Randle McMurphy (played by Jack Nicholson) is strapped to a gurney, surrounded by people in white coats, and is seemingly unaware of what is about to happen to him. They hold him down, forcibly insert a mouth guard and begin a procedure that looks nothing short of barbaric. A device is brought to each of Randle’s temples and a knob on a machine is turned – it begins. His entire face contorts in pain as his body begins to convulse violently. They continue to hold him down and the convulsions continue, until mercifully, the scene comes to an end.
For many of us, this infamous scene from One Flew Over The Cuckoo’s Nest (1975) imprinted what Electroconvulsive Therapy (ECT) looks like – a cruel procedure. Walking through the history of ECT with no bias, however, paints a strikingly different picture.
Let’s go back to several centuries ago. It was a time when all Mental Illnesses were amalgamated into one word – ‘insane’. People began to observe a strange relationship between seizures and a subsequent decrease in the level of insanity. When people experienced seizures, the severity of the symptoms of the mental illness seemed to come down almost immediately, sometimes to the point where the individual would become ‘almost normal’. Soon enough, the scientific community began to wonder whether it is possible to induce a seizure to treat mental illnesses.
At first, they tried to induce seizures chemically with substances such as camphor and metrazol . This turned out to be a dead end; the onset of a seizure was unpredictable, and the patient often suffered from several side-effects of these chemicals.
Psychiatrists in Italy stumbled on butchers, who used electricity to induce epileptic-comas in pigs before slaughter. It was a lightbulb moment (pardon the pun) in the history of psychiatry and by the late 1930s, the first session of ‘convulsive therapy’ was administered with electricity, and “Electroconvulsive therapy” was born. The use of electricity allowed the entire procedure to be much more focused and predictable unlike the earlier primitive attempts.
The first patient that it was administered on was an extreme case. He was incoherent, spoke gibberish, was unaware of his own identity, and seemed to neither eat nor bathe. After several sessions of Electroconvulsive Therapy, he showed an astonishing improvement! He regained composure, orientation, and even began to converse coherently. And so, it became the foundation for the practice that continues today.
By the mid-1940s, the standards of ECT had settled, and look similar to what it is today. Patients are given an anaesthetic and muscle relaxant prior to the procedure, and therefore, do not feel anything while it is happening. An electric current, equivalent to burning a 40-watt bulb for two seconds, is administered and the brain seizes. The electric circuit is closed in the brain itself and does not reach any other part of the body. The procedure, in fact, is safe enough to administer on women of near term pregnancy. Physiological symptoms such as an increase in heart rate and breathing during and immediately after the procedure are completely normal, similar to what would be experienced with a natural seizure. Short term memory-loss and disorientation are also common amongst patients; most regain their composure within 30 to 60 minutes after the procedure.
A strikingly different picture than what Randle McMurphy painted for all of us…
Electroconvulsive Therapy is not a cure, it is a temporary solution. In fact, if the patient does not receive either medication and other forms of psychological and therapeutic treatments after the procedure, they are very likely to relapse within a few days.
In many cases, ECT buys time for other interventions to help an individual discover their path to long-term recovery. It is used as a first-line treatment for patients who are perceived as high-risk for suicide or are completely catatonic for alleviating symptoms, and therefore, giving them the time and space they need with medication and other forms of therapies. ECT could also be used for individuals who have not improved with even high doses of medications and/or are unable to bear their side-effects.
World over, the practice of Electroconvulsive Therapy is declining. Far from common belief, however, this isn’t because the procedure is inhumane or barbaric in any way. It is merely because we have started to get access to more sustainable alternatives. Medications and therapeutic techniques for depression, bipolar disorders, schizophrenia, amongst others, are becoming more advanced and more effective. People are also beginning to seek treatment early and preventing the mental illness from reaching a point of severity where ECT can be considered effective. This does not imply, however, that the practice of Electroconvulsive Therapy needs to be banished, demonised, or dismissed.
At NIMHANS, we administer ECT to approximately 900 patients every year. This would amount to around 8000 sessions in total. Patients and their families are given all the information beforehand and always have the choice to opt for ECT or other alternatives, it is never a rigid prescription and different options do exist. ECT is never administered without an explicit written informed consenting process.
In a world that is already struggling to talk about mental illnesses, the demonisation rather than the knowledge of practices will only take us steps back; at a time when, more than ever before, all of us must leap forward.