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 with electricity.

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 attack.

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 electroencephalogram.

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.

After the 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 a writer.

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.

Third, the 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.

Some 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 altered.)

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.

But, despite all the controversy, doctors still administer ECT.

Professor 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.

These authors 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 therapy.'

`Is ECT necessary as a treatment modality in psychiatry?' ask Youssef and Youssef. Their answer to their own question is that it is `absolutely not'.

In the United States, 92% of psychiatrists do not use ECT. And the `therapy's is used by a minority of psychiatrists in other countries.

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.