A negative spin was put on ECT (Electro Convulsant Therapy) or Electric Shock Therapy in Ken Kesey’s book,”One flew over the Cuckoo’s Nest” and the subsequent movie with Jack Nicholson. The book was published in 1962 and the movie released in 1975 were possibly the leading cause of ECT’s stigma. And yet ECT became accepted and used in the U.S. and worldwide in 1960.
Ken Kesey had worked the graveyard shift as an orderly at a mental facility in Menlo Park, California. He was also taking LSD voluntarily and other psychoactive drugs. He ascribed LSD and mesculine as part of Project MKUltra (the voluntary experimental government project) espousing its use as the best access to the human psyche.
Kesey became sympathetic to psychiatric patients and critical of treatments of the time which admittedly included drugs that were not very effective, various forms of seizure therapy, ECT or Electric Shock Therapy and of course frontal lobotomy. He felt the institutions were only a vehicle towards mind control.
In 1975 Kesey’s book was banned from some public schools as too biased. The epitome of the counter-culture of the 60’s he subsequently led a secluded life in his home state of Oregon the setting of the novel. In the novel nothing stigmatizes hospitalization more than nurse Ratched and the narrator “Chief” Bromden”. I say all this as a prelude to telling the real story of ECT’s development and its remarkable role in treatment of Major Depression Disorder and Bipolar Depression today.
Certainly when first put into use ECT got a bad rap as the procedure led to broken bones before muscle paralytics were used.
The History of Electro Convulsant Therapy or Electric Shock Therapy
As to the history of any kind of seizures used for mental illness including schizophrenia this is the fascinating part of the story. As far back as the 19th century it was observed that head trauma, seizures and fever improved symptoms of mental patients in insane asylums. Dramatic improvement in long term patients was seen surreptitiously.
In 1917 Dr. Wagner-Jauregg found that “insane patients” improved after develping infections from typhoid fever. The most common disease leading to institutionalization at the time was tertiary syphilis. Malaria INDUCED fever also seemed to improve the neurological symptoms. The association of the specific mosquito vector in 1895 allowed for creating malaria in syphilitic patients.
In 1927 Manfred J. Sakel in Berlin induced seizures by administering insulin to non-diabetics to induce hypoglycemia to the point of seizure led to improvement in schizophrenic patients and psychotic patients with depression or mania.
Of course glucose levels and insulin doses could not be quantified so levels of sugar went beyond seizure and sometimes to death. This became known as insulin-shock therapy. “Sakel’s technique” became routine for treatment of these ailments in Vienna in 1930 and in the U.S. in 1934. In 1939 a study of 1700 cases of schizophrenia showed complete or partial improvement in sixty-three per-cent using this treatment.
In 1933 a Hungarian man named Ladislau von Meduna tried various chemicals injected intravenously to induce seizures. He settled upon metrazol. The latter had been used to treat folks with seizure disorders and he tried using the drug for depression. Although effective the seizures were too severe and caused multiple bone fractures.
Finally in 1937 Drs. Cerletti and Bini in Rome used electric shock to induce seizures. Seizure was induced by passing electric current across the head. Although highly effective the lack of general anesthesia and muscle relaxants led to great stigma due to wakefulness and bone fractures. By sedating and administering muscle paralytics seizures could only be seen on EEG. The procedure became used world-wide n the 1950s.
The methodology, including alternate day treatments with the paddle placed on just one temple is still used today. The average number of treatments then and now is about ten. More stigma and mercenary use of unlimited treatments is still a problem today with the advent of free-standing ECT units and monetary gain for the physician and facility. As a nephrologist I see this incentive today in the form of placing patients on dialysis who are futile care and with co-morbid diseases allowing for no quality of life.
The only side-effects are transient nausea, vomiting and retrograde amnesia for events just prior to the procedure and some days beyond that. The possibility of creating permanent memory loss can occur when treatments are spread out indefinitely.
Current opinion is that if not improved after eight or ten treatments than the ECT should be considered a failure and stopped. Some psychiatrists are advocates of maintenance ECT every three months (one treatment) to prevent further episodes of depression. This is also controversial. Another area of controversy is the use of ECT for the depression seen in demented patients due to vascular or senile dementia or Alzheimer’s. One has to wonder again about when treatment becomes for mercenary gain.
ECT has been shown to have a 65% remission rate compared to medications but should be used only when medications have failed or caused side-effects. Treatment of major depression with Electro Convulsant Therapy in pregnant women is the treatment of choice as the newer medications’ deleterious effect on the fetus or drugs that have not been around long enough to know whether there is teratogenicity.