reviewed by Sigurd Ackerman, MD*

Shock is the story of the evolution of electrically induced convulsions as a method of treating certain forms of severe mental illness. Variously called electroshock therapy (EST) or electroconvulsive therapy (ECT), its evolution, especially in America, is a fascinating drama interweaving science, politics, sociology and even religion. At various times in its nearly 70-year history ECT was viewed as a medical miracle and as a barbaric torture; as an instrument for giving the mentally ill their freedom and as an instrument for taking it from them; as a precise, scientific tool and as a very unscientific shot in the dark; an example of the enlightenment of modern psychiatry and an example of its ignorance; a treatment that makes patients well and an assault that makes them worse. In fact, ECT has been all of those since 1938, when the use of electricity to shock a patient into a seizure was born in the Rome clinic of Dr. Ugo Cerletti.

Chapters alternate between a personal reflection on ECT from a patient and an historical recounting of its past and present state. Larry Tye, a former medical writer for the Boston Globe, is the historian of the story. Kitty Dukakis is the memoirist.

Dukakis tells her story of a lifelong struggle with depression and an adult-life struggle with alcohols and pills. The depths of her despair come through clearly as she recounts failed treatment after failed treatment and relapse after relapse.

The reader is not surprised to learn that ECT finally ended all of that. This is, after all, a book about the healing power of ECT. The story of the devastating effects of persistent mental illness has been told better by others, but her story is nonetheless important. She is well known as the wife of the former governor of Massachusetts and former presidential candidate Michael Dukakis, and each public telling of such a story by a well-known person helps to lessen the burden of stigma. More importantly, she was helped by ECT and her story helps to reassure others who may benefit from it. She is straightforward in describing some of the treatment side effects she encountered, notably memory loss, and in telling how she weighed the potential benefits against the possible risks.

A more important story, however, is told by Larry Tye. The history of ECT is such that, at various times in the past, it has been alternately praised and vilified. Today, the great paradox about ECT is that it is both praised and vilified. For severe depression, ECT is the most effective treatment we have. It has the greatest chance of returning a severely depressed person to a non-depressed state and in the shortest period of time - more effective than any medication and much more effective than any psychotherapy. Yet, if it is so effective, why is it viewed with such fear and seen as such an appalling, barbaric assault by so many?

A very important reason, as recounted by Tye, is that most people still associate ECT with the problems of its earlier history which, although no longer applicable, really were quite awful. Today, ECT is administered under general anesthesia in a hospital treatment room attended by a psychiatrist, an anesthesiologist and a nurse. The patient is given a muscle relaxant so the spasms and contortions associated with generalized convulsions do not occur. The patient is given oxygen and his breathing is controlled by the anesthesiologist. The electrical current is delivered by a machine calibrated to give the lowest effective dose, through electrodes placed on the patient in positions that minimize side effects.

In the early days of ECT, none of that took place. The patient was awake, the electrical current was large and mainly unregulated and broken bones and teeth were common. Profound side effects, mainly on memory, occurred routinely. And worse, a dread of the next session was commonplace.

It was obvious from the beginning that when ECT works the results can be spectacular. Mid-century psychiatrists finally had an effective treatment for severe mental illness and, since they did not know which mental illnesses it might help, they used it for almost everyone with an illness severe enough to require hospitalization. They also had little understanding of when to stop, typically believing they should continue delivering shocks until the patient got better. The results of these approaches were often disastrous.

Moreover, as its critics contended, ECT was used at times for mere behavioral control, like lobotomy, or used as a punishment for patients who could not or would not cooperate with the hospital staff. In other countries it was sometimes used as a "treatment" for political dissidents.

By the late '50s and for several decades beyond, powerful anti-ECT grass-roots movements developed, spearhead mainly by "survivors," former recipients of ECT who were psychologically or neurologically damaged by their experience. The efforts of these movements carried into the courts and into several state legislatures, resulting in laws that strictly regulated and limited the use of ECT.

Perhaps more significantly, images of ECT as damaging, punitive and dehumanizing were carved into the public consciousness through frequent and sometimes lurid newspaper stories and by films such as The Snake Pit (1948), Shock Corridor (1963) and One Flew Over the Cuckoo's Nest (Ken Kesey's book appeared in 1962 and the film version in 1975). Even religious groups joined the anti-ECT movement, notably the Church of Scientology, through it's surrogate, the Citizens Commission on Human Rights.

ECT did not do well under these assaults and almost did not survive. By the '70s and into the '80s its use was suspect and, in many places, it was no longer considered part of mainstream psychiatry. It was employed much less frequently and, in many states, under strict constraints.

As more people in psychiatry became interested in clinical research and as research methods improved, so did our ability to match illnesses to treatments. This new trend had a gradual impact on ECT as well. With better selection of patients and fewer side effects because of technical improvements it became once more accepted by the psychiatric community and more widely available as an important piece of its treatment armamentarium. Yet the public acceptance of ECT has lagged far behind these changes and the old images linger.

Despite the improvements in ECT, in both patient selection and treatment methods, it remains very far from perfect. Loss of some prior memories and, occasionally, difficulties retaining new memories still affect some patients, although to a much diminished extent. Research in this area continues, with a shift in emphasis toward developing methods of electrical stimulation of the brain that effectively treat illnesses such as depression without producing generalized seizures and with fewer side effects.

At the moment, ECT is often the best we have. When nothing else works or when it its dangerous to prolong the treatment period, ECT can be a life saver - an imperfect one but a life saver nonetheless.

*President and Medical Director
Silver Hill Hospital
New Canaan, CT