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The History of ECT: Unsolved Mysteries

The History of ECT: Unsolved Mysteries

Following the success in 1917 of Vienna psychiatry professor Julius Wagner von Jauregg, M.D.'s, malarial-fever treatment of neurosyphilis, there was great interest in using such "physical therapies" for other neuropsychiatric illnesses as well. It was in this context of enthusiasm for treating the brain itself in mental illness on the model of neurosyphilis--rather than relying upon the resources of psychotherapy--that the convulsive therapies arose (Shorter, 1997).

Over the years these therapies--the mechanisms of which even today are unknown--have demonstrated considerable efficacy in the treatment of major depression, catatonia, mania, psychosis and other psychiatric disorders. An impressive body of opinion now holds that electroconvulsive therapy has such a demonstrated record of efficacy that it, rather than medication, should be the treatment of choice in major depression. The real question today is: Why is it not? Why does the idea of applying ECT still cause a chill among many psychiatrists and patients, who consider it only as a treatment of last resource, rather than the first-line approach?

The first of the convulsive therapies was initiated in 1934 in Budapest, Hungary. It entailed inducing convulsions with pentylenetetrazol, a compound first introduced as a cardiac drug and sold under the trade name Cardiazol in Europe and Metrazol in the United States. Psychiatrist Ladislas von Meduna, M.D., hypothesizing an antagonism between epilepsy and schizophrenia, reasoned that chemically inducing convulsions might somehow meliorate the psychotic symptoms of schizophrenia. He first tried camphor, then pentylenetetrazol, which was more soluble and acted faster (Fink, 1985). In fact, he achieved considerable results, and treatment units sprang up before World War II at a number of centers in Europe. In the United States, such disparate institutions as the Georgia state asylum at Milledgeville and the Sheppard-Pratt private clinic in Baltimore installed Metrazol units.

Yet, Meduna's convulsive treatment was quickly pushed to the margins by ECT, initiated in 1938. In one of the few Italian contributions to modern psychiatry, psychiatry professor Ugo Cerletti, M.D., inspired by the successful treatment of a rapidly accumulating list of physical disorders (including fever, deep sleep and insulin coma) resolved to induce convulsions by applying electricity directly to the brain. Like Meduna, he and his assistant Lucio Bini selected patients with schizophrenia for their trials and enjoyed a record of success (Cerletti, 1950). Their publications created a major stir in psychiatry, and in May of 1940, Cincinnati psychiatrist Douglas Goldman, M.D., demonstrated ECT at the annual meeting of the American Psychiatric Association (Shorter, 1997).

Electroconvulsive therapy spread quickly in popularity, and handbooks were not long in appearing. In 1941, Lucie Jessner, M.D., at Massachusetts General Hospital and V. Gerard Ryan, M.D., at Harvard University published Shock Treatment in Psychiatry: A Manual, the introduction written by Harry Solomon, M.D., chief of research at the then Boston Psychopathic Hospital (later Massachusetts Mental Health Center). In 1944, William Sargant, M.D., and Eliot Slater, M.D., at The Maudsley Hospital in London, themselves noted figures in English psychiatry, brought out An Introduction to Physical Methods of Treatment in Psychiatry. In 1946, Lothar Kalinowsky, M.D., who was instrumental in bringing ECT to the United States, and Paul Hoch both wrote the influential book Shock Treatment and Other Somatic Procedures in Psychiatry. Thus, major figures weighed in on behalf of the new treatment.

The U.S. military made wide use of ECT during World War II, and by the 1950s, ECT had become one of the standard treatments for hospital depression, accepted as a matter of course in U.S. and European psychiatry.

The rise of ECT in psychiatry is one of the discipline's great success stories. The technique became steadily modified. In 1940, curare was introduced to moderate the vertebrae-cracking force of the convulsions, and succinylcholine was introduced in 1952. In the early 1940s, it became customary to anaesthetize patients with barbiturate injections. In 1949, Goldman introduced unilateral ECT, placing the electrode over the right hemisphere in order to avoid the speech areas. Abrams and Taylor (1976) introduced bifrontal ECT by moving the electrodes forward over the forehead. In the 1950s, a patient hospitalized for depression stood an excellent chance of receiving ECT, and an even better chance of benefiting from it.

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