Electro convulsive therapy and brain surgery

  ECT was certainly overused after it was introduced in the 1930s right through to the 1960s. It continued to be used in schizophrenia and for disturbed behaviour although it had become clear that its main effect is in depression. The original treatments were given without anaesthetic. Ostensibly to ‘treat’ disturbed behaviour, its application, and the threat of it, was undoubtedly sometimes misused as punishment. Sensationalist and misleading portrayals, such as the unmodified ECT given to Jack Nicholson in One Flew Over the Cuckoo’s Nest, continued to fan the controversy.

  In many countries ECT is almost impossible to obtain in public psychiatry – in Italy and Greece and Spain for instance and in California in the US. In England and several US states a ban has been proposed several times but not legislated. Some of this is undoubtedly because of its earlier overuse – many of its fiercest critics are people who received it inappropriately without benefit. However, even for those who support it, there is something very offputting about it. It seems such a ‘crude’ assault on that most delicate and important of our organs, the brain. ECT is experienced as an affront to our nature as creative and sentient beings – particularly so as we really do not know how it works. It is vigorously opposed by groups such as the Church of Scientology.

  Even more shocking than the overuse of ECT was the crusade of brain surgery conducted by Watts and Freeman in the early 1950s in the US. Brain surgery in psychiatry followed the observation of a freak accident in a Pittsburgh steel mill where a foreman, Phineas Gage, survived a bar passing through his head. The only damage noted was some change in personality – he became more easy-going (but also a bit more disinhibited and foul-mouthed). Severing the connections to the front part of the brain (where the bar had passed) was tried as a last-ditch attempt to reduce intolerable chronic anxiety or disturbed behaviour. It is called leucotomy in Europe and lobotomy in the US and was introduced by a Portuguese psychiatrist Egon Moniz in 1935. He received the Nobel Prize for it in 1949 and, in an ironic twist of fate, was shot dead by a disgruntled patient in 1955.

  Psychosurgery probably can help a very limited group of individuals absolutely disabled with severe obsessive compulsive disorder or chronic depression. It appears to work by making the patient uninterested in their symptoms, rather than abolishing them. The patient experiences the obsessional thoughts but doesn’t ruminate on them and is able to ignore them. There are changes in personality with the operation – the patient is said to become somewhat ‘blunted’.

  Brain surgery evokes the same disquiet as ECT. It seems altogether too invasive and brutal. The explanation of how it works is superficial and unconvincing. Freeman and Watts developed a very simple version of the operation that only required a local anaesthetic. Playing down the risks, they travelled across the US carrying out thousands of these operations in large mental hospitals. Between 1939 and 1951 over 50,000 such operations were performed in the US, 3,439 by Freeman alone. Modern techniques are very different (usually involving the destruction of a couple of cubic millimetres of brain tissue) and highly regulated. Only a couple of dozen operations a year are conducted in the UK and the same number in the US. Nevertheless it remains a highly charged issue and one where people rarely change their opinions.