Review – Shock Therapy
A History of Electroconvulsive Treatment in Mental Illness
by Edward Shorter and David Healy
Rutgers University Press, 2012
Review by Diana Soeiro
Nov 12th 2013 (Volume 17, Issue 46)
Shock therapy: the book’s topic is a controversial one. Almost instinctively, the mere mention of it provokes a strong reaction — either in favour or against. Also, it is an uncomfortable topic, both for patients (and their families) and for health care professionals. Both authors, Edward Shorter (Professor in History of Medicine, University of Toronto/ Canada) and David Healey (Professor in Psychological Medicine, Cardiff University School of Medicine/ UK) are aware of that but still, in this book, they decided to take a stand on it that is perhaps the most controversial: they support the use of electroconvulsive shock therapy (ECT) and they hope that “[a] treatment of last resort may again be a therapy of first choice, particularly for the nonresponder group of psychiatric patients.” (p.7) Moreover, “ECT has a long story of underuse, not overuse”. (p.94) Therefore, the book aims at promoting ECT use, in order to make it widely available as a first-option treatment (instead of a last-resource treatment). Shorter and Healey defend that ECT is the penicillin of psychiatry (p.161) and that though “[w]e still know neither what causes mental illness nor how to cure it (…) denying patients the benefits of an effective therapy on the grounds that it is theoretically poorly understood would be unethical.” (p.7) Strong words.
Briefly, the story of ECT, whose men who have contribute for its development, Shorter and Healey, perceive as “unacknowledged heroes” (p.v): in the 1930s there were three main psychical therapies: 1) Manfred Sakel’s (1900-1957) Insulin Coma Therapy — ICT (“insulin shock”); 2) Metrazol (USA)/ Cardiazol (Europe) which was the beginning of ECT and; 3) ECT, that had as originator Ladislaus Meduna (1896-1964), later supported by Ugo Cerletti (1877-1963). (Ch.1) Let’s take a closer look at each of them: 1) Insulin Coma Therapy: its main disadvantage was that it brought patients “to the brink of death” (p.18) still, “powered by positive results [it had a] twenty-year reign” (p.58) — which is a puzzling observation, with no apparent cause-effect relation. 2) Metrazol: was very effective in psychosis, “the side effects were minor inconveniences” (p.28). It began being used in Germany in 1938 (p.61). Main inconvenience: “Metrazol convulsions were often quite violent, putting patients at risk for fractures of vertebrae and other bones. The early convulsive therapists tried to dismiss fractures as an insignificant side effect.” (p.65, also p.125) The authors conclude: “There is always a balancing of risk and benefit in medicine.” (p.66) Again, a puzzling observation, but the authors’ perspective starts to get clearer. 3) ECT, quickly replaced Metrazol, not for the principle of electricity but for the “triumph of the principle of convulsive therapy” (p.32). After the first experiments being conducted on dogs in order to make it safe for humans, in 1938 (p.37) still in the early 1940s there was the general opinion that patients were dosed “with far too much electricity” (p.69). In Germany, UK (mainly due to Lothar Kalinowsky (1899-1992)) and in France, throughout the 1940s it was heavily used. Around that time, in France several voices rose against it, such as Antonin Artaud (1896-1948) or Dora Maar (1907-1997) who had been subjected to ECT.
In the late 1930s — early 1940s, ICT, Metrazol and ECT left their institutional homelands in Vienna, Budapest, and Rome to become applied worldwide. ECT was the one that has prevailed. ICT was much used in schizophrenia but the first antipsychotic drugs in the 1950s made it useless. Between Metrazol and ECT, ECT prevailed because Metrazol had the inconvenient of having occasional tardive convulsions (which did not happen with ECT). So by the late 1950s, “ECT remained alone on the field among somatic therapies.” (p.51) USA showed its interest in ICT back in 1932 (p.54) but only in 1939-1940 did ECT arrived there (Kalinowsky’s having moved there in 1940, contributed to this).
Though psychopharmacology solved one of the ECT’s secondary effects (bone breaking due to convulsions caused by the seizure) by combining it with the administration of a muscle relaxer (1951), plus anaesthetics (p.128,129), from around 1955 to late 1970s, ECT almost eclipses from common practice (p.160). Why has this happened? According to Shorter and Healey, around the 1970s ECT became ultimately impossible to perform because its reputation was badly damaged mainly by media intellectuals and Hollywood movies (p.139) which led to a lack of progress in the treatment due to lack of research to improve it. “This is the result of psychiatry’s massive disengagement from ECT after the 1960s as a result of stigma” (p.141) A complete reliance on psychopharmacology during those decades is also an important cause for ECT’s abandonment (which authors criticize, commenting also, negatively, on the pharmaceutical industry’s interests, see Ch.8); along with the antipsychiatry movement, led by Thomas Szasz (1920-1912), which is also heavily criticized (Ch.9). These are the factors that Shorter and Healey identify as being grounded on “(…) philosophical, not scientific, judgments.” (p.140)
In the 1970s and 1980s ECT was a treatment “that only the rich could buy, not one that the poor might deserve” (p.145). “ECT is administrated largely in non-public facilities to a relatively advantaged population of white, middle-class females whose treatment is covered by private insurance.” (p.145) Strangely enough, a few pages ahead, it can be read: “In the 1980s though in decay but still practised, it was not updated and not being conducted properly.” (p.202, ch.9) Does this mean the rich, advantaged and white population was not being treated properly though they were paying for the best ‘penicillin’? Though in the 1970s, the USA started their desinstitutionalization process (p.162,182), the authors reveal themselves perplexed since ECT required no hospital admission, only “maintenance” (p.99), which meant less beds occupied (p.166).
After a huge downfall that led almost to extinction in around the late 1970s, ECT experienced a revival in the early 2000s, due to nonresponsive patients to pharmacology use. (p.220) The revival happened due to Max Fink’s (b.1923) efforts in NY during the late 1970s, precisely when ECT was being phased-out, believing ECT showed “remarkable efficacy” (p.230). At first seen as a last-choice treatment, slowly during the 1980s/ 2000s it started gaining support (particularly from Richard Weiner’s, American Psychiatric Association, positive report on ECT, in 1990). Then another positive report on 1999 (p.239) and in 2004 the World Psychiatric Association endorsed ECT.
In general Shorter and Healey consider that “ECT triumphed [over psychoanalysis] because it ultimately was able to deliver the goods”. (p.84) When compared to psychopharmacology, it does not create zombies, and offers fast results (Ch.6). Even paralleled with modern technology use, (Magnetic Seizure Therapy/ MST; Transcranial magnetic stimulation/ TMS; Vagus Nerve Stimulation/ VNS; Deep Brain Stimulation/ DBS), ECT wins (Ch.11). The seizure is the therapeutic element and that is why the book focuses on the conclusion that is produced rather than on ECT as an episode of the history of medical electricity. (p.270).
What will you not find in this book?
· Brain damage or memory loss is dismissed as a secondary effect that has not yet been fully proven. Strong and solid research on this is not provided by the authors, perhaps because the book is addressed to the layman and not to the scientific community – in order to contribute for the destigmatization of shock therapy.
· Reliable statistics: eg. “It was clear that, on a statistical basis, ECT was a highly effective therapy.” (p.80) “Electricity [to apply voltage] was effective” (p.94); ECT reduces suicide rates (p.97); in 1977, even though banned from psychiatric use, doctors remained “fond” of ECT (p.000000).
· The problem of consent: in the 1960s, “[i]t became less acceptable for physicians to decide for patients without consulting them” (p.191) Earlier, patients had typically been sent for lobotomies without being consulted, and they had ECT, perhaps after being informed, but not with an option to refuse.” (p.199) Though this has changed in the 1970s, authors do not seem to favour too much patients’ perspective.
· No report from patients: “although ECT appears less effective when judged by patients, it nevertheless still appears effective” (p.218); ECT was stigmatized by the media elite and by former patients “who refer themselves as ‘survivors’ (not to the illness but to the treatment), and who claim a place at the table in scientific discussion of ECT. (…) it is right that patient-driven research should occur. Yet the line between research and advocacy can be a thin one.” (p.249)
The short version of this book would be: “Mental illnesses are organic diseases. The convulsion, in ECT is the curative aspect that needs to be maintained: “[b]ecause it works.” (p.252) Therefore, bring ECT back, as a first-option treatment so ‘we’ can improve it.” All in all, I would recommend its reading: if you are in favor of ECT, you will find in this book a good example of the rhetoric of those who defend its use (with a few fallacies in between) but that give you a general frame of how far can one go; if you are against ECT, you will be highly educated on a possible pop-version discourse of those who are in favor. If you want to decide if you are in favor or against ECT, with real information, I would advise you to read journal articles and perhaps a different book.
© 2013 Diana Soeiro
Diana Soeiro (b. 1978). Philosophy, PhD (2011). Postdoctoral Research Fellow at Institute for Philosophy of Language/ New University of Lisbon. Updated information: www.linkedin.com/in/DianaSoeiro