Assignment: Evidence-Based Project, Part 1: Identifying Research Methodologies

 

s there a difference between “common practice” and “best practice”?

When you first went to work for your current organization, experienced colleagues may have shared with you details about processes and procedures. Perhaps you even attended an orientation session to brief you on these matters. As a “rookie,” you likely kept the nature of your questions to those with answers that would best help you perform your new role.

Over time and with experience, perhaps you recognized aspects of these processes and procedures that you wanted to question further. This is the realm of clinical inquiry.

Clinical inquiry is the practice of asking questions about clinical practice. To continuously improve patient care, all nurses should consistently use clinical inquiry to question why they are doing something the way they are doing it. Do they know why it is done this way, or is it just because we have always done it this way? Is it a common practice or a best practice?

In this Assignment, you will identify clinical areas of interest and inquiry and practice searching for research in support of maintaining or changing these practices. You will also analyze this research to compare research methodologies employed.

To Prepare:

• Review the Resources and identify a clinical issue of interest that can form the basis of a clinical inquiry. Keep in mind that the clinical issue you identify for your research will stay the same for the entire course. 
• Based on the clinical issue of interest and using keywords related to the clinical issue of interest, search at least four different databases in the Walden Library to identify at least four relevant peer-reviewed articles related to your clinical issue of interest. You should not be using systematic reviews for this assignment, select original research articles.
• Review the results of your peer-reviewed research and reflect on the process of using an unfiltered database to search for peer-reviewed research.
• Reflect on the types of research methodologies contained in the four relevant peer-reviewed articles you selected.

Part 1: Identifying Research Methodologies

After reading each of the four peer-reviewed articles you selected, use the Matrix Worksheet template to analyze the methodologies applied in each of the four peer-reviewed articles. Your analysis should include the following:

• The full citation of each peer-reviewed article in APA format.
• A brief (1-paragraph) statement explaining why you chose this peer-reviewed article and/or how it relates to your clinical issue of interest, including a brief explanation of the ethics of research related to your clinical issue of interest.
• A brief (1-2 paragraph) description of the aims of the research of each peer-reviewed article.
• A brief (1-2 paragraph) description of the research methodology used. Be sure to identify if the methodology used was qualitative, quantitative, or a mixed-methods approach. Be specific.
• A brief (1- to 2-paragraph) description of the strengths of each of the research methodologies used, including reliability and validity of how the methodology was applied in each of the peer-reviewed articles you selected.

ARTICLE ONE

Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness.
Authors:
Hirshbein, Laura D.
Source:
Journal of the History of the Behavioral Sciences Spring2010; Vol. 46 (2).
Language:
English
Journal Info:
Publisher: Wiley-Blackwell ISSN: 0022-5061
Update Code:
20100427
DOI:
10.1002/jhbs.20431
PMID:
EPTOC49733042
Database:
MEDLINE with Full Text

ARTICLE 2
History, power, and electricity: American popular magazine accounts of electroconvulsive therapy, 1940–2005.
Authors:
Hirshbein, Laura1 lauradh@med.umich.edu
Sarvananda, Sharmalie2
Source:
Journal of the History of the Behavioral Sciences. Winter2008, Vol. 44 Issue 1, p1-18. 18p.
Document Type:
Article
Subject Terms:
*ELECTROCONVULSIVE therapy
*PSYCHIATRIC treatment
*ELECTROTHERAPEUTICS
*SHOCK therapy
Geographic Terms:
UNITED States
Abstract:
Electroconvulsive therapy (ECT) is a psychiatric treatment that has been in use in the United States since the 1940s. During the whole of its existence, it has been extensively discussed and debated within American popular magazines. While initial reports of the treatment highlighted its benefits to patients, accounts by the 1970s and 1980s were increasingly polarized. This article analyzes the popular accounts over time, particularly the ways in which the debates over ECT have revolved around different interpretations of ECT’s history and its power dynamics. © 2008Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

Copyright of Journal of the History of the Behavioral Sciences is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)
Author Affiliations:
1Assistant Professor of Psychiatry, University of Michigan
2University of Michigan
ISSN:
0022-5061
DOI:
10.1002/jhbs.20283
Accession Number:
28528289
Database:
Academic Search Complete
Publisher Logo:
Wiley-Blackwell
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article 3

Effects of electroconvulsive therapy in the systemic inflammatory balance of patients with severe mental disorder.

Images

Diagram Chart Graph Graph Chart

Authors:

Bioque, Miquel1,2,3,4 (AUTHOR)

Mac‐Dowell, Karina S.3,5 (AUTHOR)

Meseguer, Ana1,3 (AUTHOR)

Macau, Elisabet6 (AUTHOR)

Valero, Ricard7,8 (AUTHOR)

Vieta, Eduard2,3,4,9 (AUTHOR)

Leza, Juan C.3,5 (AUTHOR) jcleza@med.ucm.es

Bernardo, Miquel1,2,3,4 (AUTHOR) bernardo@clinic.cat

Source:

Psychiatry & Clinical Neurosciences. Oct2019, Vol. 73 Issue 10, p628-635. 8p. 1 Diagram, 2 Charts, 2 Graphs.

Document Type:

Article

Subject Terms:

*ELECTROCONVULSIVE therapy

*MENTAL illness

*NITRIC-oxide synthases

*MENTALLY ill

*INFLAMMATORY mediators

Author-Supplied Keywords:

biomarkers

ECT, electroconvulsive therapy, immune system, inflammation

Abstract:

Aim: There is a great interest in the role of the immune system and the inflammatory balance as key mechanisms involved in the pathophysiology of severe mental disorders. Previous studies have indicated that electroconvulsive therapy (ECT) produces changes in certain inflammatory mediators or in the immune system response. This study aimed to explore the effects of ECT on the nuclear transcription factor
κB (NFκB) pathway, a main regulatory pathway of the inflammatory/immune response. Methods: Thirty subjects with a severe mental disorder receiving treatment with ECT in our center were included. Thirteen systemic biomarkers related to the NFκB pathway were analyzed right before and 2
 
h after a single ECT session. Results: An ECT session significantly decreased the expression of NFκB (P =
 
0.035) and of the inducible nitric oxide synthase (P =
 
0.012), and the plasma levels of nitrites (P =
 
0.027), prostaglandin E2 (P =
 
0.049), and 15‐deoxy‐PGJ2 (P <   0.001). Decrease in plasmatic levels of nitrites was greater in females than in males (P =   0.021). A positive correlation between the ECT stimulus load and changes in the expression of NFkB was found (P =   0.036). Thiobarbituric acid reactive substance levels were decreased in treatment responders and increased in non‐responders (P =   0.047). Conclusion: Our study shows the effects that a single session of ECT produces on a canonical regulatory pathway of the inflammatory/innate immune system and the inflammatory balance. These biomarkers could be useful as treatment response targets and could help to clarify the biological basis of ECT action. These findings warrant greater attention in future investigations and in the translational significance of these data. [ABSTRACT FROM AUTHOR] Copyright of Psychiatry & Clinical Neurosciences is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.) Author Affiliations: 1Barcelona Cl ínic Schizophrenia Unit, Neuroscience Institute, Hospital Clínic de Barcelona, Barcelona Spain 2Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona Spain 3Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Madrid Spain 4Department of Medicine, University of Barcelona, Barcelona Spain 5Department of Pharmacology & Toxicology, Faculty of Medicine, Universidad Complutense de Madrid, Instituto de Investigación I+12 y IUIN, Madrid Spain 6Psychiatry Department, Neuroscience Institute, Hospital Clínic de Barcelona, Barcelona Spain 7Anesthesia Department, Hospital Clínic de Barcelona, Barcelona Spain 8University of Barcelona, Barcelona Spain 9Barcelona Bipolar Disorder Program, Psychiatry Department, Neuroscience Institute, Hospital Clínic de Barcelona, Barcelona Spain Full Text Word Count: 6282 ISSN: 1323-1316 DOI: 10.1111/pcn.12906 Accession Number: 138990292 Database: Academic Search Complete Publisher Logo: Wiley-Blackwell Article 4 Adverse effects of electroconvulsive therapy on cognitive performance Authors: Sasha S. Getty Lawrence R. Faziola Source: Mental Illness, Vol 9, Iss 2 (2017) Publisher Information: Emerald Publishing, 2017. Publication Year: 2017 Collection: LCC:Medicine LCC:Psychiatry Subject Terms: electroconvulsive therapy, cognitive performance Medicine Psychiatry RC435-571 Description: Not available Document Type: article File Description: electronic resource Language: English ISSN: 2036-7457 2036-7465 Relation: http://www.pagepress.org/journals/index.php/mi/article/view/7181; https://doaj.org/toc/2036-7457; https://doaj.org/toc/2036-7465 DOI: 10.4081/mi.2017.7181 Access URL: https://doaj.org/article/f3ec8b67b007478b8b01590f1cc0f5b2 Accession Number: edsdoj.f3ec8b67b007478b8b01590f1cc0f5b2 Database: Directory of Open Access Journals Result List Refine Search PrevResult 20 of 293

Journal of the History of the Behavioral Sciences, Vol. 46(2),

208

–209 Spring 2010
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20426
© 2010 Wiley Periodicals, Inc.

B O O K R E V I E W S

Benjamin Reiss. Theaters of Madness: Insane Asylums and Nineteenth-Century American
Culture. Chicago, IL: University of Chicago Press, 2008. xi � 237 pp. $50 (cloth).
ISBN-13: 978-0-226-70963-5.

Benjamin Reiss’s Theaters of Madness is a fascinating attempt to enliven and deepen the
literature on cultural definitions of madness and their implications for democratic institutions.
A literary scholar with historical sensibilities, Reiss offers readings of a wide variety of
“texts” to add irony and nuance to our understanding of what he views as a central problem
for nineteenth-century Americans: the involuntary restraint of those deemed mentally inca-
pable of responsibly exercising personal liberty. He demonstrates from the outset that the
issue resonated beyond legal and medical circles to the broader cultural horizon. Politicians,
reformers, and creative artists grappled with the challenge of insanity to republican institu-
tions and focused on the asylum as the embodiment of their hopes and fears. Reiss presents
brief insightful commentary on major scholarly views of the asylum movement and attempts
to penetrate the consciousness of incarcerated citizens even as he assesses the meaning of asy-
lum reform in its own time and for the present.

Theaters of Madness gives us neither a comprehensive historical reconsideration nor a
thoroughgoing revision of Erving Goffman or Michel Foucault. Rather, Reiss uses a kaleido-
scopic approach that mines forgotten details of asylum history and offers new readings of
classic texts. He brings together six essay-length chapters engaging “cultural life in the
nineteenth-century asylum and asylum life in nineteenth-century culture” in the cause of
“recording the dialectical tension between the institutional processing of culture and the cul-
tural processing of the institution” (p. 17).

These “snapshots,” as Reiss calls his individual explorations, remind one of the occa-
sional motion picture that seeks the soul of a city or the essence of an emotion by collecting
short subjects around its theme, but instead of Paris or Love the focus is the asylum. Three
pieces look at aspects of life inside the walls and three take the view from without. Woven
into all six chapters are considerations of race, creativity, gender, power, and the paradoxical
responses of republican society as it sought a means to control personal behavior it deemed a
threat to personal liberty. Reiss makes no claim for “thoroughness or even representativeness”
and describes some of his cases as “transparently exceptional, strange, or offbeat.” Instead, he
notes, he followed his nose in seeking subjects that illustrated “individuals caught up in a sys-
tem that would erase their particularity in order to return them—paradoxically—to a society
that valued individual liberties above all” (p. 17).

The most original chapters are those devoted to the inmates themselves. Reiss tracks the
career of A. S. M., who became a patient at the New York State Lunatic Asylum at Utica in
1843, less than a year after its founding. Eight years later he became editor of the Opal,
a patient-run and -written literary magazine of the sort most scholars have deemed simply tightly
controlled “house organs” that reflected little of the patients’ true feelings about incarceration.
Assuming that central truth, Reiss argues that subtexts abound in such writings, and spins out an
extremely wide-ranging and interesting argument that places the Opal within antebellum literary
culture as well as within the internal structure of the institution. The author sees in the talented
but odd A. S. M.—he writes on asylum walls and eats his own feces—a creative mind who actu-
ally feels safer at the asylum than in society and, as Reiss notes, wants “to stay put.”

208

Reiss argues that this position was itself a rebuke of the official asylum vision, which sought
ways to make the insane normal enough to return to society (p. 47).

A chapter on the inmate troupe of blackface minstrels active at the Utica asylum in the
1840s and 1850s reveals an equally fascinating interpretive weave that moves from institution
to society at large. Reiss juxtaposes questions of race and freedom as well as order and dis-
order. He finds complex meaning in the pairing of two marginal groups, black and insane, on
the stage of the asylum, and explores the intentions of the asylum’s administrators and doc-
tors in encouraging these “entertainments.” Reiss also speculates on the possible meanings of
such shows for the patients, with twists and turns that illuminate the history of minstrelsy in
“normal” society as well as within the institutions. A similar juxtaposition of the visions of
authorities and inmates highlights the chapter on Shakespeare and his vogue among psychia-
trists of the era.

The last three chapters, not quite as startlingly engaging, in part because of our famil-
iarity with the literary figures involved, continue an unfolding interpretation through literary
works and circumstance that link society and institutions for the insane: Ralph Waldo
Emerson sadly endorses the incarceration of a poet whose talents he celebrated; Edgar Allan
Poe comments on society, republicanism, and madness in his short story, “The System of
Doctor Tarr and Professor Fether”; and popular exposés of patient life dampen public enthu-
siasm for the asylum. Themes the author articulates in the early chapters now find expression
outside the asylum walls.

Despite its wide-ranging and highly speculative bent, Theaters of Madness serves the
salutary function of reopening the question of the asylum and madness in original readings of
both familiar and unfamiliar cases. It does so across disciplines and with due respect for the
scholarship that preceded it. One need not agree with Reiss’s methods or interpretive sugges-
tions to sense their usefulness. He admits the limits of his inquiry early on and throughout but
employs this strategic modesty in the cause of humanizing and rehistoricizing his subject.
Always creative, though sometimes with a frustratingly thin supply of evidence, Theaters of
Madness offers a rich read of nineteenth-century America’s grappling with one of the most
intractable aspects of the human condition.

Reviewed by ROBERT H. ABZUG, Department of History, University of Texas at Austin, Austin,
TX 78712.

Journal of the History of the Behavioral Sciences, Vol. 46(2), 209–211 Spring 2010
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20427
© 2010 Wiley Periodicals, Inc.

George Makari. Revolution in Mind: The Creation of Psychoanalysis. New York: Harper-
Collins, 2008. 613 pp. $32.50 (cloth). ISBN 978-0-06-134661-3.

George Makari, a psychoanalyst, psychiatrist, and historian, set himself an ambitious,
seemingly unattainable task. He sought to provide a detailed, comprehensive account of the
development of psychoanalysis from the beginnings in the late nineteenth century until
the end of World War II. In accomplishing his task, he has created a masterwork. Despite my
having what I think of as an extensive background in this area, I found myself continually sur-
prised by how much new I was learning. Makari not only provides all the specifics, such as

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accounts of the thinkers and intellectual movements that set the stage for psychoanalysis, of
the battles among various early psychoanalysts, and of the interaction between psychoanalytic
ideas and the surrounding culture. He also formulates integrative theses about the larger
themes of each period of psychoanalytic history.

As Makari argues, a great challenge faced the Western world in the second half of the
twentieth century: how to understand the inner life of human beings. The traditional explana-
tions offered by philosophy and religion were seen as wanting. Science seemed to have ex-
plained the workings of the outer world, with discoveries in physics, chemistry, and biology.
But how to make sense of what goes on in the deepest recesses of a person, in a person’s mind?

At the same time, various odd phenomena, little understood by science, seemed to point
in the direction of the hidden workings of the mind. There was the disease of hysteria, in which
an apparently physical disorder, such as a paralysis, exists despite there being no physical
cause. Hypnosis also showed that the mind operates out of consciousness. And then there were
sexual perversions and fetishes; why would people act in such seemingly irrational ways?

Sigmund Freud, Makari points out, developed a theory of mind that co-opted three of the
major movements of the time: psychophysics, an attempt to construct a scientific psychology;
French psychopathology, which showed that psychiatric disorders had causes; and sexology,
the study of sexual behavior as pioneered by Richard von Krafft-Ebing and Havelock Ellis.
Not only was Freud’s early version of psychoanalytic theory more elegant and comprehensive
than any of the other views of the day, but it came with a method of treatment, the first widely
used form of psychotherapy. By contrast to Freud, the consensus view of the French psy-
chopathologists, such as Jean-Martin Charcot, was that psychiatric disorders, because they
stemmed from degeneracy, could not be cured.

As psychoanalysis developed, there were constant battles. Those who differed too
sharply with Freud, such as Alfred Adler and Carl Jung, came to be branded as dissidents and
they quit, or were expelled from, the movement. Makari perceptively notes that Freud regu-
larly extruded the dissidents and then incorporated key elements of their thinking in his var-
ious reformulations of psychoanalytic theory. For example, he drew from Adler’s emphasis on
the importance of inferiority when he introduced the concept of narcissism, and he partially
answered Jung’s complaint about the overemphasis on sexuality when he added the aggres-
sive drive to his focus on the sexual drive.

By the 1920s and 1930s, Freud was still the central figure in psychoanalysis, but others
now played a role in contributing to the field. For example, Karl Abraham, while using some
of Freud’s formulations, systematized the theory of psychosexual stages (oral, anal, phallic).
Wilhelm Reich, again taking some hints from Freud, went beyond him in pointing out the im-
portance of character (prefiguring our current interest in disorders of the whole personality,
as opposed to discrete symptoms such as depression or a phobia). And Anna Freud took her
father’s stray comments about defenses and developed a systematic theory of the mechanisms
of defense.

At Freud’s death in 1939, psychoanalysis was a powerful, widespread movement that
could carry on without him. Although Nazism virtually killed it off in Germany and Austria,
psychoanalysis emerged from World War II with a strong foundation, especially in the United
States and Great Britain. Makari notes that it was “the leading modern theory of the mind”
(p. 485), with influence throughout Western culture, not only in psychiatry but also in liter-
ary studies, the courts, education, film, and our view of politicians.

It seems to me petty, in the light of Makari’s achievement, to point out criticisms. I do
note, though, that in concentrating on the German-speaking and English-speaking countries,
he has little to say about France and South America. And, in his discussion of the United

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States, he focuses on New York City and underemphasizes developments in other cities, such
as Chicago and Boston.

Makari delineates convincingly the central problem for psychoanalysis throughout its
development. Psychoanalysis revolves around the unconscious, but the unconscious, by its
very nature, is not accessible to consciousness; it cannot be known. When there were disputes
between two thinkers, as there were constantly, there was no valid way of deciding which
point of view was better. Is there such a thing as the death instinct? Do women think of them-
selves as castrated men? Should psychoanalytic clinicians stick strictly to interpreting the
unconscious or should they try to help patients in other ways? There is no sure way of an-
swering these questions and many others that confront psychoanalysts.

Yet psychoanalysis has developed into an invaluable, varied, penetrating set of under-
standings of the inner world. The large majority of its practitioners have moved beyond the nar-
row, doctrinaire aspects that were so limiting in the earlier years. While Makari does not say
explicitly how this happened, his study provides the material for constructing an explanation.
Freud developed an elegant theory, or, more accurately, series of theories, that sought to give
explanations for a wide range of psychological phenomena, including psychiatric symptoms,
artistic creation, character problems, ambition, and leadership. His theory attracted followers
and provided them with a basic approach that could be altered and improved upon. Many, per-
haps most, of the specifics are no longer widely accepted by psychoanalysts, even notions that
were central to Freud, such as the universality of the Oedipus complex and the pervasiveness
of sexual conflict. But the contours of Freud’s approach provided a general view of the mind
that is central to our culture’s current view and that forms the underpinnings of psychody-
namic and cognitive psychology. The view is that people are frequently unaware of their mo-
tivations, they suffer from unconscious conflicts, and they form relationships based on their
previous experiences, especially those of childhood.

Freud also created psychotherapy, a method for treating psychiatric disorder, at a time
when no effective treatments existed. And capitalizing on the attraction that his theories and
method of treatment had, he built a movement that grew steadily over the years. Hence there
was a body of intelligent, curious people who were dedicated to the understanding of the inner
world. And one factor kept them grounded. They treated patients. Because psychoanalytic
method is based on listening as patients explore their thoughts in depth, the psychoanalytic
practitioners all had extensive exposure to other people’s personal experience. In addition,
there is a self-correcting factor built into the field. Systematic studies of different treatment
approaches seem to be of limited value for psychoanalysis and psychoanalytic therapy. But
over the years, and in a myriad of ways, the field changes and improves based on what brings
the best results. Individual therapists learn from supervisors and case conferences and from
the psychoanalytic literature, and treatment methods increasingly, if imperfectly and slowly,
become more refined.

Reviewed by JAMES WILLIAM ANDERSON, Clinical Professor of Psychiatry and Behavioral
Sciences, Northwestern University, Chicago, IL.

Journal of the History of the Behavioral Sciences, Vol. 46(2), 212–213 Spring 2010
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20428
© 2010 Wiley Periodicals, Inc.

Kurt Danziger. Marking the Mind: A History of Memory. Cambridge: Cambridge
University Press, 2008. 320 pp. $108 (cloth) ISBN-13: 978-0521898157. $42 (paper)
ISBN-13: 978-0521726412. $37.32 (Kindle edition) ASIN: B001JEPW9K.

This book is a continuation of Kurt Danziger’s last book, Naming the Mind (1997). The
latter covered the history of psychological categories like intelligence, behavior, attitude, mo-
tivation, and personality. All of them are of relatively recent origin and it is easy to appreci-
ate their social basis when it is known that they have a short history. The category of memory
is a very different proposition. It has existed since the beginning of recorded history and has
been the subject of human discourse ever since. It might, therefore, be tempting to see it as a
natural kind, that is, a category that reflects the division of nature itself.

Because of this, Danziger opens the book with a question: “Does memory have a his-
tory?” Memory is usually seen as a quasi-biological phenomenon that does not vary over
time. The only thing that might vary is our understanding of how it works. Danziger clearly
does not accept this view. A key concept here is that of “mnemonic values.” Societies differ
in the expectations they place on memory and the resources they provide for the fulfillment
of these tasks. To take an obvious example, greater demands are placed on memory in non-
literate societies. This explains the importance of mnemonics in the ancient and medieval
worlds. It is no accident that they declined in importance after the invention of the printing
press. Technological developments can also lead to new demands. In nonliterate societies, ac-
curate recall is not an important issue. Thus, music that is part of an oral tradition is rarely
played the same way twice, just as stories that are part of an oral tradition are rarely told the
same way twice. The availability of written records, as well as later developments like
the photograph and the phonograph, brought the issue of accuracy to the fore. Technology has
also provided us with metaphors of memory. These have ranged from the wax tablet to the
digital computer. An important point that Danziger makes is that these metaphors are not
adopted at random. They are intimately related to the memory practices of the society in
which they exist. For example, the adoption of accuracy as a mnemonic value led to the idea
of memory as a copying machine. The very notion of memory had changed as a result.

As Danziger points out, the entire history of memory cannot be covered in a single book.
Indeed, one human lifetime would not be enough to cover it. He therefore selects different
topics for the chapters of the book. Each one has its own chronology and is almost an inde-
pendent piece of work. The topics covered include metaphors of memory, the use of mnemon-
ics for improving memory, the relationship between memory and truth, the medicalization of
memory, the rise of experimental psychology, the different types of memory that have been
postulated over the years, such as episodic and semantic memory, and the various attempts to
locate memory in the brain. Some of the details in these discussions are very interesting. We
learn, for example, that Wundt did not establish an experimental psychology of memory be-
cause he did not regard it as a legitimate scientific category. Like reading or counting, “re-
membering” was an activity of the mind that was based on more fundamental processes.
These views were not unusual in Germany at the time. We also learn that the work of Wilder
Penfield has been widely misinterpreted. Penfield famously applied electrical stimulation to
the brains of his patients during surgery, and they are said to have experienced memories of
events that had been long forgotten. In reality, only a small percentage of his patients reported
experiences of this kind and, even in these cases, it is far from clear that the reports were of

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genuine memories. The misinterpretation is a product of the long-held desire to find a loca-
tion for memory in the brain.

Space restrictions prevent me from discussing each one of these topics in detail. I will
therefore concentrate on a key question that is posed at the end of the book: “Is memory in
the head?” As Danziger points out, psychology has inherited an individualistic metaphysics
from philosophy. Psychological phenomena are thought to occur in the heads of individuals,
hence the long history of trying to find their location in the brain. Also, they have been tradi-
tionally studied in isolation from the social context in which they occur. Memory is not some-
thing we can see, touch, or smell. What we see are human activities, and we have learned
through the course of socialization to apply the label “remembering” to some of them.
However, these activities always take place in a social context, and it is only by studying them
in this context that we can hope to understand them. Danziger points to Bartlett and Vygotsky
as examples of psychologists who studied psychological phenomena in their social context.
Thus the book is not just a contribution to history; it points to a different way of doing psy-
chology. These views were implicit in Naming the Mind, but they are discussed in much
greater detail in Marking the Mind. It goes without saying that these points apply not just to
memory but also to the various other basic categories of psychology.

Danziger’s previous works, Constructing the Subject (1990) and Naming the Mind, broke
new ground in the history of psychology and are now regarded as modern classics in the field.
Marking the Mind is at least the equal of these works. It should be obligatory reading for his-
torians of psychology. It should also be obligatory reading for experimental psychologists and
cognitive scientists, but that may be too much to expect.

REFERENCES

Danziger, K. (1990). Constructing the subject: Historical origins of psychological research. Cambridge: Cambridge
University Press.

Danziger, K. (1997). Naming the mind: How psychology found its language. London: Sage.

Reviewed by ADRIAN C. BROCK, School of Psychology, University College, Dublin.

Journal of the History of the Behavioral Sciences, Vol. 46(2), 213–215 Spring 2010
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20429
© 2010 Wiley Periodicals, Inc.

Edwin R. Wallace IV and John Gach (Eds.). History of Psychiatry and Medical
Psychology: With an Epilogue on Psychiatry and the Mind–Body Relation. New York:
Springer Science � Business Media, 2008. 862 pp. $219.00 (cloth). ISBN-13: 978-
0387347080.

As psychiatrists busy themselves with working out the details of the fifth version of the
Diagnostic and Statistical Manual—shrouded in secrecy, it must be added—the history of
psychiatry, psychotherapy, and mental illness is as active and popular as ever before.
Monographs, articles, biographies and memoirs, documentaries, and films about mental dis-
orders and their treatment are now a regular part of historical scholarship and popular culture.
The field has come a long way since its beginnings in the first half of the twentieth century,
when mostly practitioners wrote histories in a more or less internalist and Whiggish fashion.

Cultural history, gender studies, the social study of race, science and technology studies, lit-
erary studies, ethnography, critical psychology, and bioethics have now all left their mark on
how madness and psychiatry have come to be understood as artifacts of human history.

And yet, despite how much has changed in the ways we now come to see the history of
madness and therapeutic work, few archivally informed, comprehensive histories of this ter-
rain have been written in English since the 1960s. Two exceptions—Gerald N. Grob’s The
Mad among Us (1994) and Edward Shorter’s History of Psychiatry (1997)—have their limi-
tations. Grob focuses only on the United States, while Shorter is exclusively concerned with
modern history, and his interpretations are often skewed by his dogged defense of biological
psychiatry. Unfortunately, Roy Porter’s 2002 Madness: A Brief History appears to have little
currency. As Edwin R. Wallace IV and John Gach lament, it is Gregory Zilboorg’s 1967 edi-
tion of The History of Medical Psychology and Franz Alexander and Sheldon Selesnick’s
1966 The History of Psychiatry that are most often used in psychiatric residencies. The time
is certainly ripe for an up-to-date, broad, and affordable history of psychiatry and psy-
chotherapy.

This is the need that Wallace and Gach try to address, with partial success. At 800�
pages and a price tag of $219, the book is cumbersome and unaffordable for most students
and scholars. The essays in the volume, however, do give the reader a decent sense of the find-
ings and range of approaches in the historiography of psychiatry today. Some of the most
prominent names in the field are here: German Berrios, Sander Gilman, Gerald Grob, David
Healy, Nancy Tomes, and Dora Weiner, among others. Their essays often do little more than
summarize some of their earlier contributions to the historiography of psychiatry, but in doing
so, they provide a useful introduction to the state of the art.

As in any edited volume, the quality of the essays is uneven. Bennett Simon’s piece on
madness in the ancient world, for instance, relies on no original sources other than English
translations, while George Mora’s essays on medieval and Renaissance developments rely al-
most exclusively on secondary literature published before 1985. The selection of topics
covered—organized into the capacious categories “proto-psychiatry,” “growth of psychiatry
as a medical specialty,” “concepts and topics,” and “psychiatry and the mind–body
relation”—at times appears to reflect the interests of the editors and individual authors, rather
than the field as a whole.

That said, there are some real gems here. Edwin Wallace’s introduction to historiography
is ambitious and nuanced. Dora Weiner’s essays on the impact of the Enlightenment and
Philippe Pinel on French psychiatry are refreshingly insightful, allowing us to see how the
myth of Pinel as chain-breaker has made us blind to the many novel contributions of a host of
mad-doctors in the eighteenth century. German Berrios unpacks the epistemology of modern
psychiatry, arguing that what distinguished nineteenth-century psychiatry from its predeces-
sors was that the former came to assume a common descriptive language “based on an ana-
lytical and pictorial epistemology that dealt with symptoms independently and assumed the
same symptom might be seen in different forms of madness” (p. 355).

But, in the end, this volume should probably be evaluated not on the merits of its novelty
for specialists, but of its usefulness for novices. On that count, the book accomplishes some
things, but it misses the mark on other counts. The essay by Nancy Tomes on the development
of clinical psychology, social work, and psychiatric nursing is a good example. Tomes does a
commendable job in exploring the manner by which the mental health team concept displaced
medical hegemony over psychiatric care during the last two-thirds of the twentieth century. In
doing so, she highlights the critical role played by non-medical caretakers in history. Yet this
critically important dimension in the history of madness is, at best, only sparsely thematized

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in the volume’s essays. Little mention is made of the central role played by families, friends,
and religious counselors—along with the variety of other non-medical healing practitioners—
who have historically had the most direct and persistent effect on the lives of those afflicted.

In the end, it is fair to ask whether an edited volume is, in fact, the best way to achieve
the goals of the editors. The different voices effectively highlight the interpretive open-
endedness of the historiography of madness and mental illness. But they also lend a certain
choppiness to the volume, and the style of a number of the essays is rather like that of an
encyclopedia entry. This may be just the thing for medical students, but it limits the book’s
utility for other readers.

REFERENCES

Alexander, F., & Selesnick, S. T. (1966). The history of psychiatry: An evaluation of psychiatric thought and practice
from prehistoric times to the present. New York: Harper & Row.

Grob, G. N. (1994). The mad among us: A history of the care of America’s mentally ill. New York: Free Press.
Porter, R. (2002). Madness: A brief history. New York: Oxford University Press.
Shorter, E. (1997). A history of psychiatry: From the era of the asylum to the age of Prozac. New York: Wiley.
Zilboorg, G. (1967). A history of medical psychology. New York: Norton.

Reviewed by GREG EGHIGIAN, Director of the Science, Technology, and Society Program and
Associate Professor of Modern History and Science, Technology, and Society, Penn State
University, University Park, PA 16802.

Journal of the History of the Behavioral Sciences, Vol. 46(2), 215–217 Spring 2010
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20430
© 2010 Wiley Periodicals, Inc.

Pierre Saint-Arnaud. African American Pioneers of Sociology. Toronto: University of
Toronto Press, 2009. 381 pp. $80 (cloth). ISBN: 0802091229.

Pierre Saint-Arnaud’s African American Pioneers of Sociology focuses on the major
African American sociologists who came of age in the pre–civil rights era: W. E. B. Du Bois,
Oliver C. Cox, Horace Cayton, St. Clair Drake, E. Franklin Frazier, and Charles Johnson.
Saint-Arnaud provides detailed expositions of the major works and career trajectories of each
sociologist, paying particular attention to Du Bois and Frazier. He also analyzes how the in-
stitutional constraints of a segregated university system affected their work and situates
“African American sociology” as a whole in relation to “Anglo American sociology.” This
work was first published in French in 2003, and its appearance now in a fine translation into
English is one indication that research into the history of the American social sciences is be-
coming an increasingly international endeavor.

Scholars and students will find African American Pioneers of Sociology to be a useful
overview of the topic. However, Saint-Arnaud does not make a significant contribution to-
ward explaining the distinctive relationship between African American intellectuals and
sociology. His analysis is limited by the use of two tropes that will strike twenty-first-century
historians of social science as outdated: a celebration of the contributions of an “authentically
African American sociology” (p. 3) in the face of the “unjust disregard” with which Saint-
Arnaud believes they are now held (p. 119), and an insistence that the story of sociology is
best understood as one of scientific progress.

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Saint-Arnaud hopes to “rescue these first American sociologists of color from obscurity”
(p. 3). While few scholars have considered these figures together as sociologists, their repu-
tations today hardly need rescue. Rephrasing Talcott Parsons’s question, “Who now reads
Spencer?” Saint-Arnaud opens by asking “Who now reads . . . Du Bois?” (p. 3). In fact, many
people now read Du Bois, plenty more than read Spencer or Parsons. Any respectable list of
classic American works of sociology includes Du Bois’s The Philadelphia Negro (1899).

Saint-Arnaud’s contention that his protagonists created an authentically “African
American sociology” is equally problematic. (One wonders what an “inauthentic” African
American sociology would look like.) This claim leads Saint-Arnaud to overstate the extent
to which black scholars created a distinct sociological discourse. He often acknowledges in
passing the importance of exchanges between black and white sociologists; his suggestion
that Frazier and Johnson played a key role in influencing the later writings of their former
teacher Robert Park is particularly intriguing. Yet, by including separate sections on “Anglo-
American sociology” and “African American sociology” he gives the unfortunate impression
that the two discourses operated in entirely different intellectual universes.

Saint-Arnaud celebrates early African American sociologists for their contributions to
research methods and for the richness of their particular insights into American society. Yet
he casts them as “pioneers” who made important contributions to the development of a sci-
entific sociology but whose works lack contemporary relevance because they do not meet the
more advanced standards of our time. In particular, he argues that they failed to develop a sys-
tematic scientific theory along the lines adopted by late twentieth-century sociologists such
as Pierre Bourdieu. Though he blames the racist structure of power for this failure more than
the sociologists themselves, he nevertheless faults African American sociologists for “the sys-
tematic interference or intrusion of ideology into their production of scientific knowledge
about race” (p. 268). He also claims that they “did not succeed in building an abstract system
of concepts that could interrogate social facts at a high level of generality and predict their
likely empirical outcomes” (p. 269). Such arguments, however, substitute Saint-Arnaud’s con-
temporary sense of what sociology should do for the expressed views of the sociologists he
studies. Sociologists such as Du Bois and Frazier could hardly have viewed the goal of creat-
ing a systematic sociology free from ideology as a positive or possible goal. While Saint-
Arnaud ascribes their inability to predict the coming of the civil rights movement to their lack
of a systematic sociological framework free from ideologically contaminated concepts, it is
more accurately attributed to the particular positions they adopted (such as the presumed con-
servatism of black churches).

By placing these African American sociologists within a narrative that emphasizes the
development of scientific progress according to today’s standards, Saint-Arnaud misses much
of their significance. He evaluates them according to what he claims was “their fundamental
objective[:] the institutionalization of a new sociological paradigm as legitimate and credible
as the mainstream paradigm, if judged by the epistemological standards of the day” (p. 285).
Yet this seems to reverse the actual priorities of these figures. These African American intel-
lectuals wanted to provide an analysis that would lay bare the structures of American racism
and by so doing aid in the pursuit of freedom and equality. Sociology was a means to that end.
The historical question should not be, as it is for Saint-Arnaud, how did racist institutional
structures prevent African American scholars from developing a more systematic sociology?
Rather, it should be: Why did sociology, perhaps more than any other social scientific disci-
pline, appeal to so many African American intellectuals? Answering that question would in-
volve understanding Saint-Arnaud’s cast of characters as more than sociologists (and indeed
many of them are best known for their anti-racist activities). Ideally, it would also involve

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investigating the work and careers of less illustrious African Americans who were drawn to
sociology. While a comprehensive history of African American sociologists in the twentieth
century remains to be written, in the meantime, African American Pioneers of Sociology pro-
vides a useful compilation of information on the subject.

REFERENCE

Du Bois, W. E. B., & Eaton, I. (1899). The Philadelphia Negro: A social study. Philadelphia: University of
Pennsylvania Press.

Reviewed by DANIEL GEARY, Mark Pigott Lecturer in U.S. History, Trinity College, Dublin.

Journal of the History of the Behavioral Sciences, Vol. 46(2), 217–218 Spring 2010
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20431
© 2010 Wiley Periodicals, Inc.

Edward Shorter and David Healy. Shock Therapy: A History of Electroconvulsive
Treatment in Mental Illness. New Brunswick, NJ: Rutgers University Press, 2007. 398
pp. $27.95 (cloth). ISBN 978-0813541693.

Electroconvulsive therapy (ECT), or shock therapy as it is more popularly known, is
unique in the history of psychiatry—it has a long, contentious past and is still in use today.
When the subject of ECT is raised, many become uncomfortable, imagining scenes of grue-
some brutality or at least social control. Moreover, ECT polarizes practicing psychiatrists, as
some groups advocate for increased use of ECT while others refuse to refer patients for fear
of major side effects. Although historians of psychiatry in recent years have become interested
in a range of somatic therapies, ECT has received relatively little attention. Shock Therapy, by
historian Edward Shorter and psychopharmacologist and historian David Healy, begins to fill
in the gap on this important topic.

Shock Therapy carefully documents the rise, decline, and rise again of convulsive
therapies—insulin coma, metrazol, and especially electroconvulsive therapy (ECT). Within
the hopelessness of early-twentieth-century institutional psychiatric care, pioneers such as
Manfred Sakel (insulin coma) and Ladislaus Meduna (metrazol) developed somatic interven-
tions with the hope of bringing life to profoundly ill patients. Ugo Cerletti and others devel-
oped a more effective method (using electricity) for producing the convulsions that seemed to
help patients. In the 1930s and 1940s, especially during the turmoil of World War II, somatic
treatments became important to psychiatrists and patients, and convulsive therapy practition-
ers and practices spread throughout the world. By mid-century, ECT had gained priority over
the other methods of convulsive treatment, and enjoyed remarkable popularity within
American and European psychiatry. Indeed, although American psychoanalysts were vocal in
their public criticism of the treatment in the 1950s, they often quietly referred their patients
for ECT.

As Shorter and Healy point out, the original methods for producing therapeutic convul-
sions were problematic in that they could be misused and often produced major side effects
such as bone fractures. ECT practitioners by the 1960s and 1970s addressed these problems
by modifying the treatment technique with anesthesia and decreased electrical stimulus
strength. Yet by the 1970s, ECT was in serious disfavor in professional circles, as it was

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opposed by both psychoanalysts (who decried anything other than psychotherapy) and bio-
logical psychiatrists (who were invested in medications). Further, movie portrayals and media
coverage characterized ECT as barbaric and inhumane. Opposition to ECT became a rallying
point within the rising anti-psychiatry movements of the 1960s and 1970s. Through a combi-
nation of professional and public concerns, ECT was placed under increasing legislative and
professional scrutiny, and was restricted in a number of settings. Though the use of ECT had
declined to low levels by the 1980s, Shorter and Healy point out that it underwent a resur-
gence in the last two decades, especially through the efforts of advocates such as New York
psychiatrist Max Fink. The principles behind ECT have been so persuasive, Shorter and Healy
explain, that the treatment has given rise to novel therapies such as transcranial magnetic
stimulation (TMS), vagal nerve stimulation (VNS), and deep brain stimulation (DBS).

Shorter and Healy provide an important foundation in the history of ECT, especially in
their discussions of historical actors’ personalities and contexts, as well as the professional
networks of practitioners in electroconvulsive therapy. Their variety of sources, including in-
terviews as well as published and archival materials, create an evocative picture of the world
of ECT development and practice. In addition, the authors make the interesting and provoca-
tive observation that psychoanalysts and psychologists have helped to fuel public opposition
to ECT. Shorter and Healy are able to outline the methods of practitioners and researchers in
convulsive therapy, and illustrate the thinking of these individuals in the past and the present.
They also help us to understand how ECT advocates perceived that ECT works, even though
the theories of its mechanism have changed over time.

Readers will likely be struck by the authors’ unequivocal argument that ECT is a safe and
effective treatment. In the context of the increasingly tense battles between ECT activists
and opponents, it has become challenging to avoid a stand on one side or another of the issue
of ECT safety and side effects. Shorter and Healy take the position that ECT is beneficial and
that its drawbacks have been overblown (especially in comparison to medications). Although
Shorter and Healy address opposition to ECT within their book, they tend to characterize anti-
ECT opinion as irrational, especially as they frequently draw a comparison between penicillin
and what they argue has been psychiatry’s most effective treatment, ECT. Future historians
will hopefully pick up on some threads of the story suggested in Shock Therapy, especially
the role of gender, race, and ethnicity and the perspective of patients who have received ECT.
In addition, other historians might help us better understand the nuances of the opposition to
ECT, such as the role of the rhetoric of Nazism that has penetrated the anti-ECT crusade. But
whatever history is written in the future, Shock Therapy will provide an invaluable base.

Reviewed by LAURA D. HIRSHBEIN, Clinical Assistant Professor, University of Michigan
Department of Psychiatry, 1500 E. Medical Center Dr., SPC 5020, Ann Arbor, MI 48109-
5020.

Journal of the History of the Behavioral Sciences, Vol. 46(2), 219–220 Sping 2010
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20432
© 2010 Wiley Periodicals, Inc.

John C. Burnham. Accident Prone: A History of Technology, Psychology, and Misfits of the
Machine Age. Chicago: University of Chicago Press, 2009. 336 pp. $40.00 (cloth).
ISBN-13: 978-0226081175.

This book tells the story of how the “accident prone” became a human kind as Ian
Hacking’s might say, but only briefly, and only for a limited group of professionals in the
twentieth century. The idea of the accident-prone individual emerged simultaneously in
Britain and Germany in the 1920s, reflecting the tensions and trials of an increasingly tech-
nical age, only to be eclipsed a few short decades later by the dominance of engineering mod-
els for improving safety, and a systems approach rather than a focus on individual behavior.
Surprisingly, accident proneness did not become a psychiatric kind—it was not taken up by
psychiatrists as a distinct illness category despite the fact that it evolved from the medical no-
tion of individual susceptibility, and despite psychoanalytic inclinations to do so. In short, this
volume stands as a history and an intriguing counter-history—a biography of an idea with a
short but intense life.

Burnham tracks the origins of the concept of the accident prone from early designations
of a careless person, or a person susceptible to accidents, to the simultaneous appearance of
“accident prone” or Unfallneigung in 1926 in the work of the British psychologist Eric Farmer
and the thought-psychologist Karl Marbe in Würzburg, Germany. Combing through insurance
statistics, Marbe found that those who had had an accident were likely to have another, a find-
ing attributable both to heredity and habit, and a tendency he likened to a propensity to make
psychomotor errors on psychological tests. In Britain, studies on susceptibility to accidents
and industrial fatigue from munitions factories were the conduit to a notion of the accident
prone in the work of Eric Farmer on the Industrial Fatigue Research Board (with the assis-
tance of E. G. Chambers). Psychological testing of reaction times in various experimental
situations demonstrated a link between accident proneness and some kinds of motor coordi-
nation and nervous instability. “Accident prone” soon became a loosely linked type, a class of
individuals defined by a host of factors measured by industrial psychologists with their bat-
teries of vocational, psychophysiological, and reaction time tests. Other indicators of the
accident-prone personality noted at the time were constitution, sensory acuity, eyesight, use
of alcohol, medical disorders such as epilepsy, and temporary mental agitation.

Although the idea of the accident prone had only limited influence in Germany, it gained
ground in Britain, and enjoyed even greater traction in the United States, particularly with
safety experts of the 1930s who evaluated the skills of motor vehicle and public transport op-
erators. Although accident proneness often had a hereditary component, it could also describe
transient traits like fatigue that could be remedied by training and education. Some pro-labor
industrial psychologists and supervisors argued that the accident prone problem was in good
part environmental, and opted for education and transfer of accident-prone workers rather
than discharge.

One fascinating chapter in the book details the resistance of psychiatrists to molding the
accident-prone individual into a full-fledged disease type. Although Freudian psychoanalysts
such as Karl Menninger explained some accidents as the fruits of unconscious wishes, these
were seen as singular events, and not as a propensity to suffer multiple accidents. One ex-
ception was the psychosomaticist Helen Flanders Dunbar, who combined her analysis of car-
diac and diabetic patients with those suffering from bone fractures, and viewed personality as

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an important factor in what she called the “accident habit.” Her popularization of this idea
reached the public with a description of, among other things, an accident-prone dog named
Nick! Dunbar’s holistic psychosomatic perspective lost ground with psychiatrists in the
post–World War II period, however, and with the slow decline in psychoanalytic views, acci-
dent proneness did not appear as a pathological syndrome or symptom in any formal psychi-
atric classification. Neither a generalizable trait, nor a treatable one, it was never central to
psychiatric diagnostics.

Accident proneness thus remained in the purview of psychologists, safety experts, and
physicians, particularly pediatricians. It also emerged in popular arenas as a recognizable sort
or type of person. By the post–World War II period, the earlier concern with industrial acci-
dents gave way to a dominating concern with traffic accidents, and a shift from a focus on in-
dividual behavior to engineering safety foreshadowed the decline of the importance of the
idea of accident proneness. Other factors contributing to its demise were the popularity of
cognitive psychology, the questioning of underlying stable personality traits and hereditary
notions, and cautions against labeling groups socially deviant. The language of injury and
error rather than accident became commonplace, leading to engineering and technical solu-
tions rather than to an assessment of defective individuals.

Burnham’s research skills are in ample display in this volume, as he meticulously tracks
the concept of the accident prone in industrial psychological and safety literature, medical ac-
counts, and popular writings. Burnham is attentive to the many genres in each of these fields,
shedding light on the ways an idea circulates through expert literatures, textbooks, and popu-
lar articles. With numerous interpretive contexts or streams of thought feeding into the con-
cept of the accident prone, his account cuts across histories of technology, psychology, and
medicine, with a breadth that reveals at once the fruits as well as some of the drawbacks of
interdisciplinary study. In broad strokes, this account provides a window onto the shift from
an early-twentieth-century conception of the techno-human encounter as a simple dyad, with
a lens trained to the psychological and medical incapacities of the individual user, to a com-
plex systems approach, identifying risk groups rather than individuals, and intervening to ma-
nipulate the environment rather than the individual. With its copious notes, extensive bibliog-
raphy, and descriptions of many individual studies over the course of more than half a century,
this book will certainly serve as an indispensable resource on the idea of the accident prone.

Writing the life history of an idea does not easily yield a death date, as Burnham points
out, and even now, the notion of the accident-prone person persists in popular commentary,
cartoons, and even poetry. What this book ably shows is that it has already lost its short-lived
scientific soul.

Reviewed by SUSAN LANZONI, Visiting Scholar (Science, Technology, and Society Program),
MIT, Cambridge, MA.

Journal of the History of the Behavioral Sciences, Vol. 46(2), 221–222 Spring 2010
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20433
© 2010 Wiley Periodicals, Inc.

Bruce H. Weber and David J. Depew (Eds.). Evolution and Learning: The Baldwin Effect
Reconsidered. Cambridge, MA: MIT Press, 2003 (cloth), 2007 (paper). x � 341 pp.
$26.00 (paper). ISBN 978-0-262-23229-6 (cloth), ISBN 978-0-262-73181-2 (paper).

The “Baldwin Effect,” as such, has existed only since the mid-twentieth century. It was
then that American paleontologist George Gaylord Simpson (1953) revived a late-nineteenth-
century evolutionary theory just long enough to rename it and then downplay its evolutionary
import. The theory Simpson recast as the Baldwin Effect was proposed independently, and
near simultaneously, in 1896 by developmental psychologist James Mark Baldwin
(1861–1934), comparative psychologist Conwy Lloyd Morgan (1852–1936), and vertebrate
paleontologist Henry Fairfield Osborn (1857–1935). The Baldwin Effect, as it is now com-
monly known, contends that learning may guide the course of biological evolution in a non-
Lamarckian way, if organisms and their descendents can be kept alive long enough for chance
biological variations to arise that enhance or supplant initially learned behavior.

Although Simpson briefly resurrected organic selection in the 1950s, the most recent re-
vival of the theory occurred in the late 1980s when computer simulation studies demonstrated
the effect’s theoretical plausibility (Hinton & Nowlan, 1987). Discussion of the Baldwin
Effect has proliferated since this time. As a result of this renewed interest, an interdisciplinary
conference was held at Bennington College in the fall of 1999. This conference led to the pub-
lication of Evolution and Learning: The Baldwin Effect Reconsidered, edited by Bruce H.
Weber (Robert H. Woodworth Professor of Science and Natural Philosophy at Bennington
College and Professor of Biochemistry at California State University at Fullerton) and David
J. Depew (Professor of Communication Studies and Rhetoric of Inquiry at the University of
Iowa).

This book charts the reception of the Baldwin Effect from its initial proposal at the end
of the nineteenth century up to modern times. Portions of this volume also delve into the more
general contemporary issues in biology, specifically the relationship between development
and evolution. Here, discussion turns to the appearance of evolutionary developmental biol-
ogy (evo-devo), developmental systems theory (DST), and complex systems perspectives in
the latter decades of the twentieth century. In large part, it is this resurgence of interest in the
developmental constituents of evolution that has drawn attention to the Baldwin Effect in re-
cent years.

The book is divided into three sections. In the first, “Baldwin Boosters, Baldwin
Skeptics,” the intellectual history of the Baldwin Effect is examined, while the evolutionary
import of the effect is also debated. The second and third sections of the book, “Baldwinism
and Development” and “Beyond Baldwinism,” then move beyond historical accounts of the
Baldwin Effect to current theoretical issues in development and evolution.

In part one, several accomplished philosophers of science, biology, and mind—Depew,
Daniel Dennett, Terrence Deacon, Stephen Downes, and Peter Godfrey-Smith—address the
contested evolutionary standing of the Baldwin Effect. While doing so, these scholars also
chart the intellectual climate in which the effect was initially proposed, as well as the effect’s
various manifestations over the course of the twentieth century. Here, the Modern Synthesis
of Mendelian genetics and Darwinian evolutionary theory that began in the 1930s takes cen-
ter stage. This synthesis entrenched reductionistic accounts of evolutionary change into evo-
lutionary discourse, and assigned development a limited evolutionary role. Within the

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Modern Synthesis, the Baldwin Effect had no place. Yet, even at the height of the synthesis,
there were some who challenged the assumptions that excluded development from evolution.
Throughout the chapters in this section, the Baldwin Effect is compared to another theory that
gave plasticity a role in biological evolution: Conrad Waddington’s mid-twentieth-century de-
velopment of the theory of genetic assimilation. (Waddington argued that environmental
change may expose previously hidden genetic variation, which may then be selected.)
Although there is some debate over the exact relationship between the Baldwin Effect and ge-
netic assimilation, the general conclusion presented in these chapters is that Waddington’s
ability to experimentally demonstrate the occurrence of genetic assimilation created theoret-
ical space for the Baldwin Effect in twentieth-century evolutionary discourse.

The remaining two sections of this volume largely move beyond historical accounts of
the Baldwin Effect to discuss the current theoretical issues in development and
evolution. Arguments here use the Baldwin Effect as a rhetorical device to open up discussion
of the importance of developmental perspectives for our understanding of evolution. Although
theoretical considerations dominate the remaining chapters of the book, historical discussion
is present throughout the volume. In the latter two-thirds of the book, the chapter by Griffiths
is a particularly strong contribution. In it Griffiths accounts for Baldwin’s development of the
Baldwin Effect by relating the evolutionary theory to his other social theories. Nonetheless,
most of the chapters in the two final sections of this volume address current evolutionary is-
sues, including evo-devo, DST, and mind as an emergent phenomenon, with little mention of
the Baldwin Effect itself.

Of the chapters that comprise this volume, the opening chapter by Depew provides the
most detailed account of the intellectual trajectory of the Baldwin Effect, from its appearance
in 1896 to modern times. For the historian of psychology or biology, Evolution and Learning:
The Baldwin Effect Reconsidered, or roughly the first third thereof, provides a detailed ac-
count of the Baldwin Effect’s place in the evolutionary discourse of the past century. In doing
so, it is a valuable resource for those engaged in historical scholarship on topics that intersect
with psychology, biology, and evolution.

REFERENCES

Hinton, G. E., & Nowlan, S. J. (1987). How learning can guide evolution. Complex Systems, 1, 495–502.
Simpson, G. G. (1953). The Baldwin Effect. Evolution, 7, 110–117. doi:10.2307/2405746.

Reviewed by JACY L. YOUNG, doctoral student, Program in History and Theory of Psychology,
Department of Psychology, York University, Toronto, ON, Canada.

Journal of the History of the Behavioral Sciences, Vol. 46(2), 222–224 Spring 2010
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20434
© 2010 Wiley Periodicals, Inc.

Thomas C. Patterson. Karl Marx, Anthropologist. Oxford: Berg Publishers, 2009. 256 pp.
$115.00 (cloth). $36.00 (paper). ISBN 978-1-84520-511-9.

The title of Thomas C. Patterson’s book, Karl Marx, Anthropologist, is deliberately
provocative. In this book, Patterson sets out to do justice to Marx and show his relevance for
today’s anthropology by systematically reviewing the way Marx’s interests are relevant for,

222 BOOK REVIEWS

JOURNAL OF THE HISTORY OF THE BEHAVIORAL SCIENCES DOI: 10.1002/jhbs

or correspond to, themes in today’s anthropology. Consequently, each chapter in Patterson’s
book deals with one aspect of the Marxian body of thought and Marx’s ideas about the nature
of people and society. While Chapters 1 and 2 review the main influences on the development
of Marx’s ideas and the fundamental tenets of his anthropology, Chapters 3 to 7 systematically
treat topics in chronological order, beginning with Marx’s ideas on prehistory and the evolu-
tion of human society, his thoughts on historical change and pre-state societies, and finally
moving on to his interests in capitalism. The last chapter of Patterson’s book examines impli-
cations of the Marxian oeuvre for future directions in anthropology. How persuasive is
Patterson’s case? Though there are aspects of Patterson’s reasoning and conclusion that are
questionable, he has nonetheless produced a useful book with important implications—
maybe even for the direction anthropology might take in the future.

Throughout the book, Patterson convincingly shows the correspondence between
Marxian interests and developments in contemporary anthropology. To begin with, he argues
that for Marx, different pre-capitalist modes do not constitute evolutionary stages. Unlike
nineteenth-century evolutionists, Marx did not believe that development occurred through
necessary evolutionary stages, and neither did he believe in environmental determinism
(pp. 53–54, 57). Instead, Marx advocated “development contingency” or “non-teleological di-
rectionality” (ibid.). Similarly, Patterson suggests that Marx’s was an integrative, engaged an-
thropology (pp. 61, 159, 171), shifting between different levels of abstraction, between local
and regional levels of analysis (p. 108). Finally, like contemporary anthropology, Marx em-
phasized holism and a synthesis of arts and sciences (pp. 51–52, 65). Yet, while these and sim-
ilar arguments appear compelling, upon examination, one realizes that, given the continuous
influence of Marxian thought on the development of anthropology, the correspondence be-
tween Marxian ideas and the direction anthropology has taken in the last century is less than
remarkable.

The direct influence of Marx on the development of anthropology both in North America
and European tradition is well known and easy to demonstrate. One only has to consider neo-
evolutionary thinkers, such as Leslie A. White and Julian Steward in North America, neo-
liberal Marxist and feminist anthropologists of the 1960s and 1970s on the same continent, or
the Marxist leanings of French anthropologists and intellectuals with considerable influence
on anthropology—Louis Althusser, Claude Meilasseaux, Claude Lévi-Strauss, Michel
Foucault, and Pierre Bourdieu—to realize that the correspondence between Marxian and an-
thropological interests is more predetermined than coincidental. The influence of Marxian
ideas on the development of anthropology makes arguments by Patterson that the work of
these philosophers and anthropologists—for instance that of Bourdieu (p. 167)—would in-
trigue Marx seem circular.

Even where there is no direct influence, as in much of pre–World War II British social
anthropology and early North American cultural anthropology, anthropology and Marxian
thought were based on a common intellectual tradition. British social anthropology was in-
fluenced by Durkheim, whose ideas, like those of Marx (as Patterson so persuasively demon-
strates in the first part of the book), were in turn developed on Enlightenment thought.
Similarly, North American cultural anthropology was founded on the German intellectual tra-
dition to which Marx was also indebted. Though Marx may have been less influenced by Kant
and Herder than by Hegel and Enlightenment thinkers, several of his ideas overlap with those
of both Kant and Herder. For instance, he shared Kant’s conviction of the importance of
praxis, that the human character can only be known through the study of human actions
(pp. 25–26, 60). Similarly, Marx’s appreciation of variation was akin to that of Herder and
even to that of Geertz. According to Patterson, “It was impossible in his view to speak of

BOOK REVIEWS 223

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224 BOOK REVIEWS

JOURNAL OF THE HISTORY OF THE BEHAVIORAL SCIENCES DOI: 10.1002/jhbs

either nature or society in general or in some abstract sense; it was necessary instead to think
of the spatial and temporal peculiarities of both” (p. 52; see also pp. 28, 31, 47; Geertz, 1973).

In evaluating Patterson’s claim on Marx, one ought to also consider that nineteenth-cen-
tury thinkers were generalists. Undoubtedly, Marx was interested in questions which have
since been developed by anthropologists. Yet not only anthropologists, but representatives of
several other fields, such as history, philosophy, economics, or political science, could argue
that he was one of their own with equal justification. In fact, there are indications that what
has become the strength of anthropological research in the twentieth century represented the
weakest aspect of the Marxian body of work. Though interested in all aspects of human soci-
eties, anthropology’s greatest contribution as an academic discipline in the past hundred years
has arguably been to the study of small-scale contemporary and prehistoric societies, which
were only of instrumental secondary interests to Marx and Engels, whose primary goal was
to understand the development of capitalist societies and their various forms around the world
(pp. 92, 106). Even more importantly, Marx and Engels’s speculations about the type of soci-
eties which have been at the center of anthropological interest in the past century were based
on extremely limited data (ibid., p. 65). This in turn has implications both for Patterson’s rea-
soning in Karl Marx, Anthropologist, and for anthropological theories.

In the book, Patterson not only presents useful summaries of Marxian thought and links
these to contemporary advancement in corresponding areas in anthropology, but, at the end of
each chapter, he also speculates on how Marx would have perceived these developments and
interpreted anthropological research that has taken place since his time (pp. 75, 93). This ex-
ercise is futile. Marx’s theories were what they were because of the nature and amount of data
available to him and to everyone else in the second part of the nineteenth century. In the light
of Marx’s intellectual rigor and respect for evidence, which Patterson so excellently elucidates
in his book, it is reasonable to assume that, had the data collected by anthropologists since his
death been available to him, his theories would have been different. Thus, there is no reason to
believe that he would have approached the data accumulated by twentieth-century anthropol-
ogy with the mind frame he had developed on the back of nineteenth-century evidence.

This realization has an additional implication. As a result of limited available data, in
Marxian theories of tool use, evolution of human production and social institutions, and “prim-
itive communism,” missing evidence is often supplemented by imagination, just-so stories, and
wishful thinking, often resulting in unfounded assumptions, which, however, as Patterson
rightly points out, continue to influence anthropological thinking on these subjects. Thus, apart
from providing a useful review of parallels between Marxian thought and contemporary an-
thropology, one of the most important, and perhaps inadvertent, contributions of Patterson’s
latest book is that it alerts anthropologists to the need and possibility to revise, develop, and
correct Marxian misconceptions of contemporary and prehistoric small-scale societies.

REFERENCE

Geertz, C. (1966). The impact of the concept of culture on the concept of man. In J. Platt (Ed.), New views of the
nature of man (pp. 93–111). Chicago: University of Chicago Press.

Reviewed by CSILLA DALLOS, PhD, Associate Professor of Anthropology, St. Thomas
University, Fredericton, New Brunswick.

Journal of the History of the Behavioral Sciences, Vol. 46(2), 225 Spring 2010
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20435
© 2010 Wiley Periodicals, Inc.

Response to Csilla Dallos’s Review of Karl Marx, Anthropologist

I am always pleased when readers find something I write useful but do not expect them
to agree necessarily with everything I have said. In the same vein, I do not necessarily agree
with everything I read about what reviewers write about my work. Here are some points of
difference—differences that may be matters of emphasis, on the one hand, or more substantial,
on the other. First, I think the reviewer underestimates the depth and extent of anti-socialist
thought from the 1870s onward, of which the Cold War is but one facet, and the stifling effects
this had had and continues to have in both the West and the former socialist states. One effect
is that we read commentaries on Marx, or Geertz for that matter, rather than what was actually
written; this is sad. Second, I find the reviewer’s assertion that “anthropology’s greatest contri-
bution . . . has arguably been to the study of small-scale contemporary and prehistoric soci-
eties” debatable. The contribution of anthropology might be viewed in terms of the impact of
capitalist expansion, the emergence of diverse forms of social inequality and state-based soci-
eties, and resistance to those processes at home and abroad. Such a reconceptualization of the
field potentially provides alternatives to concepts, like “prehistoric,” that are not especially use-
ful; facilitates communication between practitioners with different research interests who may
talk too infrequently with one another; and does not fall into the trap of viewing the people
with whom anthropologists work as all that different from themselves. Third, I agree with the
reviewer that all of us should continually tack back and forth between empirical evidence and
the analytical frameworks we use in order “to revise, develop, and correct . . . misconceptions”;
however, I would not limit the practice of honing and refining arguments to just the theories
sketched by Marx more than a century ago. I would also extend it to the works of contempo-
rary writers who theorize, for example, neoliberalism or globalization in order to see how what
they suggest actually or potentially impacts the people with whom I work and among whom I
live.

THOMAS C. PATTERSON

BOOK REVIEWS 225

JOURNAL OF THE HISTORY OF THE BEHAVIORAL SCIENCES DOI: 10.1002/jhbs

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REGULAR ARTICLE

Effects of electroconvulsive therapy in the systemic
inflammatory balance of patients with severe mental disorder

Miquel Bioque, MD, PhD,1,2,3,4† Karina S. Mac-Dowell, MSc, PhD,3,5† Ana Meseguer, RN,1,3 Elisabet Macau, RN,

6

Ricard Valero, MD, PhD,7,8 Eduard Vieta, MD, PhD,2,3,4,9 Juan C. Leza, MD, PhD3,5* and
Miquel Bernardo, MD, PhD 1,2,3,4

*

Aim: There is a great interest in the role of the immune sys-
tem and the inflammatory balance as key mechanisms
involved in the pathophysiology of severe mental disorders.
Previous studies have indicated that electroconvulsive ther-
apy (ECT) produces changes in certain inflammatory media-
tors or in the immune system response. This study aimed to
explore the effects of ECT on the nuclear transcription factor
κB (NFκB) pathway, a main regulatory pathway of the
inflammatory/immune response.

Methods: Thirty subjects with a severe mental disorder
receiving treatment with ECT in our center were included.
Thirteen systemic biomarkers related to the NFκB pathway
were analyzed right before and 2 h after a single ECT session.

Results: An ECT session significantly decreased the
expression of NFκB (P = 0.035) and of the inducible nitric
oxide synthase (P = 0.012), and the plasma levels of nitrites
(P = 0.027), prostaglandin E2 (P = 0.049), and 15-deoxy-
PGJ2 (P < 0.001). Decrease in plasmatic levels of nitrites was

greater in females than in males (P = 0.021). A positive corre-
lation between the ECT stimulus load and changes in the
expression of NFkB was found (P = 0.036). Thiobarbituric
acid reactive substance levels were decreased in treatment
responders and increased in non-responders (P = 0.047).

Conclusion: Our study shows the effects that a single ses-
sion of ECT produces on a canonical regulatory pathway of
the inflammatory/innate immune system and the inflamma-
tory balance. These biomarkers could be useful as treatment
response targets and could help to clarify the biological
basis of ECT action. These findings warrant greater attention
in future investigations and in the translational significance
of these data.

Keywords: biomarkers, ECT, electroconvulsive therapy, immune

system, inflammation.

http://onlinelibrary.wiley.com/doi/10.1111/pcn.12906/full

Electroconvulsive therapy (ECT) is considered an effective and safe
treatment for patients with a severe mental disorder, being used
mainly in certain cases of major depression, bipolar disorder (BD),
and schizophrenia-related disorders resistant to pharmacological
treatments.1–5 Despite the extensive clinical experience accumulated
with this technique and all the scientific knowledge acquired about its
mechanisms of action at the molecular level, this field of knowledge
requires more research on its biological basis to better understand its
mechanistic basis and in order to help clinicians in decision-making.

Moreover, in recent years we have witnessed a renewed interest
in the role of certain changes in the innate immune system and
inflammatory balance as key mechanisms involved in the pathophysi-
ology of these mental disorders.6,7 Thus, several meta-analyses have
described inflammatory mediator alterations – such as certain cyto-
kines – in patients with depression,8 BD,9 and schizophrenia.1

0

One of the main actors regulating the immune system response
is the activation of the nuclear transcription factor κB (NFκB) path-
way.6 This prototypic inflammatory pathway is mainly activated in the
unspecific innate immune response through toll-like receptor
4 (TLR4) in certain scenarios of biological or psychosocial stress,
cytokine release, damage-associated patterns, or as a response to lipo-
polysaccharide from gram-negative bacteria.11 Through recruiting
adapter proteins, such as the myeloid differentiation factor
88 (MyD88) and the TIR-domain-containing adapter-inducing
interferon-β (TRIF), NFκB is activated.12 NFκB acts on the gene pro-
moters of inducible forms of the enzymes nitric oxide synthase
(iNOS) and cyclooxygenase-2 (COX-2), increasing their expression.
The overactivation of these enzymes can produce an accumulation of
oxidative and nitrosative mediators (i.e., nitric oxide, peroxynitrite
anion, and prostaglandins, such as prostaglandin E2 [PGE2]), which

1 Barcelona Clínic Schizophrenia Unit, Neuroscience Institute, Hospital Clínic de Barcelona, Barcelona, Spain
2 Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
3 Centro de Investigación Biomédica en Red en Salud Mental (CIBERSAM), Madrid, Spain
4 Department of Medicine, University of Barcelona, Barcelona, Spain
5 Department of Pharmacology & Toxicology, Faculty of Medicine, Universidad Complutense de Madrid, Instituto de Investigación I+12 y IUIN, Madrid, Spain
6 Psychiatry Department, Neuroscience Institute, Hospital Clínic de Barcelona, Barcelona, Spain
7 Anesthesia Department, Hospital Clínic de Barcelona, Barcelona, Spain
8 University of Barcelona, Barcelona, Spain
9 Barcelona Bipolar Disorder Program, Psychiatry Department, Neuroscience Institute, Hospital Clínic de Barcelona, Barcelona, Spain
* Correspondence: Email: bernardo@clinic.cat; jcleza@med.ucm.es
† The first and second authors contributed equally to this work.

© 2019 The Authors
Psychiatry and Clinical Neurosciences © 2019 Japanese Society of Psychiatry and Neurology

Psychiatry and Clinical Neurosciences 73: 628–635, 201

9

62

8

PCNPsychiatry andClinical Neurosciences

https://orcid.org/0000-0001-8748-6717

http://onlinelibrary.wiley.com/doi/10.1111/pcn.12906/full

can cause the depletion of endogenous antioxidant defenses and
attack membrane phospholipids causing cell damage in a process
known as lipid peroxidation, a byproduct of which can be detected by
thiobarbituric acid reactive substances (TBARS). On the other hand,
some endogenous counterbalancing mechanisms, activated in
response to an inflammatory/immune stimulus, have also been
described, including the activation of the gamma isoform of the per-
oxisome proliferator activated receptor (PPARγ). Besides, several
COX-2 derived products, such as the prostaglandin 15-deoxy-PGJ

2

(15d-PGJ2), act as endogenous anti-inflammatory agents by targeting
PPARγ, and being involved in the endogenous compensatory mecha-
nism regulating the inflammatory process.13 See a detailed scheme of
the whole pathway in Figure 1.

Previous works have identified differences in the expression of
certain components of this pathway comparing subjects affected by

a

serious mental disorder with matched healthy controls. These studies
included nearly 400 subjects with schizophrenia-related disorders,
674 with BD, 148 with major depressive disorder (MDD), and
643 healthy subjects. In particular, patients in an early phase of a psy-
chotic disorder showed increased levels of pro-inflammatory NFκB,
iNOS, and COX-2, while the anti-inflammatory inhibitory subunit of
NFκB, 15d-PGJ2, and PPARγ expression and transcriptional activity
were lower.13,14 In patients with established schizophrenia, NFκB,
iNOS, COX-1, COX-2, TLR4, and PGE2 expression were found to
be elevated,15–18 while the anti-inflammatory prostaglandin 15d-PGJ2
and its nuclear receptor PPARγ were decreased.19 A recent study
found higher levels of COX-1 in BD patients compared with healthy
controls,16 while TLR4 genetic variations have been associated with
this disorder.20 Finally, patients with MDD showed higher expression
of TLR421,22 and elevated TRIF and MyD88.23 A study with post-
mortem brain samples also showed an altered TLR4 immune response
in the brains of subjects with MDD.2

4

Following this hypothesis, a successful treatment would help to
normalize the inflammatory imbalance that some of these individuals
present.14,2

5

Previous studies have indicated that an ECT treatment associates
certain changes in inflammatory mediators or in the immune system
response in patients with various mental disorders, principally major
depression and schizophrenia. Most of these studies are heterogeneous

in the number of ECT sessions received (one vs 9–12), the biomarkers
measured, and the pathways implicated.26,27

In patients with MDD (see review by Guloksuz et al.26),
increased activity of the NK cells28–30 and interleukins (IL)-6 and IL-
1β have been described after an ECT session.31–33 Lehtimaki et al.
reported that the elevation of both IL normalized at 24 h.31 Fluitman
and colleagues also showed that an ECT session produced a decrease
in interferon-γ production and an acute increase in the total number
of leukocytes, monocytes, granulocytes, and NK cells,32 returning to
baseline at 30 min. They did not find an additive effect of these
changes with successive ECT sessions. Finally, Arts and colleagues
described an increase in serum levels of the S100B protein, a marker
of glial injury, 1 h and 3 h after an ECT session,33 but another study
did not find any changes.34

In addition to these acute effects to a single ECT session, long-
term effects of a treatment with repeated sessions of ECT have been
described in patients with MDD (see review by Guloksuz et al.26). In
a recent study, Järventausta and colleagues showed how high levels of
IL-6 normalized only in patients who remitted clinically after several
sessions of ECT.35 Rush et al. did not find this normalization in IL-6
or transforming growth factor (TGF)-β levels after obtaining a clinical
response to several sessions of ECT.36 Albrecht et al. reported a
reduction in phytohemagglutinin and concanavalin A in T lymphocyte
cultures.28 Another study showed the activation of the immune system
mediated by an increase in the number of lymphocytes expressing
activation antigens (CD25 and CD38).29 The increase in NK cell
activity in the acute phase was not sustained after completing the
treatment with several sessions of ECT.29,30,32 Hestad et al. reported
that high levels of tumor necrosis factor (TNF)-α normalized after a
period of treatment with ECT, but not if the treatment was exclusively
with drugs.37 After completing 12 sessions of ECT, they found a
decrease in the signaling of proinflammatory cytokines IL-5 and
eotaxin-3, together with an increase in TNF-β.38 Finally, several stud-
ies have shown that S100B concentrations in serum and cerebrospinal
fluid are not altered after several sessions of ECT.33,34,39

There is a single study in patients with resistant schizophrenia,27

in which after nine sessions of ECT the authors found that an increase
in the anti-inflammatory response was demonstrated by increases in
IL-4 and TGF-β, without altering the activation of myeloperoxidase

BIOLOGICAL/PSYCHOSOCIAL

STRESS

PBMC
(cellular

machinery

)

PLASMA
(soluble mediators)

NUCLEUS

CYTOKINE

RELEASE

TLR4

MyD88 TRIF

NFκB

iNOS

NITRITES

CELL DAMAGE

OXIDATIVE/NITROSATIVE STRESS

LIPID PEROXIDATION

PGE
2

COX-2

15dPGJ
2

PPARγ

LIPOPOLYSACCHARIDE

Fig.1 Detailed scheme of the nuclear tran-
scription factor κB (NFκB) pathway.
Proinflammatory components are
highlighted in blue and solid lines; anti-
inflammatory pathways in magenta and
dotted lines. COX-2, cyclooxygenase-2;
15d-PGJ2, 15-deoxy-prostaglandin J2;
iNOS, inducible nitric oxide synthase;
MyD88, myeloid differentiation factor 88;
PBMC, peripheral blood mononuclear
cells; PGE2, prostaglandin E2; PPARγ,
gamma isoform of the peroxisome
proliferator activated receptor; TLR4, toll-
like receptor 4; TRIF, TIR-domain-
containing adapter-inducing interferon-β.

Psychiatry and Clinical Neurosciences 73: 628–635, 2019 629

PCNPsychiatry andClinical Neurosciences Effects of ECT in inflammatory balance

and NFkB. The same group had previously shown that treatment with
ECT did not affect parameters of oxidative stress in patients with
schizophrenia, neither after one nor after nine treatment sessions.

40

As far as we know, there are no studies that have analyzed the effect
of ECT related to inflammatory changes in BD.

Taking into account this heterogeneous background (in the bio-
markers studied, clinical setting, and timing of the disease course),
this study aimed to explore the effects of a single ECT session on the
inflammatory balance in a selected group of patients with a severe
mental disorder by studying the main intercellular (citoplasmatic and
nuclear) and intercellular components of the canonical innate immune
response and the inflammatory/oxidative consequences of their over-
activation. It also aimed to explore whether there are differences in
these effects depending on clinical variables of the patients and
parameters related to ECT administration.

Methods
Subjects
Thirty subjects were recruited according to the following criteria:
(i) patients who attended an ECT session in the Hospital Clínic de
Barcelona following the usual practice in this center; (ii) patients who
met the DSM-5 criteria for a severe mental disorder (MDD, BD,
schizophrenia, or schizoaffective disorder); (iii) patients aged 18 to
70 years; and (iv) patients able to sign the informed consent.

The exclusion criteria were: (i) being pregnant; (ii) being in treat-
ment with anti-inflammatory drugs (including steroids), antioxidants,
antibiotics, or immunological therapies; (iii) presenting fever (>38�)
or leukocytosis (>10 000 leukocytes/mm3) in the previous 24 h;
(iv) having received a vaccine in the previous 4 weeks; and
(v) presenting a history of neurological diseases, a history of trau-
matic brain injury with loss of consciousness, mental retardation, or
generalized developmental disorders.

Members of the research team informed all the potential candi-
dates who came to receive an ECT session during the period of
recruitment about the study and obtained the informed consent from
all the participants. In an interview prior to the ECT session, and
together with the medical records, the sociodemographic and clinical
data of the patients were collected. The study had been approved by
the Ethics Committee of the Hospital Clínic de Barcelona (record
HCB/2017/0369).

ECT treatment
All treatment stimuli were administered using a MECTA SPEC-
TRUM 5000Q device (MECTA, Lake Oswego, OR, USA). Electro-
encephalographic (EEG) and motor seizure manifestations were
monitored to ensure that an adequate ictal response occurred (>20 s)
or to detect prolonged seizure activity. Patients were continuously
monitored (noninvasive arterial blood pressure, electrocardiogram,
and heart rate and pulse oximetry) using a PHILIPS MP-20 Anesthe-
sia (PHILIPS, Boeblingen, Germany). Succinylcholine (30–120 mg),
atropine (0–1 mg), and sodium thiopental (75–450 mg) were used for
general anesthesia. Ventilation was supported with a facemask at high
oxygen concentration before and after the stimulus. The characteris-
tics of the electrical stimulus were automatically recorded by the
MECTA EMR software connected to the stimulator. Patients could be
in any ECT regimen (acute: first 6–12 ECT sessions; continuation:
first 6 months of treatment after acute regimen; maintenance: after
first 6 months).

Demographic characteristics of the patients (age, sex), diagnosis,
ECT regimen (acute, continuation, or maintenance), ECT electrode
placement, EEG time of convulsion, and total number of lifetime
ECT sessions were recorded.

All medical records were reviewed to determine patients’
responses to ECT treatment. Adapting to our sample the methodology
used in previous studies,41 we scored the Clinical Global Impressions
(CGI)-Improvement scale of all participants in the studied episode.42

CGI-I scores of 1 and 2 (very much improved and much improved)

were considered ‘responders,’ while scores of 3 or more (from mini-
mally improved to much worse) were labeled as ‘non-responders.’

Sample collection
Venous blood samples (10 mL) were collected between 08:30 hours
and 09:30 hours after overnight fasting and 2 h after the stimulation.
Samples were maintained at 4�C until preparation after approximately
1 h. Blood tubes were centrifuged (641 g × 10 min, 4�C). The resul-
tant plasma samples were collected and stored at −80�C. The rest of
the sample was 1:2 diluted in culture medium (RPMI 1640, LifeTech,
Merck KGaA, Darmstadt, Germany) and a gradient with Ficoll-Paque
(GE Healthcare, Madrid, Spain) was used to isolate mononuclear cells
by centrifugation (800 g × 40 min, room temperature [RT]). A
peripheral blood mononuclear cells (PBMC) layer was aspired and
resuspended in RPMI and centrifuged (1116 g × 10 min, RT). The
supernatant was removed and the mononuclear cell-enriched pellet
was stored at −80�C. Once the whole sample recruitment was fin-
ished in the Hospital Clínic de Barcelona, all samples were sent to
Universidad Complutense de Madrid for subsequent determinations.

Biochemical measurements in plasma
Prostaglandin levels

Plasma levels of COX by-products PGE2 and 15d-PGJ2 were mea-
sured by a commercially available enzyme immunoassay following
the manufacturer’s instructions (PGE2 ELISA Kit and 15-deoxy-
Δ12,14-PGJ2 ELISA Kit, Enzo, Lausen, Switzerland). The sensitivity
of the assay for PGE2 was 13.4 pg/mL; intra- and interassay coeffi-
cients of variation (CV) were 5.8% and 5.1%, respectively, and for
15d-PGJ2 the sensitivity was 36.8 pg./mL; intra- and interassay CV
were 5.7% and 13%, respectively.

Lipid peroxidation

Lipid peroxidation was determined by TBARS assay (Cayman
Europe, Tallinn, Estonia), based on the reaction of malondialdehyde
and thiobarbituric acid under high temperature (95�C) and acidic con-
ditions. Intra- and interassay CV were 5.5% and 5.9%, respectively.

Nitrites

NO−2, the final and stable product of nitric oxide, was measured
using the Griess method. Briefly, in an acidic solution with 1% sulfa-
nilamide and 0.1% N-(1-Naphthyl)ethylenediamine, nitrites convert
into a pink compound that is photometrically calculated at 540 nm in
a microplate reader (Synergy 2; BioTek, Bad Friedrichshall,
Germany).

Measurements in PBMC
To carry out all biochemical determinations on PBMC, samples were
first fractionated in cytosolic and nuclear extracts, using a modified
procedure previously described.13 Protein levels were measured using
the Bradford method based on the principle of protein–dye binding.

Determination of proinflammatory p65 NFκB subunit and anti-
inflammatory PPARγ activity were carried out in nuclear extracts
from PMBC using commercially available enzyme immunoassays
NFκB (p65) and PPARγ transcription factor assay (Cayman Europe,
Tallinn, Estonia) following the manufacturer’s instructions.

On the other hand, inflammatory enzymes and elements of
TLR4 pathways were measured in cytosolic extracts by the western
blot method.

Western blot analysis

After determining and adjusting protein levels, cytosolic and nuclear
extracts were mixed with loading sample buffer and 15 μg was loaded
into an electrophoresis gel. Once separated on the basis of molecular
weight, proteins from the gels were blotted onto a nitrocellulose mem-
brane with a semi-dry transfer system (Bio-Rad, Madrid, Spain) and
were incubated with specific antibodies: (i) iNOS, rabbit polyclonal

Psychiatry and Clinical Neurosciences 73: 628–635, 20196

30

Effects of ECT in inflammatory balance PCNPsychiatry andClinical Neurosciences

antibody dilution of 1:750 in 1% BSA (sc651; Santa Cruz Biotech-
nology, Dallas, TX, USA); (ii) COX-2, goat polyclonal antibody dilu-
tion of 1:750 in 2.5% BSA (sc-1747; Santa Cruz Biotechnology);
(iii) TLR4, rabbit polyclonal antibody dilution of 1:750 in BSA 1%
(sc10741; Santa Cruz Biotechnology); (iv) TRIF, rabbit polyclonal
antibody dilution of 1:1000 in TBStween (ab13810, abcam);
(v) MyD88, rabbit monoclonal antibody dilution of 1:1000 in
TBStween (ab133739, abcam); (vi) β-actin mouse monoclonal in a
dilution 1:10000 (A5441, Sigma, Madrid, Spain). Proteins were rec-
ognized by the respective horseradish peroxidase-linked secondary
antibodies and visualized using an Odyssey Fc System (Li-COR Bio-
sciences, Lincoln, NE, USA) and quantified by densitometry (NIH
ImageJ software; ). Values were normal-
ized to the loading control (β-actin, the blots are shown in Fig. 2). All
western blots were performed at least three times in separate assays.

Statistical analysis
Differences in biomarker expression before and after the ECT session
were assessed using a paired t-test on those variables where distribu-
tion met the assumption of normality in the Kolmogorov–Smirnov
(with Lillierfors correction) test. For the rest of the biomarkers, a non-
parametric Wilcoxon signed rank test was used. A value of P < 0.05 was taken to be statistically significant in all analyses.

We carried out a series of sub-analyses with the aim of exploring
whether the changes in the expression of inflammatory biomarkers
were associated with some of the sociodemographic, clinical, or treat-
ment characteristics with ECT. To limit the number of post-hoc ana-
lyses, we only explored the changes in those biomarkers with
significant changes in the activity. Thus, a mixed between/within-
subjects analysis of variance was conducted to assess the impact of
categorical variables (sex, diagnosis, ECT regimen, electrodes place-
ment, response/non-response) on the expression of these biomarkers.
The relations between the biomarker changes and continuous vari-
ables were investigated using the Pearson correlation coefficient.
Being an exploratory analysis, corrections were not made for multiple
comparisons.43

Data were managed and analyzed with the IBM SPSS Statistics
v.23 (SPSS, Chicago, IL, USA).

Results
Demographic/clinical characteristics and ECT parameters from the
30 participants in this study are presented in Table 1. Eighty percent
of the subjects were in the continuation or maintenance ECT program,
having received a mean of around 60 ECT sessions. No incidences
were recorded during the ECT procedures in these patients.

Table 2 summarizes the differences in the biomarker expression
between baseline and 2 h after the ECT session. ECT decreased the
expression of NFĸB, iNOS, nitrites, PGE2, and 15d-PGJ2 activity in a
statistically significant level (P-value < 0.05). A graphic representa- tion of the main results is summarized in Figure 2.

We carried out a series of exploratory sub-analyses to detect
whether the significant changes in NFKB, iNOS, nitrites, PGE2, and
15d-PGJ2 expression were associated with certain sociodemographic,
clinical, or ECT treatment characteristics. We found that the decrease
in nitrites plasmatic levels was greater in females compared to males
(1.41 vs 0.25 μM; F = 5.977, P = 0.021). We also found a positive
correlation between the ECT stimulus load and changes in the expres-
sion of NFĸB (r = 0.385, P = 0.036). Finally, we found differences in
the changes of PGE2 and 15d-PGJ2 levels regarding the ECT regimen
(acute, continuation, or maintenance). In the case of PGE2, patients
under the continuation regimen showed a mean increase of 747.5 pg./
mL for this biomarker, while the acute and maintenance ECT regimens
were associated with a decrease (−1556.62 and −765.12 pg./mL,
respectively; F = 0.359, P = 0.041). Regarding 15d-PGJ2 levels, all
three regimens were associated with a decrease of this anti-
inflammatory marker, but it was more accentuated in the acute regimen

than in continuation or maintenance (−9.01, −6.72, and − 9.26 pg./
mL, respectively; F = 4.879, P = 0.016; F = 4.879, P = 0.016).

We searched for significant differences between responders and
non-responders on the analyzed biomarkers expression. We found that
TBARS levels were decreased after the ECT session in patients who
were considered responders, while this lipid peroxidation determina-
tion was increased in non-responders (F = 4.3, P = 0.047; Fig. 3).

We did not find significant differences in the expression of any of
these biomarkers associated with diagnosis, ECT electrode placement,
EEG time of convulsion, or total number of lifetime ECT sessions.

Discussion
Our findings highlight the effects that a single ECT session produces
on the inflammatory balance, concretely on the NFĸB pathway, a
canonical regulator of the inflammatory/immune system response.
Two hours after an ECT session, we found a statistically significant
decrease in the levels of various proinflammatory components of this
pathway: NFĸB, iNOS, nitrites, and PGE2. Overall, these findings
suggest that ECT produces a rapid systemic anti-inflammatory effect
on patients with severe mental disorders. ECT treatment was also
associated with a significant decrease of the expression of the 15d-
PGJ2, an endogenous anti-inflammatory regulator. Furthermore,
patients considered as responders to ECT treatment showed decreased
TBARS levels, while these levels increased in non-responders. To our
knowledge, this is the first time that such effects on the inflammatory
balance have been reported in a sample of patients with a severe men-
tal disorder after receiving an ECT session, when such a number of
intra- and intercellular components of this innate-immune and inflam-
matory pathway are measured.

These results are in line with most previous studies that have
examined the inflammatory effects of acute treatment with ECT, find-
ing that this treatment has a relatively fast impact on the systemic
inflammatory and immune response, taking into account that there are

Table 1. Demographic, clinical characteristics, and
electroconvulsive therapy parameters

n = 30

Age 52.97 (16.81)
Sex

Female 19 (57.7%)
Male 11 (33.3%)

Diagnosis
Schizophrenia 6 (18.2%)
Schizoaffective disorder 7 (21.2%)
Bipolar disorder 13 (39.4%)
Major depressive disorder 4 (12.1%)

ECT regimen
Acute 6 (20.0%)
Continuation 7 (23.3%)
Maintenance 17 (56.7%)

ECT application
Bitemporal 27 (90%)
Right unilateral 3 (10%)

Lifetime ECT number of sessions 60.77 (66.27)
Duration (s) of EEG convulsion 40.27 (12.49)

Data expressed as number of patients (percentage) or mean (SD). In
ECT regimen: ‘Acute’ refers to the first 6–12 ECT sessions,
‘Continuation’ for the following sessions during the first 6 months,
and ‘Maintenance’ for the sessions received after this first 6-month
period.
ECT, electroconvulsive therapy; EEG, electroencephalographic.

Psychiatry and Clinical Neurosciences 73: 628–635, 2019 631

PCNPsychiatry andClinical Neurosciences Effects of ECT in inflammatory balance

important methodological differences among the relatively few avail-
able studies. This set of studies suggests that certain inflammatory
parameters could be used as biomarkers of response to ECT treatment
and that certain subpopulations of patients might benefit most from

this treatment. Seeing the effects of this technique on the immune sys-
tem, these results also increase the interest in knowing ECT’s effects
on certain psychiatric disorders mediated by immunity, such as auto-
immune encephalitis.44,45

PRE

T
L

R
4

/β
-a

c
ti
n

(
%

O
D

)

β actin

0

50

100

150

POST

PRE

TLR4 89 kDa

42 kDa

POST
PRE

T
R

IF
/β

-a
c
ti
n

(
%
O
D
)
β actin
0
50
100
150
POST
PRE

TRIF 66 kDa

42 kDa
POST
PRE

M
y
D

8
8

/β
-a
c
ti
n
(
%
O
D
)
β actin
0
50
100
150
POST
PRE

MyD88 35 kDa

42 kDa
POST
PRE

A
U

0

0.2

0.4

0.8

0.6

POST

NFκB (p65) Activity

*
PRE

iN
O

S
/β

-a
c
ti
n
(
%
O
D
)
β actin
0
50
100
150
POST
PRE

iNOS 130 kDa

42 kDa
POST
PRE

C
O

X
-2

/β
-a
c
ti
n
(
%
O
D
)
β actin
0
50
100
150
POST
PRE

COX-2 72 kDa

42 kDa
POST
PRE

P
la

s
m

a
(

p
g

/m
L

)
0

1000

2000

4000

3000

POST
PGE
2

TBARS Nitrites

*
*
PRE

M
a

lo
n

d
ia

ld
e

h
y
d

e
p

la
s
m

a

(

μ
M

)
0
5

10

15

POST PRE

P
la
s
m

a
N

O
–
2
(

μ
M
)
0
4
2
6
8
POST

15d-PGJ
2

***

PRE
P
la
s
m
a
(
p
g
/m
L
)
0

20

10
30
40
POST

PPARγ Activity

*
PRE
A
U
0
0.2
0.4
0.6
POST

(a) (b) (c)

(d) (e) (f)

(g) (h)

(j) (k)

(i)

Fig.2 Mean differences (SD) on biomarkers at baseline and 2 h after an electroconvulsive therapy session (univariate analysis). (a) Western blot analysis of the toll-like
receptor 4 (TLR4) activity in peripheral blood mononuclear cells (PBMC); (b) western blot analysis of the TIR-domain-containing adapter-inducing interferon-β (TRIF)
activity in PBMC; (c) western blot analysis of the myeloid differentiation factor 88 (MyD88) activity in PBMC; (d) p65 nuclear transcription factor κB (NFκB) subunit activ-
ity assay in nuclear extracts from PMBC; (e) western blot analysis of the inducible nitric oxide synthase (iNOS) activity in PBMC; (f) western blot analysis of the
cyclooxygenase-2 (COX-2) activity in PBMC; (g) plasma levels of prostaglandin E2 (PGE2); (h) lipid peroxidation determined by thiobarbituric acid reactive substances
(TBARS); (i) plasma levels of nitrites; (j) plasma levels of 15-deoxy-prostaglandin J2 (15d-PGJ2); (k) gamma isoform of the peroxisome proliferator activated receptor
(PPARγ) activity assay in nuclear extracts from PMBC. AU, arbitrary units; OD, optical density.

Psychiatry and Clinical Neurosciences 73: 628–635, 2019632

Effects of ECT in inflammatory balance PCNPsychiatry andClinical Neurosciences

Apart from decreasing some proinflammatory parameters, an
interesting result observed was the decrease in the expression of 15d-
PGJ2. Though the general approach of our study was exploratory, this
was the most robust finding from a statistical point of view, being sig-
nificant even after applying multiple testing corrections. The decrease
of such anti-inflammatory mediators could be related to the appear-
ance of some of the most common side-effects of ECT, such as cog-
nitive effects. Our group has recently reported an association between
the expression of this biomarker and the presence of certain cognitive
deficits in patients with a first psychotic episode.46 These results sug-
gest that future research will identify the role of inflammatory bio-
markers in relation to the cognitive deficits that some people under
treatment with ECT present.

Interesting differences in lipid peroxidation results were found;
this was one of the most relevant parameters of the pathway studied

and was determined by the TBARS assay. Specifically, those patients
who were considered responders showed decreased TBARS levels
after the ECT session, while non-responders showed increases of this
lipid peroxidation determination. These results indicate that in the
subpopulation of responders, ECT could mitigate cell damage pro-
cesses mediated by lipid peroxidation, while in non-responders these
processes could get worse.

Some limitations should be taken into account when analyzing
these results. First, the relatively small sample size could be limiting
the statistical power. Second, the sample was heterogeneous regarding
certain clinical variables (i.e., diagnosis, psychopharmacological treat-
ment, or ECT regimen). Third, we studied the effects of an ECT ses-
sion, while it would be also very informative to have retested the
patients 24 h after the ECT session and at the end of the whole acute
treatment (generally 9–12 sessions). Fourth, as the main aim of our
study was to explore the effects of a single session of ECT on the
inflammatory balance in a selected group of patients with a severe
mental disorder, we did not have a group of healthy controls paired
with the study sample with which to compare the expression of bio-
markers at baseline. Fifth, we do not know the effects of anesthesia,
the apnea time, or the tonic–clonic seizures on the biomarkers
studied.

Despite these limitations, we believe that our study has identified
significant effects of ECT treatment over PBMC pro-/anti-
inflammatory pathways in a group of patients with severe mental
disorders; and these findings warrant greater attention in future inves-
tigations. Furthermore, key strengths of the study deserve mention:
(i) we included a wide spectrum of biochemical inflammatory markers
both in plasma samples and peripheral blood mononuclear cells, all-
owing in-depth insights and relations between multiple components
of the pro- and anti-inflammatory signaling pathways; and (ii) the
diagnostic evaluation was performed with a very comprehensive pro-
tocol and inclusion–exclusion criteria were applied in a strict manner.

In conclusion, and regarding the implications for clinical prac-
tice, in this study we have identified the effects that an ECT session
produces on the inflammatory balance of patients with a severe men-
tal disorder. Although more scientific evidence is needed to expand
this preliminary data, the determination of multiple components of
pro- and anti-inflammatory cellular pathways, including the activity
of nuclear receptors, have interesting potential as biological markers
and potential targets. These results can also be helpful to clarify the

Table 2. Mean differences (�SD) in the biomarker levels between pre-ECT and post-ECT session (2 h after stimulus) in 30 patients with severe
mental disorders

Marker Pre-ECT Post-ECT Statistics P-value

TLR4 WB, % OD 100.13 � 17.15 93.24 � 21.22 t = 1.763 0.089
TRIF WB, % OD 100.22 � 18.26 96.42 � 15.92 t = 1.175 0.250
MyD88 WB, % OD 105.32 � 41.29 102.81 � 46.84 z = −0.205 0.837
NFKB AAnucl, AU 0.58 � 0.26 0.45 � 0.17 z = −2.108 0.035
iNOS WB, % OD 99.77 � 10.44 93.37 � 14.64 t = 2.698 0.0

12

COX-2 WB, % OD 100.44 � 17.31 104.56 � 29.81 t = −0.845 0.405
PGE2 plasma, pg/ml 2976.21 � 1891.15 2405.73 � 2475.15 z = −1.964 0.049
15d-PGJ2 plasma, pg/ml 35.78 � 7.49 28.30 � 7.22 t = 4.633 <0.001 Nitrites plasma, μM 7.09 � 2.60 6.11 � 3.27 z = −2.211 0.027 TBARS plasma, μM MDA 11.44 � 4.98 11.04 � 5.24 z = −0.936 0.349 PPARγ AAnucl, AU 0.477 � 021 0.37 � 0.14 z = −1.861 0.063 Data expressed as mean � SD. Immune/inflammatory/oxidative parameters shown in white cells; anti-inflammatory/antioxidative parameters in gray cells. See Methods section for detail. AAnucl, activity assay in nuclear extracts; AU, arbitrary units; COX-2, cyclooxygenase-2; 15d-PGJ2, 15-deoxy-prostaglandin J2; iNOS, inducible nitric oxide synthase; MyD88, myeloid differentiation factor 88; NFκB, nuclear transcription factor κB; OD, optical density; PGE2, prostaglandin E2; Plasma, plasma levels; PPARγ, gamma isoform of the peroxisome proliferator activated receptor; TBARS, thiobarbituric acid reactive substances; TLR4, toll-like receptor 4; TRIF, TIR-domain-containing adapter-inducing interferon-β; WB, western blot.

PRE-ECT

8
9
10

11

12

13

POST-ECT

TBARS

Fig.3 Differences between treatment ( ) responders and ( ) non-
responders in thiobarbituric acid reactive substance (TBARS) levels at baseline
and 2 h after an electroconvulsive therapy (ECT) session.

Psychiatry and Clinical Neurosciences 73: 628–635, 2019 633

PCNPsychiatry andClinical Neurosciences Effects of ECT in inflammatory balance

mechanisms of actions of ECT. Such findings warrant greater atten-
tion in future investigations and in the translational significance of
these data.

Acknowledgments
The authors wish to acknowledge Sonia Hernández, Marc Valentí,
and all members of the Neuroanesthesia Section at the Hospital Clínic
de Barcelona. This study was supported by Instituto de Salud Carlos
III, Fondo Europeo de Desarrollo Regional, Unión Europea, ‘Una
manera de hacer Europa’, MINECO SAF2016/75500-R, Centro de
Investigación Biomédica en Red de Salud Mental (CIBERSAM), and
by Generalitat de Catalunya and Secretaria d’Universitats i Recerca
del Departament d’Economia i Coneixement (2014SGR441 and
2014SGR398).

Disclosure statement
Dr Bernardo has been a consultant for, has received grant/research
support and honoraria from, and has been on the speakers/advisory
board of ABBiotics, Adamed, Angelini, Casen Recordati, Eli Lilly,
Janssen-Cilag, Lundbeck, Otsuka, Takeda, and Somatics; and has
obtained research funding from the Ministry of Education, Culture
and Sport, the Spanish Ministry of Economy, Industry and Competi-
tiveness (CIBERSAM), by the Government of Catalonia, Secretaria
d’Universitats i Recerca del Departament d’Economia i Coneixement
(2017SGR1355), Foundation European Group for Research In
Schizophrenia (EGRIS), and the 7th Framework Program of the
European Union. Dr Bioque has received honoraria from talks and
consultancy from Adamed, has received honoraria from consultancy
for Ferrer, has received research support and honoraria from talks and
consultancy from Janssen-Cilag, has received honoraria from talks
and consultancy from Lundbeck, has received honoraria from talks
and consultancy from Otsuka, and has received a research prize from
Pfizer. Dr Vieta has received grants and served as consultant, advisor
or CME speaker for the following entities: AB-Biotics, Allergan,
Angelini, AstraZeneca, Bristol-Myers Squibb, Dainippon Sumitomo
Pharma, Farmindustria, Ferrer, Forest Research Institute, Gedeon
Richter, Glaxo-Smith-Kline, Janssen, Lundbeck, Otsuka, Pfizer,
Roche, Sanofi-Aventis, Servier, Shire, Sunovion, Takeda, the Brain
and Behaviour Foundation, the Spanish Ministry of Science and Inno-
vation (CIBERSAM), the Seventh European Framework Programme
(ENBREC), and the Stanley Medical Research Institute. The rest of
authors report no competing interests for this study.

Author contributions
M. Bioque conducted the literature review, recruited the participants,
applied the ECT session, collected data, conducted the main statistical
analysis, wrote the first draft of the manuscript, and handled subse-
quent drafts after receiving coauthors’ feedback. K.S.M.-D., per-
formed all biochemical determinations in plasma and in cells and
prepared subcellular samples, assisted with the analysis, and wrote
the first draft of the manuscript. A.M. collected the biological samples
and separated plasma and PBMC. E.M. recruited the participants, col-
lected the blood samples, and applied the ECT session. The rest of
the coauthors participated in the ECT procedures, collected data, and
commented on drafts. All of the authors contributed to the final ver-
sion of the paper.

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• Effects of electroconvulsive therapy in the systemic inflammatory balance of patients with severe mental disorder

Methods
Subjects
ECT treatment
Sample collection
Biochemical measurements in plasma
Prostaglandin levels
Lipid peroxidation
Nitrites
Measurements in PBMC
Western blot analysis
Statistical analysis
Results
Discussion
Acknowledgments
Disclosure statement
Author contributions
References

[Mental Illness 2017; 9:7181] [page 63]

Adverse effects of electrocon-
vulsive therapy on cognitive
performance
Sasha S. Getty,1 Lawrence R. Faziola2
1University of California at Irvine,
School of Medicine; 2Department of
Psychiatry and Human Behavior,
University of California, Irvine Medical
Center, CA, USA

Electroconvulsive therapy (ECT) has his-
torically been shown to be a highly effective
method of treating major depression and
catatonic state otherwise resistant to psy-
chopharmacotherapy.1-5 However, ECT has
also been associated with a variety of tran-
sient impairments in cognitive performance
during and following the treatment.6-10 The
side effects, often subjectively reported by
the patients, include deficits in orientation,
short term memory function, attention,
speech fluency, and executive functions
lasting from hours to perhaps months in a
number of cases.6-10 These reported attrib-
utes often lead to limited use of ECT as an
acute treatment of treatment-resistant
depression and other conditions where it
can potentially produce positive overturn-
ing effects. There appears to be a lack of
clarity and consensus in the literature
regarding ECT-related adverse effects on
cognitive performance. While some studies
have reported absence of any effects on
memory and implicit learning,6 several oth-
ers have shown diverse negative impacts
across various domains of cognition includ-
ing greatest global decline associated with
bitemporal ECT, major deterioration of ver-
bal memory attributed to bifrontal ECT, and
largest decline in visual memory related to
right unilateral ECT, as measured by tests
such as Mini Mental State exam,7 Trail-
Making,11,12 Rey Auditory Verbal
Learning,11,12 autobiographical memory,
visual memory, and verbal fluency.11,13
Therefore, this topic remains much debat-
able, and can still benefit from investiga-
tions that would add to the body of evidence
to further elucidate and clarify different
aspects and extent of these adverse effects
in terms of factors such as distinction
between immediate versus delayed impacts,
different electrode placement methods and
dosing, as well as the appropriate measure-
ment methods sensitive to particular cogni-
tive domains.

Authors of this study14 investigated the
potential immediate short-term adverse
effect of right unilateral ECT on cognitive
function using digital ascending number
tapping test (DANTT) as a novel psycho-

metric measurement modality. Using
DANNT, the authors specifically studied
speed of processing, executive function,
and visual search before and after treatment
in patients of both genders between the ages
of 36 to 76 years. They concluded that ECT
does not significantly alter cognitive per-
formance in those domains up to 2 hours
after receiving therapy, which is in stark
contrast to the results of previous investiga-
tions.14 Results of this study revealed no
measurable impairment of concentration
resulting from single or multiple ECT treat-
ments. In addition, patients with a longer
seizure duration elicited by ECT did not
exhibit greater concentration impairment as
evidenced by absence of any significant dif-
ference in performance times.14

Adverse effects of ECT on cognitive
function has been the subject of investiga-
tion in several studies. However, current lit-
erature does not provide sufficient and spe-
cific data in order to draw reliable conclu-
sions as to the degree and extent of potential
impairments in various particular domains
of cognitive performance.1-13 In contrast to
previous studies, this study did not reveal
any significant post-ECT deficit in select
cognitive domains, namely speed of pro-
cessing, executive function, and visual
search as measured by DANNT.14 This
finding raises the possibility that perhaps
some elements of cognition may be immune
to ECT, whereas other domains, shown to
have exhibited deficits in other studies,
might be more susceptible. This demands
further subtyping of cognitive domains and
deficits, as well as designing measurement
tools tailored to more accurately and specif-
ically target those areas. Use of DANTT
introduced in this study in lieu of tests used
in previous studies such as trail-making and
MMSE, which provide o

nly

an overall
score without localizing function to particu-
lar cognitive domains, is an example of this
approach. This novel modality for measur-
ing visual search and speed of processing in
particular allows for higher precision and
accuracy by eliminating problems associat-
ed with trail-making test such as memoriza-
tion biases and line drawing which can hin-
der identification of numbers, and can be
employed in future trials to reproduce the
findings of this study.

References
1. Kellner CH, Greenberg RM, Murrough
JW, et al. ECT in treatment-resistant
depression. Am J Psychiatry 2012;169:
1238-44.

2. Bschor T, Bauer M, Adli M. Chronic
and treatment resistant depression:

diagnosis and stepwise therapy. Dtsch
Arztebl Int 2014;111:766-75.

3. Bschor T. Therapy-resistant depression.
Expert Rev Neurother 2010;10:77-86.

4. Pagnin D, de Queiroz V, Pini S, et al.
Efficacy of ECT in depression: a meta-
analytic review. J ECT 2004;20:13-20.

5. Gábor G, László T. [The efficacy of
ECT treatment in depression: a meta-
analysis]. Psychiatr Hung 2005;20:195-
200. [Article in Hungarian].

6. Andrade C, Arumugham SS, Thirthalli
J. Adverse effects of electroconvulsive
therapy. Psychiatr Clin N Am 2016;39:
513-30.

7. Dunne RA, McLoughlin DM.
Systematic review and meta-analysis of
bifrontal electroconvulsive therapy ver-
sus bilateral and unilateral electrocon-
vulsive therapy in depression. World J
Biol Psychiatry 2012;13:248-58.

8. Prudic J. Strategies to minimize cogni-
tive side effects with ECT: aspects of
ECT technique. J ECT 2008;24:46-51.

9. Datka W, Siwek M, Dudek D, et al.
[Working memory disturbances in
patients with major depression after
ECT treatment]. Psychiatr Pol
2007;41:339-49. [Article in Polish].

10. Maric NP, Stojanovic Z, Andric S, et al.
The acute and medium-term effects of
treatment with electroconvulsive thera-
py on memory in patients with major
depressive disorder. Psychol Med
2016;46:797-806.

11. Kellner CH, Knapp R, Husain MM, et
al. 2010. Bifrontal, bitemporal and right
unilateral electrode placement in ECT:
randomised trial. Br J Psychiatry

Mental Illness 2017; volume 9:7181

Correspondence: Sasha S. Getty, University of
California, Irvine, School of Medicine, 1001
Health Sciences Rd, Irvine, CA 92617, USA.
Tel.: +1.310.980.2267.
E-mail: sgetty@uci.edu

Key words: electroconvulsive therapy, cogni-
tive performance.

Contributions: the authors contributed equally.

Conflict of interest: the authors declare no
potential conflict of interest.

Received for publication: 11 April 2017.
Accepted for publication: 11 April 2017.

This work is licensed under a Creative
Commons Attribution-NonCommercial 4.0
International License (CC BY-NC 4.0).

©Copyright S.S. Getty and L.R. Faziola, 2017
Licensee PAGEPress, Italy
Mental Illness 2017; 9:7181
doi:10.4081/mi.2017.7181

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al

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[page 64] [Mental Illness 2017; 9:7181]

196:226-234.
12. Sienaert P, Vansteelandt K,

Demyttenaere K, et al. Randomized
comparison of ultra-brief bifrontal and
unilateral electroconvulsive therapy for
major depression: cognitive side-
effects. J Affect Disord 2010;122:60-7.

13. Eschweiler GW, Vonthein R, Bode R, et
al. Clinical efficacy and cognitive side
effects of bifrontal versus right unilater-
al electroconvulsive therapy (ECT): a
short-term randomised controlled trial
in pharmaco-resistant major depression.
J Affect Disord 2007;101:149-57.

14. Müller HH, Reike M, Grosse-Holz S, et
al. Electroconvulsive therapy does not
have negative effects on short-term
memory function, as assessed using a
bedside hand-held device. Ment Illn
2017;9:7093.

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HISTORY, POWER, AND ELECTRICITY: AMERICAN POPULAR MAGAZINE
ACCOUNTS OF ELECTROCONVULSIVE THERAPY, 1940–2005

LAURA HIRSHBEIN* AND SHARMALIE SARVANANDA

Electroconvulsive therapy (ECT) is a psychiatric treatment that has been in use in the
United States since the 1940s. During the whole of its existence, it has been extensively
discussed and debated within American popular magazines. While initial reports of the
treatment highlighted its benefits to patients, accounts by the 1970s and 1980s were
increasingly polarized. This article analyzes the popular accounts over time, particularly
the ways in which the debates over ECT have revolved around different interpretations of
ECT’s history and its power dynamics. © 2008 Wiley Periodicals, Inc.

On June 25, 2005, NBC aired a Today Show interview of actor Tom Cruise during which
Cruise took to task fellow actor Brooke Shields about her decision to take antidepressant
medication. His remarks centered not on medication, though, but rather on the psychiatric
enterprise as a whole, including electroconvulsive therapy:

I’ve never agreed with psychiatry, ever. Before I was a Scientologist I never agreed with
psychiatry. And when I started studying the history of psychiatry, I understood more and
more why I didn’t believe in psychology. . . . Here we are today, where I talk out against
drugs and psychiatric abuses of electric shocking people, okay, against their will, of
drugging children with them not knowing the effects of these drugs. . . . You don’t know
the history of psychiatry. I do. (Lauer, 2005)

Cruise’s avowed stance as a member of the Church of Scientology, a group that has been
aggressively opposed to psychiatry in the last few decades, certainly explains the vehemence
with which he attacked psychiatry. Yet he was not content to merely attack current psychiatric
practice or even just medications. Instead, he invoked the evidence of history to demonstrate
the problems with psychiatry, including electroconvulsive therapy.

1

In 1940, the first descriptions of new treatments for mental illness appeared in the pop-
ular press in the United States: convulsive therapies or shock treatments. Magazine accounts
of the time enthusiastically reported the benefits of shock for a hopeless patient population.

Journal of the History of the Behavioral Sciences, Vol. 44(1), 1–18 Winter 2008
Published online in Wiley Interscience (www.interscience.wiley.com). DOI 10.1002/jhbs.20283
© 2008 Wiley Periodicals, Inc.

1

LAURA HIRSHBEIN, MD, PhD, is Assistant Professor of Psychiatry at the University of Michigan.
Dr. Hirshbein completed her MD and residency training in psychiatry at the University of Michigan, and re-
ceived her PhD in the history of medicine from the Johns Hopkins University. She is completing a book on the
history of depression in the twentieth century, American Melancholy: A History of Depression in the United
States, 1900–1990. E-mail: lauradh@med.umich.edu

SHARMALIE SARVANANDA, MD, completed her psychiatry residency training at the University of
Michigan and is currently in private practice in Lapeer, Michigan.

* I would like to thank the two anonymous reviewers who helped enormously as I worked on revisions for this paper.
I would also like to thank the psychiatry residents at the University of Michigan who have engaged with me in
thoughtful, provocative discussions about power and ECT.

1. Scientology has aggressively used the history of psychiatry as a weapon to attack the specialty. The public relations
group connected with Scientology, the Citizens Commission on Human Rights (CCHR), has worked hard to drive
ECT machine manufacturers out of business and has actively contributed in the laws limiting ECT in many states. The
CCHR has recently opened a museum, “Psychiatry: The Museum of Death,” that prominently features ECT.

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2 LAURA HIRSHBEIN AND SHARMALIE SARVANANDA

By the 1970s, however, shock treatment appeared much more problematic. In 1972, Senator
Thomas Eagleton was forced to withdraw his Democratic vice-presidential candidacy after he
revealed that he had received electroconvulsive therapy (ECT) the decade before his nomina-
tion. As popular magazine writers attempted to make sense of Eagleton’s story, they particu-
larly addressed the history of ECT: where did this therapy come from and why was it being
used? A shock no longer appeared progressive, but rather suggested a potentially troubling
treatment that harkened back to a dark past of psychiatric coercion. More recently, public dis-
cussions around ECT have become more and more polarized, and the history of the treatment
plays a central role in these discussions. Advocates of ECT insist that present-day ECT is
much better than in the past, while opponents use the concept of shock therapy in order to
berate psychiatry for continuing to assert control over patients with barbaric treatments.

The different narratives about ECT and its history are part of a broader ongoing public
discourse about the power of psychiatry to define normality. It is no accident that the turning
point in the popular press accounts of ECT was in the 1970s—the time when many different
groups within America were struggling against hegemonic psychiatric definitions of normal
sexuality and gender relationships (Bayer, 1987; Tomes, 1994). Indeed, the most potent image
of ECT in popular culture remains that from the 1975 film One Flew Over the Cuckoo’s Nest.
While the main character’s experience with ECT comprises less than five minutes of screen
time, ECT is very much connected with the other strategies of control that the psychiatry team
exerts over the main character in the film. In retrospect, ECT opponents still find the Cuckoo’s
Nest image compelling because it effectively captures the power dynamics they still see as
problematic in patients’ encounters with psychiatry. ECT advocates respond to the Cuckoo’s
Nest image, in contrast, by explaining that this representation reflects past abuses, not current
scientific use.

As the endurance of Cuckoo’s Nest in the popular imagination indicates, the public has
been and remains intensely interested in the concept of ECT. In this article, we examine pop-
ular magazine accounts of ECT and shock therapies from the 1950s through 2005 (as indexed
in the Reader’s Guide) in order to understand change over time in the public encounter with
ECT and its changing power dynamics (Reader’s Guide to Periodical Literature). Within pop-
ular representations of ECT, its history has become a way for both advocates and opponents
to express their views about ECT and psychiatric power. As with other accounts of social or
cultural events, including scientific or medical discoveries (Abir-Am, 1999; Bodnar, 1992;
Kammen, 1991; Micale & Porter, 1994; Novick, 1999; Silber, 1993), the histories of ECT
have changed over time in response to changing social and cultural circumstances, as well as
changes in the broader implications of psychiatric treatment. The history of ECT has become
a metaphor for both advocates and opponents to explain their vision of psychiatric power and
its promise for or threat to society.

POPULAR MAGAZINES AND SHOCK TREATMENTS, 1940–1970

In the first half of the twentieth century, psychiatrists increasingly used new treatments on
patients’ bodies in order to cure, or at least ameliorate, their mental illnesses (Braslow, 1997;
Scull, 2005). Convulsive therapy was originally conceived as occurring through three different
mechanisms: insulin coma, metrazol shock, and electric shock (Berrios, 1997; Kneeland &
Warren, 2002; Lebensoh, 1999; Shorter, 1997; Weiner & Coffey, 1991). These treatments were
particularly used for seriously ill patients within the center of psychiatric practice of the time,
the mental hospital (Grob, 1983; Lunbeck, 1994). Mentally ill patients were typically divided
into groups based on their likelihood of recovery: manic-depressive patients appeared to

JOURNAL OF THE HISTORY OF THE BEHAVIORAL SCIENCES DOI: 10.1002/jhbs

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HISTORY, POWER, AND ELECTRICITY: AMERICAN POPULAR MAGAZINE 3

recover their ability to function, while schizophrenic (or dementia praecox) patients tended
to decline over time (Hoenig, 1995; Jackson, 1986; Kraepelin, 1907; Turner, 1995). All three
of the convulsive therapies were originally hailed as treatments for schizophrenia, but the
association of particular diagnoses with specific convulsive therapies gradually disappeared
(Kalinowsky & Worthing, 1943; Malzberg, 1943; Rennie & Fowler, 1943).

The rationale for all forms of convulsive therapy was that the convulsion disrupted
problems in the patient’s thinking and restored some semblance of normality. This rationale
seemed to be supported by practitioners’ experiences—patients did seem to become calmer
after treatments. Insulin coma treatment (which sometimes resulted in convulsions), made
possible because of the exciting isolation of insulin in the 1920s (Bliss, 1984), was the first
of the three convulsive therapies to be introduced in the United States in the 1930s (Appel,
Farr, & Marshall, 1928; Rinkel & Himwich, 1959). Metrazol, a drug that was originally used
for patients with heart difficulties, was used to induce convulsions that appeared to reduce or
eliminate patients’ agitation and psychoses (Bennett, 1939; McCrae, 2006; Menninger, 1940;
Wilson, 1939). Although metrazol was robust in its ability to produce a convulsion, it was also
universally disliked by patients (Kennedy, 1940; Nussbaum, 1943; E. Ziskind, Somerfeld-
Ziskind, & Ziskind, 1942). Electroconvulsive therapy (ECT) was developed in the late 1930s
by two Italian psychiatrists who discovered how to induce convulsions with electricity.
Although not all psychiatrists believed that ECT was superior to insulin, it was easier to
administer and better tolerated than metrazol (Bianchi & Chiarello, 1944; Sulzbach, Tillotson,
Guillemin, & Sutherland, 1943). ECT was modified in the late 1950s by the introduction
of anesthesia (both sedation and muscle relaxation), a change in the procedure that most
psychiatrists hailed as a significant improvement for patient comfort and safety (English &
Finch, 1964). Between 1940 and the late 1950s, shock treatments appeared in popular maga-
zine accounts of seriously ill patients and their providers. Although magazine writers did
make distinctions within articles among insulin, metrazol, and electric shock, the treatments
were often discussed together, generally reflecting clinical practice in which they were used
together (Messinger, 1941; Read, 1940).

When shock therapies were originally introduced to American popular audiences through
magazines, the treatments exemplified the growing power of medical practitioners over dis-
ease. For the most part, magazine accounts of shock treatments in the 1940s and 1950s enthu-
siastically described the possibilities of improving very ill patients. One Science News Letter
article explained that these treatments “restore to sanity the ‘living dead’ affected by the
dementia praecox form of mental illness.” In this context, the subsequent risk for vertebral
fractures caused by “violent convulsive shocks” appeared entirely reasonable (“Many Spinal
Fractures in Shock Treatments,” 1940). One Hygiea writer emphasized that these treatments
were producing success in “supposedly incurable mental disorders” (Read, 1940, p. 627).
Treatment for these previously incurable diseases was not a minor accomplishment: “Coming
at a time when war is subjecting the population of the whole world to those intolerable mental
strains that precipitate mental disease, this new use of electricity for mental health instead of
for death is being enthusiastically welcomed by the medical profession” (Van de Water, 1940,
p. 42)2 (Messinger, 1941). Although some writers warned against becoming too enthusiastic
about treatments, the recovery rates for patients undergoing convulsive therapies appeared to
be much better than the usual recovery rates (“Many Mentally Ill Now Getting Shock
Treatment,” 1942).

JOURNAL OF THE HISTORY OF THE BEHAVIORAL SCIENCES DOI: 10.1002/jhbs

2. At the time that the electric chair was introduced in the U.S. in the 1880s, it was hailed as a modern signal of
advancing civilization. See Martschukat (2002). For more on the history of the electric chair, see Essig (2003),
Moran (2002)

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4 LAURA HIRSHBEIN AND SHARMALIE SARVANANDA

JOURNAL OF THE HISTORY OF THE BEHAVIORAL SCIENCES DOI: 10.1002/jhbs

While shock treatments came to prominence in America at the same time that psycho-
analysis was gaining wider acceptance (Hale, 1995), there was no necessary conflict between
the two types of treatments for either psychiatrists or the public (Levy & Grinker, 1943;
Menninger, 1940; Rennie & Fowler, 1943; Rosen, Secunda, & Finley, 1943; Sadowsky, 2006).3

Popular accounts of shock treatments used explanations and metaphors for the procedures that
drew on both somatic and psychoanalytic models. As one account of ECT in 1941 explained,
the shock was intended to “jolt a mental patient out of his dream world and back into sanity”
(“Electric Shock Treatment Causes Partial Memory Loss,” 1941, p. 182). While some writers
explained this effect in terms of applied electricity to the brain (Galton, 1958; “Meeting On
Minds,” 1949), others used psychological terms (“Insulin Sub-Shock Treatment for Mental
Illness,” 1949). As a physician outlined in 1945, “the patient’s subconscious mind regards the
shock as a threat to his very existence. This thought so jars him that his mental conflicts take on
secondary importance. The instinct of self preservation is profoundly affected and suicidal
impulses quickly disappear. The patient—if he is to recover—develops a willingness to face
reality” (Feldt, 1945, p. 21). A 1948 Newsweek report of shock used to treat a young woman
with a very bad stutter explained that the treatment worked by releasing the “patient’s inner
tension” and allowed her to participate in psychotherapy (“Shock for Stammerers,” 1948).

Throughout this initial period when convulsive therapies were introduced, popular com-
mentators framed the therapies in terms of the battle of the psychiatrists against the disease
(“Meeting On Minds,” 1949; “More or Less Shock?,” 1955; “Photoshock Treats Psychosis,”
1952; L. Ziskind, 1948). Although the treatments could have negative side effects, commen-
tators generally explained them as unavoidable consequences of the larger fight (“Electric
Shock Treatment Causes Partial Memory Loss,” 1941). This interpretation of ECT as one
method of conquering mental illness also appeared in other popular media of the time. In the
1948 film, The Snake Pit, for example, the heroine receives a large number of therapies—
from electric shock to hydrotherapy to narcosynthesis to psychoanalytic psychotherapy. While
the heroine is clearly under the power of her psychiatrist, he is presented as a benevolent
figure who uses treatments in order to “make contact” with his patient. In this context,
although ECT is frightening, it is one of many tools he employs to try to help his patient.
Although the patient ultimately improves with psychoanalysis (at least in the film), the
psychiatrist is able to make significant inroads with her because of her other types of therapies
(Fishbein, 1979; McDonald & Walter, 2001).

Many of the early stories of the convulsive therapies placed them within a narrative of
recent medical discoveries. Writers contrasted the past, which they characterized as a time
without any psychiatric interventions, with the present, with its dramatic new discoveries of
effective treatments. As physician Robert Feldt explained in 1945, “insanity is no longer
regarded as a hopeless, hideous disease. A revolutionary new treatment is restoring sanity to
thousands of patients by shocking them with drugs or electricity” (Feldt, 1945, p. 21). Feldt went
on to characterize the discoveries of each of the kinds of shock treatment, emphasizing the role
of scientific experiment and chance that stimulated further work. Feldt even mentioned that a
psychiatrist tested electric shock therapy on himself and determined that it was safe, a true
marker of both the treatment’s safety and his credibility as a scientist (Lederer, 1995).

Indeed, by the 1950s, electric shock was so well established as a modern effective treat-
ment that journalists who described new medical applications of shock cited psychiatry’s use

3. At the University of Michigan, for example, psychiatrist Dr. Moses Frohlich was in charge of insulin, metrazol, and
electric shock treatments in the 1940s, at the same time that he was undergoing his training analysis with the Detroit
Psychoanalytic Society. Moses Frohlich Papers, Bentley Historical Library, University of Michigan, Ann Arbor, MI.

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HISTORY, POWER, AND ELECTRICITY: AMERICAN POPULAR MAGAZINE 5

JOURNAL OF THE HISTORY OF THE BEHAVIORAL SCIENCES DOI: 10.1002/jhbs

of it as a model (Bukstein, 1963; “Electric Shock Stops Heart Twitching,” 1957; “Electric
Shock Used to Halt Heart Twitching,” 1957). In 1952, physicians first used electricity on
a patient in order to induce cardiac defibrillation. Articles in both Time and Newsweek
explained that a cardiologist had developed a machine for shocking the heart, based on the
principles of shocking patients developed in ECT. The first patient reported to have experi-
enced cardiac defibrillation was a nurse who was helped by the direct transfer of technology:
“Electric shock, which has brought back to sanity hundreds of bewildered psychotics, has
saved the life of a pretty Chicago nurse whose heart had stopped beating” (“The Shocked
Heart,” 1952). The patient reported that she was so indebted to psychiatry after this experience
that she was seriously considering going into psychiatric nursing (“Shocked to Life,” 1952).4

But though convulsive therapies could act as powerful tools for practitioners (“Mental
Disease Preventive,” 1945), at least one commentator in the early 1950s identified problems
that could result from the dynamic between practitioner and ECT patient. In 1953, journalist
Lucy Freeman explained that the widespread use of convulsive therapies acted as a quick fix
for patients and complained that this approach interfered with psychiatrists’ abilities to truly
understand their patients: “Some psychiatrists—particularly neuropsychiatrists—think
people become severely troubled because something is chemically or glandularly wrong with
them. They look for a magic formula that will catapult the unhappy into sudden happiness.
They search for a chemical compound, a form of brain surgery, or a physical process to solve
the mystery of emotional illness” (26). Freeman argued that psychiatrists needed to talk with
their patients and get to know them rather than assume that a psychiatric treatment adminis-
tered from a distance could solve complex human problems (Freeman, 1953). While some
practitioners were very happy to embrace the idea of a somatic intervention from a distance
(Laqueur, 1959; “New Shock Treatment,” 1958), Freeman’s concerns about the dynamics of
power between patients and practitioners were expanded and amplified in the 1970s.

In the 1960s, possibly because of the rise of public awareness of psychoanalysis and new
medications for mental illness (Healy, 2002), ECT seldom appeared in popular magazines.
In one of the few mentions of ECT in this decade, shock appeared less progressive or precise
than medications: “Drugs, as every bathroom medicine chest will testify, are more accept-
able than electric current” (Schreiber & Herman, 1965, p. 30). As we discuss below, ECT
came back to popular attention in the 1970s and 1980s in a series of dramatic stories about
patients, effective treatment, and side effects. In these accounts, the power issues within shock
treatment began to appear to be more problematic. These power issues were often expressed
from the perspective of history: was ECT a desperate measure from a bygone era, or a modern
new treatment of the future?

EAGLETON AND AFTERMATH

In the summer of 1972, Senator Thomas Eagleton was selected by Democratic Presidential
candidate George McGovern as his vice-presidential running mate for the upcoming election
(“McGovern Begins,” 1972). Only days after his nomination, however, Senator Eagleton
revealed that he had been treated for “nervous troubles” in the 1960s, had been institutionalized,
and had received ECT. While newspaper articles of the time seemed to indicate that the
American people were not as troubled by Eagleton’s history of mental difficulties as his fellow
politicians (“Evaluating Eagleton,” 1972), McGovern evidently thought that Eagleton would

4. The concept of shock used elsewhere in the body continued to have a positive resonance, even when ECT itself
was more widely criticized. See for example, SerVaas (1981); “Shocking Alternative to Open Heart Surgery.”

jhbs441_01_20283.qxp 12/17/07 6:17 PM Page 5

be a liability and asked him to step down as candidate less than a week after his revelation
(“McGovern Calls Eagleton Affair ‘Saddest Part’,” 1972).5 Eagleton’s personal history of
having received ECT generated a renewed public interest in the treatment but also represented
a turning point in popular accounts of ECT. With this very high profile patient, accounts of
ECT became more concerned with the power transaction that occurred with the treatment, and
commentators increasingly raised questions about psychiatrists’ right to wield this kind of
power (Talkington, 1972). ECT coverage in popular magazines began to focus more on the
effects of ECT on the patients and also became a metaphor to explore the increasingly prob-
lematic power dynamics between psychiatry and society.

In August of 1972, not long after Eagleton made his disclosure about having had ECT,
both Time and Newsweek carried informative articles on ECT and Eagleton for their readers.
Yet what they presented was quite different—the Time coverage was generally negative (even
inflammatory), while the Newsweek coverage was more balanced and sympathetic toward
Eagleton. While this is fairly easily explained by the different politics of the two news maga-
zines, what is striking about the differences between the two portrayals of ECT is the role of
history in telling the story of the treatment. The Newsweek article emphasized the ways in
which modern ECT was a significant improvement over the past practice, while Time por-
trayed ECT as a relic from the past.

The Newsweek article explained that ECT was a poorly understood but nevertheless
effective treatment that originated as an alternative to insulin convulsive therapy. The author
conceded that ECT used to be “medieval” in its appearance and that this was what gave it a
bad name, but modern treatments were not at all dangerous and were quite mundane: “Sponge
rubber electrodes are placed like headphones above and slightly in front of each ear. The
physician throws a switch on a control box that sends the shock in to the patient’s brain for no
more than one second. Two or three minutes later, the patient wakes up relaxed and slightly
euphoric and is able to get up and walk away.” Not only was the simile of headphones used
to explain the electrodes, but also the photograph that accompanied the story was of a
respectable, bearded white psychiatrist holding onto the equipment over a very quiet, docile,
older white woman (“Depression and Electroshock,” 1972). In the Newsweek account, ECT
was misunderstood because of its history, but was in fact a modern, easy procedure.

The Time article constructed the history of ECT in a somewhat different way. First, the pho-
tograph that accompanied the article illustrated several African American orderlies holding down
a white, male patient who was visibly convulsing. The caption beneath the photograph indicated
that it was taken in 1949, but there was no explanation for why a picture from two decades before
was used in the article. Further, it is easy to imagine that, at the time that this photo was published,
the specter of strong, black men holding down a struggling white man could have been quite
inflammatory (Ogbar, 2004; Schulman, 2001). The power struggle conveyed in this image
suggested that ECT was a violent means by which psychiatrists assumed control over their
patients, and the representation of that power by African American men further problematized the
treatment. When the patient in question was running for office in which he would be literally a
heartbeat away from the Presidency, the specter of ECT as a means for producing complete
subjugation could easily mobilize the existing fears of the magazine’s readership.

Not only was the image in the Time article more dramatic, the language of the treatment
was not nearly as reassuring as the Newsweek account. According to the Time writer,

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5. On the media coverage of the Eagleton story, see Altheide (1977), Bormann (1973), Ostlund (1973/74). On the
contrast between Eagleton’s experience in exposing his history of mental illness and the experience of a more recent
candidate, see Strout (1995).

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“As practiced today, shock treatments are administered through electrodes attached to the
patient’s temples. A device the size of a file-card box is used to send an alternating current of
about 400 milliamperes through the brain at roughly 100 volts for seven seconds (electric
chairs employ a seven-ampere current at 50,000 volts)” (“Most Common Mental Disorder,”
1972). While the dose of electricity in relation to that used in the electric chair was clearly
less in ECT, the mention of the electric chair in the same sentence as ECT might have been
quite alarming to readers. The author also explained that it was difficult to know how to
evaluate the extent of Eagleton’s illness because at the time the article was written, ECT was
generally only used for the most severe cases. However, Eagleton’s treatment occurred at a
time (in the mid-1960s) when ECT was much more commonly used. The article implied that
ECT was a procedure of the past and raised the question of whether Eagleton would have
received it if treated in the present.

The public controversy around Eagleton’s disclosure about his psychiatric treatment
occurred at a time when a growing number of scholarly and popular writers were beginning
to express significant dissatisfaction with American psychiatry. These commentators, who
were part of a broad movement of social protest in the United States, particularly targeted
psychiatry’s power over patients (Dain, 1989; Vatz & Weinberg, 1994). Historians and cultural
critics focused on psychiatry’s history of social control over patients in areas such as institu-
tionalization (Foucault, 1967; Rothman, 1990; Tomes, 1994). In addition, as psychiatrist Max
Fink pointed out in the early 1990s, anti-psychiatry activists very early targeted ECT as a
problematic aspect of psychiatrist–patient relationships (Fink, 1991). Popular discussions of
ECT by this time period began to reflect the broader context of criticism of psychiatry in
general and of ECT in particular. In these critical pieces, ECT’s history recalled a past (that
may or may not have existed) in which psychiatrists actively sought out control over all
aspects of patients’ lives and indeed anyone else who crossed their paths.6

In 1974, the first of what would become a series of highly negative articles appeared that
characterized ECT as a harmful relic from a bygone era during which psychiatrists did what
they wanted with patients. New Yorker writer Berton Roueche published an extensive article
about a woman who had apparently gone to a mental hospital for a rest and to avoid stress. As
the article unfolded, it was revealed that the woman had lost all memory of what was hap-
pening to her at the time, or even what happened in the past. Through her inquiries, she dis-
covered that she had been given ECT in the hospital (with questionable consent proceedings).
In an interview with Roueche, she claimed that ECT had entirely erased her memory and
eliminated her ability to perform at her job, even years after her treatment (Roueche, 1974).
While the woman’s true identity in the New Yorker article was disguised, later popular press
articles revealed that she was Marilyn Rice, a once-successful federal employee. In later
years, Rice organized a movement of former ECT patients that aimed to have the procedure
entirely banned (“ECT: It Works, But at What Cost?,” 1978).

Roueche’s 1974 account of Rice’s treatment not only illustrated the dangers of ECT’s
side effects, but also Roueche’s history of the treatment itself suggested that it should be
treated with great suspicion. Roueche traced the history of ECT from the eighteenth-century
German neurologist Johann Reil who attempted to frighten—or shock—patients into sanity.
Roueche also claimed that eighteenth-century American physician Benjamin Rush employed
a kind of shock treatment. In Roueche’s history, insulin treatment was really just a precursor

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6. This constructed past crops up periodically in popular culture to illustrate villains. For example, Disney anima-
tors used the image of an asylum doctor (psychiatrist) who is only too happy to allow himself to be bribed to help
control Belle and her father in Beauty and the Beast (1991).

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to electric shock treatment, both of which were based on a superstitious two-century old treat-
ment method. While the mechanism for inducing convulsions had changed over time, the
rationale for doing so was quite old and not particularly scientific.

Roueche’s article marked the beginning of what would become a series of narratives
about ECT that emphasized its history, with the implication that there were many problems
with using old, even barbaric, treatments on patients. Indeed, in these narratives, the history
of ECT was an active part of the argument against psychiatric treatment. Historical narra-
tives of ECT were actually used by many activists to protest the use of psychiatric treatments
on local and state levels. ECT opponents worked closely with anti-psychiatry activists who
insisted that psychiatry was not scientific, that mental illness did not exist, and that psychia-
trists were merely engaging in social control. In 1975, ECT opponents were able to get a
statute proposed in California that would have required a review committee to oversee all
decisions for ECT and psychosurgery to make sure that the patient had consented (Ellis,
1975). Even though psychosurgery was seldom performed by this time period (Pressman,
1998; Valenstein, 1986), ECT and psychosurgery were lumped together as treatments that had
been performed against a patient’s will in the past. Mental health advocates in California and
elsewhere insisted that patients’ rights with regard to ECT included the right to not be forced
to undergo treatment.

The discussion around the 1975 proposed statute in California (which was eventually ruled
unconstitutional) elided ECT with involuntary treatment of patients in a long (constructed)
tradition of psychiatric dominance of patients through invasive practices. Indeed, one of the
major activists in the law, Dr. John Friedberg, insisted that the ongoing use of ECT represented
a conspiracy on behalf of psychiatrists who covered up their long-standing knowledge that ECT
caused brain damage (Clark & Lubenow, 1975). As Friedberg explained, ECT was in the tradi-
tion of “beating up those labeled insane with methods ranging from torture to lobotomy to psy-
chosurgery” (20). He traced the evolution of ECT from Meduna (convulsive therapy) to Sakel
(insulin coma) to Moniz (lobotomy) to Cerletti (electric shock) to the Germans who killed
their mental patients during World War II. Indeed, he several times invoked the language of
concentration camp torture in order to make his point about the dangers of the treatment
(Friedberg, 1975).

But while Friedberg linked ECT’s history to Nazi atrocities, ECT advocates used an evo-
lution narrative for their history of ECT to illustrate the upward progress of modern science.
They insisted that the power of ECT lay in its ability to help patients and its links to the grow-
ing power of scientific discovery in medicine. In 1977, David Avery (at that time a fellow in
psychopharmacology), observed that the use of a treatment for mental illness directed toward
the brain represented a major step forward in science. He suggested that the opponents of
ECT had old-fashioned notions about mental illness: “The ECT controversy reflects a
tendency to see a natural antagonism between science and humanism. Many critics reject the
treatment because they wish to see the mind as separate from the brain—free from the bio-
logical whims that affect every other organ of the body. Yet, much can be learned from both
the recent biological data and the insights of humanism” (Avery, 1977). Avery emphasized the
modern views of ECT and its uses in patients and suggested that the opponents of ECT were
acting under a misguided misinterpretation of the treatment. For Avery and other advocates,
the power of ECT was its position within modern medical advances.

Through the late 1970s and 1980s, advocates and opponents rehashed significant events
in ECT’s history, particularly its origin in the work of Italian psychiatrists Cerletti and Bini in
the late 1930s (Passione, 2004). According to many popular press writers, Cerletti visited a
pig slaughterhouse in the 1930s and witnessed how electricity was used there. But popular

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writers used dramatically different interpretations of this story in order to make arguments
about the value or horror of ECT. Journalist Maggie Scarf, who published a very sympathetic
account of ECT in the New York Times Magazine in 1979, described ECT’s originator
Cerletti as a caring physician whose slaughterhouse investigation represented his attempt to
test the effect of electrical current without endangering human life (Scarf, 1979). But while
Scarf interpreted Cerletti as humane, ECT opponent John Friedberg alleged that Cerletti’s visit
to the pig slaughterhouse gave him the inspiration to treat humans as pigs by shocking them.
In addition, Friedberg reported that Cerletti had experimented on patients without their con-
sent, going so far as to inject a suspension of pig cells into a human being (Friedberg, 1975;
Hapgood, 1980). Cerletti’s relationship with the pigs was presented to illustrate the authors’
assumptions about the power relationships in ECT. For Scarf, animal observation could lead to
improved science and better treatments, while Friedberg placed Cerletti in a long tradition of
psychiatrists who actively designed different means by which to gain control over patients.

Although differing opinions about the past and present of ECT continued to characterize
popular magazine accounts, all authors could agree that ECT generated strong opinions.
A Science News article in 1980 explained matter-of-factly that ECT had been controversial
over the whole of its 40-year history in the United States (“Depression: Safer Shock Therapy,”
1980). Most interestingly, though, by the 1980s psychiatrists began to concede that there had
been abuses of ECT in the past—although they hastened to add that ECT was much better in
the present (Rogers, 1982). Melvin Sabshin, at that time the medical director of the American
Psychiatric Association, argued that former patients who protested the treatment were basing
their ideas on treatments that had experienced more than 20 years before. Opponents of the
treatment claimed that the changes in ECT were immaterial, while advocates insisted that
ECT had been significantly improved (Clark, Schmidt, & Hager, 1982; W. Herbert, 1982;
W. Herbert, 1983).

In a little more than a decade from the disclosure that Thomas Eagleton had received ECT,
public discussions of the treatment became a battleground in which opponents and advocates
expressed their beliefs about aggressive psychiatric treatment and about psychiatry’s traditional
power over patients. Opponents insisted that ECT fit within a long trajectory of psychiatrists
taking violent control over their patients. These narratives continued in subsequent decades as
opponents laid out more and more lurid stories about victims of ECT. By the late 1980s and
1990s, though, ECT advocates shifted their focus in defending the treatment. Instead of just
stressing the ways in which ECT had improved, they attempted to illustrate that the power
dynamics in the treatment had changed by taking their explanations directly to popular maga-
zines and by invoking the positive experiences of patients themselves.

POLARIZED ACCOUNTS AND NEW VOICES

Thomas Eagleton was by no means the only major public figure to have popular press
coverage about his treatment with ECT. Several other major celebrities also became the
subject of intense public scrutiny after their treatments, some many years later. Although Ken
Kesey’s book One Flew Over the Cuckoo’s Nest was published in 1962 (Kesey, 1962), its
representation of ECT did not generate discussion in the popular press. Instead, it remained
for the 1975 film of Cuckoo’s Nest to dramatically illustrate ECT as a form of control
(McDonald & Walter, 2001). Although critics at the time, and later, protested that the film was
not accurate in its portrayal of ECT (by the time of the film’s release, ECT was usually given
with anesthesia, not without it as the film depicted), the film still presented viewers with a
powerful impression of ECT (Gabbard & Gabbard, 1999). The Cuckoo’s Nest image of ECT

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as a method of sadistic psychiatric control over patients permeated popular discussions
of ECT, and Jack Nicholson’s character as a victim of ECT appeared in
popular accounts of the treatment. A 1979 Newsweek article that covered a psychiatric
conference in Britain—as well as its herds of ECT protesters outside—commented that
advocates of the treatment had to contend against the film image: “Proponents of ECT also
point out that modern techniques are far removed from the horror of Cuckoo’s Nest”
(“Comeback for Shock Therapy?,” 1979). Though psychiatrists insisted that ECT had
changed, the film had given ECT a bad reputation that was difficult to shake. Duke
psychiatrist Richard Weiner was quoted in 1984 as saying that the film representation was
a problem because it scared off patients who really needed the treatment (Chinnici, 1984).

While ECT sympathizers emphasized the need to overcome the vivid (and negative)
image of Jack Nicholson receiving ECT as part of a system of control, ECT opponents
mobilized the image of another famous ECT recipient, Ernest Hemingway, to illustrate the
treatment’s dramatically negative consequences. Hemingway evidently received ECT on two
separate occasions in the one to two years prior to his suicide in 1961. The issue raised by
ECT opponents was the relationship between his ECT and his suicide. Although there was no
popular press linkage of Hemingway’s suicide to his ECT at the time of his death, later arti-
cles and biographies made a case for the connection. According to ECT opponent John
Friedberg, Hemingway allegedly said that ECT-induced memory loss led directly to his sui-
cide (Friedberg, 1975). Another anti-ECT activist, Jan Eastgate, characterized Hemingway as
a “victim” of ECT (Eastgate, 1998). Two of Hemingway’s biographers, A. E. Hotchner and
Kenneth Lynn, emphasized that Hemingway’s serious mental illness and plans for suicide sig-
nificantly predated his ECT treatments (Hotchner, 1966; Lynn, 1987). Two other biographers,
though, quoted extensively from anti-ECT literature and implied that the treatment was at best
an atrocity committed on the great writer, at worst a direct cause of his suicide (Meyers, 1985;
Reynolds, 1999). Since Hemingway was unable to speak for himself, and there was a clearly
bad outcome to his life, his story was used by opponents of ECT to illustrate the profound
dangers of psychiatric control over patients, especially ones as beloved as Hemingway. ECT
opponents suggested that if someone as powerful as Hemingway was unable to withstand his
psychiatrists’ suggestions to undergo ECT, the rest of the public was in grave danger.

While opponents of ECT told the story of Hemingway and other individuals they identi-
fied as victims of the treatment (Barber, 1995; Bockris, 1995), psychiatrists began to more di-
rectly engage the public on the importance of ECT as a modern treatment by the middle of the
1980s. A number of psychiatrist groups began to meet to discuss the treatment and its uses, and
an increasing number of psychiatrist advocates for ECT, particularly Harold Sackheim and
Max Fink, began to make more assertive efforts to counter opponents’ representations of ECT.
And, as they constructed their arguments in favor of ECT, they also placed ECT in a frame-
work of a history of progression in science and medicine. While opponents of ECT continued
to link the treatment to cruelties in the past and the present, advocates extolled ECT’s place
among modern psychiatric treatments. Further, these advocates reiterated the older image of
ECT as a positive tool against psychiatric illness, not a tool to be used against patients.

One of the ways in which advocates for ECT began to focus on its status as a modern
treatment was by describing its specificity of action on the brain. To illustrate this, researchers
pointed out that the “bad image” of ECT in the past had been due to psychiatrists’ old prac-
tice of using too many treatments (sometimes 50 or more) in patients with a wide variety of
ailments. Instead, the modern method of ECT was to use the lowest possible electrical dose
for the lowest number of treatments, and to focus the treatment on specific illnesses such as
depression (Bower, 1985a, 1985c; Rosenfeld, 1985). In an era in which medications for the

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diagnosis of depression were increasingly seen as specific and scientific, advocates were able
to place ECT in the spectrum of treatments available to patients who were experiencing
depressive symptoms (Healy, 1997; Hirshbein, 2006).

In 1985, Columbia University researcher Harold Sackheim explained and defended ECT
within a lengthy article in Psychology Today. While acknowledging that “Many people
believe that ECT is barbaric and repugnant,” Sackheim insisted that ECT had been used
successfully for more than 40 years. He admitted that there were several aspects of ECT’s past
that probably led to problems with ECT, particularly the once-held belief that epileptics do
not suffer from schizophrenia (leading to an inappropriate use of ECT for schizophrenics).
Sackheim acknowledged that, although the procedure itself had significantly improved, not
all physicians were updating themselves or their equipment—he pointed out that a survey in
Great Britain found that “Too many doctors used antiquated or questionable procedures” (40).
Sackheim expressed confidence that new research and refined techniques would lead to a
greater acceptance of ECT (Sackheim, 1985).

At the same time that Sackheim published his Psychology Today article, the National
Institutes of Health assembled an advisory panel to address the issues of safety and efficacy
in ECT. The panel, which included psychiatrists and psychologists, as well as a lawyer and a
consumer advocate, cautiously endorsed ECT, but only for treatment for depression. As
Science News coverage explained, “The panel acknowledges that during the 1940s and 1950s
ECT was often overused and misused with a variety of disorders” (Bower, 1985b). A Science
explanation of the panel also alluded ECT’s problematic past: “Introduced in the United States
in 1940, ECT has a checkered past, having been applied indiscriminately to a range of men-
tal disorders and misused for the purpose of making patients more tractable” (Holden, 1985,
p. 1510). As part of the evaluation of ECT, the Federal Drug Administration reviewed ECT
machines for their use in treating mental disorders. Advocates for approval of the machines
insisted that the treatment had been considerably refined since it origins with Cerletti and Bini
and their observation of pigs (Weck, 1986).

By the late 1980s, ECT was increasingly mentioned as a possible therapy for depression
for patients who had not responded to medication. But writers acknowledged that the image
of ECT was not good: ECT, “the oldest of the treatments in use for depression—has never
quite lived down its spooky reputation as a psychiatric torture callously practiced on the poor
and helpless, an indelible image left behind by popular movies like One Flew Over the
Cuckoo’s Nest” (Cherry, 1986, p. 38). In contrast to what they asserted was the misrepresen-
tation of Cuckoo’s Nest, advocates by the late 1980s began to tell the story of ECT as a mis-
understood progressive treatment. As journalist Susan Squire wrote in 1987 in the New York
Times Magazine, “ECT’s appearance in American psychiatric hospitals in 1940 greatly ex-
cited medical humanitarians. In comparison with the largely inadequate and often cruel phys-
ical treatments that were then available—insulin coma, sedation, psychosurgery and restraint
in wet-sheet packs—ECT seemed clean, even benevolent” (Squire, 1987, p. 85). In this ac-
count, ECT became the more progressive option against a backdrop of a history of frighten-
ing and extreme psychiatric treatments—none of which was in use anymore. Although
psychiatrists were still quoted as admitting that ECT was misused in the past, advocates of the
treatment began to make more explicit links of ECT to research and to more modern techno-
logical devices. In Squire’s article, for example, the ECT machine was reported to look like a
VCR. Further, Squire framed her article with the account of a profoundly depressed woman
whose depression was eliminated with ECT.

Like the Squire article, sympathetic accounts of ECT increasingly began to emphasize
the effects of the treatment on people with severe depression (Lally, Meyers, & Sangiorgio,

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1990). ECT opponents’ dire warnings that ECT caused brain damage were not supported by
new brain imaging techniques and new uses of ECT for ailments such as Parkinson’s disease
(“An Inside Look at Electroshock,” 1988; “Shock Therapy’s Parkinsonian Potential,” 1989).
Popular writers began to report that ECT had returned and that, despite its “checkered history
of abuse” it had improved so much that the National Institute of Mental Health endorsed it as
a valuable treatment (“Shock Therapy Returns,” 1990). In addition, writers stressed that the
amount of electricity used for ECT was “barely enough to cause a 10-watt light bulb to
flicker” (Perlmutter, 1990, p. 52). The power of ECT, by these accounts, lay not in its electri-
cal power but rather in its links to new brain technologies.

The language used to describe ECT by the supporters and the opponents of ECT revealed
a great deal about how they understood the treatment and its relationship to history. Those
who were generally disposed to favor the treatment used metaphors that reflected modern, late
twentieth-century society, while those who were opposed to ECT used the language of fright-
ening events from the past in order to describe the treatment. For example, writer Nicholas
Owen published a 1998 article in Washingtonian describing the miracle of his mother’s
recovery after ECT. While he was nervous about the treatment (because of images provided
by The Snake Pit and One Flew Over the Cuckoo’s Nest), “One doctor compared ECT to
rebooting a computer when the screen freezes; it fixes the problem, although you’re not sure
how” (Owen, 1998). This metaphor made a great deal of sense to the growing number of read-
ers of popular magazines in the 1990s who were experiencing computer rebooting as part of
everyday life. Further, recent articles about ECT have emphasized that ECT had given rise to
“high tech anti-depression therapy” research, particularly in interventions such as transcranial
magnetic stimulation (TMS) and vagus nerve stimulation (VNS) that worked on the same
principle as ECT but without the side effects (Arner, 2003; Beame, 1999; Fischer, 2000;
Hochman, 2004).

While computers and high-tech interventions appeared comfortingly modern, opponents
of ECT focused on the power dynamics of ECT and used images of near-electrocution and
Nazi torture to describe the treatment. Kathleen Hirsch wrote a 1995 Ms. article about the
return of ECT and expressed her worry about the treatment of the past, characterized by “sev-
eral weekly treatments of near-lethal amounts of electricity, for as many as 100 sessions—all
without the benefit of anesthesia, and often without [the patients’] consent” (Hirsch, 1995,
p. 35). Jan Eastgate, the president of the Citizens Commission on Human Rights (an activist
group founded by the Church of Scientology that was opposed to psychiatric therapies,
including ECT) (Kneeland & Warren, 2002; Smith, 2001; Vatz & Weinberg, 1994), published
a 1998 USA Today article that was strident in its opposition to ECT. Eastgate explained the
history of the treatment, that “electroshock ‘treatment’ first was used to render slaughterhouse
pigs unconscious to make it easier to slit their throats. In 1938, Italian psychiatrist Ugo
Cerletti decided to try this procedure on humans” (28). Eastgate went on to claim that ECT
was used by Nazi psychiatrists during World War II. Eastgate even implied that the treatment was
a lead-in to the mass gassing of mental patients during the war (Eastgate, 1998).

Was ECT a modern tool that could be used to eradicate illness, or an ongoing method
in psychiatry’s tradition of subjugating patients? By the 1990s, popular accounts of ECT
began to question this dichotomized view, particularly as they included patients’ perspectives.
ECT recipients, while acknowledging the power issues with ECT, tended to emphasize the
ways in which the treatment helped them in their battle against disease. In 1994, for example,
journalist Gene Stone wrote an article for New York that centered on an ECT patient whom
Stone was allowed to shadow at Hillside Hospital in Queens. Although he was prepared for
drama because of the major controversy over the procedure, Stone reported that he found the

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treatment somewhat mundane. According to Stone, the ECT machine “resembles an old
stereo receiver component” (57), while the ECT doctor himself was warm and supportive:
“It’s hard to portray him as the hard-hearted villain the anti-ECT forces believe he is” (Stone,
1994, p. 58). Other patients who experienced benefit from ECT wrote or were quoted in the
1990s emphasizing both how beneficial they found the treatment, and how undramatic it
really was (“Electroconvulsive Therapy Works Well,” 1995; Hubbard & Kramer, 1995).

Over the last decade, more individuals who directly experienced ECT have made the
public point that the treatment helped them in ways that medications and psychotherapy could
not. Martha Manning, a psychologist, wrote a memoir about her treatment for depression and
her attempt to be treated with psychotherapy. Much to her dismay, therapy did not seem to
work: “‘I saw therapy alone couldn’t fix it. It was like practicing a religion and finding out
when you die that it wasn’t the right one’” (Hubbard & Kramer, 1995). Manning went on to
recover with the help of ECT. Andy Behrman, a New Yorker who was diagnosed with manic-
depressive disorder, wrote first person accounts of his experiences with ECT (first an article,
then a book) in which he embraced the treatment and how it made him feel. Although he
reported some memory problems, he also used language of religious experience in order to
describe his appreciation of what the treatment had done for him (Behrman, 1999, 2002).

Kitty Dukakis, the most recent celebrity to discuss her experience with ECT, did not let
anyone else define her experience with the treatment. In a well-publicized book (Dukakis,
2006), Dukakis and her co-author, former Boston Globe health journalist Larry Tye, inter-
spersed Dukakis’s accounts of her mental illness and ECT with Tye’s perspective on the
history and controversy over the treatment (Dukakis & Tye, 2006). Although Tye discussed the
unpleasant and unfortunate aspects of ECT’s history, he placed the treatment in the context of
other drastic medical interventions: “Like chemotherapy, ECT is a toxic treatment for a crip-
pling disease. Like any surgery requiring anesthesia, it carries risks. And like the electric pad-
dles that cardiologists use to shock a fibrillating heart back into rhythm, ECT is not a cure but
can offer relief and even remission” (xi). In Dukakis’s part of the story, she embraced the idea
of shock as a treatment and even named her book Shock. Dukakis acknowledged that the treat-
ment was controversial, but pleaded for discussion about it:

So let me be clear. I am saying that ECT worked for me, not that it will work for every-
body. I am saying that we need to face up to ECT’s risks and try to reduce them, but we
also need to acknowledge its potential benefits. I am saying, more than anything, that
talking about this is a good thing. There are too many people in desperate need of a work-
able treatment to limit any viable options. There is too much need for open discussion to
continue the vitriol and finger pointed that have characterized the last half century of
debate about ECT (194).

Dukakis, like other recent patients, insisted that informed patients were able to make
clear choices for themselves. ECT was not a torture imposed on her or others against their
will, nor was it entirely free of risks. Instead, it was a powerful tool with possible side effects
that dramatically helped some people.

CONCLUSION

In 1999, State University of New York at Stony Brook psychiatrist Max Fink published
a book intended to educate the public about ECT. After explaining the procedure and the
typical patient’s experience, Fink went on to describe the origins of ECT. He reported that
electroconvulsive therapy came from chemical convulsive therapy developed by Hungarian
physician Ladislas Meduna. Like other writers who described the origins of ECT, Fink

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explained that abuses were common in its early history. In Fink’s account, the abuses largely
stemmed from a lack of science: “chance, adventurism, bravado, and disregard for scientific
investigation set off a rash of treatments that were most often applied without formal testing
for efficacy or for safety” (90). Fink also explained that ECT was often done without regard
to patient consent in its early years—but that consent procedures set up specifically to address
the issue of ECT helped to shape the concept of informed consent for psychiatric treatment
in the 1970s. According to Fink, the problems from the past had all been solved with regard
to ECT (Fink, 1999).

Fink’s account, like other advocate explanations of ECT, emphasized that problematic
power relationships between psychiatrists and patients were only in the past. According to
Fink, historical psychiatric abuses with ECT stemmed from overly zealous psychiatrists who
wanted too much to help their patients—these abuses were eventually corrected by improved
scientific understanding and technique. But opponents of ECT have argued in contrast that
the dynamics of the treatment continue to depend on an absolute power relationship in which
psychiatrists inflict dangerous procedures on duped or powerless patients. By invoking the
language of concentration camp torture, ECT opponents have made the strongest possible
connection between totalitarian practices and psychiatric interactions with patients.

Within the conflict generated by advocate and opponent opinions of ECT, new voices
have appeared in the last few decades. Consumers of ECT have had an increasingly vocal
presence within this debate about the power and the history of ECT. Some ECT patients have
declared themselves victims of this procedure and have worked hard to ban the practice.
Others, however, have gone public and insisted that they chose ECT with open minds in order
to help treat their severe illnesses. In the case of ECT, as with many other areas of medicine
in the twentieth century (Tomes, 2001), consumers’ entrance into the discourse around their
treatment has amplified and complicated the discussion about ECT’s present, past, and ongo-
ing power dynamics. Part of the job of advocates and opponents has become to persuade
potential consumers of their version of the history of ECT.

From a strategic point of view, it is obvious why the opponents of ECT want to maintain
that the treatment was characterized by abuses early (as well as later) in its history. The worst
thing that could happen is that contemporary testimonies of celebrities such as Kitty Dukakis
could undermine their argument that ECT is still barbaric and essentially a way to torture
patients. But ECT supporters who use a progressive historical narrative and blame the past in
order to highlight ECT’s present scientific status are taking a bit of a gamble. First, the argu-
ment that ECT is much better than it used to be does not explain the uncomfortable fact that
ECT practitioners still do not have a clear idea of why ECT works. Second, patient advocates
of ECT temper their enthusiasm for the treatment with warnings about serious side effects
that still affect patients, even with improved modern procedures. Finally, the positioning of
older styles of ECT as characteristic of the bad old days—eliminated through the use of new
interventions—puts leaders in American psychiatry in a bind as they have to comment on
the ECT practices in other countries, some of which do not have enough resources to implement
ECT improvements such as anesthesia.7

No matter who defines the history of ECT, the treatment does involve a very real power
dynamic between practitioner and patient. In no other psychiatric treatment is a patient as
passive—or as unaware of the treatment itself while it is occurring. Patients who undergo the
treatment have to accept that their surrender of power is worth it in the end. And psychiatrists

7. Personal communication, Dr. Daniel Maixner, Director, ECT Program, University of Michigan Hospitals,
8 January 2007.

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who perform the treatment have to understand and respect the power that they wield. While
ECT is seldom performed on involuntary patients and ECT opponents are wildly distorting
the past by connecting the treatment to Nazi atrocities, critics have identified a power dy-
namic that has existed to some extent through much of psychiatry’s history. Psychiatrists can-
not simply claim that all of that is in the past.

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