Introduction to: Discussion, questions and answers
Our next discussion question takes us back over 50 years in time, to the setting of the closed psychiatric institutions where persons with serious mental illnesses were often confined under dismal and overcrowded conditions. Psychiatric researchers were desperately seeking new and effective treatments which could enable the residents to return to the community and thus to relieve the pressure on the institutions. A team of Italian researchers, led by the psychiatrist Cerletti, were working on a new technique which they hoped would provide a quick and effective treatment for schizophrenia.
Unfortunately, their research programme was guided by what was later shown to be a false hypothesis: that persons who suffered from epilepsy did not develop schizophrenia. On the basis of this false hypothesis it was predicted that indu-cing epileptic convulsions would help to reduce the signs and symptoms of schizophrenia. Thus, in the late 1930s thousands of mentally ill persons were administered convulsants, such as the drugs cardiazol and metrazol. The drugs induced convulsions that were difficult to control and proved to be very dangerous. Cerletti argued that the use of electrical shocks to induce epileptic convulsions would be a safer approach than the drugs.
In an article which outlines the historical development of electroshock, Krzyzowski (1989) reported what happened when Cerletti and his assistant Bini first presented these ideas to their colleagues.
Bini, at a conference in Munich in 1936, and Cerletti in the same year in Milan, mention the possible application of electric current to cause therapeutically desired epileptic attacks. The idea was almost unanimously rejected on the grounds of its barbarity and associated hazard. It should be noted that the electric chair had just been introduced in America.
(Krzyzowski 1989, p. 51)
Despite this hostile reaction, Cerletti and his team continued research into electric shock, experimenting with animals in Rome’s slaughterhouses. According to Krzyzowski (1989, pp 51–52) the team was ready for their first human subject by 1938.
On April 15 1938, a patient manifesting distinct symptoms of mental illness was admitted into the clinic in Rome after having been arrested by the police for travelling on a train without a ticket. The condition of the patient was then as follows: fully normal orientation, expressed distinct introversion and persecution delusions often using neologisms. He considered himself to be under telepathic influence directing his behaviour. At the same time he exhibited hallucinations thematically related to the delusions. He was depressed and altered neurological conditions were found. Schizophrenia was diagnosed.
Having selected their first subject, the team administered the first electroconvulsive therapy (ECT) procedure.
Two electrodes were attached symmetrically in the vicinity of the crown and forehead and then a relatively low 80 V current was passed for 1.5 s. On switching the current on, the patient sat upright on the bed, his muscles contracted and he fell back onto the bed, not losing consciousness, however. He cried out for a while and then became quiet.
It appeared that the voltage applied was too low to induce the convulsion required for the therapeutic effectiveness of the ECT procedure. What happened next is discussed by Krzyzowski:
Continuation of the treatment was postponed until the next day. The patient, on hearing of such suggestions, roused himself and shouted normally: ‘No more. It could kill me’. The words were spoken aloud normally, while previously he used only a specific and hardly understandable jargon, self-devised and full of neologisms. This normal utterance confirmed and assured Cerletti of the effectiveness of the method and, in spite of the strong reservations of his assistants, he decided to repeat the ECT without delay. This time a 110 V current with a pulse duration of 1.5 s was used. Once again a short lived, general contraction of all muscles was observed followed by a full classic epileptic type attack of convulsions. All those present uneasily watched the pallidness and cyanosis accompanying the attack, relaxing as the patient gradually recovered.
The story, you will be pleased to hear, had a happy ending.
After prolonged treatment consisting of 11 full and 3 incomplete shocks, the patient was discharged from the clinic in good health. At follow-up a year later, the mental state of the patient was seen to be good and stable. Subsequent years evidenced a widening application of ECT.
(Krzyzowski 1989, p. 52)
As a matter of interest, ECT is still used by contemporary psychiatrists, but in a greatly modified fashion:
•
It is used with anaesthetized patients, with electrodes placed only on one side of the head.
•
It is not used with persons with schizophrenia (for whom it was found to be ineffective) but rather with persons who are profoundly depressed.
•
It is used as a ‘last resort’ when current pharmaceutical treatments are ineffective.
Questions
The following questions concerning research planning are related to the above narrative:
1.
On the basis of the information given propose aims and/or hypotheses which might have guided the above study.
2.
Given the state of psychiatric knowledge and practice of the late 1930s, do you think the above study was justified?
3.
Give three or four reasons why a contemporary ethics committee might reject such a research project.
4.
By present ethical standards, what should have been done after the patient shouted ‘No more, it could kill me’?
5.
Cerletti proceeded with a more severe shock on the grounds that the previous shock ‘improved’ the patient’s condition. Comment on this logic, in the context of scientific methodology.
6.
Do you think such dangerous experiments are ever justified in the context of health care? If yes, under what conditions?
7.
Discuss two or three problems with the ‘internal validity’ (
Ch. 4) of this study. Suggest simple changes in ‘control’ which may help to improve internal validity.
8.
Comment on the ‘external validity’ of this study in the light of the fact that in subsequent studies ECT was shown to be ineffectual as a treatment for schizophrenia.
9.
Do you think Cerletti and his colleagues were guided by a rather simplistic paradigm of schizophrenia? Explain, by comparing the biomedical and biopsychosocial approaches discussed in
Section 1.
Answers
1.
The research seems to have been guided by several interrelated aims and/or hypotheses.
(a)
The first aim was to find the electrical shock intensity that was sufficient to induce an epileptic seizure in a human.
(b)
The second aim was to demonstrate that the seizure did not result in death or disability; that is, that the treatment was ‘safe’.
(c)
The hypothesis implicit in the research might be stated as: ‘A course of ECT is effective for reducing the signs and symptoms of schizophrenia’.
You may be able to suggest other aims and hypotheses. None of the outcomes was stated precisely in the paper quoted.
2.
As you may have judged from this brief excerpt, the state of knowledge concerning the biological causes of mental illness was confused and had a weak empirical basis. Biological treatments, such as drug-induced epileptic seizures, were poorly theorized, dangerous and generally ineffective. In this context, in the late 1930s, it could be argued that experimenting with new and safer treatments was justified.
3.
We outlined some relevant ethical guidelines in
Chapter 2 in terms of which the present study would be judged as problematic, e.g. questionable benefits for patients, lack of informed consent, dangerous and painful intervention and lack of consultation with the relatives/guardians of a mentally ill person.
4.
Obviously, discontinue the research. Even though the person was confused when admitted to the hospital, his request was rational and reasonable. There was no doubt whatsoever concerning the patient’s desires, and by present ethical standards researchers must comply with such requests.
5.
The first electrical shock did not induce the epileptic convulsion which was postulated as the factor ‘causing’ the therapeutic change. As the first shock simply hurt the man, there was no theoretical or empirical justification for his apparent improvement being due to this shock.
6.
One could argue that risking people’s health and lives in the context of ‘heroic’ medicine is never justified. Rather, we should look to prevention or gentler, more natural treatments. The other point of view is that aggressive medical treatment is justified if there are incapacitating and chronic problems, such as schizophrenia. According to this approach, painful and potentially harmful experimental treatments are justified provided that the study is well designed and the participants are well informed and have consented.
7.
The issue is whether or not the apparent improvement in the patient’s condition was due to the ECT or to other ‘extraneous’ factors or variables. There are several possibilities which provide plausible alternative explanations, such as:
(a)
History. The patient may have been frightened by the treatment and ‘pretended’ to be better to escape the situation.
(b)
Maturation. The patient may have recovered anyway: his condition may be cyclical.
(c)
Testing or instrumentation. There may have been inaccuracies and bias in the way in which the patient’s condition was assessed.
Control may be introduced by using groups of persons who have (a) no treatment and/or (b) another treatment for schizophrenia. The appropriate designs for showing causal effects are outlined in Section 3. However, because of the poorly designed research in the area, there were almost two decades of useless treatments before it became evident that ECT was not an effective treatment for schizophrenia.
8.
Clearly, there was no evidence that the improvement claimed in this study was caused by ECT. In addition, it is tricky to make inferences from unrepresentative samples to populations. In this study, the patient may have shown symptoms of depression, which perhaps responded to the treatment. But this may not be generalizable to persons who show other patterns of schizophrenia. External validity is ensured by appropriate sampling procedures (
Ch. 3) and clear operational definition and assessment of the condition, as outlined in
Chapter 12. Without appropriate sampling and assessment procedures, we may use inappropriate treatments, unsuitable for the specific needs of our patients.
9.
The researchers were working in the context of a ‘biomedical’ model, assuming that schizophrenia was simply a biological disorder which could be suddenly cured by a heroic treatment such as ECT. A biopsychosocial approach takes a more complex view of chronic disorders, and research programmes include identifying and treating both psychological disabilities and social handicaps entailed in schizophrenia. Biopsychosocial research may involve both quantitative and qualitative methods.