Stereotypes of Hispanic and Latino Americans in the United States

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Stereotypes_of_Hispanic_and_Latino_Americans_in_the_United_States

A political cartoon by Edmund S. Valtman from 1961 depicting stereotypical negative caricatures of Cubans, Brazilians (with a "Mexican" aspect), and former Cuban prime minister Fidel Castro

Stereotypes of Hispanic and Latino Americans in the United States are general representations of Americans considered to be of Hispanic and Latino ancestry or immigrants to the United States from Spain or Latin America, often exhibited in negative caricatures or terms. Latin America comprises all the countries in the Americas that were originally colonized by the Spaniards, French, or Portuguese. "Latino" is the umbrella term for people of Latin American descent that in recent years has supplanted the more imprecise and bureaucratic designation "Hispanic." Part of the mystery and the difficulty of comprehension lie in the fact that the territory called Latin America is not homogeneous in nature or culture. Latin American stereotypes have the greatest impact on public perceptions, and Latin Americans were the most negatively rated on several characteristics. Americans' perceptions of the characteristics of Latin American immigrants are often linked to their beliefs about the impact of immigration on unemployment, schools and crime.

Portrayal in films and television

Lack of representation

When discussing how Hispanic and Latino individuals are represented in television and film media, it is also important to acknowledge their vast underrepresentation in popular programming. The individuals are often stereotyped on television, but they are rarely even seen. Latino Americans represent approximately 18% of the U.S. population but only 0.6 to 6.5% of all primetime program characters, 1% of television families, and fewer than 4.5% of commercial actors. That poses the issue that Hispanic and Latino characters are not rarely seen, but even when they are, they are more than likely to be stereotyped. In the unlikely case that they are depicted, they are more likely to be limited to stereotypic characters, usually negatively. In September 2021, Bryan Dimas, co-founder of Latinx in Animation, mentioned an animated series with about 52 episodes which never "had a person of color that was a writer...other than one of the executive producers and some of the production crew," but said that shows are moving away from "having white writers writing for Black characters or Asian characters or Latino characters," and said that he believed there was a wave of more diverse representation in the future.

Stereotypical representation

Stereotypical representation of Hispanic and Latino characters are typically negatively presented and attack the entire ethnic group's morality, work ethic, intelligence or dignity. Even in non-fiction media, such as news outlets, Hispanics are usually reported on in crime, immigration, or drug-related stories than in accomplishments. The stereotypes can also differ between men and women. Hispanic and Latino men are more likely to be stereotyped as unintelligent, comedic, aggressive, sexual, and unprofessional, earning them titles as "Latin lovers", buffoons or criminals. That often results in the individuals being characterized as working less-respectable careers, being involved in crimes (often drug-related), or being uneducated immigrants. Hispanic characters are more likely than non-Hispanic white characters to possess lower-status occupations, such as domestic workers, or be involved in drug-related crimes. Hispanic and Latina women, similarly, are typically portrayed as lazy, verbally aggressive, and lacking work ethic. Latinas in modern movies follow old stereotypes. Latinas are still deemed as "less than", objectified and known for being to be alluring to others. Because of this, many Hispanics are treated terribly and seen as invaders to Americans. 

Resulting perspectives

According to Qingwen, "the impact of television portrayals of minorities is significant because of the ability of television images to activate racial stereotypes and the power exerted by visual images." Non-Hispanic white Americans who lack real-life contact with Hispanic or Latino individuals are forced to rely heavily on television and film, their only source of exposure to the ethnic group, as the foundation of perceiving Hispanic and Latino individuals. If nearly all of the few representations of the individuals are negatively stereotyped, non-Hispanic and Latino white individuals are likely to carry the perception into real life, embedding that stereotypical image of Hispanic and Latino individuals into their consciousness. Bandura's Social Cognitive Theory gives insight into how the stereotypical character representations are carried into the real world and points to the way in which individuals' perceptions are limited to what they have experienced. Those who lack real-life contact with the stereotyped individuals are unable to counter the television portrayals of this ethnic group with a more realistic and less negative image.

Stereotypes in news media

Between 2001 and 2010, the Hispanic population increased significantly in the United States, marking Hispanics as the largest minority in California. The news media began negatively framing Hispanics as criminals, illegal immigrants, dangerous and violent, further perpetuating prejudice, discrimination, and stereotypes of Hispanics. According to Loyola Marymount University researchers Santiago Arias and Lea Hellmueller:

"Research shows that on English-language news media networks, during the 1990s, negative attitudes started to arise against Hispanics-and-Latinos. This began after voters approved California Proposition 187 in 1994."

Proposition 187 was a 1994 ballot initiative to establish a California-run citizenship screening system and prohibit illegal aliens from using non-emergency health care, public education, and other services in the state. Arias and Hellmueller stated that the proposition spurred a slate of negative images and claims associated with Hispanics and Latinos in the United States, and affected the Hispanic community greatly by limiting employment opportunities, increasing maltreatment in the criminal justice system, and perpetuating victimization through violent hate crimes against Latinos. Studies show that from 2003 to 2007, violent hate crimes against Latinos rose by 40%.

Instead of focusing on positive attributes related to Hispanics and Latinos, Arias and Hellmueller wrote that news media content focused mainly on stereotypes and misjudgments when they addressed the population. As a result, news media programs helped build a "semantic meaning of the Hispanic-and-Latino identity as a metonym for illegal immigration."

"This discourse consists of promoting the idea that crime and undocumented immigrants, and the costs of illegal immigration in social services and taxes directly result from the increase of Hispanics-and-Latinos in the United States."

According to Arias and Hellmueller, the news media portrayed Hispanics as the enemy, consistently labeling them as illegal immigrants and violent criminals without statistics or facts to support their claims. A 2002 study conducted by Chiricos and Escholz examined race and news media content and investigated how news media content primes the local public's fear of crime.

"The findings suggested fear of crime forms part of a new 'modern racism'; that is, that local television news may contribute to the social construction of threat in relation to both minorities; television over-represents African Americans and Hispanics in crime news in relation to their share of the general population."

Another study conducted by Waldman and colleagues analyzed three cable commentators: Lou Dobbs, Bill O'Reilly, and Glenn Beck and their discussion of illegal immigration. These results concluded that 70% of the Lou Dobbs Tonight episodes in 2007 contained discussion of illegal immigration, 56% of the O'Reilly Factor episodes in 2007 discussed illegal immigration and Glenn Beck discussed illegal immigration in 28% of his year 2007 programs. As a result of popular shows labeling Hispanics as "illegal immigrants" and often portraying Hispanics in a negative light, the programs gave anti-immigration activists a platform for discrimination.

In attempt to verify the accuracy of stereotypes held against Latinos, studies conducted at Harvard and Michigan showed that undocumented and foreign-born immigrants were far less likely to commit acts of deviance, crime, drunk driving, or any kind of action that may jeopardize US citizens' well-being. In addition, the study found that the incarceration rate of foreign-born citizens is five times less the rate of native-born citizens.

Hispanics and crime

According to several scholars, the stereotypes of Hispanics are similar to the ones associated with African-Americans. Often characterized as being drug traffickers, drug users, dangerous and violent, Hispanics are subjected to much stereotyping in the United States in relation to crime, especially by their white counterparts. However, contrary to popular belief, Hispanic immigrants commit crime at lower rates than the general population.

Stereotypes of Hispanic and Latino men

Latino male stereotypes are drug dealer, Latin lover, greaser and bandito. Latinos males are also stereotyped as hypersexual, aggressive and "macho".

Cholo

A very common stereotype of Hispanic/Latino males is that of the criminal, gang member or "cholo". It is connected to the idea of Hispanic/Latinos being lower class and living in dangerous neighborhoods that breed the attitude of "cholo". Cholo and chola are terms often used in the United States to denote members of the Chicano gang subculture. The individuals are characterized by a defiant street attitude, a distinctive dress style, and the use of caló, slang, speech. In the United States, the term "cholo" often has a negative connotation and so tends to be imposed upon a group of people, rather than being used as a means of self-identification. That leads to considerable ambiguity in the particulars of its definition. In its most basic usage, it always refers to a degree of indigeneity.

"Illegal alien"/ "job stealer"

Hispanic/Latinos are frequently seen as the "others" in the United States despite their large percentage of the population. The otherness becomes a lens in which to view them as foreign or not being American. That mentality creates the illegal stereotype and the concept of job stealing. Generally, the term "immigrant" has positive connotations in relation to the development and operation of democracy and US history, but "illegal aliens" are vilified. The term "illegal alien" is defined as "a foreign person who is living in a country without having official permission to live there." Although many Latino/Hispanic Americans were born in the United States or have legal status, they can be dismissed as immigrants or foreigners who live without proper documentation taking opportunities and resources from real Americans. Immigrants have been represented as depriving citizens of jobs, as welfare-seekers, or as criminals. Especially with the recent political/social movement in the United States for stricter immigration law, Americans are blaming Hispanics for "stealing jobs" and negatively impacting the economy.

Homogeneous origin

A very common stereotype, as well as mentality, is that all Hispanic/Latino individuals have the same ethnic background, race and culture, when in reality there are numerous subgroups with unique identities. Americans tend to explain all of Latin America in terms of the nationalities or countries that they know. For instance, in the Midwest and the Southwest, Latin Americans are largely perceived as Mexicans, but in the East, particularly in the New York and Boston areas, people consider Latin Americans through their limited interactions with Dominicans and Puerto Ricans. In Miami, Cubans and Central Americans are the reference group for interpreting Latin America. The idea of homogeneity is so extensive in U.S. society that even important politicians tend to treat Latin America as a culturally-unified region.

Hard-labor worker or uneducated/lazy

There are two conflicting common stereotypes in accordance with employment that male Hispanic/Latinos tend to fall into a manual labor worker or an unemployed/lazy citizen. Many Hispanic/Latino Americans have equally as much education and skill level but are seen as "hard labor workers" such as farmhands, gardeners and cleaners. This stereotype goes along with that of the immigrant in believing all Hispanics/Latinos work in hard labor fields and manual labor only because they arrive in the country illegally, which is false. Latin Americans are also often pictured as not strongly inclined to work hard, despite the conflicting stereotype of working manual labor jobs. Today, negative stereotypes against certain ethnic groups about low cognitive abilities exist in many world regions, including stereotypes about people with a Latino background in the United States.

Machismo

Latino masculinity, which is already coded as violent, criminal, and dangerous (Collins 1991; Ferguson 2000; Vasquez 2010), makes the racial project of controlling images systematically restrict Latinos' lives. Machismo is depicted as the cult of male strength, which implies being fearless, self-confident, capable of making decisions, and able to support one's family. It also emphasized an acceptance of male dominance over women, including the valorization of Don Juanism, and, in its extreme form, a defense of the traditional division of labor (women in the kitchen and taking care of the children and men as providers). Hollywood movies, along with some American scholars and other people in the country, tend to regard machismo as unique to Latin America.

"Latin lover"

Main article: Latin lover

The "latin lover" stereotype is a Hispanic male who is seen as sexually sophisticated and is a threat to white women.

Stereotypes of Hispanic and Latina women

Entertainment and marketing industries

According to a Framing Latinas: Hispanic women through the lenses of Spanish-language and English-language news media, a 2010 paper by Teresa Correa, Latinas have been historically depicted as possessing one of two completely-contrasting identities. They have been depicted as either "virginal", "passive" and "dependent on men" or as "hot-tempered", "tempestuous", "promiscuous" and "sexy". A 2005 study conducted by Dana Mastro and Elizabeth Behm-Morawitz, professors of communication studies at the University of Arizona, found depictions of Latina Americans on primetime television are both limited and biased. The study analyzed the frequency and the quality of the depictions of Hispanic individuals on primetime television in 2002. The study found that "Latinas were the laziest characters in primetime... they were the least intelligent, most verbally aggressive, embodied the lowest work ethic, and (alongside whites) were the most ridiculed." According to the same studies, the marketing industry has also played a role in stereotyping females with Hispanic origin by using the stereotypical identities to sell product. Specifically, the bodies of Latina women have been used and sexualized to sell product targeted to men. According to Mary Gilly, a professor of business at the University of California Irvine, Latina women, in particular, are eroticized in the marketing industry because of their frequent portrayal as "tempestuous", "promiscuous" or "sexy".

Fiery Latina and the hot señorita

Further information: Mami (hip hop)

Stereotypical identities that have spurred from the idea that Hispanic and Latina women are "hot-tempered", "tempestuous", "promiscuous" and "sexy" include the "fiery Latina" and the "hot señorita". Both stem from the fact that Hispanic and Latina women are continually sexualized and eroticized in popular programming and in the entertainment industry as a whole. Recent examples include Sofia Vergara's character on Modern Family, but examples date back to the 1920s and 1930s with "Dolores del Río playing the exotic and passionate lover of the 1920s, and Carmen Miranda playing sexy and bombshell characters in the 1930s and 1940s." In Modern Family, Vergara portrays Gloria Delgado-Pritchett, a "trophy wife" often seen in provocative clothing and high heeled shoes. She often has trouble pronouncing English words and speaks with a heavy accent. Among the contemporary depictions accused of promoting the "Latina bombshell" include Iris Chacón's image, Naya Rivera in Glee, and Shakira and Jennifer Lopez's music videos.

Fertility threat

One reason for Latinas being stereotyped as hyper-sexualization is the idealistic picture of large Latino families with multiple children because of Latinas wrongly thought of as being highly sexual in nature. That has created the political and social threat of Latina's "hyper-fertility" in which there is a concern that the hypothetical fertility and birthing rates of Latinas is much more than that of non-Hispanic white women, adding to the threat of the Latino presence in the United States (Gutiérrez 2008; Chavez 2004).

A study compared the sexual activity of non-Hispanic white women and Latinas in Orange County, California, where there is a high population of Mexican American families. Non-Hispanic white women began sexual relations about a year younger than all of the Latinas in the survey reported. The non-Hispanic white women were more likely to report having had five or more sexual partners, but Latinas were more likely to report no more than two. Both non-Hispanic white women and Latinas showed a trend towards fewer children per household. In fact, second-generation Latinas were shown to have fewer children than non-Hispanic white women.

News and media

According to several sources, the entertainment industry can be credited with the creation and frequent reinforcement of the stereotypes, but the news is particularly important in the maintenance of these stereotypes. Unlike the entertainment and marketing industries, according to several studies, the press produces representations that are based on "reality". A 1994 study by Macrea et al., found stereotypes are generalizations that our culture has defined for us, and that using stereotypes is "more efficient". Thus, according to Macrea et al., journalists, because of time and space constraints, may be more likely to rely on stereotypic portrayals.

Correa found that both Hispanic Americans have been underrepresented in news media and that their limited portrayal have been depicted as a burden on contemporary American society. The 2016 election of President Donald Trump brought the issue to the forefront of American news, and issues relating specifically to immigration perpetuated stereotypes of Hispanic and Latino Americans as criminals.

Inaccuracies

Lazy stereotype

Ethnic-minority students, who are in the lower-income bracket, are more likely to attend schools that are overcrowded, dangerous and limited in the opportunities offered for advanced coursework with experienced teachers. Because of the inequalities in education, the graduation rate for Latino students is substantially below the rate for white students.

Contrary to the belief that Hispanics are "lazy", a study by Andrew J. Fuligni has shown that "students from ethnic minority backgrounds often have higher levels of motivation than their equally achieving peers from "pan-white" backgrounds.... Latin American and Asian families have significantly higher values of academic success and a stronger belief in the utility of education." The high level of motivation comes from Hispanics having a greater sense of obligation to support, assist, and respect the family.

A common misconception about Latinos and language learning is that not being able to speak English is a sign of unwillingness to learn. Some immigrants, from Mexico and other Latin countries, live in the United States for decades without acquiring a basic command of English. The primary reason is that it is difficult to learn a second language as an adult. Another reason is that finding time to learn a new language while struggling to financially support and spend time with family may be impossible.

Job-stealing stereotype

The "job-stealing Hispanic" stereotype is also false. According to Pastora San Juan Cafferty and William C. McCready, "a preliminary study of labor market competition among the black, Hispanic, and non-Hispanic white population (Borjas, 1983) found no evidence that Hispanics had a negative impact on the earnings of the other two groups." Hispanics are not "taking away" jobs that non-Hispanic groups want. The blue-collar jobs Hispanics obtain are low paying and have few fringe benefits, leading to little or no health insurance coverage.

Criminal stereotype

The aggressive "Hispanic gang member/criminal" stereotype, which is often see in movies and on television, is inaccurate. Gang-suppression approaches of numerous police departments have become "over-inclusive and embedded with practices that create opportunities for abuse of authority." This means most of the gang enforcement police stops are based on racial profiling. These stops involve no reasonable suspicion of criminal activity and oftentimes include non-gang members.

Impacts

Trouble establishing identities

Hispanic youth have a more difficult time establishing a positive school identity because of the negative academic stereotypes regarding their racial-ethnic group. The academic stereotypes, which negatively affect the academic performance of Latinos, focus on inability, laziness, and a lack of interest and curiosity.

Adolescence makes teenagers come face to face with deeply-rooted social issues, and the challenges they face can be daunting. For young Latinas in particular, the societal and emotional issues that they must come to terms with can be complicated. These issues can be complicated because they are learning who they are and what they want their role to be in society, but they also must fight against the stereotypes that have been imposed upon them by culture. Positive identity formation for young Latinas may be more difficult to achieve than it is for young Anglo girls. Some have postulated that providing young Latinas with the concepts of feminism may enhance their abilities to believe in themselves and improve their chances of realizing that they have the abilities to be successful because of who they are, not because of who they married. However, a recent study published in the Journal of Adolescent Research found that young Latinas may have a "different perspective" on feminism than their Anglo counterparts. The study found that Latinas experienced feminism differently because of cultural values; young Latinas "face an intricate balance between future family and career goals in their identity development." Some Latinas interviewed in the study expressed concern that if they told a young man that they were feminists, "they might assume that the girls didn't like men" and a large number also opposed the ideas of feminism and equality because of traditional values. The study ultimately determined that the majority of the young Latinas interviewed considered themselves to be feminists but a relatively large minority of the young women rejected the idea of feminism and equality because they were fearful of possible female superiority and endorsed traditional family values and female occupations.

Research shows that many Latinos in the United States do not identify as "American" but instead with their or their parents' or grandparents' country of origin. One of the reasons is the misbelief that to be an American, one needs to be white. Latinos who have experienced racial discrimination are more likely to identify as Latino or Latino American than simply American because they feel they are not treated as "real" Americans.^[35]

Mental instability

A study by Suárez-Orozco and Suárez-Orozco (2001) has shown that the internalization of perceived stigmatized identity of Hispanics can lead to resigned helplessness, self-defeating behavior, and depression.

Academic performance

Findings from an experimental study of college-bound Hispanic students showed that when Hispanic students were faced with stereotype threat, their academic performance suffered. Results of the study showed that Latino students who internalized racial stereotypes performed worse on a standardized test than Hispanic students who did not internalize those same stereotypes. The negative impact of racial stereotypes on student performance has implications for the overall educational journey of Hispanic and Latino students. Performing poorly on standardized tests could lead to limitations in the options available for furthering education. Another experimental study of Latino undergraduate students found that Latino students in the stereotype threat condition performed worse on an exam than all other students with which they were compared (Latino students in non-stereotype threat condition and white students in both stereotype threat and non-stereotype threat conditions). A study by Fischer (2009) found that Hispanic college students who internalize negative stereotypes about themselves tend to spend fewer hours studying, which further decreases their academic performance.

Psychosurgery

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Psychosurgery

Psychosurgery, also called neurosurgery for mental disorder (NMD), is the neurosurgical treatment of mental disorders. Psychosurgery has always been a controversial medical field. The modern history of psychosurgery begins in the 1880s under the Swiss psychiatrist Gottlieb Burckhardt. The first significant foray into psychosurgery in the 20th century was conducted by the Portuguese neurologist Egas Moniz who, during the mid-1930s, developed the operation known as leucotomy. The practice was enthusiastically taken up in the United States by the neuropsychiatrist Walter Freeman and the neurosurgeon James W. Watts who devised what became the standard prefrontal procedure and named their operative technique lobotomy, although the operation was called leucotomy in the United Kingdom. In spite of the award of the Nobel prize to Moniz in 1949, the use of psychosurgery declined during the 1950s. By the 1970s the standard Freeman-Watts type of operation was very rare, but other forms of psychosurgery, although used on a much smaller scale, survived. Some countries have abandoned psychosurgery altogether; in others, for example the US and the UK, it is only used in a few centres on small numbers of people with depression or obsessive-compulsive disorder (OCD). In some countries it is also used in the treatment of schizophrenia and other disorders.

Psychosurgery is a collaboration between psychiatrists and neurosurgeons. During the operation, which is carried out under a general anaesthetic and using stereotactic methods, a small piece of brain is destroyed or removed. The most common types of psychosurgery in current or recent use are anterior capsulotomy, cingulotomy, subcaudate tractotomy and limbic leucotomy. Lesions are made by radiation, thermo-coagulation, freezing or cutting. About a third of patients show significant improvement in their symptoms after operation. Advances in surgical technique have greatly reduced the incidence of death and serious damage from psychosurgery; the remaining risks include seizures, incontinence, decreased drive and initiative, weight gain, and cognitive and affective problems.

Currently, interest in the neurosurgical treatment of mental illness is shifting from ablative psychosurgery (where the aim is to destroy brain tissue) to deep brain stimulation (DBS) where the aim is to stimulate areas of the brain with implanted electrodes.

Medical uses

All the forms of psychosurgery in use today (or used in recent years) target the limbic system, which involves structures such as the amygdala, hippocampus, certain thalamic and hypothalamic nuclei, prefrontal and orbitofrontal cortex, and cingulate gyrus—all connected by fibre pathways and thought to play a part in the regulation of emotion. There is no international consensus on the best target site.

Anterior cingulotomy was first used by Hugh Cairns in the UK, and developed in the US by H.T. Ballantine Jr. In recent decades it has been the most commonly used psychosurgical procedure in the US. The target site is the anterior cingulate cortex; the operation disconnects the thalamic and posterior frontal regions and damages the anterior cingulate region.

Anterior capsulotomy was developed in Sweden, where it became the most frequently used procedure. It is also used in Scotland and Canada. The aim of the operation is to disconnect the orbitofrontal cortex and thalamic nuclei by inducing a lesion in the anterior limb of internal capsule.

Subcaudate tractotomy was the most commonly used form of psychosurgery in the UK from the 1960s to the 1990s. It targets the lower medial quadrant of the frontal lobes, severing connections between the limbic system and supra-orbital part of the frontal lobe.

Limbic leucotomy is a combination of subcaudate tractotomy and anterior cingulotomy. It was used at Atkinson Morley Hospital London in the 1990s and also at Massachusetts General Hospital.

Amygdalotomy, which targets the amygdala, was developed as a treatment for aggression by Hideki Narabayashi in 1961 and is still used occasionally, for example at the Medical College of Georgia.

There is debate about whether deep brain stimulation (DBS) should be classed as a form of psychosurgery.

Effectiveness

Success rates for anterior capsulotomy, anterior cingulotomy, subcaudate tractotomy, and limbic leucotomy in treating depression and OCD have been reported as between 25 and 70 percent. The quality of outcome data is poor and the Royal College of Psychiatrists in their 2000 report concluded that there were no simple answers to the question of modern psychosurgery's clinical effectiveness; studies suggested improvements in symptoms following surgery but it was impossible to establish the extent to which other factors contributed to this improvement. Research into the effects of psychosurgery has not been able to overcome a number of methodological problems, including the problems associated with non-standardised diagnoses and outcome measurements, the small numbers treated at any one centre, and positive publication bias. Controlled studies are very few in number and there have been no placebo-controlled studies. There are no systematic reviews or meta-analyses.

Modern techniques have greatly reduced the risks of psychosurgery, although risks of adverse effects still remain. Whilst the risk of death or vascular injury has become extremely small, there remains a risk of seizures, fatigue, and personality changes following operation.

A 2012 follow-up study of eight depressed patients who underwent anterior capsulotomy in Vancouver, Canada, classified five of them as responders at two to three years after surgery. Results on neuropsychological testing were unchanged or improved, although there were isolated deficits and one patient was left with long-term frontal psychobehavioral changes and fatigue. One patient, aged 75, was left mute and akinetic for a month following surgery and then developed dementia.

By country

China

In China, psychosurgical operations which make a lesion in the nucleus accumbens are used in the treatment of drug and alcohol dependence. Psychosurgery is also used in the treatment of schizophrenia, depression, and other mental disorders. Psychosurgery is not regulated in China, and its use has been criticised in the West.

India

India had an extensive psychosurgery programme until the 1980s, using it to treat addiction, and aggressive behaviour in adults and children, as well as depression and OCD. Cingulotomy and capsulotomy for depression and OCD continue to be used, for example at the BSES MG Hospital in Mumbai.

Japan

In Japan the first lobotomy was performed in 1939 and the operation was used extensively in mental hospitals. However, psychosurgery fell into disrepute in the 1970s, partly due to its use on children with behavioural problems.

Australia and New Zealand

In the 1980s there were 10–20 operations a year in Australia and New Zealand. The number had decreased to one or two a year by the 1990s. In Victoria, there were no operations between 2001 and 2006, but between 2007 and 2012 the Victoria Psychosurgery Review Board dealt with 12 applications, all them for DBS.

Europe

In the 20-year period 1971–1991 the Committee on Psychosurgery in the Netherlands and Belgium oversaw 79 operations. Since 2000 there has been only one centre in Belgium performing psychosurgery, carrying out about 8 or 9 operations a year (some capsulotomies and some DBS), mostly for OCD.

In France about five people a year were undergoing psychosurgery in the early 1980s. In 2005 the Health Authority recommended the use of ablative psychosurgery and DBS for OCD.

In the early 2000s in Spain about 24 psychosurgical operations (capsulotomy, cingulotomy, subcaudate tractotomy, and hypothalamotomy) a year were being performed. OCD was the most common diagnosis, but psychosurgery was also being used in the treatment of anxiety and schizophrenia, and other disorders.

In the UK between the late 1990s and 2009 there were just two centres using psychosurgery: a few stereotactic anterior capsulotomies are performed every year at the University Hospital of Wales, Cardiff, while anterior cingulotomies are carried out by the Advanced Interventions Service at Ninewells Hospital, Dundee. The patients have diagnoses of depression, obsessive-compulsive disorder, and anxiety. Ablative psychosurgery was not performed in England between the late 1990s and 2009, although a couple of hospitals have been experimenting with DBS. In 2010, Frenchay Hospital in Bristol performed an anterior cingulotomy on a woman who had previously undergone DBS.

In Russia in 1998 the Institute of the Human Brain (Russian Academy of Sciences) started a programme of stereotactic cingulotomy for the treatment of drug addiction. About 85 people, all under the age of 35, were operated on annually. In the Soviet Union, leucotomies were used for the treatment of schizophrenia in the 1940s, but the practice was prohibited by the Ministry of Health in 1950.

North America

In the United States, the Massachusetts General Hospital has a psychosurgery program. Operations are also performed at a few other centres.

In Mexico, psychosurgery is used in the treatment of anorexia and aggression.

In Canada, anterior capsulotomies are used in the treatment of depression and OCD.

South America

Venezuela has three centres performing psychosurgery. Capsulotomies, cingulotomies and amygdalotomies are used to treat OCD and aggression.

History

Main article: History of psychosurgery

Early psychosurgery

Evidence of trepanning (or trephining)—the practice of drilling holes in the skull—has been found in a skull from a Neolithic burial site in France, dated to about 5100 BC although it was also used to treat brain cranial trauma. There have also been archaeological finds in South America, while in Europe trepanation was carried out in classical and medieval times. The first systematic attempt at psychosurgery is commonly attributed to the Swiss psychiatrist Gottlieb Burckhardt. In December 1888 Burckhardt operated on the brains of six patients (one of whom died a few days after the operation) at the Préfargier Asylum, cutting out a piece of cerebral cortex. He presented the results at the Berlin Medical Congress and published a report, but the response was hostile and he did no further operations. Early in the 20th century, Russian neurologist Vladimir Bekhterev and Estonian neurosurgeon Ludvig Puusepp operated on three patients with mental illness, with discouraging results.

1930s–1950s

Although there had been earlier attempts to treat psychiatric disorders with brain surgery, it was Portuguese neurologist Egas Moniz who was responsible for introducing the operation into mainstream psychiatric practice. He also coined the term psychosurgery. Moniz developed a theory that people with mental illnesses, particularly "obsessive and melancholic cases", had a disorder of the synapses which allowed unhealthy thoughts to circulate continuously in their brains. Moniz hoped that by surgically interrupting pathways in their brain he could encourage new healthier synaptic connections. In November 1935, under Moniz's direction, surgeon Pedro Almeida Lima drilled a series of holes on either side of a woman's skull and injected ethanol to destroy small areas of subcortical white matter in the frontal lobes. After a few operations using ethanol, Moniz and Almeida Lima changed their technique and cut out small cores of brain tissue. They designed an instrument which they called a leucotome and called the operation a leucotomy (cutting of the white matter). After twenty operations, they published an account of their work. The reception was generally not friendly but a few psychiatrists, notably in Italy and the US, were inspired to experiment for themselves.

In the US, psychosurgery was taken up and zealously promoted by neurologist Walter Freeman and neurosurgeon James Watts. They started a psychosurgery program at George Washington University in 1936, first using Moniz's method but then devised a method of their own in which the connections between the prefrontal lobes and deeper structures in the brain were severed by making a sweeping cut through a burr hole on either side of the skull. They called their new operation a lobotomy.

Freeman went on to develop a new form of lobotomy which could be dispensed without the need for a neurosurgeon. He hammered an ice pick-like instrument, an orbitoclast, through the eye socket and swept through the frontal lobes. The transorbital or "ice pick" lobotomy was done under local anesthesia or using electroconvulsive therapy to render the patient unconscious and could be performed in mental hospitals lacking surgical facilities. Such was Freeman's zeal that he began to travel around the nation in his own personal van, which he called his "lobotomobile", demonstrating the procedure in psychiatric hospitals. Freeman's patients included 19 children, one of whom was 4 years old.

The 1940s saw a rapid expansion of psychosurgery, in spite of the fact that it involved a significant risk of death and severe personality changes. By the end of the decade, up to 5000 psychosurgical operations were being carried out annually in the US. In 1949, Moniz was awarded the Nobel Prize for Physiology or Medicine.

Beginning in the 1940s various new techniques were designed in the hope of reducing the adverse effects of the operation. These techniques included William Beecher Scoville's orbital undercutting, Jean Talairach's anterior capsulotomy, and Hugh Cairn's bilateral cingulotomy. Stereotactic techniques made it possible to place lesions more accurately, and experiments were done with alternatives to cutting instruments such as radiation. Psychosurgery nevertheless went into rapid decline in the 1950s, due to the introduction of new drugs and a growing awareness of the long-term damage caused by the operations, as well as doubts about its efficacy. By the 1970s, the standard or transorbital lobotomy had been replaced with other forms of psychosurgical operations.

1960s to the present

During the 1960s and 1970s, psychosurgery became the subject of increasing public concern and debate, culminating in the US with congressional hearings. Particularly controversial in the United States was the work of Harvard neurosurgeon Vernon Mark and psychiatrist Frank Ervin, who carried out amygdalotomies in the hope of reducing violence and "pathologic aggression" in patients with temporal lobe seizures and wrote a book entitled Violence and the Brain in 1970. The National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research in 1977 endorsed the continued limited use of psychosurgical procedures. Since then, a few facilities in some countries, such as the US, have continued to use psychosurgery on small numbers of patients. In the US and other Western countries, the number of operations has further declined over the past 30 years, a period during which there had been no major advances in ablative psychosurgery.

Ethics

Psychosurgery has a controversial history, and despite modifications, still raises serious questions about benefit, risks, and the adequacy with which consent is obtained. Its continued use is defended by references to the "therapeutic imperative" to do something in the case of psychiatric patients who have not responded to other forms of treatment, and the evidence that some patients see improvement in their symptoms following surgery. There remain however problems concerning the rationale, indications and efficacy of psychosurgery, and the results of the operation raise questions of "identity, spirit, relationships, integrity and human flourishing".

Racism in Canada

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Racism_in_Canada

 

Racism in Canada traces both historical and contemporary racist community attitudes, as well as governmental negligence and political non-compliance with United Nations human rights standards and incidents in Canada. Contemporary Canada is the product of indigenous First Nations combined with multiple waves of immigration, predominantly from Europe and in modern times, from Asia.

Overview

In a 2013 survey of 80 countries by the World Values Survey, Canada was ranked among the most racially tolerant societies in the world. In 2021, the Social Progress Index ranked Canada 6th in the world for overall tolerance and inclusion.

Canadian author and journalist Terry Glavin claims that white Canadians consider themselves to be mostly free of racial prejudice, perceiving the country to be a "more inclusive society" than its direct neighbor the United States, a notion that has come under criticism. For instance, Galvin cites the treatment of the Aboriginal population in Canada as evidence of Canada's own racist tendencies. These perceptions of inclusion and "colour-blindness" have also been challenged in recent years by scholars such as Constance Backhouse stating that white supremacy is still prevalent in the country's legal system, with blatant racism created and enforced through the law. According to one commentator, Canadian "racism contributes to a self-perpetuating cycle of criminalization and imprisonment". In addition, throughout Canada's history there have been laws and regulations that have negatively affected a wide variety of races, religions, and groups of persons.

Canadian law uses the term "visible minority" to refer to people of colour (but not aboriginal Canadians), introduced by the Employment Equity Act of 1995. However, the UN Committee on the Elimination of Racial Discrimination stated this term may be considered objectionable by certain minorities and recommended an evaluation of this term.

In 2019, the English and Art departments at Kwantlen Polytechnic University collaborated to put on an exhibition called Maple-Washing: A Disruption, which featured various works examining Canadian history from diverse perspectives. With "Maple-Washing" (portmanteau of maple and "whitewash") referring to the alleged tendency of Canadian institutions to sanitize Canadian history. Historical topics and events covered in the exhibition included Canadian participation in the trans-Atlantic slave trade, the Komagata Maru incident, the internment of Japanese Canadians during World War Two, and the Chinese head tax, frequently "maple-washed" incidents.

Examples

Indigenous Peoples

See also: Canadian genocide of indigenous peoples, Gustafsen Lake standoff, Burnt Church Crisis, Grand River land dispute, Ipperwash Crisis, and Oka Crisis

Canada's treatment of First Nations people is governed by the Indian Act. The Canadian Indian Act helped inspire South Africa's apartheid policies. Many Indigenous people were forced into assimilation through the Canadian Indian residential school system. From 1928 to the mid-1990s, Indigenous girls in the residential school system were subject to forced sterilization once they reached puberty. The number of sterilized girls is not known because the records were destroyed. European colonizers assumed the Indigenous peoples needed saving, a form of "charitable racism". However, this attitude is not absent from modern Canada, for example, in August 2008, McGill University's Chancellor and International Olympic Committee representative Richard Pound told La Presse: "We must not forget that 400 years ago, Canada was a land of savages, with scarcely 10,000 inhabitants of European origin, while in China, we're talking about a 5,000-year-old civilization", implying that the First Nations people were "uncivilized".

In 1999 the Canadian government created an autonomous territory, Nunavut, for the Inuit living in the Arctic and northernmost parts of the country. The Inuit compose 85% of the population of Nunavut, which represents a new level of self-determination for the Indigenous peoples of Canada.

Slavery of Aboriginals and Black Canadians

Ku Klux Klan members, on foot and horseback, by a cross erected in a field near Kingston, Ontario, in 1927

There are records of slavery in some areas of British North America, which later became Canada, dating from the 17th century. The majority of these slaves were Aboriginal, and United Empire Loyalists brought slaves with them after leaving the United States.

Segregation and the Ku Klux Klan

Canada had also practiced segregation, and a Canadian Ku Klux Klan also exists. Racial profiling occurs in cities such as Halifax, Toronto and Montreal. Black people made up 3% of the Canadian population in 2016, and 9% of the population of Toronto (which has the largest communities of Caribbean and African immigrants). They disproportionately lived in poverty, they were three times as likely to be carded in Toronto than Whites were, and incarceration rates among Blacks were climbing faster than they were among any other demographic. A Black Lives Matter protest was staged at Toronto Police Headquarters in March 2016.

Order-in-Council P.C. 1911-1324

Main article: Order-in-Council P.C. 1911-1324

On August 12, 1911, the Governor General in Council approved a one-year prohibition of black immigration to Canada because, according to the Order-in-Council, "the Negro race" was "unsuitable to the climate and requirements of Canada." It was tabled on June 2, 1911, by the Minister of the Interior, Frank Oliver, following mounting pressure from white prairie farmers who were discontented with an influx in the immigration of black farmers from the United States. It was never officially enforced or added to the Immigration Act, likely because the government—led by Prime Minister Wilfrid Laurier—was hesitant to alienate black voters ahead of the 1911 federal election. It was repealed later that year.

Africville

Main article: Africville

See also: Black Nova Scotians

In Nova Scotia, a community which mainly consisted of Black Canadians were forcibly removed and eventually razed between 1964 and 1967 after years of intentional neglect by the government in Halifax.

Greek-Canadians

Main article: Greek-Canadians

See also: 1918 Toronto anti-Greek riot

The 1918 Toronto anti-Greek riot was a three-day race riot in Toronto, Ontario, Canada, targeting Greek immigrants during August 2–4, 1918. It was the largest riot in the city's history and one of the largest anti-Greek riots in the world.

Jews

See also: Antisemitism in Canada, History of the Jews in Canada, and MS St. Louis

Jewish students were prohibited from studying at Canadian universities. Canada had imposed restrictive policies on Jewish immigration. In 1939, Jewish refugees who were escaping from WWII in Europe by traveling aboard the MS St Louis were not allowed to enter Canada due to racist immigration policies.

The government's policies have changed, however, antisemitism remains problematic. Jews are a tiny-and therefore a more vulnerable-minority in Canada, in 2018, they only comprised 1.1% of Canada's entire population. Partially due to the small size of the community, hate crimes against Jews (also referred to as "violent antisemitism") is the highest per-capita form of race-based violence reported in Canada.

Black people

Main article: Black Canadians § Racism

Black Canadians are discriminated in Canada.

Romani people

Main article: Anti-Romani sentiment § Canada

Asian Canadians

Indo-Canadians

See also: British Raj

In 1914, Indians arriving in Canada were not allowed to enter despite being British subjects, leading to the deaths of dozens of immigrants in the Komagata Maru incident.

Chinese Canadians

Boarded windows and storefronts on Pender Street in Chinatown after the September 1907 riots

Starting in 1858, Chinese "coolies" were brought to Canada to work in British Columbia in the mines and on the Canadian Pacific Railway. After anti-Chinese riots broke out in 1886, a "Chinese head tax" was implemented to curtail immigration from China. In 1907, the Anti-Oriental Riots in Vancouver targeted Chinese and Japanese-owned businesses, and the Asiatic Exclusion League was formed to drive Asians out of the province. League members attacked Asians, resulting in numerous riots. In 1923, the federal government passed the Chinese Immigration Act, commonly known as the Exclusion Act, prohibiting most Chinese immigration. The Act was repealed in 1947, but discrimination limiting non-European immigrants continued until 1967 when a points-based system was introduced to assess immigrants regardless of origin.

Japanese Canadians

A Royal Canadian Navy officer questions Canadian fishermen of Japanese descent as their boats were confiscated.

See also: Japantown, Vancouver and Internment of Japanese Canadians

Although a British–Japanese treaty guaranteed Japanese citizens freedom of travel, they were nevertheless subject to anti-Asian racism in Canada, though a slightly lesser degree at the time than the Chinese before World War II, as an informal agreement between the Japanese and Canadian governments limited Japanese immigration in the wake of the Vancouver anti-Asian riots.

In 1942, during World War II, many Canadians of Japanese heritage—even those born in Canada— were forcibly moved to internment camps under the authority of the War Measures Act. At first, many men were separated from their families and sent to road camps in Ontario and on the British Columbia–Alberta border. Small towns in the BC interior such as Greenwood, Sandon, New Denver and Slocan became internment camps for women, children and the aged. To stay together, Japanese–Canadian families chose to work in farms in Alberta and Manitoba. Those who resisted and challenged the orders of the Canadian government were rounded up by the Royal Canadian Mounted Police and incarcerated in a barbed-wire prisoner-of-war camp in Angler, Ontario. Japanese–Canadians fishing boats were also seized, with plans to drastically reduce fishing licenses from them and forcibly redistribute them for white Canadians. With government promises to return the land and properties seized during that time period, Japanese Canadians left their homes. This turned out to be untrue, as the seized possessions were resold and never returned to the Japanese Canadians. Unlike prisoners of war, who were protected by the Geneva Convention, Japanese–Canadians were forced to pay for their own internment.

COVID-19 pandemic

In the midst of the COVID-19 pandemic, Asian Canadians reported increased incidents of violent assaults, especially against women of Asian descent. According to an Angus Reid survey from 22 June 2020, up to 50% of Chinese-Canadians had experienced verbal abuse, and 29% had been made to feel feared, as if they posed a threat to public safety. Another survey of 1,600 adults conducted by ResearchCo and obtained by the Agence France-Presse revealed one in four Canadians of Asian descent (70% of whom were of Chinese descent) who lived in British Columbia knew someone within their household who had faced discrimination. The survey also revealed 24 percent of Canadians of South Asian descent reported racist insults. Canadians of Indigenous origin had also reported discrimination.

Sikhs

See also: Anti-Sikh sentiment in Canada

Anti-Sikh sentiment in Canada has a historical and contemporary presence marked by several key events and ongoing issues. Early instances include the 1907 Bellingham Race Riot, where South East Asian and South Asian immigrants, mostly Sikhs, were violently targeted by white mobs in Washington (state), spilling over into Canadian anti-immigrant sentiments and the Pacific Northwest. 

The 1914 Komagata Maru incident incident further highlighted institutional racism when 376 Indian passengers, mostly Sikhs, were denied entry into Canada and forced to return to India, where many faced persecution. 

Post September 11 attacks, Sikhs in Canada experienced increased xenophobia and hate crimes, often being mistaken for Muslims due to their turbans and beards.

Missing and murdered Indigenous women

Main article: Missing and murdered Indigenous women

The representation of murdered Indigenous women in crime statistics is not proportionate to the general population. In 2006, Amnesty International researched racism specific to Indigenous women in Canada. They reported on the lack of basic human rights, discrimination, and violence against Indigenous women. The Amnesty report found that First Nations women (age 25–44) with status under the Indian Act were five times more likely than other women of the same age to die as a result of violence. In 2006, the documentary film Finding Dawn looked into the many missing and murdered Aboriginal women in Canada over the past three decades. In September 2016, in response to repeated calls from Indigenous groups, activists, and non-governmental organizations, the Government of Canada under Prime Minister Justin Trudeau, jointly with all provincial and territorial governments, established a national public inquiry into Missing and Murdered Indigenous Women and Girls.

Indigenous people still have to deal with racism within Canada and the challenges that the communities face are often ignored. There are still negative stereotypes associated with Indigenous people such as being freeloaders, drug addicts or dumb. Indigenous people are more likely to feel depression due to several factors such as poverty, loss of cultural identity, inadequate health care and more.

In 2020, the staff at a hospital in the Quebec city of Joliette were shown on video mocking and making racist remarks at an Atikamekw woman who eventually died. Indigenous leaders say the video exposes the grim realities of systemic racism that have long gone ignored or suppressed throughout Canada.

Electroconvulsive therapy

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Electroconvulsive_therapy

 

Electroconvulsive therapy
MECTA spECTrum 5000Q with electroencephalography (EEG) in a modern ECT suite

Electroconvulsive therapy (ECT) or electroshock therapy (EST) is a psychiatric treatment during which a generalized seizure (without muscular convulsions) is electrically induced to manage refractory mental disorders. Typically, 70 to 120 volts are applied externally to the patient's head, resulting in approximately 800 milliamperes of direct current passing between the electrodes, for a duration of 100 milliseconds to 6 seconds, either from temple to temple (bilateral ECT) or from front to back of one side of the head (unilateral ECT). However, only about 1% of the electrical current crosses the bony skull into the brain because skull impedance is about 100 times higher than skin impedance.

Aside from effects on the brain, the general physical risks of ECT are similar to those of brief general anesthesia. Immediately following treatment, the most common adverse effects are confusion and transient memory loss. Among treatments for severely depressed pregnant women, ECT is one of the least harmful to the fetus.

ECT is often used as an intervention for major depressive disorder, mania, autism, and catatonia. The usual course of ECT involves multiple administrations, typically given two or three times per week until the patient no longer has symptoms. ECT is administered under anesthesia with a muscle relaxant. ECT can differ in its application in three ways: electrode placement, treatment frequency, and the electrical waveform of the stimulus. These treatment parameters can pose significant differences in both adverse side effects and symptom remission in the treated patient.

Placement can be bilateral, where the electric current is passed from one side of the brain to the other, or unilateral, in which the current is solely passed across one hemisphere of the brain. High-dose unilateral ECT has some cognitive advantages compared to moderate-dose bilateral ECT while showing no difference in antidepressant efficacy.

History

A Bergonic chair, a device "for giving general electric treatment for psychological effect, in psycho-neurotic cases", according to original photo description. World War I era.

Further information: History of electroconvulsive therapy in the United Kingdom and History of electroconvulsive therapy in the United States

As early as the 16th century, agents to induce seizures were used to treat psychiatric conditions. In 1785, the therapeutic use of seizure induction was documented in the London Medical and Surgical Journal. As to its earliest antecedents one doctor claims 1744 as the dawn of electricity's therapeutic use, as documented in the first issue of Electricity and Medicine. Treatment and cure of hysterical blindness was documented eleven years later. Benjamin Franklin wrote that an electrostatic machine cured "a woman of hysterical fits." By 1801, James Lind as well as Giovanni Aldini had used galvanism to treat patients with various mental disorders. G.B.C. Duchenne, the mid-19th century "Father of Electrotherapy", said its use was integral to a neurological practice.

In the second half of the 19th century, such efforts were frequent enough in British asylums as to make it notable.

Convulsive therapy was introduced in 1934 by Hungarian neuropsychiatrist Ladislas J. Meduna who, believing mistakenly that schizophrenia and epilepsy were antagonistic disorders, induced seizures first with camphor and then metrazol (cardiazol). Meduna is thought to be the father of convulsive therapy.

In 1937, the first international meeting on schizophrenia and convulsive therapy was held in Switzerland by the Swiss psychiatrist Max Müller. The proceedings were published in the American Journal of Psychiatry and, within three years, cardiazol convulsive therapy was being used worldwide.

The ECT procedure was first conducted in 1938 by Italian neuro-psychiatrist Ugo Cerletti and rapidly replaced less safe and effective forms of biological treatments in use at the time. Cerletti, who had been using electric shocks to produce seizures in animal experiments, and his assistant Lucio Bini at Sapienza University of Rome developed the idea of using electricity as a substitute for metrazol in convulsive therapy and, in 1938, experimented for the first time on a person affected by delusions.

It was believed early on that inducing convulsions aided in helping those with severe schizophrenia but later found to be most useful with affective disorders such as depression. Cerletti had noted a shock to the head produced convulsions in dogs. The idea to use electroshock on humans came to Cerletti when he saw how pigs were given an electric shock before being butchered to put them in an anesthetized state. Cerletti and Bini practiced until they felt they had the right parameters needed to have a successful human trial. Once they started trials on patients, they found that after 10–20 treatments the results were significant. Patients had much improved.

A positive side effect to the treatment was retrograde amnesia. It was because of this side effect that patients could not remember the treatments and had no ill feelings toward it.

ECT soon replaced metrazol therapy all over the world because it was cheaper, less frightening and more convenient. Cerletti and Bini were nominated for a Nobel Prize but did not receive one. By 1940, the procedure was introduced to both England and the US. In Germany and Austria, it was promoted by Friedrich Meggendorfer. Through the 1940s and 1950s, the use of ECT became widespread. At the time the ECT device was patented and commercialized abroad, the two Italian inventors had competitive tensions that damaged their relationship. In the 1960s, despite a climate of condemnation, the original Cerletti-Bini ECT apparatus prototype was contended by scientific museums between Italy and the US. The ECT apparatus prototype is now owned and displayed by the Sapienza Museum of the History of Medicine in Rome.

In the early 1940s, in an attempt to reduce the memory disturbance and confusion associated with treatment, two modifications were introduced: the use of unilateral electrode placement and the replacement of sinusoidal current with brief pulse. It took many years for brief-pulse equipment to be widely adopted.

In the 1940s and early 1950s, ECT was usually given in an "unmodified" form, without muscle relaxants, and the seizure resulted in a full-scale convulsion. A rare but serious complication of unmodified ECT was fracture or dislocation of the long bones. In the 1940s, psychiatrists began to experiment with curare, the muscle-paralysing South American poison, in order to modify the convulsions. The introduction of suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to the more widespread use of "modified" ECT. A short-acting anesthetic was usually given in addition to the muscle relaxant in order to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants.

The steady growth of antidepressant use along with negative depictions of ECT in the mass media led to a marked decline in the use of ECT during the 1950s to the 1970s. The Surgeon General stated there were problems with electroshock therapy in the initial years before anesthesia was routinely given, and that "these now-antiquated practices contributed to the negative portrayal of ECT in the popular media." The New York Times described the public's negative perception of ECT as being caused mainly by one movie: "For Big Nurse in One Flew Over the Cuckoo's Nest, it was a tool of terror, and, in the public mind, shock therapy has retained the tarnished image given it by Ken Kesey's novel: dangerous, inhumane and overused".

In 1976, Dr. Blatchley demonstrated the effectiveness of his constant current, brief pulse device ECT. This device eventually largely replaced earlier devices because of the reduction in cognitive side effects, although as of 2012 some ECT clinics still were using sine-wave devices.

The 1970s saw the publication of the first American Psychiatric Association (APA) task force report on electroconvulsive therapy (to be followed by further reports in 1990 and 2001). The report endorsed the use of ECT in the treatment of depression. The decade also saw criticism of ECT. Specifically, critics pointed to shortcomings such as noted side effects, the procedure being used as a form of abuse, and uneven application of ECT. The use of ECT declined until the 1980s, "when use began to increase amid growing awareness of its benefits and cost-effectiveness for treating severe depression". In 1985, the National Institute of Mental Health and National Institutes of Health convened a consensus development conference on ECT and concluded that, while ECT was the most controversial treatment in psychiatry and had significant side-effects, it had been shown to be effective for a narrow range of severe psychiatric disorders.

Because of the backlash noted previously, national institutions reviewed past practices and set new standards. In 1978, the American Psychiatric Association released its first task force report in which new standards for consent were introduced and the use of unilateral electrode placement was recommended. The 1985 NIMH Consensus Conference confirmed the therapeutic role of ECT in certain circumstances. The American Psychiatric Association released its second task force report in 1990 where specific details on the delivery, education, and training of ECT were documented. Finally, in 2001 the American Psychiatric Association released its latest task force report. This report emphasizes the importance of informed consent, and the expanded role that the procedure has in modern medicine. By 2017, ECT was routinely covered by insurance companies for providing the "biggest bang for the buck" for otherwise intractable cases of severe mental illness, was receiving favorable media coverage, and was being provided in regional medical centers.

Though ECT use declined with the advent of modern antidepressants, there has been a resurgence of ECT with new modern technologies and techniques. Modern shock voltage is given for a shorter duration of 0.5 milliseconds where conventional brief pulse is 1.5 milliseconds.

In a review from 2022 of neuroimaging studies based on a global data collaboration ECT was suggested to work via a temporary disruption of neural circuits followed by augmented neuroplasticity and rewiring.

Modern use

ECT is used, where possible, with informed consent in treatment-resistant major depressive disorder, bipolar depression, treatment-resistant catatonia, prolonged or severe mania, and in conditions where "there is a need for rapid, definitive response because of the severity of a psychiatric or medical condition (e.g., when illness is characterized by suicidality, psychosis, stupor, marked psychomotor retardation, depressive delusions or hallucinations, or life-threatening physical exhaustion associated with mania)." It has also been used to treat autism in adults with an intellectual disability, yet findings from a systematic review found this an unestablished intervention.

Major depressive disorder

For major depressive disorder, despite a Canadian guideline and some experts arguing for using ECT as a first line treatment, ECT is generally used only when one or other treatments have failed, or in emergencies, such as imminent suicide. ECT has also been used in selected cases of depression occurring in the setting of multiple sclerosis, Parkinson's disease, Huntington's chorea, developmental delay, brain arteriovenous malformations, and hydrocephalus.

Efficacy

A meta-analysis on the effectiveness of ECT in unipolar and bipolar depression indicated that although patients with unipolar depression and bipolar depression responded to other medical treatments very differently, both groups responded equally well to ECT. Overall remission rate for patients given a round of ECT treatment was 50.9% for those with unipolar depression and 53.2% for those with bipolar depression. Most severely depressed patients respond to ECT.

In 2004, a meta-analysis found in terms of efficacy, "a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus tricyclics and ECT versus monoamine oxidase inhibitors."

In 2003, The UK ECT Review Group published a systematic review and meta-analysis comparing ECT to placebo and antidepressant drugs. This meta-analysis demonstrated a large effect size (high efficacy relative to the mean in terms of the standard deviation) for ECT versus placebo, and versus antidepressant drugs.

Compared with repetitive transcranial magnetic stimulation (rTMS) for people with treatment-resistant major depressive disorder, ECT relieves depression as shown by reducing the score on the Hamilton Rating Scale for Depression by about 15 points, while rTMS reduced it by 9 points.

Other estimates regarding the response rate in treatment resistant depression vary between 60–80%, with a remission rate of 50–60%. In addition to reducing symptoms of depression and inducing relapse, ECT has also been shown to reduce the risk of suicide, improve functional outcomes and quality of life as well as reduce the risk of re-hospitalization. Efficacy does not depend on depression subtype. With regards to treatment resistant schizophrenia, the response rate is 40–70%.

Follow-up

There is little agreement on the most appropriate follow-up to ECT for people with major depressive disorder. The initial course of ECT is then transitioned to maintenance ECT, pharmacotherapy or both. When ECT is stopped abruptly, without a bridge to maintenance ECT or medications (usually antidepressants and Lithium), it is associated with a relapse rate of 84%. There is no defined schedule for maintenance ECT, however it is usually started weekly with intervals extended permissibly with the goal of maintaining remission. When ECT is followed by treatment with antidepressants, about 50% of people relapsed by 12 months following successful initial treatment with ECT, with about 37% relapsing within the first 6 months. About twice as many relapsed with no antidepressants. Most of the evidence for continuation therapy is with tricyclic antidepressants; evidence for relapse prevention with newer antidepressants is lacking. Adjunct maintenance ECT paired with cognitive behavioral therapy has also been shown to reduce relapse rates. Maintenance ECT may safely continue indefinitely, with no set maximum treatment interval established.

Lithium has also been found to reduce the risk of relapse, especially in younger patients.

Catatonia

ECT is generally a second-line treatment for people with catatonia who do not respond to other treatments, but is a first-line treatment for severe or life-threatening catatonia. There is a plethora of evidence for its efficacy, notwithstanding a lack of randomised controlled trials, such that "the excellent efficacy of ECT in catatonia is generally acknowledged". For people with autism spectrum disorders who have catatonia, there is little published evidence about the efficacy of ECT.

Mania

ECT is used to treat people who have severe or prolonged mania; NICE recommends it only in life-threatening situations or when other treatments have failed and as a second-line treatment for bipolar mania.

Schizophrenia

ECT is widely used worldwide in the treatment of schizophrenia, but in North America and Western Europe it is invariably used only in treatment resistant schizophrenia when symptoms show little response to antipsychotics; there is comprehensive research evidence for such practice. It is useful in the case of severe exacerbations of catatonic schizophrenia, whether excited or stuporous. There are also case reports of ECT improving persistent psychotic symptoms associated with stimulant-induced psychosis.

Effects

Aside from effects in the brain, the general physical risks of ECT are similar to those of brief general anesthesia; the US Surgeon General's report says that there are "no absolute health contraindications" to its use. Immediately following treatment, the most common adverse effects are confusion and memory loss. Some patients experience muscle soreness after ECT. Other common adverse effects after ECT include headache, jaw soreness, nausea, vomiting and fatigue. These side effects are transient and respond to treatment. There is evidence and rationale to support giving low doses of benzodiazepines or otherwise low doses of general anesthetics, which induce sedation but not anesthesia, to patients to reduce adverse effects of ECT.

While there are no absolute contraindications for ECT, there is increased risk for patients who have unstable or severe cardiovascular conditions or aneurysms; who have recently had a stroke; who have increased intracranial pressure (for instance, due to a solid brain tumor), or who have severe pulmonary conditions, or who are generally at high risk for receiving anesthesia.

In adolescents, ECT is highly efficient for several psychiatric disorders, with few and relatively benign adverse effects.

Risk of death

A meta-analysis from 2017 found that the death rate of ECT was around 2.1 per 100,000 procedures. A review from 2011 reported an estimate of the mortality rate associated with ECT as less than 1 death per 73,440 treatments.

Cognitive impairment

Cognitive impairment sometimes occurs after ECT. The American Psychiatric Association (APA) report in 2001 acknowledges: "In some patients the recovery from retrograde amnesia will be incomplete, and evidence has shown that ECT can result in persistent or permanent memory loss". It is the purported effects of ECT on long-term memory that give rise to much of the concern surrounding its use. However, the methods used to measure memory loss are non-specific, and their application to people with depressive disorders, who have cognitive deficits related to the depression, including problems with memory, may further limit their utility.

The acute effects of ECT can include amnesia, both retrograde (for events occurring before the treatment) and anterograde (for events occurring after the treatment). Memory loss and confusion are more pronounced with bilateral electrode placement rather than unilateral, and with outdated sine-wave rather than brief-pulse currents. The use of either constant or pulsing electrical impulses also varied the memory loss results in patients. Patients who received pulsing electrical impulses, as opposed to a steady flow, seemed to incur less memory loss. The vast majority of modern treatment uses brief pulse currents. A greater number of treatments and higher electrical charges (stimulus charges) have also been associated with a greater risk of memory impairment.

Retrograde amnesia is most marked for events occurring in the weeks or months before treatment. Anterograde memory loss usually resolves 2–4 weeks after treatment, whereas retrograde amnesia (which develops gradually after repeated treatments in the initial course) usually takes weeks to months to resolve, and amnesia rarely persist for more than 1 year. Retrograde amnesia after ECT usually affects autobiographical memory, rather than semantic memory. One published review summarizing the results of questionnaires about subjective memory loss found that between 29% and 55% of respondents believed they experienced long-lasting or permanent memory changes. In 2000, American psychiatrist Sarah Lisanby and colleagues found that bilateral ECT left patients with more persistently impaired memory of public events as compared to right unilateral ECT. However, bilateral ECT may be more efficacious than unilateral in the treatment of mood disorders.

ECT has not been found to increase the risk of dementia nor cause structural brain damage.

Effects on brain structure

Considerable controversy exists over the effects of ECT on brain tissue, although a number of mental health associations—including the APA—have concluded that there is no evidence that ECT causes structural brain damage. A 1999 report by the US Surgeon General states: "The fears that ECT causes gross structural brain pathology have not been supported by decades of methodologically sound research in both humans and animals."

Many expert proponents of ECT maintain that the procedure is safe and does not cause brain damage. Dr. Charles Kellner, a prominent ECT researcher and former chief editor of the Journal of ECT, stated in a 2007 interview that, "There are a number of well-designed studies that show ECT does not cause brain damage and numerous reports of patients who have received a large number of treatments over their lifetime and have suffered no significant problems due to ECT." Kellner cites a study purporting to show an absence of cognitive impairment in eight subjects after more than 100 lifetime ECT treatments. Kellner stated "Rather than cause brain damage, there is evidence that ECT may reverse some of the damaging effects of serious psychiatric illness." Two meta-analyses find that ECT is associated with brain matter growth.

Effects in pregnancy

If steps are taken to decrease potential risks, ECT is generally accepted to be relatively safe during all trimesters of pregnancy, particularly when compared to pharmacological treatments. Suggested preparation for ECT during pregnancy includes a pelvic examination, discontinuation of nonessential anticholinergic medication, uterine tocodynamometry, intravenous hydration, and administration of a nonparticulate antacid. During ECT, elevation of the pregnant woman's right hip, external fetal cardiac monitoring, intubation, and avoidance of excessive hyperventilation are recommended. In many instances of active mood disorder during pregnancy, the risks of untreated symptoms may outweigh the risks of ECT. Potential complications of ECT during pregnancy can be minimized by modifications in technique. The use of ECT during pregnancy requires thorough evaluation of the patient's capacity for informed consent.

Effects on the heart

ECT can cause a lack of blood flow and oxygen to the heart, heart arrhythmia, and "persistent asystole". A 2019 systematic review and meta-analysis of 82 studies found that the rate of major adverse cardiac events with ECT was 1 in 39 patients or about 1 in 200 to 500 procedures. The risk of death with ECT however is low. If death does occur, cardiovascular complications are considered as causal in about 30% of individuals.

Procedure

Electroconvulsive therapy machine on display at Glenside Museum in Bristol, England

ECT device produced by Siemens and used for example at the Asyl psychiatric hospital in Kristiansand, Norway from the 1960s to the 1980s

The placement of electrodes, as well as the dose and duration of the stimulation is determined on a per-patient basis.

In unilateral ECT, both electrodes are placed on the same side of the patient's head. Unilateral ECT may be used first to minimize side effects such as memory loss.

In bilateral ECT, the two electrodes are placed on opposite sides of the head. Usually bitemporal placement is used, whereby the electrodes are placed on the temples. Uncommonly bifrontal placement is used; this involves positioning the electrodes on the patient's forehead, roughly above each eye.

Unilateral ECT is thought to cause fewer cognitive effects than bilateral treatment, but is less effective unless administered at higher doses. Most patients in the US and almost all in the UK receive bilateral ECT.

The electrodes deliver an electrical stimulus. The stimulus levels recommended for ECT are in excess of an individual's seizure threshold: about one and a half times seizure threshold for bilateral ECT and up to 12 times for unilateral ECT. Below these levels treatment may not be effective in spite of a seizure, while doses massively above threshold level, especially with bilateral ECT, expose patients to the risk of more severe cognitive impairment without additional therapeutic gains. Seizure threshold is determined by trial and error ("dose titration"). Some psychiatrists use dose titration, some still use "fixed dose" (that is, all patients are given the same dose) and others compromise by roughly estimating a patient's threshold according to age and sex. Older men tend to have higher thresholds than younger women, but it is not a hard and fast rule, and other factors, for example drugs, affect seizure threshold.

Immediately prior to treatment, a patient is given a short-acting anesthetic such as methohexital, propofol, etomidate, or thiopental, a muscle relaxant such as suxamethonium (succinylcholine), and occasionally atropine to inhibit salivation. In a minority of countries such as Japan, India, and Nigeria, ECT may be used without anesthesia. The Union Health Ministry of India recommended a ban on ECT without anesthesia in India's Mental Health Care Bill of 2010 and the Mental Health Care Bill of 2013. The practice was abolished in Turkey's largest psychiatric hospital in 2008.

The patient's EEG, ECG, and blood oxygen levels are monitored during treatment.

ECT is usually administered three times a week, on alternate days, over a course of two to four weeks.

An illustration depicting electroconvulsive therapy

Neuroimaging prior to ECT

Neuroimaging prior to ECT may be useful for detecting intracranial pressure or mass given that patients respond less when one of these conditions exist. Nonetheless, it is not indicated due to high cost and low prevalence of these conditions in patients needing ECT.

Concurrent pharmacotherapy

Whether psychiatric medications are terminated prior to treatment or maintained, varies. However, drugs that are known to cause toxicity in combination with ECT, such as lithium, are discontinued, and benzodiazepines, which increase the seizure threshold, are either discontinued, a benzodiazepine antagonist is administered at each ECT session, or the ECT treatment is adjusted accordingly.

A 2009 RCT provides some evidence indicating that concurrent use of some antidepressant improves ECT efficacy.

Course

ECT is usually done from 6 to 12 times in 2 to 4 weeks but can sometimes exceed 12 rounds. It is also recommended to not do ECT more than 3 times per week. Evidence suggest that ECTs for depression may be stopped if there is no improvement during the first six sessions.

Treatment team

In the US, the medical team performing the procedure typically consists of a psychiatrist, an anesthetist, an ECT treatment nurse or qualified assistant, and one or more recovery nurses. Medical trainees may assist, but only under the direct supervision of credentialed attending physicians and staff.

Devices

Vintage ECT machine from before 1960

Modern ECT machine

Most modern ECT devices deliver a brief-pulse current, which is thought to cause fewer cognitive effects than the sine-wave currents which were originally used in ECT. A small minority of psychiatrists in the US still use sine-wave stimuli. Sine-wave is no longer used in the UK or Ireland. Typically, the electrical stimulus used in ECT is about 800 milliamps and has up to several hundred watts, and the current flows for between one and six seconds.

In the US, ECT devices are manufactured by two companies, Somatics, which is owned by psychiatrists Richard Abrams and Conrad Swartz, and Mecta. In the UK, the market for ECT devices was long monopolized by Ectron Ltd, which was set up by psychiatrist Robert Russell.

Mechanism of action

Despite decades of research, the exact mechanism of action of ECT remains elusive. A review from 2022 of neuroimaging studies based on a global data collaboration resulted in a model of temporary disruption of neural circuits followed by augmented neuroplasticity and rewiring. Other brain changes observed after ECT include increased gray matter volume in the frontolimbic areas including the hippocampus and amygdala, increased white matter tracts in the frontal and temporal lobes, increased monoamine neurotransmitters and increased neurogenesis in the dentate gyrus. Changes in sleep architecture due to the induced seizures have also been hypothesized as a mechanism of action.

Use

As of 2001, it was estimated that about one million people received ECT annually.

There is wide variation in ECT use between different countries, different hospitals, and different psychiatrists. International practice varies considerably from widespread use of the therapy in many Western countries to a small minority of countries that do not use ECT at all, such as Slovenia.

About 70 percent of ECT patients are women. This may be because women are more likely to be diagnosed with depression. Older and more affluent patients are also more likely to receive ECT. The use of ECT is not as common in ethnic minorities.

In Sweden, which has a complete register of all ECT treatments in the country, in 2013 the rate of persons treated in that year per 100,000 inhabitants was 41. Almost the same rate had already been present in 1975 with 42 patients per 100,000 inhabitants.

United States

ECT became popular in the US in the 1940s. At the time, psychiatric hospitals were overrun with patients whom doctors were desperate to treat and cure. Whereas lobotomies would reduce a patient to a more manageable submissive state, ECT helped to improve mood in those with severe depression. A survey of psychiatric practice in the late 1980s found that an estimated 100,000 people received ECT annually, with wide variation between metropolitan statistical areas.

Accurate statistics about the frequency, context and circumstances of ECT in the US are difficult to obtain because only a few states have reporting laws that require the treating facility to supply state authorities with this information. In 13 of the 50 states, the practice of ECT is regulated by law.

In the mid-1990s in Texas, ECT was used in about one third of psychiatric facilities and given to about 1,650 people annually. Usage of ECT has since declined slightly; in 2000–01 ECT was given to about 1,500 people aged from 16 to 97 (in Texas it is illegal to give ECT to anyone under sixteen). ECT is more commonly used in private psychiatric hospitals than in public hospitals, and minority patients are underrepresented in the ECT statistics.

In the United States, ECT is usually given three times a week; in the United Kingdom, it is usually given twice a week. Occasionally it is given on a daily basis. A course usually consists of 6–12 treatments, but may be more or fewer. Following a course of ECT some patients may be given continuation or maintenance ECT with further treatments at weekly, fortnightly or monthly intervals. A few psychiatrists in the US use multiple-monitored ECT (MMECT), where patients receive more than one treatment per anesthetic. Electroconvulsive therapy is not a required subject in US medical schools and not a required skill in psychiatric residency training. Privileging for ECT practice at institutions is a local option: no national certification standards are established, and no ECT-specific continuing training experiences are required of ECT practitioners.

United Kingdom

In the UK in 1980, an estimated 50,000 people received ECT annually, with use declining steadily since then to about 12,000 per annum in 2002. It is still used in nearly all psychiatric hospitals, with a survey of ECT use from 2002 finding that 71 percent of patients were women and 46 percent were over 65 years of age. Eighty-one percent had a diagnosis of mood disorder; schizophrenia was the next most common diagnosis. Sixteen percent were treated without their consent. In 2003, the National Institute for Health and Care Excellence, a government body which was set up to standardize treatment throughout the National Health Service in England and Wales, issued guidance on the use of ECT. Its use was recommended "only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening in individuals with severe depressive illness, catatonia or a prolonged manic episode".

The guidance received a mixed reception. It was welcomed by an editorial in the British Medical Journal but the Royal College of Psychiatrists launched an unsuccessful appeal. The NICE guidance, as the British Medical Journal editorial points out, is only a policy statement and psychiatrists may deviate from it if they see fit. Adherence to standards has not been universal in the past. A survey of ECT use in 1980 found that more than half of ECT clinics failed to meet minimum standards set by the Royal College of Psychiatrists, with a later survey in 1998 finding that minimum standards were largely adhered to, but that two-thirds of clinics still fell short of current guidelines, particularly in the training and supervision of junior doctors involved in the procedure. A voluntary accreditation scheme, ECTAS, was set up in 2004 by the Royal College, and as of 2017 the vast majority of ECT clinics in England, Wales, Northern Ireland and the Republic of Ireland have signed up.

The Mental Health Act 2007 allows people to be treated against their will. This law has extra protections regarding ECT. A patient capable of making the decision can decline the treatment, and in that case treatment cannot be given unless it will save that patient's life or is immediately necessary to prevent deterioration of the patient's condition. A patient may not be capable of making the decision (they "lack capacity"), and in that situation ECT can be given if it is appropriate and also if there are no advance directives that prevent the use of ECT.

China

ECT was introduced in China in the early 1950s and while it was originally practiced without anesthesia, as of 2012 almost all procedures were conducted with it. As of 2012, there are approximately 400 ECT machines in China, and 150,000 ECT treatments are performed each year. Chinese national practice guidelines recommend ECT for the treatment of schizophrenia, depressive disorders, and bipolar disorder and in the Chinese literature, ECT is an effective treatment for schizophrenia and mood disorders.

Although the Chinese government stopped classifying homosexuality as an illness in 2001, electroconvulsive therapy is still used by some establishments as a form of "conversion therapy". Alleged Internet addiction (or general unruliness) in adolescents is also known to have been treated with ECT, sometimes without anestheia, most notably by Yang Yongxin. The practice was banned in 2009 after news on Yang broke out.

Society and culture

Controversy

Surveys of public opinion, the testimony of former patients, legal restrictions on the use of ECT and disputes as to the efficacy, ethics and adverse effects of ECT within the psychiatric and wider medical community indicate that the use of ECT remains controversial. This is reflected in the January 2011 vote by the FDA's Neurological Devices Advisory Panel to recommend that FDA maintain ECT devices in the Class III device category for high risk devices, except for patients with catatonia, major depressive disorder, and bipolar disorder. This may result in the manufacturers of such devices having to do controlled trials on their safety and efficacy for the first time. In justifying their position, panelists referred to the memory loss associated with ECT and the lack of long-term data.

Legal status

Informed consent

The World Health Organization (2005) advises that ECT should be used only with the informed consent of the patient (or their guardian if their incapacity to consent has been established).

In the US, this doctrine places a legal obligation on a doctor to make a patient aware of the reason for treatment, the risks and benefits of a proposed treatment, the risks and benefits of alternative treatment, and the risks and benefits of receiving no treatment. The patient is then given the opportunity to accept or reject the treatment. The form states how many treatments are recommended and also makes the patient aware that consent may be revoked and treatment discontinued at any time during a course of ECT. The US Surgeon General's Report on Mental Health states that patients should be warned that the benefits of ECT are short-lived without active continuation treatment in the form of drugs or further ECT, and that there may be some risk of permanent, severe memory loss after ECT. The report advises psychiatrists to involve patients in discussion, possibly with the aid of leaflets or videos, both before and during a course of ECT.

According to the US Surgeon General, involuntary treatment is uncommon in the US and is typically used only in cases of great extremity, and only when all other treatment options have been exhausted. The use of ECT is believed to be a potentially life-saving treatment.

In one of the few jurisdictions where recent statistics on ECT usage are available, a national audit of ECT by the Scottish ECT Accreditation Network indicated that 77% of patients who received the treatment in 2008 were capable of giving informed consent.

In the UK, in order for consent to be valid it requires an explanation in "broad terms" of the nature of the procedure and its likely effects. One review from 2005 found that only about half of patients felt they were given sufficient information about ECT and its adverse effects and another survey found that about fifty percent of psychiatrists and nurses agreed with them.

A 2005 study published in the British Journal of Psychiatry described patients' perspectives on the adequacy of informed consent before ECT. The study found that "About half (45–55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not." The authors also stated:

Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form. The proportion who feel they did not freely choose the treatment has actually increased over time. The same themes arise whether the patient had received treatment a year ago or 30 years ago. Neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ECT, at least in England and Wales.

Involuntary ECT

Procedures for involuntary ECT vary from country to country depending on local mental health laws.

United States

In most states in the US, a judicial order following a formal hearing is needed before a patient can be forced to undergo involuntary ECT. However, ECT can also be involuntarily administered in situations with less immediate danger. Suicidal intent is a common justification for its involuntary use, especially when other treatments are ineffective.

United Kingdom

Until 2007 in England and Wales, the Mental Health Act 1983 allowed the use of ECT on detained patients whether or not they had capacity to consent to it. However, following amendments which took effect in 2007, ECT may not generally be given to a patient who has capacity and refuses it, irrespective of his or her detention under the Act. In fact, even if a patient is deemed to lack capacity, if they made a valid advance decision refusing ECT then they should not be given it; and even if they do not have an advance decision, the psychiatrist must obtain an independent second opinion (which is also the case if the patient is under age of consent). However, there is an exception regardless of consent and capacity; under Section 62 of the Act, if the treating psychiatrist says the need for treatment is urgent they may start a course of ECT without authorization. From 2003 to 2005, about 2,000 people a year in England and Wales were treated without their consent under the Mental Health Act. Concerns have been raised by the official regulator that psychiatrists are too readily assuming that patients have the capacity to consent to their treatments, and that there is a worrying lack of independent advocacy. In Scotland, the Mental Health (Care and Treatment) (Scotland) Act 2003 also gives patients with capacity the right to refuse ECT.

Regulation

In the US, ECT devices came into existence prior to medical devices being regulated by the Food and Drug Administration. In 1976, the Medical Device Regulation Act required the FDA to retrospectively review already existing devices, classify them, and determine whether clinical trials were needed to prove efficacy and safety. The FDA initially classified the devices used to administer ECT as Class III medical devices. In 2014, the American Psychiatric Association petitioned the FDA to reclassify ECT devices from Class III (high-risk) to Class II (medium-risk). A similar reclassification proposal in 2010 did not pass. In 2018, the FDA re-classified ECT devices as Class II devices when used to treat catatonia or a severe major depressive episode associated with major depressive disorder or bipolar disorder.

By country

Australia

In Western Australia, ECT has been heavily restricted since 2014, after a bill passed with bipartisan support introducing restrictions on ECT, which were welcomed by mental health experts. Children under 14 are prohibited from receiving ECT, while those aged 14 to 18 must have informed consent approval from the Mental Health Tribunal. The law imposes a $15,000 fine on anyone who performs ECT on a child under the age of 14.

Similarly, ECT is also banned on children under the age of 12 in the Australian Capital Territory (ACT).

United States

Many mental health facilities offer ECT for specific diagnoses, such as chronic depression, mania, catatonia and schizophrenia. However, ECT is often only used as a treatment of last resort. To be considered for ECT, often testing such as an EKG and lab tests are required, in addition to a physical and neurological exam. Certain medications and conditions, such as cardiac conditions or hypertension, may disqualify a patient from ECT. Patients should give proper informed consent before ECT is performed. In the United States, ECT is performed under general anesthesia. Both trained health professionals with experience in ECT administration as well as a specifically trained and certified anesthesiologist should administer the procedure and anesthesia respectively.

Judge Rotenberg Center

In 2020 the Food and Drug Administration (FDA) implemented a rule previously drafted in 2016 banning the use of ECT to treat disabilities. This ban specifically had major complications for the controversial Judge Rotenberg Center (JRC) in Canton, Massachusetts, which uses various methods of ECT. Specifically, it is believed by many that most of the cases at JRC do not require the use of ECT.

Public perception

A questionnaire survey of 379 members of the general public in Australia indicated that more than 60% of respondents had some knowledge about the main aspects of ECT. Participants were generally opposed to the use of ECT on depressed individuals with psychosocial issues, on children, and on involuntary patients. Public perceptions of ECT were found to be mainly negative. A sample of the general public, medical students, and psychiatry trainees in the United Kingdom found that the psychiatry trainees were more knowledgeable and had more favorable opinions of ECT than did the other groups. More members of the general public believed that ECT was used for control or punishment purposes than medical students or psychiatry trainees.

Famous cases

Main article: List of people who have undergone electroconvulsive therapy

• Ernest Hemingway, an American author, died by suicide in 1961 half a year after ECT treatment at the Mayo Clinic in 1960. He is reported to have said to his biographer, "Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure but we lost the patient." However, the same biographer (Hotchner, 1966) and also a second biographer (Lynn, 1987) emphasized - according to a review from 2008 - "that Hemingway’s serious mental illness and plans for suicide significantly predated his ECT treatments."

• Robert Pirsig had a nervous breakdown and spent time in and out of psychiatric hospitals between 1961 and 1963. He was diagnosed with paranoid schizophrenia and clinical depression as a result of an evaluation conducted by psychoanalysts, and was treated with electroconvulsive therapy on numerous occasions, a treatment he discusses in his novel, Zen and the Art of Motorcycle Maintenance.

• Thomas Eagleton, United States Senator from Missouri, was dropped from the Democratic ticket in the 1972 United States Presidential Election as the party's vice presidential candidate after it was revealed that he had received electroshock treatment in the past for depression. Presidential nominee George McGovern replaced him with Sargent Shriver, and later went on to lose by a landslide to Richard Nixon.
• American surgeon and award-winning author Sherwin B. Nuland is another notable person who has undergone ECT. In his 40s, his depression became so severe that he had to be institutionalized. After exhausting all treatment options, a young resident assigned to his case suggested ECT, which ended up being successful.
• Author David Foster Wallace also received ECT for many years, beginning as a teenager, before his suicide at age 46.
• New Zealand author Janet Frame experienced both insulin coma therapy and ECT (but without the use of anesthesia or muscle relaxants). She wrote about this in her autobiography, An Angel at My Table (1984), which was later adapted into a film (1990).
• American actor Carrie Fisher wrote about her experience with memory loss after ECT treatments in her memoir Wishful Drinking.
• Lou Reed had ECT as a teenager to "cure" his homosexuality. He later claimed it had induced multiple personality disorder, and resulted in his hatred of psychiatrists. After Reed's death, his sister denied the ECT treatments were intended to suppress his "homosexual urges", asserting that their parents were not homophobic but had been told by his doctors that ECT was necessary to treat Reed's mental and behavioral issues.

Fictional examples

Electroconvulsive therapy has been depicted in fiction, including fictional works partly based on true experiences. These include Sylvia Plath's semi-autobiographical novel, The Bell Jar, Ken Loach's film Family Life, and Ken Kesey's novel One Flew Over the Cuckoo's Nest; Kesey's novel is a direct product of his time working the graveyard shift as an orderly at a mental health facility in Menlo Park, California.

Two analyses of large numbers of films using ECT scenes found that almost all presented fictional settings that were unrelated to real treatment routines and were apparently aimed at stigmatizing ECT as a tool of repression and of mind and behavior control - having effects of memory-erosion, pain and damage.

The song “The Mind Electric” by Miracle Musical is typically interpreted as depicting someone undergoing ECT.

In the television series "Mr Bates vs The Post Office", which is based on true events, the character of Saman Kaur receives ECT following a deep depression and attempted suicide.