Thus, major figures weighed in on behalf of the new treatment. The U. The rise of ECT in psychiatry is one of the discipline's great success stories. The technique became steadily modified. In , curare was introduced to moderate the vertebrae-cracking force of the convulsions, and succinylcholine was introduced in In the early s, it became customary to anaesthetize patients with barbiturate injections.
In , Goldman introduced unilateral ECT, placing the electrode over the right hemisphere in order to avoid the speech areas. Abrams and Taylor introduced bifrontal ECT by moving the electrodes forward over the forehead. In the s, a patient hospitalized for depression stood an excellent chance of receiving ECT, and an even better chance of benefiting from it. Then suddenly, a page turned, and ECT disappeared from psychiatry. In psychiatric training from to about , ECT virtually vanished.
Why this sudden disappearance of a safe and effective therapy occurred is one of the riddles of the history of psychiatry. It is not that the growing power of the pharmaceutical industry marginalized ECT. In the early days, industry executives and scientists often had a kind word for ECT.
The Geigy company now folded into Novartis once conceded that ECT was the appropriate treatment for hospital depression, and Paul Janssen, of the pharmaceutical company founded by his family, had no hesitation in declaring that ECT was far superior for endogenous depression to the tricyclic antidepressants Healy, Of course, industry's attitude would later change as ECT was excluded from discussion at industry-sponsored events.
Yet the opposition of industry does not explain the bizarre initial vanishing of ECT for two decades. Nor is it the case that psychoanalysis, based on a totally different model of brain-mind function, chased ECT from the temple. In the late s and early s, plenty of analysts were ready to mix ECT with talk therapy. The early group therapists, for example, would alternate between community sessions and ECT.
What seems to have happened was a combination of s-style counterculture hostility to ECT together with the enthusiastic reception of Ken Kesey's antipsychiatry novel One Flew Over the Cuckoo's Nest, published in There is no doubt that the generation of flower children was hostile to psychiatry in general and to ECT in particular. Sociologist Erving Goffman's influential work Asylums, published in , bore a scanting reference to "shock treatment.
Prior to his arrival in Rome, Cerletti already had some experience with electricity, as he had used an electric current in animal studies of epilepsy in Genoa[ 13 ]. In Rome, Cerletti continued these studies with the involvement of his assistant, Lucio Bini.
The idea of using electricity to induce seizure first occurred to Cerletti and Bini when they witnessed cardiazol therapy in Vienna[ 14 ]. After defining the parameters of a safe electric stimulus through animal studies, they performed the first electric seizure induction in a psychotic patient named Enrico X on April 11, Although the initial stimulation did not result in an epileptic seizure, stimulation at a higher voltage induced an eighty seconds tonic-clonic seizure on April After 11 further treatments, Enrico recovered and was released from the university psychiatry clinic[ 14 ].
Although the technical details of electric seizure induction were published shortly after the first treatment[ 1 ], their results with electroshock therapy were not summarized until 2 years later, which attests to the careful attitudes of the inventors[ 15 ].
In response to frequent criticism regarding the latter point, significant efforts have been made to clarify the mechanism underlying ECT. One theory explains the therapeutic effects of ECT by referring to its effects on neurotransmitters, particularly the serotonin and dopamine systems[ 16 ]. Another theory conceptualizes depression as a pro-inflammatory state wherein ECT acts on cytokines, thereby treating the inflammation and normalizing mood[ 17 ].
Furthermore, clinical evidence indicates a hypertensive surge during ECT that causes transient blood-brain barrier permeability which may also play a role in its therapeutic effect[ 18 ].
Animal studies suggest that electrically induced seizures have epigenetic effects that may also add to the clinical effectiveness of ECT[ 19 ]. Finally, the most promising new findings appear to involve ECT-induced changes in structural brain plasticity. Recent studies also identified ECT as a strong stimulator of neurogenesis by promoting the proliferation of stem cells[ 20 ]. Notwithstanding major advances in psychopharmacology and several recently introduced brain stimulation methods, ECT is not a closed chapter in the history of psychiatry but is rather a treatment modality used widely throughout the world[ 21 ].
ECT has well-defined indications[ 22 , 23 ] and remains one of the most effective treatment methods in psychiatry[ 24 ]. Meduna[ 12 ] considered convulsive therapy as a treatment for schizophrenia. However, it was soon found to be even more effective for the treatment of affective disorders[ 25 ]. Currently, major depression is the first indication for ECT[ 22 , 23 , 26 ].
Between the s and s, several studies investigated the efficacy of ECT. The majority of randomized controlled studies confirmed the superiority of ECT relative to sham ECT or antidepressants for the treatment of affective disorders, and these findings were supported by meta-analyses[ 24 , 27 - 29 ]. Independent of its antidepressant effects, ECT also has a clear anti-suicidal effect[ 30 ].
Therefore, ECT is recommended as the first choice of treatment for patients at a high risk of suicide[ 31 ]. In pharmacotherapy-resistant patients, maintenance ECT proved to be an effective alternative in relapse prevention[ 32 ].
In several developing countries, including India[ 33 ] and China[ 34 ], the two most populous nations, schizophrenia remains the first indication for ECT. Although antipsychotics are equally effective for schizophrenia[ 35 ], financial reasons may explain the common use of ECT in this patient population[ 36 ]. Unmodified ECT is still practiced in the developing world due to limited financial resources[ 34 ]. Resistance to pharmacotherapy remains a serious problem in the treatment of schizophrenia[ 37 ].
ECT could be an augmentation strategy to enhance the effects of antipsychotic drugs[ 38 ]. ECT could also augment clozapine in clozapine-resistant patients[ 39 ]. Psychotic conditions that respond well to ECT include catatonia and pre- and postpartum psychotic states[ 40 ]. Combining maintenance ECT with antipsychotic medications is an effective strategy for relapse prevention in schizophrenia[ 41 ]. From the beginning, psychiatrists' intentions was to make ECT as safe as possible by decreasing its side effects to the minimum.
As a result of these efforts, muscle relaxation[ 42 ] and anaesthesia[ 43 ] were introduced by the early s. The importance of minimizing cognitive side-effects was recognized early and unilateral stimulation technique was introduced as early as [ 44 ].
Recent efforts to further reduce cognitive side effects focus on changing from brief to ultra brief pulse stimulation[ 45 ]. While a few individual testimonies reported longlasting and severe memory disturbances after ECT[ 46 ], extensive psychological tests could not detect significant memory deficits beyond six months following a course of ECT[ 47 ].
ECT is probably the most controversial form of treatment in medicine. It has been banned in certain parts of the world[ 48 ] while remaining widely practiced in other countries[ 49 ]. Besides economic and socio-cultural factors, historical contexts, such as the misuse of ECT during the Nazi era[ 50 ], might have contributed to the negative perceptions of this form of therapy.
Misleading media representations of ECT have contributed further to this negative image. Recently, however, a slow tendency towards a more objective depiction of ECT has been observed[ 52 ]. In contrast to its negative image in the media and the public misperception[ 53 , 54 ], attitudes towards ECT in patients, relatives and the mental health professionals are mainly positive[ 55 , 56 ]. In the last two decades several new neurostimulation methods have been introduced in psychiatry mainly from the field of neurology.
These include transcranial magnetic stimulation TMS , vagus nerve stimulation, deep brain stimulation, transcranial direct current stimulation. Most of these new techniques were introduced to treat major depression. To date, only TMS has been compared with ECT in randomized controlled trials, which consistently proved the superior efficacy of ECT in the treatment of major depression[ 57 ].
No other neurostimulation technique has a firm place in the treatment algorithm for major depression[ 58 ]. After 80 years, electroconvulsive therapy remains one of the most effective treatment modalities in psychiatry. However, the popular image of ECT is controversial and mainly negative. But it survived in the social memory of the therapy. By the s, the evidence that ECT was very effective for treating depression was robust. But there were also good reasons for patients to fear ECT.
These reasons, combined with widespread revolts against authority and conformity that flourished in the s, also gave rise to a revolt against medical authority — the anti-psychiatry movement. In its most extreme versions, the anti-psychiatry movement rejected the very idea of mental illness.
But physical treatments, and most especially ECT, aroused its strongest rejections. Most advocates of anti-psychiatry — even those who questioned the very reality of mental illness — were supportive of talk therapy.
This provides another clue about why ECT occasions such deep divides. It evens raises questions about who we are, and what a person is. ECT use declined in the s and s, but revived starting in the early s. Now, psychiatrists estimate that about , Americans receive ECT. That is hard to square with a stereotyped view of ECT as a form of abusive social control. ECT continues to have many critics, often people who received the treatment unwillingly, or who felt pressured into receiving it.
There is no question that ECT causes some memory loss, particularly of events near the time of the treatment. These memories often return, however. And there is also little doubt that many patients get potent therapeutic results, and many patients say they have little, if any, permanent memory loss. But permanent long-term memory loss does occur, and it is uncertain how common it is. But again, the whole point was to see if they could prompt a seizure, not just one convulsion. Cerletti wanted to attempt the procedure one more time—with volts.
At this point, according to Cerletti , some of those involved became uneasy, and urged him to stop. Someone suggested the patient be given time to rest; someone else thought it would be better to wait until the next day to continue testing.
Bini set the machine for the maximum voltage of volts. When the switch was flipped, that dull humming noise briefly filled the room again. But this time, they did not relax immediately afterward. His body began convulsing with the rhythmic shaking of a seizure. As his body shook, his face began to turn pale due to lack of breathing. Then, it took on a bluish-purple hue—a clear sign of oxygen deprivation. Bini was timing the asphyxia with his watch.
It got up to twenty seconds, then thirty…. Surely many in room feared they had finally gone too far. But at 48 seconds, the patient exhaled violently and fell back to the bed—fast asleep. His vitals were normal. It turned out that he was not just a vagrant. He had a wife who had been searching desperately for him, and eventually they were reunited—providing a nice conclusion to a success story that was uncomfortably close to being a tragedy.
The use of electroshock therapy—which would eventually come to be known as electroconvulsive therapy , or ECT—spread rapidly.
More substantial changes were made as well. Initially, the convulsions evoked by ECT were violent enough to sometimes cause fractures often spinal fractures along with other injuries. So, practitioners started administering muscle relaxing drugs before ECT to reduce the severity of the convulsions. This created another issue: the muscle relaxants temporarily induced complete paralysis, which was often terrifying for patients.
Thus, physicians began using anesthesia before the procedure, which allowed patients to remain unaware of the paralysis or any other unpleasant aspect of the period of time surrounding the seizure. With these and other modifications, ECT today is considered a safe practice.
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