Electroconvulsive therapy (ECT, in the past sometimes called electric convulsion therapy, convulsion treatment or electroplexy) is a controversial psychiatric treatment in which seizures are induced with electricity.Carney S and Geddes J (2003) Editorial: electroconvulsive therapy. British Medical Journal 326: 1343-4. ECT was first used in the United Kingdom in 1939 and, although its use has been declining for several decades, it was still given to about 11,000 people a year in the early 2000s.Electroconvulsive therapy: survey covering the period from January 2002 to March 2002, Statistical Bulletin 2003/08. Department of Health.

In contemporary psychiatric practice, ECT is used mainly in the treatment of depression. It is occasionally used in the treatment of other disorders such as schizophrenia. When undergoing modern ECT, a patient is given an anaesthetic and a muscle relaxant. A brief-pulse electric current of about 800 milliamperes is passed between two electrodes on the head for several seconds, causing a seizure.Lock T (1995) Appendix VI: review of ECT machines. In C Freeman (ed) The ECT Handbook. London: Royal College of Psychiatrists. The resulting convulsion is modified by the muscle relaxant. ECT is usually given on an inpatient basis; about one in five treatments are given on an outpatient basis. Treatment is usually given twice a week (occasionally three times a week) for a total of 6–12 treatments, although courses may be longer or shorter. About 70 per cent of ECT patients are women. About 1,500 ECT patients a year in the UK are treated without their consent under the Mental Health Acts or the provisions of common law.Care Quality Commission 2010 Monitoring the use of the Mental Health Act in 2009/10 : 89–93

Early years: 1938–1969

ECT was invented in Italy in 1938. In 1939 it was brought to England and replaced cardiazol (metrazol) as the preferred method of inducing seizures in convulsion therapy in British mental hospitals. Although soon established as especially useful in the treatment of depression, it was also used on people with a wide variety of mental disorders. There was large variation in the amount of ECT used between different hospitals. As well as being used therapeutically, ECT was used to control the behaviour of patients. Originally given in unmodified form (without anaesthetics and muscle relaxants) hospitals gradually switched to using modified ECT, a process that was accelerated by a famous legal case.

Origins of ECT

ECT originated as a new form of convulsive therapy, rather than as a completely new treatment.Berrios, GE (1997) The Scientific Origins of electroconvulsive therapy: a conceptual history. History of Psychiatry 8: 105-119. Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J Meduna who, believing that schizophrenia and epilepsy were antagonistic disorders, induced seizures in patients with first camphor and then cardiazol.Mowbray RM (1959) Historical aspects of electric convulsant therapy. Scottish Medical Journal 4: 373-378.

Meanwhile, in Rome, professor of neuropsychiatry Ugo Cerletti was doing research on epilepsy and using electric shocks to induce seizures in dogs.Cerletti U (1956) Electroshock therapy. In AM Sackler et al. (eds) The Great Physiodynamic Therapies in Psychiatry: an historical appraisal. New York: Hoeber-Harper, 91-120. Cerletti visited the Rome abattoir where electric shocks were used to render pigs comatose prior to slaughter. Inspired by the fact that the pigs were not actually killed by a voltage of 125 volts driving an electric current through the head for a few tenths of a second, he decided to experiment on a person. In April 1938 Cerletti tried ECT for the first time on a man who had been brought to his clinic in a confused state by police. The man was given a total of 11 treatments and recovered. It later emerged that he had had cardiazol treatment in another hospital three months previously. Cerletti called his treatment "electroshock" and developed a theory that it worked by causing the brain to produce vital substances that he called "acro-agonines" (from the Greek for "extreme struggle"). He put his theory into practice by injecting patients with a suspension of electroshocked pig brain, with encouraging results. Electroshocked pig brain therapy was used by a few psychiatrists in Italy, France and Brazil but did not become as popular as ECT. Cardiazol convulsion therapy was soon replaced by ECT all over the world. Cerletti and Bini were nominated for a Nobel prize but did not get one.

As a trace origin, galvanism may have been a more primitive form of ECT such that James Lind was among the first to suggest electroshock therapy for insanity in the late 1700s.

Early use of ECT in the UK

ECT arrived in the UK with Lothar Kalinowsky, one of Cerletti's assistants, who was on his way to the USA. Kalinowsky demonstrated Cerletti's technique at the Burden Neurological Institute (BNI) and wrote an article about ECT which appeared in the Lancet in December 1939.Kalinowsky L (1939) Electric convulsion therapy in schizophrenia. Lancet 234, 9 December: 1232-33. He said that electrically induced seizures were cheaper and easier to administer than cardiazol seizures. The first paper on ECT by British authors appeared three weeks later in the same journal.Fleming GWTH, Golla FL and Grey Walter W (1939) Electric convulsion therapy of schizophrenia. Lancet 234, 30 December: 1352-1355. Gerald Fleming, the medical superintendent of Barnwood House Hospital in Gloucester and editor of the Journal of Mental Science, psychiatrist Frederic Golla and neurophysiologist William Grey Walter (both from the BNI) described how they had tested the new method of convulsion therapy on five chronic schizophrenic patients from Barnwood House. Electrical parameters, technique of administration, seizures and electroencephalograms, but not therapeutic results, were discussed. An accompanying editorial entitled "More shocks" said that ECT "may well turn out to be a valuable step forward" but criticised Fleming's claim that the use of ECT required only minimal training, expertise and patient preparation. The editorial also queried Kalinowsky's dismissal of concerns about brain damage. "There is still a chance" it said "that the brain has nemo me impune lacessit for its motto."Editorial (1939) More shocks. Lancet 234, 30 December: 1373.

ECT soon became more popular than cardiazol convulsion therapy in mental hospitals in the UK.Mccrae N (2006)'A violent thunderstorm': cardiazol treatment in British mental hospitals. History of Psychiatry 17: 67-90. It was quickly identified as being especially useful in the treatment of affective psychosis.Brain WR and Strauss EB (1945) Recent advances in neurology and neuropsychiatry, 5th edition. London: J & A Churchill Ltd. The therapeutic value of ECT in schizophrenia was recognised as limited, but some psychiatrists saw it as useful to control the behaviour of institutionalised patients who had been diagnosed as schizophrenic. Some psychiatrists thought that ECT should be restricted to the treatment of depression;Allen C (1949) Modern discoveries in medical psychology, 2nd edition. London: MacMillan and Co Ltd. others used it in the treatment of a wide variety of disorders, for example, schizophrenia, epilepsy, neurosis, and hysteria.Hemphill RE and Grey Walter W (1941) The treatment of mental disorders by electrically induced convulsions. Journal of Mental Science 87: 257-275. It was also used on people who had suffered war trauma.Sargant W (1942) Physical treatment of acute war neurosis: some clinical observations. British Medical Journal, 14 November: 574-576. By the mid 1950s there was a 20 fold difference in the rate of ECT use in mental hospitals in the UK, and a similar difference in its rate of use in teaching hospitals.Barker JC and Baker AA (1959) Deaths associated with electroplexy. Journal of Mental Science 105: 339-348. In the 1940s and 1950s ECT machines used sine-wave current and patients were given a shock lasting a fraction of a second.

Views on ECT were generally positive in the early days of its use. The Ministry of Labour ran a recruitment campaign for psychiatric nurses featuring a picture of someone undergoing ECT.Times, February 20, 1947, p7. Barnwood House, which catered for "ladies and gentlemen suffering from nervous and mental disorders", said in advertisements that it offered "all the most modern methods of treatment including electric shock and prefrontal leucotomy".Advertisement for Barnwood House. Journal of Mental Science, January 1948, page vii. There were however dissenting voices. Cyril Birnie, the medical superintendent of St Bernard's Hospital, Middlesex, raised concerns about persistent intellectual deficits following treatment and said that mental patients were "in danger of having a pretty thin time of it".Golla FL (1940) Electrically induced convulsions. Lancet 235, January 20: 127-128.

Anaesthesia

In the 1940s and early 1950s ECT was usually given in unmodified form, that is, without muscle relaxants, and the seizure resulted in a full-scale convulsion. An anaesthetic was used by a few psychiatrists but most considered it unnecessary as the electric shock produced instant unconsciousness.Kiloh LG, Smith JS, Johnson GF (1988). Physical Treatments in Psychiatry. Melbourne: Blackwell Scientific Publications, 190-208. ECT was even occasionally used to anaesthetise patients for psychosurgical operations.Freeman W (1948) Transorbital leucotomy. Lancet 252, 4 September: 371-37.

A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones, caused by the violence of the muscular contractions during the convulsion. In the 1940s psychiatrists began to experiment with curare, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction in 1951 of succinylcholine, a safer synthetic alternative to curare, led to the more widespread use of modified ECT. A short-acting anaesthetic was usually given in addition to the muscle relaxant in order to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants. By the mid 1950s most hospitals in Britain routinely used modified ECT, although a few still used unmodified ECT or ECT with muscle relaxants but without anaesthetic. In 1957 a patient who had sustained fractures to both hips whilst undergoing unmodified ECT at a London hospital took legal action. He lost the case but it had far-reaching consequences, encouraging a debate about ECT techniques which led to the abandonment of routine use of unmodified ECT in British hospitals.Barker JC (1958). Electroplexy (ECT) techniques in current use. Journal of Mental Science 104: 1069-78. The case is also famous for having established the Bolam principle.

Intensive ECT