Electroconvulsive Therapy: A Historical and Legal Perspective

Electroconvulsive therapy (ECT) is one of the oldest medical treatments still in regular use. First performed in 1938 in Italy, ECT was invented to replace less reliable, more unpleasant methods of inducing seizures (e.g., camphor, insulin-coma therapy) (1).

Until the 1950s, pharmacotherapy for psychiatric disorders was extremely limited. Hence, ECT was applied broadly—for substance abuse, schizophrenia, hysteria, and anxiety. It was even used for homosexuality, which remained a diagnosis in the DSM until 1973. Earlier forms of ECT often caused severe confusion and memory loss, without justifiable accompanying benefits (1). Safety and side-effect concerns have since been addressed by methodological changes, including the use of neuromuscular blockers, sedatives, physiologic monitoring, airway management, dose titration, and varied electrode placements (2). Nevertheless, such historical precedents have contributed to the stigmatization of ECT among the public.

Legislative hurdles have limited the use and availability of ECT, at times resulting in treatment being delayed for weeks while patients await court hearings (1). Unlike most other treatments in medicine, including far more invasive procedures, a health-care power of attorney may not be able to consent to ECT on a patient's behalf (see Table 1). Ten states require court approval if the patient is unable or unwilling to consent (3). Twenty states have specific legislation limiting ECT use, and three have legislation more stringent than APA guidelines (3). For example, in Texas, ECT is banned for use among all patients under age 16, and the state mandates registration of ECT devices and quarterly reports from treating facilities.

Such restrictions on ECT stemmed in part from the antipsychiatry and antiauthoritarian movements of the post-World War II era, as well as negative media portrayals (4). These movements brought to the mainstream the ideas that psychiatric illness was a social construct and psychiatrists were agents of the state who enforced societal norms by pathologizing undesirable behaviors (1). By the 1970s, activists seeking to limit psychiatric treatment found that lobotomies and other biological treatments had been largely phased out. ECT and involuntary commitment remained legislative targets within the broader movement for patient rights and deinstitutionalization. Wyatt v. Hardin (1975), Aden v. Younger (1976), Price v. Sheppard (1979), and similar suits mandated additional ECT oversight, mainly from courts, physicians, and hospital directors (5). Since 1978, APA task force reports on ECT have supported the use of ECT for medication-resistant depression, pregnant or elderly patients, and cases necessitating rapid treatment responses. However, ECT is often the treatment of last resort (5). Delaying ECT not only prolongs distressful symptoms, but also contributes to the development of treatment-resistant affective disorders and worsens catatonia, and it can be lethal in malignant catatonia.

With advances in neurobiological research, the line between psychiatry and neurology has become increasingly blurred and there has been a resurgence in the use of ECT. Yet clinicians may still find themselves having to delay safe and effective treatment while awaiting court approval due to outdated, inaccurate perceptions. As a matter of justice and timely access to effective treatment—and with new knowledge—perhaps it is time to revisit these laws that bar much-needed care.