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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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.

CIA brainwashing victims seek Canada court action

Monsters and Critics

Americas Features
CIA brainwashing victims seek Canada court action
By James Stairs
Jan 19, 2007

Montreal – In a case that sounds like science fiction, a Montreal court is deciding whether a class action lawsuit can be brought against the Canadian government on behalf of more than 250 psychiatric patients who were unwittingly subjected to radical experiments in the 1950s.

The so-called MK-ULTRA tests were part of a secret mind-control programme funded by the US Central Intelligence Agency (CIA) and the Canadian government in the 1950s.

The Cold-War-era experiments, carried out by a Scottish doctor in Montreal, included forced isolation, induced-comas, electro-shock therapy and the use of hallucinogenic drugs, including LSD and paralysis-inducing narcotics.

Lawyers for Janine Huard, a 78-year-old great-grandmother, told a Montreal court last week that their client suffered for years as a result of Dr. Ewan Cameron’s experiments at the Allan Memorial Institute, a psychiatric hospital based at Montreal’s McGill University.

The experiments were part of a controversial secret CIA programme, aimed at uncovering techniques of mind control and led by Cameron, who died in 1967.

MK-ULTRA was launched by the CIA in 1953 and headed by the American chemist Sidney Gottleib. It reportedly funded projects both at home and abroad, including the Montreal study, and hoped to be able to find ways to extract information from prisoners and influence foreign leaders through brainwashing.

The project was brought under scrutiny in 1974 when newspaper reporters uncovered that MK-ULTRA had drugged unwitting subjects in the US with hallucinogens and secretly observed their actions. The project had been disbanded a year earlier and all record of its activities were destroyed.

Cameron’s research specifically revolved around ‘psychic driving’ – a potential cure, he believed, for depression and dementia that involved erasing patients memories and then building them back up again.

Huard said that she first came under the care of Cameron, a former president of the World Psychiatric Association, when she consulted him in 1951 regarding a case of postpartum depression after the birth of the second of her four children. She was in his care another two times up to 1962.

The court heard that Huard and hundreds of others were test subjects for Cameron’s ‘de-patterning’ experiments, which included the repeated playing of recorded messages while patients lay in a drug-induced semi-comatose state.

Huard said that she underwent electro-shock treatments and was administered dozens of unknown pills a day, keeping her semi- conscious.

‘She never knew that she was being subjected to these experiments or that she was being used by Dr. Cameron and his staff as a guinea pig,’ Alan Stein, Huard’s lawyer told the court.

The aftermath of the tests, she said, left her unable to function normally, afflicted by memory loss, depression and by migraine headaches.

‘I came out of there so sick that my mother had to live with me for ten years,’ she told reporters. ‘I couldn’t take care of my children any more.’

The CIA paid Huard and several others 67,000 US dollars each as part of a 1988 class action settlement.

In 1994, the Canadian government compensated 77 of the most severely incapacitated former patients 100,000 US dollars each for damage they suffered from the programme.

Huard and 252 others were denied compensation at the time, since the long-term affects of the testing were not deemed serious enough to warrant payment.

In 2004, a court overturned one of the decisions and awarded 100,000 Canadian dollars (85,259 US dollars) to Gail Kastner, a former patient who had undergone severe electro-shock therapy to treat her depression in 1953 at the hospital but whose claim had been previously deemed ineligible.

This decision, Huard’s lawyers argued, opens the door for the current class-action request.

Lawyers for the government did not dispute Huard’s claims but argued that the tests happened too long ago for her to make another attempt at compensation.

‘They demolished me,’ Huard told reporters as she entered the court. ‘They gave me terrible drugs, electroshocks, and made me stay in a bed with a mask over my face listening to recordings for hours a day. I was afraid.’

No timetable has been given regarding a decision from the court.

Professional accounts of electroconvulsive therapy: A discourse analysis

Peter Stevens a, , and David J. Harper b,

aOxleas NHS Trust, Dartford, Kent, UK
bUniversity of East London, UK

Available online 8 January 2007.

Abstract
Electroconvulsive therapy (ECT) is a socially contested psychiatric intervention. However, the accounts of professionals involved in its use have rarely been systematically investigated. This study aimed to examine the accounts of clinicians who have used ECT on a routine basis. Eight health professionals (psychiatrists, anaesthetists and psychiatric nurses from a major city in the United Kingdom) with experience of ECT administration were interviewed about the procedure. Discourse analysis was used to interpret the interview transcripts. Interviewees appeared to draw on a repertoire, which constructed ECT recipients as severely ill. This was used to support claims which had the effect of: defining who should receive ECT; warranting the use of urgent physical psychiatric treatments; reformulating distress in biological terms; and discounting the therapeutic value of alternative, non-physical interventions. The interviewees managed concerns about ECT in a variety of ways, for example by: rendering it as a medical procedure with concomitant risks and benefits; downplaying a lack of clarity over its evidence base; and undermining the legitimacy of criticisms. Implications of these findings are discussed.

Keywords: Discourse analysis; Electroconvulsive therapy; Debates; Persuasive communication; UK

Article Outline
Introduction
The unconscious motives of professionals: psychoanalytic research
From motives to attitudes, belief and knowledge: cognitive research
From motives, knowledge and attitudes to accounts: the contribution of a discursive approach
Method
Participants
Interviews
Initial reading and coding
Results
The biomedicalˆmedical repertoire
The Œsevere end‚ rhetorical device
Who is appropriate for ECT?
ECT as Œlife-saving‚
Locating the focus of concern at the biological level
Exclusion of non-physical interventions
Managing concern about ECT
Acknowledging grounds for concern: weighing up risks and benefits
Rendering ECT as a medical procedure
Downplaying debate: the evidence is becoming clearer
Managing criticism of ECT: who has rights to speak?
Discussion
Implications
Researchers
Mental health professionals
Service users
Appendix A. Appendix
A.1. Transcription notation
References

Introduction
Electroconvulsive therapy (ECT) remains one of the most widely used but contested and debated interventions in psychiatry. Advocates argue that the procedure is safe, effective and often life-saving (e.g., Abrams, 1997; Fink, 1979) whilst critics argue that it is ineffective and has the potential to cause psychological and neurological harm (e.g., Breggin, 1993; Friedberg, 1977; Johnstone (2000) and Johnstone (2003); Read, 2004).

However, there are two neglected areas in the research literature. The first is the relative lack of interest in the experiences of ECT recipients. Recently, researchers, including those with direct personal experience of receiving ECT have tried to redress this imbalance (Johnstone, 1999; Rose, Wykes, Leese, Bindman, & Fleischmann, 2003; Rose, Fleischmann, & Wykes, 2004), and there is a need for further investigation in this area.

A second neglected area is the empirical investigation of the accounts of those involved in ECT administration. The two most popular investigatory paradigms here have been psychoanalytic and cognitive. We will briefly review studies from these two paradigms, arguing that these studies are both theoretically and methodologically limited, before making the case for the contribution of a discursive approach.

The unconscious motives of professionals: psychoanalytic research
In the two decades following the introduction of ECT in the late 1930s, a variety of theories emerged to explain how Œshock treatments‚ worked and affected patients˜Gordon (1948), for example, reviews 50 of these. Less frequently, theorists examined the way ECT affected the professionals involved in its administration (e.g., Abse & Ewing, 1956; Fenichel, 1945; Wayne, 1955). Both were characterised by a psychoanalytic approach.

Abse and Ewing (1956) analysed Œoff guard‚ statements made by psychiatrists who were experienced in administering Œshock treatments‚. They suggested that such accounts were characterised by themes of hostility and punishment. For example, Œlet’s see if a few shocks will knock him out of it‚; Œwhy don‚t you put him on the assembly line‚; and the description of ECT as Œa mental spanking‚ (all p. 37). The authors suggested that Œthe very nature of the treatment itself can produce the attitudes described‚ (p. 38).

In a more recent example, Levenson and Willett (1982) reported observing Œsplitting‚ (divided clinical opinions), and disruption to the Œtherapeutic alliance‚ (rapport and empathy) in a multidisciplinary team involved in the care of two patients who received ECT. They concluded that ECT was an upsetting procedure because it Œoften produces rapid improvement in patients who had previously not responded to treatment‚ (p. 298) and the staff team experienced the therapeutic success as Œimplying devaluation of their own therapeutic skills‚ (p. 302).

However, this paradigm suffers from a number of limitations. For example, these studies have tended to be based on anecdotal reports rather than a more systematic gathering of material. Moreover, the reported comments are open to a number of competing explanations. Since psychoanalytic interpretations rely for their plausibility on inferred constructs which lie, as it were, within the person’s unconscious and thus cannot be demonstrated in the texts, they remain largely speculative.

From motives to attitudes, belief and knowledge: cognitive research
The second dominant approach in this area is cognitive, with questionnaires as the primary methodology. There have been a number of questionnaire-based studies investigating the attitudes and knowledge of professionals who are involved with ECT (e.g., Finch, Sobin, Carmody, deWitt, & Shiwach, 1999; Janicak, Mask, Trimakas, & Gibbons, 1985; Kalayam & Steinhart, 1981; Lutchman, Stevens, Bashir, & Orrell, 2001). Janicak et al. (1985) compared the knowledge and attitudes of psychiatrists, nurses, psychologists and social workers in relation to ECT. They reported that a positive attitude towards ECT in professional groups was correlated with increased knowledge about the procedure, and they concluded that educating staff about the facts of ECT would increase its utilisation in conditions where they suggested it should be the treatment of choice. Lutchman et al. (2001) used a similar design and drew similar conclusions finding differences in attitudes and knowledge across different disciplines, with psychiatrists being the most positive about ECT and psychologists the least.

However, as Diana Rose and her colleagues (Rose, Fleischmann, & Wykes (2004) and Rose, Wykes, Leese, Bindman, & Fleischmann (2003)) have argued in relation to investigations of ECT recipients‚ experiences, questionnaire-based methods limit and reduce the responses available to participants (see also Rosier, 1974). As a result, the possibility that factors other than knowledge might correspond with attitudes towards ECT has remained unexplored. More importantly, perhaps, this paradigm is methodologically and conceptually limited as a result of its assumptions about what constitutes Œknowledge‚ and Œattitudes‚ which are, again, inferred constructs thought to lie within the individual’s head.

A more fundamental problem with this approach is the way in which knowledge about ECT is presented as uncontested fact when the reality is much more complicated. Both the Janicak et al. (1985) and Lutchman et al. (2001) studies asked participants whether they agreed or disagreed with statements about the procedure. Despite being presented as Œfactually correct‚ or Œfactually incorrect‚ each statement could be interpreted in different ways and their facticity has been disputed in the literature. For example, the first statement from Janicak et al. (1985)˜Œthe therapeutic effect of ECT is related to the induction of a seizure in the brain‚˜is both supported (West, 1981) and contradicted by research demonstrating the effectiveness of placebo ECT (see Medical Research Council, 1965).

Similar assumptions have been made about Œattitudes‚ towards ECT. Janicak et al.’s (1985) participants were asked whether they would have ECT themselves if they were Œsuffering from varying degrees of depression‚ (p. 263). These responses were then regarded as demonstrating positive or negative attitudes toward the procedure. However, as with most attitude research there are fundamental epistemological difficulties with the notion that responses to lists of statements are unproblematically transformed into inferred mental constructs like beliefs or attitudes or unproblematically linked with conduct. Discursive psychologists like Potter and Wetherell (1987) dispute the idea that completing an attitude questionnaire represents a neutral and transparent transfer of an internal cognitive state to a mark on a page. Instead, they argue that people construct what they say in order to serve a range of functions (though not necessarily intentionally) and that this can be seen in intra- and inter-participant response variation. Thus the meaning of a psychiatrist agreeing with the statement that they would undergo the procedure if they were depressed (as 76.6% of Janicak et al.’s participants did) is not straightforward. For example, such agreement might enable participants to counter the potential charge of ethical inconsistency which might accompany disagreement with the statement. Moreover, the statement is abstracted from a context: there might conceivably be situations where these participants would be less likely to agree to have ECT.

From motives, knowledge and attitudes to accounts: the contribution of a discursive approach
Variation, disagreement and contradiction are usually rigorously controlled for in traditional cognitive research but at the cost of focusing on attitudes shorn of their context and this may tell us little about situated Œattitudes‚. In contrast, such variation is a topic of analytic importance for discourse analysts. For example, Harper (1999), in his study of professional and service user accounts of psychiatric medication, reported that a variety of explanations could be used in order to account for events such as the apparent failure of medication. Moreover, these explanations could be seen as having a variety of rhetorical effects˜in other words, they served a persuasive function, though this was not necessarily seen as an intentional action on the part of speakers. For example, when speakers claimed that medication had not worked because of the chronicity of the service user’s Œillness‚, this emphasised the permanence and severity of biological symptoms and shifted responsibility for treatment failure away from the medication and on to the illness.

Discourse analysis (DA) has been used to explore the accounts of health professionals in relation to a number of topics (Griffiths & Hughes, 2000; Parker, Georgaca, Harper, McLaughlin, & Stowell-Smith, 1995; Soyland, 1995). Because of its focus on the inherent variability of accounts, it is particularly useful in understanding how contested issues are constructed by participants. For example, Horton-Salway (2002) has shown how general practitioner’s discussions about ME (myalgic encephalomyelitis or CFS) are often concerned with the management of blame for the condition. Boyle (2002) and Boyle (2004) has suggested that professionals‚ use of rhetorical resources can make some ways of talking about a topic like schizophrenia seem more reasonable than others. In his study of talk about medication, for example, Harper (1999) argued that one of the effects of such talk was to serve certain institutional interests. For example, accounting for medication failure as due to the chronicity of illness could be seen to serve the interests of the Œpsychopharmaceutical complex‚ (Breggin, 1993) because questions about the efficacy of medication were deflected when such responses were deployed.

Johnstone and Frith (2005) have recently used DA to examine Freeman and Kendall’s (1980) study of ECT recipients‚ experiences and attitudes. They describe how patients are rhetorically constructed in this article in a number of ways, for example as passive and compliant or as hostile and unreasonable. They note that one of the effects of such constructions is to Œpreserve the view of ECT as a benign and beneficial procedure, and to validate both psychiatrists and psychiatry in the continued use of this treatment‚ (p. 200).

DA thus provides a novel perspective on the accounts of professionals. However, the kind of accounts presented in published research articles are highly systematised and organised and are likely to differ from those found in more informal settings. The aim of the present study, therefore, was to conduct an empirical qualitative investigation of accounts of the administration of ECT by those who administer it in the more informal context setting of a semi-structured interview.

Method
Eight clinicians involved in administering ECT were interviewed about it by the first author. The interview transcripts were interpreted using DA, which draws on a broadly social constructionist epistemology. Here we will briefly note key discourse analytic concepts on which we drew in the present study. Following Wetherell’s (1998) suggestion, we have drawn on both discursive psychology and Foucauldian discourse analytic traditions (Willig, 2001).

In discursive psychology, the systematic ways of talking about a topic generally found in conversations are termed interpretative repertoires. Edwards and Potter (1992) have described a number of ways in which speakers use rhetorical devices which have the effect of making what they are saying appear factual˜an example is the empiricist forms of accounting found in journal articles, where the agency of the scientist is minimised and agency is implicitly located in the objects of research. Such devices are often deployed when there is some disagreement about the facts and when the speaker has a stake in the outcome.

The analysis also drew on positioning theory (Davies & Harré, 1990), which attempts to re-conceptualise static and essentialist notions like role and identity. It assumes that when people speak they implicitly position themselves and others in relation to the topic under discussion. For example, in a conversation between a doctor and a patient, the doctor is implicitly assumed to have expertise about topics like illness, diagnosis and so on, whilst the patient is implicitly assumed to have expertise about topics like their health concerns. Parker (1997) notes that all positions carry Œcertain rights to speak and specifications for what may be spoken‚ (p. 291). Thus there are certain things which can and cannot be said from particular positions and within particular interpretative repertoires.

Discourse analysts try to avoid the ascription of intentionality to participants‚ accounts. In other words, it is not assumed that participants strategically design their talk in order to have certain effects. Parker (1992) comments that Œpeople make discourse, but not in discursive conditions of their choosing‚ (p. 32). One significant context-marker for the present study is that the participants were being interviewed by a psychologist who, by virtue of his discipline (see Lutchman et al., 2001), might be thought to have a different position to them on ECT, and this may well have influenced the results. Walkup (1994) has argued, for example, that such situations may well lead to Œquite self-conscious attention to legitimation themes‚ (p. 149). The reader needs to take this into account in judging the quality of the analysis.

Participants
All the interviews took place in a major city in the United Kingdom. The interviewees represented the cross-professional involvement in ECT administration, including pre- and post-procedure care (psychiatric nurses), prescription and delivery of the treatment (psychiatrists) and the administration of anaesthetic and muscle relaxant (anaesthetists). The research aim was to identify which positions and repertoires were culturally available to the speakers˜in other words to see what range of things could be said about ECT by professionals. Since discourse analysts are critical of abstract notions like Œattitude‚ and Œview‚, the aim was not to represent participants‚ views nor to compare views within the sample.

We considered that eight participants would produce a reasonable range of possible repertoires and positions, and this is consistent with previous DA research. A purposive sampling strategy was followed in that a range of disciplines were interviewed: four psychiatrists, two psychiatric in-patient nurses, and two anaesthetists. More psychiatrists were interviewed since ECT is primarily a psychiatric intervention.

Potential participants were identified and recruited through liaison with departments of anaesthetics or old age psychiatry˜the latter departments prescribe a substantial portion of the total number of ECT administrations in the UK (Pippard & Ellam, 1981). All were sent a standard invitation letter followed by a telephone call. The first eight professionals invited to take part agreed to do so.

The small number of participants increases the risk that they will be identified and so, in order to protect confidentiality, we will present demographic information for the group as a whole and not for individuals. Four men and four women were interviewed. Three participants were aged in their 30s, three in their 40s and two in their 50s. Five of the six medical professionals were consultants and one was a senior registrar. The two nurse participants had considerable involvement with ECT. All but one participant was involved with ECT administration at the time of the interviews.

Interviews
Potter and Hepburn (2005) have cautioned against what they see as the inappropriate and over-use of interview methods in DA studies. It is certainly true that interviews create particular kinds of interaction, and they should not be seen as a proxy for more Œnaturally occurring‚ kinds of conversations. However, it seemed that interviews were an appropriate source of data here because the study was interested in how professionals constructed accounts about ECT, for example how they might provide justifications for a contested intervention.

Interviews took place at a time and place of participants‚ choosing, usually at their workplace. The aims of the investigation were explained, anonymity was guaranteed and consent to both audio-taping the interviews and publishing extracts was obtained. A semi-structured interview schedule was followed, covering the participants‚ experiences of ECT and issues that had been debated within the literature. Appropriate ethical permission had previously been granted from a University Ethics Committee and interviews were conducted in 2001.

Initial reading and coding
Following Wood and Kroger’s (2000) guidelines, all the transcripts were read through in their entirety while a separate list of recurring or interesting categories and features were noted and eventually categorised. Extracts seen as related to each category were copied and pasted into correspondingly named computer topic files. Once printed, these became the material for analysis.

Results
Discourse analysts see their interpretation of such texts as only one of a number of possible readings and not the definitive one (Willig, 2001). Our reading of the interview transcripts indicated that different interpretative repertoires and rhetorical devices were drawn on by the interviewees, suggesting that a range of such features were culturally available to them. During the reading, the subject of interest was talk about ECT and, increasingly, as the analysis progressed, about those to whom it was administered. Although a range of features were identified, because of limitations of space, our analysis is structured by a focus on the Œbiomedicalˆmedical‚ interpretative repertoire and the Œsevere end‚ rhetorical device. We will also discuss how interviewees managed concerns about ECT. We will also draw on some of the psychiatric literature in order to place the interview material in context.

Transcription notation is described in the Appendix A. The code underneath each extract refers to the participant (e.g., Dr. A), their discipline (e.g., consultant psychiatrist) and the line numbers of the interview transcript from which the extract derives (e.g., lines 20ˆ22).

The biomedicalˆmedical repertoire
Throughout the interviews, it was common for ECT recipients to be described with diagnostic medical language, which typically referred to their behaviour and the consequences of that behaviour. For example, asked who was most likely to receive ECT, Dr. A responded Œpatients with severe depression who may be in a depressive stupor˜that means that they‚re sort of bed-bound, immobile, not eating not drinking‚ (Dr. A, consultant psychiatrist: lines 54ˆ55). Such lists of behaviour were described elsewhere as Œclear biological features‚ (Dr. E, consultant psychiatrist: lines 753ˆ754) or Œprominent physical symptoms‚ (Dr. B, senior psychiatric registrar: line 117).

A variant of the biomedicalˆmedical conceptualisation of patient behaviour and psychiatric interventions were accounts framed in electro-chemical terms. These are also to be found in some of the professional literature, for example, Œrepeated treatments [of ECT] alter chemical messages in the brain and bring them back to normal‚ (Royal College of Psychiatrists, 1995, p. 104).

The biomedicalˆmedical repertoire was often accompanied by a rhetorical device which focused on the chronicity and severity of problems.

The Œsevere end‚ rhetorical device
In the following extract the characteristics of those who are seen as most likely to be appropriate for treatment with ECT are discussed. Dr. A is discussing the occasions when ECT might be used to save life:

Dr. A: They‚re sort of bed bound, immobile, not eating, not drinking, er at risk of developing um major medical problems such as deep vein thrombosis, pulmonary embolic complications, which will kill them.

Interviewer: Right. Is that as a result of er (.)

Dr. A: Depression. Because they‚re severely depressed, they‚re in a depressive stupor. It’s defined as stuporous, literally.

(Dr. A, consultant psychiatrist: lines 54ˆ60)

Who is appropriate for ECT?
One feature of the extract is the way in which Dr. A constructs those patients who are seen as appropriate for ECT. They are Œbed bound, immobile, not eating, not drinking‚˜and located at what another interviewee described as Œthe severe end‚ of the clinical spectrum (Dr. E, consultant psychiatrist: line 56). Examples of the use of the Œsevere end‚ device can also be found in the professional literature:

It is recommended that electroconvulsive therapy (ECT) is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with: severe depressive illness; catatonia; a prolonged or severe manic episode.

(National Institute for Clinical Excellence, 2003, p. 1)

ECT as Œlife-saving‚
A formulation of ECT recipients as Œsevere‚ appeared to warrant the use of ECT on occasions when the person was viewed as at risk of dying either because of their attempts to actively kill themselves or because they were not eating or drinking. Both these kinds of behaviour were seen as symptoms of depression with failure to eat or drink viewed more seriously if the person was older, thereby potentially increasing the risk of physical health complications. The claim that ECT was life-saving was common across the interviews, regardless of participants‚ professional orientation. One effect of the Œlife-saving‚ repertoire was to sanction the use of ECT under conditions of compulsory psychiatric treatment (i.e., without requiring recipients‚ consent). This was termed Œemergency ECT‚ by participants. The grounds for such treatment are highly contested: both Johnstone (2003) and Read (2004) argue that there are no studies to support the claims of advocates for Œemergency ECT‚. Read comments that ECT Œdoes not prevent suicide and for a small number may precipitate it‚ (2004, p. 95).

Locating the focus of concern at the biological level
Another feature of interest in Dr. A’s extract is that there appears to be a causal chain in the location of the cause of problems. Causal agency initially appears to be located in physical health problems but these are then framed as caused by the patients‚ self-destructive behaviour, which in turn is seen as caused by depression. Ultimately, these biological signs and symptoms are presented as the threat to life. One effect of using technical descriptions (Œpulmonary embolic complications‚) is to construct the patient as both the cause of, and passive victim of, biological processes.

A second effect of constructing the problem at the biomedicalˆmedical level, rather than, say the psychological, or societal, is that it then becomes difficult to argue for alternative, especially non-biomedical, explanations and interventions. ECT was thus constructed not only as a reasonable intervention, but also an obvious one because it was viewed as fast-working and effective. One effect of this was that non-physical interventions were often discounted.

Exclusion of non-physical interventions
In the following extract, a participant describes the importance of early treatment when service users are extremely Œill‚:

Dr. E: ∑ if you delay effective treatment, you often have a tougher fight to fight.

(Dr. E, consultant psychiatrist: lines 789ˆ709)

In this extract Œtreatment‚ is implicitly seen as synonymous with ECT and the notion of time is foregrounded. It is implied that the use of other interventions would mean delaying the use of ECT, which is constructed as an Œeffective treatment‚. Elsewhere in the interviews the term Œtreatment‚ was seen as synonymous with pharmaceutical interventions. The ECT fact sheet for patients published by the UK’s Royal College of Psychiatrists (1995) states, Œthe alternative [to ECT] is drug therapy which also has risks and complications‚ (p. 104). Non-physical interventions such as psychotherapy or increased social support are absenced in these accounts, and one effect of this is to preclude them from being offered as alternative interventions. Arscott (1999) points out, Œit is likely to be difficult for a patient to refuse treatment with ECT if they believe that this is their only chance of cure‚ (p. 106).

Managing concern about ECT
All of the interviewees recognised that there was public concern about ECT and that it was seen as controversial, and they managed this in a number of ways. They acknowledged grounds for concern but framed ECT within a risks and benefits calculus similar to other medical procedures, sometimes accompanying this with claims that the evidential basis was becoming clearer. The interviewees acknowledged criticisms of ECT but in some of their accounts, more rights to speak were accorded to service user critics who had undergone it.

Dr. E: And I‚m actually quite scrupulous about g-, giving the pros and cons I, I, I very often clear with people, I really think this is the treatment you should be having, but I‚m also very clear ab-, that many people don‚t agree with this treatment, it’s still regarded as controversial, there are some things you probably will experience which you will not like. You probably will find your memory’s adversely affected. Er there are, you know, having an anaesthetic is at, at some level a risk, oh, the figure that’s quoted in the College of Psychiatrists Handbook is three deaths per one hundred thousand anaesthetics.

(Dr. E, consultant psychiatrist: lines 193ˆ202)

Acknowledging grounds for concern: weighing up risks and benefits
One way in which concern about ECT was managed was by drawing on a notion of informed consent. In this extract Dr. E notes how ECT recipients are presented with Œthe pros and cons‚. He includes some of the key concerns that critics of ECT have raised: that many disagree with it; that memory problems may occur; and that the administration of the anaesthetic itself is a risk. However, at the same time Dr. E says that he states ŒI really think this is the treatment you should be having‚. Also, the risk from the anaesthetic is slightly downplayed by noting that it is a risk Œat some level‚, although it was the risk seen as raising the most concern. This informed consent account is commonly encountered in discussions about medical procedures like major surgery, and so one effect of employing such a risk and benefits calculus is that ECT was seen as similar to other medical procedures.

Rendering ECT as a medical procedure
Within the interviews, ECT was often discussed through analogies with effects or processes associated with general medical procedures, and this also had an effect of managing concern about ECT. If ECT can be seen as a medical procedure with concomitant risks and benefits, then its particularly controversial status within the popular imagination (e.g., from films like One Flew over the Cuckoo’s Nest) can be minimised. Differences between the work of psychiatrists administering ECT and that of their medical colleagues carrying out surgery are de-emphasised and the procedure is presented as reasonable˜as Johnstone and Frith (2005) put it, ECT is thus presented as a Œbenign and beneficial procedure‚ (p. 200). Pilgrim and Rogers (1993) have argued that linking the content of psychiatric procedures with those of other medical procedures is one way of increasing the institutional alignment between psychiatry and general medicine˜an enterprise which Baruch and Treacher (1978) have suggested began in the 1960s when psychiatrists shifted their site of operation from separate institutions to district general hospitals. Equating the physical processes involved in psychiatric treatment with those involved in general medical treatment allows the status of the problem to be more easily conceptualised as biomedicalˆmedical. Moreover, Bracken and Thomas (2001) note that attempts to assert the equivalence of psychiatric and medical illness ignore the power of psychiatrists to use psychiatric treatments coercively. They remark, Œpatients and the public know that a diagnosis of diabetes, unlike one of schizophrenia cannot result in their being forcibly detained in hospital‚ (p. 725) and note, Œit is hard to imagine the emergence of Œanti-paediatrics‚ or Œcritical anaesthetics‚ movements‚ (Bracken & Thomas, 2001, p. 724).

Downplaying debate: the evidence is becoming clearer
A common theme in many psychiatric accounts of contested treatments is that the grounds for debate are lessening with increased research (see, for example Clare, 1976). This was evidenced in the interview material. In the transcript just before the next extract, Dr. B had noted that patient concerns about the lack of knowledge about how ECT works was understandable.

Dr. B: If the case for ECT was (.) crystal clear, that it does definitely work, then that wouldn‚t happen. (.) But as it happens, the case is not crystal clear, but I think it’s clearing up.

(Dr. B, senior psychiatric registrar: lines 447ˆ449)

Here Dr. B acknowledges that the case for ECT is Œnot crystal clear‚. Left at this point, Dr. B could potentially be challenged on why he continues to prescribe ECT. However, he then goes on to claim that it is Œclearing up‚. This could be seen as a form of Œrhetorical inoculation‚ (Sorenson, 1991) where a speaker deflects anticipated criticism.

In addition to these ways in which ECT recipients‚ concerns were managed within the interviews, the interviewees also drew on a range of other responses to direct challenges from ECT critics including groups of patients who have received ECT.

Managing criticism of ECT: who has rights to speak?
In the following extract, a participant discusses the confusion which they suggest can be experienced by patients and relatives regarding the behaviour of service users after they have received ECT. Dr. B is discussing the case of a patient who had Œlost her memory of her holidays‚ (line 89):

Dr. B: ECT is given to people who are very ill. And it’s very easy for relatives and patients (.) to (.) mix the two, sort of to (.) blame (.) ECT, the ECT for things that are to do with the illness.

(Dr. B, senior psychiatric registrar: lines 93ˆ95)

Here Dr. B suggests that behaviour could be viewed both as the direct result of ECT or, instead, Œto do with the illness‚. In claiming that it is due to the latter, Dr. B draws on the Œsevere end‚ device by describing those receiving ECT as Œvery ill‚. If this statement was made by a non-professional, it might be seen simply as an assertion. However, discourse analysts note that the force of a statement comes not only from its content but who makes it. Edwards and Potter (1992) describe the Œcategory entitlement‚ device which refers to the way in which the veracity of a report can be warranted by the entitlement of a speaker in a particular category to know certain things or have certain skills. Dr. B’s professional status confers rights to speak about what might constitute both unwanted effects of ECT and symptoms of illness. Others, like the relatives and patients mentioned here are positioned as less informed about the medical understanding of emotional distress and the effects of treatment. Thus it becomes possible to construct them as less authorised to make such judgements. One effect of this is to undermine the legitimacy of criticisms made by non-experts and especially recipients of ECT and their relatives. Johnstone and Frith (2005) have noted similar strategies at work in their DA of Freeman and Kendall’s (1980) article.

Of course, service users can attempt to claim certain kinds of category entitlements. As recipients of ECT they might understandably argue that they had expertise in understanding the effects of ECT. Indeed, such arguments have enabled users‚ experiences of ECT to gain a foothold in research conducted by ECT recipients themselves (Rose, Fleischmann, & Wykes (2004) and Rose, Wykes, Leese, Bindman, & Fleischmann (2003)). However, in the next extract, we see how attempts to gain such rights to speak can be challenged:

Interviewer: What, and when you talk about er (.) lay views of depression, many people underestimate how profoundly depressed people can be, what, what is the lay view of depression do you think? What is the standard view?

Dr. F: Well, I, it could be people who don‚t feel like going to work, who don‚t feel like going out, who don‚t feel like getting out of bed in the morning (.) er and they‚re a bit low (.) er it’s really, they stop socialising. I don‚t think people realise that depression is also, you stop eating, (.) that you‚ve stopped having baths, that you don‚t have a bath for three months and they find you at home. You know, that’s what they don‚t realise. You know, because as I said, most people have felt a bit low, but they don‚t really realise that depression is a serious illness. I don‚t know if you‚re a patient. Did, did you talk to the patient groups?

Interviewer: Well I‚ve read some of their literature.

Dr. F: I don‚t know, do they really know how bad these people are (.) those, those who are against ECT? (.) Do they ever come across, them, do they ever see how bad they are, do they/

Interviewer: /Do you mean people in the anti-ECT groups?

Dr. F: That’s right, do they really see them? You see it’s so easy for them to say when they get better Œoh ECT is a cruel treatment‚, but do they remember how bad they were to start with? Do they really know how severely ill?

(Dr. F, consultant anaesthetist: lines 342ˆ364).

Dr. F’s account here follows a similar trajectory to that of the previous extract from Dr. B in that lay views of depression are challenged: Œthey don‚t really realise that depression is a serious illness‚. In this extract, the Œsevere end‚ device is drawn on by describing Œhow bad‚ and how Œseverely ill‚ patients can be before they have ECT. However, Dr. F goes on to use a similar formulation to challenge the legitimacy of accounts of Œpatient groups‚. These critical accounts are implicitly challenged for being selective or lacking in objectivity in some way: Œdo they really see them?‚

There is an interesting shift in this extract, from describing individuals who are against ECT, but who have not Œcome across‚ those who receive it, to describing those who have received it (Œpatient groups‚), but who are Œbetter‚ and might have forgotten Œhow bad they were to start with‚. This account appears to challenge the legitimacy of the criticisms of both groups by drawing on the implied category entitlement of Œdoctor‚, which is set against the category entitlement of Œpatient‚. Thus, the knowledge and claims of ECT recipients who have experienced adverse effects are positioned as secondary to the knowledge and claims of the professionals who administer the procedure. These service users are positioned as poorly informed and forgetful. However, those who are critical of the procedure, but who have not been recipients, are implicitly positioned as even less authorised to criticise ECT. Elsewhere this is put more explicitly:

Nurse A: And especially if the person is really anti-ECT and had ECT then I haven‚t got too much of a problem. (.) It’s the ones that haven‚t had ECT that are against it that I‚ve got a bit of a problem with.

(Nurse A, Psychiatric Nurse: lines 364ˆ367)

By singling out those who are critical but who Œhaven‚t had ECT‚, Nurse A’s account appears to imply a hierarchy of authority to speak about ECT with those who have received ECT seen as having more rights to speak than those who have not. However, as we have seen, even those service users who have received ECT can still have the validity of their views challenged.

Discussion
We have presented a reading of professionals‚ accounts of ECT in which interviewees appeared to draw on a repertoire which constructed ECT recipients as severely ill. This was used to support claims which: circumscribed who should receive ECT; warranted the use of urgent physical psychiatric treatments; reformulated distress in biological terms; and discounted the therapeutic value of alternative, non-physical treatments. The interviewees managed concerns about ECT by: rendering it as a medical procedure with concomitant risks and benefits; downplaying a lack of clarity over its evidence base; and undermining the legitimacy of criticisms.

The use of the Œsevere end‚ rhetorical device is interesting in the light of evidence that the strongest predictor of ECT prescription is gender and age, rather than severity of illness: women and those aged over 65 (again, predominantly women for demographic reasons) are most likely to receive ECT (Read, 2004; Salford Community Health Council, 1998). Moreover, the viewing of memory problems as resulting from depression rather than ECT seems a little dated˜the consensus view from a range of studies does appear to demonstrate a range of cognitive problems following ECT administration (McElhiney et al., 1995; Neylan et al., 2001; Robertson & Pryor, 2006).

In interviewees‚ accounts, the agency of psychiatrists in prescribing ECT was downplayed with the decision portrayed as flowing from factors relating to the severity of illness. However, this does not account for the variability of ECT prescription over time, in different regions and also between psychiatrists. For example, the study of ECT prescription in Salford and Greater Manchester (Salford Community Health Council, 1998) detailed wide variations both between individual psychiatrists and over time. In his analysis of discourse concerning paranoid delusions, Harper (1994) reported that professionals used empiricist forms of accounting to explain how they reached diagnoses but he noted that they drew on a more contingent and subjective form of accounting to explain variations in diagnoses between professionals. This could be explored in further research focused on professionals‚ accounts.

Implications
There are epistemological challenges associated with applying findings from discourse analytic research (Willig, 1999). However, some discourse analysts explicitly seek to promote Œsubversive discursive practices and spaces of resistance‚ (Willig, 1999, p. 12). Here we will suggest some implications consistent with our analysis for different interest groups in mental health: researchers, professionals and service users.

Researchers
DA can provide a useful way both of examining some of the assumptions implicit in professional accounts and of detailing their effects. This can be most useful in relation to topics like mental health where conceptualisations are contested. Future research could explore whether the strategies employed here can be seen in other accounts both of ECT and of other psychiatric interventions. However, there is also a need for further research into the experiences of the recipients of psychiatric interventions, including studies conducted by service user researchers.

Mental health professionals
It may be possible to draw on some of the insights of studies like this to develop training packages to help mental health professionals become aware of the ways in which particular rhetorical resources may foreclose the offering of choices about interventions, like ECT, to service users. Such training could be aimed not only at psychiatrists, but also other health professionals (e.g., psychiatric nurses and social workers, psychologists and anaesthetists, etc.).

It is important to note that ECT recipients, like other users of mental health services, are not a homogeneous group of individuals (see Campbell, 1999). For example, some (e.g., ECT Anonymous, 1999a) have called for ECT to be banned, whilst others (e.g., Perkins, 1994) have made a case for its benefits. Service users could be provided with specific information about the type of accounts which they might expect prescribing clinicians to draw on during discussions about ECT. Robertson and Pryor (2006) have provided a useful format for discussing the benefits and risks associated with ECT with mental health service users. Informing service users about the ways in which health professionals can use language to construct ECT as Œordinary‚ or Œurgent‚, and patients as Œseverely ill‚ for example, could allow them to recognise that this is only one possible way of understanding their situation. Simply knowing that other accounts are available could empower service users to ask more questions about ECT and alternative treatments.

Service users
Service users could also develop training packages˜similar to assertiveness training˜in managing psychiatric interviews by role-playing possible responses. Such training would need to be accessible and to acknowledge both the emotional distress experienced by potential ECT recipients and the difficulties associated with challenging professional power. An example of what such training might look like can be seen in the ECT Anonymous (1999b) factsheet which pre-empts a list of questions and suggests possible responses with the suggestion that Œthere are simple answers to all these queries, even ones with technical terms. If there is a deep reluctance to answer these questions you should suspect the likely quality of your treatment‚ (p. 1).

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Appendix A.
A.1. Transcription notation
Noticeable pauses of less than one second were indicated by a full stop in brackets (.) while pauses of between 1 and 3 s are indicated by the word Œpause‚. A slash (/) indicates interruption and triangular brackets (< and >) indicate incidental contributions that were made by speakers during the other speaker’s turn. Transcripts were punctuated to facilitate reading. Identifying details were changed to preserve the anonymity of participants.

Corresponding author. Tel.: +44 1322 297151; fax

Electroconvulsive Therapy Causes Permanent Amnesia and Cognitive Deficits

ect.org note: This article is appearing in numerous publications and websites, so to avoid repeating the same information again and again, an ongoing list of publications will be posted below.

———–

Forbes
Electroconvulsive Therapy Causes Permanent Amnesia and Cognitive Deficits, Prominent Researcher Admits
12.21.06, 3:38 PM ET

NEW YORK, Dec. 21 /PRNewswire-USNewswire/ — In a stunning reversal, an article in the journal Neuropsychopharmacology in January 2007 by prominent researcher Harold Sackeim of Columbia University reveals that electroconvulsive therapy (ECT) causes permanent amnesia and permanent deficits in cognitive abilities, which affect individuals’ ability to function.

“[T]his 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,” the study notes.

For the past 25 years, ECT patients were told by Sackeim, the nation’s top ECT researcher, that the controversial treatment doesn’t cause permanent amnesia and, in fact, improves memory and increases intelligence. Psychologist Sackeim also taught a generation of ECT practitioners that permanent amnesia from ECT is so rare that it could not be studied. He asserted that most people who said the treatment erased years of memory were mentally ill and thus not credible.

The National Institute of Mental Health (NIMH) estimates that more than 3 million people have received ECT over the past generation. “Those patients who reported permanent adverse effects on cognition have now had their experiences validated,” said Linda Andre, head of the Committee for Truth in Psychiatry, a national organization of ECT recipients.

Since the mid-1980s, Sackeim worked as a consultant to the ECT device manufacturer Mecta Corp. He never revealed his financial interest in ECT to NIMH, as required by federal law, and, until 2002, did not reveal it to New York officials as required by state law. Neuropsychopharmacology has endured negative publicity over its failure to disclose financial conflicts of journal authors, resulting in the editor’s resignation and a promise to disclose such conflicts in the future; yet there is no disclosure of Sackeim’s long-term relationship with Mecta, nor did Sackeim disclose his financial conflict when his NIMH grant was renewed to 2009 at approximately $500,000 per year.

The six-month study followed about 250 patients in New York City hospitals, an unusually large number; most ECT studies are based on 20 to 30 patients. Sackeim’s previously published studies were short term, making it impossible to assess long-term effects. “However, in other contexts over the years — court depositions, communications with mental health officials, and grant protocols — Sackeim has claimed to follow up patients for as long as five years. This raises serious questions as to how long he has actually known of the existence and prevalence of permanent amnesia and why it wasn’t revealed until now,” Andre said.

Besides finding that ECT routinely causes substantial and permanent amnesia, the study contradicts Sackeim’s oft-published statements that ECT increases intelligence and that patients who report permanent adverse effects are mentally ill.

“The study is a stunning self-repudiation of a 25-year career,” Andre said.

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Other publications that have picked up the story:

Dec 22 2006:

Forbes
Medical News Today
Brietbart
Dallas News
Kron.com
MedicalDevices.org
TXCN.com – Healthcare & Hospitals
WFAA
Philadelphia Weekly
Genetic Engineering News
Pharma-Lexicon

Electroconvulsive Therapy Causes Permanent Amnesia And Cognitive Deficits, Prominent Researcher Admits

Electroconvulsive Therapy Causes Permanent Amnesia And Cognitive Deficits, Prominent Researcher Admits

Medical News Today
Dec 22 2006

In a stunning reversal, an article in the journal Neuropsychopharmacology in January 2007 by prominent researcher Harold Sackeim of Columbia University reveals that electroconvulsive therapy (ECT) causes permanent amnesia and permanent deficits in cognitive abilities, which affect individuals’ ability to function.

“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,” the study notes.

For the past 25 years, ECT patients were told by Sackeim, the nation’s top ECT researcher, that the controversial treatment doesn’t cause permanent amnesia and, in fact, improves memory and increases intelligence. Psychologist Sackeim also taught a generation of ECT practitioners that permanent amnesia from ECT is so rare that it could not be studied. He asserted that most people who said the treatment erased years of memory were mentally ill and thus not credible.

The National Institute of Mental Health (NIMH) estimates that more than 3 million people have received ECT over the past generation. “Those patients who reported permanent adverse effects on cognition have now had their experiences validated,” said Linda Andre, head of the Committee for Truth in Psychiatry, a national organization of ECT recipients.

Since the mid-1980s, Sackeim worked as a consultant to the ECT device manufacturer Mecta Corp. He never revealed his financial interest in ECT to NIMH, as required by federal law, and, until 2002, did not reveal it to New York officials as required by state law. Neuropsychopharmacology has endured negative publicity over its failure to disclose financial conflicts of journal authors, resulting in the editor’s resignation and a promise to disclose such conflicts in the future; yet there is no disclosure of Sackeim’s long-term relationship with Mecta, nor did Sackeim disclose his financial conflict when his NIMH grant was renewed to 2009 at approximately $500,000 per year.

The six-month study followed about 250 patients in New York City hospitals, an unusually large number; most ECT studies are based on 20 to 30 patients. Sackeim’s previously published studies were short term, making it impossible to assess long-term effects. “However, in other contexts over the years — court depositions, communications with mental health officials, and grant protocols — Sackeim has claimed to follow up patients for as long as five years. This raises serious questions as to how long he has actually known of the existence and prevalence of permanent amnesia and why it wasn’t revealed until now,” Andre said.

Besides finding that ECT routinely causes substantial and permanent amnesia, the study contradicts Sackeim’s oft-published statements that ECT increases intelligence and that patients who report permanent adverse effects are mentally ill.

“The study is a stunning self-repudiation of a 25-year career,” Andre said.

Harold Sackeim reverses position in upcoming study

by Linda Andre
Director, CTIP

The Cognitive Effects of Electroconvulsive Therapy in Community Settings

NIMH-funded research study published in the January 2007 issue of Neuropsychopharmacology

Author and primary investigator: Harold Sackeim

Funding: NIMH grants

#35636, Affective and Cognitive Consequences of ECT, funded since 1981 for a total of approximately ten million dollars so far (grant has been renewed through 2009)

#59069, ECT Practices in Community Settings—Evaluating Outcomes, funded since 1999 for a total of approximately 3.5 million dollars so far

Summary: After 25 years and millions of dollars of federal funding to research the adverse cognitive effects of ECT—25 years in which not one single longterm followup study was ever published—self-proclaimed “world expert” on ECT Harold Sackeim has now reversed his position, admitting that ECT routinely causes permanent memory loss and deficits in cognitive abilities. His new study—the first to be published in which he followed patients as long as six months, and one of his only studies to use controls—validates a generation of patient reports of permanent iatrogenic disability, and disproves Sackeim’s previously published claims that these reports were simply symptoms of mental illness. Other findings: there is no evidence that ECT increases intelligence, as Sackeim has previously claimed; and women are much more likely than men to experience severe permanent amnesia.

Significance: Harold Sackeim has been called the Pope of ECT, and for good reason. He’s published more on ECT than anyone in the world, has received more money to research it than anyone in the world, and is the author of the American Psychiatric Association’s patient information statement and consent forms, which are used by most hospitals in America. Through his writing, teaching, testimony—and positions on peer review, editorial, and funding boards, including NIMH grant review panels—he has more influence on what the profession and the public believe about ECT than anyone in the world. What Harold says goes.

Conclusion: This study could have been done at any point in the past 25 years. If it had, a generation of patients could have been warned of the likelihood of permanent significant memory and cognitive deficits before, instead of finding out after, ECT. In fact, there is evidence—from Harold’s own statements—that over the years he has in fact conducted studies following up ECT patients for a long as five years…but never published the results. Why not? Why did it take 25 years and over ten million dollars to validate what patients have been saying all along? In other words: What did Harold know, when did he know it, and why wasn’t it revealed?

Quotable quote from the study: This study provides the first evidence in a large, prospective sample that the adverse cognitive effects can persist for an extended period, and that they characterize routine treatment with ECT in community settings.

For a detailed critique, see below.

For the past 25 years, patients who received electroconvulsive therapy (ECT) have been told by the nation’s top ECT doctor that the controversial treatment doesn’t cause permanent amnesia or cognitive deficits and, in fact, improves memory and increases intelligence. Psychologist Harold Sackeim of Columbia University also taught a generation of ECT practitioners around the world that permanent amnesia is so rare it could never be studied. Sackeim was the popularizer if not originator of the position that former patients who said the treatment erased memory were simply mentally ill and thus not credible.

His newest and perhaps last ECT research study disproves his tenaciously held claims about the treatment’s harmlessness. It is, in effect a stunning self-repudiation of a 25-year research career…one in which he accepted federal research money with one hand and consulting fees from shock machine companies with the other.

See, for instance, the key finding:

This study provides the first evidence in a large, prospective sample that the adverse cognitive effects can persist for an extended period, and that they characterize routine treatment with ECT in community settings.

Similarly, from the abstract:

Despite ongoing controversy, there has never been a large scale, prospective study of the cognitive effects of electroconvulsive therapy

Sounds like the research team is congratulating itself for being “the first,” as if they’d made a discovery before anyone else, doesn’t it? You might think that…if you didn’t know that Sackeim has held the only available NIMH research grant to study ECT’s adverse effects, titled “Affective and Cognitive Consequences of ECT,” continuously since 1981…and if you didn’t know what Sackeim promised the federal government in his original application for grant funding:

“The major objective of the proposed research is to examine the effects of bilateral and right unilateral electroconvulsive therapy on affective and cognitive functioning. The consequences of the two treatment modes will be studied in regard to neuropsychological functions that have previously not been studied…Drug-free inpatients presenting major unipolar depressive disorder will be tested before, during and after treatment and a matched normal control group will be tested at comparably spaced times.”

Instead of doing this, however, he used his grant money largely to compare different types of ECT to each other, not to examine the effects of ECT; and only less than a handful of his 200+ published studies used normal controls, an absolute necessity to isolate the effects of ECT.

Why did it take 25 years to conduct one large, long-term controlled follow-up study? And in the absence on this research, why did Harold so confidently assure professionals, patients, legislators, and the public that ECT was safe?

A closer look at the study shows us that, in fact, Harold and his team are still not being honest with us, still not revealing all they know. They tried their damnedest not to find out what ECT really does…but failed. Here they reveal only the minimum information they had to concede after using every trick in the book to bias their research in favor of not finding negative effects of ECT.

What tricks did they use here?

1) The assumption that ECT does not cause permanent amnesia and cognitive deficits was built into the design of the study. How so? The study allowed subjects who’d had ECT before, as recently as two months prior, to be counted as the “before ECT” patients–meaning before this course of ECT. It assumed that any effects of ECT resolve within two months. 43% of the subjects had had prior ECT, so that at least half of the data involved comparing the effects of ECT to the effects of more ECT–not isolating the effects of ECT.

2) The outcome measures used to measure amnesia and cognitive function are irrelevant and inadequate to measure the known effects of ECT. Yet even deliberately using measures that would result in underestimating deficits, these deficits were still found to be profound and persistent!

For a critique of the tests used by Sackeim, see Robertson and Pryor’s article, Memory and cognitive effects of ECT: informing and assessing patients, in Advances in Psychiatric Treatment (2006), vol. 12, p. 228-238. For example, the Mini Mental Status exam used by Sackeim is a test that screens for dementia, the grossest and most glaring form of cognitive disability, and is useless for detecting the kinds of deficits caused by ECT.

Sackeim uses a memory test he invented himself, the Autobiographical Memory Inventory. This test is unpublished, not publicly available, not validated, and is not used except by ECT advocates. Robertson and Pryor note that the majority of questions are not relevant to the types of information forgotten by ECT survivors, nor can the test detect amnesia beyond a one-year period. A string of references in Sackeim’s new article attempt to provide support for the claim that the AMI “has shown strong reliability and validity as a measure of retrograde amnesia.” Not only do they not show this, but all the referenced articles were written by Sackeim himself!

3) Patient IQs were estimated pre-ECT using a method that underestimates intellectual ability especially with much higher than average IQs; no attempt was made to ascertain actual IQ. No one looked at these patients’ IQs post-shock to see what happened to them; why not?

Sackeim et al. conclude, based on inaccurate assumptions and no data from these or any other patients, that “Individuals with greater premorbid abilities can better compensate for the impact of ECT on cognitive functions” (references claiming to support this point have nothing to do with ECT but are articles about an unproven theory of “cognitive reserve”).

Even if the researchers didn’t choose to seek out survivors of ECT who once had very high IQs, or to respond to the many survivors of formerly superior IQs who have contacted them, there is a substantial record of accounts by persons who had extremely high or genius IQs who have spoken and written publicly of the devastating effects of having those IQs lowered by ECT (Jonathan Cott, Linda Andre, Anne Donahue, and Marilyn Rice are four such individuals.) None of these accounts suggests that people with “greater premorbid abilities” have an easier time after ECT; in fact, they strongly suggest the opposite.

In addition to these tricks, the researchers used one of the most reliable methods of biasing results: concealing data.

1) “A substantial number of secondary cognitive measures” are said to have been administered along with the named tests, yet the researchers nowhere reveal what they were and what the results were.

2) The names of the seven facilities in the New York City metropolitan area are not revealed. While this isn’t necessary for evaluating the results of the study, it means the facilities with the worst outcomes can’t be held publicly accountable, nor can the millions of city residents protect themselves from the worst offenders.

3) The results of the cognitive tests on the 24 control subjects are not revealed, nor is how they compared to the people who had ECT.

It’s a very big deal for the Sackeim team to use matched normal controls; in 25 years and hundreds of studies they have not done so. Normal controls are essential to ethical and valid research. This article states that “The comparison sample completed the same neuropsychological battery at time points corresponding to the assessment period in patients.” But you search in vain to find out how the controls did on the five named tests of memory and cognitive functioning and the unnamed “secondary measures”, and how they compared to the ECT patients immediately and six months after ECT. It’s not in the text, and it’s not in the tables. So why have the controls take the tests at all, if you’re not going to reveal the results?

Only one thing is revealed: The normal controls did much better than the bilateral ECT patients on the (flawed) measure of amnesia:

“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 post-ECT and 6-month time periods, respectively, suggesting that the deficits were substantial.”

4) Sackeim does not reveal—has never revealed in hundreds of published articles—his financial ties to the shock machine companies Mecta and Somatics. Yet in sworn testimony, Sackeim admits he has worked for Mecta for at least twenty years. He designs their shock machines for them. Not only is disclosure required by journals such as Neuropsychopharmacology (ironically, the subject of a recent scandal in which authors and even the journal’s editor did not reveal their ties to another company which has hired Sackeim, Cyberonics), it is also required by state law (because Sackeim is an employee of New York State) and federal law (because Sackeim accepts NIMH money).
Sackeim flaunts these laws by not disclosing the money he makes from the shock machine manufacturers.

This article is a damning critique of work done over 25 years (and at the expense of millions of taxpayer dollars) by this very team of researchers.

If you know that Sackeim’s been funded for decades to do this research and chose not to do it, the following statements read very differently than the researchers intended. Instead of self-congratulation, they read as condemnation.

“Empirical information about ECT’s long-term effects derives mainly from small sample studies conducted in research settings, with follow-up intervals limited to two months or less…These studies could not adequately assess the severity and persistence of long-term deficits.”

The use of small samples and short-term follow-up characterizes all of Sackeim’s work until now, and was their choice, deliberately made so as not to know (officially) about “the severity and persistence of long-term deficits.” These researchers single-handedly had the wherewithal to address these belatedly-acknowledged flaws in their own research at any time since 1981.

“We conducted the first large-scale, prospective study of cognitive outcomes following ECT.”

Why the first study only after 25 years? What of the generation of patients—two and a half million people according to their own estimate—who have received shock in those years without knowing the long-term consequences?

“Severity of depressive symptoms showed little relationship with the cognitive measures. At the post-ECT time point, none of the 11 measures were related to concurrent HRSD scores. Findings were also negative for 8 of the 11 measures at the six-month follow-up.”

Translation: patients aren’t just imagining or lying about their cognitive and memory deficits because they’re crazy. Yet in many published articles written on the NIMH dime, and over and over in public testimony and in court, that is exactly what Sackeim and Prudic have claimed. And they have influenced countless others to believe it.

DAMNING FINDING #1: amnesia is substantial and permanent

“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 post-ECT and 6-month time periods, respectively, suggesting that the deficits were substantial.”

“At the six-month time point, there continued to be a significant relationship between the number of BL ECT treatments and the extent of retrograde amnesia.”

“Greater amnesia for autobiographical events was significantly correlated with the number of ECT treatments received 6 months earlier.”

DAMNING FINDING #2: cognitive deficits are substantial and permanent

“Compared to baseline performance, at the postECT time point the total patient sample showed deficits in the mMMS, sensitivity of the CPT, delayed recall of the BSRT, delayed reproduction on the CFT…” (All are measures of memory and cognitive ability).

“This study provides the first evidence in a large, prospective sample that the adverse cognitive effects can persist for an extended period, and that they characterize routine treatment with ECT in community settings.”

DAMNING FINDING #3: ECT permanently affects reaction time

“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…”

(Once again: Whose fault is that?)

“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 levels…The findings here raise the concern that this form of stimulation has deleterious long-term effects of elemental aspects of motor performance or information processing.”

DAMNING FINDING #4: Bilateral ECT is no good

“For decades, BL ECT represented the gold standard with respect to ECT efficacy…A majority (of US ECT practitioners) administer mainly or exclusively BL ECT…
There appears to be little justification for the continued first-line use of BL ECT in the treatment of major depression.”

(More than 90% of the ECT given in the U.S., and at least as high a proportion in other countries, is bilateral.)

DAMNING FINDING #5 They lied when they wrote in the APA consent form that ECT improves your memory

What this team has said in numerous published articles—and what Sackeim wrote into the American Psychiatric Association guidelines on ECT, the “bible” used by all rank and file shock doctors—that ECT improves memory and intelligence, is not true.

“It is noteworthy that most cognitive parameters were substantially improved at 6-month follow-up relative to pre-ECT baseline, presumably because of the negative impact of the depressed state on baseline performance…It cannot be concluded, however, that the extent of improvement in any group returned to premorbid levels.”

DAMNING FINDING #6: A much greater percentage of women than men are damaged by ECT than men: 81% vs. 18%.

“There was a gender difference, with a greater preponderance of women (81.6%) compared to men (18.4%) in the persistent deficit group.”

No doubt Sackeim and his handlers will try to “spin” this study as a scientific breakthrough, and hold him up as a reformer and patient advocate. Nothing could be farther from the truth.

Where is the apology to the generation of people who were lied to, who will never regain their memories and their cognitive abilities?

Full study

Jane Pauley suit against NYT says paper duped her into being drug stooge

News flash: New York Times takes a crap on the small amount of credibility it had left. Stick a fork in it…they should merge with CBS News and just call themselves THE BIG PILE.

Jane Pauley Sues New York Times
Broadcaster claims fraud over appearance in drug industry advertorial

Oct. 25, 2006
The Smoking Gun

OCTOBER 25–Claiming that The New York Times duped her into granting an interview for what turned out to be a drug company-funded advertising supplement, Jane Pauley has sued the newspaper for fraud. In a lawsuit filed Tuesday in U.S. District Court, the 55-year-old broadcaster charges that she believed that the Times interview was for a news article on mental health issues, but that the story (accompanied by a full-page photo) ran in an October 2005 “special advertising supplement” promoting psychotherapeutic drugs sold by Eli Lilly and other pharmaceutical firms. Pauley, who in September 2004 disclosed her battle with bipolar disorder, alleges that the Times “duped” her into lending her name to its advertising gambit, according to the lawsuit, an excerpt of which you’ll find below. After going public about her bipolar disorder, the lawsuit notes, Pauley has worked with several mental health advocacy groups, including the National Mental Health Association. Pauley’s lawsuit seeks unspecified damages from the newspaper and DeWitt Publishing, which helped arrange the advertorial.

Court records

Patients decide which treatments they would allow

Pact gives mentally ill options
Patients decide which treatments they would allow

October 16, 2006

If you’re hospitalized and unable to make health decisions, a living will can guide doctors about how much medical intervention you want.But what if you have a mental breakdown? A similar document, called a psychiatric advance directive, details the mental health treatments you would prefer.

Psychiatric advance directives, or PADs, have been available for years, and Illinois’ document is among the best, experts say. But PADs are little known and seldom used.

To raise awareness, the National Resource Center for Psychiatric Advance Directives has started a Web site, www.nrc-pad.org, providing state-by-state PAD information and downloadable forms.

A PAD is prepared when a patient is lucid. “The benefit is that the patient feels heard,” said Dr. Marvin Swartz, co-director of the center. “The patient feels empowered.”

The center was developed by Duke University Medical Center and the Bazelon Center for Mental Health Law.

PADs are intended for people with a history of severe and persistent mental illness such as schizophrenia or bipolar disorder — about 3 percent of the population.

Good for three years

The Illinois PAD allows you to state whether you agree to be hospitalized for up to 17 days, and whether you would consent to electroconvulsive (shock) therapy. It also lists what psychotropic drugs you would take. You might, for example, agree to take a certain drug, but only after your doctor has tried your preferred drug.The directive takes effect if two doctors or a court determine you are unable to make reasonable decisions. (You can name one of the doctors in the PAD.) The PAD must be followed, unless there is an emergency or unless a court contradicts your wishes. And you still could be hospitalized, regardless of what your PAD says, if it’s determined you are a danger to yourself or others.

The PAD designates a friend or relative to make decisions about your mental health treatment. It must be signed by two competent adults who attest you were of sound mind when you signed it.

The directive remains in effect for three years. You can revoke it only if a doctor determines, in writing, that you are competent to cancel it.

Illinois’ law is 10 years old but only recently has begun to catch on, the Illinois Guardianship and Advocacy Commission said.

jritter@suntimes.com

Shock Treatment: Efficacy, Memory Loss and Brain Damage

Shock Treatment: Efficacy, Memory Loss, and Brain Damage – Psychiatry’s
Don’t Look, Don’t Tell Policy
by Richard A. Warner

This downloadable paper was written by a paralegal in an ECT case that is currently on appeal. He researched the subject for two years, and decided to put that research to use, in this paper.

Shock Treatment: Efficacy, Memory Loss, and Brain Damage

PDF: 300k

Electro therapy facts ‘not given to patients’

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.

ECT cognitive effects: unpublished article reveals damning information

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.

4,247 Words
5 Tables
5 Figures

The Cognitive Effects of Electroconvulsive Therapy in Community Settings

Harold A. Sackeim1,2,3, Joan Prudic1,2, Rice Fuller4, John Keilp2,5, 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


Harold Sackeim Mecta deposition video clips

Here are a number of clips from the videotaped deposition of Harold Sackeim (2004). Sackeim was the expert witness for Mecta in a lawsuit in California.

You can read most of the deposition here, in PDF format.

I’m splitting the videos into two pages to reduce your load. If the page loads slowly, or the videos don’t load, try again in thirty minutes…it’s likely YouTube is down.

Richard Abrams is defensive, says Harold Sackeim

Harold Sackeim, king of ECT, discusses his complaints about Richard Abrams, president of Somatics, Inc., saying that Abrams is defensive because of the “fascist” groups, and goes too far with his defensiveness by ignoring the “problems” inherent with ECT. Meow!

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Harold Sackeim tells NY Assemblyman Rivera he “discarded” requests

After making a public offer to evaluate individuals with damage after ECT, Sackeim explains that he told the NY Assemblyman Peter Rivera (D-Bronx) he discarded the responses. They “spent the day” together. How cozy. Rivera is head of the New York Committee on Mental Health. Harold has more than one cozy relationship, and it’s paid off in a big way for him.

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Killroy was here

An endorsement? No, but Harold admits he’s been here. Everyone, please, a warm welcome to the Lord of the Dance, Harold Sackeim.

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He’s said it, very clearly

Very emphatically: “I don’t dispute that there are some people who have very severe memory loss. I’ve been the one who’s been saying that very clearly.”

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2 million people?

“Uh, what I do know is that probably about 2 million people are receive ECT each year…” When questioned by the attorney asking if he “knows” that, Harold backpedals and says he said “estimate.” A few years ago he told Extra it was a million. I guess that Cyberonics VNS device isn’t working out so well.

Perhaps saying “I do know” and then claiming he said “estimate” is being a tad picky. But consider that this seems to be a habit with him: reinventing himself, parading himself as the champion of the shock patient by criticizing “Dick” Abrams, and claiming he’s a purist scientist, even when he admits statistics were not genuine statistics as claimed, but merely a guesstimate. Since the long-held guess of how many Americans receive ECT annually is 100,000 to 200,000 (usually quoted as 100,000 in the media), where on earth did he get this 2 million figure for the world?

Oh, it’s an estimate. He made it up.

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Follow the money…

Here’s something he can’t make up, because there’s a paper trail. He billed Mecta for $10,875 for pretrial consulting. And that was *before* the trial, or even this deposition, took place. No telling what the final bill will be! His rate is $500 an hour to help Mecta defend against a lawsuit. Notice how he refuses to say the amount, instead, referring to the “rate that’s there.” For whatever reason, Harold Sackeim cannot say the words “I charge $500 an hour.”

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Part 2 of the video deposition

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