GE: One of the claims you make is that ECT does indeed work, but you also point out that historical research shows that the methods of assessing the effectiveness of treatments have changed significantly over time. So, what does the history of ECT and the debate surrounding it tell us about how we might measure progress in psychiatry?
JS: Historians of medicine have shown that the meaning of whether a therapy “works” changes. It is an appealing idea to historians, because change over time is our sacred specialty. It is short step from there to finding all therapies equal, provided they work in their historical context. I worry there may be costs to taking that step.
Many historians have also criticized “progress narratives” in medicine. And with good reason—many depictions of progress had been too linear, and implied inevitability of progress, even as they celebrated the Great Doctors whose genius produced the results. But simply debunking progress narratives is not enough, if you believe—as I do, and as most people do —that medical progress is possible.
ECT is interesting here because of its image as a remnant of a period of barbaric psychiatry, despite its reputation among many psychiatrists as possibly psychiatry’s best treatment. I was often urged by colleagues not to comment on whether ECT worked. That, they said, is not a historical question. But would a historian of penicillin for infections, or aspirin for pain, or insulin for diabetes, be asked to refrain from judgment about whether these treatments work? Of course not, because their historical meaning is steeped in their efficacy.
The efficacy of ECT is its power to remit symptoms of some severe mental illnesses (SMIs). This is not the same as cure, but permanent cure for SMI remains elusive. Psychiatry is hardly unique in medicine in this regard. In this sense, ECT’s efficacy has been recognized over 8 decades. During this period, the scientific standards for showing clinical power changed dramatically, as randomized trials became the gold standard of clinical evidence. ECT’s efficacy is also recognized by the everyday working experience of doctors. And much patient testimony tells us that it works—even testimony from patients embittered by adverse effects. It’s telling that few of even the most vehement critics of ECT deny that it works, and they focus their criticism on whether it is worth the costs it might exact.
For these reasons, I consider the case for efficacy very robust. And if that’s true, then there is progress in psychiatry, just as there is in other branches of medicine. I doubt anyone familiar with the treatments for SMI that were used before ECT would advocate returning to them.
Dr. Eghigian is Associate Professor of Modern History and former Director of the Science, Technology, and Society Program at Penn State University, University Park, PA, and Section Editor for Psychiatric Times History of Psychiatry.
1. Hirshbein L. Electroconvulsive therapy, memory, and self in America. J Hist Neurosci. 2012;21:147-169.