Shock therapy (psychiatry)

Shock therapy describes a set of techniques used in psychiatry to treat depressive disorder or other mental illnesses. It covers multiple forms, such as inducing seizures or other extreme brain states, or acting as a painful method of aversive conditioning.

Two types of shock therapy are currently practiced:

• Electroconvulsive therapy (ECT), in which a seizure is induced in the brain, often as an intervention for major depressive disorder, mania, and catatonia. ECT remains a safe and effective treatment in some circumstances in modern psychiatry.
• The graduated electronic decelerator (GED), an aversive device that applies a powerful electric shock as a punishment for undesirable behavior. The device is manufactured by and used exclusively by the Judge Rotenberg Educational Center, a special education institution in Canton, Massachusetts. The GED has been condemned as a torture device by the United Nations Special Rapporteur on Torture.

Other forms, no longer in use, include:

• Insulin shock therapy, introduced by Manfred Sakel in 1933 for the treatment of schizophrenia. This resulted in a coma state for a short amount of time.
• Convulsive therapy, using pentylenetetrazol or other agents to induce seizures. The first use was with cardiazol by von Meduna of Budapest; the belief at the time was there was "some kind of biological antagonism between schizophrenia and epilepsy".
• Deep sleep therapy.

Shock therapy (other than ECT), however, has fallen away in use in lieu of other forms of treatment.

Historical development

Julius Wagner-Jauregg's discovery in 1917 of malaria-induced fever therapy for neurosyphilis highlighted the potential of physical methods to treat mental diseases. This innovative approach, leveraging the therapeutic effects of severe fever, drew inspiration from ancient observations and scientific insights dating back to Hippocrates. Following this, several methods for inducing physiological shock, including insulin coma therapy by Manfred J. Sakel in 1927, metrazol-induced convulsions by Ladislaus J. von Meduna in 1934, and electroconvulsive shock therapy by Ugo Cerletti and Lucio Bini in 1937, were developed. These methods were primarily applied in Europe and were based on the principle that inducing a shock or convulsion could lead to improvements in various mental conditions, particularly schizophrenia and affective psychoses.

The term "shock therapy" gained widespread attention following Sakel's 1933 publication on the efficacy of insulin therapy in schizophrenia treatment. This method, revolutionary at the time for addressing psychosis, entailed insulin injections to induce convulsions and comas. Similarly, the introduction of metrazol-induced convulsions offered a more cost-effective and reliable shock induction method, although it came with severe side effects, including spine fractures in a significant number of patients. By 1938, electroconvulsive therapy (ECT) had emerged as a safer, more reliable alternative, quickly becoming the preferred method for severe depression and other mood disorders due to its safety and efficacy.

Matthew Israel, a psychologist, and the founder of the Judge Rotenberg Educational Centre (JRC), was initially inspired by a utopian depiction where behaviour was regulated through rewards and deterrents. Beginning in 1971, Israel adopted aversive techniques, transitioning in the 1990s to electric shocks and creating the Graduated Electronic Decelerator (GED) to address severe behavioural issues with immediate, discomforting stimuli.

Deep sleep therapy, introduced in the late 20th century, involved placing patients into a drug-induced coma for extended periods, purportedly to treat various mental illnesses.< This approach to mental health treatment was part of a broader search for effective therapies during a time when the psychiatric field was struggling with managing complex conditions. The drugs used for inducing deep sleep, including Tuinal,Neulactil, Sodium Amytal, Placidyl, and Serenace, were highly controlled substances, reflecting the serious nature of the treatment. Despite its innovative promise, this method raised significant ethical and safety concerns, especially regarding patient selection and oversight.

Criticism

The use of shock treatments, especially insulin and metrazol, was initially enthusiastic and widely adopted, but it subsequently decreased as more potent neuroleptics and antidepressants were developed, along with rising ethical concerns and the emergence of the anti-ECT movement in the 1970s.

The dangers of deep sleep therapy were highlighted by the tragic case of 23-year-old Ronald Carter, reported by the Sydney Morning Herald in November 1967. On May 3, 1967, Ronald Carter passed away while undergoing the treatment, indicating the risks involved and sparking a debate about the ethical considerations of using this approach to treat mental illness. Despite this incident, and the reported discretion by nurses in administering drug cocktails to patients, there was a notable lack of regulatory action from health authorities, allowing the practice to continue unchecked for another 12 years under the direction of Dr. Bailey. When the Chelmsford Private Hospital in Australia reported the death of 24 patients between 1963 and 1979 due to this treatment, deep sleep therapy was generally rejected as a treatment option.

Insulin shock therapy was discontinued due to critical concerns over its safety and effectiveness. This method, which induced comas in patients through insulin injections, resulted in severe adverse effects, including hypoglycemic episodes, seizures, obesity, and in some cases, irreversible brain damage that was mistakenly regarded as therapeutic progress. With a fatality rate up to nearly 5 percent and the advent of antipsychotic drugs offering safer alternatives, the intense care needed and lack of conclusive evidence supporting its efficacy led to its discontinuation in favour of more humane and evidence-based psychiatric treatments. In the 1960s insulin shock therapy was largely discredited and is now no longer used.

Additionally, the Judge Rotenberg Educational Center's use of the GED has been criticised for years. The device was declared to pose an "unreasonable and substantial risk of illness or injury" in July 2021, prompting a one-year ban on its use, which many disability activists view as torture. The facility claims that GEDs are only given as a last resort and only in situations when the beneficiaries would otherwise be in risk of dying or suffering serious physical harm, which is why the prohibition was only in place for a year.

Efficiency of currently practiced shock therapies

Although the ineffectiveness of shock therapies, such as insulin shock therapy and deep sleep therapy, resulted in their discontinuation, contemporary forms still in use have demonstrated their effectiveness and significance in medical practice.

The Lima et al.'s (2013) study offers a comprehensive systematic review of electroconvulsive therapy (ECT) for adolescents, concentrating on its efficacy, application criteria, and associated risks. Highlighting ECT's notable success in addressing diverse psychiatric conditions among adolescents, the study portrays it as a highly effective treatment strategy that yields substantial remission rates while incurring minimal and generally mild side effects.

According to further studies, the Graduated Electronic Decelerator (GED) was found to be highly effective in managing violent self-injurious and assaultive behaviours in a cohort of patients with intellectual disabilities (IDs) and/or autism spectrum disorder (ASD). The study reported a significant reduction in the frequency of severe problem behaviours by 97% within the observed patient group. This effectiveness was observed across various patterns of patient response to the GED, including cases where behaviours immediately returned upon removal of the device and cases where the GED could be permanently removed after the cessation of problem behaviours. The findings underscore the GED's potential as a critical intervention for individuals with treatment-resistant violent behaviours, despite the controversies surrounding its use.

See also

• Shock therapy (disambiguation)