Electroconvulsive therapy (ECT) is a controversial therapy used to treat certain mental illnesses such as major depressive disorder, schizophrenia, depressed bipolar disorder, manic excitement, and catatonia.^[1] These disorders are difficult to live with and often very difficult to treat, leaving individuals suffering for long periods of time. In general, ECT is not looked at as a first line approach to treating a mental disorder, but rather a last resort treatment when medications such as antidepressants are not helpful in reducing the clinical manifestations.

"Electroconvulsive therapy entails deliberately inducing a modified generalized seizure under medically-controlled conditions to obtain a therapeutic effect."^[1] The therapeutic effect being reduced clinical manifestations of one's mental disorder, therefore leading to less suffering. “ECT has been shown through various research trials to cause significant physiological and chemical changes at a molecular level of the brain; however, it is thought that the sustainability of ECT is threatened due to associated stigma and poor impression of the treatment itself”.^[2]

The use of electricity as medical treatment dates back to the Romans in 47 AD. Back then, it was used for a variety of conditions such as headache, paralysis, gout, and epilepsy.^[3]  Beginning in the 16^th century, it was observed that seizures could, at times, improve mental illness. In fact, Paracelsus induced seizures by giving camphor as a treatment for “lunacy.”^[4]  However, it was not until the 20^th century that induced seizures were successfully used as a treatment for mental illness, reflecting what is now known as electroconvulsive therapy (ECT).^[3] In 1934, Hungarian psychiatrist Ladislas Meduna believed that people with schizophrenia had an excess of glial cells, while those with epilepsy had a deficiency.^[4] Based on this theory, he believed that schizophrenia could be treated by inducing seizures. To test this idea, he induced a grand mal seizure in a patient with schizophrenia by injecting camphor. The patient went on to receive several additional treatments and eventually made a full recovery.^[4]  After this patient, Meduna successfully treated 5 more patients with schizophrenia.^[3]

The development of ECT is often credited to the Italian physician Ugo Cerletti. In 1935, Cerletti used metrazol to induce seizures for the treatment of schizophrenia.^[3] He later considered using electricity to induce seizures and began testing the idea on animals.^[3] He tested several electrode placements but many of these experiments resulted in the death of the animals. It was his colleague, Lucio Bini, who suggested bitemporal placement, a method that is still used today. ^[3]Through these experiments, they determined the therapeutic range for the dose of electrical current. ^[4] In April 1938, Cerletti and Bini performed the first ECT treatment on a patient using electrical current.^[5] The patient was a 39-year-old man who was found wandering in a train station and was later diagnosed with schizophrenia. He received a total of 11 treatments and made full recovery.^[5] This marked the first demonstration that seizures could be safely and effective induced using electrical current to treat mental illness.^[5] In May 1938, Cerletti and Bini presented their findings at the Royal Medical Academy in Rome, and the ECT device was patented the following year.^[4]

A colleague of Cerletti, Renato Almassi, brought the first ECT machine from Italy to the United States in 1939.^[6] The following year, he and an American physician, David Impastato, carried out the first ECT treatment in the United States.^[6] The patient, a 29-year-old woman with schizophrenia, was treated at Columbus Hospital in New York City.^[6]

In May 1940, psychiatrist Douglas Goldman demonstrated ECT at the annual American Psychiatrist Association meeting. ^[5] Later that year, a German scientist, Lothar Kalinowsky began treating patients with ECT at the New York State Psychiatric Institute. ^[4] From this point through the 1950s, ECT became widely used in the treatment of psychiatric disorders.^[4] In fact, it was widely used by the U.S. miliary during World War II. ^[3]

Until the end of the 1960s, the way in which ECT was performed could be considered, for lack of a better term, shocking. "In these early days clients might be ‘shocked’ in open, communal wards of psychiatric asylums, tied to beds, without anaesthetic or muscle-relaxing agents, often several times a week. As an unfortunate consequence, many of the patients who underwent ECT felt abused, oppressed, punished and damaged, all of which had a negative impact on the treatment itself and psychiatry as a whole".^[7]

"Aside from the therapy’s crude beginnings, controversy may have also been caused by a lack of information given when practitioners obtain informed consent before treatment, unknown mechanism of action, lack of knowledge about the cognitive adverse effects that can occur, divergent views of clinicians and consumers about ECT, and wide variations in official guidelines on minimal standards of ECT use".^[7]  

Essentially, the usage of ECT to treat mental disorder has been highly scrutinized by practitioners, and the general public as whole due to its controversial history in psychiatry, combined with its negative stigma in the modern world. This negative stigma in the modern world has created little importance in providing the adequate education for medical personnel at all levels, including medical student and board-certified psychiatrists.^[8] “It should be standard practice for all medical students to learn the basics of ECT and for all psychiatric residents to know enough about it to refer patients for whom ECT is an appropriate treatment consideration”.^[8] The effectiveness of ECT is high compared to antidepressants and other antidepressant treatments such as vagus nerve stimulation and transcranial magnetic stimulation;^[8] for this reason, clients, students, and medical professionals should be informed about the benefits and effectiveness that ECT can offer.

"Some of the professional and popular ambivalence toward ECT is related to the fact that we still do not know exactly how it works”.^[8] The lack of awareness on the effectiveness of ECT and the poor understanding of the exact functionality behind the treatment leads others to believe that ECT is unscientific. “The precise mechanism underlying the efficacy of ECT remains unclear, but one theory is that it promotes neuroplasticity by optimizing or “resetting” existing brain networks".^[9] ECT is thought to be morally wrong, just like other medical procedures that bring up controversy, such as abortion. However, “The best spokespeople for ECT are those patients and their family members who know from personal experience how debilitating depression can be and how effectively ECT can provide relief”.^[8]

"Although electroconvulsive therapy (ECT) is one of the most effective treatments for various psychiatric disorders since its introduction, it is one of the most controversial and scrutinized therapies in psychiatry".^[10] Because it is highly controversial and scrutinized there is lack of importance given to educating students about ECT. "The negative connotations related to ECT tend to get reinforced from lack of knowledge and negative attitudes".^[10] With the lack of knowledge students cannot provide client's all alternatives to their entitled care. Educating students is important because they can go through their career understanding the many alternatives and they can provide patients with a knowledgeable background to support it. "Nurses play an essential role in ECT, because of their close involvement with patients before and after the procedure. The knowledge and attitude of the nursing staff working ECT rooms can have direct impact on the quality of their nursing practice".^[10] In a study, published in the Journal of Neuroscience in Rural Practice, there was a total of 183 nursing students that were surveyed on their knowledge about electroconvulsive therapy. “Only about half (53.6%) of the participants were aware that ECT cannot be given against the wishes of the patients”.^[10] This result has a lot to do with the associated stigma, that patients receive ECT against their will, no treatment is given against the patients wishes. Changing this stigma can happen with knowledge that starts at school. "The present study shows that there are gaps in knowledge about ECT among nursing students… To fill such gaps there is a need to develop more pro-ECT curriculum".^[10]

With the addition of multiple antidepressants and antipsychotics to treat mental disorders, ECT is not widely implemented in the U.S. today, despite the research that suggests it is an effective treatment for severe depression and other mental illnesses. The negative stigma surrounding ECT, thanks to its crude beginnings in psychology along with its perhaps not so accurate portrayal in movies and television, is still alive and well. However, because the methods used to perform ECT have drastically changed since its earlier days, individuals may be more open to trying ECT to relieve their symptoms of severe mental illnesses that have not responded to first line treatment. The fears surrounding the procedure are somewhat justified considering the history, but research and new implementation of ECT by trained physicians has proven that this is a safe and effective treatment that has the potential to help many individuals. Further education in medical and nursing schools will help to further promote the implementation of ECT and help those suffering in the vicious cycle of trying to relieve the symptoms of their mental illness.