ECT: Sham Statistics, the Myth of Convulsive Therapy, and the Case for Consumer Misinformation - ECT: Sham Statistics

Written by Douglas G. Cameron

Brief Pulse Fails

Despite the advantages of the Liberson ECT device, physicians in clinical practice did not use it widely. Brief pulse devises may have been slightly more expensive to build. Also, the earliest BP device emitted such low electrical dosage that unconsciousness was sometimes induced by the convulsion rather than by the electricity. In these instances the ECT recipient remained conscious until the convulsion, resulting in even more apprehension than in unmodified (without anesthesia) high dosage SW EST (Liberson, 1948, p. 30). The problem was corrected by a slight increase in the pulse width or by the utilization of sodium pentothal or both (Liberson, 1948, pp. 30, 35). (9) Some psychiatrists believed fear to be a necessary dimension of the procedure and so increased apprehension may not have been a negative factor for physicians in using the device (Cook, 1940; Liberson, 1948, p. 37). However, most clinicians complained that the same anti-depressant effect attainable with high dosage EST devices could not be achieved with Liberson's low-current BP ECT device (Impastato et al., 1957, p. 381). Many psychiatrists were not convinced the treatment worked without the higher dosage of electricity and its accompanying side effects. In fact, since the treatment appeared less effective with reduced side effects, many practitioners held side effects to be desirable, an integral part of the treatment itself (Alexander, 1955).

Although Liberson claimed complete therapeutic success with his device, he soon began proposing more treatments per series - in fact, as many as thirty (Liberson, 1948, p. 38) Rationalizing, Liberson proposed "a relatively great number of BST (brief stimulus) treatments in order to consolidate the therapeutic results...As BP treatments are not followed by as much organic disturbance as with the classical ones, one should be particularly eager not to stop the treatments too early" (Liberson, 1948, p. 36). Liberson failed to explain why, if the anti depressant effect was a product of the adequate convulsion, a greater number of individual treatments would be required.

As early as 1948 then, it was known that, even with potent seizures, the anti depressant effect at low electrical dosages was simply not satisfactory. (10) Liberson (1946, p. 755) must have understood that electricity was the true therapeutic agent, but rather than publish findings showing von Meduna's convulsion theory weakened considerably, he focused instead on making his BP ECT device "work." After calling for more and more treatments, he recommended longer doses of BP ECT (Liberson, 1945b), eventually marketing a machine which allowed the current to flow between the temples for a full five seconds (compared to between 0.5 and one second previously). The Liberson device could no longer be called an ECT, but was now an EST device. Next, although Liberson had already increased the wave length duration from 0.3 to between 0.5 and one millisecond (11), his newer BP model offered adjustable wave lengths from between 1.5 to two milliseconds. The current was eventually stepped up to between 200 and 300 milliamps and finally, Liberson returned to AC - doubling the power.

All these modifications, of course, defeated the original purpose of the BP experiment: to induce adequate seizures at just above threshold electrical dosage. But even as Liberson continued increasing the anti depressant effect of his BP machines by augmenting the dosage of electricity in various ways, the machines still lacked the power of the original or newer Cerletti-Bini style EST devices. Physicians everywhere seemed to prefer the higher dosage machines for their greater effectiveness (Cronholm and Ottosson, 1963; Page and Russell, 1948). Eventually, Liberson stopped increasing the power of his own device any further.

No one, including Liberson, mentioned that the convulsion theory might have been shown false, that adequate convulsions by themselves did not appear to produce a therapeutic effect. Nor did anyone suggest that it was electroshock that psychiatrists preferred, not minimal dosage electroconvulsion at all. By the mid-1950s, the Liberson BP ECT series disappeared forever from the marketplace.

The Wilcox-Reiter Device

Just as Liberson originally adopted the Wilcox-Reiter modification of DC in lieu of AC, Wilcox and Reiter soon incorporated Liberson's electronic BP principle into their own device. Wilcox and Reiter held one additional advantage: a cumulative sub-convulsive technique culminating in just above threshold seizures. This allowed the Wilcox-Reiter devices to surpass even Liberson's BP in ability to induce grand mal convulsions with the least electricity possible. The Reuben Reiter Company (producer of the Wilcox-Reiter machine) continued to produce such ECT devices into the 1950s.

Even so, by 1953, it was apparent that the Wilcox-Reiter ECT "electro-stimulators" also began to decline in popularity and could not compete with the more powerful Cerletti-Bini style American EST machines (i.e., Radha, Lectra, and Medcraft). in December 1956, at the Second Divisional Meeting of the APA in Montreal, Canada, psychiatrist David Impastato (12) and his colleagues made this announcement:

These currents (unilateral currents of the previous Reiter machines) evoke convulsions after three to five or more seconds of stimulation. In view of this, we may call such convulsions threshold convulsions...The fracture rate is moderately reduced when these currents are used, but apnea, post-convulsive confusion and agitation and subsequent memory changes are greatly reduced. In spite of these advantages, the use of unidirectional currents has not found favor in all quarters because a number of observers feel that with these currents more treatments than with AC currents are needed to effectuate a remission or to quickly bring under control such abnormal behavior as unmanageable agitation and suicidal drives. The psychiatrist of this faith therefore continues to use the old AC current machines and makes the best of the undesirable side actions. (Impastato et al., 1957, p. 381)

This announcement was, in effect, the unprecedented concession that the Wilcox-Reiter experiment with ECT had failed; that adequate convulsion alone had not, according to clinicians everywhere, created the desired anti-depressant effect Wilcox, Friedman, Reiter, and Liberson had hoped for, 15 years earlier. ECT had failed and EST had emerged victorious. Almost all manufacturers of the popular SW devices recognized the "adequate dosage" precept. The more powerful their machines became, the more "effective" and commercially successful.