Electroshock therapy has long suffered from a controversial and bizarre public image, effectively removing it as a treatment option for many patients. In Electroshock, Max Fink, M.D., draws on 45 years of clinical and research experience to argue that ECT is now a safe, painless, and sometimes life-saving treatment for emotional and mental disorders.
Dr. Fink traces the development of ECT from its discovery in 1934 followed by widespread use for two decades, to the 1950s when it was largely replaced by the introduction of psychotropic drugs, to its revival in the past twenty years as a viable treatment. He provides actual case studies of patients who have been treated with ECT and illustrates that many disorders--such as depression, mania, catatonia, and schizophrenia--respond well to it. As he explains the whole procedure from preparation to recovery, we see what the patient experiences. Fink also shows how anesthesia and muscle relaxation have refined ECT, minimizing discomfort and reducing risks to a level far lower than those experienced by patients using psychotropic drugs routinely prescribed for the same problems.
Clarifying the many misconceptions surrounding ECT, Electroshock is an excellent sourcebook for patients, their families, and mental health professionals.
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From The New England Journal of Medicine:
Max Fink, M.D., is Professor of Psychiatry and Neurology Emeritus at the State University of New York at Stony Brook and Attending Psychiatrist at the Long Island Jewish-Hillside Hospital Medical Center. He is the author of Convulsive Therapy: Theory and Practice, Psychobiology of Convulsive Therapy, and other books. He lives in Nissequogue, New York.
In this book, Dr. Max Fink has made another important contribution to patients and physicians by filling the gap between standard patient-education materials on electroconvulsive treatment, most of which are dated as compared with information available at www.electroshock.org or other Web sites, and the specialized literature. Electroshock is written in language that will be easily understood by laypersons, and the supplemental notes and references will be very informative for primary care physicians who treat most of the depressed patients who should be referred for electroconvulsive treatment when standard medication is ineffective.
Psychiatrists unfamiliar with electroconvulsive treatment may be embarrassed to discover that concern about its risk is greatly exaggerated and that relapse after electroconvulsive treatment indicates a need for maintenance treatment, not a lack of efficacy. Even authorities on drug treatment are puzzled by the broad spectrum of efficacy of electroconvulsive treatment. For example, all antidepressants can cause mania, but only electroconvulsive treatment can treat it, and no antidepressant drug has been shown to be as effective as electroconvulsive treatment for treating schizophrenia. In bipolar disorder, electroconvulsive treatment is often effective when mood stabilizers fail. In treating catatonic states for which benzodiazepines are the best drug treatment, electroconvulsive treatment succeeds when these drugs fail. These findings do not fit with any data from the neurosciences on receptor mechanisms or second and third messengers.
After briefly defining electroconvulsive treatment and outlining its uses, Fink discusses the patient's experience. He then describes the risks and technical features of the treatment and the contraindications to it. There are chapters on each of the principal indications for electroconvulsive treatment: depression, mania, thought disorders, and movement disorders, which include catatonic states and parkinsonian rigidity. There is some speculation about the mechanism of action (which is unknown), a brief account of the fascinating origins of electroconvulsive treatment, and considerable discussion of how electroconvulsive treatment became controversial. Each of the clinical chapters contains detailed case reports, and some chapters also contain autobiographical accounts from the popular literature. These profiles reiterate the benefits of the treatment, the often tragic consequences of withholding it or using it inappropriately without consideration of the need for maintenance treatment, and the minimal medical risks and cognitive side effects with current practice. The discussion of informed consent for use in minors and incompetent patients is exemplary.
The negative feelings about electroconvulsive treatment evoked by the movie One Flew over the Cuckoo's Nest, based on the novel by Ken Kesey (New York, Viking Press, 1962), are still widespread, but most people, when faced with drug-refractory mental illness in a family member or themselves, realize that the movie does not reflect reality. A more important contribution to the decline in the availability of electroconvulsive treatment in this country was an influential report by the Group for the Advancement of Psychiatry, published in 1947, that stressed its overuse. This accusation was based on the now absurd idea that because all mental illness could be treated effectively only by psychotherapy, any other intervention might interfere with the patient's working through the underlying psychological issues. The frequent two-to-three-week period of confusion associated with electroconvulsive treatment at this time supported this idea. Further criticism came from the now discredited works of Thomas Szasz and other "antipsychiatrists."
Despite the advent of effective pharmacologic agents, psychogenic theories of mental illness remained prominent until the mid-1970s, and the use of electroconvulsive treatment was considered to be an indication of inadequate psychotherapy. The more economically pragmatic Church of Scientology viewed electroconvulsive treatment as a threat, regularly demonstrated against its use, and spearheaded severe legislative restrictions in California. The legislatures of Colorado, Tennessee, and Texas have banned electroconvulsive treatment for suicidal adolescents. Similar bills are pending in Arizona and Vermont. Uninformed criticism was also recently evoked by the leaking of a draft of the surgeon general's favorable report on electroconvulsive treatment.
Despite intensive pharmaceutical research, it now appears that the benefits of the new drugs for depression and schizophrenia are mostly decreased side effects and improved compliance; there is little increased efficacy in refractory conditions, which underscores the need for a trial of electroconvulsive treatment. Although new agents for bipolar disorder are more promising, the need for electroconvulsive treatment to treat refractory conditions remains.
My only concern about Electroshock is that the author is rather unfocused in his critique of psychopharmacologic treatment. The kernel of truth is that such treatment often harms patients by repeated switching or adding of drugs during refractory states owing to the unavailability of or ignorance about electroconvulsive treatment. Nevertheless, it would be unfortunate if some inaccurate or controversial details in the book were misused to justify failing to use electroconvulsive treatment when indicated. On the positive side, by increasing general awareness, the book should facilitate the restoration of electroconvulsive treatment to its appropriate place in contemporary psychiatric treatment.
Reviewed by Chester Pearlman, M.D.
Copyright © 2000 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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