Angelina Koh
Melbourne, Australia

Introduction

Amongst all the treatments in psychiatry, electroconvulsive therapy (ECT) is perhaps the most misunderstood and controversial.¹ Its portrayal in popular media and misuse in history have contributed to its reputation, despite ECT being an effective treatment for severe and refractory affective and psychotic disorders. This review aims to uncover the origins of ECT and show its development as an evidence-based treatment.

Efficacy of ECT

ECT utilizes the delivery of small, pulsed electrical currents to the brain to induce a seizure.² Although the exact mechanism is unknown, there are four theories that attempt to explain how ECT works³: the neurotransmitter theory, the neuroendocrine hypothesis, the anticonvulsant theory, and the neuroplasticity hypothesis.⁴ ECT can relieve symptoms of severe psychiatric disorders rapidly and is particularly effective in the treatment of severe depressive and psychotic disorders.² According to the American Psychiatric Association, ECT provides substantial improvement in approximately 80% of patients suffering from severe major depressive disorder.⁵ A 2021 narrative review of ECT found it to be an effective form of treatment with high rates of remission.⁶ Moreover, in its modern form, it is safe and tolerable with mild, transient side effects.⁶

Factors contributing to negative perceptions of ECT

Despite overwhelming evidence supporting its safety and efficacy, many people are averse to ECT because of historical and socio-cultural factors. ECT was used by the Nazis during the Second World War, first as a treatment in order to empty psychiatric institutions and open hospital beds for wounded soldiers.⁷ However, when psychiatrist Emil Genly took charge of Austrian psychiatric hospitals in Gugging and Mauer-Öhling in 1943, he added four additional electrodes to existing ECT machines to deliver lethal shocks to patients.⁷ The connection ECT has to Nazi war crimes has led to its continued stigma.

Misleading media representations of ECT have also contributed to negative perceptions of ECT. For example, the portrayal of ECT in the film One Flew Over the Cuckoo’s Nest by Milos Forman has had a long-lasting effect on audiences.⁸ Although a fictional story, it reflected the situation psychiatric patients faced in the 1950s when some mental hospitals used ECT to control difficult patients and maintain order on the wards.⁹ During this time, ECT was also used as a treatment for homosexuality, which was believed to be an illness.⁹

The origins of ECT

Before the 1930s, treatment options for psychiatric inpatients were scarce. Apart from social support and sedation, little was done for them.¹⁰ Julius Wagner-Jauregg (1857–1940), an Austrian neurologist and psychiatrist, was the first to develop “shock” therapy. Wagner-Jauregg observed that psychiatric symptoms of tertiary syphilis such as delusions and hallucinations would improve following high fevers. He sought to prove that these fever peaks were the cause of the improvement by injecting malaria-infected blood into patients with tertiary syphilis. His patients improved, and he was awarded the 1927 Nobel Prize in Medicine.¹¹ In an attempt to replicate Wagner-Jauregg’s fever shock as a treatment for schizophrenia, Manfred Sakel (1900–1957), a Viennese psychiatrist, introduced the use of insulin-induced hypoglycemic comas to cure schizophrenia. He termed this “insulin shock treatment.”¹⁰ However, Sakel was getting inconsistent results with his insulin shock therapy, as some patients developed convulsions instead of comas, which he viewed as an unwanted complication of his treatment.¹⁰

Toward the end of the 1920s, Ladisla von Meduna (1896–1964) started to comprehend the positive effects of epileptic seizures on schizophrenia and introduced convulsive therapy in Budapest, Hungary in 1934. This was done by injecting camphor, and subsequently Metrazol, intramuscularly into schizophrenic patients. Meduna’s treatment was predicated on clinical observations and a theory that seizures were antagonistic towards schizophrenic symptoms. Meduna’s theory would subsequently influence Italian psychiatrists who developed electroshock in 1938.¹⁰

The term “electroshock” was originally coined by Romanian psychiatrist Constance Pascal (1877–1937), who believed that mental illness was a result of chemical imbalances in the brain that could be rectified by electric shocks.¹¹ Influenced by Wagner-Jauregg’s fever treatment, she explained that the body can be shocked into cure by certain substances or therapies such as electricity.¹¹ The administration of electricity in patients to treat medical illnesses had existed for centuries. In fact, before the development of electric generators, electric eels and torpedo fishes were fastened to the heads of patients in the eighteenth century to cure headaches.¹⁰ In 1755, electricity was used to treat psychogenic blindness in France, and in 1814 electricity was used to treat depression in England.¹⁰ Despite the use of electricity in these treatments, none of them were used with the aim of inducing a seizure.

Ugo Cerletti (1877–1963) and Lucio Bini (1908-1964) were profoundly influenced by Wagner-Jauregg, Sekel, and Meduna when they sought to develop a method of seizure induction that was quicker in onset and had fewer adverse effects.¹² The idea of using electricity to induce seizures first occurred when they witnessed Meduna’s Cardiazol therapy in Vienna.¹⁰ Cerletti started experimenting and fine-tuning the voltage for a safe level of electric shock that would induce seizures in animals. In 1937, Cerletti and his assistant Bini were successful, and they presented their research findings at the first international meeting on “New Therapies for Schizophrenia” in Switzerland.

In 1938, Cerletti and Bini induced an electrical seizure on a thirty-nine-year-old male with schizophrenia who had been admitted to the mental hospital when he was found wandering at a train station in Rome.¹² They successfully induced an electrical seizure after applying 110 volts of alternating current for 0.2 seconds. After ten further treatments administered over the course of his hospitalization, the patient’s psychosis improved. He was subsequently discharged and was able to return to his family, hold a job, and reintegrate into the community.¹²

The success of this trial spread quickly throughout Europe and North America and was used for various neurological and psychiatric illnesses, including major depressive disorder. Since that time, continuous refinements have been made to the ECT protocol to improve patient comfort. In 1944, Wladimir T. Liberson (1904–1944) decreased the duration of electrical stimulus, which helped decrease the risk of aphasia and cognitive blunting and shortened the duration of recovery. In 1952, Holmberg and Thesleff pioneered the use of anesthesia in ECT, further improving patient comfort and satisfaction with ECT.¹²

Conclusion

After eighty years of use, electroconvulsive therapy remains one of the most effective treatment modalities in psychiatry. However, despite its efficacy, ECT is severely underutilized and is even banned in certain parts of the world. Negative perceptions have had a long-lasting and detrimental impact, jeopardizing the chance of recovery for patients who could benefit from an effective and potentially lifesaving treatment.

References

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