"What these shock doctors don't know is about writers and such things as remorse and contrition and what they do to them . . . Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure, but we lost the patient."
-- Ernest Hemingway, talking about electric shock therapy, as quoted by author and confidant A.E. Hotchner in his book "Papa Hemingway."
Ask almost anyone what image is evoked by the words "shock treatment." Usually it will be something like this: a confused and terror-stricken patient, strapped down, kicking and screaming, suddenly involuntarily convulsed, arms and legs twitched into distorted positions. Then the limp, lifeless-looking victim is hauled off like so much meat.
Although electroconvulsive therapy, or ECT, hasn't been done that way for nearly two decades, this technique for treating mental disorders remains controversial. There are unresolved disputes over who should receive it, when it should be used, and even whether it should be used at all.
Some psychiatrists and neurologists, and even some groups of patients who believe they were permanently brain-damaged by its use, remain convinced that ECT is as bad as its public image.
Yet others, like those 1960s Mayo Clinic psychiatrists who treated Hemingway, and some 5,000 psychiatrists who use it today, mostly in private mental hospitals, are convinced ECT is effective, safe and often better than anything else in the treatment of certain mental illnesses.
Controversial or not, ECT is used on perhaps 100,000 patients a year in this country, an estimated 70 percent of whom are women. Ninety percent of the three-times-a-week ECT treatments are conducted on psychiatric hospital in-patients. Monday, Wednesday and Friday are ECT days all over the country.
Electroconvulsive therapy has been around since the late 1930s, when it was developed as a treatment for schizophrenia. Its use in schizophrenia is considered marginal now, says Dr. Jack Blaine, a psychiatrist at the National Institute of Mental Health. But it is still widely regarded as a useful tool in the treatment of certain depressions, manias and delusional states.
The techniques for giving ECT have been refined. Broken bones, once a common problem because the powerful shocks caused violent muscular contractions, are no longer a side effect of treatment. Now, most ECT users believe the greatest danger to the patient is a relatively minor one from an anesthetic and a drug that paralyzes the muscles to limit the effects of the shock to the brain.
Opponents and many former patients are convinced, however, that these changes are cosmetic at best. Today's techniques may be even more damaging to the brain than the older method because more electrical current is used to overcome the antiseizure effects of the drugs used during the procedure, says Dr. Peter R. Breggin, one of ECT's most implacable opponents.
Scientists do not know, even now, how the induction of grand mal seizures created by ECT treatment lessens psychotic symptoms. But psychiatrists believe that in patients with severe depression who do not respond to psychoactive drugs, ECT is indicated. An article in the New England Journal of Medicine last summer also suggested that because ECT works more rapidly than do most of the drugs, its use is also indicated in cases where there is a serious risk of suicide.
There is unanimity that the procedure causes some brain damage -- memory deficits, learning disabilities, confusion. But ECT users -- or "shock doctors," as their opponents call them, borrowing Hemingway's term -- hold that these intellectual side effects are slight and transient. Opponents and many ex-patients believe them profound and virtually permanent.
Even some experts in the use of ECT believe that its side effects should be more carefully studied. Dr. Richard D. Weiner, a leading ECT authority, professor of psychiatry at Duke University and psychiatrist at the Veterans Administration Medical Center in Durham, N.C., wrote last year in the journal Behavioral and Brain Sciences that although "evidence that ECT typically leads to . . . brain damage . . . is weak, still, enough data exist, particularly for autobiographic memory for recent events and for subjective complaints, to call for further, more definitive research."
Weiner, who was chairman of an American Psychiatric Association task force on ECT safety and efficacy also wrote that "given the misery, anguish and risk of death by suicide, starvation or debilitation associated with severe depressive illness, for example, it still appears that ECT, at least for the present, must continue to be available."
ECT opponents like Breggin, on the other hand, suggest that ECT itself may induce suicidal feelings, and they point to the Hemingway suicide, only days after his last course of ECT treatment.
Recently there has been a series of conferences devoted to current research on ECT, mostly conducted among psychiatrists already convinced of its usefulness, much of it involving research into the effects on brain chemistry, including neurotransmitters and the way they affect moods.
"In any case," snaps Breggin, "that kind of research is total hypocrisy. What they don't face is that a blow on the head is a blow on the head. You have a post-ECT patient who has got a severe headache, can't recognize his mother, can't find his way around the ward, and they're studying which biochemical went up or down."
Breggin, a Bethesda psychiatrist, one-time Harvard Medical School psychiatric fellow and for several years a full-time psychiatric consultant at the National Institute of Mental Health, sees ECT as the "lobotomy of the '80s." His book, "Electroshock: Its Brain-Disabling Effects" (Springer, $19.95), published in 1979, hypothesizes that the apparent improvement in mood and the lessening of manic or psychotic symptoms is symptomatic of brain damage, not a marker of improvement. "Head injury, carbon monoxide poisoning or sniffing glue can produce euphoria," says Breggin. "It is an artificial high typical in the early stages of brain damage. The shock doctors say the depression has lifted. It hasn't lifted, the ability has been destroyed."
NIMH's Blaine, who participated earlier this month in a New York conference cosponsored by his institute and the New York Academy of Sciences, is also preparing a National Institutes of Health consensus development conference to be held in June on the clinical usefulness of shock treatment.
Peter Breggin was not invited to the New York conference, although ex-ECT patient and full-time anti-ECT activist Leonard Frank from Berkeley, Calif., insisted on being heard, and roundly criticized the organizers for excluding critics. Blaine has, however, invited Breggin to give a paper at the NIH conference. "We think new research supports ECT as an effective treatment for a number of conditions," says Blaine, "but part of the problem is that it is used sometimes on a population for whom it is not effective -- neurotics, personality disordered, drug or alcohol abusers, for example."
In any case, says Blaine, "consensus development is, by its very nature, intended to be a focus for medical and public controversy. ECT certainly fits that."