a form of treatment that
still hasn't been properly tested. No one has any idea why it should work, or
indeed if it works. No one knows the extent of the damage it can do. No one
knows when it should be given or when it should be avoided at all costs. No one
knows what sort of machinery should be used or what dosage of electricity should
be given. No one really knows where the electrodes should be applied.'
Over a quarter of a century ago a wise psychiatrist told me that in his
view blasting electricity into the brain (an organ about which we understand
little more now than we knew then) was about as rational, as scientific and as
logical as blasting 30,000 volts into a malfunctioning TV set.
despite all the controversy, doctors still administer ECT.
Hanafy A Youssef D.M., D.P.M, F.R.C.Psych, recently sent me a paper entitled
`Time to Abandon Electroconvulsion as a Treatment in Modern Psychiatry' which he
had co-authored with Fatma A Youssef, D.NSc, M.P.H, R.N. of School of Health
Professions, Marymount University, Arlington, Virginia, USA and which had
appeared in `Advances in Therapy' earlier this year.
concluded 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.'
Youssef and Youssef argue that `terror as a
therapy for insanity has been used since antiquity' and report that: `From the
earliest uses of convulsive therapy, it was recognised that the treatment is
unspecific and only shortens the duration of psychiatric illness rather than
improves the outcome. Convulsive therapy based on the old belief of shocking the
patient into sanity is primitive and unspecific....For ECT to remain an
option...transcends clinical and common sense.'
`When an electrical
current is applied to the body by tyrannical rulers, we call this electrical
torture,' write these two authors, `however, an electric current applied to the
brain in public and private hospitals by professional psychiatrists is called
`Is ECT necessary as a treatment modality in psychiatry?' ask
Youssef and Youssef. Their answer to their own question is that it is
In the United States, 92% of psychiatrists do not use
ECT. And the `therapy's is used by a minority of psychiatrists in other
In my view, the fact that ECT is still used at all is a
disgrace to psychiatry and to the medical profession as a whole. A psychiatrist
who attacks his patients with such a bizarre and unscientific form of
pseudo-therapy is not to be trusted.