It may seem strange to use the phrase “coming-of-age” for a treatment that is more than 70 years old. However, electroconvulsive therapy (ECT) may finally be coming-of-age thanks to recent portrayals in the media.

Here I will discuss several examples of recent, reasonable depictions of ECT in the media, and I Charles H. Kellner, MD will suggest how they could represent a shift in the way that this “controversial” therapy is regarded. I use the word “controversial” advisedly, because even on the day I write this, a newspaper article on deep-brain stimulation, in which ECT is described, reads: “New reports this month show that some worst-case patients—whose depression wasn’t relieved by medication, psychotherapy, or even controversial shock treatment—are finding lasting relief.”1 Thus, the coming-of-age for ECT is, as this example indicates, still incomplete.

War and ECT

A recent New York Times article titled “War Takes Toll on Baghdad Psychiatric Hospital” was previewed on the front page.2 The article continued on the International Report page and was accompanied by 2 photographs; it chronicled the efforts of a psychiatrist to deliver decent psychiatric care in a war-devastated Baghdad hospital. The smaller photograph in the piece included the caption, “Electroshock therapy is administered with a dilapidated machine and without anesthesia,” and showed a patient receiving ECT with 3 staff members holding him down. The text tells the horrifying yet inspiring story of Dr Amir Hussain, 1 of 4 remaining psychiatrists at Ibn Rushid psychiatric hospital.

"He does his best to help his patients. Some he treats with the limited number of psychiatric drugs at his disposal. For others, patients who are suicidal or catatonic or do not respond to drugs, he prescribes [ECT], administered with a 25-year-old machine that, he says, has “technical problems.”"

"The patients are sometimes given Valium before the treatments. But because there is no anesthesiologist on staff, the shocks are delivered without anesthesia, as they were decades ago in the United States."

"Dr Hussain is acutely aware that what he has to offer is far from ideal—that the way the hospital gives electroshock therapy is “inhuman and dangerous,” that patients do not receive the panoply of special programs and therapies routinely available in other countries."

This article is important for many reasons, but here I will discuss only those that relate to ECT. My impression was that the article represented ECT fairly—something that until recently has been quite rare in the lay media. Dr Hussain described its appropriate use, and he expressed dismay that it could not be performed to modern-day standards. ECT was not being criticized, just the outmoded technique performed “decades ago” in the United States. The message was a call to perform ECT correctly; it was not the typical response of surprise that ECT is still being used or the demand for it to be eliminated.

The New York Times article raises at least 2 important questions:

  • What can we do to improve the situation it describes?
  • What should be our stance about unmodified ECT in such dire circumstances?

Both are tough questions that are beyond the scope of the current column, but they are certainly ones that should be answered.

Correcting misconceptions

Recently, the documentary “Depression: Out of the Shadows” (written, directed, and produced by Larkin McPhee) aired on public television.3 It presented patients who had serious mood disorders and provided descriptions of several treatment modalities, including ECT. One of the patients was Dr Sherwin “Shep” Nuland, the well-known Yale surgeon who had a severe, treatment-refractory episode of major depression in the 1970s and who recovered after treatment with ECT. Dr Nuland remains an eloquent supporter of ECT.

Contemporary ECT practice was covered in an interview with Dr William McDonald of Emory University using footage of one of his patients receiving the treatment and interviews with the patient and her husband. It presented a clear, favorable, and nonsensationalist view of ECT. Such portrayal is extremely helpful in educating patients and, even more important, in not scaring them away from ECT—as has been the unfortunate result of many previous media depictions.

Two recent books about ECT, Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness, by Edward Shorter and David Healy,4 and Shock: The Healing Power of Electroconvulsive Therapy, by Kitty Dukakis and Larry Tye,5 are noteworthy and should help correct some of the public misperception about ECT. The former is a comprehensive and scholarly history of ECT from its origins to the present, and it is a must-read for any mental health professional interested in ECT. From it I learned (among many other things) that the word “shock” in the out­moded name “electroshock” does not refer to an electrical shock; rather, it is a holdover from the term “insulin shock,” which refers to hypotension or circulatory collapse.

Shock is a memoir detailing Mrs Dukakis’s experiences with mental illness and her successful treatment with ECT. This book is also an informative guide to clinical ECT for patients and for those interested in facts about contemporary ECT practice in the United States.

The above-mentioned portrayals of ECT in the media, while very different from one another, are all part of a trend of viewing ECT as the mainstream psychiatric treatment that it has become, or more correctly, remained. This is a good thing for our patients because they are more likely to be open to considering it as a therapeutic option when a psychiatrist suggests it. Modern ECT is a very important therapy for treatment-resistant depression. It is still imperfect mainly because of adverse effects on recent memory and because a substantial proportion of patients relapse within months of successful ECT that was performed for an acute episode of depression.6 The field of brain stimulation is burgeoning with innovative and new experimental treatments that may replace ECT, partly or wholly. Until that occurs, ECT should be given appropriate consideration in treatment algorithms and fair portrayals in the media. The portrayals cited give us reason to hope that this may be happening.