Introduction of Electroshock Therapy

Overview

Electroshock was one of a number of "antagonist therapies" introduced in the early part of the twentieth century. Based on a belief that epilepsy and schizophrenic disorders had opposite effects on human brain anatomy, a number of physicians tried to relieve the symptoms of serious mental illness by inducing convulsions, first by chemical means and then by passing a current through the brain. Electroshock was opposed by the advocates of "talk" psychotherapy, and was largely supplanted by new tranquilizing drugs after 1950. In its modern form, drugs are used to eliminate the actual convulsion, and memory loss is minimal, so that it has become more acceptable for patients who do not respond to other treatments. The mechanism by which electroshock acts on the brain is still poorly understood.

Background

The humane treatment of the mentally ill made great strides in the nineteenth century, representing both the efforts of social reformers and a degree of progress in medical knowledge. By the year 1900, there were asylums for the mentally ill in most industrialized countries, and a number of physicians were restricting their practice to psychiatry, the treatment of mental illness. Early psychiatry recognized three major mental illnesses: dementia paralytica, now called neurosyphilis, the third stage of the venereal disease syphilis; dementia praecox, now called schizophrenia; and manic-depressive disorder, which today would include bipolar disorder and severe clinical depression. In 1900, the largest portion of hospitalized mental patients were being treated for neurosyphilis.

The microorganism causing syphilis, the spirochete Treponema pallidum, had been discovered in 1905, and a treatment effective against the early stages of the disease—injection of the arsenic-containing drug salvarsan—had been introduced in 1910 by the German medical researcher Dr. Paul Ehrlich (1854-1915). Prospects for those patients in which the disease had advanced to the third stage, however, remained bleak. Drawing on the discovery by the French chemist Louis Pasteur (1822-1895), that heat could kill many kinds of bacteria, and reports that mental patients sometimes improved after recovering from fever-producing illness, there was speculation that neurosyphilis patients could be cured by deliberately inducing fever.

With the discovery that quinine provided a cure for malaria, Professor Julius Wagner-Jauregg (1857-1940), a member of the psychiatric faculty of the University of Vienna, began injecting neurosyphilis patients with the malaria parasite, allowing the patients to experience recurring fevers for about a month before treating them with quinine. In 1918, he was able to report that of an original experimental group of patients, two-thirds experienced improvement, while none deteriorated. With this work, for which Wagner-Jauregg received the Nobel Prize in 1927, began a major effort to discover other "antagonist therapies" in which one disease might cure another.

Anecdotal reports also existed about schizophrenic patients who improved after experiencing epileptic-like seizures caused by head injury or infection. Experiments were done on epileptic patients, injecting them with the blood of schizophrenics, but without success.

Ladislas Meduna (1896-1964), a Hungarian physician, believed that he had discovered differences in brain anatomy between schizophrenics and epileptics in the 1930s. The brains of schizophrenic patients were found to have fewer cells of a certain cell type, called neuroglia, than normal brains, while the brains of epileptics were found to contain an excess of these same cells. Meduna reasoned that inducing seizures might stimulate the brain to form additional neuroglia. After experimenting on animals to find a safe method of producing seizures, he began inducing seizures in his patients by the injection of a solution of camphor in oil. He later chose the drug Metrazol to induce seizures. In 1937 he was able to report improvement in roughly half of the 110 severely ill patients on whom he had tried the procedure.

Drug-induced seizures were, however, a terrifying experience for the patient, who experienced extreme anxiety prior to loss of consciousness. The use of electrical shocks, with current passing through the brain, to induce convulsions was introduced on April 28, 1938, by Italian psychiatrists Ugo Cerletti (1877-1963) and Luigi Bini (1908- ). These physicians sought to eliminate the unpleasant preliminary effects found with drugs. Like Meduna, they did not begin experiments on humans until they had a seizure-inducing procedure that worked safely when applied to animals. A 39-year-old man suffering from a psychotic episode was the first patient. After three weeks of treatments on alternate days, the patient was considered to have recovered. By 1940, both electroshock and drug-induced shock therapies were being used on hundreds of patients a year.

Impact

The early twentieth century was indeed a period of experimentation with drastic therapies for the seriously mentally ill. Also originating in this period were insulin shock or insulin coma therapy, in which the patient is rendered unconscious by a high dose of the hormone insulin, and the operation called prefrontal lobotomy, in which some of the connections between the brain's frontal lobe and the remainder of the brain are severed. While lobotomized patients might cease to exhibit some undesirable behaviors, they would often exhibit personality changes and a reduced ability to cope with social situations. As a result, such operations have largely been abandoned today.

An alternative to the drastic physical interventions of shock therapy and lobotomy appeared to be offered by psychoanalysis, a technique introduced by the Austrian neurologist Sigmund Freud (1856-1939), and the many variations of "talk" psychotherapy that followed. Freud theorized that mental illness, except that resulting from infection or injury to the brain, was caused by the patient having repressed memories or desires, often of a sexual nature. Using a process of free association, the patient would be guided to make those repressed thoughts conscious, whereupon the troubling symptoms would often disappear. Having demonstrated that many serious psychological problems could be treated without medical intervention, psychotherapists, even those with medical training, tended to consider the more drastic treatments primitive and unnecessary. In addition, the potential of abuse inherent in the drastic therapies and brain surgery was increasingly appreciated after the treatment of political dissidents as insane in Nazi Germany and Stalin's Soviet Union became known.

The nature of the relationship between mental phenomena and the physical structure that exhibits them, the so-called mind-body, or mind-brain, problem, has stimulated philosophical discussions since the ancient Greeks. For several centuries the dominant position in Western thinking had been that of Cartesian dualism, first proposed by the great French Philosopher Rene Descartes (1596-1650), in which the mind was of a separate nature yet connected to the brain and body in some fashion. As understanding of the brain improved through experiments on animals and the observation of individuals with injured brains, more, but not all, scientists and philosophers have tended to accept the position that "the mind is what the brain does." The psychotherapists generally followed the dualist position. The advocates of the more drastic therapies, of course, were less inclined to the dualist view.

A third alternative for the treatment of serious mental illness was provided by the development of psychotropic drugs in the years following the Second World War. With the proper medications many mental patients became able to function in society. During the 1960s and 1970s many state governments passed laws restricting the practice of electroshock, which was opposed by therapists and the pharmaceutical industry. Opposition to the drastic therapies was also expressed in the popular media. In the 1975 film One Flew over the Cuckoo's Nest, the main character is subjected to repeated electroshock therapies and then surgery by the sadistic medical staff.

Since the 1970s, however, electroshock, more often called electroconvulsive therapy, has become a bit more acceptable in the United States, particularly in hospitals affiliated with medical schools. Its use outside the United States varies from one country to another. The fourth edition of the Diagnostic and Statistical Manual, published by the American Psychiatric Association in 1994, lists 18 diagnoses in which electroconvulsive therapy is believed to be effective. The illnesses listed are mainly forms of depression and schizophrenia, although a category of atypical psychosis is included. Generally, electroshock is not given unless a signed consent is obtained from the patient or (rarely) after a court has given permission. The consent form includes a description of the procedure and the likely number of repetitions, and informs the patient that he or she may discontinue treatment at any time. In modern practice the patient is sedated and given pure oxygen to breathe for the period preceding surgery. He or she is also given a muscle-relaxing drug so that the seizure occurs without violent movements. Vital functions, including brain wave activity, are continuously monitored. Modern practitioners claim that there is no significant memory loss or other injury with the current procedure.

The mechanism of electroshock therapy is not well understood, and there is little financial support for research on its use. Meduna's theory is no longer taken seriously. Current speculation centers on the release of hormones from the hypothalamus and pituitary gland, which have been shown to appear in the fluid surrounding the brain within a few minutes following the induced seizure. With a better understanding of the effect, it is possible that even less drastic forms of the therapy will be developed.

DONALD R. FRANCESCHETTI