Toward a Better Understanding of Electroconvulsive Therapy

On July 25, 1972, Democratic vice-presidential candidate Senator Thomas Eagleton of Missouri revealed that he had received electroconvulsive therapy (ECT) for depression in the 1960s. After initially supporting him, presidential candidate George McGovern dropped him from the ticket. For many, the notion that someone had received shock treatment disqualified them from being that close to the presidency.

To be sure, McGovern was probably right to be upset that Eagleton had not disclosed his medical history of severe depression before accepting a spot on the ticket. It is also true that severe depression is a recurrent illness, and one could argue that this is a legitimate reason to be wary of having someone with that history at the helm of the country.

Yet it was mainly the fact that Eagleton had received ECT that seemed to unnerve people. The “Eagleton Incident” influenced political candidate selections for decades after and ECT today remains the subject of misinterpretation and stigma. One wonders whether new research attempting to elucidate how ECT works might help relieve some of that suspicion. When we don’t understand how something works, we are prone to cast aspersions on it.

Popular Depictions

The image many have of ECT is derived from its depiction in the 1975 movie One Flew Over the Cuckoo’s Nest, in which Jack Nicholson’s character is administered ECT as a punishment. In that scene, he is strapped to a gurney and, fully conscious without the benefit of anesthesia or muscle relaxants, given ECT. He is shown violently convulsing and writhing in pain. How, one might reasonably ask, could a person be the president of the United States if he required that kind of extreme intervention?

Of course, the depiction of ECT in the movie is not close to what actually occurs when a patient with depression receives the therapy. Patients are under general anesthesia during the treatment, fast asleep, and, because of the administration of muscle relaxants, do not have physically apparent convulsions. Most importantly, ECT is not given as a punishment. Patients with depression who do not respond to other interventions like psychotherapy or antidepressant medication or whose depression is so severe as to be immediately life-threatening must give informed consent to have the procedure. When administered by experienced clinicians, modern ECT is one of the most effective treatments in all of clinical medicine, producing significant improvement in approximately 80 percent of patients. It is also a safe procedure that is well-tolerated by most patients.

Why then is there such a difference between public perception of ECT and the facts about it? Why does the response to Thomas Eagleton’s admission that he received ECT or to the movie One Flew Over the Cuckoo’s Nest still dominate how people perceive ECT, even though the reality is vastly different?

What We Don’t Understand, We Fear

One possible explanation for this disparity is the fact that we have very little understanding of how ECT works. Passing an electric current through someone’s brain seems a rather blunt instrument. How is it that this so dramatically relieves the symptoms of depression and some other psychiatric illnesses like mania? A recent study published in the journal Nature Communications may shed some light on the mechanism of action of ECT. Scientists have always believed that the convulsion itself that is induced in the brain by ECT is the therapeutic mechanism behind its effectiveness. Now, however, investigators from the University of Pennsylvania with collaborators at other institutions challenge that idea.

The researchers first developed a mouse model for ECT and found that immediately after the seizure itself there is a second brain event called cortical spreading depolarization (CSD). CSD is like a wave that travels through the brain, decreasing the activity of neurons it touches and causing them to reset. The scientists then used sophisticated imaging techniques during ECT and found that CSD also occurred in human patients. The authors of the paper speculate that the inhibitory effects of the CSD wave may in fact be the key to understanding how ECT works. As is the case with all scientific papers, this one concludes with a call for more research to better understand if this is indeed the case.

The research is important because it represents the first time in the more than 80-year history of ECT that real progress has been made in understanding how ECT works. This progress is made possible only by the advent of more sophisticated neuroscience technologies, including those used to study mouse models and to image human brain waves.

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When we don’t understand how a medical intervention works—even an intervention as effective as ECT—we tend to be suspicious of it. Of course, we cannot always affirm the converse of that statement: Knowing how something works does not always alleviate unfounded suspicions. We know fully well how vaccines work, for example, yet entirely too many people continue to question their safety and effectiveness. Still, throwing electricity into that very mysterious black box known as the human brain without knowing exactly what it does befuddles us, leading to gross misrepresentations.

Perhaps research moving us closer to understanding how ECT works will reduce some of the stigma surrounding it. Maybe the day will come when a candidate for high office acknowledges receiving the treatment and it will be regarded as no more troublesome than any other successful intervention for a serious medical condition. Not knowing the way it works, however, continues to drive suspiciousness about ECT. That is a significant problem because it limits the number of people who could be helped.