FDA ADVISORY PANEL RECOMMENDS KEEPING SHOCK MACHINES IN CLASS 3

More info coming, this is fantastic news everyone!!! Thank you to the good people here who worked on this, wrote letters to the FDA, testified, etc. There’s still more to go, the final FDA vote, but this is fantastic!

You all ROCK THE WORLD.

URGENT: FDA Wants to Declare Shock Treatment Safe Without a Safety Investigation! Public Docket is Now Open (Sept. 10, 2009-Jan. 8, 2010)For Your Comments—Tell Them No!

The Food and Drug Administration is in charge of regulating medical devices just as it does drugs, including the machines used to give shock treatment. But it’s not doing its job. It has allowed these machines to be used on millions of patients over the past generation without requiring any evidence whatsoever that shock treatment is safe or effective! This is so even though shock machines are Class III—high risk—devices, which by law are supposed to be investigated by clinical trials as thoroughly as new drugs and devices just coming onto the market. But because of intense lobbying by the American Psychiatric Association—which claims the devices are safe but opposes an investigation—the FDA has disregarded its own law. (For the full story of how shock survivors have fought for a scientific safety investigation of ECT for the past 25 years, see the new book Doctors of Deception: What They Don’t Want You to Know About Shock Treatment by Linda Andre.) Read the rest of this entry »

Linda Andre’s New Book, “Doctors of Deception: What They Don’t Want You to Know About Shock Treatment,” Just Out From Rutgers University Press!

If you buy and read only one book on ECT, this should be the one. Andre is not only a survivor of ECT, but has spent the past 25 years listening to, and documenting the experiences of, other survivors. With her exhaustive knowledge of what passes for scientific research on the subject, and an insider’s knowledge of the politics behind that “science” as well as the pronouncements of supposedly trustworthy authorities like the FDA, no one is more qualified to demolish the claims of the shock industry. Andre does so with thoroughness, style, and even wit. Everything she says is documented, but never before has all this information been gathered in one volume.
Read the rest of this entry »

Book Review: Shock Therapy by David Healy, Edward Shorter (and Max Fink)

“When science has a commercial basis, those who make a living out of one point of view seem much less likely to tolerate dissent than is normal in the rest of science.”

(David Healy, from his 2004 book Let Them Eat Prozac)

Once, just once, it would be nice to see doctors who use ECT make an argument for their product based on facts and science, without lies and omission, without making stereotypical errors of reasoning, and without lowering themselves to the level of libel by disparaging the sanity and veracity of their former patients. Read the rest of this entry »

Cure for Pakistan: ECT on elderly

Professor: 67 percent of elderly are depressed; ECT could be a “useful treatment”
December 13, 2007
‘ECT — most useful to treat depression’
Daily Times, Lahore Pakistan

Staff Report

LAHORE: Despite all myths and misconceptions, electro-convulsive therapy (ECT) also known, as electric shock treatment, is most effective treatment to treat depression, said Dr Ashar Khan, Bond University, Australia.

He was delivering a lecture on ECT – An Evidence-based Approach on Monday at the University of Health Sciences (UHS). UHS vice chancellor Prof Malik Hussain Mubashir, senior professors and postgraduate medical students attended the lecture.

Highlighting the history, types and procedure of ECT, Dr Ashar said it had been shown clinically to be the most effective treatment of severe depression and to result in improved quality of life in both short and long-term. He said ECT was also being used in the treatment of mania, catatonia, schizophrenia and Parkinson’s disease.

Dr Ashar said it was widely accepted that ECT did not cause brain damage, though its side effects included confusion and memory loss around the time period of the treatment. He maintained that the treatment was also safe during pregnancy.

He informed the audience that ECT was generally reserved for use as a second-line treatment for patients who had not responded to drugs. The first-line use of treatment, he said, was for situations where immediate clinical intervention needed or alternative treatments were not advisable. Its effectiveness had not been demonstrated in substance abuse, anxiety or personality disorders, he added.

Dr Ashar said hundreds of thousands of people across the world had received ECT every year, usually in a course of 6-12 treatments administered 2 or 3 times a week. After the treatment, he said, drug therapy could be continued and some patients received continuation/maintenance ECT.

Prof Malik said about 67 percent elderly people in Pakistan were suffering from depression. He said for these people ECT could be a useful treatment. He said ECT was useful in ischemic heart diseases than tricyclic anti-depressants.

Prof Haroon and Prof Riaz Bhatti also spoke on the occasion.

Warning against overuse of shock therapy: New Zealand

NZPA | Tuesday, 27 November 2007

A committee of MPs says electro-convulsive therapy (ECT) should only be used as a treatment of last resort.

Under ECT, specialised medical equipment is used to induce an epileptic seizure by passing a small electrical current across the brain.

Parliament’s health select committee has been considering a petition by doctor Helen Smith who wants ECT to be voluntary, and its use with children, pregnant women and the elderly either banned or severely restricted.

Dr Smith argued the elderly should be given the opportunity to formally decline ECT prior to becoming elderly or unwell.

She also said there should be stricter regulatory reporting and controls in place for ECT use.

The health select committee, in its report on Dr Smith’s petition, has agreed with her in some areas.

It recommended that ECT “should only be used as a treatment of last resort when all other options have been considered”.

It said the Royal Australian and New Zealand College of Psychiatrists should urgently developing its guidelines into a national professional standard.

The circumstances for a patient to be required to undergo ECT should be more restricted, it said.

The committee also recommended the Mental Health (Compulsory Assessment and Treatment) Act 1992 be amended to ensure ECT was administered only with a patient’s consent where this was possible.

Where this was not possible it should be administered on the basis of a “truly independent second opinion” from certifying clinicians that were not attached to the institution from which the first opinion was obtained.

A majority on the committee recommended ECT be administered to pregnant women with informed consent only in cases of emergency where there was no other option available.

It wanted data on the rate ECT was administered to pregnant women to be collected and reported annually.

It said ECT should only be administered to children and young people “where in the opinion of certifying clinicians there is no other option available”.

The majority of the committee recommended that consideration be given to requiring an order under the Protection of Personal Property Rights Act when ECT was administered to the elderly, because of its presumption of competence and the least restrictive intervention.

The majority on the committee also recommended that where patients had made valid advance directives that they did not wish to undergo ECT, that these directives should be given effect.

ECT is used to treat severe depression and some other mental disorders.

Side effects include headaches, muscle aches or soreness, nausea, confusion and memory loss.

Critics condemn its use but the Ministry of Health says it is a valuable and sometimes life-saving treatment.

The Ministry of Health said 70 to 80 per cent of patients who received ECT responded to it well.

In 2004/05, 307 people received ECT. In the 2003/04 year, 305 received it.

Disproportionately more women than men received ECT and the committee was not given a satisfactory reason why this was the case.

While no statistics were given, the college of psychiatrists said it was rare to treat pregnant women with ECT.

In the 2003/04, 2004/05 and 2005/06 years five, two and one person under the age of 20 received ECT treatment.

The elderly were the main group to receive ECT.

The committee said in its report, tabled in Parliament today, that it was concerned about wide regional variations in its use. Some district health boards were administering as many as 18 treatments as part of a course of ECT, when guidelines stated six to 10 treatments.

“Given it is a controversial treatment, we consider it is essential that ECT be governed by a national standard and not by just guidelines,” the committee said.

The National Party had a minority view included in the committee’s report on the petition.

It felt the use of ECT was “an important life-saving treatment option that must remain available to clinicians”.

It said ECT was already generally a treatment of last resort, and there was “a very real risk of suicide” if the patient were left untreated.

Electroconvulsive Therapy – Guidelines for Health Authorities in British Columbia

2000 document from UBC Department of Psychiatry and the BC Ministry of Health

Download PDF File (3.7 mb)

An unpalatable reality in the age of improving care

New Zealand Herald
November 06, 2007
By Chris Barton

It happens more often than you’d think. A person arrives at a mental health unit in a psychotic state and is immediately put into a seclusion room.

Mental health consumer adviser Vicki Burnett tells the story of patient A. “When psychotic, she thought she was on fire and her hands were on fire. Put into a seclusion room, all the walls appeared to her to be on fire. I can’t think of anything worse or more terrifying.”

Why, asks Burnett, when someone is struggling with reality, lock them into a stark empty space with nothing to anchor them to the real world? “That’s not low stimulus, it’s worse than low stimulus because there is nothing – there is no reality.”

The sticking point for this story is getting a photo of a seclusion room. No one is keen to provide an image of this unpalatable reality that harks back to the days of the padded cell. Locking people up in solitary confinement is not a good look for enlightened, recovery-based mental health services in the 21st century.

We can get a description. “A seclusion room is a bare room with a plastic mattress on the floor and a disposable potty that’s made out the same stuff that egg cartons are,” says Burnett.

We know, too, the effect of being put in seclusion. Anne Helm, a member of the Confidential Forum for Former In-Patients of Psychiatric Hospitals, says: “If you are in a seclusion cell you have feelings of worthlessness, of loss of dignity and, at the very time when you are most fragile, you are removed from any human contact. It’s counterproductive to what people generally need.”

For the first time, we also know just how much this outmoded practice is still being used in mental health units around the country today.

Data just made public by the office of the director of mental health shows that 477 people were locked in seclusion rooms during the last quarter of last year. The bulk (383) were in adult mental health units, 59 were in forensic (crime related) services and 18 in child and young persons facilities. Data for those over the age of 65 was incomplete, but it appears most mental health units for the elderly do not have seclusion rooms.

Maori are more often secluded than other ethnic groups, accounting for 186 of the 477 locked up. Most stays (82 per cent) were shorter than one day. The longest recorded was 30 days.

There were 1514 seclusions in adult services during the quarter, indicating the same people are secluded multiple times – about four times on average. There is a wide variation in the data from district health boards (DHB). Tairawhiti (Gisborne), Canterbury and Bay of Plenty had the highest incidence of locking people up, and Auckland, Waitemata and Capital and Coast were among the lowest.

“Seclusion is a worry to us,” says the mental health director for the Ministry of Health, Dr David Chaplow. “We want it to start trending down and we want to really minimise, possibly even extinguish, the use of seclusion.”

The worry for the ministry is unavoidable evidence that the practice has no therapeutic purpose and that its continued use may breach fundamental human rights – and expose mental health services, already tainted by a legacy of inhumane practices, to further compensation claims.

Chaplow says the latest statistics are one of the steps in setting a benchmark for acceptable practice. At present, the use of seclusion is allowed under the Mental Health Act for the “care” or “treatment” of the service user, or protection of other users in the ward. It’s operation is outlined in the ministry’s Restraint Minimisation and Safe Practice Standard (2001), which is about to be updated.

With only three months of reporting, not too much can be read into the wide variation of figures by district. Tairawhiti, for example, which has the highest number of seclusion events (120 for the quarter) is a six-bed unit with two seclusion rooms.

Its statistics have been looked at by the mental health district inspector, who has reported that the use of seclusion in each of the cases was justified.

But Chaplow says that when the full figures for last year come out such discrepancies will be weighed against the wider picture. “If we do have DHBs wildly out of step, we’ll be saying to them they had better have a look at this.”

He points to reasons for the variations, including data being skewed by one or two difficult patients, demographic differences, ward design, staff training and differences in seclusion practices.

“In the past, it would not be uncommon for people to be secluded as a type of punishment. We are rigorously combating that in our training.”

Burnett is not so sure the message is getting through. “I think seclusion rooms are a threat to people and I think they are used as a threat: ‘If you don’t settle down we’ll have to put you into seclusion.”‘

She argues that it’s not necessary to lock someone in a room to reduce stimuli and says the ministry shouldn’t be approving any new buildings that have seclusion rooms.

Although the ministry wants the use of seclusion minimised in mental health services, many – including the Mental Health Foundation, the Mental Health Commission and the Mental Health Advocacy Coalition – want its routine practice eradicated. “We would like to see it become unacceptable as a norm to use seclusion – and if it is used, there has to be a thorough justification and explanation,” says Judi Clements, chief executive of the Mental Health Foundation. Clements says that, aside from seclusion, other statistics in the director’s report raise concerns, such as that 224 patients were treated with electroconvulsive therapy (ECT) last year and that 17 per cent of the treatments given did not have consent.

Seventy per cent of the recipients were women, most aged in the 64 to 84 age age group.

“We need to keep asking, what place does compulsion have in an environment that is moving towards a more enlightened approach towards people with mental illness?” says Clements.

Being forced to accept assessment and intervention against their will is a common complaint among mental health service users, and seclusion – forced restraint and imprisonment – is a prime example.

Psychiatrist David Codyre, also a member of the Mental Health Advocacy Coalition, agrees. He sees no evidence that seclusion is of any benefit and much confirmation from consumers that it is harmful and a significant breach of human rights. “It is no longer sustainable to say this is a necessary evil,” says Codyre. “It’s an unnecessary evil in the vast majority of cases.”

Codyre says studies show that when staff work in ways that minimise confrontation and maximise reassurance and engagement, the need to use seclusion as an intervention reduces dramatically.

Importantly, when staff work to reduce the use of seclusion, the level of violence in in-patient units, and particularly assaults on staff, reduces in a parallel line. “While seclusion was viewed as a way to keep everyone safe, what it actually was doing was increasing levels of trauma and violence for everyone involved .”

Consumer advocate Burnett sees the use of seclusion as poor nursing practice. “In nearly all instances it could have been avoided by better engagement with the person before that was necessary.”

But not everyone is convinced that it’s possible to totally eradicate seclusion. “That’s a good aim to have – whether it’s realistic I’m not entirely sure,” says Nigel Fairley, Capital and Coast DHB director of area mental health services, a DHB which is among the lowest users of seclusion practices. “The problem with that aim is that it does not recognise that, in some circumstances, there is a therapeutic value for the use of seclusion in that it provides the person a low stimulus environment, which is important at that point in time in their mental health issue.” He sees seclusion as a compulsory time out to deal with risky situations – a last, but legitimate, resort.

One who is determined to see seclusion completely removed is Karla Bergquist, the manager of district mental health services for the Waitemata District Health Board.

“We’re supposed to be providing services for people who have experienced trauma that are supportive and caring and therapeutic,” Bergquist says. “I don’t think that seclusion and restraint fit into those categories.”

The DHB has introduced “trauma informed care” projects, where staff use debriefing and analysis of each incidence of restraint and seclusion to understand why they happened and what could be done differently.

Bergquist says studies show that while initially there may be a small increase in the use of psychotropic medication – sometimes called the chemical straitjacket – when seclusion is removed it’s not a lasting effect. “When you’ve had an option that has been available to you for a very long period of time it’s hard to imagine what life would be like without it.” As to staff reaction to her ideas, “A lot of people say ‘You’re off your head’, but we’ve also got a group who are really passionate about moving towards that goal.”

Helm sees seclusion as part of our institutional legacy and no longer appropriate as a response to distress in the light of what is now call recovery-based practice. “It’s basically used as a behavioural management tool in controlling very complex environments.”

Like most, Helm agrees there are instances – such as for those in drug-induced psychosis – when restraint will be required. But seclusion is usually the result of impaired judgment by overworked, over-stressed staffing regimes where room for more appropriate responses is not possible.

“Solitary confinement might be perceived as therapeutic by the staff, when the recipient is seen as calm and contemplative. Mostly, that’s just the trauma of confinement. It breaks the spirit and sometimes results in long held fears which means the service user doesn’t want to use the service again.”

PUNISHED FOR SOMETHING I HAD NO CONTROL OVER
Big guy Mark tells his side of story

Mark, at the time 28, describes his experience of being put into seclusion in an Auckland mental health unit for three days.

I was diagnosed bipolar schizoaffective. At the time I wasn’t aware I had problems. I thought what I was going through was natural – that it was a spiritual awakening when you start hearing voices. I got hospitalised in February 2003. I had no clue about why I was there. I wanted to escape and one night I did. I took off out the door, jumped the fence and was away.

I got caught and put into the acute service. In the ward I was wrestled to the floor and given an injection to calm me down. I was afraid for my life. I thought they were going to do something to me. I spent the next few days locked up in a daze – you don’t know what time it is. All I recall is waking up and going back to sleep again. Sometimes there would be food and water. It was a lock-up room. It felt like being chucked into prison without a conviction – without any reason for why I was there.

I remember the smell of urine. The room wasn’t cleaned often. The walls were yellowish brown. My bed was just a flat pillow on the floor. They would come and give me another injection. There was nothing to look at all day – except out the window in the door which had a view of the corridor. There was no other window. The lights were on 24/7. The only person I saw was the one who brought the tray in and took away the waste. It’s something you shelve – try to forget about. I felt helpless and kept thinking I had done something wrong to be locked up. It felt like I was being punished for something I had no control over.

At the end of it, in the review, the staff told me the main problem was they thought I would be violent and psychotic and basically because I’m a big guy, they thought it was better to keep me monitored. I was in there for three days. My parents cried when they saw me – they thought going to hospital was the only and best choice for me. They didn’t realise anything like this would have occurred.

Harold Sackeim’s letter to the editor

Sometimes I really LOVE LIFE!!! This is one of those days.

Letter To Editor from Harold Sackeim

p.s. Hi everybody, I’m crazy busy and will be back in the flow soon.

The Top Three Questions

What follows are the three most frequently asked questions sent via email:

1. Where can I find a facility that gives ECT?

I don’t have a master list of ECT providers. I am concerned, however, that you would be seeking out ECT on your own. It is unlikely that you would find a clinic or hospital that would give you ECT without a doctor’s recommendation.

This is something that should be discussed with your psychiatrist. Your doctor will know of facilities that perform ECT and will give you a recommendation if s/he feels ECT would be beneficial. If you do not have a relationship with a psychiatrist and wish to have ECT, you will have to find a psychiatrist who will fully evaluate you.

2. I had ECT and it was successful. Why is it necessary to put so much negative information on the web?

I am always curious about one thing when I get this question: if ECT was successful, why are you searching the Internet for ECT information? It seems to me that you would simply accept that it worked and move on to other more interesting pursuits. (I do not doubt your enthusiasm, but it’s something that has always puzzled me – I’m interested in responses!)

That said; why NOT put it on the web? I sincerely believe that patients should be told all sides of the ECT story before making their decision. Anything less is unfair and it’s patronizing.

Until recently there appears to have been a general reluctance among psychiatrists to admit that ECT could cause memory or other cognitive problems that are severe, persistent and disabling.” This bold statement comes from a recent article in the British medical journal Advances in Psychiatric Treatment. (1)

The majority of people who find their way to ect.org AFTER ECT are at the very least disappointed. At worst, they’re devastated. If they had known before ECT that it causes a number of side effects (with discouraging efficacy and high relapse rates), they could have at least gone into it armed with information and lowered expectations. It’s less devastating to know the possibilities beforehand than to be caught completely blindsided. The latter leaves patients feeling deceived and swindled. That is much of the reason there is so much anger on the part of ECT patients who have a bad outcome. If they had clearly known the risks, they likely would have made the same decision to have ECT, but would not end up feeling so mislead.

Robertson and Pryor emphasized that “prospective patients should be warned of the significant risk of permanent amnesia and the possibility of permanent memory and cognitive disability.” (2)

You may have had a good outcome, but many do not. The negative side of ECT is discussed on ect.org to provide the full set of facts instead of the sanitized version many ECT practitioners choose to supply. Additionally, after a person is left bewildered, with no answers, this site provides a sense of fellowship with others, knowledge that they are not alone.

ECT is NOT a cure and any doctor who sells it as such is guilty of snake-oil salesmanship.

3. I told my doctor I searched the Internet and found information contrary to what s/he told me regarding ECT. His/her response was that the Internet is full of material not based on scientific facts and I should ignore it and stay off the web. Why would s/he be dishonest? What reasons could my doctor possibly have to hide these things from his/her patients?

Two simple answers followed up by more thorough discussion:

1. They are unaware or more commonly, don’t listen to their patients and have their heads in the sand.

2. They are paternalistic and think they know what’s best for you. They know if they provided a full set of facts, some patients would reject ECT.

Neither explanation means that your psychiatrist is a demon or a bad doctor. The very nature of psychiatry is based on paternalism, a view that you are mentally ill and therefore are incapable of decision-making. By removing some of the variables (information), your decision is easier to make. Unfortunately, this point of view is strongly rooted in psychiatry and in the public perception. That doesn’t make psychiatrists bad, just old fashioned and in need of a makeover.

Paternalism

“Persons with mental illness cannot make decisions on their own.” Most are lumped into that category. Yes, there are some individuals who are so ill they cannot function and make a decision. But you are obviously well enough to surf the Internet, to perform a search and find ect.org, and you’re well enough to compose an email to me, type in the email address and operate your computer to send the mail. You’re very likely well enough to make an informed decision, based on ALL the facts, not the selected few chosen by the person in charge.

There is a debate within the ECT industry concerning when ECT should be prescribed. Should it be used early in a depressive episode, or saved for those who are the most severely ill, desperate and treatment resistant? One of the leading psychiatrists in the latter camp once said that if a person is well enough to surf the Internet, he or she is not ill enough to consider ECT. (Many would disagree with that statement, but I toss it out as an interesting observation.)

Without a clue

I did a small research study called “Voices” a decade ago. An unsurprising finding from that study was that when ECT patients tell their doctors that they HAVE suffered devastating memory loss and other side effects, the doctors dismiss their complaints. But there was a highly surprising finding: many of those patients get frustrated at their psychiatrists but feel trying to convince them of the existence of the effects is futile. They move on to a new psychiatrist, or give up on psychiatry completely.

That treating psychiatrist, who has already discounted that they had side effects, never sees the individual again. S/he logically assumes that the person got better and moved on. Another success story! And since the doctor had not listened to the patient’s complaints, those complaints are never registered in the psychiatrist’s mind, and therefore, do not exist.

You can make up a variety of scenarios regarding the psychiatrist’s thinking along that path, but the bottom line is that to the psychiatrist, that patient did not have side effects. It’s a misperception, based on a refusal to acknowledge the patient’s complaints, but the doctor probably genuinely does not know it.

The second scenario is of course knowing the truth, but failing to share it. That sounds a bit more devious that I believe it is. I don’t think it’s a case of an evil doctor knowing and not telling because s/he’s a bad person. I think it’s just more of a case of this paternalism I keep talking about, a view that the doctor knows what’s best for you, so why bog you down with too much information, particularly negative information.

Another possibility is that your doctor simply has not kept up with the literature. What your doctor may consider “scientific fact” may be the statistic that has been quoted for many years, that only 1 in 200 persons suffer severe memory loss. Several years ago, that statistic was shown to be, depending on your point of view, either misleading or an outright lie. Harold Sackeim, considered the King of ECT, admitted it on a television show, although it softened the blow by calling the number “Impressionistic.”

impressionistic:

adjective

1. of or relating to or based on an impression rather than on facts or reasoning; “a surprisingly impressionistic review bearing marks of hasty composition”; “she had impressionistic memories of her childhood”

In more recent writings and testimonies, Mr. Sackeim has said that now it’s known ECT does, in fact, cause severe memory loss much more often than has been acknowledged. In his defense, he said the industry “Just didn’t know,” and that he has been trying to get industry leaders and doctors in the field to acknowledge what is now known.

For seventy years, patients have been reporting the same complaints, but “they just didn’t know.” Sackeim claims that they only discovered the hard science a few years ago.

The information is now out there, it’s being published, and your doctor’s only excuse will soon be that s/he’s not keeping up with current literature.

If your doctor is promoting ECT as a cure for depression, consider that a red flag and get a second opinion. Even the most enthusiastic ECT cheerleaders will tell you it’s most often a temporary fix, one that will require regular treatments indefinitely.

References:

1. Mangaoang, M. & Lucey, J. (2007) Cognitive rehabilitation: assessment and treatment of persistent memory impairments following ECT. Advances in Psychiatric Treatment, 13, 90-100.

2. Robertson, H. & Pryor, R. (2006) Memory and cognitive effects of ECT: informing and assessing patients. Advances in Psychiatric Treatment, 12,228-237.

Cognitive Rehab After ECT: New Journal Article

Advances in Psychiatric Treatment (2007), vol. 13, 90-100 doi: 10.1192/apt.bp.106.002899

Cognitive rehabilitation: assessment and treatment of persistent memory impairments following ECT

Maeve A. Mangaoang & Jim V. Lucey

Abstract
Few tests address the types of memory problem commonly reported after electroconvulsive therapy (ECT). Here, we focus on the importance of neuropsychological assessment in ECT-treated patients and describe a number of tasks that may be useful in measuring the everyday memory problems of such patients with ongoing memory difficulties. At the time of writing, no attempts have been made to rehabilitate patients who experience persistent adverse cognitive effects, but clinicians should be aware of the potential beneficial role of cognitive rehabilitation in the treatment and management of these effects.

In a recent issue of APT, Robertson & Pryor (2006) drew attention to a number of issues regarding the assessment of cognitive function in patients treated with electroconvulsive therapy (ECT). In particular, they highlighted the paucity of tests that are sensitive and relevant to the specific memory problems commonly reported after ECT. Here, Mangaoang & Lucey return to this problem, discussing neuropsychological assessment in ECT-treated patients.

Electroconvulsive therapy (ECT) has been used for many years, but it remains one of the most controversial psychiatric treatments. In recent years, a considerable amount of research has attempted to highlight the efficacy and safety of ECT, in addition to emphasising the overall improvements in current ECT techniques, equipment and standards (Sharma, 2001; Chung, 2002; UK ECT Review Group, 2003; Prudic et al, 2004). However, there also exists a growing body of research consistently reporting the adverse cognitive and psychological consequences of ECT among a substantial minority of patients (Johnstone, 1999; Service User Research Enterprise, 2002; Koopowitz et al, 2003; Rose et al, 2003; Scott, 2005). Although discrepancies exist between clinician-led or hospital-based studies and those undertaken in collaboration with patients regarding the nature and extent of adverse side-effects, there is a general consensus that memory loss (Box 1) is the most frequently and consistently reported side-effect following ECT (Rose et al, 2003). There have been many conflicting accounts of the severity and duration of the memory and other cognitive difficulties (Weeks et al, 1980; Squire et al, 1981; Templer & Veleber, 1982; Squire & Slater, 1983; Lisanby et al, 2000; Brodaty et al, 2000), but to date there has been a distinct lack of routine neuropsychological assessment of individuals receiving ECT at any stage during their treatment.

Designing an assessment battery that is sensitive to the nature of the everyday problems experienced by patients with memory and/or cognitive disability is challenging, and standard neuropsychological tests may not adequately reflect the levels of impairment experienced by patients on a daily basis (Robertson & Pryor, 2006). Thus, the use of novel, personally relevant memory tasks such as those described below may be warranted.

Furthermore, no attempts have been made to provide any form of memory rehabilitation or cognitive retraining to patients who experience persistent memory and other cognitive problems in these areas following ECT. Here we argue that cognitive rehabilitation could be offered to such patients as a means of addressing these difficulties in a constructive way.

The importance of assessment

What is striking from the literature in this area is the lack of routine, formal assessment of patients’ neuropsychological performance following a course of ECT, despite the long-known risk to memory functioning (Squire & Chace, 1975; Squire et al, 1975; Freeman et al, 1980; Squire & Slater, 1983; Robertson & Pryor, 2006). Furthermore, the lack of consistency in the types of measures used to assess patients has made it difficult to clarify the extent and duration of the reported cognitive problems and the impact they may have on the individual’s overall quality of life and sense of self.

In Ireland, for example, there is no published research on the long-term effects of ECT on cognitive functioning among Irish patients. The failure to conduct such assessments means that there may be a significant delay in detecting patients who have experienced a marked decline in memory function.

Guidelines

The importance of assessing and monitoring patients’ cognitive function throughout their treatment has been recognised in guidelines on the commissioning of ECT services within the National Health Service (NHS) (Royal College of Psychiatrists, 1995,1999), and the ECT Accreditation Service (ECT Accreditation Service, 2005) includes assessment and monitoring of cognitive function as standards required for accreditation of a clinic. However, there has been a relative neglect to include such measures in routine clinical practice. It appears that even when they have been explicitly recommended (Freeman et al, 1980; Salford Community Health Council, 1998 ; Royal College of Psychiatrists, 2005) patients who report persistent memory loss have not been systematically followed-up or referred for neuropsychological assessment. As a result, their progress or deterioration over time in terms of cognitive performance has not been monitored.

Monitoring patients’ self-reports of adverse side-effects to ECT has also been recommended by the Royal College of Psychiatrists (1995, 2005) and the National Institute for Clinical Excellence (NICE, 2003). Benbow & Crentsil (2004) have shown the importance of measuring such experiences during treatment, as it allowed the ECT staff to take immediate action to try to relieve the problems. For instance, if patients reported persistent confusion or memory difficulties, staff could change from bilateral to unilateral ECT or increase the interval between treatments.

Longer-term implications

The failure to adequately provide neuropsychological assessments to patients receiving ECT means that the impact of additional, subsequent episodes of depression and/or future courses of ECT on overall cognitive functioning remains unknown (Robertson & Pryor, 2006). Establishing a baseline of functioning before an individual’s first ECT treatment is extremely important in terms of its association with ‘cognitive reserve’. This concept refers to individual differences in factors such as education and occupation, which may be protective against ECT’s adverse effects on memory functioning (Legendre et al, 2003).

The Society for Cognitive Rehabilitation (SCR; Malia et al, 2004) recommends that a combination of standard and novel tasks to assess current cognitive status should be administered to patients. Objective and subjective self-report questionnaires and collateral information from family or caregivers should be used, and the assessment battery should provide sufficient information to form hypotheses about the underlying cognitive impairments and deficits that interfere with the individual’s cognitive functioning. These recommendations concur with Robertson & Pryor’s (2006) proposal that ECT-treated patients who report ongoing memory disability should be referred for neuropsychological assessment. The purpose of this is both to determine their general cognitive abilities and to measure specific cognitive functions, such as attention, concentration and information processing, that may be related to memory functioning in everyday life (Ponds & Hendriks, 2006).

Making use of assessments results

Rather than merely describing problems, the results of neuropsychological assessments should be explained in terms that the patient can understand and explicitly related back to the functional problems that have been identified (Mateer et al, 2005). They should be interpreted in a holistic way that takes account of the individual’s personality and emotional characteristics and used to inform decisions about preparing a suitable rehabilitation programme (Malia et al, 2004).

Neuropsychological assessment of memory

There are many factors to consider in the neuropsychological assessment of patients receiving ECT. These include the selection or development of appropriate testing materials, the timing of testing sessions (Robertson & Pryor, 2006) and the effects of factors such as mood, metamemory and memory self-efficacy on performance (Mateer et al, 2005; Ponds & Hendriks, 2006). Additional problems, such as limited access to neuropsychology services, financial and time constraints, may have an impact on the number and frequency of assessment sessions that can be undertaken.

Design of appropriate tests

Although Robertson & Pryor (2006) recommend that patients who have had ECT should be assessed with the kind of neuropsychological tests that are used for patients with known or suspected brain injury, they acknowledge some of the problems associated with these traditional, standardised tasks. The main challenge appears to be designing tests that are sensitive to the memory and other cognitive demands placed on patients in their everyday lives. This task is made even more difficult by the realisation that patients with memory disability may not be able to give reliable self-reports of their memory functioning (Cronholm & Ottosson, 1963; Robertson & Pryor, 2006). Rose et al (2003) note that neuropsychological assessment of the extent of memory loss in ECT patients has tended to focus on the ability to form new memories (anterograde memory, Box 1), whereas patients have commonly reported the loss of autobiographical memory (retrograde amnesia, Box 1) following ECT (Coleman et al, 1996; Peretri et al, 1996; Donahue, 2000). However, loss of autobiographical memory does not appear to have been adequately investigated (Robertson & Pryor, 2006). Furthermore, alternative versions of tests may be required to reduce practice effects over repeated assessments.

Timing of testing

As mentioned above, encouraging patients who are undergoing a course of ECT to give self-reports of any adverse side-effects can be beneficial in terms of allowing staff to take immediate actions to reduce or relieve these effects (Benbow & Crentsil, 2004). However, in many studies the premature assessment of memory and overall cognitive functioning following ECT has led to inaccuracies and underestimations of patients’ impairment (Squire & Slater, 1983; Weiner et al, 1986; Coleman et al, 1996; Peretti et al, 1996; Donahue, 2000; Rogers et al, 2002; Robertson & Pryor, 2006). It may take a number of months for patients to gain a more stable view of permanent changes in their memory and cognition (Weiner et al, 1986; Coleman et al, 1996; Donahue, 2000).

A further problem relates to the ambiguity of meaning in the phrase ‘short-term memory loss’. Does it refer to type of memory or duration of loss? Robertson & Pryor (2006) recommend that the phrase ‘temporary memory loss’ should be used when referring to duration. Patients who interpret short-term memory loss in terms of duration may not be inclined to complain about memory difficulties, believing that they are to be expected and will resolve within the ‘short term’. This may lead to an underreporting of memory problems among patients who are assessed only a few days or weeks after the completion of ECT and highlights the importance of scheduling follow-up assessments after the 6-month time point (Service User Research Enterprise, 2002; Robertson & Pryor, 2006).

Effects of mood and emotional valence on performance

Many studies have shown that individuals who are depressed are more likely to recall negative events than positive or neutral ones (Teasdale et al, 1980; Parrott & Sabiny, 1990; Williams et al, 1988; Lemogne et al, 2005). The performance of people without depression on tasks measuring memory and cognition may also be influenced by their current mood. Recently, Beatty et al‘s (2006) study involving healthy adults showed the significance of both current mood and emotional valence (the subjective emotions associated with an event) on participants’ ability to recall events they had experienced over the past year. Therefore, any assessments of cognitive and memory functioning in patients who have received ECT should take account of the individual’s mood at the time of testing and also whether they perceive the event recalled as positive, negative or neutral.

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The concept is strongly linked to Mateer et al‘s (2005) theory of metamemory, which is defned as an awareness of one’s own memory processes, knowledge and use of memory strategies, self-perceptions of one’s memory abilities and beliefs about the functioning of ones’ own memory.

Memory self-efficacy and metamemory

According to Ponds & Hendriks (2006), patients’ complaints about their memory do not necessarily reflect memory deficits; furthermore, there may be large discrepancies between the severity of memory disturbances as measured by memory tests and the impact of these problems in daily life. Finding only moderate correlations between self-reported memory problems and objective results on standardised neuropsychological assessments, Ponds & Hendriks introduced the idea of memory self-efficacy (Box 2) to explain this discrepancy. They argue that an individual’s beliefs and perceptions about their memory may be extremely influential in determining their level of engagement and performance during memory assessment. The belief that one has a poor memory may lead to increased dependence on others, avoidance of memory challenges, and a pattern of helplessness and demoralisation when faced with memory difficulties (Elliot & Lachman, 1989). Additional evidence of the impact of self-perceived memory capacity on control of memory efficiency (Cavanaugh & Poon, 1989; Hertzog et al, 1990; Jonker et al, 1997) supports the argument that neuropsychological assessments of patients who have had ECT should take account of the patient’s own metamemory or sense of memory self-efficacy.

Novel tasks for measuring everyday memory

A few years ago one of us (M. M.) was involved in a study of the effects of surgery for temporal lobe epilepsy (Mangaoang et al, 2004). The study team developed tasks for assessing aspects of everyday memory functioning and spatial representation in patients after surgery (Box 3). These have since been administered to large numbers of healthy control individuals of all ages and to people with chronic major depression (McMackin et al, 2005). These tasks, which are outlined in this section, might be considered for use with patients following ECT.

Sensitivity to the nature of the patients’ memory problems

Episodic and autobiographical memory

The Mundane Memory Questionnaire specifically measures personally relevant episodic memory of typical daily events over the previous four consecutive days. Participants are asked to indicate (by circling either ‘yes’ or ‘no’) whether they recall a particular event, for example, watching television or eating lunch. If the event is recalled, they are asked to give additional information such as what programmes they watched or what food they ate. If participants are unable to provide additional details, they are asked to proceed to the next question.

This measure was extremely sensitive to the types of everyday memory problem experienced by the patients in our study of temporal lobe epilepsy (Mangaoang et al, 2004). It differs from questionnaires such as the Everyday Memory Questionnaire (Sunderland et al, 1984), the Prospective and Retrospective Memory Questionnaire (Smith et al, 2000) and the Cognitive Failures Questionnaire (Broadbent et al, 1982) in that it does not require patients to rate their own memory performance, thereby taking account of the observation that some people with memory problems cannot accurately rate the level of their impairment.

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The Everyday Memory Interview is based on an interview used by Eldridge et al (1994) in their assessment of the role of schemas in autobiographical memory. In a tape-recorded interview, the participant is asked to describe, in as much detail as possible, their typical day, yesterday and a day in the previous week, in counterbalanced order (to control for order effects or bias). The interview is scored by focusing on the number of basic activities that are recorded for each of the target days. Discourse analyses of the interview content can also be undertaken to measure the frequency of repetition of events, pragmatic problems and the use of verbal tics.

The merit of both the Mundane Memory Questionnaire and the Everyday Memory Interview is that they measure the ability of patients to recall personally relevant events, are straightforward to administer and are free from practice effects. Modified versions of the tasks could also be completed by patients’ caregivers or spouses, should collateral information be desired.

Semantic and phenomenal characteristics

Although both episodic and autobiographical memory have been widely researched, very few studies have used tasks that are concise, distinguish between semantic and episodic information, and control for emotional valence. Semantic information consists of general knowledge: things we know without any connection to personal experience, whereas episodic information refers to details such as time, person, place and emotions about specific personally experienced events. Levine et al‘s (2002) Autobiographical Memory Interview separates the semantic from episodic details of events. Beatty et al (2006) adapted and extended this measure to show how the recall of specific personally relevant events over the previous 12 months was influenced by whether participants construed the events as positive, negative or neutral. The transcribed interviews were analysed in terms of the number of specific episodic details recalled for each type of event, thereby controlling for the emotional valence of the event. This interview can be extended to include events from the less recent past, in order to gain a thorough appreciation of the extent of a patient’s retrograde amnesia.

Beatty et al (2006) also used the Memory Characteristic Rating Scale (adapted from Johnson et al, 1988) in conjunction with Levine et al‘s (2002) Autobiographical Memory Interview to measure the phenomenal characteristics of the different events. The Memory Characteristic Rating Scale uses a seven-point Likert scale to rate the vividness with which participants can recall specific aspects of an event, such as visual and auditory details. This combination of tasks facilitates examination of the association between the emotional valence of an event and the vividness with which different characteristics can be recalled.

Topographical memory

The effects of ECT on topographical memory, way-finding and spatial representation are largely unknown. We can find only one self-report of such deficits (Anonymous, 1965). Assessments of patients who have received ECT do not appear to consider the possibility of such impairments, despite their impact on everyday life. In our work on temporal lobe epilepsy (Mangaoang et al, 2004; Roche et al, 2005), we developed a number of tasks (the Landmark Location, Landmark Recognition and Virtual Map tasks) to measure the ability of patients with left or right unilateral hippocampal damage to recognise photographs of well-known Dublin landmarks and to accurately name their location on a modified map of the city. Patients also described in writing the routes they would take to get from one landmark to another on a map of a virtual city. These tasks were extremely sensitive to the everyday way-finding problems experienced by many of the patients, particularly those with right-sided hippocampal damage (Mangaoang et al, 2004) and could potentially be used to identify whether patients treated with ECT experience similar difficulties.

Sensitivity to metamemory and mood

In considering metamemory and memory self-efficacy (Box 2), the study team used a simple memory rating scale, asking patients to rate their own perception of their current memory functioning at the time of assessment on a five-point Likert scale (1 = ‘very bad’, 5 = ‘excellent’).

Patients’ self-reported symptoms of depression can be assessed using the Beck Depression Inventory (Beck et al, 1996). Alternatively, McMackin et al (2005) have used a mood rating scale that asks patients to rate their mood state at the time of assessment on a nine-point Likert scale (1 = ‘worst you’ve ever felt’, 9 = ‘best you’ve ever felt’). Either instrument could be easily incorporated into an assessment battery for patients receiving ECT.

Potential role of memory rehabilitation and cognitive retraining

Although reports have claimed that about one-third of people receiving ECT experience persistent memory loss (Service User Research Enterprise, 2002; Rose et al, 2003; Scott, 2005), it is unclear whether patients receive treatment or assistance from psychiatrists or other mental health professionals to deal with this disability. We do know that some patients turn to sources of help outside psychiatry (e.g. self-help groups) for support (Johnstone, 1999). This failure to attempt to rehabilitate patients may reinforce the negative public image of ECT specifically and psychiatry in general.

Adopting extisting techniques: brain trauma

The importance of carrying out detailed neuro-psychological assessments of patients following ECT in order to identify persistent cognitive problems was recognised over a decade ago (Calev, 1994). Unfortunately, however, even when cases of severe and persistent memory loss are highlighted in the literature, no study has recommended or attempted to provide any kind of rehabilitation or follow-up care. Documenting persistent and severe deficits in memory and cognition is not enough; patients need to be helped to adjust to the major effects that such disabilities may have on their everyday lives. Robertson & Pryor (2006) recommend that tests assessing neuropsychological function of brain-injured patients be used for ECT-treated patients. We would argue that the cognitive rehabilitative techniques that are used with brain-injured patients should also be considered for use with patients experiencing memory and/or other cognitive disability following ECT.

During the past 20 years, the course and nature of cognitive difficulties after brain injury and the key components of rehabilitation have become better understood. The significance of personal background, the range of emotional responses to injury and its consequences, and the role of coping skills in long-term adjustment are now more readily accepted (Mateer et al, 2005).

Cognitive rehabilitation therapy

Cognitive rehabilitation therapy is ‘a systematic, functionally oriented service of therapeutic cognitive activities and an understanding of the person’s behavioural deficits’ (Malia et al, 2004). Its aim is to achieve functional changes by reinforcing or strengthening previously learned patterns of behaviour, or establishing new patterns of cognitive activity or mechanisms to compensate for impaired neurological systems (Bergquist & Malec, 1997). Cognitive rehabilitation therapy has a large evidence base and has been widely researched among patients with acquired brain injury.

Memory rehabilitation

Recently, Ponds & Hendriks (2006) have described what appears to be the first formal attempt to offer a rehabilitation programme focusing on memory to patients with epilepsy. However, no attempts have yet been made to extend such treatment to patients who experience memory deficits following ECT.

What rehabilitation could achieve

Designing a rehabilitation programme for patients with memory or other cognitive disability associated with ECT would constitute the first step towards treating these deficits rather than merely reporting them. Such a programme would also acknowledge the individual’s difficulties and the challenges they face in coping with the demands of everyday life.

How it could be done

Baseline and post-treatment neuropsychological assessments could be used to clarify the nature and extent of cognitive difficulties. From there, appropriate steps towards memory rehabilitation and cognitive retraining (see below) could be undertaken in individual and/or group sessions, and could be extended to include the individual’s family or caregivers. Follow-up assessments of progress would allow any changes in cognitive status to be measured and also to monitor the transfer of acquired skills to other areas of functioning such as the social and occupational domains of the individual’s life. In this way it would be possible to determine whether the rehabilitation programme was having a beneficial effect on the patients’ overall quality of life.

Ultimately, successful practical attempts to address the impact of cognitive disabilities on the lives of patients treated with ECT would be welcomed not only by the patients themselves but also by their relatives and caregivers. The provision of such a service might also improve potential patients’ attitudes towards ECT, by reassuring them that, should they develop a persistent cognitive problem following treatment, some form of structured treatment and assistance would be made available to them. This might help the decision-making process for patients who are considering ECT as a treatment option.

Design of a successful rehabilitation programme

There are many factors to consider in the design of a cognitive rehabilitation programme. These include understanding that rehabilitation is a collaborative process, recognising the importance of including family and/or caregivers and being sensitive to the impact that a patient’s level of awareness, meta-memory, mood and motivation can have on their ability to take part in a programme. Premorbid personality and psychological functioning are also extremely important. Therefore, cognitive rehabilitation should involve work on the patient’s psychosocial skills such as coping, anxiety control, self-esteem, self-concept, motivation, locus of control and adjustment (Malia et al, 2004).

Existing programmes

Mateer et al (2005) believe that a combination of neuro-rehabilitation, pharmacotherapy and cognitive-behavioural therapy is often needed. Thus, many programmes incorporate multiple interventions such as attention training, memory compensations, skills training, feedback on performance, psycho-education, stress management, confidence-building and psychotherapy aimed at increasing self-awareness, acceptance and adjustment.

Cognitive rehabilitation programmes that take into account the emotional as well as the cognitive aspects of the injury appear to offer patients the best chance of adapting to their altered situations (Mateer et al, 2005). Being aware of the patient’s emotional well-being is extremely important as it may help identify the development of cognitive distortions such as catastrophic thinking (in which the individual imagines the worst possible outcome of events and situations). Catastrophic thinking can occur when an individual has a distorted belief about the implications of a cognitive error or episode of forgetfulness (Mateer et al, 2005). For example, a patient may interpret normal lapses of memory as confirmation of a memory impairment that will never improve. They may have difficulty in distinguishing between a normal memory lapse and a cognitive error that commonly results from a genuine brain impairment and this may reduce the individual’s ability to cope. Cognitive appraisal and beliefs of self-efficacy are increasingly recognised as being crucial to an individual’s ability to manage stress (Lachman et al, 1992; Mateer et al, 2005).

Recommendations for successful rehabilitation

Approaches to successful cognitive rehabilitation consider both general and specific aspects of the patient’s difficulties (Box 4). The general aspects focus on psychoeducation covering the effects of brain damage and cognitive difficulties, the impact of personality changes and emotional reactions, and the perception of cognitive disorders (Malia & Brannagan, 2004; Ponds & Hendriks, 2006). Aspects specific to memory rehabilitation address the types of memory problem that should be targeted for treatment and the best strategies that could be used (Ponds & Hendriks, 2006). Treatment plans should be given to the patient, caregivers or family members and the appropriate hospital staff. Progress on the treatment plan should be reviewed regularly (Malia et al, 2004).

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Psychoeducation

At the earliest possible stage, patients should be fully informed of their cognitive problems and their likely prognosis in terms of cognitive function (Malia et al, 2004; Mateer et al, 2005). Education should take place both in formal educational groups for patients and their careers/families and during regular individual contact with the patient, and it should be seen as an ongoing process (Malia et al, 2004). Group sessions should focus on understanding specific brain injuries and what rehabilitation is all about, cognitive and emotional problems following brain injury, how to cope with the changes experienced and developing a new sense of self.

The Society for Cognitive Rehabilitation (Malia et al, 2004) states that the aim of psychoeducation is to help the patient develop appropriate self-awareness, self-esteem, confidence, feelings of personal control and a trusting, working relationship with the therapist. It believes that the importance of education cannot be overemphasised: without good awareness, much of what is subsequently offered will have no enduring effects on the individual’s life in the outside world.

At present, very few patients and families are informed about the consequences of acquired cognitive deficits for future life or the possibilities to train or restore memory (Ponds & Hendriks, 2006). Creating a realistic perspective about the impact and possibilities for improvement of memory problems is the first important step in every memory treatment programme. Mittenberg et al (1996) showed that giving head-trauma patients a booklet on recovering from head injury had a significant positive effect on the number, duration and severity of reported symptoms (headache, memory, fatigue, concentration difficulties, anxiety, depression and dizziness) at 6-month follow-up.

It is crucial to give patients information on ECT during the consent process (Robertson & Pryor, 2006). Moreover, if the results from neuropsychological assessments indicate a need for intervention, patients should also be given psychoeducation or information booklets such as those given to head-injured patients, as these can be extremely beneficial in helping to alleviate the distress experienced by patients with mild brain damage. The information may also help patients adjust to any persistent cognitive difficulties they experience.

Rehabilitation techniques and strategies

The aim of rehabilitation is not restoration but compensation (Malia et al, 2004). This can be achieved through the use of internal or external rehabilitation strategies and modifications to the environment. Strategies adapted for use with people who have epilepsy have been shown to improve many aspects of their lives, including attention and memory, emotional regulation and psychosocial functioning (Ponds & Hendriks, 2006). Cognitive rehabilitation should improve the individual’s ability to function as independently as possible in the least restrictive setting and its end result must be to improve quality of life and real-life skills (Malia et al, 2004).

Studies investigating memory rehabilitation have focused on alleviating many different aspects of memory difficulties. These include both general memory problems such as learning and retrieval, and specific problems with orientation, dates, names, faces, routes or appointments (Wilson et al, 2001; Boman et al, 2004; Avila et al, 2004). Rose & Brooks (2003) have highlighted the potential role of virtual reality paradigms in memory rehabilitation.

According to Ponds & Hendriks (2006), two general approaches are currently used in memory rehabilitation: drill and practice, and compensatory strategies.

Drill and practice

The patient is encouraged to practice repeatedly specific memory tasks. This leads to an improvement on these tasks only; there is no transfer of benefits to general memory.

Compensation

This second approach involves teaching the patient compensatory internal and/or external strategies for coping better with everyday memory problems. Internal memory strategies comprise verbal and visual techniques. These encourage the patient to focus on linking isolated items, via associations, and on enriching the ‘to-be-remembered’ information with additional retrieval cues. The success of internal memory strategies may be due to the deeper level of processing and the elaboration of information that this brings about (Ponds & Hendriks, 2006). External memory strategies include devices that are used to store information (e.g. a calendar, diary, voice recorder or portable electronic organiser) or remind people to perform a particular activity at a specifed time (Wilson et al, 2001; Hart et al, 2004; Kapur et al, 2004; Kirsh et al, 2004).

External strategies also include rearranging or making modifications to the individual’s environment, for example always keeping important items such as keys, wallet or purse and diary together in a labelled drawer in the kitchen (Ponds & Hendriks, 2006). Clearly, internal strategies require greater cognitive capacity and insight than external strategies because the strategy has to be remembered at the very time the individual is becoming overwhelmed with the demands of a task (Malia & Brannagan, 2004).

Process training

Strategy teaching is an integral part of what is known as ‘process training’ in cognitive rehabilitation (Malia et al, 2004). Process training attempts to stimulate poorly functioning neurological pathways in the brain in order to maximise their efficiency and effectiveness. It aims to overcome damage by using both new, undamaged pathways and old partially damaged ones. Process training involves comprehensive assessment and an analysis of the results of this using a practical cognitive model. Regular reassessment should be undertaken to ensure that the patient is moving towards the agreed functional goals, and the results should determine the direction and progress through the process-training exercises.

Evidence shows that the use of process-training materials designed on the basis of neuropsychological theories and arranged into a structured programme can lead to gains in the majority of patients (Boman et al, 2004). Studies have also highlighted the benefits of using computerised assessment and rehabilitation tools in memory process training (Moore et al, 2001; Tarn & Man, 2004; Cappa et al, 2005).

Why is post-ECT rehabilitation so uncommon?

There are many reasons why no one has yet tried to introduce cognitive rehabilitation for patients who report persistent cognitive difficulties after ECT Until recently there appears to have been a general reluctance among psychiatrists to admit that ECT could cause memory or other cognitive problems that are severe, persistent and disabling. Even when patients show significant impairments in memory functioning, there has been considerable debate regarding the extent to which these may be attributable to ECT as opposed to factors such as depression (Robertson & Pryor, 2006). There has also been a failure to acknowledge the effect these consequences on the patient’s sense of self (Johnstone, 1999).

The delay in implementing in routine clinical practice the guidelines and recommendations for the neuropsychological assessment of patients at any stage during programmes of ECT has been a significant contributory factor. Furthermore, when patients receiving ECT have been assessed, the focus has generally been on documenting deficits rather than suggesting how to treat them. It is possible that psychiatrists have limited knowledge about the types of cognitive problem experienced by patients, how they affect their lives and what could be done to facilitate the recovery of cognitive functions or compensate for persistent deficits. They may also be unaware of the potential role of rehabilitation, what it involves and how it may inform the treatment and management of patients under their care.

However, the main reason for the near absence of post-ECT rehabilitation may be the lack of specialist neuropsychological services available to ECT psychiatrists and treatment teams (Robertson & Pryor, 2006). A psychiatrist may well recognise the merit of rehabilitation programmes but have no one to whom the patient can be referred. In Ireland, neuropsychology services are severely underdeveloped, particularly outside of Dublin. Therefore, the lack of suitably qualified personnel with expertise in this area is a significant problem. Multidisciplinary team approaches that include psychiatrists, neuropsychologists, occupational therapists, social workers and community liaison officers may be an integral part of best practice recommendations in cognitive rehabilitation, but in reality such services may not be available.

Conclusions

All patients should undergo cognitive assessment before their first ECT session. Subsequent comprehensive neuropsychological assessments should be routinely undertaken if patients report memory and cognitive disability following ECT. Assessments should take into account baseline (pre-treatment) functioning and should use tasks that are sensitive to the nature of the patient’s everyday problems and that take account of the influence of patient’s current memory, sense of memory self-efficacy and mood. Reassessment should be scheduled after a sufficiently long interval (more than 6 months after treatment) so that persistent cognitive and memory deficits can be identified. Furthermore, patients’ self-reports of adverse side-effects, particularly those concerning deterioration in memory and cognition while undergoing a course of ECT, should be properly investigated by staff in the ECT clinic (NICE, 2003; Benbow & Crentsil, 2004).

It should now be clear that documenting neuropsychological deficits is not enough; a specific programme of cognitive rehabilitation should be designed and made available to all patients with persistent cognitive difficulties following ECT, and details about this treatment should be included with the information that patients receive prior to treatment. This programme should incorporate methods of training and strategy learning of known efficacy that aim to generalise skills to all domains of the patient’s life. Clinicians should be aware cognitive rehabilitation appears to be most successful when patient’s physical, psychological, social and vocational well-being are considered together and when the programme is extended to include the family or caregivers (Mateer et al, 2005).

Cognitive rehabilitation following ECT offers a constructive way of treating and managing the most commonly reported side-effect, which is currently left untreated. Over time, this acknowledgement of the presence and impact of cognitive disability in ECT-treated patients, together with the education of patients, families and mental health professionals about ways to deal with these difficulties, would lead to better overall adjustment by patients and the development of a new sense of self.

Declaration of interest

None.

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Malia, K. B. & Brannagan, A. E. (2004) How to Do Cognitive Rehabilitation Therapy: A Guide for All of Us. Brain Tree Training.

Malia, K. B., Law, P., Sidebottom, L., et al (2004) Recommendations in Best Practice in Cognitive Rehabilitation Therapy: Acquired Brain Injury. Society for Cognitive Rehabilitation.

Mangaoang M. A., McMackin D., Quigley J., et al (2004) The effects of left and right selective amygdalohippocampectomy on everyday memory, discourse production and spatial representations. FENS Forum Abstracts, 2, A124.19.

*Mateer, C. A., Sira, C. S. & O’Connell, M. E. (2005) Putting Humpty Dumpty together again: the importance of integrating cognitive and emotional interventions. Journal of Head Trauma and Rehabilitation, 20, 62-75.

McMackin, D., Mangaoang, M. S., Anderson, M., et al (2005) Group cognitive behavioural therapy for major depressive disorder: relationship to neuropsychological function and measures of stress. Acta Neurobiologiae Experimentalis, 65, S64.

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National Institute for Clinical Excellence (2003) Guidance on the Use of Electroconvulsive Therapy (Technology Appraisal 59). NICE. http://www.nice.org.uk/pdf/59ectfullguidance.pdf

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*Peretti, C. S., DAnion, J. M., Grangé, D., et al (1996) Bilateral ECT and autobiographical memory of subjective experiences related to melancholia. A pilot study. Journal of Affective Disorders, 41, 9-15.

*Ponds, R. W H. M. & Hendriks, M. (2006) Memory rehabilitation in epilepsy. Seizure, 16, 267-273.

Prudic, J., Olfson, J., Marcus, S. C, et al (2004) Effectiveness of electroconvulsive therapy in community settings. Biological Psychiatry, 55, 301-312.

*Robertson, H. & Pryor, R. (2006) Memory and cognitive effects of ECT: informing and assessing patients. Advances in Psychiatric Treatment, 12,228-237.

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Rogers, M. A., Bradshaw, J. L., Philips, J. G., et al (2002) Attentional asymmetries following ECT in patients with major depression. Neuropsychologica, 40, 241-244.

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MCQs

1 Patients currently referred for ECT complete routine neuropsychological assessments:

a following the course of ECT treatments
b prior to receiving the first ECT treatment
c 3 months after the last ECT treatment
d 6 months after the last ECT treatment
e patients do not routinely complete neuropsychological assessments at any stage during treatment.

2 The following are not necessary in neuropsychological assessment of patients receiving ECT:

a the Eysenck Personality Inventory
b recommendations for treatment or rehabilitation of
impairments
c tasks measuring ‘real-world’ functioning
d collateral information from the patient’s family or caregivers
e measurement of factors influencing a patient’s ‘cognitive reserve’.

3 Tasks that require patients to self-rate their own memory functioning include:

a the Landmark Recognition Task
b the Mundane Memory Questionnaire
c the Autobiographical Memory Interview
d the Prospective and Retrospective Questionnaire
e the Everyday Memory Interview.

4 Cognitive rehabilitation is least successful when it focuses on:

a compensation for deficit rather than restoration of function
b the cognitive and emotional aspects of brain injury
c including the patient’s family or caregivers in the rehabilitation process
d the drill and practice approach
e the generalisation of acquired skills to the social and vocational domains of the patient’s life.

5 Cognitive rehabilitation techniques have been adapted and used for:

a patients with acquired brain injury
b patients with permanent memory and cognitive disability following ECT
c patients with intellectual (learning) disability
d patients with temporary memory and cognitive problems following ECT
e all of the above.

mcq.jpg

Maeve Mangaoang is a research psychologist at St Patrick’s Hospital (St Patrick’s Hospital, PO Box 136, James’s Street, Dublin 8, Ireland. Email: mangaom@tcd.ie) and a research associate at the Trinity College Institute of Neuroscience. Her interest in cognitive rehabilitation stems from her current research on electroconvulsive therapy (ECT) as a treatment for major depressive disorder and previous work in experimental neuropsychology among patients with temporal lobe epilepsy. Jim Lucey is a consultant psychiatrist and Head of the ECT Department at St Patrick’s Hospital. He also has a special interest in the treatment of obsessive-compulsive disorder.

Linda Andre’s new book scheduled for 2008 publication

Linda Andre’s new book scheduled for 2008 publication

If you visit ect.org next year, expect that I’ll be promoting Linda Andre’s new book! And you’d better plan on buying.

Her book was purchased this week by a major publisher!

This book will shed light on an industry that has fed on a plague of self deception, of defensiveness, and of outright lies. Might as well put the shock industry on official notice: the chipping away at your ivory wall continues. This time, Ms. Linda Andre will be wielding a jackhammer.

I confess I’ve had a peek, and the writing is stunning. That’s not a surprise to me and won’t be to anyone who knows Linda’s skills. It may be a surprise to the “gang” (Sackeim, Ricky and friends), who won’t be able to conceive that she’s far more articulate than they are.

This book will illuminate the practices of an industry the way that my favorite book “And The Band Played On” by Randy Shilts did regarding the AIDs epidemic and the Reagan Administration’s failure to react. In a year’s time, Shilt’s book will have to accept its role as “second-favorite” book.

Please check back in a year, or head to your favorite bookstore to purchase Linda Andre’s upcoming book.

Congratulations, Linda!!!!!!!

Little merit in ECT, US study finds

Opponents of electric-shock therapy are calling for a ban on its use in the elderly after a new study shows they are at increased risk of permanent brain damage.

The Press (New Zealand)
Feb 7 2007
By KAMALA HAYMAN

The elderly, women and people with lower IQs are the most vulnerable to brain damage, particularly memory loss, according to the first large-scale study on the long-term effects of electroconvulsive therapy (ECT).

About 300 patients a year are given ECT in New Zealand. Two-thirds are women and about 60 per cent are over the age of 50.

In a report released last year, the Health Ministry said ECT was “a valuable and sometimes life-saving” treatment for depression, mania and catatonia, although its effects were typically short-term.

In the New York study, just published in the Neuropsychopharmacology international journal, researchers followed 347 patients for six months.

The research team, led by Harold Sackeim, said the study provided the evidence that “adverse cognitive effects can persist for an extended period and that they characterise routine treatment with ECT”.

The “more severe and persisting” memory problems were found in those given ECT to both sides of the brain, leading the team to conclude there was “little justification” for such treatment.

Some patients were given ECT to only the right side of the brain, to protect the memory centre in the left.

Auckland clinical psychologist John Read said some New Zealand patients were still being given ECT on both sides of the brain.

Read, a long-standing campaigner against the use of ECT, has sent a second petition to the parliamentary health select committee calling for a ban on the treatment in older people, pregnant women and those under 18.

Read said the beneficial effects of ECT were short-term and there was no evidence it saved lives by preventing suicide.

He said patients given ECT should be told: “It does make some people feel better for a short period of time and it causes permanent brain damage for a significant proportion of people.”

A Christchurch 53-year-old, given ECT for severe depression last year, said she had consented to her 12-dose treatment but did not believe it was informed consent as she was not warned of the risk of permanent memory loss. “I have lost my long-term memory and I have lost totally the ability to administer and organise things,” she said.

Despite the “dreadful” side-effects, the woman, who did not want to be named, said ECT was a valuable treatment. Severe depression was not only life-threatening, it was a horrendous experience. “I was like the walking dead.”

She said her depression returned several months after the ECT, although it had since lifted, possibly due to acupuncture and meditation.

Canterbury psychiatric patients are among the most likely in the country to have ECT. In the year to June 2005, 79 Canterbury patients had a course of ECT, about one-quarter of the 307 treated nationally.

Health select committee chairwoman and Green MP Sue Kedgley said ECT was a “barbaric and old-fashioned technique” used in New Zealand with little regulation, monitoring or evaluation. The number of patients given ECT varied wildly in different parts of the country, as did the length of each course.

Kedgley was concerned that one in five patients had ECT without giving consent, and the rate was above 50% in some districts.

“If it is going to cause the harm that this research shows, then I certainly question why it should be given to people without their consent,” she said.

Canterbury psychiatrist Richard Porter, who oversees ECT use, said one-sided (unilateral) ECT was usually prescribed unless treatment was particularly urgent or there was no response to unilateral ECT.

“The choice is discussed with patients and family and the pros and cons explained before the decision is made,” he said. This particularly applied to the elderly, in whom it had been “known for a long time” that memory loss was more likely, he said.

Video Overview of ECT

A video overview of electroconvulsive therapy by Dr. John Friedberg, author of “Shock Treatment is Not Good for Your Brain.

Says the neurologist: “ECT isn’t new and it isn’t effective. It causes brain damage manifested mostly by amnesia. This video is a brief overview from my perspective as a neurologist.”

Click here to view video at You Tube.

[gv data="fBK5Y5rmAy0"width="425" height="350"][/gv]

Panel Questions Magnet Therapy Results

By ANDREW BRIDGES
The Associated Press
Friday, January 26, 2007

WASHINGTON — A novel machine designed to treat depression by zapping the brain with magnetic pulses shows no clear evidence of working, federal health advisers concluded Friday.

The device is called the Neurostar TMS, or transcranial magnetic stimulation, system. It uses magnetic energy to induce electrical currents in the region of the brain associated with mood.

Neuronetics Inc. believes those currents stimulate neurons in the region and relieve the symptoms of depression. The Malvern, Pa., company seeks clearance from the Food and Drug Administration to market the machine _ something the panel’s lukewarm reception may make less likely. The FDA isn’t required to follow the advice of its outside experts, but it usually does.

A clinical trial of the device provided results that, in one analysis, suggested it’s no better than sham treatment, according to FDA documents. Still, the FDA asked its neurological devices panel to review the overall safety and efficacy of the device.

Panelists said there was some suggestion the Neurostar works, but they called the effect marginal, borderline and questionable, an FDA spokeswoman said.

The company intends the device to be used by psychiatrists on an outpatient basis as an alternative to electroconvulsive therapy, or shock treatment, for the treatment of major depression. It would be used on depressed patients for whom therapy and antidepressants have not worked.

To gain federal approval, the FDA told Neuronetics that its device doesn’t necessarily have to be as effective as shock treatment if it can be shown to be a safer treatment option. Shock therapy can cause memory and cognitive changes, as well as headaches and burns.

Panelists said there were no important safety issues with the Neurostar. But none of the experts said the device works as substantially well as does shock therapy.

Company spokesman Peter Anastasiou said the company was confident in its efficacy data.

“In our view, we showed efficacy in a very tough to treat patient population,” Anastasiou said.

More here.

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