Psychiatry, Diagnosis and Non-Drug Treatment

Psychiatry is the medical specialty for diagnosing and treating mental, emotional, and behavioral disorders. During the twentieth century, psychiatry adapted and abandoned several technologies in the treatment of mental illness with the notable exception of electroconvulsive therapy, which from its invention in 1938 has remained an important treatment for mental illness.

At the beginning of the twentieth century, there were few nondrug treatments available in psychiatry. Psychotherapy was available for the well-to-do, but others went untreated or were consigned to asylums that were little better than prisons.

One method used for the first two decades of the century was electrotherapy. Electrotherapeutic devices used static electricity, induction coils, or direct current electricity drawn from simple batteries ranging in size from small wooden boxes to the room-sized static electric machines. By passing an electrode, or wand, along the spine and nape of the patient’s neck, physicians claimed to cure intractable neuroses such as neurasthenia or hysteria. In other cases patients were seated in front of giant static electrical machines and received a static wind.

Electrotherapy fell out of favor after World War I when psychiatrists redefined mental illness and the symptoms clustered under neurasthenia and hysteria were reclassified as psychodynamic rather than physical ailments. Throughout the twentieth century variations of electrotherapy survived as part of physical therapy.

Hyperthermal cabinets, used from the late 1930s through to the early 1950s, were also once part of the psychiatric treatments. The idea for fever therapy, as it was known, came from Julius Wagner von Jauregg who injected patients with blood-borne malaria to induce high fevers and successfully treated general paresis. Rather than risk the side effects of malaria, hyperthermal cabinets were manufactured and sold to hospitals as a safer, more controlled means of raising the body’s temperature.

The devices, shaped much like the iron lung, encased the patient below the neck and raised the body to temperatures above 106° F (41.1°C). Despite clinical success on both schizophrenia and depression, this treatment was abandoned with the advent of electroconvulsive therapy.

Electroconvulsive therapy, or ECT, was invented in 1938 by Ugo Cerletti who sought to replicate the convulsive therapy pioneered by Ladislas von Meduna. Meduna believed that epilepsy was antagonistic to mental disease and so contrived a convulsive medication called metrazol or cardazol which sent patients into convulsive fits that seemed to cure schizophrenia.

Cerletti’s research team set about to find a technologically cleaner and simpler method to create convulsions and succeeded in 1937 when Cerletti’s assistant Lucio Bini invented a simple electroconvulsive machine. The machine ran on a standard household alternating current of 125 volts and sent electricity through the brain using a pair of calipers attached to the temples. In April 1938 Cerletti gave ECT to a mental patient and his published findings confirmed his success.

In the U.S., machines were first built by psychiatrists themselves and had several common features. Machines tended to be small devices encased in wood with a glass-covered meter that gave the voltage of the electricity, while another dial allowed the physician to increase the voltage, and a button that when pushed began or ended a treatment. ‘‘Home made’’ devices of wood gave way to metal and a number of manufacturers competed for the practitioners by including a variety of designs and features between 1940-1960.

Lektra, Medcraft, Offner, and Reiter were important manufacturers of ECT machines throughout this period and each added technical refinements. The size could vary from 13 by 8 centimeters to that of a large suitcase. The standard models incorporated instruments that could read the patient’s electrical resistance and provide a slow rise in current (or glissando); some included so-called reverse glissando because they started with a higher current that stepped down gradually.

There were also machines that used the so-called brief stimulus method that delivered electricity in short bursts or waves which presumably lessened the prevalent side effects such as marked memory loss. It was not uncommon in the 1950s to find machines that would also provide what was called electrosleep or electronarcosis. This was a subconvulsive dose of continuous electricity that led to unconsciousness without convulsion. Some physicians used this a treatment for mental or nervous disorders, while others used it to put patients to sleep prior to administering ECT.

ECT fell from favor after the advent of psychopharmacology, and beginning in the 1960s, manufacturers abandoned the field one by one. In the 1980s Medcraft, now called Hittman-Medcraft, was the only original manufacturer remaining in the U.S. However, the psychiatrist Paul Blachy modified a machine in 1973 to incorporate an electroencephalogram (EEG) and electrocardiogram (EKG) to monitor patient’s vital signs before and after the treatment.

He called his design the monitored electroconcovulsive therapy apparatus (MECTA) and began manufacturing his machines under the MECTA name in the mid-1970s. In the mid-1980s, Richard Abrams and Conrad Swartz combined their efforts to create Somatics, which is the leading manufacturer and seller of ECT devices (particularly its Thymatron line). The new devices incorporated computer chips to provide a number of read-outs and deliver precise amounts of electricity at precise time intervals. Although using higher voltage, some estimates suggested 180 or more volts, these devices cycled at faster rates and had shorter pulses of electricity over a longer duration.

Devices constructed in the 1980s also allowed physicians to set the machine according to the age of the patient, an important factor in determining the body’s electrical resistance. With the advent of so many new features, the devices have become larger and approximately the size of a large stereo receiver. ECT, which in the 1960s seemed destined for the same end as electrotherapy, hydrotherapy, and fever therapy, made a dramatic resurgence in the 1980s and is particularly useful for medically resistant forms of depression. Estimates suggest as many as a 100,000 treatments are given annually.

The popularity of ECT technology has inspired the use of the experimental treatment known as transcranial magnetic stimulation (TMS), which employs some of the ideas of electrotherapy. In TMS an electromagentic coil is placed on the scalp and an electric current of high intensity is turned on and off through the coil. This creates a magnetic field lasting from 100-200 microseconds, which is repeated in a process known as rTMS.

Clinical reports show efficacy among treatment-resistant depressions. Unlike ECT, which employs a general electrical charge through the head, rTMS can be situated to deliver electricity to a more specific region of the brain. Side effects such as headache and memory loss are lessened, patients remain awake throughout the treatment and, though still not approved by the Food and Drug Administration (FDA) as a treatment for depression, this technology remains promising.

The last major medical breakthrough in twentieth-century psychiatry may well be the introduction of vagus nerve stimulation (VNS) to treat depression and anxiety. In the late 1990s psychiatrists began employing this technique, which involves implanting a pacemaker-sized device into the chest wall. The device delivers a short pulse of electricity to the vagus nerve located in the neck, which in turn stimulates a series of nerves that seem to be involved in brain chemistry. Since 1998 clinical results have demonstrated the promise of this new technique.