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Getting better

2018; Elsevier BV; Volume: 5; Issue: 4 Linguagem: Inglês

10.1016/s2215-0366(16)30320-0

2215-0374

The Lancet Psychiatry,

Electroconvulsive Therapy Studies

Merete Osler and colleagues' Article on Electroconvulsive therapy and risk of dementia in patients with affective disorders comes, as do all Lancet Psychiatry papers, with a Research in Context panel. In this case, the cultural context, as well as the clinical background, is essential to understand the significance of the paper and to interpret its reception. April, 2018, marks the 80th anniversary of Ugo Cerletti and Lucio Bini's introduction of electroconvulsive therapy (ECT) into modern psychiatry. Cerletti's account of the procedure is neither edifying nor inspiring. The patient—a 40-year-old man with a form of schizophrenia characterised by marked thought disorder—was administered an initial shock, which made his muscles tense up, but did not induce a seizure. Not put off by the patient's cries of “Non una seronda! Mortifera!” (“Not again, it will kill me!”), Cerletti increased the voltage and tried again. This time, the patient had an epileptic seizure: “all had their hearts in the mouths”, wrote Cerletti, “and were truly oppressed during the tonic phase…until at the first deep, stertorous inhalation…the blood ran more freely in the bystanders' veins as well”. While Cerletti's consideration for the feelings of his colleagues is admirable, this attentiveness might have been better bestowed on his patient. According to Cerletti's account, the treatment resulted in immediate lucidity, which makes it surprising that 13 further sessions of ECT were given. Although the patient was discharged in a state of remission, he was lost to follow up after 2 years. The Lancet Psychiatry editors' revulsion at Cerletti and Bini's experiment is clear: a 21st century research Article reporting this sort of practice would not only be rejected, but would probably lead to investigation of the authors. But history is complex. Without losing sight of ethical standards, the specific circumstances in which professionals did this research, and in which ECT was enthusiastically taken up by the rest of the medical world, must be considered. The purpose of this consideration is not to excuse or explain away the misdeeds of the past: it is to understand better the assumptions—and treatments—that we have inherited, and to gain a meaningful perspective on practice today. In the late 1930s, similar to the late 2010s, the mental health sciences enjoyed a high popular profile, thanks in a large part to psychoanalysis. But clinicians desperately needed acute and effective treatments. ECT filled that gap. The precise mechanism of the therapy was unclear, but this was possibly an advantage: the response to the electric shock could be explained biologically or psychoanalytically, according to preference. And, as documented by medical historian Jonathan Sadowsky, ECT was perceived as a humane alternative to the previous practice of administering metrazol, a substance associated with a so-called feeling of terror. ECT soon fell prey to the original sin of psychiatry: mission creep. Uses extended to an attempted cure for homosexuality and the control of alleged challenging behaviour on hospital wards. By the time Miloš Forman's film adaptation of Ken Kesey's novel One Flew Over the Cuckoo's Nest was released in 1975, ECT had gone, in a little less than 40 years, from a symbol of a futuristic, humane, and efficient form of psychiatry, to a shorthand for sadistic authoritarianism. Both continuity and radical difference might be seen in today's use of ECT when compared with Cerletti and Bini's work, and indeed the ECT of Cuckoo's Nest. The therapy is almost exclusively restricted to mood disorders; is used with anaesthetic and muscle relaxants to avoid distress and injury; and in countries such as the UK, strict legal and ethical frameworks govern its use. But, similar to psychiatrists 80 years ago, doctors today find themselves with few therapeutic options, and a great deal of anxiety. What are the side-effects of ECT, and are they really outweighed by the benefits? Although it is reassuring that Osler and colleagues' cohort study did not find an association between ECT and dementia, it would be naive to expect that this will lead to the treatment being enthusiastically embraced by all. Objections to ECT go back decades, and are very understandable in view of the treatment's history, but they must be engaged with rather than simply dismissed; data are necessary but not sufficient to this process. Furthermore, the history of ECT—of a treatment being introduced at a point of therapeutic desperation; of dismissed adverse events; of overuse; and of the patient's voice being ignored—is essential reading for modern-day psychiatrists and researchers. Even if a knowledge of history will not help psychiatry to avoid repeating its mistakes, it will, at least, prompt individuals to ask hard questions about authority, evidence, andthe rights of patients. For more on the history of ECT see https://theconversation.com/electroconvulsive-therapy-a-history-of-controversy-but-also-of-help-70938andhttp://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1256&context=jeffjpsychiatry For more on the history of ECT see https://theconversation.com/electroconvulsive-therapy-a-history-of-controversy-but-also-of-help-70938 and http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1256&context=jeffjpsychiatry Electroconvulsive therapy and risk of dementia in patients with affective disorders: a cohort studyECT was not associated with risk of incidental dementia in patients with affective disorders after correcting for the potential effect of patient selection or competing mortality. The findings from this study support the continued use of ECT in patients with severe episodes of mood disorders, including those who are elderly. Full-Text PDF