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Toronto Star

Robert Pirsig has a bone to pick with philosophers. As his era-defining memoir Zen and the Art of Motorcycle Maintenance levitated up the bestseller lists in 1974, all he heard from them was grumbling.

This story of a father-son motorcycle trip across America was just a skeleton of a philosophy, they said. What exactly was this “metaphysics of quality” he kept talking about? And who was he to tell them about it?

Seventeen years later Pirsig gave his answer and it came in the form of a 500-page novel, Lila: An Inquiry into Morals. Now, at last, the thinkers of the world had something to tinker with. Their response? “Silence. They have just given me zero support and great hostility,” Pirsig says on the eve of the novel’s reissue in Britain.

“It’s just they don’t say anything.” Now, Pirsig believes that he has one last shot at explaining his philosophy to the public, and if it means coming out of seclusion, so be it.

Sitting in a hotel suite overlooking the Charles River in Boston, a meditation mat at his feet, his wife Wendy at his side, New England’s second-most reclusive novelist does not appear to have sweated much over his celebrity.

At the age of 77, Pirsig is a white-haired, bandy-legged old coot. Years at sea and on the road have given his face a sun-blasted quality. His voice is strong and clear, but when he takes out a pen and paper to demonstrate a concept, his hands shake.

“As I see these two books,” Pirsig says, drawing an oval on a notepad, “there is a Zen circle. You start here with Zen,” he says, marking an X, “and then you go here to enlightenment, that’s what’s called 180 Zen.

“Then you go back to where you started from — that’s 360 Zen — and the world is exactly as it was when you left it.” Pirsig sits back and lets that sink in, then adds: “Well, I felt that Zen and the Art of Motorcycle Maintenance was the journey out, and Lila was this trip back.”

This might explain why Lila was not as universally adored as its predecessor. Zen was a serious feelgood book, a modern day “Thoreau,” written by a man who had been through the wringer, but emerged having identified a better way to live.

It was also as picturesque a tour of western America as one could find between two covers. Lila is an almost noir-like novel about a writer who falls in love with a former prostitute. As they float down a brooding river toward New York City, the writer — whose name is Phaedrus, the name Pirsig gave his insane alter ego in Zen — muses on her nature and on the metaphysics of quality (MOQ).

The novel is structured like a river with many locks — each stage a new level of Pirsig’s philosophy. The mental work it takes to measure these ideas explains why Lila has sold 600,000 copies, hardly a failure, but nowhere near the 4 to 6 million of Zen.

There are two types of Quality, as Pirsig sees it, Dynamic and Static.

“Without dynamic quality an organism cannot grow,” he explained in an essay. “But without static quality an organism cannot last.”

While it became a cultural cliché to say that we have moved beyond good and evil, Pirsig believes just the opposite — and he believes that the MOQ can be a useful tool in bringing order to a chaotic world.

“You know the structure of the MOQ,” he says, bringing out the pad again. “Static quality can be divided into intellectual, social, biological and inorganic realms. Any attempt by a lower order to overcome a higher order represents evil. So those forces which prohibit intellectual freedom are evil according to the MOQ.”

Pirsig’s insistence on the existence of evil has a painful personal note. In November 1979, his son Chris was stabbed to death in a robbery outside the San Francisco Zen Center. He was two weeks shy of his 23rd birthday. Pirsig was living on a houseboat in England at the time. He came home for the funeral, and wrote a moving epilogue about his son — the child at the heart of Zen — and it has been printed in every edition since.

This loss can be felt in Lila and might explain why it took Pirsig almost two decades to write it. “One reviewer said that the shadow of Pirsig’s son’s death seems to hang over this entire book,” Pirsig says, looking bewildered. “I had no idea that was true at the time, but now I see in retrospect. I was very gloomy.”

Born in 1928 in Minneapolis, Minn., Pirsig was a gifted child, whose IQ was measured at 170 when he was 9.

His father was a law professor who studied in England, so Pirsig learned to read and write in England. He returned to Minnesota and entered grade school so young that he was picked on. He entered university at the age of 15, flunked out, then served in the Korean War, coming home with an interest in philosophy. He eventually finished his degree and went on to get a graduate degree in oriental philosophy from Benares Hindu University in India. And here’s where the drifting begins. Pirsig returned to the U.S. in the 1950s and began to study journalism.

To make a living he began technical writing and doing some editing at a university newspaper where he met his first wife. For 20 years they would move around, Pirsig doing odd jobs, raising their two kids.

Without knowing it, he had begun a kind of internal philosophical quest, but the heat of his intellectual searching pushed him over the edge.

In 1960, he began the first of a series of hospital treatments for mental illness. Pirsig’s father obtained a court order to commit him to a hospital where he received electro-convulsive shock therapy. It seemed to work, but Pirsig maintains that he was not insane. “I never thought I was crazy.”

Pirsig took to writing as a life raft. In 1965 he bought a motorcycle, and in 1967 began what he thought would just be a few essays on motorcycle maintenance but the book grew into a fully fledged project.

In 1968 he wrote to 122 publishers offering sample chapters. Only one wrote back. This was enough encouragement for him. He rented a room at a flophouse and would go there from midnight until 6 a.m. to write, then he would go to work.

“When I talk about compulsion in that book,” Pirsig says, “that’s what I mean. I was compelled to write that book.”

Pirsig admits that this regimen had as much to do with his ambitions as with “problems at home,” as he calls them. When the book finally became a bestseller, Pirsig felt he needed to get away. He and his wife bought a yacht and planned to travel the world. Instead they divorced.

Pirsig’s response was to keep moving, and it was in this fashion that he met his second wife, Wendy Kimball, and they started a life of travel together.

That same year Pirsig’s son was murdered. He has moved forward. He and Wendy had a daughter, Nell, in 1980.

The success of Zen has afforded Pirsig and his wife “a very nice life,” he admits, and he doesn’t want to appear ungrateful for this gift. But he says that it is not for his sake that he wants Lila to be read. “I think this philosophy could address a lot of the problems we have in the world today,” he says, leaning forward. “Just so long as people know about it.”

3 Responses »

Psychiatric Services
August 2006
David Oaks

Letter to the Editor

To the Editor: The essay “Evolution of the Antipsychiatry Movement Into Mental Health Consumerism” (1) in the June issue attempts to impose false labels and a skewed history on activists for human rights in mental health, including the nonprofit organization that I direct, MindFreedom International.

The origin of our social change movement cannot be traced to a few antipsychiatry theoreticians and campus intellectuals. Many of us actually credit the civil rights movement and our own experiences of psychiatric abuse as the original sources of our inspiration. We can and do organize on our own. The authors use the undefined term “antipsychiatry” 34 times in their essay, applying that label to many of us who do not describe ourselves or our groups in that way. There are, for example, compassionate, practicing psychiatrists who play an active role in MindFreedom.

The authors claim that psychiatry has addressed our key grievances “to some degree.” Even if some psychiatrists have reduced the dosages of neuroleptics prescribed, overall neuroleptic prescriptions are skyrocketing. Neuroleptic prescriptions for youths have shot up more than fivefold in less than a decade (2). From our perspective, both electroshock and psychosurgery have experienced a resurgence in popularity within psychiatry and the mainstream press. Many states have greatly expanded commitment criteria, and most states have implemented involuntary outpatient commitment. Courts now order some MindFreedom members who live peacefully in their own homes to take neuroleptics involuntarily.

The authors appear to observe us from afar through a flawed lens, which may explain their factual errors. The well-respected activist Leonard Roy Frank is not the founder of Support Coalition International. Support Coalition International and MindFreedom International are not two separate organizations—our name change occurred in 2005. The essay aligns the history of our movement with the “radical left” to a great extent, ignoring decades of outstanding work by conservatives and libertarians in fighting psychiatric abuse. Today, conservatives lead the grassroots opposition to mental health screening in schools.

Consider the bias inherent in this sentence: “Psychiatry continues to fight antipsychiatry disinformation on the use of involuntary commitment, electroconvulsive therapy, stimulants and antidepressants among children, and neuroleptics among adults.” The authors appear to transmogrify into “antipsychiatry disinformation” all public education efforts that are inconsistent with the American Psychiatric Association’s official position.

This is my 30th year working for human rights and alternatives in the mental health system. We have made mistakes. We are not perfect. But I am very proud of our social change movement, which includes concerned family members, advocates, attorneys, mental health professionals, and interested members of the public. The authors claim that the psychiatric profession finds it difficult to communicate with us. The fact is that the American Psychiatric Association has generally refused our repeated invitations for conversation.

Somehow, some people who have experienced serious human rights violations in the mental health system—including unscientific labeling, forced drugging, solitary confinement, restraints, involuntary commitment, electroshock, and more—have reached deep within the human spirit and found the power to speak out and unite nonviolently (3). Please reply with dialogue, not distortion.

David Oaks

Footnotes

Mr. Oaks is director of MindFreedom International, Eugene, Oregon.

References

1. Rissmiller D, Rissmiller J: Evolution of the Antipsychiatry Movement Into Mental Health Consumerism. Psychiatric Services 57:863–866,2006[Abstract/Free Full Text]

2. Carey B: Use of antipsychotics by the young rose fivefold. New York Times, June 6, 2006, p A18

3. Mahler J, Unzicker R, Foner J, et al: Taking issue with taking issue: “psychiatric survivors” reconsidered. Psychiatric Services 48:601,1997[Medline]

One Response »

Psychiatric Services
June 2006
Rissmiller DJ, Rissmiller JH.

Department of Psychiatry, School of Osteopathic Medicine, University of Medicine and Dentistry of New Jersey, Cherry Hill, New Jersey 08002, USA. rissmidj@umdnj.edu

This essay reviews the history and evolution of the antipsychiatry movement. Radical antipsychiatry over several decades has changed from an antiestablishment campus-based movement to a patient-based consumerist movement. The antecedents of the movement are traced to a crisis in self-conception between biological and psychoanalytic psychiatry occurring during a decade characterized by other radical movements. It was promoted through the efforts of its four seminal thinkers: Michel Foucault in France, R. D. Laing in Great Britain, Thomas Szasz in the United States, and Franco Basaglia in Italy. They championed the concept that personal reality and freedom were independent of any definition of normalcy that organized psychiatry tried to impose. The original antipsychiatry movement made major contributions but also had significant weaknesses that ultimately undermined it. Today, antipsychiatry adherents have a broader base and no longer focus on dismantling organized psychiatry but look to promote radical consumerist reform.

Radical antipsychiatry in the past four decades has changed from an influential international movement dominated by intellectual psychiatrists to an ex-patient consumerist coalition fighting against pharmacological treatment, coercive hospitalizations, and other authoritarian psychiatric practices. This Open Forum article explores the history of the antipsychiatry movement and attempts to define how the movement has evolved.

The antecedents of the antipsychiatry movement can be traced to the early 1950s, when deep divisions were developing between biological and psychoanalytic psychiatrists. Psychoanalytic psychiatry, which had exerted unchallenged control of the profession for decades, endorsed treatment that was subjective and dynamic and that involved protracted psychotherapy. It was being challenged by biological psychiatry, which claimed that psychoanalysis was unscientific, costly, and ineffective.

Conversely, an outcry was mounting against psychiatry’s practice of compulsory admission of mental patients to state institutions, where they were coerced into taking high doses of neuroleptic drugs and undergoing convulsive and psychosurgical procedures. The antipsychiatry movement arose as a group of scholarly psychoanalysts and sociologists shaped an organized opposition to what were perceived as biological psychiatry’s abuses in the name of science. This protest was joined by a 1960s worldwide counterculture that was already rebelling against all forms of political, sexual, and racial injustice.

The term “antipsychiatry” was first coined in 1967 by the South African psychoanalyst David Cooper (1) well after the movement was already under way. It was internationally promoted through the efforts of its four seminal thinkers, Michel Foucault in France, R. D. Laing in Great Britain, Thomas Szasz in the United States, and Franco Basaglia in Italy. All four championed the concept that personal reality was independent from any hegemonic definition of normalcy imposed by organized psychiatry.

In Madness and Civilization: A History of Insanity in the Age of Reason (2), Foucault traced the social context of mental illness and noted that external economic and cultural interests have always defined it. During the Renaissance, madmen were characterized as fools who figured prominently in the writings of Shakespeare and Cervantes. Beginning in the 17th century, madmen were confined and locked away, justified by the state’s “imperative of labor.” The poor, criminals, and the insane were all isolated as a condemnation of anyone unwilling or unable to compete for gainful employment.

In the early 1800s madmen were separated from prisoners and beggars and forced into hospitals run by medical doctors. Madness was reinvented as a disease, and inhumane treatment was begun. It consisted of classification, custody, and coercion by a psychiatric authority, which operated as an arm of the state, ridding it of unwanted individuals. Psychiatry became “a jurisdiction without appeal … between the police and the courts … a third order of repression” (2).

While Foucault was writing in France in the early 1960s, R. D. Laing, in England, joined other authors of the period who were describing the social origins of behavior. Fanon (3) demonstrated how blacks often would fulfill racist stereotypes; Lessing (4), how women commonly conformed to society’s expectation of passivity and femininity; and Goffman (5), how patients, stripped of normal social responsibilities, developed institutional behavior. Laing promoted the idea that severe mental illness, similarly, had a social causality.

In The Divided Self: An Existential Study in Sanity and Madness (6), a best-seller in colleges across the United States and Great Britain, Laing noted that a patient with psychosis could be viewed in one of two ways: “One may see his behaviour as ’signs’ of a ‘disease’ [or] one may see his behaviour as expressive of his existence.” For Laing, paranoid delusions were not signs of an illness but an understandable reaction to an inescapable and persecutory social order. If Laing was correct, and schizophrenia were not a disease but rather an existential fight for personal freedom, then logic allows that it could be cured through social remediation. Laing, through the Philadelphia Association founded with Cooper in 1965, set up over 20 therapeutic communities throughout England where staff and patients assumed equal status and any medication used was voluntary. A recounting of a seven-week stay in one of these communities was chronicled in the 1972 film Asylum (7).

Other psychoanalysts were also exploring the social context surrounding mental illness. Thomas Szasz, having recently been appointed to the faculty of the State University of New York, in 1957 wrote his most influential paper, “The Myth of Mental Illness.” Over the next three years, it was rejected by at least six psychiatric journals, including the American Journal of Psychiatry, until it was finally accepted for publication in the American Psychologist (8) in 1960. As the antipsychiatry movement gained momentum, this article became the core of his best-selling book (9) by the same name and the slogan around which many in the movement rallied.

Because schizophrenia demonstrated no discernible brain lesion, Szasz believed its classification as a disease was a fiction perpetrated by organized psychiatry to gain power. The state, searching for a way to exclude nonconformists and dissidents, legitimized psychiatry’s coercive practices. Equating the resulting psychiatry-government collusion with the Spanish Inquisition, Szasz (10) called it “the single most destructive force that has affected American society within the last 50 years.” Such a conspiratorial link between the government and psychiatry was an appealing concept to such counterculture icons as Timothy Leary (11), who, preceding his termination from Harvard, wrote to Szasz in 1961 that “the Myth of Mental Illness is the most important book in the history of psychiatry … perhaps … the most important book published in the twentieth century.”

Citing the principle of “separation of church and state,” Szasz argued for a similarly clear division between “psychiatry and state.” Otherwise, the state would ultimately corrupt psychiatry for its own purposes, as occurred in Nazi Germany and the Soviet Union. As a preventive measure, Szasz helped launch the Libertarian Party in 1971, and its platform called for a halt to government-psychiatry mind control operations.

Others involved in the antipsychiatry movement were even more condemning. In 1969, Scientology’s charismatic founder, L. Ron Hubbard (12), wrote, “There is not one institutional psychiatrist alive who … could not be arraigned and convicted of extortion, mayhem and murder.” Hubbard and Szasz cofounded the still powerful Citizens Commission on Human Rights, which encouraged the arrest and incarceration of psychiatrists for their crimes against humanity.

Alliances were formed with other contemporary activist groups. In May 1970, hundreds in the antipsychiatry movement joined gay activists in forming a human chain barring psychiatrists from entering the American Psychiatric Association’s 124th annual meeting. During a similar disruption the following year, gay activist Frank Kameny grabbed the podium and declared war on psychiatry for its DSM classification of homosexuality as a psychiatric disorder. Wanting the protests to stop, the American Psychiatric Association formed a task force, which, by a vote of 58 percent, officially deleted homosexuality as a mental illness in 1973.

Psychiatry’s purported abuse of patients was popularized in Kesey’s 1962 novel, One Flew Over the Cuckoo’s Nest (13), which contributed to reforms in mental health public policy. David Bazelon, a jurist of the powerful United States Court of Appeals for the District of Columbia, deplored authoritarian psychiatric practices. In 1966, he established in Lake v. Cameron that all psychiatric treatment must be carried out in the least restrictive setting possible. In the early 1970s the antipsychiatry attorney Bruce Ennis created the “Mental Health Bar.” Its goal was to completely abolish involuntary commitments or prevent them by making them too arduous to secure. These and other initiatives heralded the release of hundreds of thousands of patients from state hospitals.

Deinstitutionalization in Europe occurred over a decade later. The Italian psychiatrist Franco Basaglia, its leading proponent, while working at the asylum in Trieste, came to believe that mental illness was not a disease but rather an expression of human needs. Over the next decade he personally mobilized an antipsychiatry movement in Italy that culminated in the 1978 Italian National Reform Bill that banned all asylums and compulsory admissions and established community hospital psychiatric units, which were restricted to 15 beds. This reorganization of mental health services in Italy resulted in the “democratic psychiatry movement,” wherein hundreds of psychiatric institutions were closed throughout Europe, New Zealand, and Australia, including many in Ireland and Finland, where the highest number of asylum beds were located.

Despite such notable successes and after nearly two decades of prominence, the international antipsychiatry movement began to dramatically diminish in the early 1980s, both in visibility and impact. Organized psychiatry, by addressing some of the movement’s key grievances, was able to defuse it to some degree. The adoption of the biopsychosocial model narrowed the gap between analytic and biological practitioners. Neurotransmitter discoveries and schizophrenia twin registries offered support that schizophrenia was at least partially biologically based. As comparison studies failed to support efficacy and as tardive dyskinesia became more apparent, psychiatrists markedly reduced dosages of neuroleptics prescribed. Electroconvulsive therapy and psychosurgery became marginalized as treatments and compulsory commitments came under close judicial scrutiny.

But by far the most important determinant of the movement’s demise was its loss of broad-based support. To a great extent, the antipsychiatry movement was derived from its close relationship to other progressive leftist coalitions that, by association and overlapping membership, supported the movement. With the decline of other student, feminist, gay, and black coalitions, the antipsychiatry movement could no longer rely on counterculture support. The radical left, with its utopian vision, was being replaced, worldwide, by an emerging conservative political landscape. Since the antipsychiatry movement’s raison d’être was inherently antiestablishment, it, like the other militant movements of the day, was at risk of becoming increasingly irrelevant.

The mental health consumerist movement offered a struggling antipsychiatry coalition the mainstream collaborator it needed for rejuvenation. Since its inception in the early 1900s by former patient Clifford Beers and through organizations such as the Anti-Insane Asylum Society and the National Committee on Mental Hygiene, the consumerist movement had achieved significant international mental health reforms. Its tactics of forming political alliances and lobbying instead of confrontation appealed to conservative politicians who were weary of civil disobedience. The movement’s vision of patients helping one another addressed a growing concern over the cost of mental health treatment.

But consumerists considered the antipsychiatry movement as “largely an intellectual exercise of academics” (14). Consumerists wanted to keep their movement in the hands of prior patients. They had no interest in being led by psychiatrist intellectuals who had done little during the antipsychiatry movement to “reach out to struggling ex-patients” (14). As a result, as the antipsychiatry movement evolved from being campus based to being patient based, its founders were marginalized as bystanders to a movement they had begun. Appelbaum (15) in 1994 observed, “Now, more than three decades later, … Szasz, Laing, and their colleagues are no longer fixtures … and … most college and graduate students have never heard of them or their argument that mental illness is a socially derived myth.”

With over a half million deinstitutionalized patients to draw from, there was a potential for the new antipsychiatry consumerist coalition to be extensive. Many former patients, angry about the coercive treatment they had received and looking for support and identity, would be ideal carriers of the antipsychiatry message. They joined local consumerist radical groups, and new ex-patient leaders arose. Leonard Frank, founder of Support Coalition International, after undergoing over 80 insulin comas and electroshock treatments, became electroshock therapy’s new outspoken critic. Ex-patient Judi Chamberlin, cofounder of the Mental Patients Liberation Front, mobilized the movement with On Our Own: Patient-Controlled Alternatives to the Mental Health System (16).

The formative years of this movement in the United States saw “survivors” promoting their antipsychiatry, self-determination message through small, disconnected groups, including the Insane Liberation Front, the Mental Patients’ Liberation project, the Mental Patient’s Liberation Front, and the Network Against Psychiatric Assault. The fragmented networks communicated through their annual Conference on Human Rights and Psychiatric Oppression (held from 1973 to 1985), through the ex-patient-run Madness Network News (from 1972 to 1986), and through the annual “Alternatives” conference funded by the National Institute of Mental Health for mental health consumers (from 1985 to the present). Similar groups arose throughout Canada and, later, Europe, where the name “survivor” brought more public criticism because of its association with the holocaust. The movement searched for a unifying medium through which to integrate.

The growing Internet “global community” offered just such a medium. Numerous radical antipsychiatry Web sites, such as Support Coalition International, Citizens Commission on Human Rights, the Antipsychiatry Coalition, and MindFreedom International, linked antipsychiatry movements in over 30 countries. Their capacity to instantaneously reach millions meant that “despite its modest head count, the consumer/survivor movement … exerted a significant sociopolitical influence on the mental health care system” (17). By avoiding the antipsychiatry movement flaw of being radicalized without being politicized, radical consumerists continued to maintain informal ties with more conservative consumerist organizations such as the National Alliance for the Mentally Ill in the United States and the Mental Health Foundation in England. Mainstream consumerist groups benefited from such unofficial relationships through increased impact in grassroots lobbying and legislative advocacy efforts.

Such joint efforts exerted a palpable effect. In 1986 the survivor-antipsychiatry-consumerist triumvirate succeeded in getting Congress to mandate independent protection and advocacy programs for people with mental illness in all 50 states. The mission to investigate allegations of patient abuse came with a mandate that at least 60 percent of the membership of the governing advocacy councils be ex-psychiatric patients or their families.

In 2000 the National Council on Disability, an independent federal agency charged with making recommendations to the President and Congress, heard strong antipsychiatry testimony from survivors “describing how people with psychiatric disabilities have been beaten, shocked, isolated, incarcerated, restricted, raped, deprived of food and bathroom privileges, and physically and psychologically abused in institutions.” The council concluded that “People with psychiatric disabilities are routinely deprived of their rights in a way no other disability group has been [and] … the manner in which American society treats people with psychiatric disabilities constitutes a national emergency and a national disgrace” (18).

Radical consumerists were instrumental in getting the United Nations General Assembly to adopt its 1991 Principles for the Protection of Persons With Mental Illness and the Improvement of Mental Health Care. In 2002 the Scientology-funded Commission on Human Rights successfully petitioned the Secretary-General of the United Nations to report annually to the General Assembly on the progress of human rights, including as it relates to persons with mental illness.

Organized psychiatry has found it difficult to have a constructive dialogue with the evolving radical consumerist movement. Consumerist groups are viewed as extremist, having little scientific foundation and no defined leadership. The profession sees them as continually trying to restrict “the work of psychiatrists and care for the seriously mentally ill” (17). Psychiatry continues to fight antipsychiatry disinformation on the use of involuntary commitment, electroconvulsive therapy, stimulants and antidepressants among children, and neuroleptics among adults.

Conversely, radical consumerists remain disinclined to soften their antipsychiatry stance toward a territorial and biologically oriented profession that, in their view, has profited from patients it neglected and abused. Seeing themselves as “the last minority” (17), unfairly stigmatized by psudoscientific classification, and denied self-determination, they will undoubtedly continue to play an assertive role in the delivery of mental health services worldwide.

Footnotes

Dr. Rissmiller is affiliated with the Department of Psychiatry, School of Osteopathic Medicine, University of Medicine and Dentistry of New Jersey, Cherry Hill, New Jersey 08002 (e-mail, rissmidj@umdnj.edu

). Mr. Rissmiller is attending Harvard College in Cambridge, Massachusetts.

References

1. Cooper D: Psychiatry and Anti-Psychiatry. London, Tavistock Publications, 1967
2. Foucault M: Madness and Civilization: A History of Insanity in the Age of Reason. New York, Random House, 1965
3. Fanon F: The Wretched of the Earth. New York, Grove Press, 1963
4. Lessing DM: The Golden Notebook. New York, Simon and Schuster, 1962
5. Goffman E: Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York, Anchor Books, 1961
6. Laing RD: The Divided Self: An Existential Study in Sanity and Madness. Harmondsworth, England, Penguin, 1960
7. Robinson P (director): Asylum. Kino Video, 1972
8. Szasz TS: The myth of mental illness. American Psychologist 15:113–118,1960
9. Szasz TS: The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York, Hoeber-Harper, 1961
10. Szasz TS: The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement. New York, Harper and Row, 1970
11. Leary T: A letter from Timothy Leary, Ph.D., July 17, 1961. Available at www.szasz.com/leary.html
12. Hubbard LR: Crime and psychiatry, June 23, 1969. Available at http://freedom. lronhubbard.org/page080.htm
13. Kesey K: One Flew Over the Cuckoo’s Nest. New York, Viking Press, 1962
14. Chamberlin J: The ex-patients’ movement: where we’ve been and where we’re going. Journal of Mind and Behavior 11:323–336,1990
15. Appelbaum PS: Almost a Revolution: Mental Health Law and the Limits of Change. New York, Oxford University Press, 1994
16. Chamberlin J: On Our Own: Patient-Controlled Alternatives to the Mental Health System. New York, Hawthorne, 1978
17. Satel SL, Redding RE: Sociopolitical trends in mental health care: the consumer/survivor movement and multiculturalism, in Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th ed. Edited by Sadock BJ, Sadock VA. Philadelphia, Pa, Lippincott Williams and Wilkins, 2005
18. Bristo M: From Privileges to Rights: People Labeled With Psychiatric Disabilities Speak for Themselves. Washington, DC, National Council on Disability, Jan 20, 2000

2 Responses »

Cambridge Evening News
August 11, 2006

INFORMATION given to some mental patients are before they undergo electric shock treatment has been criticised.

Supporters of Electric Convulsive Therapy (ECT) say the treatment is a “last resort” for patients who are severely depressed and it can help stop them committing suicide.

ECT “resets” the brain with an electric pulse.

Opponents say there is little evidence it works. They claim it can have severe side-effects and is a form of torture.

Cambridgeshire and Peterborough Mental Health Trust has revealed it has conducted 2,600 ECT treatments since 2002.

On average 50-55 people a year are given ECT by the trust in a course of six to 12 treatments. It said 26 people were done in Cambridge during the past year.

Mental health charity MIND, which found information about side-effects is often inadequate, said patients should be given a choice of receiving the treatment.

Paul Farmer, MIND chief executive, said: “Some people do find ECT helpful, but 84 per of respondents to our last survey on ECT had experienced side- effects.

“Our survey found nearly twothirds of people given ECT were not provided with information about its side-effects beforehand.

“Nearly half said they would not agree to have the treatment again. The most common longterm side-effects are memory loss, difficulty concentrating, and problems remembering new information, while headaches and dizziness are common in the short term.

“ECT is an invasive and irreversible procedure. It should only ever be used as a last resort for cases of extreme depression, when every other treatment has been tried.

“Even then, it should certainly never be given without fullyinformed consent, except in an emergency.”

But the mental health trust said the number of ECT treatments was small compared to the 4,000 in-patient admissions a year.

Dr Fiona Blake, consultant psychiatrist, said all patients were fully informed before undergoing treatment.

She said: “ECT is an effective treatment for depression, but our consultants take great care to ensure it is only offered in cases where it is likely to be clinically effective.

“The treatment is always discussed and explained, and we have good-quality information leaflets to support clinical consultations and a robust consent procedure.

“ECT treatment is a ‘last resort’ for depression when the patient has symptoms that indicate a likely good response and when other strategies have failed.”

She said it was sometimes the preferred treatment, for example for someone intensely suicidal, or too depressed to eat or drink.

She said the trust had been approved by the Royal College of Psychiatrists to administer ECT and commended by it for its consent procedures.

6 Responses »

Professor, wife sue online pharmaceuticals company

August 10, 2006
By Mandy Kovach
Stanford Daily

No Responses »

Friday, 11 August 2006, 11:46 am
Press Release: Ministry of Health 11 August 2006

Annual report on ECT statistics released

A total of 307 people with a serious mental illness received electroconvulsive therapy (ECT) last year, an annual report on the treatment released today by the Ministry of Health shows.

The figure is equivalent to 7.5 people per 100,000 receiving ECT, which is significantly lower than the level recorded in many countries.

About 80 per cent of ECT was given with informed consent, though the actual number is hard to gauge because of coding inconsistencies. Nearly four out of five patients were aged over 40 and about two out of three were women.

ECT has been proven internationally to be an effective treatment for severe depression, with over 8 out of 10 patients responding well to it. It is used when antidepressant medication, psychotherapy or both have been ineffective, when the side effects from the use of medication make ECT the most appropriate treatment option, or other treatments would be too slow.

It is also considered the safest treatment option in cases where depression is accompanied by a physical illness or pregnancy, which renders the use of the usually preferred antidepressants dangerous to the patient or to a developing foetus.

The annual report covering the period from 1 July 2004 to 30 June 2005 also showed that: - 69 per cent of patients given ECT were female

- 85 per cent of patients were European, 6 per cent were Maori, 7 per cent were Pacific Islanders and 2 per cent were Asians

- 79 per cent of patients given ECT were over 40 years old

- 78 per cent of treatments were given with the patient’s consent

A total of 305 people or 7.5 people per 100,000 received the treatment from 1 July 2003 to 30 June 2004.

“ECT has been demonstrated to be a relatively safe and effective treatment, which may actually be lifesaving as serious mental illness is associated with significant mortality,” said Dr Jeremy Skipworth, Deputy Director of Mental Health.

Although the treatment can be given under compulsion under Section 60 of the Mental Health Act, this requires a second opinion from a suitably qualified psychiatrist.

“Some patients are seriously unwell and have no capacity to make an informed decision even though ECT is the best treatment option available,” Dr Skipworth said. “The Mental Health Act provides for this situation.”

“District Health Boards have assured the Ministry of Health that the Mental Health Act was not used to enforce treatment in any case where the patient retained decision making capacity,” he added.

Dr Skipworth said the marked regional variations in the number of ECT treatments could reflect differences amongst boards’ populations.

For example, DHBs with psychogeriatric services may use more ECT than those without these facilities. ECT is more often the treatment of choice for the elderly as prescribing medications is associated with more side effects in this population.

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J Forensic Sci 2000
Nov;45(6):1197-202

Scarano VR, Felthous AR, Early TS

Forensic Psychiatry Services, Baylor College of Medicine, Houston, TX 77030, USA.

The Texas Legislature in 1993 mandated a quarterly reporting requirement for hospitals and physicians performing electroconvulsive therapy (ECT) in the state (United States Government hospitals were excluded). The Texas Department of Mental Health and Mental Retardation (TDMHMR) was designated as the agency responsible for collecting and maintaining the data. This paper reviews the ECT data from 16 quarterly reports (09/01/93 through 08/31/97). The reports contained data on 41,660 ECT treatments in approximately 5971 patients. The results of this study support the proposition that ECT is an extremely safe and effective treatment for those individuals suffering from a serious mental illness. In Texas, ethnic groups other than non-Hispanic Anglo-Americans appear to be underserved in regards to ECT. Those patients without appropriate insurance or adequate personal finds are also underserved as a result of the few county and state hospitals performing ECT and the relatively small number of patients treated with ECT at those hospitals. Recommendations are suggested to improve the quality of the database and in informing the public as to the safety and efficacy of this valuable treatment modality. What, at first, was seen as an unwarranted legislative foray into the practice of medicine, has, in the end, become a source of valuable data supporting the use of ECT as an important treatment modality.

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J Clin Psychiatry
1995 Sep;56(9):390-4

Clinical Neuroscience Branch, National Institute of Mental Health, Bethesda, Md 20892, USA.

BACKGROUND: Recent reports have called into question the safety and effectiveness of electroconvulsive therapy (ECT).

METHOD: To investigate these claims, the effects of ECT on clinical outcomes were examined as part of a retrospective, naturalistic study of 192 geriatric patients consecutively admitted between 1980 and 1987 to a large midwestern tertiary care center for the treatment of depression. Data were analyzed by a variety of parametric and nonparametric methods including ANOVA and survival analysis.

RESULTS: Patients who received ECT (N = 108) were more likely to exhibit psychomotor retardation and to have had prior courses of ECT than those who did not receive ECT (N = 84). Furthermore, despite the absence of differences in the overall rate or severity of medical comorbidity, patients receiving ECT were more likely to be alive at follow-up and to demonstrate greater clinical improvement than those treated only with pharmacotherapy.

CONCLUSION: These results confirm previous studies demonstrating the superior efficacy of ECT as compared with conventional pharmacotherapy treatment in patients hospitalized with depression and document its safety in long-term follow-up.

Download full study (pdf 700k) ECT Mortality Geriatric

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Note: The Electroshock Quotationary is the ONLY place you can read my article “March of the Damned.” It’s a Quotationary EXCLUSIVE!

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by John Breeding, PhD
In the 1990s update to his terrific book, Electroshock: The Case Against, which offers summaries of activist resistance to electroshock over the last four decades of the 20th century, Robert Morgan offered the following acknowledgment of Leonard Frank.

His written work on ECT and advocacy against it have straddled the decades covered in this book. Initially disabled by ECT, Leonard devised some particularly ingenious organizational and memory techniques to overcome his resultant learning disabilities. He has devoted his life to addressing and correcting abuses of the psychiatric system, particularly ECT. Although he has been a strong and effective figure in this history over the decades, it is particularly now that he has emerged as a key figure. A tough, gentle, articulate and consummately effective organizer, he has probably done more to advance survivors’ rights than anyone else. A former editor of the Madness Network News (survivors journal) and current primary leader of the opposition, both scientist/professional and survivor, he has been the role model and integrity for a very diverse coalition of independent individuals. Thanks to Leonard, a very well financed and credentialed initiative was defeated, at least in San Francisco, at least for now.

Leonard Frank has been strong, effective, gentle and tough with me over the last decade as he became a primary mentor and very close friend. He is best described, however, by the dynamics of love and truth. More than anyone, he has helped me to become more clear about language and the patterns of psychiatric oppression. When the idea to form the Coalition for the Abolition of Electroshock in Texas came into my head last summer, Leonard nurtured the idea with enthusiastic support, and helped us be clear about our Gandhian approach of active, transparent, nonviolent resistance. As we organized ourselves into existence this past fall, Leonard stepped up and has been an integral voice of wisdom, guidance and encouragement. I am grateful to be working shoulder to shoulder with this awesome man, in his fifth decade of activism against psychiatric oppression in general, and electroshock in particular.

The Electroshock Quotationary is the single best document available to learn about the reality of this horrific practice.

Download the entire book for free!

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Israel’s Habimah Theater Finally Arrives Stateside
By Mr. Raphael Mostel

For its first New York visit in 40 years, the renowned National Theater of Israel, Habimah, will present two fact-based modern dramas involving Jewish children growing up with a parent veering into madness.

The main production comprises four evening performances, from September 18 to September 21, of the big-scale “Kaddish L’Naomi,” Habimah’s theatrical adaptation of Allen Ginsberg’s searing memorial poem for his mother. It will be performed in Hebrew with English subtitles, multimedia and a cast of nine. On September 20 and September 21, there will also be two matinee performances of the small-scale “Summer of Aviyah,” Gila Almagor’s one-woman dramatic adaptation of her famous coming-of-age memoir of her own mother, performed in English.The run is a major showcase for Almagor, Israel’s most acclaimed actress, as she will also star at Naomi in the Ginsberg show.

Full story 

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Update: The full article has been published in Nature and may be read here in PDF format.

An unpublished article, send by an insider to ect.org, reveals what ECT activists have been saying for years: ECT does cause cognitive damage. The “running title” of the article is “Cognitive Effects of ECT.”

The article is scheduled to be published in Neuropsychopharmacology in January.
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4,247 Words
5 Tables
5 Figures

The Cognitive Effects of Electroconvulsive Therapy in Community Settings

Harold A. Sackeim^1,2,3, Joan Prudic^1,2, Rice Fuller⁴, John Keilp^2,5, Philip W. Lavori⁶, and Mark Olfson*,^2,7

¹ Department of Biological Psychiatry, New York State Psychiatric Institute, New York, NY; ²Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY; ³ Department of Radiology, College of Physicians and Surgeons, Columbia University, New York, NY; ⁴Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ; ⁵Department of Neuroscience, New York State Psychiatric Institute, New York, NY; ⁶Department of Veterans Affairs Cooperative Studies Program and the Division of Biostatistics, Department of Health Research and Policy, Stanford University, Palo Alto, CA; ⁷Department of Clinical and Genetic Epidemiology, New York State Psychiatric Institute, New York, NY.

* Correspondence: Dr Harold A. Sackeim, Department of Biological Psychiatry, New York State Psychiatric Institute, 1051 Riverside Drive, New York, NY 10032 USA. Tel: (212) 543-5855, Fax: (212) 543-5854, E-mail: has1@columbia.edu

Running title: Cognitive Effects of ECT

ABSTRACT

Despite ongoing controversy, there has never been a large scale, prospective study of the cognitive effects of electroconvulsive therapy (ECT). We conducted a prospective, naturalistic, longitudinal study of clinical and cognitive outcomes in patients with major depression treated at 7 facilities in the New York City metropolitan area. Of 751 patients referred for ECT with a provisional diagnosis of a depressive disorder, 347 patients were eligible and participated in at least 1 postECT outcome evaluation. The primary outcome measures, Modified Mini- Mental State exam scores, delayed recall scores from the Buschke Selective Reminding Test, and retrograde amnesia scores from the Columbia University Autobiographical Memory Interview–SF (AMI– SF), were evaluated shortly following the ECT course and 6 months later. A substantial number of secondary cognitive measures were also administered. The 7 sites differed significantly in cognitive outcomes both immediately and 6 months following ECT, even when controlling for patient characteristics. Electrical waveform and electrode placement had marked cognitive effects. Sine wave stimulation resulted in pronounced slowing of reaction time, both immediately and 6 months following ECT. Bilateral ECT resulted in more severe and persisting retrograde amnesia than right unilateral ECT. Advancing age, lower premorbid intellectual function, and female gender were associated with greater cognitive deficits. Thus, adverse cognitive effects were detected 6 months following the acute treatment course. Cognitive outcomes varied across treatment facilities and differences in ECT technique largely accounted for these differences. Sine wave stimulation and bilateral electrode placement resulted in more severe and persistent deficits.

Key words: electroconvulsive therapy, major depression, memory, cognitive side effects, amnesia

INTRODUCTION

Electroconvulsive therapy is widely considered the most effective antidepressant treatment, with medication resistance its leading indication (American Psychiatric Association, 2001). However, critics contend that ECT invariably results in substantial and permanent memory loss (Breggin, 1986; Sterling, 2000), with some patients experiencing a dense retrograde amnesia extending back several years (Donahue, 2000; Sackeim, 2000). In contrast, some authorities have argued that, with the introduction of general anesthesia and more efficient electrical waveforms, ECT’s adverse cognitive effects are short-lived, with no persistent effects on memory (Abrams, 2002; Fink, 2004).

Shortly following the ECT course most patients manifest deficits in retaining newly learned information (anterograde amnesia) and recalling events that occurred in the weeks or months preceding the ECT course (retrograde amnesia) (Sackeim, 1992; Squire, 1986). Randomized controlled trials have shown more severe short-term memory deficits with sine wave compared to brief pulse stimulation (Valentine et al, 1968; Weiner et al, 1986), bilateral (BL) compared to right unilateral (RUL) electrode placement (Lancaster et al, 1958; Sackeim et al, 1986; Sackeim et al, 1993; Sackeim et al, 2000), and higher electrical dosage (McCall et al, 2000; Ottosson, 1960; Sackeim et al, 1993). These adverse effects are reduced by the use of RUL ECT with brief or ultrabrief pulse stimulation and electrical dosage titrated to the needs of the individual patient (Sackeim, 2004b). Nonetheless, a minority of US practitioners still use sine wave stimulation, approximately half do not adjust dosage relative to the patient’s seizure threshold, and a majority administer mainly or exclusively BL ECT (Farah and McCall, 1993; Prudic et al, 2004; Prudic et al, 2001). The continued use of treatment techniques associated with more severe short-term cognitive deficits may reflect the beliefs that the cognitive deficits are transient and that older treatment methods provide greater assurance of efficacy (Scott et al, 1992).

Empirical information about ECT’s long-term effects derives mainly from small sample studies conducted in research settings, with follow-up intervals frequently limited to two months or less. By excluding individuals with significant medical and psychiatric co-morbidities, use of optimized forms of ECT, and limited statistical power, these studies could not adequately assess the severity and persistence of long-term deficits. In a sample treated in community settings, we conducted the first large-scale, prospective long-term study of cognitive outcomes following ECT. We characterized the profile of cognitive change immediately and 6 months following completion of ECT, and examined the relationships of treatment technique and patient characteristics to cognitive outcomes. We also determined whether a patient subgroup had especially marked long-term deficits and whether particular forms of ECT administration were overrepresented among these patients.

PATIENTS AND METHODS
Study Sites and Study Participation

The study was conducted at 7 hospitals in the New York City metropolitan area: 2 private psychiatric hospitals, 3 community general hospitals, and 2 hospitals at university medical centers. A clinical outcomes evaluator was assigned to each hospital and collected all research information. The study was conducted by investigators at the New York State Psychiatric Institute (NYSPI), and patients at this facility did not participate. Institutional Review Boards at NYSPI and each of the 7 hospitals approved the study.

Participants were recruited from the inpatients and outpatients referred for ECT with a clinical diagnosis of a depressive disorder. Over a 26-month period, 751 patients were so referred [see Prudic et al (2004) and Figure 1 for details on sample composition]. Study participants met the Diagnostic and Statistical Manual (DSM-IV) criteria for a major depressive episode (unipolar or bipolar) or schizoaffective disorder, depressed, on the basis of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I/P) (First et al, 1996a). Patients were excluded if they received ECT in the past 2 months, scored below 15 on the Mini-Mental State Exam (Folstein et al, 1975), or spoke neither English nor Spanish. Patients were at least 18 years of age and provided informed consent after study procedures had been fully explained.

Study Measures

The primary instrument to assess severity of depressive symptoms was the Hamilton Rating Scale for Depression (HRSD, 24- item) (Hamilton, 1967). Comorbid DSM-IV psychiatric Axis I disorders, including substance abuse or dependence, were determined using a full SCID-I/P interview (First et al, 1996a). Medical comorbidity was assessed with the Cumulative Illness Rating Scale (CIRS) (Miller et al, 1992). At preECT baseline the North American Adult Reading Test (NAART) provided an estimate of premorbid intelligence (Johnstone et al, 1996).

An extensive neuropsychological battery was administered at preECT baseline, within days of completing the ECT course, and at 6-month (24-week) follow-up. A description of the battery and the derived outcome measures are presented in Table 1. The modified Mini-Mental State exam (mMMS) (Stern et al, 1987), a measure of global cognitive status and an expanded version (range 0-57) of the original MMS (Folstein et al, 1975), has shown sensitivity to variation in ECT technique (Sackeim et al, 1993; Sackeim et al, 2000). Psychomotor function was assessed with 3 measures of reaction time (RT): Simple (SRT) (Benton, 1977), Choice (CRT) (Benton and Blackburn, 1957), and Stroop RT (MacLeod, 1991). In each task, median RT for correct response was determined. Although psychomotor function is of practical importance with respect to driving and other motor activities, the impact of ECT on this domain has rarely been examined (Calev et al, 1995; Sackeim, 1992). Attention was assessed with the Stroop (MacLeod, 1991) and the Continuous Performance Test (CPT) (Ballard, 1997; Cornblatt et al, 1984). In severe depression, attention is often impaired, but believed to improve with symptomatic remission (Sternberg and Jarvik, 1976; Zakzanis et al, 1998). However, there is virtually no information on the effects of ECT on these classic attentional measures.

Anterograde and retrograde amnesia are the two deficits most characteristic of ECT. Anterograde learning and memory were assessed with the Complex Figure Test (CFT) (Rey, 1941; Spreen and Strauss, 1998) and the Buschke Selective Reminding Test (BSRT) (Buschke, 1973; Hannay and Levin, 1985). Deficits in delayed recall on the BSRT have been repeatedly documented shortly following ECT, and found to be sensitive to variation in treatment technique (Sackeim et al, 1993; Sackeim et al, 2000). Retrograde amnesia for autobiographical information was measured with the Columbia University Autobiographical Memory Interview– Short Form (AMI-SF) (McElhiney et al, 1997; McElhiney et al, 1995). The original version of the AMI, containing 281 items, has shown strong reliability and validity as a measure of retrograde amnesia, and sensitivity to variation in ECT technique (Lisanby et al, 2000; McElhiney et al, 1995; Sackeim et al, 1993; Sackeim et al, 2000; Sobin et al, 1995).

Three alternate versions of the mMMS, CFT, and BSRT were randomized to testing occasion. The order of the stimuli in each of the computerized tasks was newly randomized at each testing occasion. To allow for comparison of scores across tests and time points, the baseline scores on each test were converted to standardized scores, with a mean of 0 (SD = 1) for the total sample. Scores at the two subsequent assessments were standardized in relation to the distribution of scores at baseline. In all cases, higher standardized scores reflected superior performance. The primary cognitive outcome measures were postECT scores on the AMI-SF, mMMS, and delayed recall on the BSRT. The primary measure at the 6-month follow-up was the AMI-SF score. To identify a subgroup with marked and persistent retrograde amnesia, the most common source of complaint regarding long-term deficits, individuals were identified who following both the postECT and 6-month follow-up assessments had decreases of at least –2.0 SD units or greater on the AMI-SF.

Study Procedures

The outcomes evaluators screened all patients scheduled to start ECT at the facility with a provisional clinical diagnosis of a depressive disorder (N = 751; Figure 1). After obtaining consent and determining eligibility, the evaluator administered the clinical assessment and neuropsychological batteries prior to the first ECT treatment (N = 398).

The intent-to-treat sample included those patients who received at least one treatment and participated in a postECT clinical outcome evaluation (N = 347).

Time limitations and other factors resulted in variable rates of completion of the cognitive tasks, especially at the baseline evaluation. For the baseline assessment, the sample size for the cognitive measures ranged from 242 (CPT) to 347 (mMMS). The ranges were 224 to 346 and 202 to 260 at the postECT and 6-month follow-ups. Thus, 99% of the intent-to-treat sample participated in all or part of the cognitive evaluation at postECT and 75% did so at the 6-month follow-up.

The outcomes evaluator attended ECT treatments and documented the type and doses of medications, type of physiological monitoring, ECT device model, electrical waveform, electrode placement, stimulus dosing strategy, and the specific parameters used for stimulation. The duration of the motor convulsion and, when monitored, the EEG seizure were recorded.

When the treating psychiatrist indicated that the acute ECT course was completed, the patient was scheduled for the postECT assessment. The aim was to test patients between 3 and 7 days after ECT. For the 347 patients in the intent-to-treat sample, the average interval to postECT assessment was 4.37 days (SD = 4.19). At the postECT assessment, the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) was administered to derive DSM-IV diagnoses of personality disorders (First et al, 1996b). All consenting patients were clinically monitored for a period of 24 weeks following the acute ECT course. They were administered the HRSD at 4-week intervals and interviewed regarding the treatments received since last contact. At the 6- month time point, the clinical and neuropsychological evaluations were repeated.

A group of 24 healthy comparison participants, with negative lifetime histories of psychiatric illness, were matched to the patient sample in the distributions of age, gender, and education. The comparison sample completed the same neuropsychological battery at time points corresponding to the assessment periods in patients and each test was scored in standardized units relative to the patient distribution at baseline. Only one measure, d’ or sensitivity on the CPT, showed a practice effect, with signficant improvement from baseline to the postECT time point and stable thereafter. The scoring of the AMI-SF necessarily results in higher scores at baseline than follow-up. The CPT and AMI-SF scores in the patient sample were adjusted for the average change seen in the comparison sample, removing the temporal effects on these two measures.

Average raw scores for the patient sample and average raw and standardized scores for the healthy comparison sample are presented for the baseline evaluation in Table 2. Analyses of covariance (ANCOVAs), with age, gender, and education as covariates, indicated that the healthy comparison sample had superior scores on 9 of 11 of the baseline cognitive measures.

Statistical Methods

The pattern of change in neuropsychological scores was determined for the total sample by conducting paired t-tests contrasting scores at postECT and 6-month follow-up with preECT scores. Differences among the sites in cognitive outcomes were tested with analyses of covariance (ANCOVAs). For each measure, an ANCOVA was conducted on the score at postECT with site (7 levels) as a between-subject term and patient age, estimated premorbid IQ (based on the NAART), gender, HRSD score at time of assessment, number of days intervening between the end of ECT and postECT assessment, and preECT baseline cognitive score as covariates. The ANCOVAs conducted on the neuropsychological measures at the 6-month follow-up used the same model except that the number days since end of ECT was dropped and whether or not patients had received further treatment with ECT in the follow-up period was added as a covariate. The covariates in these models were selected a priori based upon reported associations with postECT cognitive measures (Sackeim et al, 1992; Sobin et al, 1995; Zervas et al, 1993). Other potential covariates screened for inclusion in the analyses were cumulative medical burden (CIRS score), other Axis I diagnosis, Axis II diagnosis, psychotic depression subtype, inpatient vs. outpatient treatment setting, history of previous ECT, length of current depressive episode, and number of previous depressive episodes. The criterion for inclusion of a covariate in the final analyses was a significant association (p < 0.05) with at least two of the primary outcome measures. None of the screened variables met this criterion. Post hoc Tukey-Kramer comparisons identified pair- wise differences among the sites.

The associations between treatment technique and cognitive outcomes were first tested in the subgroup of patients who were treated with only one electrode placement, BL or RUL ECT, during acute phase treatment. Patients treated exclusively with bifrontal (BF) ECT (n = 12), a mixture of BL, RUL, and/or BF ECT (n = 75), or exclusively with RUL ECT with sine wave stimulation (n =2) were dropped from these analyses. The ANCOVAs used the same models as the analyses of site differences, except that the site term was deleted and terms for electrode placement, waveform nested within electrode placement, stimulus dosage, and number of treatments were added. Stimulus dosage was computed as the percentage of maximal device output averaged across all treatments. To corroborate findings, a second set of ANCOVAs was conducted in the intent-to-treat sample. In these analyses, the terms for the number of BF, BL, and RUL treatments (3 factors) replaced the categorical classification of electrode placement and the term for the total number of treatments. To determine whether the site differences were attributable to differences in treatment technique, the last set of analyses was repeated adding site as a between-subject factor. A logistic regression analysis was conducted to determine which treatment technique factors were related to likelihood of manifesting especially marked and persistent retrograde amnesia.

RESULTS

Compared to baseline performance, at the postECT time point the total patient sample showed deficits in the mMMS (t(345) = 8.0, p < 0.0001), SRT (t(281) = 4.2, p < 0.0001), sensitivity (d') on the CPT (t(221) = 7.4, p < 0.0001), learning phase of the BSRT (t(314) = 3.5, p < 0.0001), delayed recall on the BSRT (t(301) = 10.5, p < 0.0001), delayed reproduction on the CFT (t(270) = 7.2, p < 0.0001), and in AMI-SF scores (t(328) = 21.7, p < 0.0001) (Figure 2). At this time point, the Stroop interference effect was reduced (t (264) = 5.3, p < 0.0001). The deficits following ECT were greatest for the measures assessing memory for autobiographical events (AMI-SF), retention of newly learned information (delayed performance on the BSRT and CFT), global cognitive status (mMMS), and simple reaction time (SRT). Compared to the preECT baseline, there was significantly improved performance at the 6-month follow- up on all tasks other than the three reaction time measures (SRT, CRT, and Stroop RT) and sensitivity (d') on the CPT. Furthermore, AMI-SF scores remained markedly below baseline values (t(251) = 21.1, p < 0.0001). There were no significant differences among the 7 hospitals in ANCOVAs conducted on the preECT baseline cognitive measures. In contrast, the 7 hospitals differed in mMMS and AMI-SF scores at both the postECT (mMMS: F(6, 333)= 3.25, p = 0.004; AMI–SF: F(6, 313) = 2.70, p = 0.01) and 6-month follow-up (mMMS: F(6, 248) = 3.43, p = 0.003; AMI–SF: F(6, 240) = 2.26, p = 0.04) time points (Figure 3). In addition, there were significant differences among the hospitals at the postECT assessment for 5 other cognitive measures: CRT (F(6, 244) = 3.34, p = 0.004), Stroop RT (F(6, 252) = 3.02, p = 0.007), CPT sensitivity (d') (F(6, 211) = 2.23, p = 0.04), BSRT learning (F(6, 302) = 2.14, p <0.05), and BSRT delayed recall (F(6, 289) = 2.19, p = 0.04). Across these 7 measures and time points, patients at hospital D consistently showed marked deficits, while patients at hospital G showed the least impairment. The site differences in short- and long-term cognitive outcomes persisted following statistical control for the patient features most strongly associated with the cognitive measures.

When the sample was restricted to patients treated with a uniform electrode placement (N = 258), there were marked effects of specific aspects of ECT practice on short- and long-term cognitive measures. At postECT, stimulus waveform had a significant impact on 4 of the 11 cognitive measures (Table 3, Figure 4). In each case, performance was poorer with sine wave compared to brief pulse stimulation. There were robust effects of sine wave stimulation on all three reaction time measures. At postECT, patients treated with BL or RUL ECT differed significantly in 5 of the 11 cognitive measures (Table 3, Figure 4). BL ECT was associated with greater amnesia than RUL ECT on two of the three primary outcome measures, delayed recall on the BSRT and memory for autobiographical events (AMI–SF). The effects of electrode placement and number of ECT treatments were especially marked on the AMI-SF.

At the 6-month follow-up, patients treated with sine wave stimulation continued to have slower reaction time on the SRT and the Stroop RT tasks (Table 4, Figure 4). At this time point, patients treated with BL ECT had inferior performance to patients treated with RUL ECT on the mMMS, SRT, Stroop effect, learning phase of the BSRT and AMI-SF scores. Greater amnesia for autobiographical events (AMI-SF scores) was significantly correlated with the number of ECT treatments received 6-months earlier.

In the confirmatory analyses, there were significant linear relationships between the number of treatments administered and postECT AMI–SF scores for each of the three electrode placements. However, the slope of the decline in AMI–SF scores with increasing treatment number was substantially greater for BL ECT (F(1, 318) = 53.74, slope = -0.14, SE = 0.02, p < 0.0001) than RUL (F(1, 318) = 7.72, slope = -0.06, SE = 0.02; p = 0.005) or bifrontal ECT (F(1, 318) = 8.01, slope = -0.09, SE = 0.03, p = 0.005). At the 6-month time point, there continued to be a significant relationship between the number of BL ECT treatments and the extent of retrograde amnesia (F (1, 240) = 9.61, df = 1, 240, slope = -0.06, SE = 0.02, p = 0.002), while there were no relationships with the RUL or BF placements. Thus, the magnitude of long-term retrograde amnesia linearly increased with longer courses of BL ECT, but was unrelated to the number of RUL or BF treatments administered. Of the 306 patients classified, 38 (12.4%) patients met the a priori criteria for having marked and persistent retrograde amnesia on the AMI-SF. In the logistic regression analysis, number of BL ECT treatments was the only treatment variable that significantly predicted membership in this subgroup, ?2(1, 296) = 14.7, p = 0.0001. There was also a gender difference, ?2(1, 296) = 5.8, p < 0.02, with a greater preponderance of women (81.6%) compared to men (18.4%) in the persistent deficit group. The analyses of study site effects were repeated now including stimulus waveform and number of treatments with each electrode placement as independent variables. The site effects were no longer significant, with the exception of mMMS scores at the 6-month follow-up. Therefore, the site differences in short- and long-term cognitive outcomes were largely attributable to variation in the type of electrical waveform and electrode placement used in ECT administration. As seen in Tables 3 and 4, several of the covariates had powerful relations with cognitive performance at the postECT and 6- month follow-up time points. For every measure and at both time points baseline scores had strong relationships with subsequent assessments, indicating strong reliability. For 8 of the 11 postECT measures, cognitive performance was positively related to the number of days that elapsed from the end of ECT until the cognitive assessment. It is noteworthy that this effect did not occur with the AMI-SF which assessed retrograde amnesia, the deficit thought to be most persistent. Two patient characteristics, age and the estimate of premorbid IQ, had frequent and strong relationships with cognitive outcomes, especially at the postECT assessment. In each instance, older patients and those with lower estimated intellectual function had more severe deficits. The gender differences, including the AMI-SF scores at the two time points, reflected greater deficits in women than men, and women were disproportionately represented in the group with marked and persistent impairment on the AMI-SF. Women have a substantially lower seizure threshold than men (Sackeim et al, 1987) and electrical dosage was not adjusted in most cases relative to the individual patient's seizure threshold. This pattern of gender differences might reflect the fact that electrical dosage was more markedly suprathreshold in women. Severity of depressive symptoms showed little relationship with the cognitive measures.

At the postECT time point, none of the 11 measures were related to concurrent HRSD scores (Table 4). Findings were also negative for 8 of the 11 measures at the 6-month follow-up. At this time point, lesser severity of depressive symptoms was associated with superior mMMS, delayed BSRT, and AMI-SF scores.

DISCUSSION

This was the first large-scale, prospective study of objective cognitive outcomes of patients treated with ECT. The 7 hospitals differed in the magnitude of deficits at the postECT assessment (Figure 2), with significant differences in 7 of the 11 cognitive measures. At the 6-month time point, differences among the hospitals persisted for the measure of global cognitive status (mMMS) and the primary outcome measure that assessed retrograde amnesia for autobiographical events (AMI-SF). In turn, these differences among the hospitals were largely attributable to differences in ECT technique. The use of sine wave stimulation and the BL electrode placement were both associated with greater short- and long-term deficits. In particular, sine wave stimulation had a marked effect on psychomotor response speed. Patients who received this form of stimulation were slowed at the 6-month assessment relative to patients treated with brief pulse stimulation on 2 of the 3 reaction time measures. In contrast, the long-term effects due to electrode placement were expressed in the magnitude of retrograde amnesia. At both the short- and long-term time points, patients treated with BL ECT had greater amnesia for autobiographical events, and the extent of this amnesia was directly related to the number of BL ECT treatments received.

The demonstration of differences in long-term cognitive outcomes as a function of hospital setting and treatment technique supports the conclusion that some forms of ECT have persistent long- term effects on cognitive performance. However, the findings do not indicate that the treatments with more benign outcomes are free of long-term effects. It is noteworthy, for example, that most cognitive parameters were substantially improved at 6-month follow- up relative to preECT baseline, presumably because of the negative impact of the depressed state on baseline performance. Without evaluating a comparable group that did not receive ECT, it cannot be concluded, however, that the extent of improvement in any group returned to premorbid levels.

The finding that sine wave stimulation resulted in slowed reaction time could have reflected a speed/accuracy trade off, with patients receiving sine wave stimulation sacrificing response speed for accuracy. However, the sine wave and brief pulse groups did not differ in accuracy on any of the reaction time tasks where accuracy could be measured (CRT and Stroop). The fact that relative reaction time deficits were observed at the 6-month follow-up indicates a persistent change in the speed of information processing, motor initiation, or response execution. Randomized controlled studies have not found an advantage for sine wave stimulation with respect to efficacy (Andrade et al, 1988; Carney and Sheffield, 1974; Scott et al, 1992; Valentine et al, 1968; Weiner et al, 1986), and the American Psychiatric Association (2001) indicated that there is no justification for its continued use. The findings here raise the concern that this form of stimulation has deleterious long-term effects on elemental aspects of motor performance or information processing.

BL ECT results in broader and more severe short-term cognitive effects than RUL ECT, particularly with respect to retrograde amnesia. With respect to the AMI-SF scores, BL ECT resulted in greater retrograde amnesia than the other electrode placements and, even at the 6-month time point, this effect was linearly related to the number of BL treatments administered during the acute ECT course. The average decrement in AMI-SF scores in patients treated exclusively with BL ECT was 3.4 and 2.8 times the amount of forgetting seen in the healthy comparison groups at the postECT and 6-month time points, respectively, suggesting that the deficits were substantial. Furthermore, of a variety of treatment technique and patient characteristic variables, only receipt of BL treatment distinguished the group with marked and persistent retrograde amnesia. For decades, BL ECT represented the gold standard with respect to ECT efficacy, and the equivalence of RUL ECT was uncertain (Abrams, 1986). Based on accumulating evidence that the efficacy of RUL ECT is strongly influenced by dosage relative to seizure threshold, highly effective forms of RUL ECT are available (McCall et al, 2000; Sackeim et al, 2000). Indeed, recent work suggests that high dosage RUL ECT delivered with an ultrabrief stimulus maintains efficacy and results in minimal retrograde amnesia even in the period immediately following the ECT course (Sackeim, 2004b). Consequently, there appears to be little justification for the continued first-line use of BL ECT in the treatment of major depression.

While there is a large literature on patient characteristics that predict ECT clinical outcome, little is known about the individual difference factors related to cognitive outcomes (Sobin et al, 1995). Age and premorbid estimate of IQ showed robust associations, especially at the postECT time point. In line with prior reports (Sackeim, 2004a), advancing age was associated with greater deficits. The findings regarding premorbid intelligence are novel. This pattern suggests that individuals with greater premorbid abilities can better compensate for the impact of ECT on cognitive functions (Stern, 2002; Stern et al, 1994)

Among the limitations of this study is the fact that differences among patients in the treatment received were not randomized, but determined by the usual practices of the setting in which they were treated and other uncontrolled factors. Thus, in theory it is possible that the associations in this observational study between cognitive outcomes and site and treatment technique factors were due to the effects of other unmeasured variables that covaried with the settings and forms of ECT administration. This concern is mitigated by three considerations. First, the findings were consistent with the results of many randomized controlled trials demonstrating that short-term cognitive outcomes are negatively impacted by receipt of sine wave stimulation or use of the BL electrode placement. The long-term effects observed in this study reflect a lack of resolution of specific deficits observed in the immediate postECT time period (e.g., retrograde amnesia).

Second, there was evidence that the number of treatments administered, an essential characteristic of dosage, linearly covaried with the extent of long-term retrograde amnesia for autobiographical information for patients treated with BL ECT, but not for patients treated with RUL ECT.

This provided internal support for the claim that choice of electrode placement is critical in determining the severity of long-term deficits. Finally, there was considerable variability within some sites in ECT technique, such as choice of waveform and electrode placement. Site differences in cognitive outcomes dissipated when controlling for treatment technique factors. Regardless, this study provides the first evidence in a large, prospective sample that adverse cognitive effects can persist for an extended period, and that they characterize routine treatment with ECT in community settings.

Acknowledgements

Supported in part by grants R01 MH59069, R01 MH35636, R01 MH61609, and R01 MH05148 from the National Institute of Mental Health, Bethesda, MD.

We thank Dr. Bernard Lerer for his comments on this work, and the staff at the 7 hospitals who facilitated the conduct of this study.

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Tables and Figures-ECT Cognitive Effects

14 Responses »

A student working on a paper asked for information about the history of ECT, so I put these files together for him. I was pressed for time, so nothing has been OCR’d - it’s all in graphical format. You can view the gifs, one per page, and print them out.

Read about the earliest beginnings of ECT, from Leonard Roy Frank’s wonderful book “The History of Shock Treatment.” If you’re interested in reading a very detailed book on its history, this is THE book I recommend. It’s absolutely fascinating reading.

These are only the first few pages of this huge book, to go into the earliest beginnings of electricity as “treatment.”

Included:
Electric Eel Therapy
Devil Expulsion with Electricity
The