Wednesday, August 18, 2010

Psychiatric Times - The Perplexing History of ECT in Three Books

Electroconvulsive therapy (ECT) has a long and less than admirable history in the annals of psychology and psychiatry. Yet, all these years later, it is still being used - and to a certain extent, it is being used successfully. This excellent review article from Psychiatric Times looks at three new books on the topic.

The Perplexing History of ECT in Three Books

By Max Fink, MD and Charles H. Kellner, MD | August 12, 2010

Dr Fink is professor of psychiatry and neurology emeritus at Stony Brook University, Stony Brook, NY. He is founding editor of The Journal of ECT; author of several books, including Electroconvulsive Therapy: A Guide for Professionals and Their Patients (New York: Oxford University Press; 2009); and coauthor with Edward Shorter of Endocrine Psychiatry (New York: Oxford University Press; 2010). Dr Kellner is professor of psychiatry and chief of the division of geriatric psychiatry at the Mount Sinai School of Medicine in New York. In 2008, he assumed Dr Fink’s role as the ECT columnist for Psychiatric Times.

Shock Therapy:
A History of Electroconvulsive Treatment in Mental Illness

by Edward Shorter and David Healy. Piscataway, NJ: Rutgers University Press; 2007

Convulsive therapy, with chemically induced seizures, was first demonstrated in 1934 in Europe to relieve psychosis—particularly the catatonic type. Within 4 years, electrical induction (also known as electroconvulsive therapy, or ECT) was shown to be as effective and much easier to use. For the next 2 decades, ECT became the principal treatment for the severely mentally ill, especially the many thousands warehoused in state hospitals. Its use in psychiatric practice allowed many patients to avoid the stigma of hospital admission and remain at home to lead normal lives.

Introduced concurrently with insulin coma (1933) and lobotomy (1935), these 3 treatments were conflated in the public and professional psyche. As insulin coma and lobotomy fell into disuse because of their high morbidity and mortality rates, their demise contaminated the appreciation of ECT. Competition from psychotherapies and then from psychotropic drugs led to the widespread abandonment of ECT in the 1960s and 1970s.

Since the mid-1980s, doctors have gradually recognized that ECT can effectively relieve life-threatening conditions that would not otherwise be treated. This change in perspective, coupled with improvements in technique and safety, has resurrected its use throughout the world. Three recent books document this perplexing roller-coaster story.

Three books, three perspectives

In Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness, medical historians Edward Shorter and David Healy offer a verifiable history that is based on archival records and supplemented by interviews with cooperating researchers and clinicians. In Shock: The Healing Power of Electroconvulsive Therapy, Kitty Dukakis (wife of Michael Dukakis, former Governor of Massachusetts and the 1988 Democratic presidential candidate) reports how ECT relieved her depression, alcoholism, and suicidal tendencies and how continuation treatments sustained her mental health. Her chapters, favorable to ECT, alternate with chapters by popular writer Larry Tye, who provides a history of the treatment.

Conversely, Doctors of Deception: What They Don’t Want You to Know About Shock Treatment, written by public activist Linda Andre, is a different patient memoir that chastises psychiatry for promoting ECT on the (untrue) grounds that it leads to widespread and devastating memory loss.

Despite these divergent books, it is important to avoid characterizing ECT as controversial. The Shorter-Healy and Dukakis books should dampen the controversy, because they characterize ECT as a safe, effective, and important treatment that psychiatry almost forgot. With its emotion-laden accusations and name-calling, the Andre book will inflame opinions.

In Shock Therapy, Shorter and Healy describe the discoveries of ECT, insulin coma, and lobotomy; the personalities and experiences of the originators; the hazards of early treatments; and the dramatic changes that followed the introduction of anesthesia, muscle relaxants, and oxygenation. These modifications in technique reduced the risks of ECT and changed its negative image. Much attention is paid to the accuracy (or rather inaccuracy) of complaints of permanent, severe memory loss that deter the use of ECT; the role critics of ECT have played to restrict the treatment; and the social consequences of these restrictions. The book documents the irrational arguments that weaken its use and act as a bar to badly needed research in psychiatry.

Doctors of Deception: What They Don’t Want You to Know About Shock Treatment
by Linda Andre. Piscataway, NJ: Rutgers University Press; 2009

The memoir by Dukakis and Tye describes Kitty Dukakis’s decades-long painful experiences with a complex depressive illness and the many unsuccessful medication trials that finally ended when she was treated with ECT. She describes the immediate relief following her first treatments and the sustained benefits of ongoing treatment. She also tells readers about the losses of familiarity and orientation that plagued her following the first ECT treatments and the ways that she coped and returned to healthy functioning as wife, mother, and active community member. Her writing is personal, similar in intensity to prize-winning writer William Styron’s memoir, Darkness Visible: A Memoir of Madness, in which he recounts his experience with mental illness. The chapters written by Tye offer details of the medical and social history of ECT.

In Doctors of Deception, Andre presents a very different story of ECT. She has often come onto the public stage as an implacable critic of ECT, motivated by a personal agenda. She became depressed when she was a young woman. Plagued by suicidal thoughts, she was hospitalized, was treated with ECT, and recovered from serious psychiatric illness. Complaining that she suffered losses of early life memories and claiming she had not been fully informed about the risks of the treatment, she sued her treating psychiatrists and hospital for malpractice, but her suit failed. She found a calling in the public advocacy group Committee for Truth in Psychiatry, and when founder Marilyn Rice died, Andre became the group’s leader. Andre’s account is filled with inaccuracies about the medical aspects of the history of ECT, with equally unfounded personal attacks on the clinicians who sustained interest in ECT.

Shock: The Healing Power of Electroconvulsive Therapy
by Kitty Dukakis and Larry Tye. New York: Penguin Group; 2006

Finding a middle ground

These books present disparate images of a much disparaged and censured—yet widely practiced—medical treatment. Shorter and Healy present a well-documented, carefully indexed, and readable classic history that is a guide for those interested in medical history, clinicians seeking the story behind psychiatric practice, and the patients and families seeking to understand the obstacles they face in search of effective psychiatric care.

Dukakis and Tye present a personal, warm, and encouraging story of the pain and suffering associated with severe depressive illness and of the attendant relief with the alleviation of symptoms, the fear of ECT by both the public and professionals, and the success when effective treatment is properly applied. This is a very useful guide for family members torn by the doubts of practitioners and friends and the intemperate condemnation by critics on the Internet when treatment is recommended.

Andre’s anger vilifies psychiatry and the psychiatrists who continue to offer ECT. Her Web site is strident as well, filled with the kinds of misconceptions that have successfully restricted and continue to obstruct the availability of the treatment. Her book is a triumph of misinformation.

All 3 books are essential reading for anyone interested in ECT. These books offer dramatically contrasting views of a psychiatric issue that is of interest to the public. At the end of the day, patients who have serious depression and other ill-nesses responsive to ECT—together with their friends and loved ones—should read these books and decide for themselves.


David said...

William, I enjoy your blog, but I think it's sad that an integral blog would promote something that is possibly regressive and iatrogenic like ECT and repeatedly decry something with true transformational power like homeopathy.

william harryman said...

Hi David,

I appreciate your misgivings about ECT - I have them too. But I am not promoting that treatment - I posted a pretty balanced review of three books that take three perspectives (pro, it worked for me, and con).

Traditional ECT, as near as I can tell, is probably being phased out in favor of deep brain stimulation (implants) that are safer and more effective. So it's really less of an issue these days.

As for homeopathy - I have never seen a good, double-blind, placebo-controlled study showing that it works better than placebo. So, yes, I am skeptical.


David said...

Hi William,

It's fine to be skeptical; I have no problem with that. But you have gone further and said that homeopathy is "irrational," compared it to scripture and astrology, and so forth, which is why I responded.

In any case, this article from Psychology Today does mention a number of studies where homeopathy has done better than placebo, on the second page of the article:



David said...

One problem with the Psychology Today article I forgot to mention.

It mentioned a study that showed that people with wrist injury experienced "significantly less pain than did those in a placebo group." But it then goes on to say that arthritis suffers didn't enjoy the same pain relief.

The trouble with that is that the remedy they were testing, arnica, isn't generally used for arthritis pain in homeopathic doses. In homeopathic doses it is usually just used for pain and bruising that comes from blows, from trauma.

But some people have used arnica in material does, arnica gel, for arthritis pain, and apparently there are studies to support this:

But of course that isn't homeopathy; it's herbalism.