Electroconvulsive therapy, once vilified, is slowly receiving greater interest and use in the treatment of mental illness
Scene: The winter of 1934, inside a state hospital for the mentally ill at Lipotmezö, Hungary.
Zoltan, a 30-year-old Budapest laborer, lay rigidly in a bed, staring into the distance. Except for his slow and regular breathing, he appeared lifeless. He had hardly spoken or cared for himself in more than four years. His mental condition of catatonic schizophrenia was considered hopeless. No remedy was available and none was sought; the doctors believed the illness to be an immutable genetic fault. At 10:30 on the morning of January 24, 1934, the Hungarian neuropsychiatrist Ladislas Meduna approached Zoltan's bed to inject an oily extract of camphor into his right buttock. Zoltan's heart soon raced, sweat rose on his brow, and he became increasingly fearful. After 45 minutes, his eyes suddenly closed, his jaw clenched, his breathing stopped, and he lost consciousness. With a deep, noisy sigh, his arms and legs extended, he convulsed, and his bed thumped rhythmically; attendants caught him just before he rolled to the floor. His skin became ashen, and he wet the bed. After 60 seconds, as suddenly as the spasm started, it ended. His eyes opened, and a pink color slowly returned to his cheeks. He continued to stare and was as speechless as before. He had survived an intentionally induced grand mal epileptic fit.
Without any guideline as to how often seizures should be induced, Meduna adopted the schedule used in the popular malarial- fever treatment of neurosyphilis. He injected camphor at three- to four-day intervals, and two days after the fifth seizure, Zoltan awakened, looked about, got out of bed, asked where he was and requested breakfast. He did not believe that he had been in the hospital for four years, and he knew nothing of the intervening history. Later that day, he again relapsed into stupor. After each of the next induced seizures, Zoltan remained alert and interested for longer and longer periods, until after the eighth injection he left the hospital to return to his home and to work. His mental condition of four years was fully relieved. Five years later, when Meduna left Europe for the United States, Zoltan was still well and working at his job.
This dramatic account of Zoltan's recovery from schizophrenia describes the first use of the technique that evolved into electroshock, also now called electroconvulsive therapy, or simply ECT. As the modern name suggests, the method now involves the use of electrical currents to induce grand-mal seizures as a treatment for mental illness. Electroshock is applied to about 100,000 patients each year in the U.S., a figure comparable to the number of appendectomies or hernial surgeries performed. Its efficacy and safety has been recognized by the U.S. Surgeon General in his Report on Mental Health, which was released in December 1999. Clinical trials on disorders other than schizophrenia have found ECT to be effective in depression, mania, delusional states and catatonia—in the elderly and in adolescents as well as adults—and it can be safely applied to patients with severe physical illnesses.
Despite electroshock's successes, it is severely restricted by legislation in several states and continues to have an undeservedly poor image in the public mind. Fortunately, there is a growing trend to restore ECT to a reasoned place in psychiatric practice. Here I provide a brief review of the history and present state of electroconvulsive therapy, and some thoughts on its mechanism of action.
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