In the early 1970s, I was a naive 21-year-old in love with my first post-graduate job as a psychiatric nurse in New York City. Three times a week, several older women queued against the wall in the hallway. Some of them sat motionless in chairs. Others looked scared and agitated. Sometimes someone would try to run away and the kind but firm staff would push him back to his chair. When I learned that they were waiting for an "electric shock," I volunteered to sit with them while they recovered from general anesthesia, after the shock and seizure. They asked me: "Where am I?" 'Who am I?' "Why does my head hurt?" and "What did they do to me?" I remember not being able to answer an old lady who, with tears in her eyes, asked me, “Why did they do this to me?”
The Royal College of Psychiatrists in the UK in their latest white paper (2020) writes:
ECT is a treatment for some types of severe mental illness that other treatments do not respond to.
An anesthetic and a muscle relaxant are injected, and then an electric current is passed through the head. This causes a controlled landing that typically lasts less than 90 seconds.
Anesthesia means that you are asleep while this is happening. A muscle relaxant reduces the mobility of a seizure.
It is given as a course of treatment twice a week, usually for 3-8 weeks.
The most common response I get when mentioning shock therapy outside of mental health circles is, “Are we seriously still doing this?” To understand the permanence of this cure, you need to go back in time. Electroconvulsive therapy (ECT) combines a long tradition of applying extreme physical procedures to suffering or afflicted people: potent laxatives, bloodletting, forehead blistering, swivel chairs, surprise baths, ice caps, scabies inoculations, smoke soot force-feeding. and woodlice and, briefly in the early 20th century in the United States, the surgical removal of teeth, testicles, ovaries, gallbladders, and colon. The 20th century saw malaria-induced fevers, insulin-induced coma, and a series of "psychosurgical" procedures, including driving an ice pick-shaped instrument through the eye socket ("prefrontal leucotomy") and injecting radioactive yttrium (Y90) into the brain. brain ("subcaudal tractotomy"). All these "treatments" were carried out by practicing doctors who at one time sincerely believed that they were helping people. Seizures in themselves, of course, have always been considered a symptom of the disease, not a cure. So why did some Italian psychiatrists in the 1930s come to the conclusion that it would be useful to induce grand mal seizures in people thought to be insane? The key is the era's theory that epilepsy cannot exist alongside a group of symptoms lumped together and called "schizophrenia." So, while some doctors started treating epilepsy by injecting blood into people diagnosed with "schizophrenia," psychiatrists were looking for ways to induce epilepsy, or at least epileptic seizures, in "schizophrenics."
In Hungary in 1934, psychiatrist Ladislas Meduna caused convulsions in patients with injections of camphor and metrazol. According to the researchers, after the first injection, Medun "was so upset that the nurses had to escort him to the ward." Meanwhile, in Italy, the neurologist Hugo Cerletti was trying out electricity. He first experimented with dogs by placing electrodes in their mouths and rectums. Many died. He discovered a way to bypass the heart in the slaughterhouse:
The pigs were clamped by the temples with large metal tongs, which were connected to an electric current (125 volts) ... they fell unconscious, stiffened, then after a few seconds they were shaking in convulsions in the same way as our experimental dogs ... felt that we could risk experimenting on man.
His first man was a 39-year-old engineer from Milan, who was found by police wandering around the Roman train station in a confused state. When the first electric shock did not cause the desired convulsions, Cerletti and his assistant discussed whether a stronger shock should be applied. Cerletti said:
Suddenly the patient, apparently following our conversation, said clearly and solemnly, without his usual gibberish: “Not one else! It's deadly!
Cerletti continued anyway, in the first of the millions of cases that were to follow and continue today, in which people were subjected to such treatment despite clearly stating that they did not want it. After another, stronger shock, which caused a convulsion, the engineer could not remember being shocked; the first of millions of cases of short-term memory loss caused by this treatment.
Even before I knew about the ECT research, I felt that something was terribly wrong.
Like Meduna before him, Cerletti was not indifferent to the impact of what he did on the man before him:
When I saw the patient's reaction, I thought to myself:
must be cancelled! Since then, I have been looking forward to the time when another method of treatment will replace electric shock.
I had a similar reaction to Meduna and Cerletti when, at a New York hospital, I witnessed my first ECT with several medical students. When the psychiatrist asked, "Does anyone want to press the button?", the other five young men got excited. Seeing the woman convulse and then go limp, I wheeled her unconscious back down the hallway, which wasn't very reassuring for a queue. I ended up in a parking lot and threw up. Even before I knew what the research was saying about ECT, I literally had an internal reaction that something was terribly wrong. But to understand why ECT is still used today, remember that the five medical students either did not share my disgust or may have chosen to hide it from their teacher.
The acceptance of Cerletti's bizarre invention in the 1940s can best be understood if one remembers that the psychiatric "medical model" of human suffering has not yet developed effective treatments. There were hundreds of vast psychiatric hospitals full of thousands of "chronic", "incurable" patients and apparently rather demoralized, pessimistic staff.
I see what happened as a huge naturalistic experiment demonstrating the power of the placebo, including creating positive expectations in staff and ultimately in patients. In the 1940s and 1950s, many people were discharged from hospitals after ECT, sometimes after many years or even decades of confinement. This was an extremely important event, given the devastating effects of institutionalization and the belief that recovery was impossible. But the people who chose to discharge would probably be the same people who chose to prescribe ECT. The first two studies conducted in the 1950s to actually compare patients who received or did not receive ECT found lower rates of recovery for ECT recipients than those who did not, or no difference. While some critics disagreed with this work, the point is that it was impossible to make a call because there were no placebo control groups. This was a common research failure at the time, but ECT researchers had a real excuse. Due to the frequent fractures of the spine and other injuries, it was impossible to disguise the placebo.
In the early 1950s, muscle relaxants and general anesthesia were introduced, which made it possible to evaluate this new "modified ECT" by comparing it with control groups who passed out as a result of general anesthesia but did not receive ECT (mock ECT). The first such study, in 1953, which assumed that neither psychiatrists nor patients knew who received ECT, found no difference in outcomes between the two groups. By now, "antipsychotic" drugs have replaced ECT as the treatment of choice for "schizophrenia", and ECT advocates have shifted their focus to depression. In 1959, the first placebo-controlled study involving depressed patients found no significant difference between ECT and sham ECT for depression or "schizophrenia".
In the meantime, researchers have been documenting the harm. In 1946, a review in the Lancet titled "Changes in the Brain Associated with Electrical Treatment" reported massive hemorrhages in several parts of the brain. Not wanting to conclude that all the changes were due to ECT, the reviewer cited the autopsy results of a 57-year-old man who died 90 minutes after the 13th shock: “There were several small areas of devastation in the frontal and temporal lobes, the complete absence of ganglion cells ... There was diffuse degeneration of nerve cells in the cortex."
A review of autopsies over the first 20 years concluded: "In the course of the electric shock treatment, brain damage occurred, sometimes reversible, but often irreversible." Back in 1956, a "controlled study" of people over 65 found that ECT accelerated dementia. As one early commentator noted, “Given the extraordinarily sensitive electrochemical nature of the human brain, it is not difficult to recognize the overabundance of ECT…Electrical damage and destruction cannot be avoided to some extent.”
The idea that ECT causes brain damage was so obvious to early proponents that they included it in their explanation of how ECT works. In 1941, American physician Walter Freeman, best known for lobotomy, wrote about ECT:
The greater the damage, the greater the likelihood of remission of psychotic symptoms ... Perhaps it will be shown that the mentally ill can think more clearly and constructively with less brain in real work.
Freeman's paper was titled "Brain Damage Therapy".
Another American psychiatrist explained:
Organic changes must take place... for a cure to take place... I think there may be
It is true that these people at the moment, at any rate, have more intelligence than they can handle, and that the decline of intelligence is an important factor in the healing process.
The idea that brain damage could be beneficial strikes me as odd. However, variations and extensions on the theme persist into the 21st century. A 2012 study in Scotland found that ECT reduced the "functional connectivity" of the brain. Rather than caution against ECT because of this damage, the authors said it was evidence to support the theory that the brains of people with depression are "hyperconnected" and that ECT corrects this. Some psychiatrists in the Netherlands even argue that ECT can and should be used to target and erase painful memories.
Our survey found that persistent memory gaps, including weddings and birthdays, ranged from 12-55%.
As I learned years ago in a New York hospital, almost everyone experiences some combination of confusion, headaches, nausea, and muscle pain right after ECT. This usually goes away within an hour. However, most also experience some memory lapses, usually for the period immediately prior to treatment. Some lose memories of life months or years before treatment ("retrograde amnesia") and/or have difficulty remembering new information ("anterograde amnesia"). The Royal College of Psychiatrists (2020) informs the public that:
A small number of patients report gaps in their memory of events in their lives that happened before they had ECT. This tends to affect memories of events that happened during or shortly before the onset of the depression. Sometimes these memories come back in whole or in part, but sometimes these gaps can be permanent.
Unfortunately, the ECT community has not been concerned enough about long-term damage to ascertain how many people suffer from irreversible memory loss. But it's not "little".
One review identified four studies of memory loss lasting at least six months, which patients described as "permanent or permanent". They found a range of 29 to 55 percent and a weighted average of 38 percent. The most thorough study to date was conducted in 2007 by ECT proponent Harold Sakeim, a professor of psychiatry and radiology at Columbia University in New York. Six months after ECT, retrograde amnesia was generally much worse than before ECT. Importantly, the degree of deterioration was related to the number of ECTs received. Women and the elderly were disproportionately weakened. Memory loss was also greater among those who received bilateral ECT (where electrodes are placed on both sides of the head) rather than unilateral ECT (where they are both placed on the same side, thereby protecting half of the brain). Our recent survey found persistent or persistent gaps in life memories, including weddings and birthdays, somewhere between 12 and 55 percent.
Proponents of ECT often argue that memory loss after ECT for depression is caused by depression, not ECT. The review concluded that: "There is no evidence for a correlation between impaired memory/cognition after ECT and worsening mood, much less a causal relationship". Also, if depression is the cause of memory loss, how do they explain the persistence of memory loss after treating depression with ECT?
In any case, proponents of ECT dispute that the observed long-term memory loss represents "brain damage". Instead, they point to brain studies showing no clear signs of damage. Critics like myself point to other studies showing cellular, microvascular, and neuronal damage not visible on scans.
Whether we call memory loss "brain damage" or not, it's easy to find hundreds of personal reports of disabling levels of disruption to people's lives. In an email, one woman recently wrote:
Today, I'm mad at myself for agreeing to est. My long-term memory was destroyed. Memories of childhood friends, memories of major events I attended, memories of my training as a receptionist psychiatrist, academic memories, etc. I began to struggle with simple spelling and math. I basically can't remember almost three whole years (2004-06), including the relationships I was in at the time. I never told my colleagues about it because I was ashamed. But I started talking to other people who had ECT and realized that I was not alone.
And the lethal consequences? The Royal College of Psychiatrists believes that "death from ECT is extremely rare." The American Psychiatric Association reports one death per 10,000 ECT recipients, which they claim is on par with minor surgery involving general anesthesia. But this assessment
ignores the fact that the average patient will have to undergo about 10 such procedures. One of the leading causes of death from ECT is cardiovascular failure. A recent review of 82 studies involving more than 100,000 patients found that one in 50 patients experience "serious adverse cardiac events."
At a staff meeting in my very first job as a clinical psychologist in the UK, I raised the issue of a man who had died on the ECT table the day before. I still remember the psychiatrist's exact answer: "It's none of your business, and I'm personally offended by your insinuation that we killed him." When I pointed out that the man's notes said "ECT contraindicated - serious heart disease," I was kicked out of the meeting—physically. A colleague and I copied this page of notes, accurately predicting that it would be quickly removed from the file. For two years, I tried to get the hospital, professional and government agencies to investigate. I failed.
Contributed to the publication of several reviews of the research literature on whether ECT works. They all found weak evidence that, compared with placebo, ECT produced a temporary improvement in mood in a minority of patients, but there was no evidence of any benefit after treatment ended, and no evidence that ECT prevented suicide.
In the 83 years since Cerletti performed the first treatment in Rome, there have been only 11 studies comparing ECT for depression (a target group for the past 60 years) with a placebo group treated with sham ECT (S-ECT). Four of these 11 found that ECT was statistically superior to S-ECT in the short term; five found no difference; and two gave mixed results (in one of which the psychiatrists' scores made a difference, but the patients' scores did not). The only difference found after the end of the last treatment was one study, which showed that the C-ECT group felt better than the real ECT group one month after the end of treatment.
What seems surprising is that the most recent of these 11 studies was conducted in 1985. Thus, despite the unimpressive and inconclusive results of the first 11 studies, and the apparent dangers of this highly controversial treatment, psychiatry has not attempted to determine whether it actually works with a placebo-controlled study in the last 36 years.
This becomes even more disturbing when you realize how methodologically inadequate the first 11 studies were. Their average sample size (including both groups) was only 37 people. None of these are definitely double-blind studies in which neither patients nor assessors know who is in which group. Five report only some of their findings and omit others. Only four report any patient scores, and none of them have any "quality of life" scores.
The literature on ECT in general was of extremely poor quality from the outset.
Meanwhile, there have been many studies comparing different types of ECT and comparing ECT with antidepressants, which is a different question than "Does ECT work?" Our review of such studies between 2009 and 2016 concluded:
Of the 91 studies, only two were designed to evaluate the effectiveness of ECT. Both were seriously flawed. None of the other 89 provided strong evidence that ECT is effective for depression, primarily because at least 60% of ECT participants continued to take medication and 89% did not provide meaningful follow-up data after treatment ended. No studies have examined whether ECT prevents suicide.
In fact, the research literature on ECT in general has been of extremely poor quality from the outset. For example, of more than 200 studies of schizophrenia conducted with ECT between 1955 and 1960, only 10 were "deemed acceptable" in terms of meeting the minimum requirements for valid and reliable studies. Four decades later, the UK ECT Review Group (2003) reported that only 73 out of 624 studies (12 percent) met the standards for inclusion in their review and that the "quality of reporting" of 12 percent was "poor". '. For example, a study in the flagship British Journal of Psychiatry claimed that proportions showing at least "moderate improvement" were: depression, 100%; schizophrenia, 97.6%. The entire section of the methodology, describing how improvement was measured, consisted of only six words: "Progress was recorded."
However, this literature, or at least those placebo studies, have definitely taught us something. We have learned that some people who receive ECT feel better, although usually not because of the shocks or seizures, but because of the extra attention and kindness shown to them by nurses, doctors, anesthesiologists, and
other staff, and also because of the hope inspired by the expectation of all these staff members that what was to happen to them would actually make them feel better. Placebo means "I will be pleased" in Latin.
The authors of the very first placebo-controlled study noted:
It may well be that the primary therapeutic agent is the psychological significance of the treatment for the patient... The impact of the extraordinary amount of care and attention that everyone receives could be explored further.
A review focusing only on the placebo response to ECT found "an unexpectedly high response rate in the placebo groups" and concluded: "The modern ECT practitioner should be aware that placebo effects usually operate." Some of the positive outcomes of psychotherapy are due to placebo effects. I have encouraged two generations of clinical psychologists to always inspire some hope and some (realistic) positive expectations, especially in the first session. It is working. Haven't you ever felt a little better after someone you trust said, "Everything will be fine"?
DEST Saves Lives? None of the reviews I have participated in and none of the five meta-analyses (combining data from several studies) conducted by others have shown this to be the case. Several studies have shown that ECT can temporarily reduce suicidal thoughts in some participants, which is very important. However, none of them have ever found that it reduces the number of people committing suicide. In a recent study, the largest to date, 14,810 patients in the ECT cohort were 16 times more likely to commit suicide within a year of ECT than 58,369 patients in the control group. Even after adjusting for pre-treatment levels of suicidal ideation and other variables, the ECT group was still 1.31 times more likely to have committed suicide (a statistically insignificant difference).
Also, some people kill themselves because of the harm done to them by est. Memory loss is depressing. Shortly before his suicide, shortly after est, the American writer Ernest Hemingway asked: “What is the point of spoiling my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant drug, but we lost a patient."
In my latest review, with Irving Kirsch, who studies placebo studies at Harvard Medical School, I evaluated not only 11 studies (for the umpteenth time), but also (for the first time) five meta-analyses. We found that the meta-analyses, oddly enough, included between one and seven of the 11 studies and, in addition to many factual errors, paid little attention to the poor quality of the studies they relied on. In addition, none of the five meta-analyses identified any studies showing any long-term benefits or demonstrating that ECT saves lives. We came to the conclusion:
Given the high risk of irreversible memory loss and the small risk of mortality, this long-standing failure to determine whether ECT works means that its use should be stopped immediately until a series of well-designed, randomized, placebo-controlled trials can be conducted. indeed any significant benefits against which proven significant risks can be weighed.
Not only do we not know if it works, or how many people end up permanently damaged by it, we don't even know how often it is still used around the world. In the US, for example, there is no national control over numbers. The approximate figure of 100,000 people a year has become something of a mantra. We also do not know if the global use of ECT is increasing or decreasing. While use in some places, including Texas and Australia, appears to be increasing in recent times, the annual number of ECT patients in England has declined from about 20,000 in the 1980s to about 3,000 by 2006 and has since remains fairly stable.
In most of the countries studied, women are twice as likely as men to receive ECT, and the median age is around 62 years. A 170-page report from the UK National Health Service in 2005 concluded: regarding the effectiveness of ECT in ... the elderly ... and women with mental problems. This was confirmed by our recent review. However, we do know that both of these groups are more susceptible to ECT-induced memory loss.
For decades, ECT recipients, their families, and interested professionals and researchers have campaigned to restrict or ban ECT in many countries. Following the publication of our recent review calling for a suspension of ECT pending better research, a panel of 40 UK experts including psychiatrists, psychologists, researchers, ECT patients and their loved ones wrote to: Matt Hancock, British Secretary of State for Health and Social Affairs, requesting hold a wedding
required verification of the use of ECT in our country. This call is supported by many organisations, including the Royal College of Nursing, the Association of Clinical Psychologists, the National Consulting Society, the Mind (one of the UK's largest mental health charities), the Council for Evidence-Based Psychiatry and the Headway Brain Injury Association), and numerous deputies from the government and the opposition.
ECT recipients have recently filed petitions in the UK to Parliament and in the US to the American Psychiatric Association. In the meantime, a lawsuit is being prepared in the UK, with several dozen cases already involved, focusing not on memory loss and brain damage per se, but on the failure of psychiatrists to educate patients about these risks. Perhaps the courts will be more effective than research when it comes to adding ECT to the list of "treatments" that psychiatry has abandoned because the harm it brings outweighs the benefit.