This is a treatment based on the effect of electric current on the brain.
The electrical stimulus is applied for a very brief period of time (0.5–2 seconds), under general anesthesia, combined with a treatment that minimizes the ability of nerve impulses to cause contraction of the skeletal muscles, without eliminating the ability of the electrical current to stimulate nervous tissue. It is usually stated that, in order to be effective, the stimulus must produce seizures. This does not mean that the seizure itself produces the therapeutic effect, but simply that when the stimulus does not produce a seizure, the treatment is unlikely to be effective. Seizures are the peripheral manifestation of electrically induced activity in the central nervous system (measurable by EEG), which is the actual event associated with the therapeutic effect.
In the way the treatment is administered today, the seizure is deliberately made very weak (under normal circumstances it would otherwise be even stronger than that produced by a spontaneous epileptic seizure), in order to prevent musculoskeletal injuries. Nevertheless, it remains observable through EEG, providing a parameter that can be used to predict effectiveness.
Origins
The theoretical origin of ECT can be traced back to L. J. Meduna, who developed the theory that schizophrenia and epilepsy were two “antagonistic” disorders, because in his clinical series people with epilepsy appeared to be “protected” from psychosis (which at the time was classified as schizophrenia according to criteria different from those used today). Furthermore, the induction of febrile states had demonstrated a certain degree of effectiveness in some forms of progressive psychosis caused by syphilis, which was a significant problem at the time.
In 1933, M. Sakel developed a technique to deliberately induce epileptic seizures in mentally ill patients in an attempt to counteract the symptoms of schizophrenia. Sakel used insulin to induce a temporary state of hypoglycemic coma, during which epileptic seizures occurred. Other approaches involved administering drugs that directly induced seizures and, as had already been practiced, inducing febrile states in order to exploit the relationship between fever and convulsions.
The idea of inducing seizures by administering an electrical stimulus was put into practice by the Italian psychiatrists Cerletti and Bini in 1938. The technique was subsequently refined and scientifically studied in a sufficient number of cases to conclude that it was reliable for resolving acute phases of manic-depressive psychosis (currently referred to as bipolar I disorder), acute schizophrenia (a term now obsolete that corresponded to several different conditions, including less typical forms of bipolar psychosis), and severe depression.
The fact that more recent research has ruled out its usefulness in schizophrenia should not be regarded as a contradiction, because the diagnostic categories of the 1930s and those used today are not directly comparable. “Acute schizophrenia” largely corresponded to what today would be included within the diagnosis of bipolar disorder.
Ugo Cerletti was an Italian physician who specialized in psychiatry under the Kraepelin school. At that time, therapeutic tools were still scarce and crude, and were primarily directed at severe mental illnesses, namely schizophrenia and other psychoses. Various techniques were being developed to produce epileptic seizures in patients with schizophrenia, based on the theory that the phenomena associated with epilepsy (convulsions) were somehow antagonistic to those of schizophrenia.
The methods used included insulin coma therapy, the administration of cardiazol, and the production of acute febrile states (including through infectious means, such as the use of the malaria parasite, Plasmodium). As a professor of psychiatry at the University of Rome, Cerletti, in collaboration with Professor Lucio Bini, developed the first device for inducing seizures through the application of electric current to the skull.
Cerletti himself wrote an account of that first experiment.
“Vanni informed me that at the slaughterhouse in Rome pigs were being killed with electric current. This information seemed to confirm my doubts about the danger of applying electricity to human beings. I went to the slaughterhouse to observe this so-called electrical slaughter, and noticed that metal clamps connected to the electrical current (125 volts) were applied to the pigs’ temples. As soon as the clamps were applied, the pigs lost consciousness, became rigid, and then, after a few seconds, were seized by convulsions, just like the dogs we used in our experiments. During the period of unconsciousness (epileptic coma), the butcher stabbed and bled the animals without difficulty. It was therefore not true that the animals were killed by the electric current; rather, according to the suggestion of the Society for the Prevention of Cruelty to Animals, electricity was used so that the pigs could be killed without suffering.
It seemed to me that the pigs at the slaughterhouse could provide material of enormous value for my experiments. I also conceived the idea of reversing the previous experimental procedure: whereas in experiments on dogs I had always attempted to use the minimum amount of current sufficient to produce an attack without causing harm to the animal, I now decided to determine the duration, voltage, and method of applying the current necessary to cause the animal’s death.
The electrical current would therefore be applied through the skull, in different directions, and through the trunk, for several minutes. The first observation I made was that the animals rarely died, and only when the electrical current passed through the body rather than the head. Animals subjected to the most severe treatment remained rigid while the current was flowing; then, after a violent seizure, they remained lying on their side for a while, sometimes for several minutes, and finally attempted to get up. After many attempts to regain their strength, they eventually managed to stand and take a few hesitant steps, until they were able to run away.
These observations gave me convincing proof that an application of 125 volts lasting a few tenths of a second to the head, sufficient to cause a complete seizure, caused no harm. At this point, I was convinced that we could attempt experiments on human beings, and I instructed my assistants to keep their eyes open for a suitable subject.
On April 15, 1938, the Rome police commissioner sent an individual to our Institute with the following accompanying note: ‘S. E., thirty-nine years old, technician, resident of Milan, arrested at the railway station while wandering around trains about to depart without a ticket. He does not appear to be in full possession of his mental faculties, and I am sending him to your hospital for observation…’
The patient’s condition on April 18 was as follows: lucid, well oriented. He described, using neologisms, delusional ideas, claiming to be telepathically influenced by sensory interference; the slightest [stimulus] corresponded to the meaning of words; mood indifferent to the environment, with diminished affective responsiveness; physical and neurological examinations negative; marked hearing impairment and cataract in the left eye.
A diagnosis of schizophrenic syndrome was reached on the basis of his passive behavior, incoherence, diminished affective responsiveness, hallucinations, delusional ideas concerning the influences he claimed to experience, and the neologisms he used.
This subject was selected for the first experiment involving electrically induced seizures in a human being. Two large electrodes were applied to the individual’s frontoparietal region, and I decided to begin cautiously, applying a low-intensity current of 80 volts for 0.2 seconds.
As soon as the current was introduced, the patient reacted with a start and his muscles became rigid; he then fell back onto the bed without losing consciousness. He suddenly began singing loudly, and then calmed down.
Naturally, we who were conducting the experiment were under tremendous emotional strain, and it seemed to us that we had already taken a considerable risk. Nevertheless, it was obvious to everyone that we had used too low a voltage. It was proposed that the patient be allowed to rest for a while and that the experiment be repeated the following day.
Suddenly, the patient, who had evidently followed our conversation, said clearly and solemnly, without any of the speech disorganization he had demonstrated until then: ‘Not again! It’s terrible!’
I confess that such an explicit warning, under those circumstances, so emphatic and authoritative, coming from a person whose enigmatic speech had until then been extremely difficult to understand, shook my determination to continue the experiment. But it was only fear of yielding to a superstitious idea that made me decide to proceed. The electrodes were applied again, and we administered a discharge of 110 volts for 0.2 seconds.”
(quoted in Thomas Szasz, op. cit.)
The testimony of the physician Ayd, who reported Cerletti’s own shock at the violent and painful nature of the procedure, states:
“When I saw the patient’s reaction, I thought: this should be abolished! From that moment on, I hoped and waited for a new treatment to be discovered that would replace electroshock.”
This testimony is certainly not revealing in itself, since Cerletti himself describes, in his account and without euphemisms, the patient’s reaction of terror, his own emotional state, and his hesitation as a matter of concern about forcing the patient to undergo a painful and experimental procedure, albeit one intended to be therapeutic.
As further evidence of the transparency of his work, Cerletti himself stated in 1948:
“I said from the very first time that I presented E.S. that I hoped this aggressive, violent method would soon be abandoned in favor of less drastic methods, and I am actively working toward this end: I will be the first to rejoice when E.S. is no longer applied.”
And in 1950, during the First International Congress of Psychiatry in Paris:
“This does not prevent us, despite all these difficulties, from continuing to work in the hope that one day we will be able to tell you: Gentlemen, electroshock is no longer used. We have found the substances produced in the brain following the epileptic seizure, and we can use them in the treatment of different diseases as simply as other pharmacological substances are used.”
The statement reported by Ayd, which suggests a moment of ethical hesitation immediately suppressed in the name of a supposedly irrational and sadistic experiment, simply refers to the hope that medical progress would make the technique, which was then unique and remarkably effective, painless and acceptable for patients, whether consenting or not.
Cerletti therefore did not become attached to his invention, but instead attempted to overcome it and understand its mechanisms more fully, primarily concerned with developing a treatment based on the same principles but without pain:
“Cerletti continued to work on electroshock until his death. He formulated a theory according to which the humoral and hormonal changes caused in the brain by an epileptic seizure led to the formation of certain substances that he called ‘acroagonins,’ substances of extreme defense. If these substances were injected into the patient, they would have therapeutic effects similar to those of electroshock.”
(Di Cori, 1963, in Thomas S. Szasz, op. cit., 428–431).
The ethical limitations of the 1938 experiment are evident: an experimental treatment was administered to an individual who, although severely disturbed and unable to benefit from other possible therapeutic solutions, was neither terminally ill nor in imminent danger of death. The extension of the treatment to other similar cases, in a more or less systematic manner, was also outside current ethical standards, since a single case could not demonstrate certain or lasting benefits, nor establish the absence of subsequent harm.
These limitations did not appear to concern scientific communities in various countries, perhaps also because of the scarcity of therapeutic alternatives, which, compared with ECT, were perhaps less painful but associated with higher mortality and toxicity rates.
Italian health legislation adopted the new technique as an option to be preferred, presumably for reasons of safety, management, and perhaps cost, over insulin coma therapy:
“In order to reduce insulin consumption as much as possible, and taking into account the good results and advantages obtained through the use of ESK in various mental disorders, this Ministry intends for this therapy to be more widely used in psychiatric hospitals throughout the Kingdom, so that ICT will no longer be resorted to unless ESK has first been tried.”
(Health Division memorandum of October 21, 1940 – quoted by Enzilio Lupo in Psichiatria e Nazismo, Conference Proceedings).
By the time Italy entered the war, ECT was therefore no longer considered experimental. Furthermore, it had already spread to other European countries and the United States {CIT}.
Zigmond M. Lebensohn, in the article “The History of Electroconvulsive Therapy in the United States and Its Place in American Psychiatry: A Personal Memoir” (Comprehensive Psychiatry, May–June 1999), reports that one of Cerletti’s collaborators, Renato Almansi, transported an Italian-made ECT device to the United States in 1939. The procedure was first performed in New York, at 27 West 55th Street, by Dr. David Impastato in January 1940, on a patient of Italian origin suffering from schizophrenia.
Current Position
It is important first of all to distinguish between situations in which ECT has demonstrated efficacy, those in which it is currently used, and those in which it is preferable to other treatments.
ECT is useful in severe depression, particularly when complicated by psychosis. It is also used, with a success rate of approximately 50%, in cases of severe depression that do not respond to either medication or psychotherapy. It may be chosen as a first-line intervention in certain cases where rapid improvement in severe depression is desired, in order to reduce the risk of suicide or resolve states of psychomotor retardation.
It is the least risky option in patients for whom medications are contraindicated or in cases of depression during pregnancy where medications are contraindicated.
Its use as a second-line treatment for treatment-resistant depression is the most typical approach, although it is probably not always the most reasonable one. There are, in fact, circumstances in which ECT is a “first-line” intervention and, in some cases, preferable to medication precisely because it may be less risky and lacks some of the side effects that are unavoidable with long-term pharmacological treatments.
In general, the advantages of ECT lie in the rapidity of its effects and the smaller number of certain side effects associated with long-term pharmacological treatment, such as weight gain, sexual dysfunction, and cardiac risk. Some conditions in which medications are contraindicated are also incompatible with ECT, for example patients at significant cardiac risk or with brain lesions.
It is certainly reasonable to choose ECT for patients who have benefited from it in the past, provided that no contraindications have subsequently arisen.
The effects are relatively stable, and in patients with cyclical disorders who have repeatedly improved with ECT, preventive ECT administered periodically is sometimes considered useful. This possibility should be carefully evaluated on a case-by-case basis.
ECT may also be useful in certain affective disorders that are not depressive, or are not exclusively depressive, such as mania, mixed states, and some atypical forms of catatonia. In these cases, however, there are obvious limitations concerning the patient’s ability to provide consent, and the decision must be made on an individual basis.
Applying ECT to other disorders, or using it as a last resort for psychiatric disorders in general that are resistant to treatment, has no scientific basis.
The Procedure
A course of treatment consists of multiple sessions, with intervals of at least 24 hours between them (preferably 48 hours). The number of sessions usually ranges from 6 to 12.
The voltage, duration of the stimulus, frequency, length, and intensity are adjusted as part of the treatment. Typical parameters include a current of approximately 0.9 amperes and 220–250 volts, up to a maximum of 450 volts.
A gel is applied between the metal electrodes and the scalp to reduce electrical impedance and thereby prevent heat generation and consequent burns to the skin.
The risks associated with the seizure, such as suffocation, tongue injuries, muscle strain injuries, and skeletal trauma, are controlled by inducing temporary paralysis of the muscles with specific drugs (the so-called synthetic “curare-like” agents).
For this reason, before treatment begins, it is also verified that the patient can properly metabolize this type of medication, using an appropriate blood test.
The stimulus can be applied bilaterally or unilaterally. However, the combination of unilateral stimulation with low voltage (intended to reduce amnesia) has been shown to be therapeutically ineffective, although it is indeed better tolerated.
The actual risks of an ECT session, when patient-selection criteria are respected, are primarily those associated with anesthesia.
At least 24 hours should elapse between sessions, and this interval is often extended in order to minimize amnesia.
Treatment may be administered to hospitalized patients or in a day-hospital setting, similar to a minor surgical procedure. The decision is made by the physician, who considers not only any specific risks associated with the treatment but, above all, the severity and urgency of the patient’s psychiatric condition, which in itself may require hospitalization.
Side Effects
A person undergoing electroshock treatment (in approximately three out of four cases) retains confused memories or does not remember events occurring in the immediate period surrounding the session (the same day). Upon awakening, temporary disorientation may occur as a result of anesthesia.
After six months, these memory gaps are reduced to the duration of the session itself (that is, the period of anesthesia during which the person is unconscious), while other gaps tend to resolve, although gradually.
Earlier reviews of the data (NIH and NIMH, 1985) referred to memory disturbances concerning events occurring during the preceding months and up to two months after the end of ECT treatments. It should be noted that these data refer to patient populations treated with different safety parameters and with less psychiatric selection.
It should also be considered that various psychiatric disorders for which ECT was or is used are themselves associated with memory disturbances and amnesia following the resolution of acute phases of illness. Amnesia may therefore be partly related to the disorder itself, in addition to being a side effect of medications used in maintenance treatment.
Regarding the idea that ECT may cause permanent structural or functional damage, none of the studies conducted has indicated such a possibility (Devanand 1994; Weiner and Krystal 1994; Greenberg 1997; NIH; NIMH 1985; CMHS 1998).
Conversely, it has been demonstrated that ECT protects against the damage that depression may cause to the central nervous system; specifically, it stimulates neuronal growth and inhibits neuronal atrophy (Dumas and Vaidya, 1998).
The Reasons for Electroshock’s Bad Reputation and the Anti-Psychiatric Bias
In periods when therapeutic options are few and knowledge is limited, there is a tendency to use tools that have proven useful for one illness somewhat indiscriminately, perhaps according to the principle that “it cannot hurt to try.” It is possible that in the past, particularly in severe conditions such as psychoses, this approximation was also associated with an aggressive attitude toward the illness and, inevitably, toward the affected person.
It should also be noted that electroconvulsive treatment was previously administered without anesthesia and without preventing the physical consequences of the seizure. This caused suffering at the moment of stimulation and also created a risk of muscular, skeletal, and spinal injuries.
It is possible that people who were not actually ill but were considered socially deviant were subjected to this treatment, as well as to other treatments or simply to confinement, because they were regarded as individuals who needed to be re-educated or neutralized.
The same accusation has been made, and continues to be made, against certain pharmacological treatments and against psychiatric hospitals and asylums.
It should also be remembered that diagnoses in the past were based on different criteria. For example, the fact that ECT was once considered useful in schizophrenia is also related to the fact that conditions that today would be classified differently—such as psychotic depression and bipolar disorder—were once included under the diagnosis of schizophrenia.
The idea that psychiatry, and electroshock as its ultimate expression, is a technique for suppressing the critical and rebellious capacities of socially inconvenient individuals is a prejudice.
Psychiatry, as a branch of medicine, is a discipline aimed at treating the suffering associated with mental disorders, shortening their duration, controlling their symptoms, and preventing recurrence, consequences, and the long-term deterioration of the nervous system caused by these disorders.
Conclusions
It can be concluded that ECT is an effective psychiatric technique, useful in certain types of affective disorders and a preferable therapeutic resource in certain clinical situations.
Like all treatments, it has specific contraindications—that is, situations in which it should not be administered—as well as a certain level of risk and acceptable side effects.
ECT must be performed according to precise safety standards. Outside these standards, it should be regarded as an inappropriate and unreasonably risky intervention, as well as an unreliable one.