The evolution of electroconvulsive therapy: from controversial beginnings to a safe and effective treatment

Electroconvulsive therapy (ECT) has a checkered past, but its use today is markedly different from earlier practices in terms of both safety and therapeutic precision. ECT remains a highly effective treatment for certain psychiatric conditions, particularly severe depression, bipolar disorder, and treatment-resistant schizophrenia. However, historical practices and depictions of the procedure have left it with a controversial reputation.

The checkered past of ECT

Early use and lack of anesthesia. ECT was first introduced in the 1930s by Italian neurologist Ugo Cerletti, who based his method on earlier experiments using electrical stimulation in animals. Early ECT treatments were often conducted without the use of anesthesia or muscle relaxants, which led to severe side effects such as bone fractures, dislocations, and distressing experiences for patients. The lack of anesthesia, coupled with an inadequate understanding of brain function, meant that the procedure was often administered crudely.

Throughout the 1940s and 1950s, ECT became widely used in psychiatric hospitals, but the lack of standardized protocols and frequent use on institutionalized patients—sometimes without proper consent—contributed to its controversial reputation.

Public perception. The portrayal of ECT in popular culture, particularly in films such as One Flew Over the Cuckoo’s Nest (1975), solidified its negative image as a coercive and painful treatment. These depictions contributed to the public perception of ECT as an abusive or barbaric intervention, overshadowing its potential therapeutic benefits for certain psychiatric conditions.

Ethical concerns. Historically, ECT was sometimes administered without patient consent or used as a form of behavioral control in psychiatric institutions. The combination of physical trauma, memory loss, and lack of consent in certain cases further tarnished the treatment’s reputation.

How ECT is used differently today

Modern ECT is very different from the early, more controversial practices. Advances in medical technology, better understanding of brain physiology, and strict ethical guidelines have dramatically improved its safety and efficacy.

Use of anesthesia and muscle relaxants. Modern ECT is administered under general anesthesia, and patients are given muscle relaxants to prevent physical injury from convulsions. The procedure is carefully monitored, with continuous cardiovascular and respiratory support, significantly reducing the risk of complications and making the process much less physically traumatic for patients.

Controlled electrical stimulation. The electrical currents used in ECT today are much more controlled and targeted, with lower doses and refined techniques that minimize the risk of cognitive side effects, such as memory loss. Advances like unilateral electrode placement (placing the electrodes only on one side of the head) and ultrabrief pulse stimulation have further reduced cognitive impairments associated with the treatment.

Well-defined indications. ECT is now reserved for specific, well-defined cases where other treatments have failed. It is most commonly used for patients with severe, treatment-resistant depression, bipolar disorder, catatonia, and some forms of treatment-resistant schizophrenia. ECT is often considered a last resort for patients who do not respond to medications, psychotherapy, or other forms of treatment.

Improved understanding of side effects. Research has clarified the potential side effects of ECT, particularly short-term memory loss. However, modern techniques have mitigated many of these concerns. Although some patients may experience anterograde or retrograde amnesia (difficulty forming new memories or recalling recent memories), these effects are typically transient and less severe than in the early days of ECT.

Informed consent and ethical standards. Today, ECT is conducted under strict ethical guidelines that require informed consent from the patient or a legal representative. Patients are carefully screened, and the decision to use ECT is made in collaboration with the patient, their family, and a team of healthcare providers. Involuntary ECT, once common in institutional settings, is now rare and subject to stringent legal oversight.

Efficacy of ECT in psychiatric disorders

Major depressive disorder. Numerous studies demonstrate the high efficacy of ECT in treating severe, treatment-resistant depression. The remission rates for ECT are significantly higher than for pharmacological treatments. For example, a systematic review by the UK ECT Review Group found that ECT was superior to antidepressants in achieving remission in patients with major depressive disorder, with remission rates of approximately 70% to 80%, compared to 40% to 50% with pharmacotherapy (UK ECT Review Group 2003). ECT is also particularly valuable for patients with severe depression who are at high risk of suicide. The rapid antidepressant effect of ECT, often observed after only a few sessions, makes it a life-saving intervention in acute situations.

Bipolar disorder. ECT is effective in treating both the depressive and manic phases of bipolar disorder. A study by Medda and colleagues found that approximately 60% to 80% of patients with bipolar depression or mania experienced significant improvement following ECT, with patients in depressive episodes showing particularly robust responses (Medda et al 2017).

Schizophrenia. Although antipsychotic medications remain the first-line treatment for schizophrenia, ECT is often used as an adjunctive treatment in patients with treatment-resistant symptoms, particularly catatonic states or psychotic depression. A meta-analysis by Tharyan and Adams concluded that ECT, when combined with antipsychotic medications, resulted in better outcomes than antipsychotics alone in treatment-resistant schizophrenia (Tharyan and Adams 2005). ECT is also particularly effective in resolving catatonia, which can be life-threatening if not treated promptly.

Research support. Continued research into ECT is focusing on refining the technique further, with innovations such as magnetic seizure therapy and transcranial magnetic stimulation offering potential alternatives that could build on ECT's therapeutic principles with fewer side effects.

Conclusion

Although ECT’s early history is indeed checkered, involving crude methods and ethical lapses, modern electroconvulsive therapy is a highly regulated, safe, and effective procedure that plays an important role in treating severe psychiatric conditions. Advancements in medical technology, anesthesia, and ethical standards have dramatically transformed the way ECT is administered, making it a valuable option for patients with treatment-resistant mental illnesses. For neurologists and psychiatrists, understanding these changes is essential when considering ECT as a treatment option and in addressing lingering public misconceptions about its safety and effectiveness.

References cited

Perugi G, Medda P, Toni C, Mariani MG, Socci C, Mauri M. The role of electroconvulsive therapy (ECT) in bipolar disorder: effectiveness in 522 patients with bipolar depression, mixed-state, mania and catatonic features. Curr Neuropharmacol 2017;15(3):359-71. PMID 28503107

Tharyan P, Adams CE. Electroconvulsive therapy for schizophrenia. Cochrane Database Syst Rev 2002;(2):CD000076. Update in: Cochrane Database Syst Rev 2005;(2):CD000076. PMID 12076380

UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003;361(9360):799-808. PMID 12642045


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