Time to Abandon Electroconvulsion as a Treatment in Modern Psychiatry

Written by Juli Lawrence

Advances In Therapy
Volume 16 No. 1
January/February 1999

Hanafy A. Youssef, D.M. D.P.M., FRC Psych.
Medway Hospital
Gillingham, Kent, United Kingdom

Fatma A. Youssef, D.NSc, M.P.H, R.N.
School of Health Professions
Marymount University
Arlington, Virginia, USA

ABSTRACT

This review examines the evidence for the current use of electroconvulsive therapy (ECT) in psychiatry. The history of ECT is discussed because ECT emerged with no scientific evidence, and the absence of other suitable therapy for psychiatric illness was decisive in its adoption as a treatment. Evidence for the current recommendation of ECT in psychiatry is reconsidered. We suggest 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.

INTRODUCTION

Berrios (1) has thoroughly documented the history of electroconvulsive therapy (ECT). We suggest that in both the 19th and 20th centuries the social context in which ECT emerged, rather than the quality of the scientific evidence, was decisive in determining its adoption as a treatment.

The medical literature is a virtual graveyard for inadequately tested preparations that die ignominiously after a brief moment of glory. Egas Moniz won a Nobel Prize in medicine for the prefrontal lobotomy, targeted at patients in whom ECT had failed. Clearly, psychiatrists abandoned all forms of shock treatment except ECT because of the empiric nature of such therapy and the lack of a credible explanation why it should work.

The prime bases of validation for ECT are vague statements about "clinical experience." Since the introduction of antipsychotics and antidepressants, the number of people subjected to ECT has undoubtedly declined, yet it is still used by some psychiatrists as the ultimate weapon. The proponents of ECT have to preserve the integrity of its use by having more training and better technology and claiming that ECT has proved its worth in clinical "experience." Thomas Szasz wrote that electricity as a form of treatment is "based on force and fraud and justified by 'medical necessity'." "The cost of this fictionalization runs high," he continued. "It requires the sacrifice of the patient as a person, of the psychiatrist as a clinical thinker and moral agent." Some people who have had ECT believe that they were cured by it; this fact indicates that they have so little self-control over the conditions of their lives that they must be shocked by an electric current to discharge their responsibilities.

When ECT became an emotional issue in psychiatry because of pressure groups, various bills were introduced by legislators in the United States. Professional societies and colleges - the task force of the American Psychiatric Association (3) and the Royal College of Psychiatrists memoranda (4-6) - have tried to study the subject and survey ECT use. Despite these efforts, ECT is and will remain controversial.

SHOCK AND TERROR AS THERAPY

Terror as a therapy for insanity has been used since antiquity, and as late as the 19th century, the insane were submerged in cold water to terrify them with the prospect of inevitable death.

While using insulin as a sedative in Viennese drug addicts, Sakel (8) observed that accidental overdose resulted in coma or epileptic fits. In a burst of nonscientific theorizing, he wrote: "I began with the addict. I observed improvements after severe epileptic fits.... Those patients who had previously been excited and irritable suddenly became contented and quiet after this shock.... The success I had achieved in treating addicts and neurotics encouraged me to use it in the treatment of schizophrenia or major psychoses."

Meduna used camphor-induced fits on psychiatric patients in a Hungarian state mental hospital after unsuccessful attempts by Nyiro, his superior, to treat schizophrenia by injections of blood from epileptics. Meduna later employed Cardiazol-induced shock. Nyiro's and Meduna's convulsive therapies were based on the view that a neurobiologic opposition existed between epilepsy and schizophrenia. Meduna abandoned his theory of schizophrenia and epilepsy and later wrote "We are undertaking a violent onslaught...because at present nothing less than a shock to the organism is powerful enough to break the chain of noxious processes that lead to schizophrenia."

Psychiatrists of that era who used this form of shock therapy believed that the fear and terror produced were therapeutic because the "feeling of horror" before the onset of convulsion following injection of camphor, pentetrazol, triazole, picrotoxin, or ammonium chloride rendered the patients different after the experience. (10)

ELECTRICITY AS THERAPY

Extensive literature is available on the use of electricity as a therapy and the induction of epilepsy by electric current. (11) In ancient Rome, Scriborus Largus tried to cure the emperor's headache with an electric eel. In the 16th century, a Catholic missionary reported that the Abyssinians used a similar method to "expel devils out of human body." Aldini treated two cases of melancholia in 1804 by passing galvanic current through the brain. In 1872, Clifford Allbutt in England applied electric current to the head for treatment of mania, dementia, and melancholia.