Why shock therapy deserves its mini-revival.

Why shock therapy deserves its mini-revival.

Why shock therapy deserves its mini-revival.

Health and medicine explained.
Jan. 3 2008 7:38 AM

The Body Electric's New Look

Why shock therapy deserves its mini-revival.

 Edward Shorter and David Healy's Shock Therapy

The history of electric shock therapy would seem to lend itself to a rather straightforward tale of last-ditch, gruesome treatment of mental illness. After all, we've all seen One Flew Over the Cuckoo's Nest.

But in their new book Shock Therapy, Edward Shorter and David Healy say this version is almost entirely inaccurate. Shorter is a historian who has written extensively on psychiatry, and Healy is a psychiatrist who has been highly critical of the marketing of psychopharmacological drugs. They believe that electroconvulsive therapy is incredibly effective. And yet for decades, a severely depressed patient—even one on the brink of suicide—might not have been offered the therapy, or if her doctors had proposed it, she or her family might well have declined it. In explaining why, the authors demonstrate that though we may assume medical treatments get adopted or rejected based on objective statistics, in fact data are often misinterpreted and manipulated by outside influences that end up overpowering them.

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The history of ECT began in 1938, when Italian psychiatrist Ugo Cerletti connected a pair of electrodes to the head of a schizophrenic mechanic and shocked him until he seized. Cerletti was building on earlier work showing that seizures caused by injecting insulin seemed to help certain mentally ill patients. After several ECT treatments, Cerletti reported, the man's confusion and mutterings had resolved. Doctors did not know how ECT worked, although it was assumed that the seizure relieved symptoms by somehow "resetting" the nerve cells in the brain. But they were quite sure that it did work, not only for certain forms of schizophrenia but also for severe depression, a discovery made when Cerletti and others tried the technique on a broad range of patients. As one psychiatrist wrote about treating depressed patients with ECT: "It was like a miracle. I always related it to Lazarus risen from the grave." This was the professional response, moreover, even though early ECT was primitive, causing uncontrolled seizures and fractured bones even as it treated disease.

By the 1940s, Shorter and Healy write, ECT "had become part of the therapeutic apparatus of nearly every mental hospital" across the globe. In 1959, Group Health Insurance, a company that insured New York City employees, proudly announced that it would cover "ten electroshock treatments, in or out of the hospital," for all of its subscribers.

But within a decade, ECT would become stigmatized as dangerous and even sadistic, "a fearsome last-ditch remedy to be used only under extraordinary conditions and under the most elaborate legal safeguards," as the authors put it. This is the best-known part of the story. ECT fell out of favor for several reasons. When phenothiazines, the first pills that could treat schizophrenia, became available in the early 1950s, pharmaceutical companies marketed them as better and safer than shock therapy even though they did not always work and often caused jerking movements and other side effects. This marketing dovetailed with the social upheaval of the 1960s, which led to the formation of the so-called anti-psychiatry movement, a loosely based coalition of activists, disenchanted mental health professionals, and patients. They charged that psychiatric hospitals, through procedures such as ECT and lobotomy, were punitive as opposed to therapeutic—a la the 1962 novel One Flew Over the Cuckoo's Nest, which was made into a film in 1975. When the hero, Randle P. McMurphy, receives damaging ECT and a lobotomy, it is essentially to prevent him from saving the other patients. And this link between shock therapy and the second, much more dubious procedure made it seem all the more frightening.

Also influential was a 1974 New Yorker article by renowned medical writer Berton Roueche, who claimed that ECT caused permanent memory loss. Because the woman featured in Roueche's essay was not a representative case, her story exaggerated the importance of a real, but limited, side effect. The anti-ECT sentiment culminated in the passage of a 1976 California law that actually tried to prevent physicians from prescribing it—a rare instance of direct legal interference with medical practice.

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Meanwhile, what did the data about ECT actually show? Research from the mid-20th century was more susceptible to bias than more recent work, but hundreds of studies from a wide variety of institutions claimed it was effective. Shorter and Healy also argue that proponents of ECT were always concerned about the treatment's real side effects. By the 1950s, the use of better anesthetics and muscle relaxants helped control the seizures and made the procedure less violent. Other improvements sought to minimize memory loss. But the persistently suspect characterizations of ECT meant that many patients with mental illnesses who were unresponsive to drugs never received the treatment. As a result, some worsened and some died. This surely represents a lot of potentially avoidable pain and suffering. The backlash against ECT, Shorter and Healy make clear, somehow led to a collective denial about what it could accomplish.

This selective reading of scientific data has been the downfall of many treatments besides ECT. In the 1930s, researchers published studies suggesting that removal of a portion of the breast plus radiation was as effective for treating breast cancer as disfiguring radical mastectomy, which necessitated removal of the breast, local lymph nodes, and both chest wall muscles on the affected side. Yet especially in the United States, where surgeons monopolized control of the disease, these data were ignored for decades. After women began demanding less extensive operations in the 1970s, additional studies validated the earlier findings.

In other instances, the reverse has occurred: therapies not justified by the data have achieved wide popularity. One example was hormone replacement therapy, which became popular when gynecologist Robert Wilson characterized menopause as an estrogen-deficiency disease in his 1966 book Feminine Forever. Ingesting synthetic estrogen, Wilson argued, would make women feel younger and also prevent osteoporotic fractures and heart disease. Although some critics questioned HRT from the outset, its harms became apparent only in the last few years, with the publication of definitive long-term studies. For decades, the combination of Wilson's salesmanship, drug company advertising, and the pathologizing of a normal stage of life led to the widespread adoption of a treatment not supported by the science.     

These historical examples of science misused or ignored helped to usher in the now-powerful movement known as evidence-based medicine, which argues that treatments must be evaluated by the most sophisticated biostatistical and epidemiological tools. At the forefront is the randomized controlled trial, which eliminates many of the biases seen in older studies. And evidence-based medicine has come to the world of electroconvulsive therapy. Beginning in the 1980s, a series of expert task forces reviewed the existing data and concluded that in certain cases of mental illness, ECT is not only an acceptable, but a highly advantageous treatment. Its use is again on the rise, helping to alleviate the symptoms of certain patients with severe psychiatric diseases.