Film Review by Harry Karlinsky, MD, MSc, FRCPC, Clinical Professor, Department of Psychiatry, UBC;Coordinator of Medical Education, Professional Development, Richmond Mental Health Services
Film: 0.9 Ampere (Italy, 2008) Italian, with English subtitles
Director: Giotto Barbieri
Electroconvulsive therapy (ECT) was first administered over 70 years ago. The amount of electric charge required to induce a seizure in the original human subject was 0.9 ampere, a detail that generates the title of this recently-released Italian documentary, written and directed by Giotto Barbieri.
0.9 Ampere is predominantly focused on the history of ECT (referred to as electroshock throughout the film) within Italy, its birthplace. Barbieri employs the traditional attributes of the expository documentary – voiceover commentary, accompanied by archival film footage and dramatic re-enactments – to succinctly trace ECT from its origins in Italy up to the present day. Additional content emerges via opinions and reminiscences provided by a number of psychiatrists and patients as well as a former asylum attendant.
The opening scenes of the film are particularly effective. Archival footage of patients and their attending staff is projected on to the background of what is now an abandoned and dilapidated asylum. A disembodied and authoritative voice then begins to recite the Hippocratic Oath. Its words scroll across the screen, and include the following declaration:
“I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”
This immediately provides the moral undercurrent to the film. As facts concerning ECT are revealed, the viewer is continuously compelled to pass silent judgment on the ethical conduct of its adherents.
ECT’s introduction stems from the want of effective treatment alternatives. Well into the 20th century, there was little to offer the growing number of patients warehoused in large psychiatric facilities. Under the mistaken impression that individuals suffering intermittent seizures due to epilepsy were immune from schizophrenia, insulin and chemically-induced convulsions began to be used therapeutically. It was the Italian professor of psychiatry, Ugo Cerletti, who conceived the idea of using electricity as a more suitable way of inducing convulsions.
With this historical context in place, the film shifts to a unique first person narrative, courtesy of an unpublished memoir entitled An Eyewitness Account of the Discovery of Electroshock by professor Ferdinando Accorneo. Accorneo was an associate of Cerletti’s and his account describes how Lucio Bini, an assistant working under Cerletti’s supervision, constructed a rudimentary apparatus which produced an electric current that could be time- and voltageadjusted. After successfully provoking seizures in various animals by applying the electric current to the animals’ temples, Cerletti and Bini felt ready to test their machine on a human subject. It was their intent to demonstrate not only that they could provoke an epileptic seizure in a human using electric current, but that such seizures had therapeutic value.
An opportunity soon arose. An individual with schizophrenia had been found wandering in Rome’s railway station. After several weeks of observation in a psychiatric ward, he was deemed to have advanced disease and an extremely poor prognosis with conventional treatment.
The on-screen reenactment of the test is uncomfortable to watch. The unanaesthetized patient is rapidly shocked four times with increasing increments of current before a rhythmic seizure is finally induced.
For 48 seconds, the audience – like the investigators – anxiously waits for the patient to begin breathing. When he finally does, Cerletti immediately pronounces the procedure a success.
Remarkably, electroshock became an overnight worldwide sensation despite the obvious blinding enthusiasm of Cerletti and Bini, and their inattention to such fundamental considerations as informed consent and a host of safety and efficacy issues.
Not surprisingly, ECT’s reputation was soon undermined by its indiscriminate use and the resulting poor therapeutic outcomes. At times, it appears to have been applied punitively for ‘misbehaviour’ rather than as treatment for a specific psychiatric illness. The question of significant memory loss in some patients arose. A harrowing reminiscence from a patient speaks to the inconsiderate and terrifying lack of privacy which could accompany its administration.
“In the beginning they tried electroshock, a savage treatment. They gave me an injection, they took me to a room where I saw others being treated and these people jumped due to the charge, up to 25 centimeters.”
By the 1970s, ECT was largely disregarded and, in Italy at least, rarely prescribed.
Yet as the film shifts to present day Italy, ECT’s role in psychiatry appears to be undergoing a resurgence.
An Italian psychiatrist, who is a strong advocate for the use of ECT, cites such progress as the introduction of anesthetics, muscle relaxants and more sophisticated ECT machines. He is adamant that the abuses of the past cannot possibly reoccur. Indeed, intercut footage of modern day ECT administration is a remarkable contrast to earlier scenes in the film. Another psychiatrist, almost apologetic, cites ECT’s efficacy – indeed necessity – in treating illnesses such as depression. One soul-searching psychiatrist’s comments are especially moving:
“I met some patients who said they had benefited from electroshock, but I never met anyone who hadn’t associated their treatment with a sense of humiliation, grief and a sense of punishment.”
Yet, to some, the inarguable stigma still associated with the modern day version of ECT is as mystifying as its mechanism of action.1 Is it because, as one psychiatrist on camera muses, ECT literally “touches the human mind, confusing itself with the soul and the spirit?”
As the film ends, there is a closing and cryptic sound montage of symptoms common to depression, expressed by a range of suffering patients. It’s as though it is now up to the viewer as treatment provider to decide how he or she will intervene.
0.9 Ampere is a thoughtful and thought-provoking film that addresses a significant and controversial topic in the field of psychiatry. The film, however, is not without limitations. One irritant is the excessive number of ‘talking heads’. Although the film’s use of many commentators does allow for a composite and balanced narrative to emerge, a number of the perspectives are unnecessarily repetitive. Such a structure also leads to argument by anecdote. For the empiricists in the audience, a review of the significant empirical research that pertains to the benefits and risks of ECT would have been welcome, as would data addressing the experience of ECT in countries other than just Italy.
The real strength of 0.9 Ampere is its remarkable even-handedness. The controversy surrounding ECT is well-known. 2. It carries a horrific legacy of excessive and ill-defined use. Sensationalized punitive depictions in the media, particularly in films such as One Flew Over the Cuckoo’s Nest, have stigmatized ECT even further.3 And despite refinements to its administration since its inception, there remain legitimate concerns as to whether ECT results in irreversible memory loss in an uncertain proportion of patients.
Yet despite these significant, and seemingly overwhelming negative attributes, ECT remains the most effective treatment available for difficult-to-treat depression. This is not a trivial consideration, particularly given the degree of distress and the risk of suicide in this vulnerable population. ECT is also an effective treatment for other psychiatric illnesses, such as catatonia and prolonged or severe mania.2 Remarkably, all of the above considerations – both positive and negative – are represented in 0.9 Ampere.
The film correctly emphasizes the abuses associated with ECT’s hasty clinical introduction. Yet by the end of the film, the viewer is exposed to both advocates and opponents of ECT, including a patient who endured a seven-year battle with depression and who views his treatment with ECT as a lifesaving intervention.
Does the carefully considered administration of ECT contravene the Hippocratic Oath? Not from this psychiatrist’s perspective. Near the end of 0.9 Ampere, Accorneo’s translated text once again scrolls across the screen. Although written years ago, the words still resonate:
“There will come a day when this therapy will be considered childish and insufficient. Our descendants may think of it as a product of scientific eclipse. I’ll be glad to play a part in such a day, meaning something better will have been found. Because, like Ugo Cerletti had already said, our task is not that of defending this therapy but to alleviate the suffering of the ill.”
Amen to that.
- Wilkinson D, Daoud J. The Stigma and the Enigma of ECT. International Journal of Geriatric Psychiatry 13(1998):833-35.
- Persad E. Electroconvulsive Therapy: The Controversy and the Evidence. Canadian Journal of Psychiatry 46(2001):702-03.
- Domino G. Impact of the film One Flew Over the Cuckoo’s Nest on attitudes toward mental illness. Psychological Reports 53(1983):179-83.