Electroconvulsive therapy (ECT) is a treatment for mental illness, including depression and other psychiatric conditions, by the application of electric shocks to the brain.
The application of electricity to the brain to alleviate medical conditions has been noted as far back as Roman times, when electric eels were applied to the head to treat headaches. This did not induce a fit, however, and is believed to have been successful purely as a placebo - the suggestion of a cure rather than any medical benefits.
A school of thought much in vogue during the 19th Century was that to give the patient a physical shock would assist recovery from a number of psychiatric conditions. Thus a variety of physical cures were tried, including:
Wet and dry wrapping - the patient was wrapped in cold, wet blankets - or dry ones for a dry wrap - and left like that for hours upon end.
Whirligig chairs - the patient was strapped into a chair and whirled round and round until they were sick. The purgative effect on the body was supposed to be of benefit.
Showers and baths - the patient could either be left sitting in a warm bath (presumably topped up with warm water every so often) as a sedative, or immersed under a freezing cold shower for minutes at a time, as a stimulant or shock.
Emetics - the purging of the physical body was deemed to help mental health.
But except perhaps for the warm baths such 'cures', being rather unpleasant, were also applied as punishments.
Continuing in this vein, and encouraged by a further school of thought which assumed that epilepsy and schizophrenia could not co-exist, the search went on for further and 'better' ways to treat mentally ill patients. At the start of the 20th Century experiments were conducted on animals to find the best method of inducing fits, using insulin and strychnine. In 1934, Hungarian physician Laszlo von Meduna applied the new therapy to a patient in a catatonic state, and was delighted when the patient awoke in a rational frame of mind. This was the start of a wave of shock therapies administered to patients.
At the same time experiments on inducing fits in dogs through the application of electricity to the brain were being carried out in Italy. Initially the dogs died, but the technique evolved to allow electricity to be safely applied to the temples of the dog rather than the exposed brain.
In 1938 the first treatment was given to a human patient, with startling results: the confused patient awoke in a rational state of mind. Thus it was demonstrated that fits could be safely (and cheaply) induced using electricity. This added to the previous research into the benefits of induced fits in psychiatric patients.
In 1940, the first ECT treatments were carried out in the USA, and from there the practice flourished. It did fall out of favour in the 1960s, due to the perceived barbarism of the practice, and graphic film portrayals of the treatment. It has gradually become more popular again, however, and is now widely practised in the UK and the US.
Use of ECT
In the UK ECT treatment is used under the following conditions:
Where drug therapy has been ineffective.
Where significant fear of harm to the patient or to others exists, and it is considered necessary to bring relief of the condition quickly.
For pregnant women, or where other medical conditions mean the use of anti-depressants is not advisable.
Before a course of treatment can be given, a full battery of medical checks is run to ascertain whether the patient is fit enough to undergo the treatment. The main risks with ECT are actually associated with the anaesthetic rather than the shocks themselves.
There are two ways of administering ECT treatment.
Unilateral - the electrodes are attached to one side of the head, the non-dominant side, with one electrode being placed in the area of the temple, and the other attached towards the top of the head, at least 10cm away, on the same side. Thus the electric charge passes through only one hemisphere, although the induced fit is in all the brain.
Bilateral - this is where electrodes are attached to both sides of the patient's head, in the area of the temples. The current thus passes through the whole of the brain, inducing a fit. Bilateral ECT is said to produce more side-effects than unilateral ECT. It is used either when it is unclear which hemisphere of the brain is dominant, or when unilateral ECT has failed.
ECT treatment is a series of shocks rather than just one treatment, usually between four and ten shocks, at the rate of two or three per week.
A typical single treatment may follow this pattern:
The patient fasts overnight
A general anaesthetic is given. This means the patient is unconscious, and unaware of what is happening. (Originally treatments were given without anaesthetic, so the patient was aware of the fit occurring.)
An additional muscle relaxant is given. This guards against injury during the fit. (There is a significant risk of injury during the treatment, from crush injuries to the spine to broken bones.) Because of the muscle relaxant the patient is unable to breathe, so the anaesthetist 'breathes' for the patient, using a bag.
Electricity is passed through the brain, triggering a fit similar to an epileptic fit. Due to the medication given there is no major fitting, and only a slight twitching can be observed. The length of the fit is observed and recorded.
The patient is awoken.
Because of the anaesthetic, there is no physical pain. A special gel is used between the pads and the head, which conducts the electricity while preventing burns. The application of the electricity is only for a few seconds - until a fit is started - and the whole procedure lasts only minutes.
Recovery takes longer. There are the usual after-effects of the anaesthetic, and the patient may be tired and confused or disorientated. In theory, this wears off over the course of about 24 hours. Longer-term effects include memory problems, and there is fierce debate as to whether there is actual damage done to the brain during the procedure.
How Does it Work?
It is not known exactly how the treatment works, or what the effects will be for any given patient. Experiments have shown that the fit which occurs alters the brain patterns in some way. There is some evidence that it increases the amount of dopamine in the brain, helping to elevate mood. Repeated treatments are said to bring the brain patterns back to 'normal'. Results are varied. Some people find that they feel appreciatively better after just one treatment; others may have to have many before an improvement is detected.
ECT is most widely known through its use in the film One Flew Over the Cuckoo's Nest, where it was applied forcibly to patients to subdue them. This has given ECT much of its bad press, as has the practice of using ECT indiscriminately for almost all psychiatric conditions.
A Researcher's View of ECT
I have written this from my own experiences of ECT and from what I have subsequently researched. I wanted to include some of my own thoughts and experiences here, but must emphasise that it is not definitive. It seems that the treatment is so unpredictable in its effects on the physiology and psychology of different people that there is no one way to think about it. I know of people who have suffered relapses and have begged to have ECT again, as it worked well for them. I, on the other hand, would fight never to have it again.
Although I was seriously ill at the time, and in a psychiatric hospital, I can honestly say that the whole experience of ECT was incredibly traumatic. I hated the pads being put on my head (in fact I tried to pull them off while I was going under the anaesthetic) and I hated the awful disorientation after the treatment. It took a long time for my memory to return properly, and I still get frustrated at being unable to recall events or things I learned.
Apparently it helped me - but that is the opinion of my psychiatrist. I am not sure what helped pull me round - being in hospital, the medication being changed, or just natural changes. I prefer to think that it wasn't ECT.
However, again I want to stress that this was my experience alone and it is very different for others. Don't make a decision on whether to have the treatment or not based on my opinions alone.
ECT.org - A comprehensive, if negative, look at ECT, including stories from patients.
Shocked! 40,000 volts of fun - a sometimes lighthearted look at ECT, with serious statistics and information.
Committee for Truth in Psychiatry - information for former and prospective patients.