Allison Clark '01

Electroconvulsive therapy (ECT) is one of the most controversial therapies currently practiced in psychology. The technique has a relatively long and checkered past, which contributes to the negative attitude toward ECT among many clinicians, as well as within the general public. There are many issues regarding this particular therapy that render such negativity a most reasonable reaction, and there are many issues that render its continued use equally reasonable.

The use of electric shock in treating mental illness began in Italy in 1937, and soon followed in other European countries and the United States (Jessner & Ryan, 1941). It is interesting to note how greatly the response to ECT has varied over the years. When it was first introduced as a treatment for mental illness, it was used widely for many different ailments until its limitations were discovered. In a particularly telling bit of history, the technique was recognized to have very limited success on cases other than depression within a few years (Jessner & Ryan, 1941), but was used excessively for all manner of disorders starting in the1950s and continuing into the 1970s (Kalinowsky & Hippius, 1961; Cohen & Solomon, 2001). At that time, the treatment was used for depression, manic depression, hypochondriasis, schizophrenia, conversion hysteria, hysterical personality, amnesia, obsessive compulsive neurosis, insomnia, epilepsy, posttraumatic catatonia, malaria, senility, skin conditions, speech disorders, peptic ulcers, anorexia nervosa, pain (including phantom limb pain), psychopathic personality, alcoholism, hypoglycemia, menstrual disorders, vasomotor neuroses, and homosexuality (Kalinowsky & Hippius, 1961). The treatment has clearly been overused in the past, contributing to the current antipathy of many individuals toward its continued application.

More important in establishing negative sentiments against ECT than its extension to a myriad of disorders is the process of the treatment itself. In the current form, patients receive a general anesthetic and strong muscle relaxants (Myers, 1998). The electric shock is administered via an electrode attached to the head, and typically lasts only a few moments. The shock induces convulsions and general activity comparable to a grand mal seizure. The shock is typically administered three times a week for two to four weeks.

In some sense, this treatment is much milder than its earlier use, which entailed a greater intensity of shock, often administered more frequently for greater duration (Cohen & Solomon, 2001). The process of treatment continues to be associated with its earlier use, and is considered barbaric by many. As some say, with ECT, any negative reactions are not the side effects, but the treatment itself (Cohen & Solomon, 2001). It usually results in some degree of memory loss. The use of muscle relaxants prevents the breaking of bones that once--and sometimes still--resulted from the convulsions produced by the shock. Even though the relaxants keep these injuries to a minimum, the fact that there remains a risk and that such relaxants are necessary should not be ignored.

The treatment has also improved in terms of those individuals eligible to receive it. It is currently used exclusively for those with depression or bipolar disorder (manic depression). Depression is one of the most common psychological disorders, but its seriousness as a debilitating and life-affecting disorder is often underrated (Myers, 1998). It can include feelings of worthlessness and helplessness, and can lead to suicide. As a result, it is particularly noteworthy that approximately 80 percent of patients currently treated with ECT show significant improvement without apparent brain damage. Unfortunately, they are still vulnerable to relapse (Myers, 1998). As a result, there can be no claim that the treatment is a miracle cure that is only horrific in appearance. Furthermore, it is still unknown precisely how ECT works, which may be one of the most significant arguments of its detractors.

As a result of these issues, many clinicians and others object very strongly to the continued use of ECT. However, there appears to be something of a resurgence of popularity among some clinicians and something of a glorification among the media (Cohen & Solomon, 2001). It is estimated that approximately 110,000 people in the United States are treated with ECT each year. Estimates of the number of individuals treated annually in the past are highly variable, but whatever the change, it is clear that ECT is not at all a treatment of the past, but still very much a presence in therapy settings.

Given that the treatment alleviates depression much faster than psychoactive drugs or cognitive and other therapies, it is credited with saving people's lives (Depression Alliance, 2001). Furthermore, some individuals simply do not respond to drug treatments, but do respond positively to ECT. Thus, the treatment has regained some credibility and respectability, and is being used with some frequency again. Although it has clearly helped many individuals, something of a rift has developed between proponents of other therapies and those of ECT.

Considering the problems with the technique, ECT should be given very serious consideration before use, and is commonly used only as a last resort. In recent years, however, some have suggested its use as a replacement, although not a complete replacement, for drug therapies (Depression Alliance, 2001). They note that the treatment does not take as long to become effective, is a relatively simple and inexpensive procedure, and does not have the side effects of drugs. Drug therapies can indeed have side effects nearly as debilitating and bothersome as the depression that they seek to remedy. These can include insomnia, fatigue, sexual dysfunction, dry mouth, weight gain, and dizzyness (Myers, 1998).

In response, the proponents of drug therapies note that, first of all, the method of function is much more clearly understood than in ECT. Furthermore, the development of drugs has become more and more sophisticated with time, for example shifting from the use of tricyclics to monoamine oxidase (MAO) inhibitors to the ever more popular selective serotonin reuptake inhibitors (SSRIs). With each development, the drugs have become more sophisticated and fewer side effects have resulted (Cohen & Solomon, 2001).

The developments in drug therapies have certainly been significant and have greatly improved the condition for many people with depression. With these developments has followed a sudden popularity in prescription for each new drug (Myers, 1998). Drug dependence can result from overuse. When individuals attempt to discontinue use of the drugs, the uncomfortable effects may drive them back to further use. Some caution is appropriate given that ours is becoming a more drug dependent society in which pills seem to have all of the answers.

Cognitive and other therapies are also useful in treating depression, and do not carry the barbaric history and dubious mode of action found with ECT, or the side effects and dependence of drugs. Unfortunately, the "talking" therapies, as they are often called, do not make a complete answer for depressed individuals, either. Although cognitive therapies in particular have proven effective with depression, they tend to require a great deal of time, expense, and effort on the client's part before relief is experienced (Myers, 1998). In many cases, however, a combination of drug and cognitive therapies are recommended, and this does appear sufficient for many individuals.

One problem remains with the variety of therapies, however, and that is the fact that every individual is different. For some, cognitive interventions will be enough. Others will improve only with the use of psychoactive drugs. Still others will find no relief from either of these therapies, or any combination thereof. The only remotely acceptable intervention offered at that point is ECT.

ECT should not be endorsed strictly because it is the only treatment that seems to help those individuals who depression is unremitting in the face of other therapies, however. Continued concern about ECT is appropriate given that its method of working is still poorly understood, memory problems can result, and relapse is problematic. For some, however, ECT truly does seem to be the remedy for the particularly devastating disorder of depression. Given all the issues complicating treatment with ECT, it is negligent to endorse it wholeheartedly, and inhumane to refuse it to those who are suffering.

References

Cohen, J., & Solomon, N. (2001). Psychiatric technique gets shocking boost from media [On-line]. Available: http://www.psychcentral.com/electro.html

Depression Alliance. (2001). Electroconvulsive therapy [On-line]. Available: http://www.depressionalliance.org

Jessner, L., & Ryan, V.G. (1941). Shock treatment in psychiatry: A manual. New York: Grune & Stratton.

Kalinowsky, L.B., & Hippius, H. (1969). Pharmacological, convulsive and other somatic treatments in psychiatry. New York: Grune & Stratton.

Myers, D.G. (1998). Psychology. New York: Worth Publishers.