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Electroshock Revisited A reprint from American Scientist the magazine of Sigma Xi, The Scientific Research Society This reprint is provided for personal and noncommercial use. For any other use, please send a request to Permissions, American Scientist, P.O. Box 13975, Research Triangle Park, NC, 27709, U.S.A., or by electronic mail to [email protected]. ©Sigma Xi, The Scientific Research Society and other rightsholders Electroshock Revisited Electroconvulsive therapy, once vilified, is slowly receiving greater interest and use in the treatment of mental illness Max Fink cene: The winter of 1934, inside a fever treatment of neurosyphilis. He injected provide a brief review of the history Sstate hospital for the mentally ill at camphor at three- to four-day intervals, and and present state of electroconvulsive Lipotmezö, Hungary. two days after the fifth seizure, Zoltan awak- therapy, and some thoughts on its Zoltan, a 30-year-old Budapest laborer, ened, looked about, got out of bed, asked mechanism of action. lay rigidly in a bed, staring into the distance. where he was and requested breakfast. He Except for his slow and regular breathing, did not believe that he had been in the hospi- The Evolution of ECT he appeared lifeless. He had hardly spoken or tal for four years, and he knew nothing of Shortly after his success with Zoltan, cared for himself in more than four years. the intervening history. Later that day, he Meduna treated five other schizo- His mental condition of catatonic schizo- again relapsed into stupor. After each of the phrenic patients—each of whom re- phrenia was considered hopeless. No remedy next induced seizures, Zoltan remained alert covered. Published reports of Me- was available and none was sought; the doc- and interested for longer and longer periods, duna’s successes galvanized clinicians tors believed the illness to be an immutable until after the eighth injection he left the hos- throughout the world. The notion that genetic fault. At 10:30 on the morning of pital to return to his home and to work. His dementia praecox (as schizophrenia was January 24, 1934, the Hungarian neuropsy- mental condition of four years was fully re- then called) could be relieved at all chiatrist Ladislas Meduna approached lieved. Five years later, when Meduna left was remarkable to many who be- Zoltan’s bed to inject an oily extract of cam- Europe for the United States, Zoltan was lieved that the disease was relentlessly phor into his right buttock. Zoltan’s heart still well and working at his job. progressive and hopeless. Nowadays soon raced, sweat rose on his brow, and he be- it is difficult for us to appreciate how came increasingly fearful. After 45 minutes, This dramatic account of Zoltan’s re- revolutionary such an achievement his eyes suddenly closed, his jaw clenched, covery from schizophrenia describes appeared. his breathing stopped, and he lost conscious- the first use of the technique that Although the camphor-based treat- ness. With a deep, noisy sigh, his arms and evolved into electroshock, also now ment was successful, it was not with- legs extended, he convulsed, and his bed called electroconvulsive therapy, or out its drawbacks: The injections were thumped rhythmically; attendants caught simply ECT. As the modern name sug- painful, and the seizure developed af- him just before he rolled to the floor. His skin gests, the method now involves the use ter an agonizing and frightening delay became ashen, and he wet the bed. After 60 of electrical currents to induce grand- of many minutes. Another chemical, seconds, as suddenly as the spasm started, it mal seizures as a treatment for mental Metrazol, induced a fit quickly when ended. His eyes opened, and a pink color illness. Electroshock is applied to about injected intravenously. Within a slowly returned to his cheeks. He continued 100,000 patients each year in the U.S., a minute, the patient’s thoughts raced, to stare and was as speechless as before. He figure comparable to the number of ap- his heart beat rapidly, terror filled the had survived an intentionally induced grand pendectomies or hernial surgeries per- mind, and consciousness was lost. Af- mal epileptic fit. formed. Its efficacy and safety has been ter a few minutes of seizing, the pa- Without any guideline as to how often recognized by the U.S. Surgeon Gener- tient slowly reawakened, his muscles, seizures should be induced, Meduna adopted al in his Report on Mental Health, which back and head ached, and often his the schedule used in the popular malarial- was released in December 1999. Clini- tongue and lips were bleeding. Memo- cal trials on disorders other than schiz- ry of recent events was erased. Despite ophrenia have found ECT to be effec- the risks and terrors, and the need for Max Fink is an emeritus professor of psychiatry tive in depression, mania, delusional repeated frequent injections to achieve and neurology at the State University of New York states and catatonia—in the elderly a benefit, Metrazol-seizure therapy was at Stony Brook, an attending psychiatrist in the re- and in adolescents as well as adults— widely adopted. Its success changed search department at the Long Island Jewish Hill- and it can be safely applied to patients public and professional attitudes to- side Medical Center, and a professor of psychiatry with severe physical illnesses. ward mental illness from one of hope- at the Albert Einstein College of Medicine. He has Despite electroshock’s successes, it is less resignation to optimism that relief been active in electroshock research since 1952. He severely restricted by legislation in sev- was possible. published the textbook Convulsive Therapy: eral states and continues to have an un- Ways were sought to reduce the Theory and Practice in 1979 and launched the quarterly scientific journal Convulsive Therapy deservedly poor image in the public risks of chemically induced seizures. In in 1985. He is the author of Electroshock: Restor- mind. Fortunately, there is a growing 1938, the Italians Ugo Cerletti and Lui- ing the Mind (1999) and maintains the web site trend to restore ECT to a reasoned gi Bini induced seizures using electric- <www.electroshock.org>. Internet: [email protected] place in psychiatric practice. Here I ity applied through electrodes placed 162 American Scientist, Volume 88 © 2000 Sigma Xi, The Scientific Research Society. Reproduction with permission only. Contact [email protected]. Figure 1. Electroshock—the controlled induction of a grand-mal seizure for the treatment of mental illness—is given to about 100,000 people every year in the United States. Although electroshock, or electroconvulsive therapy (ECT), is successful in treating severe mental illness in instances where other therapeutic methods have failed, the technique is underutilized because of its poor public image. Modern ECT is now considered to be safe and effective for the treatment of depression, schizophrenia, mania, catatonia and delusional states. on both temples. The seizure was im- ly life and were left with feelings of pulse currents. The path of the electric mediate and just as effective as those strangeness—that they were living currents affected the treatment’s effica- induced by intravenous chemicals, and dreams in which much that should be cy. To achieve the efficacy of treatments the new technique avoided the initial familiar was not. with electrodes on both temples with fearfulness and panic. The technique To reduce the possibility of fractures, unilateral placement, it is necessary to was so easy that within a few years the muscle relaxant succinylcholine deliver stimulating currents of at least electroconvulsive therapy became the was routinely made part of each five times the strength needed for the dominant treatment of the severely seizure. This relaxed the breathing brain to seize. Such increased energy mentally ill. muscles as well, and to reduce the pa- achieves greater efficacy, but it is un- The risks persisted, however. The tient’s panic at not being able to clear whether the memory-sparing ef- treatments were administered without breathe normally, a short-acting barbi- fects of one-sided electrode placement anesthesia and often resulted in frac- turate anesthetic became part of the remain. Lately, attention is directed to tures and in severe memory loss. Occa- practice. Full oxygenation of the lungs another memory-sparing maneuver, sionally, patients suffered a second during the treatment became feasible. that of locating the electrodes over the seizure after leaving the treatment The electric currents were modified to very front of the head. Bifrontal elec- room. The treatments were unpleasant; more physiologically efficient forms. trode placement elicits effective treat- patients often had to be coaxed, and The placement of the electrodes was ments at near-threshold energies with occasionally forced, to treatment. changed to one side of the head, mov- seemingly little impact on memory. Fears of this experience, especially ing the path of the current away from This panoply of treatment modifica- the effects on memory and recall, limit- the memory centers in the brain. These tions—muscle relaxation, anesthesia, ed its use. Impaired breathing and the changes in practice reduced ECT’s im- continuous oxygenation, brief-pulse high electrical energies commonly pact on memory. currents, selected electrode placements, used in the early decades severely im- But as such methods were adopted, energy dosing and monitoring the paired the brain’s functions. Patients patients did not improve as well as be- body’s physiology during each treat- could not recall events during the ill- fore. This was particularly true when ment—changes the impact of ECT on ness and during the period of treat- practitioners combined one-sided elec- memory so markedly that when pa- ment. Many lost memories of their ear- trode placement with the newer brief- tients now recover from an illness, they © 2000 Sigma Xi, The Scientific Research Society.
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