History of Electroconvulsive Therapy (ECT)

Electroconvulsive therapy (ECT) is a medical treatment that involves the application of controlled electrical stimulation to the scalp to induce a generalised cerebral seizure under general anaesthesia. It is a form of neuromodulation primarily used to treat severe psychiatric disorders, particularly when rapid response or other treatments have failed. First performed in 1938 by Ugo Cerletti and Lucio Bini in Rome, ECT remains one of the most effective and controversial therapies in psychiatry.

Indications: ECT is most commonly used for:

• Severe major depressive disorder, particularly with melancholic, psychotic, or suicidal features
• Catatonia, especially in the context of schizophrenia or affective illness
• Treatment-resistant depression (after failed pharmacologic interventions)
• Acute mania, particularly in bipolar disorder
• Psychosis, including schizophrenia with poor response to antipsychotics
• Rapid symptom relief in situations of urgent clinical risk (e.g., suicidal ideation, malnutrition in depression)

Contraindications / Cautions: There are no absolute contraindications, but caution is advised in:

• Recent myocardial infarction or unstable cardiac disease
• Raised intracranial pressure or space-occupying lesions
• Severe osteoporosis
• Aneurysms or recent cerebrovascular accident
• Use of lithium (may prolong seizures)

Thorough anaesthetic and medical pre-assessment is routine to manage risk.

Efficacy (Statistical Overview)

• Response rates in major depression are estimated at 70–90%, with remission rates around 50–60% after a typical index course (6–12 treatments). In catatonia, response rates exceed 80%
• A 2003 Lancet meta-analysis confirmed ECT’s superiority over sham ECT and medications in severe depression
• Ultra-brief pulse unilateral ECT may reduce cognitive side-effects while retaining efficacy
• Relapse is common post-treatment without continuation therapy; hence maintenance ECT or pharmacotherapy is often employed
• Recent systematic reviews challenge long-term efficacy due to methodological heterogeneity, but confirm short-term utility in severe cases

Place in Modern Psychiatry
Despite media stigma and regulatory scrutiny, ECT remains a front-line treatment in many mental health systems. Modern ECT is anaesthetised, muscle-relaxed, and precisely dosed, with seizure quality, duration, and cognitive side-effects closely monitored. Its role is now contextualised alongside other neuromodulation treatments such as rTMS (repetitive transcranial magnetic stimulation), vagal nerve stimulation, and deep brain stimulation.

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History of ECT

1933 – Manfred Sakel (1900–1957) introduced Insulin Coma Therapy (ICT) as a somatic treatment for psychosis, particularly schizophrenia, based on the belief that shock states could recalibrate mental function.

The coma itself seems to break through the pathological processes of schizophrenia… the patient awakens with a changed state of consciousness, in many cases with striking improvement

Sakel 1935

Sakel originally tested insulin therapy for opioid withdrawal before observing the calming effects in psychotic patients. His theory aligned with a broader somatogenic trend in psychiatry: “biological shocks” (fever, insulin, seizures) were seen as catalysts for mental reset. However the mortality rate (0.5–2%) and need for prolonged hospitalisation were major drawbacks. While now obsolete, Sakel’s work paved the way for the concept of biological psychiatry and helped legitimise further convulsive therapies.

1934 – In the early 1930s, Ladislas J. Meduna (1896–1964) observed the histological distinction between patients with epilepsy and those with schizophrenia. Through autopsy studies, he noted increased glial cell counts in epileptics, and decreased glial cell counts in the brains of schizophrenic patients. Meduna proposed a biological antagonism between the two conditions and proposed that generating epileptic seizures in patients with schizophrenia might alleviate their symptoms.

…if I can stimulate epileptic seizures in schizophrenics then these… will alter the chemical and humoral processes in the body in a way… that the suppression of the disease will be made physiologically possible. The two diseases are pathophysiologically antagonistic…inducing epileptic seizures might therefore cure schizophrenia.

Meduna, 1934

Meduna used camphor oil injections, and later Metrazol (pentylenetetrazol), to provoke seizures in experimental animals. On January 23, 1934, he administered the first seizure-inducing injection to a man (Zoltán L.) with catatonic schizophrenia. The treatment produced dramatic effects and after a course of nine seizures, the patient regained speech and mobility.

By 1937, Meduna had treated over 100 patients and published “Die Konvulsionstherapie der Schizophrenie,” his seminal work on convulsive therapy. He reported early remission in 10 of his first 26 patients.

On April 11, 1938, at the University of Rome, Ugo Cerletti and Lucio Bini conducted the first electroconvulsive therapy (ECT) on a human. After extensive animal studies and practical experimentation in abattoirs using electrical stunning equipment, they applied a controlled current to a patient with paranoid schizophrenia. The induced seizure resulted in significant improvement after repeated sessions.

Cerletti sought a simpler, non-toxic method to provoke epileptic convulsions… Electroshock, unlike cardiazol, induced immediate and absolute unconsciousness… without the distressing latency period… The attack was fundamentally identical to that obtained with cardiazol and should achieve the same beneficial effects—if not more

Cerletti and Bini, 1938

1939 – At the Third International Neurological Congress in Copenhagen, Bini introduced electroconvulsive therapy (ECT) to a global audience for the first time. Bini delivered a detailed presentation titled “Seizures triggered through electrical current (electroshock)” in German, describing the technical, physiological, and clinical aspects of the newly developed therapy.

This method permits controlled, repeatable seizures without the adverse psychic effects caused by cardiazol… The psychotic symptoms receded gradually with successive treatments.

Bini 1939

His lecture outlined extensive preclinical animal trials, the physiological parameters of induced seizures, and the design of the ECT apparatus. Bini discussed the optimal settings for voltage (130–145 V), current frequency (approx. 45 Hz AC), electrode placement on the temples, and seizure classification (complete vs. incomplete). He emphasised the treatment’s safety, reporting no complications in over 3,000 cases

1940s– In the early 1940s Anaesthetists began administering ether anaesthesia to reduce psychological trauma and distress caused by the shock and seizures. Early trials were quickly replaced by barbiturates (e.g., thiopental/“Pentothal”) for better control and safety.

Pentothal Sodium modifies electroconvulsive therapy in such a manner as to make the dangers of musculoskeletal injuries negligible… and the allaying of apprehension, and elimination of postconvulsive excitement that had limited the use of electroshock.

Tarnower 1950

1941 – Henri Laborit and contemporaries first added curare to anaesthesia protocols to mitigate fractures and musculoskeletal injuries caused by unmodified seizures. However, curare’s long action and respiratory suppression led to search for alternatives.

1942 – Lothar B. Kalinowsky (1899–1992) was a key figure in the transatlantic introduction of electroconvulsive therapy, Kalinowsky helped establish ECT in the United States after observing it in Rome in 1939. He championed the therapy across American psychiatric institutions, becoming the country’s foremost proponent and co-author of the influential Shock treatments, psychosurgery and other somatic treatments in psychiatry (1946) and Biological treatments in psychiatry (1982)

It was the insulin treatment that made psychiatrists therapeutic-minded, but it was electroshock that made them effective.

Kalinowsky 1952

1944 – In one of the darkest abuses of psychiatric technology, Austrian physician Emil Gelny (1890–1961), affiliated with the Nazi party, modified electroconvulsive therapy equipment to systematically kill psychiatric patients at state institutions in Gugging and Mauer-Öhling. Gelny adapted the Vienna-made “Elkra” ECT device by adding limb electrodes to deliver lethal current under the guise of therapy.

Gelny’s actions were facilitated by his rapid appointment to psychiatric directorship after only three months of clinical training, and were embedded in the Nazi regime’s eugenic ideology.

1951 – Adoption of succinylcholine for muscle relaxation. Succinylcholine chloride, a rapidly acting depolarising agent, was introduced in clinical ECT settings. It provided profound yet short-lived muscle relaxation, reducing risk of fractures without prolonged paralysis.

Since succinylcholine was introduced… the incidence of vertebral or long-bone fractures has been reduced to zero… The combination with Pentothal sodium is now standard

Steven, 1954

Over 3,000 cases reviewed across two centres (Hartford Hospital and Institute of Living) reported only one anaesthetic-related death and marked reductions in physical and psychological complications.

1950s – Max Fink (1923–2025) was a major force in the modernisation and standardisation of ECT conducting clinical trials on ECT’s efficacy for mood and psychotic disorders. He advocated for anaesthetised ECT, evidence-based protocols, and preservation of ECT’s medical legitimacy through rigorous publishing and training.

Except for penicillin and insulin, ECT is the most effective treatment of the 20th century.

Fink, 1999

1978 – The American Psychiatric Association (APA) convened a Task Force on ECT to review usage, outcomes and adverse effects, culminating in the report Electroconvulsive Therapy. This represented the first formal professional endorsement and guideline for ECT in modern psychiatry, signalling a shift from ad‑hoc use to structured, informed practice: defining indications, technique, training and consent.

2003 – A landmark systematic review and meta‑analysis: Efficacy and safety of electroconvulsive therapy in depressive disorders (Lancet 2003) showing superior short‑term outcomes in depression for ECT. Growing evidence‑base for ECT in treatment‑resistant depression; it spurred renewed confidence and modernisation of ECT practices (anaesthesia, muscle relaxants, titrated stimulus).

2018 – On December 26, 2018 the FDA issued a final order reclassifying ECT devices for certain indications (catatonia or severe major depressive episode in treatment‑resistant patients age 13 and older) from Class III (highest‑risk) to Class II (moderate‑risk, special controls) under U.S. regulatory framework.

The safe use of ECT for treatment of these conditions has been well studied and is better understood than other uses of ECT devices

This regulatory milestone reflects a maturation of the evidence‑base and acceptance of ECT as a mainstream treatment modality under defined indications.

2020s – Procedure‑refinement, neuromodulation context & ongoing evidence‑evaluation. ECT practice has been embedded within broader neuromodulation therapies (e.g., TMS, DBS) and renewed research on dosing, electrode placement and long‑term outcomes. Efficacy reviews remain mixed: e.g., a 2021 review found limited high‑quality evidence beyond end‑of‑treatment.

The five meta‑analyses claim that ECT is more effective than simulated ECT … but the quality of most studies is so poor that the meta‑analyses were wrong to conclude anything about efficacy … either during or beyond the treatment period

Read et al, 2021

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Parameters and Placement

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Associated Persons

• Manfred Sakel (1900–1957)
• Ladislas J. Meduna (1896–1964)
• Ugo Cerletti (1877–1963)
• Lucio Bini (1908–1964)
• Friedrich Meggendorfer (1880–1953)
• Lothar Kalinowsky (1899–1992)
• Max Fink (1923–2025)

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References

Historical references

• Sakel M. Neue Behandlungsmethoden der Schizophrenie. Wiener klinische Wochenschrift. 1933; 46: 1258–1262.
• Sakel M. Schizophreniebehandlung mittels Insulin-Hypoglykamie sowie hypoglykamischer Shocks, Wiener Medizinische Wochenschrift 1934; 84: 1326-1327
• Meduna L. Versuche über die biologische Beeinflussung des Ablaufes der Schizophrenia. I: Campher- und Cardiazolkrämpfe. Zeitschrift für die gesamte Neurologie und Psychiatrie. 1935; 152: 235–262
• Meduna L. Die Konvulsionstherapie der Schizophrenie. 1937
• Cerletti U, Bini L. L’Elettroshock. Archivio Generale di Neurologia, Psichiatria e Psicoanalisi 1938; 19: 266-268
• Bini L. Der Durch Elektrischen Strom Erzeugte Krampfanfall (Elektroschock). III Congres Neurologique International. Einar Munksgaard-Copenhague, 1939; 121: 706–708.
• Kalinowsky L. Shock treatments, psychosurgery and other somatic treatments in psychiatry. 1946
• Fink M. Electroshock: Restoring The Mind. 1999

Eponymous term review

• Tarnower SM, Gladstone RW. Use of pentothal sodium in the prevention of musculoskeletal injuries during electroconvulsive therapy. N Engl J Med. 1950 Apr 27;242(17):653-5
• Steven RJ, Tovell RM, Johnson JC, Delgado E. Anesthesia for electroconvulsive therapy. Anesthesiology. 1954 Nov;15(6):623-36
• APA. Electroconvulsive Therapy. 1978
• Bauer M. Review: electroconvulsive therapy may be an effective short term treatment for people with depression. Evid Based Ment Health. 2003 Aug;6(3):83.
• Endler NS, Persad E. Electroconvulsive Therapy: The Myths and the Realities. 1988
• Endler NS. The Origins of Electroconvulsive Therapy (ECT). Convuls Ther. 1988;4(1):5-23.
• Shorter E, Healy D. Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness. 2007
• Faedda GL, Becker I, Baroni A, Tondo L, Aspland E, Koukopoulos A. The origins of electroconvulsive therapy: Prof. Bini’s first report on ECT. J Affect Disord. 2010 Jan;120(1-3):12-5. 
• Aruta A. Shocking waves at the museum: the Bini-Cerletti electro-shock apparatus. Med Hist. 2011 Jul;55(3):407-12.
• Rzesnitzek L, Lang S. A Material History of Electroshock Therapy. N.T.M. 2016; 24, 251–277
• Gazdag G, Ungvari GS, Czech H. Mass killing under the guise of ECT: the darkest chapter in the history of biological psychiatry. Hist Psychiatry. 2017 Dec;28(4):482-488.
• Rzesnitzek L, Lang S. ‘Electroshock Therapy’ in the Third Reich. Med Hist. 2017 Jan;61(1):66-88.
• Sirgiovanni E, Aruta A. The electroshock triangle: disputes about the ECT apparatus prototype and its display in the 1960s. Hist Psychiatry. 2020 Sep;31(3):311-324.
• Read J, Irving K, McGrath L. Electroconvulsive therapy for depression: a review of the quality of ECT versus sham ECT trials and meta-analyses. BJPsych Advances. 2021;27(5):284