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Electroconvulsive therapy

Controversial treatment for mental disorders

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ECT evolved from early seizure-inducing treatments and 18th–19th century electrical experiments into a formal procedure in the 1930s, later becoming widely used in the 1940s–50s. It then declined in use due to safety concerns and negative perception. With the introduction of anesthesia, muscle relaxants, and improved techniques, it became more safe and regulated, leading to its modern use as a treatment for severe psychiatric conditions.

The general physical risks of ECT are similar to those of brief general anesthesia.

Immediately following treatment, the most common adverse effects are confusion and transient memory loss. Among treatments for severely depressed pregnant individuals, ECT is one of the least harmful to the fetus.

The usual course of ECT involves multiple administrations, typically given two or three times per week until the patient no longer has symptoms. ECT is administered under anesthesia with a muscle relaxant. ECT can differ in its application in three ways: electrode placement, treatment frequency, and the electrical waveform of the stimulus. Differences in these parameters affect symptom remission and adverse side effects. ECT can be administered bilaterally or unilaterally, with high-dose unilateral matching efficacy but causing fewer cognitive effects. ECT is typically reserved for severe or treatment-resistant major depressive disorder, where it shows high efficacy and remission rates (around 50–60%), reduces suicide risk, and outperforms alternatives like antidepressants and repetitive transcranial magnetic stimulation, though relapse is common without maintenance treatment.

History

As early as the 16th century, agents to induce seizures were used to attempt to treat psychiatric conditions. In 1785, the therapeutic use of seizure induction (by administering camphor orally) was documented in the London Medical and Surgical Journal. As to its earliest antecedents one doctor claims 1744 as the dawn of electricity's therapeutic use, as documented in the first issue of Electricity and Medicine. Treatment and cure of hysterical blindness was claimed eleven years later. Benjamin Franklin claimed that an electrostatic machine cured "a woman of hysterical fits." By 1801, James Lind as well as Giovanni Aldini had used galvanism to treat patients with various mental disorders. G.B.C. Duchenne, the mid-19th century "Father of Electrotherapy", claimed its use was integral to a neurological practice.

In the second half of the 19th century, such efforts were frequent enough in British asylums as to make it notable.

Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then metrazol (cardiazol). Meduna is thought to be the father of convulsive therapy.

In 1937, the first international meeting on schizophrenia and convulsive therapy was held in Switzerland by the Swiss psychiatrist Max Müller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide.

The ECT procedure was first conducted in 1938 by Italian neuro-psychiatrist Ugo Cerletti and rapidly replaced less safe and effective forms of biological treatments in use at the time. Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his assistant Lucio Bini at Sapienza University of Rome developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1938, experimented for the first time on a person affected by delusions.

It was believed early on that inducing convulsions aided in helping those with severe schizophrenia but later believed to be most useful with affective disorders such as depression. Cerletti had noted a shock to the head produced convulsions in dogs. The idea of a procedure on humans came to Cerletti when he saw how pigs were given an electric shock before being butchered to put them in an anesthetized state. Cerletti and Bini practiced until they felt they had the right parameters needed to have a successful human trial. Once they started trials on patients, they seemed to find that after 10–20 treatments the results were significant. Patients had much improved.

A claimed 'positive' side effect to the treatment was retrograde amnesia, as after ECT they could not remember the operation, and thus had little to no ill feelings towards it.

ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening and more convenient. Cerletti and Bini were nominated for a Nobel Prize but did not receive one. By 1940, the procedure was introduced to both England and the US. In Germany and Austria, it was promoted by Friedrich Meggendorfer. Through the 1940s and 1950s, the use of ECT became widespread. At the time the ECT device was patented and commercialized abroad, the two Italian inventors had competitive tensions that damaged their relationship. In the 1960s, despite a climate of condemnation, the original Cerletti-Bini ECT apparatus prototype was contended by scientific museums between Italy and the US. The ECT apparatus prototype is now owned and displayed by the Sapienza Museum of the History of Medicine in Rome.

In the early 1940s, in an attempt to reduce the memory disturbance and confusion associated with treatment, two modifications were introduced: the use of unilateral electrode placement and the replacement of sinusoidal current with brief pulse. It took many years for brief-pulse equipment to be widely adopted.

In the 1940s and early 1950s, ECT was usually given in an "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare and serious complication of unmodified ECT was fracture and/or dislocation of the long bones. In the 1940s, psychiatrists began to use curare, a muscle-paralyzing South American poison, in order to reduce the intensity of the convulsions. The introduction of suxamethonium (succinylcholine), which was a safer synthetic alternative to curare, in 1951 led to the more widespread use of "modified" ECT. A short-acting general anesthetic was usually given in addition to the muscle relaxant in order to remove the terrifying feeling of suffocation that can be experienced with muscle relaxants.

The steady growth of antidepressant use along with negative accounts and media relating to ECT slowly led to a decline in the use of ECT from the 1950-1970s period. The Surgeon General of the United States stated there were problems with ECT in the initial years before anesthesia was routinely given, and that "these now-antiquated practices contributed to the negative portrayal of ECT in the popular media." The New York Times described the public's negative perception of ECT as being caused mainly by one fictional work: "For Big Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and, in the public mind, shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".

In 1976, Dr. Blatchley demonstrated the effectiveness of his constant current, brief pulse device ECT. This device eventually largely replaced earlier devices because of the reduction in cognitive side effects, although as of 2012 some ECT clinics still were using sine-wave devices.

In 1978 the publication of the first American Psychiatric Association (APA) task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001) endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT. Specifically, critics pointed to shortcomings such as noted side effects, the procedure being used as a form of abuse, and uneven application of ECT. The use of ECT declined until the 1980s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression". In 1985, the National Institute of Mental Health and National Institutes of Health convened a consensus development conference on ECT and concluded that, while ECT was the most controversial treatment in psychiatry and had significant side-effects, it had been shown to be effective for a narrow range of severe psychiatric disorders.

Because of the backlash noted previously, national institutions reviewed past practices and set new standards. In 1978, the American Psychiatric Association released its first task force report in which new standards for consent were introduced and the use of unilateral electrode placement was recommended. The 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task force report in 1990 where specific details on the delivery, education, and training of ECT were documented. Finally, in 2001 the American Psychiatric Association released its latest task force report. This report emphasizes the importance of informed consent, and the expanded role that the procedure has in modern medicine. By 2017, ECT was routinely covered by insurance companies for providing the "biggest bang for the buck" for otherwise intractable cases of severe mental illness, was receiving favorable media coverage, and was being provided in regional medical centers.

Though ECT use declined with the advent of modern antidepressants, there has been a resurgence of ECT with new modern technologies and techniques. Modern shock voltage is given for a shorter duration of 0.5 milliseconds where conventional brief pulse is 1.5 milliseconds.

In a review from 2022 of neuroimaging studies based on a global data collaboration, ECT was suggested to work via a temporary disruption of neural circuits followed by augmented neuroplasticity and rewiring.

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