A New Appreciation of ECT

April 1, 2004

For decades, personal essays on ECT highlighted pain and discomfort, a dismaying loss of memory, and an indifference of practitioners who forced the treatment on unwilling patients. The attacks on ECT by popular writers in the press and in film drowned out the voices that described its benefits. However, the public testimony has slowly changed toward a greater acceptance of ECT; it is time to hearken to the testimony of these witnesses and roll back the unethical restrictions that commit our most disadvantaged citizens to unnecessary chronic illness, prolonged hospital care and even death.

For decades, personal essays on electroconvulsive therapy have highlighted pain and discomfort, a dismaying loss of memory, and an indifference of practitioners who forced the treatment on unwilling patients. It took much persuasion to assure patient cooperation. In the 1960s, the raucous testimony of ECT "survivors" focused the debate on the horrors of the treatment and away from the illness and benefits. Sadly, legislators and psychiatric leaders hearkened to the ranting, and laws were passed restricting the use of ECT. Despite the limitations, increasing numbers of patients who developed "therapy-resistant depressions" from the inherent limitations of medicines encouraged another look at ECT.

Personal essays about ECT have changed their tone. Professionals who believed that they would never be subject to this outmoded and primitive treatment have experienced it and then testified publicly to their experience, changing the public rhetoric.

Norman Endler, a Canadian professor of psychology, described a severe episode of depression that failed to respond to medications and that also induced severe side effects (Endler, 1982). Electroconvulsive therapy was recommended. Chagrined that a clinical psychologist should need a somatic psychiatric treatment, he sought help in another city. He described his experience:

A needle was injected into my arm and I was told to count back from 100. I got about as far as 91. The next thing I knew I was in the recovery room. ... I was slightly groggy and tired but not confused. My memory was not impaired. I certainly knew where I was. ...

After about the third or fourth treatment, I began to feel somewhat better. ...

My last ECT session was the next morning [September 16th, treatment 6], and that evening my wife and I went to a symphony concert. ... On the next Wednesday, September 21, I taught my first class; I also played my first game of tennis in more than three months and won. That night my sex drive returned--my holiday of darkness was over. ...

In a postscript, Endler wrote:

Negative attitudes about ECT die hard. A few months later ... I phoned another friend who is a professor of psychology and a clinician. ... When we met I told him about my depression and about ECT. His response was 'Oh, my gosh! How could you let them do this to you, Norm?'

The disbelief that a rational, educated scholar would allow himself to be subjected to this primitive treatment is repeated by Martha Manning, an American psychologist and psychotherapist (Manning, 1994). She became depressed, failed to respond to insight therapy, eventually realized that she fulfilled the criteria of major depression and reluctantly concluded that the depression was not psychologically determined, but had a biological--probably hereditary--origin. Antidepressant and sedative drugs gave troublesome side effects and only temporary relief. Thoughts of death and suicide became more and more intrusive. She was hospitalized and recovered with a course of ECT. Her colleagues and friends were prejudiced against her decision for medication and ECT, and in reminiscence, she wonders why the attitude is so dissimilar to another electric treatment, that of electroconversion of a cardiac arrest, which is also life-saving. She wrote:

Telling people I've had ECT is a real conversation killer. People seem more forthright these days [1995] about discussing depression. Hell, the cashier in the grocery store told me yesterday that she's on Prozac. But ECT is in a different class. For months I have glossed over ECT's contribution to the end of my depression in my conversations with most people. But lately I've been thinking, 'Damn it. I didn't rob a bank. I didn't kill anybody. I have nothing to be ashamed of.' I've started telling people about the ECT. My admission is typically met with uncomfortable silences and abrupt shifts in topics.

An acquaintance at a party is outraged. 'How could you let them do that to you?' I bristle and answer, 'I didn't let them do it to me. I asked them to do it.'

Manning returned to a successful clinical practice and the care of her family.

Yale University professor of surgery and noted author Sherwin P. Nuland, M.D., (2003) recently related his experience in the early 1970s:

From my late thirties until my early forties, I underwent a period of depression that gradually deepened into an intensity that I finally required admission to a mental hospital, where I stayed for more than a year. Neither medication, psychotherapy, the determined efforts of friends nor the devotion of the few people whose love never deserted me had even the most minimal beneficial effect on my worsening state of mind. Finally, faced with my resistance to all forms of treatment till then attempted, the senior psychiatrists at the institution in which I was confined recommended the draconian measure of lobotomy.

I was, in fact, completely disabled by pathological preoccupations and fears. Obsessions with coincidences; fixations on recurrent numbers; feelings of worthlessness and physical or sexual inadequacy; religious anxieties of guilt and concerns about God's will; ritualistic thinking and behavior--they crowded in on one another so forcefully as to occupy every lacuna of my mind. I cowered before them, not only emotionally but physically, too--my hunched-over posture reflected my decline into helplessness.

I was saved from the drastic intervention of lobotomy by the refusal of a twenty-seven-year-old resident psychiatrist assigned to my case to agree with his teachers. At his insistence, a course of electroshock therapy was reluctantly embarked upon. I would learn later that virtually everyone familiar with my case despaired of the possibility of recovery.

At first, the newly instituted treatment made not a whit of difference. The number of electroshock treatments mounted, but still no improvement took place. The total would eventually reach twenty. Somewhere around the middle of the course, a glimmer of change made itself evident, which encouraged the skeptical staff to continue a series of treatments they had begun only to mollify a promising young man in training. I recovered so well, in fact, that in the four remaining months of hospitalization, I lost all but the dimmest memory of the obsessions and saw my depression disappear entirely.

Nuland returned to surgery, teaching and writing and, in the decades since, has written widely acclaimed books. His symptoms were evidence of an agitated psychotic depression with obsessional features, a condition that is eminently responsive to ECT. The obsessions, in all probability, led to the consideration of psychosurgery. A tragedy was averted by the courage of a subordinate physician in standing up for his beliefs.

The most recent physician witness to the tragedy of manic-depressive illness is Leon Rosenberg, M.D., former dean of Yale Medical School, head of pharmaceutical research for Bristol-Myers Squibb and now professor of molecular biology at Princeton University (Rosenberg, 2002). In 1998, around his 65th birthday, awakening in an agitated state after restless nights of insomnia, he attempted suicide by drug overdose. He was admitted to the closed ward of a psychiatric hospital. Electroconvulsive therapy was prescribed: "However groggy I still was, I registered surprise. I thought that ECT had been abandoned years before." Treatment began:

After the fourth ECT, I was noticeably less depressed. My appetite returned, as did my ability to sleep. After eight treatments, my mood was fully restored. I experienced no confusion, memory loss, headache, or any other symptom sometimes attributed to ECT. I felt so well that, with some trepidation, I prepared to go back to work.

Lithium (Eskalith, Lithobid) continuation sustained the benefit. He decided to bear witness.

I now understand that I was brainsick ('diseased of the brain and mind') when I tried to kill myself. I view my suicide attempt as the end result of mental illness in the same way I view a heart attack as the end result of coronary artery disease. Both are potentially lethal, both have known risk factors, both are major public health problems, both are treatable and preventable, and both generate fear and grief. But the shame associated with them differs greatly. Heart attack victims are consoled ('Isn't it a pity?'); suicide victims are cursed ('How could he?').

Rosenberg's illness began at age 26 when, after finishing two years of residency training in medicine, he suffered episodes of crying for no obvious reason, his sense of self-worth evaporated and he lost pleasure in his family. The funk lasted several weeks. A second episode and others were precipitated when he made professional moves:

Some of my depressive bouts would last a month, others hung on for two or three. I felt like everything--movement, thought, speech--took more energy. I had trouble connecting with either my family or my associates.

On the other hand:

I liked the way my mind worked during the long intervals when I wasn't depressed. I could work 16 to 18 hours daily, write papers quickly, make original scientific connections, speak articulately, and interact with associates and family pleasurably.

In an aside, Rosenberg commented:

Because ECT is offered at a relatively small number of hospitals, I find myself wondering what would have happened to me had I not been referred to one of them.

As a leading academic, Rosenberg decided that going public about his treatment could help destigmatize both mental illness and ECT.

The application of ECT to public figures is not limited to these reports. Kitty Dukakis, the wife of former Massachusetts governor and former presidential candidate Michael S. Dukakis, was under continuing care as of July 2003 (Smith, 2003). The pianist Vladimir Horowitz, New York Philharmonic tympanist Roland Kohloff, and TV personality Dick Cavett have each credited ECT with their return from illness (Fink, 1997).

Similar reports of the benefits of ECT dot the early professional literature. A practicing psychiatrist received ECT as an outpatient and was able to continue working throughout two courses of treatment. He was "not at all seriously hampered by memory loss or disabled in any other way," but for some time, had difficulties in finding his way around the Underground public transportation system of London. At the end of about two months, the gaps in his memory had been completely closed (A practicing psychiatrist, 1965).

Another practicing psychiatrist was barely rescued from suicide and had an excellent remission after ECT (Anonymous, 1984). Symptoms of psychomotor retardation and difficulties with memory, concentration and intellectual functioning were relieved. He had been able to work to his potential and reported no impairment in memory or concentration. Apart from minimal, transient memory impairment, the ability to learn, retain, and use new material was not disturbed.

But these reports were overwhelmed by the public literature. Sylvia Plath's autobiographical novel The Bell Jar (1996) relates her experience with ECT:

Then something bent down and took hold of me and shook me like the end of the world. Whee-ee-ee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant. ...

I wondered what terrible thing it was that I had done.

A glaring example of the abuse of electroshock (and presumably leucotomy) is dramatically presented in the play by Dale Wasserman and Ken Kesey, One Flew Over the Cuckoo's Nest: A Play in Two Acts (1970). The protagonists noted:

Harding: (Quietly) All right, friend, what would you have us do?
McMurphy: Raise jack, Tell 'er to go to hell!
Cheswick: (Jeering) Try it, buddy. They'll ship you right up to Disturbed.
Scanlon: Or down to the Shock Shop.
McMurphy: The which?
Harding: Electro-Shock Therapy my friend. A device which combines the best features of the sleeping pill, the electric chair and the torture rack.
McMurphy: You kiddin' me?
Scanlon: (Touching his temples.) Hell, no.
Harding: (With malicious relish.) They strap you to a table. You are touched on each side of the head with wires. Zap! Punishment and therapy in one shocking package. Chief Broom, there. He's had two hundred treatments.
McMurphy: What about the little fart of a doctor?
Harding: Oh, she requires his approval. But that's a formality. He's got two hundred patients, a bleeding ulcer, and no desire to make waves. The nurses run these looney bins. (With malice.) What's the trouble, friend? Losing your revolutionary spirit?

The complaints of government economist Marilyn Rice were highlighted in a widely acclaimed article titled "As Empty as Eve" in The New Yorker (Rouech,, 1974). In reporting Rice's story, author Berton Rouech, paid little attention as to why she was hospitalized and ECT was recommended, but highlighted her complaints of memory loss, casting a shadow over ECT. Rice apparently recovered from her disability and returned home:

I went back to work in July. The rest at home and some sessions with a sympathetic psychotherapist had done me good, and I felt almost like my old self again.

I came home from the office the first day feeling panicky. I didn't know where to turn. I didn't know what to do. I've never been a crying person, but all my beloved knowledge, everything I had learned in my field during twenty years or more, was gone. I'd lost the body of knowledge that constituted my professional skill. I'd lost everything that professionals take for granted. I'd lost my experience, my knowing. But it was worse than that. I'd felt I'd lost my self. I fell on the bed and cried and cried and cried.

She continued in psychotherapy:

I was still seeing my psychotherapist. ... I asked him about recovering my memory through hypnosis. ...

He was a Freudian psychoanalyst at heart. He got me talking--to blubbering out a sort of intellectual life history. ... All I wanted was a kind of parlor trick. I wanted him to pull my memory back. All he wanted was to analyze me. ... He said he could help recover an emotional memory loss--but not a loss from brain damage.

At the end of the article, Rice admitted:

I believe the electric-shock literature is right in one regard. My brain may be damaged insofar as part of my memory has been erased, but my mentality is certainly not impaired. I can still use my mind.

But I don't want to sound like a pill. ... I mustn't give the impression that my experience with electric shock was a total disaster. There have been some beneficial results. For one thing, my physical health has improved. I'm beginning to eat again, my digestion is much improved, and I have no trouble with sleep. I also feel emotionally relaxed. And I've lost a lot of bothersome inhibitions.

In the PBS/BBC supported series Madness (1991), neurologist, playwright, author and operatic impresario Jonathan Miller presented an extensive history of mental disorders. In "Brainwaves," he discussed somatic treatments of the mentally ill, from the pre-19th century restraint chairs, chains, douches and isolation chambers to insulin, electroshock and leucotomy of the first half of the 20th century, and their replacement by psychotropic drugs in the last half of the century. Miller is particularly harsh in his castigation of psychiatrists and the use of somatic treatments. In the voice-over, the following statements set the viewer's tone:

[E]lectroshock, a controversial procedure ...

The administration of an electric shock through the skull is a comparatively crude assault on the brain. ...

[A]s machines were invented to whirl, swirl, shock, rock, and douche the patient back to sanity, the sick brain was treated to a series of traumatic assaults presumably in the hope that its distorted parts would be jolted into place. ...

[T]he treatments resulted in violent convulsions with serious bruising fractures of limbs and spine and other atrocious consequences. ...

[D]espite [ECT's] understandably sinister reputation, ECT, Metrazole and insulin have much more in common with the whirling chairs and rotating cradles which they superseded, in that they were addressed to the brain as if it were a single undifferentiated organ.

Miller excoriates all aspects of modern psychiatry with equal disappointment.

These hostile pictures of psychiatry and especially of shock therapy led to the legislation that interdicted ECT in California in 1973 and Texas in 1993, and regulated its use in other states. Historian Edward Shorter, Ph.D., asked in this series, how did it come about that an effective and safe treatment was so stigmatized as to preclude its use for the many chronic mentally ill for whom it may be a benefit (Psychiatric Times February, pp93-96)? The attacks on ECT by popular writers in the press and in film drowned out the voices that described its benefits.

The public testimony has changed; it is time to hearken to the testimony of these witnesses and roll back the unethical restrictions that commit our most disadvantaged citizens to unnecessary chronic illness, prolonged hospital care and even death.