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- . 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. Reproduction 2000 March–April 163 with permission only. Contact [email protected]. are usually able to recall the events that technique now identified as rTMS. successful senate career, the 1972 vice- occurred before their illness and to uti- They applied a device typically used in presidential candidate Thomas Eagle- lize the skills of their education and rehabilitation neurology. ton was forced from the Democratic training with the same ability as oth- As it stands, however, the physio- ticket when the press trumpeted that he ers of their age and experience. Pa- logical affects of these magnetic stimu- had received this treatment for depres- tients are able to learn new information lations are modest. Some authors re- sion. In the widely hailed 1975 film One as well as they did before they became port that currents applied to electrodes Flew Over the Cuckoo’s Nest, the protag- ill. The events during the illness and on the scalp stimulate only the superfi- onist suffers both electroshock and lo- the period of treatment do continue to cial layers of the brain. To stimulate the botomy at the hands of unbridled care- be hazy, although with reminders, central regions of the brain, much high- takers. Viewers leave the theater with some memories are re-established. De- er energies are needed—and these elic- sympathy for the patients and hostility spite all these efforts, some patients it grand mal seizures. Investigators are to the caretakers. In popular books the complain of an undue impact of ECT now working on issues of safety and psychiatrist Thomas Szasz castigated on memory, and this fear inhibits its technique: How many stimulations? At psychiatrists as agents of the state who broader use. what frequency? Over which areas of coerced the mentally ill into forced and Public and professional discomfort the scalp? At this time, no published unwelcome hospital care. He especially with the use of electricity, and fear of study has demonstrated a sustained ef- criticized the use of electroshock. His the effects on a patient’s memory, have fect on behavior that matches the bene- student, Peter Breggin, canvassed Con- long fueled the search for a replace- fits of ECT. gress to outlaw the physical treatments ment therapy. The most recent offering of the mentally ill, espousing love and is the use of magnetic currents to alter Drugs, Politics and ECT talk therapy as effective agents of brain functions. In 1995, scientists at the The development of psychotropic change. Ron Hubbard, as part of the National Institute of Mental Health de- medicines in the 1950s and 1960s mission of his Church of Scientology, scribed heightened mood in volunteers spelled the beginning of a dark period unleashed a national attack on psychia- after repetitive high-energy transcranial in electroshock’s history. The drugs— try, which is active today in energizing magnetic stimulation of the brain, a Thorazine for psychosis, Tofranil for state legislatures to proscribe psychi- depression, Miltown for anxiety and atric treatments. lithium for mania—ushered in the pre- Despite a national climate of outrage sent era of psychopharmacology. The and vilification, a few psychiatrists con- medicines were easy to administer, car- tinued to use ECT for patients who had ried few immediate risks and were failed treatment with medicines and much less expensive. ECT was con- found that their patients benefited. Re- fined to the dustbin of history. ports of such success encouraged man- The political climate in the 1960s and ufacturers to improve the treatment de- 1970s did little to foster the use of ECT. vices; scientists again sought ways to The new drugs had been lauded for do- improve the practice and reduce the ing away with the large, impersonal risks; and commissions began to write state mental hospitals, and the phase- manuals for proper treatment. By the out of the nation’s mental-hospital sys- 1980s, the federal government support- tem was in full swing. Their profession- ed studies of how best to decrease the al staffs had discarded ECT, and it was effects on cognition and memory. Tech- virtually impossible to re-establish the nical improvements emerged quickly, physical facilities for the treatments or so much so that in its present use ECT find the trained personnel to carry them is considered as safe as psychotropic out. The nation had been through the medicines. Indeed, for the elderly, for political and social upheaval of the Viet- those weakened by systemic diseases nam conflict; the actions of any authori- and for pregnant women with severe ty, governmental or medical, were chal- mental illnesses, ECT is safer than the lenged. Legislators were deluged with alternative treatments. Figure 2. First ECT device was developed by calls to outlaw what were perceived as There is an uneven distribution of fa- Italian medical scientists in 1938, four years coercive psychiatric treatments—psy- cilities providing the treatment. Most after chemically based “convulsive therapy” chotropic medicines, electroshock and university hospitals treat about 5 to 10 was invented in Hungary. The electrically lobotomy. The California legislature percent of their mentally ill adult pa- induced convulsions were an improvement heeded this call in 1973 and banned the tients with ECT, whereas the treatment over the chemical methods, but the early use of electroshock and lobotomy. The rates at state, federal and Veterans Ad- years of electroshock were still risky and law was struck down by the courts as ministration hospitals are much lower unpleasant: Patients experienced severe an improper incursion into medical because few have the facilities. Com- memory loss and bone fractures until meth- practice, but a judicially acceptable bill munity and private hospitals vary ods were developed to avoid such trauma. Here the caliper-like electrodes that were regulating the treatments became law widely in their ability to offer the treat- placed on either side of the patient’s tem- the next year. It severely inhibits the ment. This results in a haphazard ap- ples are visible above the apparatus that practice of ECT in that state. plication of ECT. controlled the electric current. (Photograph Many public events also cast a pall Legal proscriptions inhibit its proper courtesy of the author.) over the use of electroshock. After a use. In California, Texas and Tennessee,

164 American Scientist, Volume 88 © 2000 Sigma Xi, The Scientific Research Society. Reproduction with permission only. Contact [email protected]. electroshock is interdicted in children and young adolescents. The legislatures in Arizona, Vermont and Texas have been considering restrictive legislation. In some states, patients may only be treated with electroshock after physi- cians and independent consultants cer- tify that all other methods of treatment have been tried and failed, an impossible standard to satisfy, consigning the mentally ill to long periods of illness before an effective treatment is given. At times, the treatment is offered too late, the patients having died by suicide or inanition while awaiting court ap- proval for treatment.

How Does ECT Work? Why are seizures, which are dangerous and damaging when they occur sponta- neously, beneficial when induced ex- perimentally? For the moment scientists have no answer to this question—we simply don’t understand how ECT has the restorative capacity that it does. For that matter, no hypothesis for the mode of action of any psychiatric treatment— be it electroshock, psychotropic medicines or the “talk” psychotherapies—is satisfactory. Explanations for the mechanism of ECT tend to be similar to those used to explain the therapeutic actions of the psychoactive drugs. Most commonly the explanations are focused on the messenger molecules, or neurotransmitters, that pass from one neuron to another. Among the more notable of these molecules are dopamine, sero- tonin, norepinephrine and gamma- Figure 3. Modern ECT methods monitor various physiological measures—heart rate (ECG), neural activity (EEG), muscular activity (EMG), blood pressure and blood-oxygen tension—to amino-butyric acid (GABA)—neuro- assess the patient’s status during treatment. In conjunction with other therapeutic advances— transmitters that are typically central anesthesia, muscle relaxants, physiologically efficient electrical currents and continuous oxy- to biologically based theories of mental genation—the negative effects of ECT have been markedly reduced. illness. Each of these molecules binds to specific receptors on neuronal-cell surfaces and in turn modifies the activ- induced in animals and people reveal seizure. If the seizure threshold is de- ity of these neurons. Psychotropic that so many neurotransmitters are re- fined in subsequent treatments, we ob- medicines alter the concentrations of leased in what appears to be a random serve a gradual rise in seizure thresh- these neurotransmitters and so modify way that it is difficult to construct a co- old. If the energies are kept constant, the activity of neurons in certain parts gent theory. the duration of the elicited seizure falls. of the brain, most notably those areas Another theory of electroshock’s In successful courses of treatment, believed to play important roles in mechanism involves the observation seizure thresholds are known to rise. mental disorders. How the activity of that the threshold needed to induce a The rise in seizure threshold varies these neurons translates into thoughts seizure rises during the course of a suc- with the rise in cerebral blood flow, and feelings is the big question now cessful series of treatments. After anes- slowing of EEG frequencies and the facing neuroscientists. thesia, it is possible to stimulate the antidepressant effects of electroshock. There is a fundamental difficulty brain with different dosages of electric Some authors conclude that the anti- with extending the neurotransmitter- current. By selecting currents that are depressant efficacy of electroshock is re- based hypotheses to the mechanism of too low to elicit a seizure and repeating lated to the anticonvulsant activity of re- electroshock, however—one that goes this procedure with incremental ener- peated seizures, as reflected in the rise beyond the question of how these gies, a seizure threshold can be defined in seizure threshold. The anticonvulsant messenger molecules play a role in the as that amount of energy that is suffi- theory is also encouraged by the effica- brain. Experiments involving seizures cient to elicit an effective grand mal cy of anticonvulsant medicines in re-

EEG site 1

EEG site 2 full-blown tonic muscle activity

EMG

ECG 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 seconds

Figure 4. Recordings during a successful ECT session reveal the changes in a patient’s electroencephalogram (EEG), electromyogram (EMG) and electrocardiogram (ECG) over the course of 60 seconds following the onset of a seizure-inducing electrical stimulus. Beginning at the 0-second mark, the stimulus is applied for a duration of 0.2 to 4.0 seconds and produces a brain seizure (lasting about 52 seconds in this instance), which is recorded in two EEG tracings (top two lines). The large excursions of the EEG trace (near the 52- to 53- second marks) are artifacts and do not represent actual brain activity. A recording of muscle activity from the foot (EMG, third line from lieving mania. However, the theory is tor molecules and the anticonvulsant electricity is not essential to our expla- weakened by the failure of antidepres- activity of electroshock have the most nation. Neither anesthesia nor the elec- sant drugs to raise seizure thresholds support today. tric current alone nor a single seizure is and the inability of benzodiazepines There is, however, an alternative hy- effective. At one time, memory impair- (anxiolytics such as diazepam) and oth- pothesis. We know a great deal about ment was an explanation for elec- er anticonvulsant drugs to elicit clinical what we must do to achieve ECT’s troshock’s effects, but we now achieve antidepressant activity. clinical benefits. Seizures induced by clinical efficacy without memory im- Despite their weaknesses, theories chemicals are just as effective as those pairment and conclude that memory based on neurotransmitters, their recep- induced by electricity, indicating that loss is not in the therapeutic chain. We also know that ECT is very broadly effective in relieving mental disorders. It relieves depressed and

Figure 5. Hypothetical mechanism to explain the effectiveness of ECT invokes changes in the activity of the hypothalamic- pituitary axis as a key to relieving mental illness. In this view, the induced seizure causes the hypothalamus to release peptides (red arrow) into the cerebrospinal fluid (CSF) of the ventricles and hormone-releasing factors (green arrow) via a blood portal system to the anterior pituitary. The peptides released into the CSF can diffuse to many other parts of the the brain (and so alter brain function), whereas the hypothalamic releasing factors stimulate the anterior pituitary to release hormones (blue arrows) that stimulate activity in various glands of the body. In turn, these glands release other hormones that affect target tissues throughout the body, as well as the brain and the hypothalamus itself. This scenario proposes that the ECT-induced “flood” of hormones and peptides “resets” the hypothalamus and perhaps other parts of the brain, and so returns emotional balance to the patient. ECT treatments do indeed readjust a patient’s hormonal balance, but whether this change is the mechanism behind electroshock’s success is unknown.

artifact

tonic muscle activity ends

45 46 47 48 49 50 51 52 53 54 55 56 57 58 seconds manic moods, thought disorders and the cerebrospinal fluid and into the dustry tends to follow a safe course of the top) reveals a rhythmic, tonic action that develops about 11 seconds into the treatment and subsides at 49 seconds. The patient’s heart rate (ECG, bottom line) rises from 84 beats per minute in the first few seconds of the treatment to about 137 beats per minute at its maxi- mum and then slowly drops back to normal starting at 45 seconds. Patients usually wake up a few minutes after the treatment and have no recollection of the procedure. In this instance, the ECT treatments have been effective in relieving the patient’s depressive illness. (Note that the section between 14 and 44 seconds is not shown.) the motor disorders of catatonia and bloodstream. How could such a re- finding “me-too” substances that can parkinsonism with almost equivalent lease relieve mental disorders? be marketed, and academic leaders efficacy. The most effective forms of Consider the following scenario. often perceive ECT research as acade- ECT are those that directly stimulate Each electroshock stimulus is focused mically incorrect. Nevertheless, the the structures in the middle of the on the hypothalamus, eliciting an im- broad efficacy of electroshock war- brain, as evidenced by the path of the mediate and large discharge of its hor- rants greater attention to its therapeu- electric current. What can we make of mones. In the ensuing cascade of hor- tic mechanism and to a campaign of these observations? Whatever the monal effects, the pituitary gland education that will encourage its use mechanism involved, it appears to af- discharges its products, and those, in for the many mentally ill who are fect a broad range of systems in the turn, alter the discharge of cortisol poorly served by other therapies. body. And the central parts of the brain from the adrenal glands. The first ef- seem to play a key role in modulating fects of the brainstem stimulations are Bibliography electroshock’s benefits. transitory, but by the fourth or fifth Abrams, R. 1997. Electroconvulsive Therapy. This train of thought leads us to stimulus, the normal feedback actions New York: Oxford University Press. the hypothalamus, a region deep in of the hormones of the hypothalamic- Fink, M. 1979. Convulsive Therapy: Theory and the brain that is known to be in- pituitary-adrenal axis are again in Practice. New York: Raven Press. volved in the expression of emotions place. Feeding and sleep become nor- Fink, M. 1990. How does convulsive therapy and that has a profound control over mal, and improvements in motor ac- work? Neuropsychopharmacology 3:73–82. the rest of the body through its activity, mood, memory and thought fol- Fink, M. 1999. Electroshock: Restoring the Mind. tions on the pituitary gland. The hy- low quickly. New York: Oxford University Press. pothalamus, the pituitary and the In treating the mentally ill, the im- Freeman, H. 1999. Taking the horror out of pineal glands in the brain produce proved endocrine functions persist af- shocks. Nature 401:327. peptides that circulate in the blood- ter a course of treatment, and the pa- Satcher, David. 1999. Mental Health: A Re- stream and the cerebrospinal fluid, tient remains well. At other times, the port of the Surgeon General. http://www. affecting other glands in the body (in- glands quickly revert to their abnor- surgeongeneral.gov/library/mentalhealth/ cluding the thyroid, parathyroid, mal activities, and the mental disorder home.html adrenal, pancreas, ovaries and testes) is again evident. In such cases, contin- and other parts of the brain. uation ECT is needed to sustain nor- The importance of the hypothala- mal glandular functions and a normal mus in mental illness is consistent mental state. with the observation that hormonal How the rush of hormones resets the functions in the mentally ill are wildly endocrine balance is not known. I pro- disordered. In the severely depressed, pose that the brain secretes a hormone- the adrenal glands produce too much like substance that regulates mental cortisol, whereas the hypothalamus is functions. Unfortunately, research into inhibited in the release of its hormones such a relation is not encouraged by and the pituitary functions are chaotic. government agencies, which are wary During a seizure, massive amounts of of the public’s apprehension toward the brain’s hormones are released into electroshock. The pharmaceutical in-