ELECTROSHOCK THERAPY (Elec- troconvulsive Therapy; EST, ECT)

Convulsive therapy was originated by the Hungarian psychiatrist, Ladislaus J. Meduna in 1935, after he had noted that epilepsy and schizophrenia rarely occur together, and that psychotic symptoms may temporarily disappear after spontaneous convulsions. Reasoning that a “biological antagonism” existed between epilepsy and schizophrenia, he began to induce convulsions by using, first, injections of camphor and oil, and later the drug metrazol. This treatment was later abandoned as “barbaric” as a result of the high incidence of fatalities and fractures and of the intense feelings of fear and apprehension experienced by the patients during the few moments between receiving the injection and losing consciousness. The idea of inducing convulsive seizures, however, was not abandoned, and in 1938 Ugo Cerletti and L. Bini introduced electro- convulsive therapy in Italy.In the ECT procedure the patient is placed on a well-padded bed with a rubber gag between his teeth to prevent injury to the tongue. Today suc- cinylcholine (Anectine) or other muscle relaxants are administered to “soften” the seizure, and virtually eliminate any danger of dislocations or fractures. Electrodes are lightly clamped to the temples and a current ranging from 70 to 130 volts is applied for .1 to .5 seconds. Since the electric current travels faster than the nerve impulse, the patient loses consciousness before he can feel any pain. He immediately goes into a brief two-stage convulsion: in the tonic phase the muscles become rigid for about ten seconds; and in the clonic phase spasmodic, quivering contractions occur throughout the body for about thirty to forty seconds. When these contractions have subsided, the patient remains unconscious for another ten to thirty minutes. After awakening he appears drowsy and confused for an hour or so, and cannot remember the shock or the events immediately preceding it.Electroshock treatment is usually contraindicated or postponed with patients who have had recent heart attacks, but is considered safe for practically all other patients, including the pregnant and the aged, when proper precautions are applied. Though some patients readily accept the treatment, others are apprehensive and may be given drugs to allay their anxiety. Treatments are generally administered two to three times a week, with depressives requiring five to ten treatments and schizophrenics twenty or more. A variation known as regressive shock therapy, in which the patient receives two or three treatments per day has also been tried. Electroshock treatment practically always produces some amnesia, which disappears in a few hours, but the regressive technique results in extensive amnesia, confusion, and reversion to infantile behavior for a period of weeks. It is said to be helpful with antisocial personalities, highly resistant cases of schizophrenia, and pseudoneurotic schizophrenia, but is still considered experimental. Other variations, such as applying the current only to the nondominant lobe of the brain (Cannicott, 1963), and electronarcosis, in which a shock is applied for thirty seconds instead of less than one second, are also under study.ECT is remarkably effectual with affective disorders. A short course of treatments produces dramatic improvement, often amounting to full recovery in at least 90 per cent of involutional melancholics and manic-depressives in the depressed phase. It is somewhat less effective with manic reactions, for even though the symptoms may often be alleviated after three or four treatments, the improvement tends to be unstable. Recovery rates as high as 68 per cent for catatonic schizophrenia have been reported (Kalinowsky and Hoch, 1961). The treatment is less successful with paranoid schizophrenics, and of limited value with simple and hebephrenic types. It is considered ineffective for neurotic patients, with the exception of neurotic depressive reactions. In general, ECT produces its best results where (a) the disorder is of recent and rapid onset, (b) the premorbid personality was relatively stable, (c) the patient is emotionally responsive, and (d) external stresses play a greater role than internal, or “endogenous” factors in precipitating a breakdown. These points apply to other forms of treatment as well.During the years following the introduction of tranquilizers and antidepressants there was a strong trend toward replacing ECT with drug therapy except in acute, urgent cases—but recently the use of ECT has increased. In reviewing the comparative value of the two procedures, Kalinowsky (1964) makes the following points. First, though antidepressants bring improvement in a fairly high percentage of depressives, ECT leads to far more full recoveries—and if drug treatments are used first, and prove insufficient, private patients often cannot afford the extra expense of ECT. Second, depressive patients quickly lose their suicidal tendencies under ECT, but the drug patient recovers more slowly and may retain his suicidal impulses even after he has gained enough initiative to act on them.Third, various investigators (Hoffet, 1962; Flynn and Hirsch, 1962) report only about 50 to 55 per cent success in treating pure depressions with drugs, as compared with 90 to 95 per cent with ECT. Some studies have also shown that ECT is successful in practically all pure depressions where drugs have failed to produce results. However, ECT is less effective than drugs with milder depressions, those of the reactive and psychoneurotic type—but there is no need to use it in these cases since there is less danger of suicide. Drugs may also be administered to patients who show incomplete recovery after ECT; as a preventive measure in recurrent depressions; and with older patients who are chronically depressed.Fourth, in schizophrenic reactions, ECT is generally effective only in the first year or two of illness, but drugs tend to remain efficacious no matter how long the disease has lasted. In addition, they also render many patients accessible to psychotherapy. In acute cases both types of treatment may successfully remove symptoms, but ECT usually produces more dramatic results and leads to fewer difficulties with patients who have physical complications. In less acute cases pharmacotherapy is generally justified, though remission tends to be “longer lasting and of better quality” among shock-treated patients than among those treated with drugs. As to other conditions, drug treatment is recommended over ECT for cases showing a mixture of schizophrenic, depressive, and neurotic symptoms, addiction withdrawal symptoms, psychotic episodes in chronic organic brain disease, and psychoses associated with postoperative, toxic, and infectious disorders.There is little agreement on the reasons for the effectiveness of ECT, but there is no dearth of theories, both psychological and physiological. Psychologically, its effectiveness has been attributed to the attention given the patient, reorganization of thinking processes during the amnesic episode, unconscious interpretation of the shock as an expiation for sins, and mobilization of the patient’s “vital instincts” as he faces the sudden threat of death in losing consciousness. None of these explanations is sufficient, for attention to the patient does not in itself effect a cure, the treatment is beneficial even when amnesia does not occur, patients who do not have guilt feelings often recover; and many patients experience no fear of the treatment and no feelings that it threatens their life.The physiological theories are equally inadequate. Meduna’s theory of an antagonism between schizophrenia and epileptic convulsions does not hold, since the two are actually found together more often than he believed—and besides, convulsive therapy is even more effective with depressive than with schizophrenic disorders. The theory has also been advanced that the temporary anoxia produced by ECT accounts for its effectiveness. No satisfactory explanation has been given as to how or why this occurs and, moreover, reduced oxygenation is only a short-lived effect and may be entirely avoided by the use of Anectine. Cerletti, the co-originator of the technique, has suggested that the electric current acts as a stressor that releases a defensive substance which has a stimulating effect on the nervous system—but he was unable to isolate this substance, if it exists at all. So far, then, ECT remains in the realm of empirical medicine, along with many other treatments of undoubted value.