Electroshock and Informed Consent

Electroshock and Informed Consent

Journal of Humanistic Psychology, Winter2000, John Breeding

Abstract: Informed consent is a vital issue in all forms of medicine, especially in psychiatry, where patients are often in extremely vulnerable states of mind, customary practice involves high risk to patients, and the law allows for abrogation of traditional civil rights based on judgments of perceived mental incompetence. This article addresses informed consent related to the practice of electroshock. The author argues that genuine informed consent for electroshock is nonexistent because psychiatrists deny or minimize its harmful effects and, as long as the threat–overt or covert–of involuntary treatment exists, there can be no truly voluntary informed consent. The author discusses four primary ways psychiatry violates informed consent in electroshock practice and presents an outline of important information to know about electroshock. An annotated review of the research is provided to back up each of the author’s assertions about medical effects and lack of efficacy of electroshock.

ELECTROSHOCK AND INFORMED CONSENT

Summary

Informed consent is a vital issue in all forms of medicine, especially in psychiatry, where patients are often in extremely vulnerable states of mind, customary practice involves high risk to patients, and the law allows for abrogation of traditional civil rights based on judgments of perceived mental incompetence. This article addresses informed consent related to the practice of electroshock. The author argues that genuine informed consent for electroshock is nonexistent because psychiatrists deny or minimize its harmful effects and, as long as the threat–overt or covert–of involuntary treatment exists, there can be no truly voluntary informed consent. The author discusses four primary ways psychiatry violates informed consent in electroshock practice and presents an outline of important information to know about electroshock. An annotated review of the research is provided to back up each of the author’s assertions about medical effects and lack of efficacy of electroshock.

Genuine informed consent for electroshock is nonexistent because electroshock psychiatrists deny or minimize its harmful effects. For example, the American Psychiatric Association (APA) (1990) states, “In light of the available evidence, `brain damage’ need not be included [in the consent form] as a potential risk” (p. 68). In addition, in all but one state, electroconvulsive therapy (ECT) may be legally forced on nonconsenting individuals who are adjudicated mentally unqualified to give their consent.

The undergirding of psychiatry is coercive. Society generally respects the right of citizens to refuse treatment of physical illnesses, however life-threatening, except for “mental illness.” As long as the threat (overt or covert) of involuntary treatment exists, there can be no truly voluntary informed consent.

There are many ways in which informed consent is violated; I will mention four. First, there is denial and minimization of harmful effects. The official APA literature and the typical hospital brochure are both travesties of truth. The consent form example provided by the APA (1990) in The Practice of Electroconvulsive Therapy states that the death rate for ECT is “approximately one per 10,000 patients treated” (p. 157). Publicly available statistics collected between 1993 and 1996 by the Texas Mental Health Department show that the rate is 50 times higher. As noted above, the APA suggests that patients need not be advised of ECT’s potential risk. The APA gives no credence to the numerous human autopsies, brainwave studies, animal studies, clinical observations, and reports from ECT subjects clearly demonstrating ECT’s brain-damaging effects (see Appendix B). In 1994, St. David’s Hospital in Austin, Texas, gave an information sheet to ECT candidates that stated ECT was safe for pregnant women.

The second reason I argue that informed consent exists only in name is that even minimal and inadequate guidelines for the administration of ECT are routinely and systematically violated. For example, a report by the Wisconsin Coalition for Advocacy (1995) thoroughly documents pervasive and systematic violations of that state’s informed consent guidelines on ECT. A study by Benedict and Saks (1987) of the regulation of professional behavior with regard to ECT in Massachusetts showed that “approximately 90% of ECT patients received treatment inappropriately, suggesting that the regulation of ECT administration is ineffective” (p. 247). It is interesting that the authors also reported that “the more familiar a psychiatrist was with threatened or instituted lawsuits involving ECT, and the more likely a lawsuit was thought to be, the greater was his or her departure from the guidelines” (p. 252).

A third point with regard to how informed consent principles are violated is rarely mentioned. Dr. Fred Baughman, a retired neurologist, in a letter to United States Attorney General Janet Reno, points out that the legal obligation under informed consent is to provide patients with all the information relevant to their decision making–not just about the treatment in question but also about their condition. Psychiatric patients are never told that their alleged disease is theoretical or metaphorical. To quote Baughman (personal correspondence, September 10, 1998),

To say or even imply that what the patient has is biologic and a disease when there is no such proof (as in all psychiatric “diseases”) is conscious deception and abrogates informed consent. That this has become the standard of practice in psychiatry does not excuse it. The abrogation of informed consent is de facto medical malpractice.

Fourth, and pragmatically crucial, is simply that people become victims of this so-called “treatment” at a time in life when they are extremely vulnerable. At vulnerable times, individuals desperately need to trust and rely on others for help. Reaching out, they need complete safety and support. Their only hope, in this desperate state, is to trust the wisdom and guidance of the professionals to whom they turn for help. Informed consent is a superlative principle, but, in practice, it is not a protection. Nevertheless, for educational purposes, I provide here an example of what authentic informed consent would involve. I encourage you to copy and share this form with others. An annotated review of the research by Moira Dolan, M.D., provided to back up each of my assertions about medical effects and lack of efficacy, is in Appendix B.

AUTHENTIC INFORMED CONSENT FOR ELECTROSHOCK

You are being asked to consider undergoing the psychiatric procedure of electroshock, commonly referred to as electroconvulsive therapy (ECT). It is your right, according to Texas state law, to be fully informed about the nature and effects of this procedure. This is so that should you choose to receive electroshock, your consent will be authentic, based on full knowledge and awareness. Of course, you also have the right to refuse the procedure.

Prerequisites to Informed Consent

State of Mind

A fundamental requisite of genuine informed consent is mental competence. This means that prospective patients are able to understand this information and make a decision. At minimum,

1. Patient is free from the influence of any and all mood-altering substances, including legally prescribed psychotropic medications.

2. Patient is evaluated by a nonpsychiatric physician, preferably a neurologist. A mental-status examination is required to reveal a well-oriented mind and adequate functioning of higher level decision-making processes.

3. Patient is functionally literate: able to read and comprehend this written material. Alternatively, he or she is able to clearly understand the communication of this material to him or her by audiotape.

State of Body

A complete physical examination by a nonpsychiatric physician, preferably an internist, is recommended. The internist should evaluate for, and inform the patient and psychiatrist of, the potential of the individual to sustain physical complications of ECT treatment. This is analogous to what an internist does in a preoperative evaluation for surgery.

Your Condition

You are labeled as “mentally ill,” diagnosed with a particular “disease” for which ECT is being recommended as “treatment.” ECT is being justified as a “treatment” based on the assertion that your “disease” (probably called depression, but possibly some other “disease” such as bipolar disorder or schizophrenia) is a biologically or genetically based illness.

Your label of “mentally ill” and diagnosis of “major depression” or other “mental illness’ is entirely hypothetical, based on subjective reports and observations of mood and behavior. There is no evidence of disease, chemical imbalance, or anything physically or chemically abnormal to validate your diagnosis with a medical illness.

What It Is

The Procedure

Electroshock involves the attachraent of electrodes to the temples outside one (unilateral) or both (bilateral) frontal lobes and the administration of electricity to the frontal lobes of the brain. Intensity of voltage may vary from approximately 70 volts to approximately 600 volts. Duration of the electrical current may vary from 0.5 to 4 seconds.

Administration of ECT also varies enormously in number of treatments, from one to literally hundreds, over time. A typical course of treatment involves 6 to 12 sessions. Multiple monitored ECT is a variation that consists of three treatments in I session, spaced about 5 minutes apart, with 3 sessions in I week; thus, nine treatments in I week.

In making your decision, it is important that you know the following:

1. The natural electrical activity of the brain is measured in millivolts, or thousandths of a volt. Thus, the power of ECT is literally hundreds of thousands of times greater than natural brain electrical activity.

2. The ECT procedure involves a level of electricity that can range from the minimum level required to induce a convulsion to 40 times greater than that level (Sackeim, Devenand, & Prudic, 1991). The official APA recommendation ranges from 1.5 to 3 times the level required to induce a convulsion (APA, 1990).

Drugs Administered

Prior to electroshock, you will be given the following:

* general anesthesia,

* tranquilizers, and

* muscle relaxants.

Each of these drugs has a wide range of effects on your body, mind, and emotions, including but not limited to the possible adverse reactions that are listed below. You can look up this information at the library in the Physicians Desk Reference (PDR) (1999) or at your local pharmacist’s office in Drug Facts and Comparisons (1999).

Anesthesia (i.e., Methohexital Sodium). Possible adverse reactions include circulatory depression, hypotension, peripheral vascular collapse, convulsions in association with cardiorespiratory arrest, respiratory depression, cardiorespiratory arrest, skeletal muscle hyperactivity, injury to nerves adjacent to injection site, seizures, emergence delirium, restlessness, anxiety, nausea, abdominal pain, pain at injection site, salivation, and headache.

Tranquilizer (i.e., Valium). Possible adverse reactions include excessive sleepiness and drowsiness, confusion, restlessness, depression, crying, sobbing, delirium, hallucinations, dizziness, blurred vision, depressed hearing, unsteady gait, hypertension, hypotension, skin rash, nausea, and vomiting.

Muscle Relaxant (i.e., Succinylcholine Chloride). Possible adverse reactions include skeletal muscle weakness; profound and prolonged skeletal muscle paralysis resulting in respiratory insufficiency and apnea, which require manual or mechanical ventilation until recovery; low blood pressure; flushing; heart attack; bronchospasm; wheezing; injection site reaction; and fever.

Prior to granting consent for ECT, a patient will be provided a list of drugs to be administered for ECT and a complete list of the effects described in the PDR.

FDA Classification

The Federal Food and Drug Administration (FDA) classifies ECT machines as Class III devices. This means that ECT is an experimental procedure, classified in the highest risk category by the FDA. Class III means that the machine has not gone through the rigorous FDA testing required of medical devices, including safety testing and efficacy assessments.

Possible Medical Effects of ECT

* death,

* brain damage,

* cardiovascular complications,

* extra risks of the three above categories for the elderly,

* seizures and epilepsy, and

* memory loss.

Note

Because ECT is a high-risk, experimental procedure and because of the possibility of permanent brain damage, you may want to consider magnetic resonance imagery (MRI) brain scans before and after this procedure. Having a pre-ECT MRI and post-ECT MRI is one way to measure the possible physical effects of ECT on your brain.

Negative Emotional Effects

* terror,

* shame,

* helplessness, and

* hopelessness.

Many individuals who have undergone ECT report horrific emotional distress resulting from this procedure (see Appendix A for contacts with outlets for the voices of outspoken survivors of electroshock). Physical and mental debilitation, together with intense fear, shame, and hopelessness, often make life and recovery a tremendous challenge for people who undergo this procedure.

Lack of Efficacy

Research indicates the following:

1. No lasting beneficial effects of ECT (Breggin, 1997; Rifkin, 1988).

2. Sham-ECT (where an individual is anesthetized and told he or she will receive ECT but actually does not) has the same short-term outcomes as actual ECT (Crow & Johnstone, 1986).

3. ECT does not prevent suicide. Suicide rates for those receiving ECT are no lower than non-ECT patients with similar diagnostic profiles (see Appendix B).

Financial Disclosure

The cost of ECT varies significantly. Cost of the procedure itself may vary from $100 to $300 per treatment for the psychiatrist’s services. “Hidden” costs include fees for the anesthesiologist and the surgery suite (up to $800 combined per session), room and board at the hospital (usually $800-$1,300 per day at a private psychiatric hospital), psychotherapy charges by the psychiatrist (average $100-$150 per hour), consultant fees, and charges for whatever drugs are administered. Depending on the setting and whether you are inpatient or outpatient, there will be variable fees for the “operating room” and the hospital. Patients will receive and sign a full financial disclosure of all costs, in writing, prior to consent for this procedure.

EDITOR’S NOTE: As the U.S. Surgeon General will soon issue a statement giving blanket approval to the use of ECT, many mental health consumers and activists are alarmed and angry. For information about this ongoing controversy, see these Web sites: www.MindFreedom.org and www.ect.org/statements/apa/contents.html.

REFERENCES

American Psychiatric Association. (1990). The practice of electroconvulsire therapy: Recommendations for treatment, training and privileging (task force report). Washington, DC: Author.

Benedict, A., & Saks, M. (1987, Summer). The regulation of professional behavior: Electroconvulsive therapy in Massachusetts. Journal of Psychiatry and Law, 15, 247-275.

Breggin, P. (1997). Consensus conference on ECT. In Brain-disabling treatments in psychiatry: Drugs, electroshock, and the role of the FDA. New York: Springer.

Crow, T., & Johnstone, E. (1986). Controlled trials of electreconvulsive therapy. Annals of the New York Academy of Sciences, 462, 12-29.

Drug facts and comparisons. (1999). St. Louis, MO: Wolters Kluwer.

Physician’s desk reference (53rd ed.). (1999). Montvale, NJ: Medical Economics.

Rifkin, A. (1988). ECT versus tricyclic antidepressants in depression: A review of evidence. Journal of Clinical Psychiatry, 49(1), 3-7.

Sackeim, H., Devenand, D., & Prudic, J. (1991). Stimulus intensity, seizure threshold and seizure duration. Psychiatric Clinics of North America, 14, 803-843.

Wisconsin Coalition for Advocacy. (1995). Informed consent for electroconvulsive therapy: A report on violations of patients’ rights by St. Mary’s Hospital, Madison, Wisc. (Available from Wisconsin Coalition for Advocacy, 16 N. Carroll St., Madison, WI 53703)

Reprint requests: John Breeding, 2503 Douglas St., Austin, TX 78741; e-mail: john@wildestcolts.com.

APPENDIX A Additional Resources

Breggin, P. (1991). Shock treatment is not good for your brain. In Toxic psychiatry: Why therapy, empathy, and love must replace the drugs, electroshock, and biochemical theories of the new psychiatry. New York: St. Martin’s.

Breggin, P. (1997). Electroshock and depression. In Brain-disabling treatments in psychiatry: Drugs, electroshock, and the role of the FDA. New York: Springer.

Dendron, published by David Oaks. (Available from P.O. Box 11284, Eugene, OR 97440; 503-341-0100) This is the best newspaper available on mental health system oppression. David Oaks is also the contact for Support Coalition International, an umbrella group of organizations devoted to the work of mental health liberation.

Dolan, M. (1999). Electroshock annotated bibliography. (Available from Electroshock Review, P.O. Box 4085, Austin, TX 78765 [$3.00])

Frank, L. (Ed.). (1978). The history of shock treatment. (Available from Leonard Frank, 2300 Webster St., San Francisco, CA 94115 [$12 postpaid])

Frank, L. (1990). Electroshock: Death, brain damage, memory loss, and brainwashing. Journal of Mind and Behavior, 11, 489-512.

Friedberg, J. (1976). Shock treatment is not good for your brain. San Francisco: Glide.

Friedberg, J. (1977). Shock treatment, brain damage and memory loss: A neurological perspective. American Journal of Psychiatry, 134, 1010-1013.

Psychiatry, Victimizing the Elderly. (Available from the Citizens Commission on Human Rights [CCHR], 6362 Hollywood Blvd., Suite B, Los Angeles, CA 90028; 800-572-2905 [in Texas]; 800-869-2247 [outside of Texas]) This is a booklet by CCHR, a private nonprofit organization whose sole purpose is to investigate and expose psychiatric violations of human rights.

Shock Waves, edited by Linda Andre. (Available from the Committee for Truth in Psychiatry, P.O. Box 1214, New York, NY 10003; 212-473-4786) This is an important newsletter for information related to ECT.

www.banshock.org. This is a Web site devoted to granting access to information with regard to electroshock treatment and attempts to ban or restrict its use. It has many links to other useful sites.

APPENDIX B Electroshock Annotated Bibliography by Moira Dolan, M.D.

Effects of Electroconvulsive Therapy (ECT): A Review of the Scientific Literature(n1)

DEATH

In a large retrospective study of 3,288 patients getting ECT in Monroe County, NY, ECT recipients were found to have an increased death rate from all causes.

Babigian, H., et al. (1984). Epidemiologic considerations in ECT. Arch Gen Psych, 41, 246-253.

Survival of 65 patients hospitalized and treated for depression was evaluated by researchers at Brown University. They reported that the 37 patients who received ECT had survival rates of 73.0% at 1 year, 54.1% at 2 years, and 51.4% at 3 years. By contrast, depressed patients who did not receive ECT had survival rates of 96.4%, 90.5%, and 75.0%, at 1, 2, and 3 years, respectively.

Kroessler, D., & Fogel, B. (1993). Electroconvulsive therapy for major depression in the oldest old. Am J Geriatr Psych, 1(1), 30-37.

The risk of death was doubled in depressed patients who got ECT, in a 7-year follow-up study of 188 patients.

O’Leary, D., & Lee, A. (1996). Seven year prognosis in depression–Mortality and readmission rates in the Nottingham ECT cohort. British Journal of Psychiatry, 169, 423-429.

The first 3 years of mandated recording of death within 14 days of ECT in the state of Texas yielded reports of 21 deaths. There were 11 cardiovascular deaths, including massive heart attacks and strokes; 3 respiratory deaths; and 6 suicides.

Gilbert, D. (Commissioner). (1996). Texas Department of Mental Health and Mental Retardation.

(n1.) Dr. Dolan periodically updates this research review. It may be obtained by sending $3.00 to Electroshock Review, P.O. Box 4085, Austin, TX 78765.

BRAIN DAMAGE

More than 20 years ago, Cotman reported in Science that ECT disrupts (protective) protein production by brain cells. More recent studies show that electric shocks to the brain also cause an increase in the production of inflammatory proteins inside brain cells.

Cotman, et al. (1971). Electroshock effects on brain protein synthesis. Science, 178, 454-456.

Marcheselli, et al. (1996). Sustained induction of prostaglandin endoperoxidase synthase-2 by seizures in hippocampus. J Biol Chem, 271, 24794-24799.

C. Edward Coffey, M.D., a leading proponent of ECT, conducted a study at Duke University Medical Center and the Durham VA Hospital that looked at the brain scans (by magnetic resonance imaging [MRI]) of patients before and after ECT. Out of the 35 patients studied, 8 had changes on MRI after shock. That is 22%, or greater than i in 5, with anatomic brain effects. Among those with the brain changes, I patient suffered a stroke and 2 had new abnormal neurologic signs on exam within 6 months of ECT.

Coffey, C. E., et al. (1991). Brain anatomic effects of ECT. Arch Gen Psych, 48, 1013-1021.

Weinberger looked at the effects of ECT on the brains of schizophrenics by comparing brain CT scans of those who had had ECT with schizophrenics who had never received shock. He documented that cerebral atrophy (brain shrinkage) was significantly more common in those who had ever been shocked.

Weinberger, et al. (1979). Structural abnormalities in the cerebral cortex of chronic schizophrenic patients. Arch Gen Psych, 36, 935-939.

Another CT scan study, done by Calloway, looking at a similar group, confirmed that frontal lobe atrophy (brain shrinkage) was significantly more common in ECT recipients.

Calloway, et al. (1981). ECT and cerebral atrophy: A CT study. Acta Psych Scand, 64, 442-445.

Andreasen used MRI scans to demonstrate a strong correlation between the number of previous ECT treatments and enlarged ventricles (loss of brain tissue).

Andreasen, et al. (1990). MRI of the brain in schizophrenia. Arch Gen Psych, 47, 35-41.

A study in England compared the brain CT scans of 101 depressed patients who had received ECT to 52 normal volunteers. They found a significant relationship between treatment with ECT and brain atrophy. In fact, ECT recipients were twice as likely to have a measurable loss of brain tissue in the front area of the brain and three times as likely to experience loss of brain tissue in the back of the brain. “Most significantly, the brain abnormalities correlated only with ECT, and not with age, alcohol use, gender, family history of mental illness, age at the time of psychiatric diagnosis, or severity of mental illness (Dolan, 1986).

Dolan, R. J., et al. (1986). The cerebral appearance in depressed subjects. Psychol Med, 16, 775-779.

An animal study sought to discover whether giving supplementary oxygen during shock would prevent brain damage; the researchers also gave vitamin E to lessen the effects of damaging “free radical” molecules that get released during a shock seizure. They found no difference in the brain-damaging effects of ECT-induced seizures when oxygen and vitamin E were given. These findings disprove the claim that modern ECT methods (complete with anesthesia and oxygen) are any less damaging to the brain than uncontrolled seizures.

Manoel, et al. (1986). Brain damage following repeated electroshock in cats and rats. Rev Rom Neurol Psych, 24, 59-64.

CARDIOVASCULAR COMPLICATIONS

ECT-induced seizures cause a rapid rise in blood pressure; at the same time, the brain experiences a significant reduction in blood flow.

Webb, et al. (1990). Cardiovascular response to unilateral ECT. Biol Psych, 28, 758-766.

Rosenberg, et al. (1988). Effects of ECT on cerebral blood flow. Convulsive Therapy, 4, 62-73.

A Mayo clinic study of 34 elderly patients receiving shock found an 18% incidence of serious heart arrhythmias during treatment: 4 had ventricular tachycardia requiring IV lidocaine and 2 had supraventricular tachycardia requiring IV beta blockers. An additional 2 patients had other cardiogram changes.

Tomac, T., & Rummans, T. (1997). Safety and efficacy of electroconvulsive therapy in patients over age 85. Am J Geriatr Psych, 5, 126-130.

After his eighth ECT, a 57-year-old man died of heart rupture.

Ali, P. B., & Tidmarsh, M. D. (1997). Cardiac rupture during electroconvulsive therapy. Anesthesia, 52, 884-895.

Physicians from Tulane University Medical School reported on a 69-year-old woman who developed brain hemorrhage during ECT. She was also left with epilepsy. This was, as expected, associated with further deterioration in her mental status from her baseline depression. They conclude that the fragile vessels of the elderly may make some patients a particularly high risk for ECT.

Weisberg, et al. (1991). Intracerebral hemorrhage following ECT. Neurology, Nov, 1849.

EXTRA RISKS IN THE ELDERLY

In an analysis of 34 persons over the age of 85 who were subjected to ECT, researchers at the Mayo clinic documented that 79% suffered treatment complications, including a 32% incidence of confusion and delirium, a 67% incidence of transient high blood pressure, and an 18% incidence of serious heart arrhythmias during treatment. There were 2 patients with other cardiogram changes, 3 patients who took falls, and i patient with a hip fracture due to a fall.

Tomac, T., & Rummans, T. (1997). Safety and efficacy of electroconvulsive therapy in patients over age 85. Am J Geriatr Psych, 5, 126-130.

ECT enthusiast, Dr. Coffey, and his associate, Dr. Figiel, found that 10 out of 87 (11%) elderly patients getting ECT for depression remained delirious between ECT sessions for no discernible medical reason other than the ECT itself. (Italicized words are those of the study authors.) They documented by brain MRI scans that 90% of these unfortunate patients had lesions in the basal ganglia areas of the brain, and 90% had moderate to severe white matter lesions.

Figiel, Coffey, et al. (1990). Brain MRI findings in ECT-induced delirium. J of Neuropsych and Clin Sci, 2, 53-58.

Kroessler and Fogel’s (1993) study on death rates was done on the “oldest old”: depressed patients at least 85 years of age. Mortality rates were significantly greater for those who received ECT, compared to those who did not.

Kroessler, D., & Fogel, B. (1993). Electroconvulsive therapy for major depression in the oldest old. Am J Geriatr Psych, 1(1), 30-37.

EPILEPSY

In a review of the literature on the well-known ECT complication of epilepsy, researchers calculated “that the age-adjusted incidence of new seizures after ECT was fivefold greater than the incidence found in the nonpsychiatric population (Devinsky & Duchowny, 1983).

Devinsky, O., & Duchowny, M. S. (1983). Seizures after convulsive therapy: A retrospective case survey. Neurology, 33, 921-925.

Persistent brain wave disruption to the point of status epilepticus has been reported to occur following ECT. Individual reports by Drs. Weiner and Varma, on different patients, describe acute disorientation and deterioration of intellectual function immediately following ECT. This was found to be due to ongoing epileptic brain wave forms that were initiated by the ECT.

Weiner, R. D. (1980). Prolonged confusional states and EEG seizure activity following ECT and lithium use. Am Journal Psych, 137, 14521453.

Varma, N. K. et al. (1992). Nonconvulsive status epilepticus following ECT. Neurology, 42, 2263-2264.

MEMORY LOSS

Publicly available data from the state of California’s Department of Mental Health reveals that more than 99% of ECT recipients complain of memory loss 3 months following treatment, with the average number of ECT sessions being five to six.

Lazarow, A. (Chief). (1996). Office of Human Rights, California Department of Mental Health.

In a chapter on the cognitive effects of ECT in a psychiatry textbook, Sackheim indicates that cognitive effects (disordered thinking), particularly amnesia, can be long lasting after shock.

Sackeim. (1992). In Moos et al. (Eds.), Cognitive disorders: Pathophysiology and treatment.

The conclusion that amnesia can be a long-lasting effect of shock is arrived at by both Squire and Weiner, in separate studies.

Squire, et al. (1981). Retrograde amnesia and bilateral ECT: Long term follow-up. Arch Gen Psych, 38, 89-95.

Weiner, et al. (1986). Effects of stimulus parameters on cognitive side effects. Ann NY Acad Sci, 462, 315-325.

LACK OF EFFICACY

In the large New York study cited earlier, the death rates from suicide among depressed patients given ECT were slightly higher at the 1-year mark. By 5 years, the suicide rate was the same for depressed patients who got ECT as for those who did not.

Babigian, H., et al. (1984). Epidemiologic considerations in ECT. Arch Gen Psych, 41, 246-253.

In a University of Iowa study of treatment effectiveness, 1,076 depressed patients were categorized according to whether they received ECT, high doses of antidepressant medications, low doses of antidepressant medications, or neither (neither ECT nor medications). Long-term follow-up revealed that all groups had the same suicide rates, indicating that the incidence of suicide is not affected by treatment. The authors concluded, “Therefore, active biological treatments, such as ECT, may not be deemed as `lifesaving’ now as in the past” (Black et al., 1989).

Black, et al. (1989). Does treatment influence mortality in depressives? Ann Clin Psych, 1, 165-173.

The same findings are documented in three other studies: ECT does not prevent suicide in depressed patients.

Eastwood, et al. (1976). Seasonal patterns of suicide, depression, and ECT. Br J Psych, 129, 472-475.

Babigian, et al. (1984). Epidemiological considerations in ECT. Arch Gen Psych, 41, 216-253.

Milstien, et al. (1986). Does ECT prevent suicide? Convulsive Therapy, 2, 3-6.

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By John Breeding

JOHN BREEDING, Ph.D. is a licensed psychologist in private practice in Austin, Texas. A significant part of his work involves counseling and consulting with parents and children. He also works with adults in psychotherapy, including many who are self-identified as psychiatric survivors. He is active in challenging various aspects of psychiatric oppression, in particular the practices of electroshock and the use of psychiatric drugs with school-age children. His book, The Wildest Colts Make the Best Horses, is a forceful and informative challenge to the use of stimulant drugs with millions of our children. Dr. Breeding has been on the advisory board of the World Association of Electroshock Survivors and has been active in the effort to ban electroshock in the state of Texas. His website, www.wildestcolts.com, is a valuable resource on psychiatry-related issues.

Testimony of Dr. John Friedberg to NY Assembly

TESTIMONY OF JOHN M. FRIEDBERG, M.D., NEUROLOGIST, BEFORE THE MENTAL HEALTH COMMITTEE OF THE NEW YORK STATE ASSEMBLY
MARTIN LUSTER PRESIDING

NYC, May 18, 2001

“In view of the primitive simplicity of their minds, they (the masses) more easily fall victim to a big lie than to a little one, since they themselves lie in little things, but would be ashamed of lies that were too big.” Adolph Hitler. Mein Kampf, Vol.1, Ch. 10, 1924 tr. Ralph Manheim, 1943

INTRODUCTION

My name is John Friedberg. I am a board certified neurologist practicing in Berkeley, California.

I was born in Far Rockaway (NYC) in 1942, graduated Lawrence High School, Yale University and the University of Rochester School of Medicine and for the past twenty years I’ve been seeing patients with every conceivable neurologic problem, from headaches to Huntington’s, in my office and in hospitals.

I am in good standing with my hospitals, professional societies and licensing boards and I’m proud to say I’ve never been successfully sued.

In 1975 I published my book “Shock Treatment Is Not Good For Your Brain” and in 1979 “Shock Treatment, Brain Damage and Memory Loss,” a peer reviewed article in the American Journal of Psychiatry.

I do not believe in mental illness. Depression is no more “the same as diabetes” than heartbreak is the same as a heart attack.

I do not believe in hypothetical diseases of the mind but there is no mistaking damage to the brain. Psychiatric drugs and electroshock inflict real injury in the name of treating fictive maladies. Paul Henri Thomas has Tardive Dyskinesia and heptatitis from psychiatric drugs and amnesia from the ECT.

BASIS FOR OPINIONS

My opinions are based on my years of experience with patients and review of records from all over the country as an expert witness electroshock malpractice cases. They are based on ECT statistics from the six states which mandate reporting; and of necessity, my opinions are based on a lifetime following publications and statements issuing from the small but vocal minority of psychiatrists who believe in ECT and usually nothing but.

Fortunately for me, the believers don’t always believe each other; their data frequently belie their conclusions; and what they actually do contradicts what they say they do. The truth slips out.

As one example: we have known since the 1950′s that confining electroshock to the non-verbal hemisphere (usually the right as in “unilateral non-dominant ECT”) causes less verbal impairment and memory loss than bilateral ECT but the recommendation to begin with non-dominant ECT is honored mostly in the breech.

Another example: the “grandfather” of ECT, Dr. Max Fink claims the rate of memory loss is 1 in 200. He has repeated this so often it sounds like a fact. But Harold Sackeim, Ph.D., just as much an enthusiast and just as aggressive, says Fink’s figure has “no scientific basis.”

Who to believe? My view is that memory loss from ECT is no “side effect;” it’s the main effect and the best studies find it in 100% of subjects.

Incidentally, Dr. Fink didn’t pick the number 1/200 out of thin air. 1/200 has consistently been the death rate from ECT administration – as far back as 1958 and as recently as Texas and Illinois in the 1990′s.

FIVE BIG LIES

Big Lie 1: Dr. Fink tells people that ECT is safer than childbirth. If one out of every 200 women were dying in delivery it would be front page news.

Big Lie 2: ECT doesn’t cause brain damage. One picture will refute that. The illustration below (MRI on the right, CT left, same patient) depicts a large hemorrhage from ECT. Hemorrhages, large and small, cause permanent seizure disorders in some patients.

Image1.jpg

( Weisberg, L. Elliott, D and Mielke, D: Intracerebral Hemorrhage Following Electroconvulsive Therapy (ECT). November 1991, Neurology V 41 p 1849.)

Another MRI study documented a breakdown of the blood brain barrier and cerebral edema – brain swelling – after each and every shock. (Mander et al: British Journal of Psychiatry, 1987: V 151, p 69-71)

Big lie 3: ECT is new and improved. The whole point of ECT is to trigger a convulsion and there is simply no way around the brain’s threshold: 100 joules of energy, a typical “dose,” whether brief pulse, square wave, sine wave, AC or DC, unilateral or bilateral, with or without oxygen equals the energy it takes to light up a 100 watt bulb for one second or drop a 73 pound weight one foot. And it’s the energy that does the damage.

Big lie 4: ECT is a “Godsend” (Fink again). In March of this year, Dr. Sackeim published a study in JAMA showing a “relapse rate” of 84% within six months of stopping ECT. It is no coincidence that improvement ceases just as the concussive effects are finally waning. Sackeim’s solution?: more ECT. Call it “maintenance” or call it “continuation,” just don’t stop. (JAMA. 2001;285:1299-1307).

Big lie 5: No one knows how ECT works. On the contrary, everyone knows how ECT works. It works by erasing memory and terrifying people.

CONCLUSION

ECT isn’t back – it never went away. It’s more common than appendectomy.

What has happened is that it’s advocates have grown more arrogant and the number of patients forced to undergo ECT against their will is increasing.

This was brought to public attention by Paul Henri Thomas fighting for his life and his mind at Pilgrim State Hospital on Long Island. Over the past two years he has been subjected to 60 shocks and a judge just ordered up 40 more. The newspapers state the Mr. Thomas was born in Haiti, emigrated from oppression and was granted American citizenship.

To be held down, drugged and forcibly administered convulsive dose after convulsive dose of electroshock to the head: can anyone think of a greater assault on a human being’s rights – short of death – in the whole world? And it’s happening here in the land of the free. That’s not acceptable.

We have had 60 years of poignant testimony from eloquent victims of electroshock. Ernest Hemingway complained it ruined his memory and put him out of business. He killed himself within weeks of concluding a second course of ECT. George Orwell ends 1984 with his protagonist being forced to love Big Brother on an electroshock table.

I urge you to declare a moratorium on electroconvulsive therapy until it can be proven safe by evidence, not proclamation.

I urge you to declare a moratorium on electroconvulsive therapy until patients can be guaranteed free and informed choice.

Thank you.

Testimony of Leonard Roy Frank to NY Assembly

TESTIMONY OF LEONARD ROY FRANK AT A PUBLIC HEARING ON ELECTROCONVULSIVE “TREATMENT” BEFORE THE MENTAL HEALTH COMMITTEE OF THE NEW YORK STATE ASSEMBLY, MARTIN A. LUSTER (CHAIRMAN), MANHATTAN, 18 MAY 2001

My name is Leonard Roy Frank, from San Francisco, and I’m here representing the Support Coalition International based in Eugene, Oregon. SCI unites 100 sponsoring groups who oppose all forms of psychiatric oppression and support humane approaches for assisting people said to be “mentally ill.” This year the United Nations recognized Support Coalition International as “a Non-Governmental Organization with Consultative Roster Status.”

I’ve taken the epigraph for my presentation from a talk on the Holocaust by Hadassah Lieberman, the wife of Sen. Joseph Lieberman, which was rebroadcast on C-SPAN last month. She quoted the Bal Shem Tov, founder of Hasidism: “In remembrance lies the secret of redemption.”

INTRODUCTION

Some personal background is relevant to the substance of my testimony: I was born in 1932 in Brooklyn and was raised there. After graduating from the Wharton School at the University of Pennsylvania, I served in the U.S. Army and then worked as a real estate salesman for several years. In 1962, three years after moving to San Francisco, I was diagnosed as a “paranoid schizophrenic” and committed to a psychiatric institution where I was forcibly subjected to 50 insulin-coma and 35 electroconvulsive procedures.

This was the most painful and humiliating experience of my life. My memory for the three preceding years was gone. The wipe-out in my mind was like a path cut across a heavily chalked blackboard with a wet eraser. Afterwards I didn’t know that John F. Kennedy was president although he had been elected three years earlier. There were also big chunks of memory loss for events and periods spanning my entire life; my high school and college education was effectively destroyed. I felt that every part of me was less than what it had been.

Following years of study reeducating myself, I became active in the psychiatric survivors movement, becoming a staff member of Madness Network News (1972) and co-founding the Network Against Psychiatric Assault (1974) — both based in San Francisco and dedicated to ending abuses in the psychiatric system. In 1978 I edited and published The History of Shock Treatment. Since 1995, three books of quotations I edited have been published: Influencing Minds, Random House Webster’s Quotationary, and Random House Webster’s Wit ?

Over the last thirty-five years I have researched the various shock procedures, particularly electroshock or ECT, have spoken with hundreds of ECT survivors, and have corresponded with many others. From all these sources and my own experience, I have concluded that ECT is a brutal, dehumanizing, memory-destroying, intelligence-lowering, brain-damaging, brainwashing, life-threatening technique. ECT robs people of their memories, their personality and their humanity. It reduces their capacity to lead full, meaningful lives; it crushes their spirits. Put simply, electroshock is a method for gutting the brain in order to control and punish people who fall or step out of line, and intimidate others who are on the verge of doing so.

BRAIN DAMAGE

Brain damage is the most important effect of ECT. Brain damage is, in fact, the 800-pound gorilla in the living room whose existence psychiatrists refuse to acknowledge, at least publicly. Nowhere is this more clearly illustrated than in the American Psychiatric Association’s 2001 Task Force Report on The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging, 2nd ed. (p. 102), which states that “in light of the accumulated body of data dealing with structural effects of ECT, ‘brain damage’ should not be included [in the ECT consent form] as a potential risk of treatment.”

But 50 years ago, when some proponents were careless with the truth about ECT, Paul H. Hoch, co-author of a major psychiatric textbook and New York State’s Commissioner of Mental Hygiene, commented, “This brings us for a moment to a discussion of the brain damage produced by electroshock…. Is a certain amount of brain damage not necessary in this type of treatment? Frontal lobotomy indicates that improvement takes place by a definite damage of certain parts of the brain.” (“Discussion and Concluding Remarks,” Journal of Personality, 1948, vol. 17, pp. 48-51)

More recently, neurologist Sidney Sament backed the brain-damage charge in a letter to Clinical Psychiatry News (March 1983, p. 11):

“After a few sessions of ECT the symptoms are those of moderate cerebral contusion, and further enthusiastic use of ECT may result in the patient functioning at a subhuman level.

Electroconvulsive therapy in effect may be defined as a controlled type of brain damage produced by electrical means….

In all cases the ECT ‘response’ is due to the concussion-type, or more serious, effect of ECT. The patient ‘forgets’ his symptoms because the brain damage destroys memory traces in the brain, and the patient has to pay for this by a reduction in mental capacity of varying degree.”

Additional evidence of ECT-caused brain damage was published in an earlier APA Task Force Report on Electroconvulsive Therapy (1978). Forty-one percent of a large group of psychiatrists responding to a questionnaire agreed with the statement that ECT produces “slight or subtle brain damage.” Only 28 percent disagreed (p. 4).

And finally there is the evidence from the largest published survey of ECT-related deaths. In his Diseases of the Nervous System article titled “Prevention of Fatalities in Electroshock Therapy” (July 1957), psychiatrist David J. Impastato, a leading ECT proponent, reported 66 “cerebral” deaths among the 235 cases in which he was able to determine the likely cause of death following ECT (p. 34).

MEMORY LOSS

If brain damage is electroshock’s most important effect, memory loss is its most obvious one. Such loss can be, and often is, devastating as these statements from electroshock survivors indicate:

“My memory is terrible, absolutely terrible. I can’t even remember Sarah’s first steps, and that’s really hurtful… losing the memory of the kids growing up was awful.”

“I can be reading a magazine and I get halfway through or nearly to the end and I can’t remember what it’s about, so I’ve got to read it all over again.”

“People would come up to me in the street that knew me and would tell me how they knew me and I had no recollection of them at all… very frightening.” (Lucy Johnstone, “Adverse Psychological Effects of ECT,” Journal of Mental Health, 1999, vol. 8, p. 78)

Electroshock proponents are dismissive of the memory problems associated with use of their procedure. The following is from the sample ECT consent form in the APA’s 2001 Task Force Report (pp. 321-322): “The majority of patients state that the benefits of ECT outweigh the problems with memory. Furthermore, most patients report that their memory is actually improved after ECT. Nonetheless, a minority of patients report problems in memory that remain for months or even years.” The text of the Report supplies flimsy documentation for the claims in the first two sentences, but the third sentence, at least, is closer to the truth than coverage of the same point in the sample consent form of the first edition of the APA’s Task Force Report (1990, p. 158) which reads, “A small minority of patients, perhaps 1 in 200, report severe problems in memory that remain for months or even years.” And even the more recent Report underestimates the prevalence of memory loss among ECT survivors.

The vast majority of the hundreds of survivors I’ve communicated with over the last three decades experience moderate-to-severe amnesia going back two years and more from the time they underwent ECT. That these findings do not appear in published ECT studies may be accounted for by the bias of electroshock investigators, virtually all of whom are ECT proponents, by denial (from ECT-induced brain damage) on the part of participants and their fear of punitive sanctions if they were to report the extent and persistence of their memory loss, and finally by the difficulty in having anything published in a mainstream professional journal that seriously threatens the vested interests of an important segment of the psychiatric community.

DEATH

The 2001 Task Force Report on ECT states, “a reasonable current estimate is that the rate of ECT-related mortality is 1 per 10,000 patients” (p. 59). But some studies suggest that the ECT death rate is about one in 200. This rate, however, may not reflect the true situation because now elderly persons are being electroshocked in growing numbers: statistics based on California’s mandated ECT reporting system indicate that upwards of 50 percent of all ECT patients are 60 years of age and older.

Because of infirmity and disease, the elderly are more vulnerable to ECT’s harmful, and sometimes lethal, effects than younger people. A 1993 study involved 65 patients, 80 and older, who were hospitalized for major depression. Here are the facts drawn from this study: The patients were divided into 2 groups. One group of 37 patients was treated with ECT; the other group, of 28 patients, with antidepressants. After 1 year, 1 patient among the 28, or 4 percent, in the antidepressant group was dead; while in the ECT group 10 patients among the 37, or 27 percent, were dead. (David Kroessler and Barry Fogel, “Electroconvulsive Therapy for Major Depression in the Oldest Old,” American Journal of Geriatric Psychiatry, Winter 1993, p. 30)

BRAINWASHING

The term “brainwashing” came into the language during the early 1950s. It originally identified the technique of intensive indoctrination, combining psychological and physical pressure, developed by the Chinese for use on political dissidents following the Communist takeover on the mainland and on American prisoners of war during the Korean War. While electroshock is not used overtly against political dissidents, it is used throughout most of the world against cultural dissidents, nonconformists, social misfits and the unhappy (the troubling and the troubled), whom psychiatrists diagnose as “mentally ill” in order to justify ECT as a medical intervention.

Indeed, electroshock is a classic example of brainwashing in the most meaningful sense of the term. Brainwashing means washing the brain of its contents. Electroshock destroys memories and ideas by destroying the brain cells which store them. As psychiatrists J. C. Kennedy and David Anchel, both ECT proponents, described the effects of this tabula rasa “treatment” in 1948, “Their minds seem like clean slates upon which we can write” (“Regressive Electric-shock in Schizophrenics Refractory to Other Shock Therapies,” Psychiatric Quarterly, vol. 22, pp. 317-320). Soon after published accounts of the erasure of 18 minutes from secret White House audiotapes during the Watergate investigation, another electroshock psychiatrist reported, “Recent memory loss [from ECT] could be compared to erasing a tape recording.” (Robert E. Arnot, “Observations on the Effects of Electric Convulsive Treatment in Man–Psychological,” Diseases of the Nervous System-, September 1975, pp. 449-502)

For these reasons, I have proposed that the procedure now called electroconvulsive treatment (ECT) be renamed electroconvulsive brainwashing (ECB). And ECB may be putting it too mildly. We might ask ourselves, Why is it that 10 volts of electricity applied to a political prisoner’s private parts is seen as torture while 10 or 15 times that amount applied to the brain is called “treatment”? Perhaps the acronym “ECT” should be retained and have the “T” stand for torture – electroconvulsive torture.

SEVEN REASONS

If electroshock is an atrocity, as I maintain, how can its use on more than 10 million Americans since being introduced more than 60 years ago be explained? Here are seven reasons:

1. ECT is a money-maker. Psychiatrists specializing in ECT earn $300,000-500,000 a year compared with other psychiatrists whose mean annual income is $150,000. An in-hospital ECT series costs anywhere from $50,000-75,000. One-hundred thousand Americans are believed to undergo ECT annually. Based on this figure, I estimate that electroshock is a $5 billion-a-year industry.

2. Biological model. ECT reinforces the psychiatric belief system, the linchpin of which is the biological model of mental illness. This model centers on the brain and reduces most serious personal problems down to genetic, physical, hormonal, and/or biochemical defects which call for biological treatment of one kind or another. The biological approach covers a spectrum of physical treatments, at one end of which are psychiatric drugs, at the other end is psychosurgery (which is still being used, although infrequently), with electroshock falling somewhere between the two. The brain as psychiatry’s focus of attention and treatment is not a new idea. What psychiatrist Carl G. Jung wrote in 1916 applies today: “The dogma that ‘mental diseases are diseases of the brain’ is a hangover from the materialism of the 1870s. It has become a prejudice which hinders all progress, with nothing to justify it.” (“General Aspects of Dream Psychology,” The Structure and Dynamics of the Psyche, 1960) Eighty-five years later, there’s still nothing in the way of scientific evidence to support the brain-disease notion. The tragic irony is that the psychiatric profession makes unsubstantiated claims that mental illness is caused by a brain disease while hotly denying that electroshock causes brain damage, the evidence for which is overwhelming.

3. The myth of informed consent. While outright force is seldom used, genuine informed consent is never obtained because ECT candidates can be coerced and because electroshock specialists refuse to accurately inform ECT candidates and their families of the procedure’s nature and effects. ECT specialists lie not only to the parties vitally concerned, they lie to themselves and to each other. Eventually they come to believe their own lies, and when they do, they become even more persuasive to the na�ve and uninformed. As Ralph Waldo Emerson wrote in 1852, “A man cannot dupe others long who has not duped himself first.” Here is an instance of evil so deeply ingrained that it’s no longer recognized as such. Instead we see such outrages as ECT specialist Robert E. Peck titling his 1974 book, The Miracle of Shock Treatment and Max Fink, who for many years edited the leading professional journal in the field, now called The Journal of ECT, telling a Washington Post reporter in 1996, “ECT is one of God’s gifts to mankind.” (Sandra G. Boodman, “Shock Therapy: It’s Back,” 24 September, Health [section], p.16)

4. Backup for treatment-resistant psychiatric-drug users. Many, if not most, of those being electroshocked today are suffering from the ill effects of a trial run or long-term use of antidepressant, anti-anxiety, neuroleptic, and/or stimulant drugs, or combinations thereof. When such effects become obvious, the patient, the patient’s family, or the treating psychiatrist may refuse to continue the drug-treatment program. This helps explain why ECT is so necessary in modern psychiatric practice: it is the treatment of next resort. It is psychiatry’s way of burying their mistakes without, except rarely, killing the patient. Growing use and failure of psychiatric-drug treatment has forced psychiatry to rely more and more on ECT as a way of dealing with difficult, complaining patients, who often are hurting more from the drugs than from their original problems. And when the ECT fails to “work,” there’s always — following an initial series — more ECT (prophylactic ECT administered periodically to outpatients), or more drug treatment, or a combination of the two. That drugs and ECT are for practical purposes the only methods psychiatry offers to, or imposes on, those who seek treatment or for whom treatment is sought is further evidence of the profession’s clinical and moral bankruptcy.

5. Lack of accountability. Psychiatry has become a Teflon profession: criticism, what little there is of it, doesn’t stick. Psychiatrists routinely carry out brutal acts of inhumanity and no one calls them on it — not the courts, not the government, not the people. Psychiatry has become an out-of-control profession, a rogue profession, a paradigm of authority without responsibility, which is a good working definition of tyranny.

6. Government support. Not only does the federal government stand by passively as psychiatrists continue to electroshock American citizens in direct violation of some of their most fundamental freedoms, including freedom of conscience, freedom of thought, freedom of religion, freedom of speech, freedom from assault, and freedom from “cruel and unusual punishment,” the government also actively supports electroshock through the licensing and funding of hospitals where the procedure is used, by covering ECT costs in its insurance programs (including Medicare), and by financing ECT research (including some of the most damaging ECT techniques ever devised). A recently published study provides an example of such research. The ECT experiment, which was conducted at Wake Forest University School of Medicine/North Carolina Baptist Hospital, Winston-Salem, between 1995 and 1998, reports the use of electric current at up to 12 times the individual’s convulsive threshold on as many as 36 depressed patients. The destructive element in ECT is the current that causes the convulsion: the more electrical energy, the greater the brain damage. This reckless disregard for the safety of ECT subjects was supported by grants from the National Institute of Mental Health. (W. Vaughn McCall, David M. Begoussin, Richard D. Weiner, and Harold A. Sackeim, “Titrated Moderately Suprathreshold vs. Fixed High-Dose Right Unilateral Electroconvulsive Therapy: Acute Antidepressant and Cognitive Effects,” Archives of General Psychiatry, May 2000, pp. 438-444)

7. Electroshock could never have become a major psychiatric procedure without the active collusion and silent acquiescence of tens of thousands of psychiatrists. Many of them know better; all of them should know better. The active and passive cooperation of the media has also played an essential role in expanding the use of electroshock. Amidst a barrage of propaganda from the psychiatric profession, the media passes on the claims of ECT proponents almost without challenge. The occasional critical articles are one-shot affairs, with no follow-up, which the public quickly forgets. With so much controversy surrounding this procedure, one would think that some investigative reporters would key on to the story. But it’s happened only rarely up to now. And the silence continues to drown out the voices of those who need to be heard. I’m reminded of Martin Luther King’s 1963 “Letter from Birmingham City Jail,” in which he wrote “We shall have to repent in this generation not merely for the vitriolic words and actions of the bad people, but for the appalling silence of the good people.”

CONCLUSION

As noted earlier, I’m here representing the Support Coalition International. But more significantly, I’m also here representing the true victims of electroshock: those who have been silenced, those whose lives have been ruined, and those who have been killed. All of them bear witness through the words I have spoken here today.

I’ll close with a short paragraph, in way of summary, and a poem I wrote in 1989.

If the body is the temple of the spirit, the brain may be seen as the inner sanctum of the body, the holiest of holy places. To invade, violate, and injure the brain, as electroshock unfailingly does, is a crime against the spirit and a desecration of the soul.

Aftermath

With “therapeutic” fury
search-and-destroy doctors
using instruments of infamy
conduct electrical lobotomies
in little Auschwitzes called mental hospitals

Electroshock specialists brainwash
their apologists whitewash
as silenced screams echo
from pain-treatment rooms
down corridors of shame.

Selves diminished
we return
to a world of narrowed dreams
piecing together memory fragments
for the long journey ahead.

From the roadside
dead-faced onlookers
awash in deliberate ignorance
sanction the unspeakable –
Silence is complicity is betrayal.

Patients often aren’t informed of danger

USA Today Series
12-06-1995

Patients often aren’t informed of danger

The electrodes were placed on her head. With the push of a button, enough electricity to light a 50-watt bulb passed through her skull.

Her teeth bit hard into a mouth guard. Her heart raced. Her blood pressure soared. Her brain had an epileptic-style grand mal seizure. Then, Ocie Shirk had a heart attack.

Four days later, on Oct. 14, 1994, the 72- year-old retired health department worker from Austin, Texas, was dead of heart failure – the leading cause of shock-related death.

After years of decline, shock therapy is making a dramatic and sometimes deadly comeback, practiced now mostly on depressed elderly women who are largely ignorant of shock’s true dangers and misled about shock’s real risks.

Some lose already fragile memories. Some suffer heart attacks or strokes. And some, like Ocie Shirk, die.

A four-month USA TODAY investigation found: The death rate for elderly patients who receive shock is 50 times higher than patients are told on the American Psychiatric Association’s model consent form. The APA sets the chance of dying at 1 in 10,000. But the death rate is closer to 1 in 200 among the elderly, according to mortality studies done over the past 20 years and death reports from Texas, the only state that keeps close track.

Shock machine manufacturers greatly influence what patients are told about shock’s risks.

Virtually all “educational” videos and brochures shown to patients are supplied by shock machine companies. And the APA’s 1-in-10,000 death rate estimate is attributed to a book written by a psychiatrist whose company sells about half the shock machines sold each year.

Shock therapy is strongly regaining favor among psychiatrists as a treatment for depression. Although exact figures are not kept, one indication of the trend comes from Medicare, which paid for 31% more shock treatments in 1993 than it did in 1986.

The elderly now account for more than half of the estimated 50,000 to 100,000 people who receive shock each year, with women in their 70s getting more shock than any other group. In the 1950s and 1960s, young male schizophrenics got most shock therapy.

Shock therapy is the most profitable practice in psychiatry, and economics strongly influences when shock is given and who gets it.

In Texas, the only state that keeps track, 65-year- olds get 360% more shock therapy than 64-year-olds. The difference: Medicare pays.

Shock treatment may shorten the lives of the elderly, even if it doesn’t cause immediate problems.

In a 1993 study of patients 80 and older, 27% of shock patients were dead within one year compared to 4% of a similar group treated with anti-depressant drugs. In two years, 46% of shocked patients were dead vs. 10% who had the drugs. The study, by Brown University researchers, is the only study of long-term survival rates in the elderly.

Doctors rarely report shock treatment on death certificates, even when the connection seems apparent and death certificate instructions clearly indicate it should be listed.

For this story, USA TODAY reviewed more than 250 scientific articles on shock therapy, watched the procedure at two hospitals and interviewed dozens of psychiatrists, patients and family members.

Outside of medical journals, accurate information about shock is sketchy. Only three states make doctors report who gets it and what complications occur. Texas has strict reporting requirements; California and Colorado less stringent rules.

The information that is available raises serious questions about how shock therapy is practiced today, particularly on the elderly.

“We’ve learned nothing from the mistakes of my generation,” says psychiatrist Nathaniel Lehrman, 72, retired clinical director of Kingsboro state mental hospital in New York. “The elderly are the people who can least stand” shock. “This is gross mistreatment on a national scale.”

A changing image

Monday, Wednesday and Friday morning is shock therapy time in hospitals across the country.

Most patients get a total of six to 12 shocks: one a day, three times a week until the treatment is finished. Patients generally receive a one- or four-second electrical charge to the brain, which causes an epileptic-like seizure for 30 to 90 seconds.

The American Psychiatric Association information sheet for patients says: “80% to 90% of depressed people who receive (shock) respond favorably, making it the most effective treatment for severe depression.” Psychiatrists who do shock therapy also are convinced of its safety.

“It’s more dangerous to drive to the hospital than to have the treatment,” says psychiatrist Charles Kellner, editor of Convulsive Therapy, a medical journal. “The unfair stigma against (shock) is denying a remarkably effective medical treatment to patients who need it.” Psychiatrists say shock therapy is a gentler procedure today than it was in its heyday in the 1950s and 1960s, when it was an all-purpose treatment for everything from schizophrenia to homosexuality.

And advocates say it’s nothing like its portrayal 20 years ago in the movie One Flew Over the Cuckoo’s Nest, which showed electroshock being used to punish mental patients.

The movie helped send shock therapy into decline and prompted laws across the nation making it hard to give shock treatment without the patient’s written consent.

Because of abuse in the past, shock is seldom done now at state mental hospitals, but mostly at private hospitals and medical schools.

The language is softer today, too, reflecting an effort to change shock’s image: Shock is “electroconvulsive therapy” or, simply, ECT. The memory loss that often accompanies it is called “memory disturbance.” These changes come as doctors expand shock’s reach – to high-risk patients, to children, to the elderly – altering the profile of who gets shock therapy so much that the typical patient now is a fully insured, elderly woman treated for depression at a private hospital or medical school.

Someone like Ocie Shirk.

Died in recovery room

Shirk, a widow coping with recurring depression, already had one heart attack and suffered from atrial fibrillation, a condition that causes rapid heart quivers.

On a Monday at 9:34 a.m., Oct. 10, 1994, she received shock therapy at Shoal Creek Hospital, a for-profit psychiatric hospital in Austin. She had a heart attack in the recovery room. Four days later, she died of heart failure.

Yet shock therapy isn’t mentioned on Shirk’s death certificate, despite repeated instructions on the form to include every event that may have played a role in the death.

The medical examiner confirms that shock should have been on the death certificate. “If it happens so close after (shock) therapy, it definitely should be listed,” says Roberto Bayardo, Austin’s medical examiner.

Gail Oberta, chief executive of Shoal Creek Hospital, declines comment on Shirk. But she says, “When I checked all our records and went through all the reviews we do, there were no deaths related to ECT.” A Texas Department of Health investigation found Shirk’s treatment didn’t meet the required standard of care because her medical records did not include a current medical history or physical that would let doctors accurately assess shock therapy’s risks. The hospital agreed to correct the problem.

In addition to Shirk, state records show two other patients died after shock therapy at Shoal Creek. Asked about these deaths, Oberta repeats: “We could find no correlation between deaths of patients and receiving ECT at this facility.” Getting to the facts behind shock-related deaths is very difficult even in Texas, which in 1993 became the only state with a strict law on shock therapy. The law, passed after lobbying from shock opponents, requires all deaths that occur within 14 days of shock therapy be reported to the Texas Department of Mental Health and Retardation.

In the 18 months after the Texas law took effect, eight deaths – including the three at Shoal Creek – were reported out of the 2,411 patients who received shock therapy in the state. About half those who received shock were elderly.

Six of the eight dead patients were older than 65.

Stated another way: 1 in 197 elderly patients died within two weeks of receiving shock therapy. The state does not release enough information to know if shock caused the deaths.

Nationally, record-keeping is almost nonexistant.

The Centers for Disease Control reports shock therapy was listed on death certificates as a factor in only three deaths over the five years ending 1993 – a number so low that it contradicts even the most favorable estimates of shock mortality.

The CDC records shock-related deaths under a category called “Misadventures in Psychiatry.” “For obvious reasons, doctors are reluctant to list anything that falls into this category,” says Harry Rosenberg, head of mortality data at the CDC, “even though we encourage them to be forthright.”

Elderly deaths: 1 in 200

The American Psychiatric Association shock therapy task force report has been the bible of shock practice since its publication in 1990. It says 1 in 10,000 patients will die from shock therapy.

This estimate is included on the APA’s model “informed consent” form, which patients sign to prove they’ve been fully informed of the risks of shock treatment.

The source for this estimate: A textbook written by psychiatrist Richard Abrams, president and co- owner of shock machine manufacturer Somatics Inc. of Lake Bluff, Ill.

Somatics is a private company. Abrams won’t say how much of the company he owns or how much he earns from it.

“I don’t know where they got that (estimate) from,” Abrams says of the 1-in-10,000 death rate.

When pointed to page 53 of his 1988 textbook Electroconvulsive Therapy, where the death rate appears twice, Abrams notes that the number was dropped from the 1992 edition.

His updated textbook states the death rate differently, but Abrams agrees it amounts to the same thing.

Abrams’ revised book says a death will occur once in every 50,000 shock treatments. He says it’s fair to assume that the average patient gets five treatments, making the death rate about 1 in 10,000 patients. Five shocks is average because some patients stop their treatment early.

Abrams’ figures are based on a study of shock deaths that psychiatrists report to California regulators. But USA TODAY found that shock deaths are significantly underreported in California and elsewhere.

At a recent professional meeting, for example, a California psychiatrist told how shock therapy caused a stroke in one of his patients. The man, in his 80s, died several days later. But the death was never reported to state regulators.

Consistently, the studies of elderly death rates conflict with the 1-in-10,000 estimate: A 1982 Journal of Clinical Psychiatry study found one death among 22 patients aged 60 and older. A 71-year-old woman had “cardiopulmonary arrest 45 minutes after her fifth treatment. She expired despite intensive resuscitative efforts.” Two men in the study, ages 67 and 68, suffered life- threatening heart failure but survived. Seven more had less serious heart complications.

A 1984 Journal of American Geriatrics Society study – often cited as proof of shock therapy’s safety – found 18 of 199 elderly patients developed serious heart problems while receiving shock. An 87-year-old man died of a heart attack.

Five patients – ages 89, 81, 78, 78 and 68 – suffered heart failure but were revived.

A 1985 Comprehensive Psychiatry study of 30 patients age 60 and older found one death. An 80-year-old man had a heart attack and died several weeks later. Four others had major complications.

A 1987 Journal of the American Geriatrics Society study of 40 patients age 60 and older found six serious cardiovascular complications but no deaths.

A 1990 Journal of the American Geriatrics Society study of 81 patients age 65 and older found 19 patients developed heart problems; three cases were serious enough to require intensive care. None died.

These studies looked only at complications that occurred while a patient was undergoing a series of shock treatments; long-term mortality rates were not considered.

Taken together, the five studies found three of 372 elderly patients died. Another 14 suffered serious complications, but survived. These results are similar to a study of shock therapy deaths done in 1957 by David Impastato, a leading shock researcher of the time.

He concluded: “The death rate is approximately 1 in 200 in patients over 60 years of age and gradually decreases to 1 in 3,000 or 4,000 in younger patients.” Impastato found heart problems were the leading cause of shock-related death, followed by respiratory problems and stroke – the same pattern as in recent studies.

“The claim that 1 in 10,000 people die from shock is refuted by their own studies,” says Leonard Roy Frank, editor of The History of Shock and a shock opponent. “It’s 50 times higher than that.” But Abrams, who has reviewed the studies, calls it “irrational and incomprehensible” to attribute so many of the deaths to shock itself. Even if a patient has a heart attack minutes later – as Ocie Shirk did – Abrams says, “it may very well not be ECT-related.” Duke University psychiatrist Richard Weiner, chairman of the APA task force, also believes studies show the 1-in-10,000 estimate is accurate and disagrees the elderly death rate could be as high as 1 in 200.

“If it were anywhere near that high, we wouldn’t be doing it,” Weiner says. He says health problems, not age, cause the appearance of a higher death rate among elderly.

Still, some doctors who consider shock therapy a relatively safe treatment are concerned about the complications in elderly patients.

“Almost every death in the literature is an elderly person,” says William Burke, a University of Nebraska psychiatrist who’s studied shock and the elderly. “But it’s hard to hazard a guess on a death rate because we don’t have the data.”

Shock is profitable The financial incentives of performing shock may be driving the increase in its use.

Shock therapy fits well into the economics of private insurance. Most policies don’t pay for psychiatric hospital stays after 28 days. Drug therapy, psychotherapy and other treatments can take much longer. But shock therapy often produces a dramatic effect in three weeks.

“We’re looking for more bang for the buck in health care today. This treatment gets people out of the hospital fast,” says Dallas psychiatrist Joel Holiner, who performs shock.

It is also the most profitable procedure in psychiatry.

Psychiatrists charge $125 to $250 per shock for the five- to 15-minute procedure; anesthesiologists charge $150 to $500.

This bill for one shock at CPC Heritage Oaks Hospital in Sacramento, Calif., is typical: $175 for the psychiatrist.

$300 for the anesthesiologist.

$375 for use of the hospital’s shock therapy room.

The patient got a total of 21 shocks, costing about $18,000. The hospital charged another $890 a day for her room. Private insurance paid.

Those figures add up. For example, a psychiatrist who does an average of three shocks a week, at $175 per shock, would increase his or her income by $27,300 a year.

Medicare pays less than private insurance – the payment varies by state – but it is still lucrative.

Before turning 65, many people are uninsured or have insurance that does not cover shock. Once someone qualifies for Medicare, the chance of getting shock therapy soars – as the 360% increase in Texas shows.

Stephen Rachlin, retired chairman of psychiatry at Nassau County (N.Y.) Medical Center, believes shock therapy is useful treatment. But he worries that financial rewards may influence its use.

“The rate of reimbursement by insurance is higher than anything else a psychiatrist can do in 30 minutes,” he says. “I’d hate to think it’s done solely for financial reasons.” Psychiatrist Conrad Swartz, co-owner with Abrams of Somatics Inc., the shock equipment manufacturer, defends the financial rewards.

“Psychiatrists don’t make much money, and by practicing ECT they can bring their income almost up to the level of the family practitioner or internist,” says Swartz, who performs shock himself.

According to the American Medical Association, psychiatrists earned an average of $131,300 in 1993.

A doctor says ‘no’

Michael Chavin, an anesthesiologist from Baytown, Texas, participated in 3,000 shock sessions before he stopped two years ago, worried he was hurting elderly patients.

“I began to get very disturbed by what I was seeing,” he says. “We had many elderly patients getting repeated shocks, 10 or 12 in a series, getting more disoriented each time. What they needed was not an electroshock to the brain, but proper medical care for cardiovascular problems, chronic pain and other problems.” In Chavin’s view, when the cardiovascular system is dramatically stressed in the elderly, doctors risk triggering a fatal decline.

“As an anesthesiologist, what I do for three to five minutes can have serious consequences later,” Chavin says. “But psychiatrists cannot bring themselves to admit any harm from ECT unless the patient gets electrocuted to death on the table while being videotaped and observed by a United Nations task force.

“These deaths are telling us something. Psychiatrists don’t want to hear it.” Chavin, then chief of anesthesiology at Baycoast Medical Center, stopped doing shock in 1993, reducing his income by $75,000 a year.

He says he feels ashamed that his waterfront home and pool were partially financed by what he considers to be “dirty money.” In spite of his growing doubts, Chavin didn’t quit doing shock right away. “It was hard to give up the income,” he says.

First, Chavin turned away patients. “I’d tell the psychiatrist: ‘This 85-year-old woman with high blood pressure and angina is not a good candidate for repeated anesthesia.’ ” Then, to confront his doubts, he began looking at the research on shock therapy. “I found it was done by psychiatrists who do electroshock for a living,” Chavin says.

He finally quit doing shock and another anesthesiologist took over. Two months later, on July 25, 1993, a patient named Roberto Ardizzone died from respiratory complications that began as he received shock therapy.

The hospital stopped doing shock altogether.

By Dennis Cauchon, USA TODAY

Patient satisfaction with electroconvulsive therapy

JESSE A. GOODMAN, MD; LOIS E. KRAHN, MD; GLENN E. SMITH, PHD; TERESA A. RUMMANS, MD; THOMAS S. PILEGGI, RN From the Mayo Medical School (J.A.G.) and Department of Psychiatry and Psychology (L.E.K., G.E.S., T.A.R., T.S.P.), Mayo Clinic Rochester, Rochester, Minn.This study was supported in part by grant R10 MH 55484-01A1 from the National Institute of Mental Health (Drs Krahn, Rummans, and Smith).

Presented in part at the 1998 Association for Convulsive Therapy Annual Meeting, Toronto, Ontario, May 31, 1998, and the 1998 American Psychiatric Association Annual Meeting, Toronto, Ontario, June 1, 1998.

Address reprint requests and correspondence to Lois E. Krahn, MD, Department of Psychiatry and Psychology, Mayo Clinic Rochester, 200 First St SW, Rochester, MN 55905.

Abstract

  • Objective: To determine whether patients who have electroconvulsive therapy (ECT) are satisfied with their treatment and demonstrate more favorable attitudes about ECT compared with controls.

  • Patients and Methods: We developed a 44-item survey measuring ECT treatment satisfaction and attitudes. The survey was administered to 24 psychiatric inpatients near the end of ECT treatment and 2 weeks later. A modified survey was administered to 24 outpatient controls who had never received ECT and who were recruited from a psychiatry clinic waiting room.

  • Results: Patients who received ECT had positive attitudes about it. For example, 21 (91 %) of 24 patient respondents endorsed the statement, “I am glad that I received ECT.” Attitude score was significantly higher for the ECT group compared with controls. A higher degree of satisfaction was associated with a higher level of education and younger age.

  • Conclusions: Patients who received ECT were satisfied with their treatment and had more favorable attitudes about it than patients who did not receive this treatment.

    Mayo Clin Proc. 1999;74:967-971

ECT=electroconvulsive therapy; Ham-D=Hamilton Depression Scale; MMSE=Mini-Mental State Examination

Used for 60 years, electroconvulsive therapy (ECT) is an effective treatment for many psychiatric conditions.1 Over the years numerous refinements to ECT have made it more efficacious with fewer complications. These improvements include anesthetic and muscle relaxant use, as well as the routine use of electroencephalographic and electrocardiographic monitoring and pulse oximetry. Further advances include administration of a titrated convulsive stimulus that triggers a seizure at a specific level above the patient’s measured seizure threshold.2-4 Clinicians have conducted research, published studies, and developed expertise regarding the administration of ECT to patients with a variety of comorbid medical disorders. However, when ECT is portrayed in the media, typically reference is made to negative images depicted in the novel and movie One Flew Over the Cuckoo’s Nest, without describing modern anesthetic agents and new procedures. As a result, the public, potential patients, and even physicians tend to view ECT as archaic and potentially dangerous. Many people suspect that patients undergo ECT as a last resort, and many doubt that patients would ever view this treatment favorably. Information about patient satisfaction with ECT is important when trying to educate potential patients and their families about this treatment option. The limited existing literature dates back many years and generally shows that patients who receive ECT have a positive attitude toward the treatment and its outcome.5-13 Relying on these previous studies is inappropriate because of the changes in ECT techniques over the decades, varied study methods, and lack of a validated survey instrument.There are at least 3 important reasons to measure satisfaction after ECT: (1) patient satisfaction is an increasingly important component of outcomes assessment; (2) satisfaction data are useful for patients considering ECT treatment; and (3) a satisfaction survey is an effective quality improvement tool for a particular program. A validated and reliable questionnaire permits the survey to be administered in a standardized fashion over time.Measuring patient satisfaction after ECT nonetheless presents a challenge. In particular, the design of a survey and timing of its administration must be done carefully because ECT alters cognition for a brief time. Also complicating the survey process are potential altered mood and insight in psychiatric patients after ECT. The present study was designed to measure patient satisfaction with ECT taking into account these factors.

Patient Satisfaction Survey

Instructions: Please read each statement below and circle one answer for each statement. Answer each question. If you are unsure about how to answer a question, give the best answer you can.

Definitely false Mostly false Not sure Mostly true Definitely true
Your Overall Satisfaction
ECT helps people. 1 2 3 4 5
People should not be afraid of ECT. 1 2 3 4 5
ECT is dangerous. 1 2 3 4 5
Many people are helped by ECT. 1 2 3 4 5
I am glad that I received ECT. 1 2 3 4 5
I had to wait too long to be treated on days I received ECT. 1 2 3 4 5
I felt safe receiving ECT. 1 2 3 4 5
If my doctor recommended ECT in the future, I would choose to have ECT treatment. 1 2 3 4 5
I was afraid to receive ECT. 1 2 3 4 5
ECT was painful. 1 2 3 4 5
I can remember having a seizure during ECT. 1 2 3 4 5
Your Satisfaction With Results
ECT improved the quality of my life. 1 2 3 4 5
I am very satisfied with the results of my ECT treatment. 1 2 3 4 5
I am more discouraged since my ECT treatment. 1 2 3 4 5
I am sleeping worse since my ECT treatment. 1 2 3 4 5
My appetite is not as good since my ECT treatment. 1 2 3 4 5
I have more energy since my ECT treatment. 1 2 3 4 5
I am more confused since my ECT treatment. 1 2 3 4 5
I am more optimistic since my ECT treatment. 1 2 3 4 5
I have less physical pain since my ECT treatment. 1 2 3 4 5
I get along with others better since my ECT treatment. 1 2 3 4 5
Your Satisfaction With Staff
I can remember being in the ECT treatment area. 1 2 3 4 5
I can remember the people who work in the ECT treatment area. 1 2 3 4 5
The ECT treatment area provided privacy for me. 1 2 3 4 5
I was treated with respect by the person who started my IV. 1 2 3 4 5
I was treated with respect by the person who was with me when I woke up after ECT. 1 2 3 4 5
I was treated with respect by the people in the room where I received ECT. 1 2 3 4 5
The ECT treatment area did not provide enough privacy for me. 1 2 3 4 5
Your Satisfaction With Education
Staff spent enough time with me describing ECT. 1 2 3 4 5
I received the right amount of information about ECT. 1 2 3 4 5
I received too much information about ECT. 1 2 3 4 5
I did not receive enough information about ECT. 1 2 3 4 5
Talking about ECT with my nurses and doctors made me less afraid of ECT. 1 2 3 4 5
I talked with another patient who had ECT, which made me less afraid to have ECT. 1 2 3 4 5
I did not know enough about ECT to decide if it was the right treatment. 1 2 3 4 5
All of my questions about ECT were answered to my satisfaction. 1 2 3 4 5
Your Feelings
I feel full of pep and energy most of the time. 1 2 3 4 5
I feel full of life. 1 2 3 4 5
I am a very nervous person. 1 2 3 4 5
I feel so down in the dumps that nothing can cheer me up. 1 2 3 4 5
I feel calm and peaceful. 1 2 3 4 5
I feel downhearted and low. 1 2 3 4 5
I feel comfortable in groups. 1 2 3 4 5
I feel tired and worn out most of the time. 1 2 3 4 5

Comments and suggestions.

Finally, please identify a way in which you would like to see the treatment you received improved.

PATIENTS AND METHODS

Eligible subjects included all psychiatric inpatients who completed a course of ECT between May 1 and July 31, 1997. All patients had a physical examination and electrocardiography before receiving ECT. A Thymatron DG ECT device (Somatics, Inc, Lake Bluff, Ill) was used. The anesthetic medications given to all patients included glycopyrrolate, thiopental, and succinylcholine, administered by an anesthesiologist. The treatment team determined on a case-by-case basis whether to use unilateral or bilateral stimuli. During the first treatment session, a stimulus titration protocol was used to determine seizure threshold, and thereafter patients were treated at 150% and 250% of this setting for bilateral and unilateral treatment, respectively.14 The patients had electrocardiographic and electroencephalographic monitoring and pulse oximetry, with periodic blood pressure checks throughout the procedure and for at least 20 minutes after the procedure until they were hemodynamically stable in the recovery room.

The only exclusion criterion was pre-ECT cognitive impairment, identified as a Mini-Mental State Examination (MMSE) score less than 26 (maximum score, 30) or an inability to complete the survey.15 Controls included consecutive patients seen in the outpatient psychiatric clinic over 2 days. Controls were excluded if they had ever received or been offered ECT. The study was approved by the Institutional Review Board of the Mayo Foundation. Patients were asked to participate while on the hospital unit away from the ECT treatment suite and were advised that their answers would not affect the nature of future psychiatric treatment at the institution.

The survey was revised several times after a set of 85 questions was tested and retested with several pilot groups of appropriate patients. The final version of the Patient Satisfaction Survey contained 44 items divided into 5 sections. Answers were scored from 1 to 5. Half of the items were positively phrased and half were negatively phrased. Statements were designed to be understandable, unambiguous, and free of value-laden terms.16 The questionnaire also encouraged patients to write comments and suggestions about their treatment. Subjects were assured that their responses were confidential.

Other data collected from patients receiving ECT included age, sex, level of education, pretreatment psychiatric diagnosis, and pre-ECT and post-ECT Hamilton Depression Scale (Ham-D) and MMSE scores.15,17 The pre-ECT and post-ECT Ham-D and MMSE evaluations for each patient were administered by the same interviewer (2 trained interviewers with good interrater reliability are part of the ECT service). The first ECT surveys were administered the evening before each subject’s last ECT treatment and at least 24 hours after the previous treatment. All the surveys were administered by 1 of us (J.A.G.) who was not part of the hospital treatment team or ECT service. The identical survey was mailed to participants at their homes 2 weeks after treatment to follow up their opinions about ECT treatment.

The survey was modified before administration to controls because many items addressed the patient’s perceptions of the actual ECT experience. Therefore, 5 items were selected from the “Overall Satisfaction” section of the ECT survey that addressed attitude (rather than actual experience). The statements selected were “ECT helps people,” “People should not be afraid of ECT,” “ECT is dangerous,” “Many people are helped by ECT,” and “If my doctor recommended ECT in the future, I would choose to have ECT treatment.” This modified questionnaire was administered once to controls in the outpatient psychiatry department waiting room.

An “Overall Satisfaction” score was generated by the sum of the 44 item scores from the surveys administered to the treated patients. The relationship between the scores resulting from the 2 administrations was evaluated with the Pearson correlation coefficient. Differences between the Ham-D and MMSE scores from the first to second survey were assessed with paired t tests.

The relationship between overall satisfaction from the first administration and age, sex, education level, and Ham-D and MMSE scores before and after ECT was also examined. For those variables that are continuous (age, education level, rating scales), significance was assessed with the Pearson correlation coefficient. For variables that take discrete values (sex), significance was evaluated by analysis of variance. To assess the difference in attitude toward ECT between subjects and controls, an attitude score was calculated for each participant by determining the mean of the 5 items that were asked of both groups. A 2-sample t test was used to assess the statistical significance of the difference of the mean scores between the 2 groups.

RESULTS

Fifty-three subjects completed ECT during the study period. Eight were excluded from study participation because of cognitive impairment. Of the 45 eligible subjects, 24 (53%) completed both survey administrations (12 males and 12 females). Five patients refused to participate, and 16 patients (34%) did not complete the follow-up questionnaire. The mean age of the 24 study patients was 58.3 years (SD, 17.6 years; range, 16-78 years). The mean level of education was 12.6 years (SD, 3.5 years; range, 8-20 years). The mean number of ECT treatments was 8.3 (SD, 3.5; range, 2-19). Major depression was the principal psychiatric diagnosis in 22 patients; 1 patient had bipolar disorder and 1 had dysthymia. Twenty-four eligible control patients completed the modified survey.

Figure 1. Mean response to 11 survey items of the “Overall Satisfaction” section of the survey by psychiatric inpatients at the end of the treatment (N=24), 2 weeks after treatment (N=24), and all 5 questions asked of the control outpatients who did not receive electroconvulsive therapy (ECT) (N=24). The 5 response options appear on the x axis.

Responses of ECT patients reflected positive attitudes toward ECT (Figure 1). Data are reported for the “overall satisfaction” component only. For example, 21 (91 %) of 24 patients endorsed (answered “mostly true” or “definitely true”) the statement, “I am glad that I received ECT” 23 (96%) endorsed the statement, “ECT helps people” 19 (81%) endorsed the statement, “I felt safe receiving ECT” and 20 (82%) endorsed the statement, “If my doctor recommended ECT in the future, I would choose to have ECT treatment.” The attitude score, comparing responses of patients and controls to the same 5 statements, was significantly higher for the ECT group (4.4 of 5; SD=0.7) compared with the control group (3.2 of 5; SD=0.9) (P<.001).

Global satisfaction at the end of treatment correlated with that at 2-week follow-up (r=0.57; P=.007). The mean global satisfaction score change from the end of treatment to 2-week follow-up was 1.48 (SD, 21.4), which was not significantly different from 0. From the first survey of ECT patients, the correlation between age and global satisfaction was 0.43 (P<.05), and the correlation between education level and global satisfaction was 0.42 (P=.05).

The mean Ham-D score at the beginning of treatment was 27.4 (SD, 7.2) and at the end of treatment was 7.9 (SD, 6.6) (P<.001). The mean decrease in Ham-D score was 19.2 (SD, 9.8). The mean MMSE score at the beginning of treatment was 27.8 (SD, 2.6) and at the end of treatment was 26.2 (SD=1.9) (P<.05). There was no significant change in the MMSE score (1.3; SD, 2.65).

DISCUSSION

The data suggest that ECT patients’ positive attitudes about ECT persisted at 2 weeks after treatment. The degree of satisfaction may be surprising to the public and non-psychiatric clinicians as well as to psychiatrists who are ambivalent about ECT. Moreover, ECT patients held significantly more favorable attitudes about ECT than the control group; ECT patients’ experience with ECT may have altered previously held beliefs that ECT is dangerous or painful.

As a consecutive series of outpatients with a variety of psychiatric diagnoses, our control group had limitations. A true control group would have been drawn from inpatients completing pharmacologic treatment for their psychiatric disorder who were not offered ECT.

A higher degree of overall satisfaction was associated with a younger age. This is interesting because the “Satisfaction With Results” score, a scale composed of 10 items, did not correlate with age. It is possible that the sample was too small to detect a difference in satisfaction with results by age. Or, while older patients receive similar benefit from ECT, their satisfaction may be diminished by more severe adverse effects.

Potential sources of error in the data include selection bias, as patients who chose not to complete the survey may have been less satisfied. The 53% response rate is a possible source of selection bias; with this population of psychiatric patients, however, obtaining high response rates is difficult. If patients are invested in their treatment, their hope that ECT is an effective treatment may inflate their degree of satisfaction. Every attempt was made to administer the survey in a manner in which patients would not feel compelled to answer in a way to please the treatment team. The possibility that mood state alters satisfaction presents another challenge. Patients with recurrence of depressed mood would likely have less positive attitudes about their ECT treatment if surveyed at a time of relapse. Post-ECT confusion may have been an issue for some patients at this point and may account for the number of ECT patients who failed to respond to the second survey.

Future research projects to study patient satisfaction with ECT could address many other issues. The study design precluded the involvement of cognitively impaired patients. A future study could enlist family members to complete surveys on patients’ behalf or could collect data from all patients regardless of their cognitive status. Another issue for further research is to survey patients who refused ECT to understand their concerns. Additional questions could be incorporated into the questionnaire to examine whether patients with subjective memory impairment have more negative attitudes toward ECT.

While the data indicate that patients were satisfied with ECT at the conclusion of treatment and at follow-up 2 weeks later, longer-term follow-up would be valuable to assess satisfaction over time.

Acknowledgment

We thank V. Shane Pankratz, PhD, for reviewing the statistical analyses used in this paper.

REFERENCES

  1. American Psychiatric Association Task Force on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. Washington, DC: American Psychiatric Association; 1990.
  2. Weiner RD, Rogers HJ, Davidson JR, Squire LR. Effects of stimulus parameters on cognitive side effects. Ann N Y Acad Sci. 1986;462:315-325.
  3. Abramczuk JA, Rose NM. Pre-anaesthetic assessment and the prevention of post-ECT morbidity. Br J Psychiatry. 1979;134:582-587.
  4. Sackeim HA, Prudic J, Devanand DP, et al. Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med. 1993;328:839-846.
  5. Mattes JA, Pettinati HM, Stephens S, Robin SE, Willis KW. A placebo-controlled evaluation of vasopressin for ECT-induced memory impairment. Biol Psychiatry. 1990;27:289-303.
  6. Pettinati HM, Tamburello TA, Ruetsch CR, Kaplan FN. Patient attitudes toward electroconvulsive therapy. Psychopharmacol Bull. 1994;30:471-475.
  7. Szuba MP, Baxter LRJr, Liston EH, Roy-Byrne P. Patient and family perspective of electroconvulsive therapy: correlation with outcome. Convuls Ther. 1991;7:175-183.
  8. Baxter LR, Roy-Byrne P, Liston EH, Fairbanks L. The experience of electroconvulsive therapy in the 1980s: a prospective study of the knowledge, opinions, and experience of California electroconvulsive therapy patients in the Berkeley years. Convuls Ther. 1986;2:179-189.
  9. Freeman CPL, Cheshire KE. Review: attitude studies on electroconvulsive therapy. Convuls Ther. 1986;2:31-42.
  10. Freeman CP, Kendell RE. ECT, I: patients’ experiences and attitudes. Br J Psychiatry. 1980;137:8-16.
  11. Kalayam B, Steinhart MJ. A survey of attitudes on the use of electroconvulsive therapy. Hosp Community Psychiatry. 1981;32:185-188.
  12. Hillard JR, Folger R. Patients’ attitudes and attributions to electroconvulsive shock therapy. J Clin Psychol. 1977;33:855-861.
  13. Battersby M, Ben-Tovim D, Eden J. Electroconvulsive therapy: a study of attitudes and attitude change after seeing an educational video. Aust N Z J Psychiatry. 1993;27:613-619.
  14. Beyer JL, Weiner RD, Glenn MD. Electroconvulsive Therapy: A Programmed Text. 2nd ed. Washington, DC: American Psychiatric Press; 1998;63-78.
  15. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198.
  16. Streiner DL, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use. 2nd ed. Oxford, England: Oxford University Press; 1995.
  17. Hamilton M. Development of a rating scale for primary depressive illness. Br J Soc Clin Psychol. 1967;6:278-296.

Video and audio clips about electroconvulsive therapy

Audio

Tune in every Tuesday at 1 ET (12 Central, 10 am Pacific) for the Mind Freedom Weekly News Hour, hosted by David Oaks.
http://www.progressiveradionetwork.org/

Electroshock as violence against women:
Dr. Bonnie Burstow explores electroshock as a form of violence against women. She is a feminist therapist, an anti-psychiatry and anti-fascist activist. She is also the former co-chiar of the Ontario Coalition Against Electroshock and is the author of Radical Feminist Therapy: Working in the Context of Violence. Listen

Weekly Paul Henri Thomas updates:
WGBB radio has vowed that it will carry weekly updates until Paul Henri is no longer at risk of forced electroshock treatments. You may listen to the show live on the net on Monday nights at 7 pm Eastern time. I will try and record the shows for those who miss them:

  • Feb. 26, 2001: WGBB on Long Island, New York carried a GREAT program that featured Sherry Taub, a New York activist, and PAUL HENRI THOMAS! (He’s the man at Pilgrim being forcibly electroshocked currently) He’s difficult to understand at times due to his French accent and the effects of the THIRTEEN psychiatric drugs he’s on, but it’s a great interview. A MUST LISTEN! (30 minutes)
  • March 5, 2001: The second show featuring advocate Anne Kraus talking about the hearing and the latest news on Paul Henri. (29 minutes)
  • March 12, 2001: The third show featuring Sherry Taub and Laura Ziegler talking about the latest legal news concerning Paul Henri. (38 minutes)
  • April 2, 2001: Another show, featuring Linda Andre of CTIP and Anne Kraus. (11 minutes)

My interview on CKLN Radio in Toronto, where I discussed ECT, the Kathleen Garrett case, forced ECT and other issues in September, 2000. (25 minutes)

Feb. 26, 2001: KUCI in Irvine, California has a weekly show on Mondays called Mind…Your Own Business, where they discuss mental health issues. I was the guest for this show and talked about ECT, Paul Henri, forced ECT and more. (50 minutes)

Three excerpts from the recent series by Gary Null (www.garynull.com) on ECT and the use of force.

  • Gary interviews a number of ECT survivors, who speak about their experiences and talk about the issues surrounding ECT. Listen (45 minutes)
  • Gary speaks to psychiatrist Dan Fisher of the National Empowerment Center, who discusses issues, plus talks about why ECT isn’t an effective treatment. Dr. Fisher says 50 percent of psychiatrists are opposed to ECT. (The audio on this is a little fuzzy). Gary also discusses the current state of research and does an exhaustive lit review. Listen (22 minutes)
  • Gary interviews more ECT survivors and continues his series. Listen (57 minutes)

Dr. Max Fink on informed consent issues and protecting yourself against lawsuits (if you’re an ECT doc). (3 minutes)

Dr. Max Fink sums up how psychiatrists are given the power to play god: “The judgment is yours. Society says….YOU’RE the psychiatrist…” (1 minute)

Video

The issues

Channel 11 in St. Louis reports on HB134 which would require ECT reporting. (48 seconds)

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An interesting clip from 60 Minutes II. (24 seconds) Oh boo hoo, CBS had the video removed.
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Extra
The Extra news show explores the issues surrounding ECT. This segment interviews Liz McGillicuddy, who lost much of her memory from electroshock in 1994. (3:47 minutes)

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It also includes interviews with Dr. John Friedberg, neurologist in California, who talks about the fact that the FDA has NEVER required safety testing of the machines, and they interview Harold Sackeim, PhD, shock proponent extraordinaire. In his interview, he *admits* that the famous 1 in 200 statistic is not based in science!
Here, Harold Sackeim admits the truth – the statistic is not based in science! (30 seconds)

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Gordon Elliot Show

Diann’a Loper discusses how a bill she helped create has helped other ECT patients. This kind of reporting MUST be made mandatory across the USA. Lobby your legislators! (30 seconds)

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Diann’a Loper fell into a post-partum depression. Her psychiatrist pushed her into ECT, and she lost everything – her marriage, her new baby, and most of her life. Says Diann’a, “I wish they would have killed me.” (2:30 minutes)

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Hope Morgan received ECT when she began suffering from insomnia. Her doctor diagnosed depression. “My life was in a shambles,” says Hope, referring to the devastation following the ECT. (3:10 minutes)

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Marcia Fink says ECT turned her life around. “I do things anyone else can do.” She says the only memory loss she suffered was three months’ worth. (1:47 minutes)

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Hal Haralson says ECT in the state hospital 40 years ago turned his depression around. (43 seconds)

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A doctor from the audience speaks against ECT, and the role of insurance companies. (1:02 minutes)

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Dr. Charles Kellner blatantly lies about the current stimulus dosing used in today’s ECT! BUSTED! (1 minute)

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More from Charles Kellner
When questioned about his financial ties to Mecta, one of the shock machine manufacturers, Dr. Charles Kellner attempts to change the subject. (32 seconds)

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Here, Dr. Kellner says the tragic experiences of patients like Hope and Diann’a are “unfortunate” and goes on to say that most people will be cured by ECT. He fails to mention the now-admitted high relapse rate, or the need for continuation/maintenance ECT. (30 seconds)

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Dr. Charles Kellner misleads the public about the effectiveness of ECT. (1 minute)

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Dr. Charles Kellner makes up a story about how ect works. The truth is, nobody knows, and he’s CAUGHT ON TAPE fabricating a nice tale. (50 seconds)

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Dr. Peter Breggin discusses the role of the FDA in the ECT controversy, and how they dropped the ball. (1 minute)

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Dr. Breggin talks about the literature, and why some people become *more* depressed after ECT. (35 seconds)

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Dr. Breggin explains how the perception of ECT has changed, and how the longstanding theory that “brain damage was helpful” has been given a new spin. (50 seconds)

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Dr. Peter Breggin sums it all up: View the clip (10 seconds)

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Scottish Documentary on Ewen Cameron, who worked with the CIA to brainwash and erase memory using electroshock. In three parts.
Part 1

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Part 2
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Part 3
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News stories on Christian Hageseth and his legal woes

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Video clips from the Mecta lawsuit, Harold Sackeim testimony

Psychiatry’s roots in paternalism: why the field has not kept up with contemporary thinking

This is an article I wrote for a feminist publication. I’m going to have to hunt down its name and when published.

Psychiatry’s roots in paternalism: why the field has not kept up with contemporary thinking

By Juli Lawrence
ect.org

At its core, the field of medicine has always been paternalistic: doctor knows best. Even the Hippocratic Oath included a line that encouraged physicians to perpetuate the imbalance of power between doctor and patient: “I will prescribe regimen for the good of my patients according to my ability and my judgment.”

But while patients’ rights activists have provoked change in this power struggle, the field of psychiatry maintains roots deeply planted in paternalism and patriarchy. This imbalance of power is evident in the privacy of the doctor’s office, among colleagues, in hospitals, and even in the courtroom.

The very nature of psychiatry seeks to modify emotions and behavior, whether through therapy, medications, electroshock and other methods, and the doctor-
patient relationship revolves around a paternalistic imbalance of power. Psychiatrists label their patients as compliant or noncompliant to characterize whether or not the psychiatrist’s power has been accepted.

The doctrine of informed consent theoretically gives a patient information about a treatment, and the right to refuse treatment for any reason. But the doctrine hinges on the patient’s competence, and in psychiatry, the concept of competence is often used to reassert the psychiatrist’s power.

In many states, a person’s competence can be decided by the views of one psychiatrist. Some states require a second opinion, though it’s rare that in a simple competency hearing one doctor will disagree with another. In the court system, psychiatrists are given even more power and it would take a unique judge to listen to a patient – particularly a psychiatric patient – over a doctor.

Consider a case of forced electroshock involving an elderly woman in St. Louis, Missouri in August, 2000.

Kathleen Garrett was a woman in her 60s, recently widowed and undergoing treatment for breast cancer, as well as enduring a recent estrangement from one of her sons. Most women in such circumstances would find themselves with feelings of grief, if not downright depressed. Mrs. Garrett, with a lifelong history of episodic depression, did become depressed. Her psychiatrist adjusted her medications, but the depression remained. He then told her she needed to have electroconvulsive therapy, or electroshock. Mrs. Garrett refused, and immediately transformed into a “noncompliant patient.”

Instead of spending time discussing other options or why she didn’t want electroshock, her psychiatrist rushed into court, told the judge that he knew best, and that Mrs. Garrett was not competent to make such a decision. He didn’t mention that until the moment she said no, he considered her competent to make the decision.

Mrs. Garrett had very little time to put together a legal defense, and her Social Security income limited her access to an experienced attorney. The judge quickly ruled against her, ordering the doctor to begin electroshock treatments against her will. Mrs. Garrett would have been just another silent victim of the abuse of psychiatric power, but a loud and angry e-mail campaign against the doctor and hospital focused negative attention on her plight, and she was released from the hospital before completing the full series of treatments against her will.

Psychiatric patients often find themselves labeled noncompliant if they dare to speak back to their doctors, challenge his authority, or even ask questions. If a prescribed treatment, such as medication, is unsuccessful, the patient is again labeled noncompliant, with the psychiatrist just assuming that the patient has not followed directions. Psychiatric patients are at a distinct disadvantage because of the psychiatrists’ ability to use force to maintain the power structure.

Certainly “noncompliance” is a term used in other medical specialties, and doctors complain that patients with high blood pressure, diabetes, and other diseases sometimes do not take medications as directed. However, despite a potential life-threatening outcome, a person with high blood pressure won’t find herself plunged into a courtroom drama to force compliance. A woman with diabetes who skips an insulin injection, or decides she’s tired of the routine, will not open her door to a nurse with a hypodermic in hand.

Psychiatric patients often face scenarios like this once they threaten a psychiatrist’s power, and states are enacting laws making it easier to force “compliance,” such as Illinois SB0198, currently undergoing Senate review. As it went through the Rules Committee, the proposed bill has had its language changed from “cause serious harm to self or others” to “engage in dangerous conduct.” Past experience has shown that dangerous conduct could be anything from eating unhealthy foods to disagreeing with a psychiatrists’ order to take medications despite having caused dangerous side effects in the patient’s past. Or dangerous conduct, more often, would simply be a “noncompliant patient.”

A mental health rights activist once said that if someone prepares a buffet of delicious, healthy food, people will come. But if that buffet serves food that makes people feel sick, they won’t return. It is an excellent analogy, and one that needs attention in the world of psychiatry. Too often, patients who tell their psychiatrists that the medications make them feel worse than their original symptoms made them feel are quickly tossed into the basket of “noncompliant patients.” The atmosphere quickly shifts from the psychiatrist’s comfortable balance of “Doctor says, patient obeys,” to one of “I am the expert, you must do as I say.” It can easily disintegrate into the psychiatrist labeling the patient incompetent, because she did not submit to his power and authority.

Experienced patients quickly learn they have a choice: they can submit and follow orders, or they can play “the game.” Most psychiatric patients fully understand that the game involves pretending to do exactly as ordered, and to put on an air of gratefulness. Unfortunately, this also means that the patient no longer confides in the psychiatrist with regard to symptoms, and their emotional disorders may grow worse. Alternately, the symptoms may abate on their own, as is common with psychiatric disorders. In the end, the doctor proclaims his methods are successful, he asserts his superiority, and the power game goes on. But under the surface of cooperative relationship, the truth reveals a relationship based on distrust and deception.

Psychiatrist Sally Satel, author of “PC, M.D.: How Political Correctness Is Corrupting Medicine,” has written extensively about the need to maintain the status quo of doctor over patient. Her writings reveal her anger that women are trying to take control of their healthcare, particularly with regard to mental healthcare.

“But it is wrongheaded to confuse the need to know more – an imperative that will always be with us – with the unwarranted and poisonous notion that women are somehow second-class subjects in the world of medicine,” she writes.

She chastises health activists for interfering with “effective diagnosis and doctoring.”

Psychiatric patients are fighting back, however.

A growing movement of patients and ex-patients is demanding change in the system, and asking that patients be given a long-overdue voice and control of their healthcare choices. Not surprisingly, activists are not generally well-
received by psychiatrists. But psychiatrists still have their secret weapon, and it’s a weapon that the general public accepts without question: the issue of competence. To discredit an activist’s words, simply declare she is suffering from mental illness, and doesn’t know what’s best. Reassert psychiatry’s authority, and you have an effective method of discrediting just about anything.

The courts buy into it, because psychiatry has been given special status in the court system. The public buys into it, because they don’t have the experience to understand how paternalistic psychiatry is. And of course the medical industry buys into it because paternalism fits in with their views to “help” anyone who needs help, even when the help is intrusive, inappropriate and unwanted. The doctor knows best.

Psychiatry has a long way to go in moving into modern times. Psychiatrists want so badly to be taken seriously as medical doctors and legitimate scientists, but until they confront a history that is full of abuses, and a method that continues today to abuse authority, psychiatry will remain mired in an atmosphere of paternalism, controversy and resentment.

Patients not being given enough info: UK Charity

14 March, 2001
BBC

No warnings before shock treatment

Patients are not being given enough information or being offered the chance to opt out of a controversial treatment for depression, says a charity.

Mind said electro-convulsive therapy (ECT) could leave patients suffering a number of side-effects – and that patients were frequently not told about these prior to treatment.

But a separate study on ECT by American scientists said the therapy had a bad reputation in the past, but was now an effective means of combating depression.

ECT involves passing a current through an anaesthetised person’s brain to produce a seizure with the aim of relieving severe depression.

Mind officials claim patients are left with permanent memory loss, anxiety, lack of concentration and forget skills such as counting or music learned before the treatment.

Out of over 400 people surveyed by Mind, 84% said they had suffered adverse side effects.

Four out of ten suffered permanent loss of some of their memories and 36% had permanent difficulty in concentrating.

But three quarters surveyed said they had not been given any information about possible side effects and only 8% were able to consult an independent expert before agreeing to treatment.

Forgotten past

One woman told Mind she could remember nothing about bringing up her children.

She said: “I can’t remember hardly anything about my past life, only very little bits.

“As for bringing up my three daughters, I can’t remember a thing.”

A former taxi driver said she had lost all her directional skills following the treatment.

She said: “I was a taxi-driver for 20 years. Now I can only find my way if I have my carer present to give directions. I do not know my left from my right.”

Worst fears

Under the Mental Health Act 1983, ECT can be given to detained patients without their consent.

Between January-March 1999, 2,800 patients received about 16,500 administrations of ECT.

Out of the quarter who were detained, well over half had not consented to the treatment.

Two thirds of the 418 people surveyed by Mind said they would not agree to have ECT again.

Margaret Pedler, head of policy development at Mind, said the results “confirmed their worst fears.”

She said: “It is clear that people are still not being given enough information about temporary and permanent side-effects and this means that those who are giving their consent to ECT are not doing so out of informed choice.”

Dr Susan Benbow, from the Royal College of Psychiatrists ECT committee, stressed the treatment is only given to seriously ill patients and was not a decision taken lightly.

“We are not talking about run-of-the-mill people who are feeling low, we are talking about seriously ill people.”

She said depression causes memory loss, as do the drugs taken to combat it, so not all the problems can be blamed on ECT.

Beating depression

But a separate study by scientists from the New York State Psychiatric Institute, and the College of Physicians and Surgeons at Columbia University, New York, found that a combination of lithium and the anti-depressant drug nortriptyline following shock therapy substantially lowered the relapse rate of patients with major depression.

The patients involved in the trial were resistant to the usual drug-based depression treatments.

Richard Glass, deputy editor of the Journal of the American Medical Association, said in an editorial the therapy got a bad name in the middle part of the last century.

He said that the usefulness of shock treatments for combating depression “are among the most positive treatment effects in all of medicine … yet this effective treatment too often remains in the shadows of stigma and fear.

“The study … is a good example of the growing scientific database that can usefully inform clinical decisions about this treatment.”

Mixed response for ECT guidance

Wednesday, December 11, 2002

Health-News.co.uk
LONDON
By Vivienne Russell

Mental health campaigners have welcomed provisional suggestions from government advisors on the use of electroconvulsive therapy (ECT), but say further changes are needed to strengthen patient rights.

The National Institute for Clinical Excellence (NICE) has published its final appraisal document on the use of ECT, which says doctors can use the treatment on individuals with severe depressive illness, catatonia or a prolonged severe manic episode.

However, NICE says the treatment should only be used to achieve rapid and short-term improvement of severe symptoms after other treatments options have proved ineffective.

The document says valid consent should be obtained in all cases where the individual has the ability to make the decision, and the choice to use the treatment should be made jointly by the clinician and patient based on an informed discussion.

During ECT, an electric current is passed through the brain in order to induce a seizure. It can increase the risk of a cardiovascular event in at-risk individuals and may lead to short-term or long-term memory loss. Although efforts have been made to standardise the use of ECT, with both the Royal College of Psychiatrists and the Royal College of Nursing publishing guidelines, there is still variation in the use and practice of the procedure throughout England and Wales.

The mental health charity Mind said it was pleased to see that the NICE guidance recognised the risk of side effects from ECT and recommended restrictions on its use. The charity agreed that steps should be taken to ensure that people were not pressured or coerced into accepting the therapy.

But the charity said it was concerned that ECT was still seen as an effective treatment. According to a recent Mind survey, two-thirds of patients who had received the therapy said they would not agree to have it again. The survey also revealed that 73 per cent of recipients were not informed of possible side effects.

Mind Chief Executive Richard Brook said NICE had missed an opportunity to allow people to refuse ECT when they are opposed to it.

But he added, “Though Mind continues to question ECT’s effectiveness, these guidelines show a step in the right direction. However, revisions to the current Mental Health Act are essential in order to provide a legal framework in which they can be enforced.”

Mind’s view was echoed by the mental health charity MACA, which said the NICE guidance was a positive first step, but that the rights of the patients needed to be safeguarded.

Simon Lawton-Smith, head of public affairs at MACA, said, “Health professionals must obtain fully informed consent from patients where possible, and take into account any advance directive. They must also be properly trained to use ECT equipment.

“This all sounds obvious, but it needs the authority of NICE to ensure improvements are made on the ground,” he said.

The groups involved in the consultation process that led to the new guidelines have until December 23 to decide whether they wish to appeal against the final appraisal document.

What Governor Pataki Won’t Let Us Know

Rights Now! Public Action Committee of The New York Organization For Human
Rights and Against Psychiatric Assault
Contact: Sherry Taub Phone: (631) 757-0394 E-mail: sherrytaub@justice.com

For Immediate Release*****For Immediate Release******
Flying Back Over the Cuckoo’s Nest: The Hidden Growth of Forced Electroshock
In New York, and What Governor Pataki Won’t Let Us Know

We are deeply dismayed by Governor Pataki’s veto of the electroshock reporting bill after its passage by a large margin in both the assembly and the senate, and we vow to seek the help of all citizens concerned about our human rights and their own, in overturning it.

The New York Organization For Human Rights and Against Psychiatric Assault is made up of New Yorkers who have psychiatric disabilities — or were diagnosed as having them — and their allies. We are people who have received the services of the mental health system or been subject to its involuntary interventions. Some of us are people who have survived electroshock, including forced electroshock. Some of us have family members who have survived electroshock. NAMI does *not* represent us. NAMI’s positions frequently diverge from ours and from those supporting disability rights.

The practice of institutional psychiatry goes on behind high walls erected to segregate people from society. The history of psychiatric treatment has proven that these walls often keep damaging practices “safe” from public scrutiny.

We have demonstrated in support of Paul Henri Thomas and Adam Szyszko, two men who were forcibly shocked at Pilgrim State Psychiatric Center on Long Island, who managed, through luck and individual circumstances, to get their plight known to advocates outside. Many of us testified at the NYS Assembly’s 2001 hearings on electroshock and worked to improve the bills originally introduced by Assemblyman Luster, chair of the Mental Health Committee. After hearing and investigating our concerns, after requesting that the New York State Commission on Quality of Care do the extensive investigation required to find what sketchy and conflicting records of shock use already existed, he saw the clear need for a bill like the one Governor Pataki has vetoed. An overwhelming majority of legislators in both the senate and the assembly also saw this clear need, and voted to begin to address it in law. Yet Governor Pataki, under admitted pressure from the Psychiatric Association and the Hospital Association and OMH, denies it.

In the course of Assemblyman Luster’s investigation of electroshock, the state Mental Hygiene Legal Service revealed that in the previous year alone, there had been a 73% increase in court-sanctioned administration of electroshock over the patient’s expressed objections. It is unlikely that this deeply disturbing fact would have come to light without our urging investigation.

The bill that the Governor rejected did not in any way attempt to regulate electroshock. It required the state Office of Mental Health to collect information on its current use. Six other states (Vermont, Colorado, California, Illinois, Texas, and Massachusetts) already have a similar or even more thorough reporting bill. In no way was this a radical initiative. To call it somehow stigmatizing, as Pataki has, is akin to claiming that FDA oversight of prescription drugs makes people feel stigmatized when they’re given a prescription. Today the powerful industry opposition to collection of data on who gets electroshocked, under what circumstances, who is forced to undergo electroshock over objection or without consent, and how many injuries or deaths occur, has been made clearly visible to all.

The industry and those who share its interests have manipulated a veto of reporting legislation that was created with overwhelming support from a broad range of advocacy groups. What are the actual reasons for this desire to suppress information? Whose interests would that information threaten?

Currently, control of information about electroshock is in the hands of those with financial and other self-serving interests in promoting it. It is a known fact that APA electroshock policy, accepted as the industry standard, was largely shaped by men who have been publicly exposed as having personal financial interests in sales of electroshock equipment. It has been shown that psychiatrists who use electroshock make appreciably more in income than those who do not. There is no reason to be surprised that the APA’s recently revised guidelines spread a far wider net for those considered to be “good candidates” for electroshock.

Perhaps it’s time the public recognized that we are not “lacking insight” here, as the psychiatric establishment has been given far too much power to declare. At long last, the public is increasingly aware of big money interests in health care, and the resulting abuse of public trust that can result from them. We must be vigilant and demand that our government seek out, record, and make easily accessible the hard data to protect against such abuses. Though Governor Pataki claims this is an unnecessary expansion of the state’s responsibility, we can think of no responsibility more appropriate and necessary for the state Office of Mental Health to undertake.

Mission Statement of The New York Organization For Human Rights and Against Psychiatric Assault

- Work/fight to end coercive psychiatry entirely

- Provide a forum to connect, educate and support human rights activists like ourselves throughout New York State

- Educate the public about our human rights demands and about alternative ways of thinking about madness

- Support and promote choice, freedom and self-determination for all human beings

- Listen and incorporate issues particularly affecting women, people of color, LGBT people, and people with other kinds of disability into our work

How do psychiatrists decide to use forced electroshock?

by Linda Andre
Director of CTIP

Have you ever wondered how psychiatrists make a decision to shock a person against his or her will? Who’s a candidate for forced shock, and why?

These questions were publicly answered by the two psychiatrists who signed the papers seeking a court order for involuntary shock of Paul Henri Thomas.

In some but not all states—New York is one of them—a person must be found to be legally incompetent before he or she can be shocked against her will.

The general public, upon hearing this, sighs in relief: of course; that’s as it should be; that could never happen to me; of course there must be safeguards in place, and standards as to what constitutes competence; a person must have to be really bad off, really crazy like catatonic, to be ruled incompetent.

Treating psychiatrist Andre Azemar and supervising psychiatrist Bob Kalani of Pilgrim State Psychiatrist Hospital both testified against their patient Paul Henri Thomas in hearings held in March and April 2001.

They were asked how they decided that Paul lacked the capacity to make this own treatment decisions.

They made it clear.

Having a diagnosis of mental illness helps you get ruled incompetent, but it’s not enough by itself. And you sure don’t need to be catatonic or psychotic. Here are the rules:

Rule # 1: You’re incompetent if you think you’re not crazy.

“Lack of insight” was cited an overwhelming number of times by witnesses against Paul as justification for forced treatment. Both doctors said, in essence, that any person who says that he is not mentally ill when a doctor says he is lacks “insight into his illness”, and that this means he lacks the capacity to make his own treatment decisions.

Paul’s lawyer Kim Darrow was thorough in his questioning, trying to elicit from the doctors any other factors they might have weighed in making their decision that Paul lacked capacity and therefore qualified for forced shock.

There were none. On further questioning, Dr. Azemar was asked why Paul doesn’t think he is mentally ill. His answer: “Because mental illness clouds his judgment.” It was clear to everyone who watched this trial (except the judge) that this was a Catch-22, no-win situation. As long as you say you’re not crazy, you’re considered crazy.

The audience waited in vain for further justification of the claim that Paul was mentally ill. He was said to have various diagnoses, including schizoaffective disorder (also the diagnosis of this reporter), bipolar disorder, and mania. Neither doctor had enough evidence against Paul to justify these diagnoses by DSM criteria. Paul was said to be “loud”, “noncompliant”, “threatening”, to have worn inappropriate clothing on the ward and to have hoarded food (which would have been entirely appropriate for someone looking to escape from the hospital, former patients concurred later). His hygiene was said to be poor; he was accused of cluttering his hospital room with books and dirty clothes—”dirty clothes on top of clean clothes!” in the words of Azemar.

The other shrink, Kalani, conceded that on the day he testified—as well as on the day he signed the petition for forced shock—his patient had no symptoms of mental illness other than denying he had a mental illness.

An independent, unpaid psychologist who examined Paul in the hospital at the end of March, interviewing him as well as performing some psychological testing, testified that he found no evidence of psychosis, mania, or mental illness. He testified that Paul is competent to make his own decision regarding ECT.

Rule #2: When you say yes, you’re competent; when you say no, you’re incompetent. Either way you get shocked.

“The staff would ask him, are you going to consent or are we going to have to go back to court?” —Bob Kalani

If Paul was really incompetent, he was incompetent not only to reject treatment, but to accept it. His yes would not have been legal. Yet both shrinks testified about attempts to talk the legally incompetent Paul into saying yes to shock.

“Did you try to get Mr. Thomas to consent to ECT in January? If he had consented, would you have sought a court order?” asked Darrow of the treating psychiatrist.

The judge objected.

“If Paul had said yes, would you have tested his competency?” Azemar looked baffled and answered, “If they say no, we have to do it.”

At this point the judge interrupted, saying, “I don’t understand the question”. No one else in the courtroom seemed to have any difficulty understanding the question or the point that had been made.

“If he accepts the illness then he can make his own decisions and we don’t have to force him,” Dr. Kalani had testified. Sure Paul can make his own decisions—-as long as he consents.

Rule #3: If you disagree with what your doctors say about treatment in general or your treatment in particular, you’re incompetent.

When asked: What constitutes capacity? Azemar replied as follows:

—Capacity depends on the person understanding what the treatment is about.
—Capacity means he understands the consequences of the treatment, and has the ability to assess benefits and risks.

Paul has had over 60 ECTs, but no one thinks this makes him qualified to understand what the treatment is about, or to understand its consequences. Only a psychiatrist can know these things.

Both doctors said Paul was incompetent because he refused to acknowledge that previous ECT had been beneficial for him. Azemar said, “Even when we tell him he is improved, he never accepted the fact that he had any benefit from it.”

Both doctors said that Paul was incompetent because he “is unable to assess the risks and benefits of ECT.”

Further questioning from Darrow clarified the situation. Did Paul have the mental capacity to understand that his doctors thought he had improved with ECT? Yes. He understood this. “Did he understand what you thought were the benefits and risks?” Yes, the doctors said. Paul was perfectly capable of hearing and understanding what his doctors were telling him.

He just didn’t agree with them.

As long as patients and doctors disagree about the nature, risks and benefits of ECT, and as long as doctors get to define the “right” answers to these questions, everyone is at risk of forced ECT. Persons who have previously had ECT, know about it from personal experience, and will not deny what they know to be true, are most at risk.

Dr. Kalani testified that he “knew” about ECT from reading a book. All books about ECT for professionals are written by financially compromised ECT proponents like Richard Abrams, shock machine company owner. Kalani couldn’t remember which book he had read…Fink’s, Kellner’s, Coffey’s? He went on to make further blatantly false statements about what he “knew”. He knew the FDA had approved shock machines. (Never happened.) He knew the FDA had conducted animal trials of shock. (Not only has it never conducted animal trials, neither the FDA nor anyone else has ever conducted human trials.) Kalani’s source was revealed when he claimed that the FDA had studied baboons. The baboon line comes�from Harold�Sackeim, prolific ECT advocate and shock machine company consultant. Even Sackeim, famous for his lies, did not say that FDA studied baboons; his claim was that epilepsy researchers had studied baboons and concluded that seizures didn’t damage their brains. Kalani got his misinformation garbled. The Pilgrim shock doctor went on to testify that there have been “lots of” before-and-after MRI studies showing that ECT doesn’t cause brain damage. Wrong again. There have been less than a handful, and they don’t show that.

Dr. Azemar wasn’t any more knowledgeable. He claimed that his own facility did not do “bipolar” ECT (the correct term is bilateral), that this was the “old fashioned way” of doing ECT that’s still done in Haiti but not here. In fact, Paul has been getting bilateral ECT at Pilgrim.

If capacity is determined by what you know about ECT’s risks and benefits, then both Kalani and Azemar flunked the test, and can now be legally forcibly shocked.

Unfortunately Darrow did not challenge Dr. Kalani’s false statements. The judge was left with the impression that ECT has been proven safe because no one contradicted it.

If Darrow had been able to raise doubt about ECT’s efficacy and safety—by invoking the FDA classification of ECT devices, for instance—a logical further question would have been: “If it were true that Paul did not benefit from ECT, would he be incompetent? What if Paul is right that the risks of ECT outweigh its benefits? Is he still incompetent?”

The judge got very upset once Darrow made the point that Paul understood but did not agree with his doctors, yelling at him to move on. This was one of three outbursts on the part of the judge that day, each one louder than the last. The judge was very, very loud.

Forced treatment and biological psychiatry go hand in glove.

If biological psychiatry is a kind of law—if we as a society have decided it is the only acceptable or permissible way to think about and treat problems—then it must have its police force for those who don’t find it helpful or agree to abide by it. It must have the doctors and judges who force treatment on these people.

Both shrinks testified that drugs and ECT were the only treatments available for Paul. When challenged, however, they claimed to be doing psychotherapy. They were questioned further about what that meant. It turns out that psychotherapy doesn’t mean what it used to mean.

“Psychotherapy consists of making him understand his mental illness and accept therapy and understand the impact of medication and ECT. Noncompliance is the issue,” said Bob Kalani. He also explained that there had been family psychotherapy, consisting of trying to talk Paul into consenting to ECT.

Dr. Azemar called his brand of psychotherapy “insight psychotherapy”. “Insight psychotherapy” consisted of trying to get Paul to accept that “It’s all chemicals. There are all these chemicals in the brain—for anxiety, for appetite, for sleep. It’s getting him to understand what these chemicals do and what drugs he needs to take.”

The drugs he has been taking have caused liver damage and tardive dyskinesia. Dr. Azemar testified that Paul wanted to take a computer class, but his hands now shake so badly that he is unable to type. He characterized TD as a “disorder of the fingers”—it’s actually permanent brain damage.

It was nearing the end of the last day of the trial when the topic of drug-induced brain damage came up. Darrow began a dramatic summing-up type question. “They’ve damaged his liver, they’ve damaged—” he might have been beginning to say “His brain”.

He didn’t get to say it because he could not longer be heard over the judge. Judge Hall pounded on his desk, stood up, and yelled at the top of his lungs: “You should be ashamed at yourself!” He said it twice. It was far from clear to anyone in the courtroom what, exactly, he was referring to. Should Darrow be ashamed because he was bringing up tardive dyskinesia in a case that was just supposed to be about ECT? Was Darrow being reprimanded because he was only allowed to talk about ECT brain damage, not drug brain damage? Was the judge himself, who is known for signing forced drugging orders, actually ashamed of himself and simply projecting those unmanageable feelings onto Darrow? Why the emotional outburst?

It was a better ending to the case than the State’s lawyer, Laurie Gatto, could have hoped for. She’s clearly clueless on shock, and her idiotic questions had her much more educated audience laughing—-like when she claimed that the MiniMental Status Exam (which you can hardly do poorly on unless you’re in a coma) could measure memory loss from ECT, or when she tried to disparage Paul’s good performance on an IQ test by saying that math doesn’t involve problem solving. But even she could sense that she didn’t need to add a single word.

Had anyone wandered into the courtroom at 4:20 p.m. on April 2nd, observed the behavior and demeanor of both Paul Henri Thomas and Judge Hall, and been asked to pick out which man was suffering from mania, there would not have been any doubt that it was the one in the black robe.

If you think you can protect yourself against forced ECT with an advance directive, think again.

Paul had an advance directive. He had signed it on October 19th, the day before his doctor signed the petition for forced shock. Paul couldn’t have executed a legal document like an advance directive if he were considered incompetent. Dr. Azemar clearly found him competent on the 19th; in fact, he even signed the advance directive as a witness. Azemar’s position at trial was that Paul became incompetent the very next day.

But wait—even if that were the case, wouldn’t the advance directive have been valid? After all, this is exactly the situation an advance directive anticipates. It specifies what should be done should a person become incompetent. Paul’s directive said that his brother would act as his proxy to make his health care decisions. He should have been consulted, and his yes or no would have been the final decision on shock for Paul. But the hospital disregarded the advance directive and went ahead with its forced shock petition.

In the words of Judge Hall: “What that document said at that time, it doesn’t say now.”

Canadian Psychiatric Association ECT Position Paper

Murray W. Enns, M.D. and Jeffrey P. Reiss, M.D.
2001

In 1980, the Canadian Psychiatric Association (CPA) published its first position paper on electroconvulsive therapy(ECT) which included a recommendation for periodic review of the position (1). During the past decade, a considerable amount of new research has been done. This has resulted in the need to update the position of the CPA on ECT.

Electroconvulsive therapy remains an important part of the therapeutic armamentarium in contemporary psychiatric practice. Although the mechanism of action of ECT is not completely understood, over 50 years of clinical experience and a substantial volume of research have lead to the CPA’s current recommendation that ECT should remain readily available as a treatment option.

Like other significant medical interventions, ECT has clearly defined indications, demonstrated efficacy and safety, well known side-effects and established standards for optimal practice. As such, the decision to use ECT in the treatment of an individual patient is a medical one, based on the psychiatrist’s assessment of the patient’s illness, an evaluation of the merits of ECT versus alternative treatments and involves the process of informed consent.

With the passage of time and the accumulation of greater knowledge, ECT has developed into a complete treatment requiring the expertise of psychiatrists, anesthesiologists and frequently other medical specialists. As our understanding of mental illness grows, the specific treatments that are offered and the techniques of these treatments, including ECT, continue to evolve. The modern psychiatrist must keep abreast of this evolution.

Definition

For the purposes of the CPA, electroconvulsive therapy (ECT) is defined as a medical procedure in which a brief electrical stimulus is used to induce a cerebral seizure under controlled conditions. Its purpose is to treat specific types of major mental disorders.

History

In order to properly understand the origins of ECT, one must have an appreciation of the context in which it was developed. Prior to the 1930s, there were few treatments to offer severely disturbed psychiatric patients. They were provided with custodial care, sedation and some social support (2). In 1918, Von Juaregg (3) had developed malarial fever therapy for general paresis. He was awarded the Nobel Prize in medicine in 1927 for his accomplishment. Effective somatic therapy for functional psychosis was not yet available.

During the 1930s four types of somatic therapies for schizophrenia were developed. The first three of these were insulin coma treatment introduced by Manfred Sakel in 1933 (4), psychosurgery (pre-frontal lobotomy) introduced by Egas Moniz in 1936 (5), and pharmacological convulsive therapy introduced by Egas Von Meduna in 1934 (6). Von Meduna based his treatment on clinical and neuropathological studies which suggested to him a biological antagonism between epilepsy and schizophrenia. Technicai problems with pharmacological convulsive therapy and the extremely uncomfortable sensations that conscious patients experienced pre-ictally, were the motivation for experimentation with other means of inducing seizures. In 1938, Ugo Cerletti and Lucio Bini pioneered the fourth innovative somatic therapy when they used electrical stimuli to induce seizures for the treatment of severe psychosis (7). Although they chose the term “electroshock” for their method, they used electricity only for the induction of convulsions, denying any effects of the electrical current, per se, on the psychotic illness. Electroshock, or ECT as it came to be known, is the only somatic therapy from that era that remains in widespread use today.

While ECT was originally developed for the treatment of schizophrenia, it was not long after its introduction that it became widely recognized that the best results were obtained in patients with major mood disorders, not those with schizophrenia. This observation has been borne out by controlled studies and is reflected in the contemporary diagnostic indications for ECT (8). Significant improvements in the technique of ECT have been made since its introduction. These have included succinylcholine induced muscular relaxation, short acting anesthesia, pre-oxygenation, the use of more efficient electrical stimulus wave forms, unilateral electrode placement, and more complete seizure monitoring (9). Despite these advances in technique, the popularity of ECT greatly diminished during the 1960s and 1970s. Both the introduction of effective pharmacological treatments and a vocal anti-ECT lobby likely contributed to this decline.

Over the last 14 years however, the practice of ECT has undergone a turnaround. In 1978, the American Psychiatric Association (APA) published the report of the ECT task force under the chairmanship of Fred Frankel (10). This report formally recognized the role of ECT in contemporary psychiatric practice and in many ways became the standard for its use. Max Fink’s monograph of 1979 (11) definitively summarized the topic from its beginnings to the mid-1970s. The Canadian Psychiatric Association published its own position paper on ECT in 1980 (1), also encouraging the availability of ECT “within the context of the usual doctor-patient relationship, the medical profession’s most current understanding of mental illness and the most apprapriate forms of treatment.” Since then, several significant comprehensive and objective reports on the topic have been published. These have included the Ontario Ministry of Health’s Report of the Electroconvulsive Therapy Review Committee (12) and the NIH/NIMH sponsored Consensus Conference Report (13). The most recent major report is the 1990 APA Task Force Report on ECT, chaired by Richard Weiner (8). Academic and research interest in ECT has grown under these developments as evidenced by the increasing number of publications on the topic and the establishment of a journal devoted exclusively to convulsive therapy issues (14).

The previous position paper of the CPA on ECT (1) noted the lack of controlled double-blind studies and anticipated further research and clarification. Although unanswered questions about ECT remain, systematic research and study has more clearly established an ongoing role for electroconvulsive therapy in the treatment of incapacitating mental disorders (8,9).

Indications

The main diagnostic indications for ECT include major depression (single episode or recurrent), bipolar disorder (depressed, manic or mixed), non chronic schizophrenia (especially when affective or catatonic symptomatology is prominent), schizoaffective disorder and schizophreniform disorder. For these disorders there is either overwhelming evidence in the literature attesting to the efficacy of ECT, or a consensus among experienced psychiatrists as to its effectiveness (8,11,15).

Under exceptional circumstances, ECT may also be considered a treatment option for disorders not included in the above list. When considering ECT for unusual indications, the psychiatrist should be aware that compelling evidence of the effectiveness of ECT is lacking and should thoroughly consider the available standard treatments before offering ECT. Consultation with a psychiatric colleague is also recommended when ECT is being considered for an unusual indication.

A small number of medical disorders have also been treated successfully with ECT — neuroleptic malignant syndrome (16), Parkinson’s disease (17,18) and refractory epilepsy (19 70), among others (8). The clinical utility of ECT in these disorders should not be considered firmly established. However, patients who suffer from one of these disorders in addition to a major diagnostic indication for ECT (for example, Parkinson’s disease and major depression) may experience improvement in both disorders with ECT (17).

The decision to use ECT in the treatment of an individual patient is based on the consideration of a number of factors in addition to diagnosis. These factors include the patient’s prior treatment response, the severity of the disorder, the relative need for rapid response to treatment, the risks and benefits of ECT in comparison with other appropriate treatments and the patient’s preferred treatment modality.

Although ECT is frequently used as a second line treatment after psychotropic medications have failed, the use of ECT need not be restricted to this setting. Consideration of some of the factors noted above may lead the psychiatrist to offer ECT as a primary treatment modality.

Contraindications

It has been stated in the past that the only absolute contraindication to ECT is an intracranial neoplasm (21). Since then, experience in the administration of ECT to patients with a variety of serious medical conditions has accumulated. Techniques have been developed to reduce the risks associated with ECT in these conditions so that no contraindication to ECT is currently considered absolute (8,15). Instead, recent reports refer to specific conditions in which there is significantly increased risk. These conditions include: space occupying intracranial lesions or other conditions associated with elevated intracranial pressure, recent myocardial infarction with cardiac decompensation, severe underlying hypertension especiaUy if related to a pheochromocytoma, evolving strokes and other risk factors for intracerebral hemorrhage, retinal detachment, and any condition in which the anesthetic risk is rated as American Society of Anesthesiologists (ASA) level 4 or 5 (8,9,15). Pregnancy is not considered a contraindication to the use of ECT. Numerous case reports suggest that ECT is a low risk and highly efficacious in treating depression at any stage of pregnancy (8). As in all applications of ECT, the decision to treat a patient in the presence of one of these conditions should be made only after careful consideration of the risks and benefits of ECT, alternative treatments, or no treatment. Particular care should be taken to optimize the patient’s medical condition prior to the administration of ECT and to modify the treatments in such a way as to minimize the risk (8,9). This preparation should include consultation with an anesthesiologist and other medical or surgical specialists, as appropriate.

Adverse Effects

When ECT was originaUy introduced, up to 40% of patients suffered from complications of various types (13). Most frequendy this involved compression fractures of the vertebrae (11). Early use of ECT was also associated with a significant mortality rate — approximately one per 1,000 patients (13).

Contemporary use of ECT including pre-oxygenation, brief anesthesia, muscular relaxation and physiologic monitoring is associated with a very low rate of morbidity and mortality. The majority of deaths associated with ECT are due to cardiarespiratory causes (22). This is consistent with the higher mortality found in patients whose cardiac function is already impaired (15). Several recent reviews of ECT related mortalities suggest a rate of 2.0 to 4.5 deaths per 100,000 treatments (23-25). It should be recognized that this mortality rate is comparable to that reposted for brief general anesthesia in minor surgery (8,11). With the advent of present day techniques, many of the significant medical complications of ECT have been eliminated. A complication rate of one per 1,400 treatments has resently been suggested (13). These complications include laryngospasm, prolonged apnea, prolonged seizures, tooth damage and circulatory insufficiency (13). Cardiac arrhythmias are frequent during the treatment and immediately post-ictally, however the majority of these are benign and resolve without intervention (22,26). Nausea, headache and muscle soreness are commonly reported but these symptoms respond to symptomatic treatment (11).

To objectively evaluate the significance of these adverse effects, it must be remembered that pharmacological treatments may have both serious and minor adverse effects as well. As examples, tachyarrhythmias, hypotension, cardiac conduction disturbances, anticholinergic toxicity and death due to overdose or idiosyncratic effects of the drugs are among the serious side-effects of heterocyclic antidepressants (27,28).

The principal adverse effect of ECT, which has been the root of much controversy, is memory impairment. Four types of cognitive impairment related to ECT can be discerned (9). Immediately following an ECT treatment there is a period of post-ictal confusion. After clearing of the post-ictal confusion, retrograde amnesia (forgetting of events prior to the seizure) and anterograde amnesia (forgetting of events after the seizure) can be demonstrated using a vasiety of neuropsychological tests. A small minority of patients also experience longer lasting subjective memory impairment which may be difficult to objectively detect.

Anterograde and retrograde amnesias subside over an interval of one to six months following a course of ECT (15,29). Although some specific memories of events during the months before and after ECT may be permanently lost (30), acquisition and retention of new memories and longer term memory are not persistently impaired (30,31).

Subjective memory impairment following ECT may be persistent. Some cases may be explained on the basis of residual psychopathology, increased awareness of essentially normal forgetfulness, or secondary gains related to the complaint of memory loss (15). However, the basis of these complaints is incompletely understood and it is possible that persistent subtle, though genuine, memory difficulties may not be adequately detected with available neuropsychological tests.

The foregoing discussion of memory side-effects of ECT refers to ECT in a general way. However, it is important to note that the severity of adverse cognitive effects of ECT is dependent upon the specific technique used. Bilateral electrode placement, higher stimulus intensity, sine wave stimulus waveform, more frequent treatments, concomitant psychotropic drug use and higher anesthetic dose are all factors associated with greater cognitive side-effects than unilateral nondominant electrode placement, moderately supra threshold intensity, brief pulse waveform, less frequent treatments given without concomitant psychotropics and more moderate anesthetic dose (8,32-34). If ECT is administered using a brief pulse stimulus on the nondominant hemisphere, patients may have no detectable memory impairment after a few days post-ECT treatment (29).

Claims have been made that ECT causes “brain damage” (35). A recent comprehensive and objective review of a large number of studies concluded that ECT, as administered today causes no detectable evidence of irreversible structural brain damage (36). However, the possibility remains that subtle deficits occur which cannot be objectified with currently available techniques.

Efficacy

A number of authors have comprehensively summarized the studies which demonstrate the effectiveness of ECT (9,11,24). No attempt will be made here to review all of the data. Instead, a summary of the conclusions which can be made on the basis of available data will be presented.

It has been clearly demonstrated in double-blind controlled studies that genuine ECT is substantially more effective than sham ECT in the treatment of major depression (37-39). In a small number of methodologicaUy sound studies it has been demonstrated that ECT is also superior to moderate doses of antidepressant drugs (4042). In a large number of studies, albeit with methodological flaws, this same conclusion has been reached (43). However, Abrams (9) notes that optimal drug therapy using serum level monitoring and possibly higher doses, has not been directly compared with ECT.

Mania generaUy responds very well to ECT (9). The number of controUed studies documenting the effectiveness of ECT in mania is small, probably because of its good response rate to pharmacological treatment. In recent years, two controlled prospective studies of ECT in the treatment of mania have been reported. Both of these studies found that ECT resulted in more rapid resolution of symptoms than the combination of lithium and neuroleptics (44,45). Some authorities recommend bilateral ECT as the preferred treatment in this patient group (46,47).

The effectiveness of ECT for schizophrenia is more difficult to evaluate than it is for mood disorders. Much of the difficulty arises because the schizophrenic patients included in the relevant studies were diagnosed using a wide variety of diagnostic criteria and had widely disparate symptomatology (9)

Recent studies have demonstrated that genuine ECT causes more rapid resolution of schizophrenic symptoms than sham ECT (48,49). Chronic patients were excluded and patients with affective symptoms were allowed in these studies. Several prospective studies of the treatment of non chronic schizophrenia have compared ECT with neuroleptics finding no significant difference between the two treatments (50-52). In addition, some studies have suggested that the combination of ECT and neuroleptics results in quicker recovery for non chronic schizophrenia than treatment with neuroleptics alone (53,54)

Earlier studies of genuine versus sham ECT, using groups of chronic schizophrenics, failed to find any difference between the two treatments (55,56).

In summary, some selected groups of schizophrenic patients, particularly those with a brief duration of illness and/or prominent affective symptoms, may respond as well to ECT as they do to neuroleptics. Patients with chronic schizophrenia, on the other hand, respond no better to genuine ECT than sham ECT. Taken together, the data indicate that ECT has a more limited role in the treatment of schizophrenia than in the treatment of mood disorders. As a second line treatment for schizophrenia, ECT still has value in contemporary psychiatric practice.

The number of treatments required for an effective course of ECT varies substantially between individuals. Typically, patients with depressive illness require six to 12 treatments, while patients with mania or schizophrenia may require a somewhat higher number (8,9). However, some patients may improve dramatically with only a few treatments. Once the patient has achieved full remission, no further benefit results from the administration of additional treatments (57,58). When patients show a slow or insignificant response to a series of treatments, it requires the clinical judgment of the psychiatrist to determine when to recommend termination or modification of the treatments. This judgment takes account of such factors as the nature and severity of the patient’s symptoms, the magnitude of cognitive side-effects, history of response to ECT, and the response obtained thus far.

It is therefore difficult to provide specific guidelines for the maximum allowable number of treatments. Nevertheless, the following recommendations are made. If after six to eight treatments there is minimal improvement, consideration should be given to changing the technique of ECT. These changes may include switching to bilateral electrode placement, increasing the electrical dose, or pharmacologicaUy augmenting the elicited seizures (8). When patients with depressive illness do not show substantial improvement after 12 to 14 treatments, another psychiatrist’s opinion should be obtained before administering further treatments. Likewise, when patients with mania or schizophrenia show little improvement after 14 to 16 treatments, a second psychiatric opinion should be obtained before proceeding further.

ECT is usually administered two or three times per week, although double ECTs (two seizures per session) or daily treatments are sometimes used early in the course of treatment in an attempt to speed the recovery of extremely ill patients (8,9,11). In the past, some clinicians used “regressive ECT” in which a prolonged and intensive course of treatment was used in order to induce a sustained delirium. The objective of this practice was to create a “regressed state” and subsequently reconstruct the patient’s character. This practice has not received scientific support and as such should not be used.

The above discussion deals with the acute treatment of psychiatric disorders. However, these disorders can be recurrent. In particular, follow-up studies of patients treated for depression, especially those with delusional or treatment resistant depression (two common indications for ECT), have high relapse rates in the year after acute treatment (59,60). For this reason, some form of maintenance treatment is indicated to prevent relapses after a course of ECT (9,61). Controlled studies directly comparing maintenance ECT to maintenance pharmacotherapy are lacking. A number of clinical studies however, have reported that maintenance ECT reduces the rate of relapse and recurrence of mood disorders (62-64). Although further prospective study is needed, maintenance ECT may be useful in selected patients who cannot tolerate pharmacotherapy or who continue to relapse despite appropriate pharmacotherapy.

Assessment and Documentation

Prior to the administration of ECT, a thorough evaluation of the patient’s psychiatric and medical status is required. This involves a psychiatric history, mental status examination including objective assessment of cognitive functions, medical history, and physical examination. Essential laboratory investigations include a complete blood count, serum electrolytes and renal function tests. Patients over 45 years of age should also receive an electrocardiogram and possibly a chest radiograph. When the patient has co-existing medical conditions or is of advanced age, further investigations and consultations should be obtained as discussed under contraindications. The results of this complete evaluation should be documented in the patient’s record prior to commencing ECT. The record must also contain documentation of informed consent and the indications for ECT. The physician’s orders for ECT should indicate treatment dates and desired electrode placement. Patients should fast for eight hours prior to treatment.

Between ECT treatments, the psychiatrist should reassess and document changes in target symptoms and the occurrence of adverse effects. Objective testing of cognitive functions is an important part of this process. The physician who administers the ECT should keep a record of each treatment including stimulus parameters the doses of anesthetic and muscle relaxant used, and the quality and duration of seizure activity elicited. After the course of ECT has been terminated, a summary note should be completed for the medical record.

Technique

It is beyond the scope of this paper to discuss details of the technique of ECT, complete descriptions are available elsewhere (8,9,11). However, it is worth emphasizing that the specific technique used in ECT is a matter of considerable consequence. Electrode placement, stimulus intensity and waveform, treatment frequency, concomitant psychotropic drugs and anesthetic medications hava been mentioned previously as factors affecting the severity of cognitive side effects. The clinical effectiveness of the elicited seizure is also affected by some of these parameters. As examples of how technique can affect outcome, a brief discussion of electrode placement and stimulus intensity and waveform will be presented.

Since the introduction of unilateral ECT, there has been considerable controversy over the merits of unilateral versus bilateral electrode placements. The two central issues are memory impairment and efficacy. Bilateral treatments have been clearly associated with greater memory impairment (11,15). Reports on the relative efflcacy of the two electrode placements have been much more divided. In about one-half of the reports the treatments were found to be comparable, and in the other half bilateral ECT was found to be superior (9). Therefore, unilateral ECT may be advantageous when it is especially important to reduce cognitive side-effects. Bilateral ECT, on the other hand, may be preferred if there is a greater treatment urgency or if unilatera ECT fails (8).

More recently it has been demonstrated that there is an interaction between electrode placement and stimulus intensity affecting the efficacy of ECT. Barely suprathreshold, brief pulse unilateral ECT is remarkably ineffective (65). However, increasing the stimulus intensity increases the efficacy of brief pulse unilateral ECT (65,66). In the case of bilateral ECT, barely suprathreshold stimuli remain effective, but increasing the stimulus intensity may speed the clinical response (66,67).

The earliest ECT devices employed a sine wave current to elicit seizures (7). This type of electrical current administers a substantial amount of energy below the patient’s seizure threshold, thereby increasing memory impairment, but not enhancing therapeutic effects (68). For this reason, sine wave currents are generally considered obsolete and brief pulse currents are the accepted standard (8,9).

The question of what constitutes the optimal technique for administering ECT is not completely answered. Therefore, the clinician administering or prescribing ECT must make decisions about various aspects of the treatment technique based on an ongoing assessment of the relative risks and benefits.

Mechanism of Action

A large number of hypotheses on the mechanism of action of ECT have been proposed (19,20,69-72). These hypotheses have included both psychological and biological explanations of the effects of ECT. Psychodynamic theories have generally emphasized the importance of fear in the patient, the role of guilt and punishment for imagined wrongdoing and amnesia for the causes of depression (69). Although the importance of psychological factors in ECT treatments should not be completely overlooked, such purely psychological explanations lack empirical support and have been abandoned by psychiatric investigators.

In contrast, biological theories of the action of ECT have been the subject of much recent investigation. Neurochemical, neuroendocrine, electrophysiological and neuropsychological hypotheses have been advanced (19,20,70-72). The role of the cerebral seizure is central to most contemporary theories of the action of ECT. A considerable amount of research supports the contention that epileptiform discharges in the brain are necessary and sufficient for efficacious ECT (68,73). Recent work challenges this view and suggests that the occurrence of a generalized seizure of “adequate duration,” by itself, may not be sufficient to ensure maximally effective treatment. In particular, the use of barely suprathreshold electrical stimulation results in diminished therapeutic response, especially with unilateral ECT (65,67,73). It appears that some aspect of the process of seizure generalization may be more closely related to the therapeutic effect of ECT than the occurrence and duration of cerebral seizures (9,15).

Research has greatly increased our knowledge about the biological effects of ECT. As with mostbiological treatments in psychiatry, however, we still do not know precisely why ECT works. As such, ECT remains an empirical treatment. Nevertheless, this does not detract from its efficacy and safety as a therapeutic modality in psychiatric practice.

Consent to Treatment

For the most part, the process of obtaining ioformed consent for ECT is no different than the consent procedure for other significant medical interventions. The attending psychiatrist or other designated medical personnel must be directly involved in obtaining informed consent. The physician should provide realistic information about the nature of the condition being treated, the expected benefits and possible risks of ECT, as well as the benefits and risks of other reasonable alternative treatments, or no treatment (74). The physician should also ensure that the patient has understood the information provided as part of the assessment of the patient’s competence to consent to treatment. Consent must be obtained from the patient unless the patient is clearly incompetent to participate in the process. For incompetent patients, substituted consent should be obtained in accordance with the requirements of provincial legislation and facility regulations. Whenever possible, the substituted consent procedure should include obtaining the views of family members and significant others, as well as a second psychiatric opinion.

It should be emphasized that informed consent is a process that begins with the provision of information and the signing of a consent document, and continues through the entire course of treatment. Therefore, consent may be withdrawn at any time. The issue of consent should be reviewed in an ongoing manner.

Education and Research

Over the years ECT has become an increasingly complex treatment. The modern psychiatrist must therefore acquire a high level of knowledge and sophistication in order to use the treatment optimally. The educational process should begin in medical school, so that graduates have an appreciation of the role of ECT in contemporary psychiatric practice. Residents in general psychiatric programs should have both didactic teaching and practical experience in the use of ECT. When ECT is performed by a psychiatric resident, adequate supervision must be provided. Psychiatrists who prescribe or administer ECT should keep their knowledge and practical skills up to date through the use of continuing education programs and/or attention to clinical and research reports in the psychiatric literature.

Research and clinical experience have already provided much information on which to base the practice of ECT. Nevertheless, much remains to be learned. Although awareness of the way treatment technique can affect outcome has increased, it is still not known how to select the ideal form of treatment for a given patient. Furthermore, a great deal has been learned about the neurophysiological effects of ECT, but it remains to be determined which of these effects, if any, is responsible for the therapeutic response. These examples serve to highlight the need for ongoing research and publication on the topic of ECT.

Summary and Recommendations

1. When used properly, ECT is a safc and effective treatment which should continue to be available as a therapeutic option for the treatment of mental disorders.

2.ECT should be used only on the recommendation of a psychiatrist, and should preferably be administered by a psychiatrist.

3. The main conditions for which ECT is indicated are major mood disorders and non chronic schizophrenia, particularly when affective or catatonic features are prominent. A second psychiatric opinion is recommended if ECT is to be used for an unusual indication.

4. A medical history, physical examination and appropriate Iaboratory investigations are necessary in order to detect any significant medical illness priasr to the administration of ECT. If an active medical disorder is present, steps should be taken to treat the disorder and/or to further modify the technique of ECT in order to minimize the possible risks. Consultation(s) from an anesthesiologists and other medical specialists should be obtained, if indicated.

5. During a course of ECT, the psychiatrist should regularly reassess and document changes in target symptoms and the occurrence of adverse effects. Objective testing of cognitive functions is part of this process.

6. Modification of ECT with brief anesthesia, muscle relaxants and pre-oxygenation should be accomplished by a suitably qualified physician, unless specific contraindications to the use of these modifications are present.

7. The decision to use ECT is a medical one, and requires informed consent. If the patient is incompetent to give this consent, a consultation from another psychiatrist with regard to the use of ECT should be obtained. Following this, the psychiatrist can decide whether to seek substituted consent for ECT or to pursue another course.

8. ECT is a complex medical intervention. Practitioners require considerable knowledge and practical skills in order to optimally perform the procedure. Psychiatric residencies should include training in ECT and psychiatrists should keep up-to-date with advances in the theory and practice of ECT.

9. Continuing basic and clinical research is encouraged in order to delineate the mechanism of action of ECT and to further improve the clinical application of the treatment.

10. The position of the CPA on ECT should be periodically reviewed, as dictated by changes in our knowledge and understanding of the treatment of major mental illness.

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The Surgeon General’s New Clothes

The Surgeon General’s New Clothes:
How the press and the SG distort the truth about mental distress

(also available in Perspectives Mental Health Magazine, April-May, 2000):

By Richard Shulman, Ph.D.

Following the issue of the Surgeon General’s report on mental health (December, ’99), press headlines echoed Dr. David Satcher in declaring a new era of enlightened understanding. Headlines and media sound bites proclaimed science’s demonstration that emotional disorders and behavioral problems were truly legitimate physical illnesses, some would say brain disorders, rooted in genetics and biochemistry.

Imagine how surprised the writers of such headlines might be to discover these research summaries in the professional literature:

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“Few lesions or physiologic abnormalities define the mental disorders, and for the most part their causes remain unknown.”
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“[N]o single gene has been found to be responsible for any specific mental disorder…”
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“[T]here is no definitive lesion, laboratory test, or abnormality in brain tissue that can identify …[mental] illness.”
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“It is not always easy to establish a threshold for a mental disorder, particularly in light of how common symptoms of mental distress are and the lack of objective, physical symptoms.”

Surprise: these are QUOTES from within the Surgeon General’s report, just some of the many similar summaries of decades of research:

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“The precise causes (etiology) of most mental disorders are not known.”
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“DSM-IV [the diagnostic manual of the American Psychiatric Association] is descriptive in its listing of symptoms and does not take a position about underlying causation.”
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“The thresholds of mental illness or disorder have, indeed been set by convention…”
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“All too frequently a biological change in the brain (a lesion) is purported to be the ‘cause’ of a mental disorder…[but] The fact is that any simple association – or correlation – cannot and does not, by itself, mean causation.”
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“[N]o single gene or even a combination of genes dictates whether someone will have … [a mental] illness or a particular behavioral trait.”
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“Even with…schizophrenia, the median concordance rate among identical twins is 46 percent…meaning that in over half of the cases, the second twin does not manifest schizophrenia even though he or she has the same genes as the affected twin. This implies that environmental factors exert a significant role in the onset of schizophrenia.”
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“Placebo (an inactive form of treatment)…is more effective than no treatment [for mental disorders]. Therefore, to capitalize on the placebo response, people are encouraged to seek treatment, even if the treatment is not … optimal…”

Why are headlines trumpeting that our emotional problems are best defined as medical illnesses, when physicians such as the SG can find no biological lesions or markers that define them? And why is the press simply parroting the SG’s summaries, when such headlines mislead the public, evidenced by details within the report?

Is it possible that this report, and the oft-repeated truisms that emotional problems are at root medical diseases, also reflect the influence of business interests, and not strictly academic science? Sound too paranoid? What’s next, would we suspect business interests of trying to influence government? Suspect the pharmaceutical industry of trying to influence the Food and Drug Administration and organized medicine? Could the press unwittingly be coopted by uncritically accepting the pronouncements of people in authoritative white lab coats?

We all know that emotional turmoil and human suffering exists — but is it disease? We’re so used to hearing that “mental illnesses” are “chemical imbalances” that we miss the point: Decades of research have failed to confirm this hypothesis. There are no “chemical imbalances” which validly and reliably define people’s troubles. That is why there are no lab tests or other assays of physical disease which confirm the “diagnosis” before you’re offered Prozac or your child is given Ritalin.

If your Aunt Doris is sad, demoralized or in a longstanding unhappy rut in her life, should we call her “dysthymic,” a psychiatric label with no demonstrable basis in biochemistry? If your 9 year old neighbor Andy’s parents inconsistently instill discipline in him, and he now misbehaves in school, do we affix the label “ADHD” [attention deficit hyperactivity disorder], a category for which there is no physical marker or disease entity? Yes, we can give Andy a medical-sounding label, and supply stimulant pills. We can give pills which have a sedative or stimulant effect on anyone; this does nothing to confirm the presence of a physical disease.

Misled by this medical paradigm, we frequently miss a key opportunity to understand the underlying personal reasons that someone is distressed.

A substantial literature now demonstrates that many psychiatric medications show only modest efficacy versus placebo, if studied scrupulously (and in research not funded or squelched by drug companies). [note: Some of this research has been published by Dr. Irving Kirsch right here at the University of Connecticut.] Interestingly, this perspective was briefly acknowledged, but minimized in the SG report.

The Wall Street Journal describes “an era of creeping commercialization in science,” citing an analysis of “210 influential journals, mostly in the bio-medical field” in which researchers publishing studies rarely disclose their financial ties to drug manufacturers. Such conflicts of interest have been covered in major medical journals and newspapers in the last year, even eliciting an apology from the New England Journal of Medicine recently, but this issue is not to be found in the SG report.

Surveys published in Psychiatric journals show that medical students are rejecting psychiatry as a specialty, often “citing a lack of scientific foundation,” with trends suggesting that psychiatry is viewed as “outside the mainstream of medical practice.” Psychiatric residents publish satires depicting their education as funded and shepherded by pharmaceutical companies, with little attention given to the subtleties of understanding the personal turmoils and hidden dilemmas of another human being. Loren Mosher, M.D., formerly a prominent researcher with the National Institute of Mental Health, published his resignation letter from the American Psychiatric Association in Psychology Today (Sept./Oct. ’99), documenting how the organization is “unduly influenced by pharmaceutical dollars;” over-relying on drugs, underemphasizing their shortcomings, side-effects, and toxicities, and virtually ignoring psychotherapy.

Even Consumer Reports and JAMA (Journal of the American Medical Association) reveal how drug companies conspire to influence prescribing Physicians and the consuming public.

But pharmaceutical company funds and influence aren’t mentioned by the Surgeon General, nor by uncritical publicists in the popular press. Nor does the report highlight that actual consumers of mental health services can be critical of groups comprised largely of family members of consumers, such as NAMI [National Alliance for the Mentally Ill]. The leadership of these latter “family” groups don’t advertise that they are covertly funded by pharmaceutical companies. Remember the group CHADD, a major proponent of stimulant medication for children, later revealed to be secretly subsidized by drug makers? NAMI advocates for biological treatment, even forced drugging, for what they repeatedly call “brain diseases.” The SG report portrays NAMI positively, minimizes the conflict over forced treatment with consumers themselves, and says nothing of NAMI’s multi-million dollar drug industry funding.

Are behavioral and emotional problems illnesses if decades of research have failed to find physical disease entities which cause them? The headlines surrounding the SG report blind us to this confounding miscategorization. Is this a summary of science, or is it marketing of psychiatric guild interests? Isn’t it in the financial and professional interest of psychiatrists (and drug companies) to insist that all of life’s confusion, unhappiness and conflict is their domain, over which they hold unique medical expertise? Especially when managed care will only pay for services deemed “medically necessary,” and clearly prefers to pay for pills over the expense of psychotherapy.

Without demonstrating any physical abnormalities, we can give disease labels that then grant a child the advantage of an extra hour and a half to take their SAT’s. Or we can fabricate disease labels which allow a criminal to murder, rape or embezzle, and then avoid legal consequences due to “psychiatric illness.” But isn’t this a subversion of logic and responsibility that the profession is purveying? Why is the press so uncritically accepting of this illogic, which spins medical illness labels out of no identifiable physical pathology, while benefiting particular “special interests?”

Here’s how two professors summarize this issue: “…American Psychiatry… has unsuccessfully attempted to medicalize too many human troubles…[A child's] school difficulties, your neighbor’s marital problems, your friend’s drinking habits, and your anxiety about an upcoming speech may cause great pain and be worthy of help from a psychotherapist, but that pain and that need for assistance require no psychiatric diagnosis to understand and no specific medical therapy to treat.”

The SG does endorse psychotherapy, but emphasizes primarily more simplistic forms of therapy that can be easily researched; those that are short-term, focused on limited problems, and that often have manuals. As H.L. Mencken said “For every complex problem there is an easy answer, and it is wrong.” Most people’s lives and problems are complex , and so is thoughtful therapy and the research which tries to document its helpfulness.

Why do we accept such oversimplified and medicalized truisms about life’s problems? Are we all blinded by the trappings of science? By misleading explanations repeated often? By appeals to political correctness? Do we prefer dreaming of “magic pills” rather than facing complex and upsetting human dilemmas that inevitably are part of life?

Why did the Surgeon General’s “sound bites” in the press misleadingly summarize the report in the first place? And why did the press repeat the SG headlines without 1) reading the report, and 2) thinking critically? There may be different answers to these questions, but none serves the advancement of the public’s knowledge.

Dr. Shulman, a Licensed Psychologist, is the Director of Volunteers in Psychotherapy, Inc. VIP provides psychotherapy in exchange for volunteer work clients donate to the charity of their choice: A nonprofit alternative to the loss of client privacy and control experienced under managed care. More information at (860) 233-5115 or on the web at www.CTVIP.org

From Privileges to Rights: People Labeled with Psychiatric Disabilities Speak for Themselves

All the recommendations in this report emphasize the basic principle that people with psychiatric disabilities are, first and foremost, citizens who have the right to expect that they will be treated according to the principles of law that apply to all other citizens. All laws and policies that restrict the rights of people with psychiatric disabilities simply because of their disabilities are inharmonious with basic principles of law and justice, as well as with such landmark civil rights laws as the Americans with Disabilities Act.

“…public policy should move toward the elimination of electro-convulsive therapy and psycho surgery as unproven and inherently inhumane procedures. Effective humane alternatives to these techniques exist now and should be promoted.”

Download full report (pdf: 380k) From Privileges to Rights

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