Electroconvulsive Therapy

   (ECT)

   (from 1938)

   Although medicine had known applications of electricity for mental symptoms since the late eighteenth century, only in the mid-1930s did the accelerating interest in somatic therapies sparked by the success of insulin coma therapy and convulsive therapy with Metrazol cause Ugo Cerletti (1877–1963), professor of psychiatry in Rome, to start thinking about the therapeutic induction of convulsions with electricity. After he and three of the assistant physicians in his clinic—Ferdinando Accornero (1910–?), Lucio Bini (1908-1964), and Lamberto Longhi (1909–?)—had established the safety of the procedure through animal research, on April 20, 1938, they treated the first psychiatric patient with ECT, a forty-ish man with schizophrenia of recent onset who responded well to a series of shocks over the next few days. Cerletti wrote up the findings in an article entitled "Electroshock" ("L’Elettroshock") in the General Archives of Neurology (Archivio generale di neurologia) in 1938. It was not the effectiveness of convulsions as such that these Italian investigators established, for countless applications of Metrazol (Cardiazol) had already clinched the point that convulsive therapy was effective, but rather, as American ECT researcher Richard Abrams (1937–) puts it, "that such convulsions could be induced safely, reliably, and inexpensively by electrical means" (Electroconvulsive Therapy, 4th ed., 2002, p. 6).

   In diffusing news of the effectiveness of ECT, a refugee German physician named Lothar Kalinowsky (1899–1992)—his mother was Jewish—who had been an assistant in Cerletti’s clinic, played a key role, helping to establish its use in England in 1939 at Warlingham Park Hospital in London. Though Kalinowsky did not introduce it to the United States, he became a central figure in demonstrations of it at the the New York State Psychiatric Institute. (Who introduced ECT to the United States remains controversial. According to psychiatry historian Walter Barton it was Cincinnati psychiatrist Douglas Goldman [1906–1986] in 1939. Goldman was clinical director at Longview State Hospital. Many authorities give credit to David J. Impastato [1903–1986] and Renato J. Almansi [1909–2000] at Columbus Hospital in New York City in February 1940.) Later, the main individual behind the diffusion of ECT in the United States was Max Fink, who learned the technique in the Army during the war and in 1952 began using it as a resident at Hillside Hospital in Glen Oaks, New York.

   To moderate the risk of fracturing vertebrae during a convulsion, in 1940 Omaha psychiatrist Abram Bennett (1898–1985) suggested in the Journal of the American Medical Association the drug curare as a way of blocking the nerve–muscle junction. This gain in safety permitted the expansion of ECT to larger numbers of depressed patients. Almost from the beginning, clinicians started administering barbiturate anesthetics to reduce patients’ anxiety, particularly in partial seizures, and to diminish the force of the grand mal seizures, in which the patients were at risk of spinal fractures. In 1942, Impastato and Almansi described in the Journal of Nervous and Mental Disease the use of phenobarbital and Sodium Amytal in order to "overcome the most dreaded complication of the method—fractures of the spine or limbs" (p. 400). In 1952 two Swedish researchers, Carl Gunnar Holmberg (1919–) and Stephen Wilhelm Thesleff (1924–) at the Karolinska Institute in Stockholm, proposed in the American Journal of Psychiatry using the less risky drug succinylcholine as a means of preventing spinal fractures.

   In 1978, the American Psychiatric Association (APA) issued its first timid acceptance of ECT in a report on Electroconvulsive Therapy. Following a consensus conference on ECT in 1985 at the National Institute of Mental Health, in the late 1980s the APA convoked a new Task Force on ECT, endorsing it more enthusiastically in The Practice of Electroconvulsive Therapy: Recommendations for Treatment (1990). In 1999, the APA reconvened its Committee on ECT (formerly the Task Force), and in 2001 issued a second edition of its 1990 report. The committee noted that, "The clinical literature establishing the efficacy of ECT in specific disorders is among the most substantial for any medical treatment." They concluded, "Severe major depression with psychotic features, mania . . . and catatonia are conditions for which there is a clear consensus favoring early reliance on ECT" (pp. 5–6).

   When ECT is properly administered, about 85% of patients with serious depression respond to it. In 2003, assessing the effectiveness of ECT in a series of depressed Israeli patients, Bernard ("Benny") Lerer (1948–), director of the Biological Laboratory of Hadassah University Hospital in Ein Karem, Israel, said to a journalist from the newspaper Haaretz, "Have you ever asked yourself how it is that a treatment with such a terrible stigma, a treatment that the public is afraid of and is said to be primitive and unhelpful—has, despite all this, survived into the 21st century, and not in obscure little places but in the world’s most advanced medical centers? The answer is simple. Because it works."