GE: At one point, you state that “fear of ECT derives not simply from prejudice, but from a social memory of uses that were fearsome.” What do you mean by this?
JS: Most lay people have been exposed to negative images of ECT. These include ECT being used as a form of discipline in mental hospitals, for example. These images, often from movies, are not based on fantasy. On the contrary, there is plenty of evidence that ECT really was used to enforce order on wards. Another example: many people know, at least vaguely, that ECT was once used to “treat” homosexuality. This is probably best known and remembered by gay communities. This practice was traumatic for some gay people who experienced it, and they are right to regard it as part of medicine’s misguided history of trying to alter people’s sexuality. There are lots of other examples.
GE: I think one of your most interesting chapters is titled “The History of a Side Effect.” In what ways do “side effects” have histories, and how is this illustrated in the history of ECT?
JS: Historians of medicine have shown that illnesses, symptoms, and treatments have histories—meaning that they are shaped by their context and are not simply physiological—though the facts of physiology can never be ignored. I wanted to show that the same is true for adverse effects. The main adverse effect of ECT is memory loss, and while the common short-term losses of memory of events close to the treatment are usually considered minor, permanent retrograde losses are possible. When they occur, they are a very disturbing effect of the therapy, even for patients who express deep relief because of symptom remission. This adverse effect has a history in at least 2 senses.
First, it has an intellectual history, in the clinical science. The problem of memory loss has been studied virtually since the inception of ECT—which is curious in itself if the therapy is as harmless as some of its strongest proponents claim. What struck me most about this history was how inconclusive it is. Some advocates are convinced permanent retrograde losses are rare, and some critics are convinced they are very common. But many researchers have stressed how elusive certainty has been.
The second sense is experiential, from the perspective of people who have undergone the treatment. Here, complaints about memory loss seem to appear more in recent patient accounts than they do in earlier ones, even as techniques of treatment have been developed for the very purpose of lessening the risk. This may simply be an artifact of the growth of illness memoirs, making more evidence available. It could also reflect how awful some of the more serious adverse effects were before the use of anesthesia and muscle relaxants became widespread.
Historian Laura Hirshbein1 has proposed that it might be related to an increasing emphasis on cognition in an information-based society, and I support this hypothesis too. But I also propose that it may be due to changing expectations of medicine: that as a society we have become more accustomed to therapies with more specific effects. None of these hypotheses are easy to prove empirically. I do think the narrative evidence shows that permanent losses may be more common than some clinical manuals allow. Given how traumatic these losses are when they occur, clinicians should keep this in mind. The public reputation of ECT is still precarious, but downplaying the possibility of adverse effects may actually do it more harm than good.
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.