'Like a Magic Wand'
Why we need to end the fear and stigma of electroconvulsive therapy.
Posted Jul 14, 2020
Electroconvulsive therapy (ECT) is among the most stigmatizing of all medical treatments, so much so that patients and their families are reluctant to accept it even when a life is at risk.
Remission rates for psychotic and nonpsychotic depression after ECT treatments are as high as 90-95 percent in some studies. In 1985, the NIH issued a consensus report about ECT that stated, “Not a single controlled study has shown another form of treatment to be superior ... in the short-term management of severe depressions.”[i] Given that suicide is increasingly common,[ii] we may need to be using more of this therapy.
Then why are we still so afraid of ECT?
One reason is that, in the mid-twentieth century, electric shocks were used together with lobotomies, and so they were closely associated with each other. When lobotomy (thankfully) fell out of favor, so too did ECT.
In addition, ECT was commonly used in state institutions without anesthesia, sometimes as a punishment.[iii] The mere mention of ECT still raises eyebrows since it is tied to images of violence from the past.
As a high school student in 1977, I worked at a psychiatric hospital and once watched a patient receive ECT. Just a year earlier, I’d seen One Flew Over the Cuckoo’s Nest, the film starring Jack Nicholson that featured a frightening though unrealistic episode of ECT. The patient I observed was a seventy-pound woman in her mid-seventies who had been depressed and was now catatonic. None of the available medicines had worked and she likely had only a few days to live. The symptoms associated with catatonia—dehydration, malnutrition, and immobility, for example—can affect every organ system and lead to death.[iv]
A nurse gave her two shots, an anesthetic to make her unconscious, and a muscle relaxant. Next, they placed electrodes on her scalp and put a bite block in her mouth to minimize the risk that she might bite her tongue. They initiated a brief delivery of electricity—a little less voltage than comes from an electrical outlet, I was told—just enough to produce a short seizure. There was a slight tremor in her toes that lasted about ten seconds.
I remember feeling disappointed. I had expected something more theatrical. But this patient barely moved. An actual ECT treatment today doesn’t look anything like shock therapy in Hollywood movies. As scholar Jenell Johnson told me about her initial protest against her grandfather receiving ECT, “I had this moment where I just thought: here I am literally making a life and death decision about someone I love, based on little more than a Jack Nicholson movie.”
Two weeks later, the patient was watching television with a bowl of popcorn in her lap. So I understand why, despite never having received ECT himself, writer Andrew Solomon uses words like “miraculously effective,” “wondrous,” “boon,” and “the most successful physical treatment for depression” to describe it.[v] I understand why talk-show host Dick Cavett said ECT was, for him, “like a magic wand.”
Why does ECT work? The received view is that ECT induces a seizure that, in turn, stimulates the brain to stop the seizure. In the process, brain cells quickly release neurotransmitters and change the metabolism and blood flow of the brain. It’s as if the brain’s effort to stop the seizure is itself an internally produced, natural antidepressant.[vi]
Psychotherapy and medications are vital to the long-term treatment of serious mental illnesses, but they may not help someone at imminent risk of dying and who has not responded to anti-depressant medicines. An anti-depressant can take six weeks or more to show any therapeutic results. And if one doesn’t work, and the patient needs to try another, they’ve lost precious time.[vii]
Although there are side effects—like memory loss—the list is much smaller than for psychotropic medications. In addition, some short-term memory loss is related not to ECT but to the anesthesia, which disrupts the memory of any patient anesthetized for any medical procedure. And depression itself often involves deficits in verbal memory, decision speed, and information processing.
To the best of my knowledge, ECT is not dangerous. But even if it was, I would still recommend it for my loved ones if it saved their lives. Yet ECT continues to be associated with violence on the body while the side effects of radiation therapy and chemotherapy for cancer—and major operations like heart surgery, in which the surgeon makes an eight- to ten-inch cut through the sternum—are associated with recovery. In her discussion of ECT, writer Mary Cregan reminds us that the hero of many television dramas is the defibrillator, which delivers a powerful electric shock to the heart to save lives—but that generates no stigma.[viii]
Unfortunately, the scientists who study ECT, and the doctors who provide it, are still harassed as if they are torturers. Not long ago, when experts on ECT arrived at the U.S. Food and Drug Administration to speak about the approval of a new ECT device, antipsychiatry activists lined the hallway, forming a gauntlet. Protestors hurled insults, addressing some of the experts as “Dr. Shock.” Others, mimicking the sound of a jolt of electricity, spit out the sound “bzzzzt.”
[i] “Electroconvulsive Therapy.” 1985. NIH Consensus Statement 5 (11), June 10–12: 1–23.
[ii] Centers for Disease Control and Prevention; https://webappa.cdc.gov/cgi-bin/broker.exe.
[iii] Whitaker, Robert. 2002. Mad in America: Bad science, Bad medicine, and the Enduring Mistreatment of the Mentally Ill. New York: Basic Books, p. 106.
[iv] Luchini, Frederica, et al. 2015. “Electroconvulsive Therapy in Catatonic Patients: Efficacy and Predictors of Response.” World Psychiatry 5 (2): 182–92; Kho, King Han, et al. 2003. “A Meta-Analysis of Electroconvulsive Therapy Efficacy in Depression.” Journal of ECT 19 (3): 139–47.
[v] Solomon, Andrew. 2003. Noonday Demon. New York: Scribner, pp. 120–23.
[vi] Prudic, J. 2005. “Electroconvulsive therapy.” In Saddock, B. J., and V. A. Saddock, eds. Comprehensive Textbook of Psychiatry. Eighth Edition. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; Singh, Amit, and Sujita Kumar Kar. 2017. “How Electroconvulsive Therapy Works: Understanding the Neurobiological Mechanisms.” Clinical Psychopharmacology and Neuroscience 15 (3): 210–21; Sackeim, H. A. 1999. “The Anticonvulsant Hypothesis of the Mechanisms of Action of ECT: Current status.” Journal of ECT 15: 5–26.
[vii] McCall, W. Vaugh. 2007. “What does Star*D Tell us about ECT?” Journal of ECT, 23 (1): 1–2.
[viii] Cregan, Mary. 2019. The Scar: A Personal History of Depression and Recovery. NY: W.W. Norton.