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18 - The paradox of electroconvulsive therapy

Published online by Cambridge University Press:  05 December 2011

Angela Merkl
University Medicine
Malek Bajbouj
University Medicine
Narinder Kapur
University College London
Alvaro Pascual-Leone
Harvard Medical School
Vilayanur Ramachandran
University of California, San Diego
Jonathan Cole
University of Bournemouth
Sergio Della Sala
University of Edinburgh
Tom Manly
MRC Cognition and Brain Sciences Unit
Andrew Mayes
University of Manchester
Oliver Sacks
Columbia University Medical Center
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One of the most dramatic paradoxes in psychiatry is the mechanism of action and efficacy of electroconvulsive therapy (ECT), in which people are anaesthesized and given an electric shock sufficient to produce an epileptic seizure. Although known for over 70 years, many of the hypothesized underlying mechanisms still remain unresolved and under debate. The practice of ECT has evolved into a complex procedure and its application worldwide has had extensive clinical impact in the field of neuropsychiatric disorders. Within this background, we report on current neurophysiological models of ECT, its efficacy and further questions and directions of its use. The chapter reports how the paradox that an epileptic seizure has a beneficial effect on mood has influenced our understanding of brain pathologies.


There is arguably no treatment more negatively judged, no treatment more controversially discussed and no treatment more effective in psychiatry than electroconvulsive therapy (ECT). This treatment raises a number of different paradoxes: first, why is a highly effective treatment perceived so negatively at the same time? Second, why can this treatment work at the same time in conditions with increased dopaminergic neurotransmission (like psychosis) and in diseases with decreased dopaminergic neurotransmission (like Parkinson's disease)? Third, why does this therapy work at the same time as an intervention against depression and against mania? And fourth, the main paradox: why does a treatment based on the repetitive induction of generalized seizure activity not lead to considerable brain damage but – on the contrary – have beneficial effects?

The Paradoxical Brain , pp. 321 - 331
Publisher: Cambridge University Press
Print publication year: 2011

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