McCall, W. Vaughn MD, MS*; Kellner, Charles H. MD†; Fink, Max MD‡
From the *Georgia Regents University, Augusta, GA; †Mount Sinai School of Medicine and ‡St. James, NY.
Received for publication December 23, 2013; accepted December 23, 2013.
Reprints: W. Vaughn McCall, MD, MS, Georgia Regents University, Augusta, GA (e-mail: WMCCALL@gru.edu).
The authors have no conflicts of interest or financial disclosures to report.
This year marks the 30th year of publication of the Journal of ECT (JECT), originally Convulsive Therapy (CT). It was in June 1984 at the meeting of the International College of Nueropsychopharmacology in Florence, Italy, after a plenary lecture on “Convulsive Therapy: How it Works” that Alan Edelson, publisher of Raven Press, invited Max Fink of Stony Brook University to edit a new journal, allowing him to pick the name and focus of interest. Both pharmacoelectroencephalography and convulsive therapy were active disciplines to which he had contributed, and both lacked dedicated journals. “Would the publisher accept a journal dedicated to Shock Therapy”? His quick response was, “Whatever you choose and edit, so long as I do not get sued.”
Fink focused on convulsive therapy because the practice was being actively challenged by both professional and public attacks. Legislatures in various states and in many countries proscribed its use. Psychiatrists enthused about the plethora of new chemical entities and created new psychotherapies but ignored the convulsive therapies.
The journal was named Convulsive Therapy as the most descriptive and least pejorative when compared to such terms as “shock therapy,” “electroshock,” or “seizure therapy.” The first issue appeared in April 1985, just 7 months after the contract was signed. An editorial board of 27 members supported the Journal.
Fifty years earlier, the Hungarian neuropathologist Ladislas Meduna reported diminished amounts of glia in patients who died with schizophrenia and a surfeit of glia in patients who died with epilepsy.1 He proposed inducing grand mal epileptic seizures—a heroic challenge in medicine that had not been done before. With his first publication in 1935, clinicians from Europe and North America made the trek to his home in Budapest. (He complained of the expense of entertaining each visitor at his home.)
Surprisingly, psychosis, then considered an inherited genetic disorder, was relieved. To do his experiments, Meduna had to move to a remote hospital for the chronically ill (away from his position at the Hungarian Academic Institute), where his work would not be impeded. His inductions of seizures were chemical, first with camphor and then with pentylenetetrazol (Metrazol). In his book of case material that he published in 1937, he reported that more than half his patients returned to the community after prolonged periods of hospital care.1
By the 1940s, electrical induction of seizures (ECT) supplanted chemical methods and was well established throughout the world as a principal treatment of the severe mentally ill. The first number of Convulsive Therapy included Meduna’s autobiography.2 The Journal’s goal was to be a forum for the ongoing debate and argument “. . . in the belief that our concerns about this therapeutic process may be satisfied by systematic observation, comparison, deduction and verification of experience with seizures and psychotic behavior.”3
In 1985, the Journal became the official voice of the Association for Convulsive Therapy (ACT). In 1994, Max Fink stepped down and Charles Kellner of the Medical University of South Carolina assumed the role of editor, with an editorial board of 36 members. Raven Press sold the ownership of the Journal to Lippincott Raven in 1998 (later Lippincott Williams & Wilkins), and the name of the Journal was changed to The Journal of ECT. In 2004, Vaughn McCall of the Medical College of Georgia became editor, with an editorial board of 39 members. The current editorial board has 48 members.
Among the first challenges was obtaining indexing of the published articles in the various indices, especially the National Library of Medicine’s Medline. Articles in new journals could not be indexed until at least 2 years of articles had been published. Yet, it took an additional few years until indexing began, and then additional years until the first years’ articles were indexed. All published articles are now available online in PubMed and in the publisher’s JECT website.
The initial success of the Journal was a matter of faith, as it could not be known whether there would be sufficient interest and sufficient material to sustain a journal with such a specific focus. The Journal, however, had 2 critical factors for success that paved its way: (1) a devoted editorial board, and (2) a specialty society that claimed the Journal as its flagship publication. The ACT offered a subscription to the Journal as an option of membership. When ACT later changed its name and interests to The International Society for Electroconvulsive Therapy and Neurostimulation (ISEN), the membership benefit of a JECT subscription continued.
Over the decades, the focus of psychiatry has changed, from the psychotherapies to pharmacotherapy, with interest in ECT not accepted within the principal psychiatric or psychopharmacologic societies. The JECT has passed through many changes, in publisher, adoption of online manuscript submission and review, online-only publication as a supplement to print publication, and the inclusion of papers on related brain stimulation topics such as transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), and deep brain stimulation (DBS). Despite all the changes, the focus of JECT remains on ECT.
Is there really anything more to be said about convulsive therapies? After all, there have been many leaps of knowledge over the past 30 years, especially in technical variations leading to changes in efficacy and adverse effects.4 Some more interesting developments have been: (1) the realization of differences in the practice of ECT across the world,5,6 (2) a renewed appreciation of ECT for patients with schizophrenia,7 (3) the rediscovery of catatonia and melancholia as target syndromes for which induced seizures are most effective,8 (4) the role of continuation and maintenance ECT as a necessary component of effective practice,9 (5) the growth of outpatient (ambulatory ) ECT,10 and (6) acknowledgment of the role of ECT in treating severely ill children and adolescents.11
Perhaps the biggest unanswered question is “what mechanism explains the efficacy of ECT?” Whereas we know that the induction of a seizure is a critical element, we have progressed little beyond that point. An improved understanding of mechanism would improve patient selection for optimized outcomes and more efficient treatment technique, and, it is hoped, would lead to a more facile, less expensive, and less threatening replacement. Surprisingly, recent neuroscience reports have verified that repeated seizures do, indeed, create new neurons and enhance gliosis, just as Meduna had believed.12 Revived interest in chemical induction of seizures, especially with the inhalant anesthetic flurothyl, offers a new challenge.13 As of today, there are no replacements for ECT on the horizon, as none of the alternatives has a therapeutic profile that matches the profile of induced grand mal seizures.
Clearly, the biggest challenge facing ECT, and therefore the Journal and the field, is the ongoing stigma associated with ECT.14 Such stigma keeps ECT from being fully accepted as part of the modern face of psychiatric medicine, thereby depriving many needy patients of its benefits. The Journal has been, and will continue to be, a major force in reducing stigma by educating readers and providing a peer-reviewed platform for the clinical and scientific evidence base for ECT.
With the support of our readership, specialty societies like The International Society for Electroconvulsive Therapy and Neurostimulation, and our editorial board, we look forward to many more years of JECT. However, mostly we are thankful for the opportunities to use our skills in treating patients with severe mental illness, as the greatest gratification comes from participating in the relief of suffering.
1. Meduna LJ. Die Konvulsionstherapie der Schizphrenie
. Halle, Germany: Carl Marhold; 1937: 121.
2. Meduna LJ. Autobiography of L. J Meduna Convuls Ther
. 1985; 1: 43–57, 121–138.
3. Fink M. Convulsive therapy (Editorial) Convuls Ther
. 1985; 1: 1–2.
4. McCall WV, Dunn A, Rosenquist PB, et al. Markedly suprathreshold right unilateral ECT versus minimally suprathreshold bilateral ECT: antidepressant and memory effects. JECT
. 2002; 18: 126–129.
5. McCall WV. Electroconvulsive therapy in Asia. J ECT
. 2010; 26: 1.
6. Tang YL, Jiang W, Ren YP, et al. Electroconvulsive therapy in China: clinical practice and research on efficacy. J ECT
. 2012; 28: 206–212.
7. Pompili M, Lester D, Dominici G, et al. Indications for electroconvulsive therapy in schizophrenia: a systematic review. Schizophr Res
. 2013; 146: 1–9.
8. Fink M. The intimate relationship between catatonia and convulsive therapy. J ECT
. 2010; 26: 243–245.
9. Petrides G, Tobias KG, Kellner CH, et al. Continuation and maintenance electroconvulsive therapy for mood disorders: review of the literature. Neuropsychobiology
. 2011; 64: 129–140.
10. Fink M, Kellner CH. A second quiet revolution: ambulatory ECT. Convuls Ther
. 1996; 12: 1–2.
11. Wachtel LE, Dhossche DM, Kellner CH. When is electroconvulsive therapy appropriate for children and adolescents? Med Hypotheses
. 2011; 76: 395–399.
12. Bolwig TG, Madsen TM. Electroconvulsive therapy in melancholia: the role of hippocampal neurogenesis. Acta Psychiatr Scand Suppl
. 2007; 130–135.
13. Small JG, Small IF, Sharpley P, et al. A double-blind comparative of flurothyl and ECT. Arch Gen Psychiatry
14. Fink M. Prejudice against ECT: competition with psychological philosophies. Convuls Ther
. 1997; 13: 253–265.