The Shady World of Shock Treatment

“Woe unto them that call evil good, and good evil; that put darkness for light, and light for darkness…” (Isaiah 5:20).

Shock treatment is also called electroconvulsive therapy, ECT, electroshock, or, simply, shock. In the procedure, electricity is passed through the brain in order to create a seizure. In modern times, the person receiving it is under general anesthesia. There is no specific theory that explains why shock treatment would be helpful, and its effects on the brain are not fully understood.

Beginnings Under Fascism

In the late 1700s, the inventor of the term “psychiatry”—German physician Johann Christian Reil—theorized that the mentally ill could be “frightened” or “shocked” back to health by means such as a sudden dunking in cold water or shooting off a cannon behind their backs.

While the treatment changed, the name “shock” stuck. Based on a mistaken assumption of an antagonism between epilepsy and schizophrenia, shock treatment (a convulsion induced by chemical or electrical means) became more commonplace in the first part of the 20th century. Manfred Sakel was the first to try the new method with insulin, followed by Ladislas Meduna with Metrazol. But too many were dying from insulin, and too many complained of pain from Metrazol.

Two Italian physicians, Ugo Cerletti and Lucio Bini, wanted to try electricity.  Cerletti feared it would be fatal until he learned that pigs shocked prior to slaughter didn’t die of the current. Bini had a way of shocking dogs that didn’t kill them, either, but not without finding widespread brain damage. Nevertheless, Cerletti went ahead with the first human trial.

The year was 1938, Italy was under the control of the fascist dictator, Benito Mussolini, and mental hospitals were overrun by patients. As Fink put it in his 2009 guide for professionals using shock therapy, “Lacking effective remedies, they permitted many experimental and unsafe interventions.”

Police found a man wandering in a train station and saying strange things, and they brought him to Cerletti and Bini. Bini described what they did with him: “The patient’s…arms are tied… [On the temporoparietal areas] …two rectangular electrodes are placed…1st time 80 volts for 1/4th second. Alternating current for the induction is allowed to flow…The patient immediately presents a tonic spasm [i.e., contraction] of all the muscles of the trunk and limbs…The experiment is repeated with a current of 80 volts for ½ second…The patient…makes us aware that he perceived the current as an unpleasant sensation and does not want to try a third time…After fifteen minutes it is repeated for a third time.” Richard Abrams, M.D. said the man’s words really were, “Not again; it’s murderous.”

A foremost critic of psychiatry, Thomas Szasz, M.D., had this to say about the first shock treatment: “S.E. [the subject] was a complete stranger to Cerletti, whose help he did not seek (and whose intervention he later rejected)… Although sent to the hospital expressly ‘for observation,’ Cerletti flagrantly disobeyed the instructions of the Police Commissioner of Rome: instead of observing S.E., he used him as an experimental subject… Cerletti does not mention having obtained permission for his experiment from anyone.”

Today, the first shock treatment would be condemned as a violation of the Nuremberg Code, which was drawn up after World War II in response to Nazi atrocities and prohibits experimentation on human subjects without their informed consent. Likewise, U.S. law prohibits human experimentation without consent.

Shock Comes to America

Lothar Kalinowsky was among the foremost advocates of shock treatment from its earliest days. He was born in Berlin in 1899, received his M.D. from the University of Berlin in 1922, and worked in Italy under Cerletti before coming to America. Kalinowsky and Paul Hock wrote Shock Treatments and Other Somatic Procedures in Psychiatry in 1946, which described ECT in a favorable light long before anything was known about its long-term effects.

While still in its infancy, shock was already widely used in state hospitals. According to the National Institute of Health (NIH): “[A]s… occurs with new therapies, ECT was used for a variety of disorders, frequently in high doses and for long periods. Many of these efforts proved ineffective, and some even harmful.” Often, according to Peter Breggin, it was used to control “difficult, unruly or uncooperative” patients.

Back then patients weren’t given anesthesia to put them to sleep or a muscle relaxant to prevent their bones from breaking. According to the NIH, fractured vertebrae were common, with up to 40% of patients experiencing “complications” from the procedure.

Even in 1947, the Group for the Advancement of Psychiatry concluded, “Abuses in the use of electro-shock are sufficiently widespread and dangerous to justify consideration of a campaign of professional education in the limitations of this technique, and perhaps even to justify instituting certain measures of control.”

The public was given a taste of what the shock treatment of the day was like in the 1975 Milos Forman film (based on Ken Kesey’s 1962 novel) One Flew Over the Cuckoo’s Nest.

A statue of Ken Kesey, author of “One Flew Over the Cuckoo’s Nest” (Photo courtesy of Michael Sturman)

In truth, according to Jonathan Sadowsky (author of a recent textbook on the long controversy over shock therapy), “[T]here was nothing that happened  [in the film] that could not have happened…The remote physicians, vengeful staff, and especially the vengeful use of ECT was all completely plausible.”

And that was hardly the end of it. As Jean Dietz wrote for The Boston Globe in 1972, “[E]lectroconvulsive therapy has had no public surveillance and practically no scientific scrutiny… [T]here are no regulations at all about how much voltage may be used, how often treatments may be given, age of patients, or whether the treatment is appropriate to diagnostic findings…[Shock Doctors] use the treatment indiscriminately without appropriate diagnosis or follow up care as long as the patient or insurance company pays.”

Dietz wrote that fifty years ago. But it’s doubtful much has changed. Now, all that most states require is “informed consent.” But what Shock Doctors tell their patients is up to them. Many use the consent form in the American Psychiatric Association’s (APA’s) The Practice of Electroconvulsive Therapy, 2nd Ed. While it states that long-term memory loss following ECT has been reported, it doesn’t indicate it’s anything to be concerned about. The worst part is most people believe whatever their shock doctors tell them.

Lies, Lies, Lies

Shock took a major hit with the introduction of new tranquilizers and antidepressants in the 1950s. It also had an ugly reputation from the antipsychiatry movement, the media, and Cuckoo’s Nest.

For shock doctors and device manufacturers (collectively, “the industry”), it meant so much money down the drain and an uncertain future. But what could they do? One of shock’s greatest problems was that so many people believed it caused brain damage and long-term impairment. Suppose the industry did a large scale, scientific study of long-term memory deficits following ECT, and it turned out their critics were right? From a purely selfish business point-of-view, why take the risk? As it turned out, the industry chose instead to “sell” shock to the public with the help of the APA.

And what did they have to “sell”?

There were the anesthesia and muscle relaxant. Before, as soon as the current was turned on, patients went into major convulsions which could break bones. But the muscle relaxant paralyzed their muscles and prevented them from breaking. And the anesthesia kept them from experiencing terror when the muscle relaxant stopped them from breathing.

It’s common knowledge that an electric current strong enough to produce a convulsion would kill brain cells. In a 2009 book, Linda Andre revealed that while the industry claimed the new procedure used “less electricity,” anesthesia increased the current needed to produce a convulsion. They claimed brief pulse technology also used “less electricity.” Yet, it used more, because there was an increased number of pulses per second and the current was applied for longer. Then they claimed unilateral electrode placement (i.e., both electrodes on the same side) “reduced current”. At the same time, though, treatment effectiveness was reduced and more current required to produce a convulsion.

Another false claim was that suicide risk is a “must” reason for ECT. But after reviewing studies on shock and suicide, Peter Breggin found that none supported the industry’s claim that shock reduces suicide risk in any diagnostic group. More recently, Munk-Olson in 2007 and Peltzman et al. in 2020 failed to show that ECT reduced suicide risk.

The top prize, though, goes to the APA for its claim in 2001’s The Practice of Electroconvulsive Therapy that there is “no evidence for brain damage” from ECT. This flies in the face of a host of animal, autopsy, and other studies and an untold number of patient complaints.

Likewise, a recent lawsuit points in a different direction from the APA. Somatics, a major manufacturer of shock devices, settled with the plaintiffs in Jose Riera v. Somatics, who alleged brain injury and impairment due to their shock devices. Moreover, Somatics issued a warning that their devices can “cause permanent brain damage.” The other major manufacturer of shock devices, Mecta Corp. had to file for bankruptcy when it was denied insurance after so many lawsuits were filed against it.

Count the Victims!

Before the first shock treatment was given, lobotomy was performed by Egas Moniz. Large fiber tracks of the brain were cut, not knowing what would happen. It took years before the medical establishment admitted how destructive lobotomy could be. The damage from ECT is frequently located in the frontal and temporal lobes, but as with lobotomy, there is no way of knowing beforehand what the specific damage will be from ECT—something like Russian Roulette!

How many do have serious problems after receiving ECT?

Rose et al. (2003) searched the published literature to find how shock patients viewed their experiences in a study commissioned by the UK National Health Service. Long-term memory loss was reported by at least a third. Estimates ranged from a low of 12% to a high of 55%.

The problem with self-report studies, though, is they can be misleading. Patients may be unaware of their own deficiencies or make up things. Responses to follow-up can depend on whether it’s done by someone from a treatment facility or outside. Those who choose to participate may be different from those who don’t.

Moreover, as Sackeim writes, “Empirical information about ECT’s long-term effects derives mainly from small sample studies conducted in research settings with follow-up intervals frequently limited to two months or less. …[T]hese studies could not adequately assess the severity and persistence of long-term deficits.”

John Read, Irving Kirsch, and Laura McGrath conducted a meta-analysis of the randomized controlled trials of ECT vs. sham ECT (i.e., the anesthesia without electricity) in 2019. Their paper illustrates the pitfalls of small sample research and the lack of evidence for ECT. They found eleven relevant studies and five meta-studies in the literature, but none since 1985. ECT subjects improved more than sham in four, no difference was found in five, and investigators expressed different opinions on the outcome in two. Analysis of the methodologies indicated that all studies were too small and too poorly done to reach any conclusions.

Instead of the many problems with self-report and small sample studies, why not a large, single, scientific study using magnetic resonance imaging (MRI) and neuropsychological testing? “MRI images are clearer and more precise than other forms of diagnostic imaging… Because an MRI provides clear pictures of soft tissues, it’s a reliable tool for diagnosing brain conditions” (What to Expect in an MRI…, undated). And neuropsychological testing can determine the degree of impairment in memory, attention, and many other areas. If done many months or years after ECT, the study could provide a good estimate of how many suffer brain damage and long-term impairment.

The National Institute of Mental Health (NIMH) would be a logical source of funding for such a study. But some on the Appropriations’ Committee belong to the APA, a strong supporter of ECT. And, so far, nothing doing. That means—at least for now—nobody knows how many do experience long-term difficulties. This means that the risk of undergoing ECT is still unknown.

Where Are the Cops?

The US Federal Drug Administration (FDA) is responsible for ensuring the safety and effectiveness of prescription medications and medical devices. Shock devices first entered the US market in 1940. But it wasn’t until 1976 when Congress passed the Safe Medical Devices Amendment to the Food, Drug, and Cosmetic Act that they came under the authority of the FDA.

The Amendment also established a system for determining the risk of medical devices.  A Class III device is one at the highest level of risk.

ECT devices were placed in Class III by the FDA in 1976. But because of several exceptions, the FDA had limited control over them for many years. To provide the FDA with greater authority to regulate medical devices, Congress passed the Safe Medical Devices Act of 1990, which required the FDA to obtain Premarket Approval (PMA) for all Class III medical devices (which would mean that the device could demonstrate safety and efficacy) or reclassify them to a lower level of risk.

Rather than obtaining PMA, the FDA chose to reclassify shock devices to a lower level of risk. To do so, it had to issue an administrative order based on scientific evidence. It also had to hold a meeting of its Neurological Devices Advisory Subcommittee to review the evidence. It didn’t start making preparation for a meeting, however, until nineteen years after the Safe Medical Devices Act was passed. By that time, ECT devices had been under the FDA’s authority for over 30 years and had never undergone the same rigorous, scientific testing as most vaccines, pharmaceuticals, or other medical devices. A study of shock devices by the same high standards was long overdue. Yet, the FDA, given its choices, decided to rely largely on smaller studies already published in the literature

When the Neurological Advisory Subcommittee met in January 2011, no consensus was reached on the reclassification of ECT devices for Depression (Unipolar and Bipolar) and Catatonia—those diagnoses where ECT was most often used. According to The New York Times, Committee members voting in favor of reclassification were largely those who did ECT themselves, or referred patients for ECT, and had a financial stake in the outcome. In contrast, according to The Washington Post, committee chairman Dr. Thomas Brott, a professor of neurosciences at the Mayo Clinic, as well as others, wanted shock devices proven safe and effective before lowering the risk.

Nonetheless, the FDA went ahead and issued a Final Order for the reclassification of ECT devices to Class II, effective December 26, 2018. A class II device requires “special controls” without oversight by the FDA, such as following the instructions in the device manual. The reclassification applied only to those with Major Depression, Bipolar Disorder, and Catatonia who were 13 years or older and required an urgent response and/or were nonresponsive to prior treatment. Schizophrenia and all other diagnoses remained in Class III and, henceforth, required PMA.

The FDA stated in the Final Order it had reviewed over 400 new studies and articles and reassessed those already reviewed previously by its Advisory Committee. It also considered observational studies, case reports, and retrospective chart reviews, which are of dubious scientific value. It said new studies since 2011 were to be found in the public docket, but no link was found. Nor did they reveal how their decision was made beyond claiming it was based on “a totality of the evidence.”

The New York Times reported that Somatics and Mechta Corp., the two companies selling shock devices, told the FDA that they could not afford the large study needed to obtain PMA. And the FDA’s reclassification decision was made partly to ensure the companies stayed in business and shock devices continued to be sold.

But the risk of undergoing shock treatment will remain until shock devices are held to the same high standards as vaccines, prescription drugs, and other medical devices. The FDA warned itself: “…The long-term safety and effectiveness of ECT treatment has not been demonstrated.”

Where Do We Go From Here?

“Unfortunately, Psychiatry shows not the slightest inclination to rein in its compulsion to damage the brains of its patients in the name of ‘treatment’…ECT will have to be stopped by forces outside the profession including public outrage, court decisions prohibiting its use, and legislation banning it.” –Peter Breggin, Brain Disabling Treatments in Psychiatry

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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