Shocking treatment

Domenico Pacitti talks to Giovanni Cassano

The Italian health ministry has decided to sanction the use of electroconvulsive shock therapy, ECT, on mental patients in state hospitals. That it has taken such a controversial step is largely due to one man, Giovanni Battista Cassano, professor of psychiatric medicine at the University of Pisa - better known as private consultant to Italy's rich and famous.

ECT involves sending an electric current through the brain and was once commonly used on the mentally ill, some would argue, with devastatingly harmful effects. Books like The Bell Jar, by the poet Sylvia Plath, who subsequently committed suicide, gave the practice a bad name and its use declined.

Cassano, however, is at the forefront of a new wave of psychiatrists, advocates of the use of drugs and physical treatments such as ECT to tackle debilitating illnesses of the mind. For these psychiatrists the more we learn about the chemical balance of the brain, the more obvious such treatments appear. This is in stark contrast to psychiatrists inspired by analysts such as Freud, who suggest that mental illness can be traced back to childhood trauma and cured by analysis.

A soft-spoken man with an aversion to interviews, Cassano is nevertheless prepared to oblige when it is a question of persuading people as to the virtues of his psychiatry. Italian departments of psychiatric medicine, Cassano complains, have a history of stubborn indifference to scientific progress in understanding the mind. No sooner had psychiatry come into existence in Italy in the early 1960s, he recalls, than it was crushed and held in check by the universities, which transformed it into a mixture of sociology, psychology and politics.

"The result was the dangerous idea that mental illness does not really exist at all, that it is simply the expression of contradictions within a diseased society, and that by curing society the problem will disappear. From this follows the argument that it is a scandal that society wants to fill patients with drugs or lock them up in psychiatric hospitals," he explains.

In Italy, says Cassano, depressives are still told they are not really ill after all - that they are simply in the wrong job, have an unhappy marriage or some sort of mother complex, or suffered violence as a child. "This has led to countless tragedies. But what is even worse is that it has also produced an impoverished form of psychiatry, one not based on the progress of research. These other forms of psychiatry," he says, "are built on explanatory models that do not search for proofs."

Predictably, Cassano's latest proposal - for the use of ECT to be extended to children and the elderly - has met with implacable opposition. "Why is it that we commonly use an electric current in the case of the heart but not the brain?" he counters. "If we accept surgical laser treatment in cases of epilepsy, why not for mental disorders? ECT consists of a small electrical discharge lasting five or ten minutes. This inspires a convulsive crisis together with all its accompanying therapeutic benefits and is carried out under anaesthetic. There is no risk: 40 minutes later the patient can go home. Possible after-effects - a slight headache or a vague feeling of amnesia - soon pass."

Cassano finds widespread neglect of ECT alarming: "There are many places in Europe where the very existence of ECT seems to have been entirely forgotten. Where it is used, it tends to be prescribed only for classic cases (of schizophrenia and depression) - about 20 per cent, with the remaining 80 per cent condemned to terrible suffering with the real risk of suicide. Despite their ideological prejudices, Italy's commissions and bioethics committees have always recognised the efficacy of ECT. The problem is adverse popular reaction."

The public has been misled too, according to Cassano, by journalists' irresponsible criticisms of psychotropic drugs. He argues that such drugs are as effective in treating mental disorders as antibiotics are in treating infectious illnesses. Psychiatrists now have distinctive drugs that will, for example, eliminate compulsive nailbiting, he says.

In his bestselling book, And Deliver Us from this Dark Illness: Depression and How to Get Rid of it, stars like the film director Federico Fellini pay witness to Cassano's methods. Fellini tells of a friend who suffered terrible depression, turning in vain to psychoanalysis and acupuncture before enlisting with a psychiatrist who diagnosed a chemical imbalance in the brain and prescribed drugs. Six months later he was well and has remained so. "What really struck me was the sheer efficacy of the treatment and the speed with which it took effect where previously nothing else had succeeded. But in a way there is really nothing to be surprised about. Aren't we all in the end no more than chemistry?" says Fellini.

Cassano is slowly getting his message about the brain across to a sceptical public. His book is a bestseller. "I believe that the progress of the neurosciences will help us to understand this instrument which so characterises our humanity," he predicts. "We are moving towards a new, neuroscientific form of humanism."

Note: This interview first appeared in The Times Higher Education Supplement on September 25 1998.