Electroconvulsive Therapy From Both Sides Now: Perspectives From Late and Early Career.

Abstract

I n this editorial, a senior electroconvulsive therapy (ECT) practitioner (C.H.K.) and a fourth-year medical student (E.H.L.) share their perspectives on ECT over the last several decades and now. I (C.H.K.) learned to do ECT as a psychiatric intern at Los Angeles County Hospital in 1978. Although the procedure was basically the same as it is practiced now, there were some notable differences. We, the interns and the psychiatry attending, were the only doctors present; there was no anesthesiologist. We put in the intravenous line, gave the drugs, managed the airway, and did the ECT itself. Not that this was a good thing, but it was testimony to the basic safety of the procedure that the patients all did fine. My experience was the typical one of first-time ECT viewers/participants, that it was “amazing,” “miraculous,” and also that it was really “cool.” Thirty-seven years, hundreds of patients, and many thousands of procedures later, I am happy to say I feel the same way. (Maybe now the descriptor would be “awesome,” instead of “cool.”) Of course, over the years, other things have changed about ECT, both technical and clinical, in addition to the composition of the health care team. Unfortunately, many others have not, notably the stigma and the reluctance, even distaste, among professionals, even within psychiatry, to recommend the treatment. Electroconvulsive therapy, after all these decades, is still struggling to find its rightful place in psychiatric medicine. Some reasons for this struggle are easily understood, some, not so much. As some German ECT colleagues recently stated in an article, “Despite positive scientific evidence, the therapy [ECT] is often approached with reserve that cannot be explained rationally.” The easyto-understand part is the reality of the brutality of original unmodified ECT, and the ubiquity of the barbaric scene from One Flew Over the Cuckoo’s Nest. But it is high time to go beyond the archaic and the fictionalized. The harder part to understand and accept is how the medical and psychiatric establishment has shunned ECT. C. P. Freeman put this into stark perspective 35 years ago in his thenanonymous editorial in Lancet, “ECT in Britain: A Shameful State of Affairs.” Commenting on the results of an audit of ECT services in Great Britain that revealed poor clinical oversight and general shabbiness of ECT suites and equipment, he concluded with the statement, “It is not ECT that has brought psychiatry into disrepute. Psychiatry has done just that for ECT.”Nowadays, things are much better, at least in terms of quality of care delivery in most countries, including Great Britain and the United States: ECT is very well supervised, and it benefits from being included under the rubric of surgical procedures, with all the safeguards of standardized hospital practices, including the addition of an anesthesiologist to the ECT team. Other factors, however, have kept ECT marginalized and raise important questions. Why, for example, is there no board certification in ECT? The pat answer from the American Psychiatric Association is that certification is for domains of practice, not for specific procedures. While technically true, it seems like an excuse, easily overcome by defining a subspecialty area of somatic treatment of severe psychiatric illnesses, with ECT as the main focus. Imagine trying to explain to medical students, let alone the man in the street, that there really is no set path to rigorous ECT training in the United States and that most psychiatrists, young and old, still have little experience with ECT. Why is ECT experience not an integral part of the medical school and psychiatry residency curricula (both didactic and practical) at all programs? All physicians, no matter their specialty, will encounter seriously depressed patients; they should know enough about treatment options, including ECT, to appropriately educate and refer such patients for specialty care. While the situation for ECT education in medical schools and residency programs is improving, there is still a long way to go. Why is research support for ECT so limited? With few exceptions, leaders in psychiatry view ECT as old-fashioned and not nearly as exciting as genetic research. One would have thought that the most effective treatment in psychiatry and the one that results in the most profound physiological changes in the brain would be a preferred platform for the investigation of the etiology of the major psychiatric illnesses. Perhaps this