Meanwhile, new guides to the procedure were in the offing. In 1979, Fink wrote the first ECT textbook for the generation that had sat on the sidelines. In 1988, Richard Abrams, M.D., published Electroconvulsive Therapy, a work that entered its 4th edition in 2002. In 1994, the APA offered Laurence B. Guttmacher, M.D.'s, Concise Guide to Psychopharmacology and Electroconvulsive Therapy.
So why has ECT not been fully rehabilitated? Why was the New York Times able to run a front-page article on the treatment of depression without a single mention of ECT? Indeed, commenting on the fact that only a small percentage of general hospital inpatients with major depression receive ECT, an editorial by Harvard's Carl Salzman, M.D., in the January 1998 issue of the American Journal of Psychiatry expressed bewilderment that it was not more widely adopted.
Electroconvulsive therapy had changed from being a first-line treatment of depression in the 1940s and 1950s to merely an approach to treatment-resistant depression in the 1990s. (Fink refers to "therapy-resistant depression" as a euphemism: It should be called, in his words, "inadequately treated" depression.) An article in the May 22, 2001, issue of The Medical Post noted that the competence of young psychiatrists in ECT was falling. The likely reason: Few of their teachers, trained in the fallow period of 1960 to 1980, felt comfortable with it.
Finally, there is the firm but silent resolution of industry not to include ECT in drug trials, satellite symposia and industry-sponsored meetings. The logic seems clear to me: ECT would show superior efficacy to whatever they have to offer, and they prefer to keep it out of scientific discussion. I once, rather puckishly, asked a drug company to support a conference on ECT and received a scrawled handwritten reply from the head of psychopharmacology saying basically, "Are you kidding?" Requests from senior psychiatrists to include papers on ECT at industry-financed meetings are routinely refused.
Are there comparable examples in medical history of an important treatment suddenly disappearing for cultural reasons? Possibly the vaccination riots of the 19th century held back that treatment's progress for a bit. Yet, to put the downplaying of ECT in perspective: It is as though penicillin had entered a fallow period because of opposition from Christian Science, then experienced difficulty struggling back from the precipice, despite compelling clinical data.
What accounts for the ongoing reluctance of a profession that now prides itself as having rejoined scientific medicine? The answer is that psychiatry remains infused with the kinds of cultural fears and prejudices that other specialties are able to insulate with the firewall of evidence-based medicine. The reality is that the culture we inhabit still fears ECT, just as many still fear vaccination. Clinicians are reluctant to recommend ECT to patients to avoid upsetting them with the fearsome words and thus break the therapeutic alliance.
Yet, we are not dealing with copper bands for rheumatism here. We are dealing with life-shattering illnesses, such as melancholic depression, mania and catatonia. A treatment of proven safety and reliability is within reach for them. It is madness not to use the full resources of scientific medicine.