Colo. Doctor Charged In Web Prescription Flap
November 29, 2007
FORT COLLINS, Colo. (CBS4) A Colorado doctor has been arrested in California, facing felony charges for prescribing medicine over the internet.
Officials said Fort Collins psychiatrist, Dr. Christian Hageseth, apparently knew nothing about the patient before prescribing Prozac, an antidepressant. The patient later committed suicide.
The criminal charges against Hageseth are not related to the patient’s death, but he faces civil charges for that. The criminal charges are based on a violation of California law, but both California and Colorado regulators say when it comes to the internet, the boundary lines are hard to draw.
The patient, John McKay, was a student at Stanford University. He committed suicide two years ago after buying Prozac from an online pharmacy. Studies have shown the drug can lead to suicidal thoughts and patients should be monitored.
Hageseth was the doctor who approved the online prescription, but he never met or talked to McKay.
“Prescribing medication is practicing medicine,” San Mateo County Deputy District Attorney Steve Wagstaffe said. “You can’t do that in this state if you’re not licensed by this state, and he is not licensed by the State of California.”
Hageseth’s attorney argues that’s not true.
“He ‘e-prescribed.’ He wrote an e-prescription in Colorado and uploaded it to a server in Texas,” attorney Carl Briggs said.
“A Colorado doctor is using a server in Texas to get meds to a kid in California; those are very difficult lines to trace back through, so it is a concern to the Board of Pharmacy,” Chris Lines with the Colorado Department of Regulatory Agencies said.
Hageseth also violated Colorado rules.
“There has to be a preexisting patient practitioner relationship to be in compliance with the regulations as they are,” Lines said.
However, regulators admit right now, there’s no good way to make sure doctors are following the rules on the internet. It’s a concern for in every state in the U.S.
“I think everyone would like a precedent set where everyone’s needs were met and everyone was protected,” Lines said. “The internet opens up a whole new series of freedom of speech questions and freedom of activity questions that at this point, it doesn’t seem we’re prepared to deal with.”
For now, it’s one case at a time, which will begin to set a precedent. All eyes are on this case, including those of the patient’s father, David McKay, who is also suing Hageseth.
“I would hope it would send a message to those who are operating illegally that they will be held accountable,” McKay said.
Hageseth was also working with a restricted license, under investigation for having an improper relationship with a patient. Although those charges were later dropped and his license re-instated, he was not allowed to write prescriptions for anyone during the time he filled McKay’s online request.
Hageseth was extradited to California and is being held on a $500,000 bond.
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Added: December 11, 2007 in
Web Doc Accused Of Aiding Bay Area Teen’s Suicide
REDWOOD CITY (CBS 5)
Nov 28, 2007
A Colorado-based doctor is facing criminal charges, after prescribing medication over the Internet to a Bay Area teen who committed suicide.
Christian Hageseth is accused of practicing medicine without a license by prescribing Prozac to John McKay, a student at Stanford. In 2005, McKay committed suicide after buying the anti-depressant drug Prozac from an online pharmacy.
Hageseth’s attorney told CBS 5 his client didn’t break any California laws because he was never in California. CBS 5 Legal Analyst LaDoris Cordell believes this case is the first of its kind, and could lead to major changes.
Our video report has more.
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Added: December 11, 2007 in
2000 document from UBC Department of Psychiatry and the BC Ministry of Health
Download PDF File (3.7 mb)
Added: December 10, 2007 in
BRIEF: Prof. sues doctor after son’s 2005 suicide
December 5, 2007
By Andrew Valencia
San Mateo County, Calif. — Structural biology Prof. David McKay has filed a lawsuit against a Colorado doctor who illegally prescribed Prozac to the professor’s son, John McKay ‘08, prior to his suicide. In the summer of 2005, Dr. Christian Hageseth III prescribed the medication to John McKay via an online pharmacy called USAnewRX.com. At the time, Hageseth did not have a valid medical license to prescribe medication, and McKay committed suicide two months later on Aug. 2, 2005. The medication was found in his system along with alcohol.
Prof. McKay has filed the suit against Hageseth in San Mateo County court, where Hageseth has been extradited to face criminal charges for practicing medicine without a license.
Added: December 10, 2007 in
Thomas F. O’Neil III and Melinda H. Waterhouse
Dec. 6, 2007
As federal and state enforcement authorities pursue companies and corporate officers with ever-increasing fervor, they are developing novel theories of liability to expand dramatically the targets of their investigations. Over the past decade, both chief legal and compliance officers have found themselves in the spotlight previously beamed on their colleagues in accounting and finance. A recent case in the health care sector highlights the potential exposure.
In September 2007, the United States Department of Justice (DOJ), through DOJ’s Civil Division and the United States Attorney’s Office for the Southern District of Florida, filed a lawsuit against Christi Sulzbach (Sulzbach), former general counsel to Tenet Healthcare Corp. (Tenet or the Company), seeking tens of millions of dollars under the False Claims Act (the FCA or the Act). In a novel application of the FCA, the complaint (filed in federal court in Miami) alleges that Sulzbach submitted one or more false sworn compliance declarations required by a corporate integrity agreement imposed on Tenet’s predecessor, National Medical Enterprises, Inc. (NME), thereby causing the government to pay claims erroneously.
Sulzbach was not involved in any facet of the claims at issue, so the lawsuit epitomizes the zeal of current recovery initiatives. It also raises important questions regarding internal investigations, settlement agreements, and voluntary disclosures.
The Corporate Integrity Agreement
In June 1994, NME settled an investigation of, among other things, alleged kickbacks, and the Company agreed to pay a then unprecedented fine of over $350 million. The Company also entered into a corporate integrity agreement (CIA) with the Office of Inspector General of the Department of Health and Human Services (HHS). Sulzbach executed the settlement agreement and the CIA on behalf of NME.
The CIA required NME to submit to HHS annual compliance reports, which would include certifications regarding the company’s compliance or non-compliance with federal program legal requirements and the status of any relevant ongoing investigations. The CIA remained in effect after NME and American Medical Holdings, Inc. merged in 1995 to form Tenet. Sulzbach became Tenet’s associate general counsel and corporate integrity program director.
The Internal Investigation
According to the complaint, in February 1997 an executive at Tenet drafted a memorandum expressing concerns regarding the legality of certain contracts with physicians. The executive later met with Sulzbach, and she retained outside counsel to conduct an internal investigation.
In or about June 1997, the law firm submitted the final version of its report, determining, in essence, that the contracts at issue had in fact violated a federal statute known as the Stark Law which prohibits kickbacks and payments for physician referrals. Those findings and conclusions were not disclosed to enforcement officers.
The CIA Compliance Reports
After receiving the report from outside counsel, Sulzbach submitted reports under the CIA in 1997 and 1998; in each instance, she certified that, to the best of her knowledge and belief, Tenet was in material compliance with the terms of the CIA and federal program legal requirements. Sulzbach filed the 1997 compliance report four days after receiving outside counsel’s findings concerning violations of the
Notably, the DOJ complaint also details an apparent effort by Sulzbach to correct the situation. Roughly a month after she submitted to HHS the 1997 compliance report, Sulzbach issued an internal memorandum to a colleague whom the executive had originally contacted, directing him to implement corrective action recommended by outside counsel, advising him that failure to do so could trigger the disclosure provisions of the CIA, and requesting that he send her a written status report within 30 days. The complaint suggests that Sulzbach failed to follow up on this memorandum and that as a result, the violations continued.
The Qui Tam Litigation
A former Tenet employee filed a qui tam action against the Company in May 1997, claiming that it had violated the FCA by, among other things, billing Medicare for referrals from the physicians who had been identified by the executive several months earlier. Tenet denied the allegations in that case and, during discovery, asserted evidentiary privileges with respect to over 15,000 documents, including the report from outside counsel and the internal memorandum from Sulzbach to her colleague.
The government intervened in that case and filed a motion to compel production of documents identified on the privilege logs; this motion was pending when the litigants settled in 2004.
The 2006 Settlement
In 2006, the Company resolved a Medicare fraud inquiry by the government. Under the settlement agreement, Tenet agreed to pay $920 million and to produce certain documents that had been withheld as privileged, including some materials from the long-settled qui tam action. That concession resulted in the disclosure of two versions of the 1997 report from outside counsel and the internal memorandum thereafter authored by Sulzbach.
The following year, the DOJ sued Sulzbach under the FCA in a
three-count complaint seeking treble damages and civil penalties.
Congress enacted the FCA during the Civil War to empower citizens to pursue fraud claims against contractors, usually in situations where contractors had made false claims or falsified records to receive payment from the government. By the late 1990s, the Act had become a significant weapon in the arsenal of federal enforcement officials and private-sector whistleblowers, primarily in the defense and health care sectors.
The FCA prohibits:
- knowingly presenting or causing to be presented to the government a false or fraudulent claim for payment or approval;
- knowingly making, using, or causing to be made or used a false record or statement to receive payment or approval for a false claim from the government;
- conspiring to defraud the government by obtaining approval or payment from the government for a false or fraudulent claim;
- intending to defraud the government or conceal property from the government by delivering less property than the receipt indicates;
- intending to defraud the government by certifying a receipt for property used by the government without knowing the truth of the information in that receipt;
- knowingly buying or receiving public property from the government when this acquisition is unlawful; or knowingly making, using, or causing to be made or used a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit property to the government.
Under the FCA, the United States can recover civil penalties of $5,000 to $10,000 per violation. The government is also entitled to recover treble damages, except when the target has provided the government information about the violation within 30 days of obtaining the information; the violator has cooperated fully with the government; and no criminal prosecution, civil action, or administrative action had previously commenced regarding the violation. Finally, the government can recover the costs of any civil action brought under the Act.
Ramifications for Legal and Compliance Officers
The heart of the DOJ’s case against Sulzbach is the notion that, as associate general counsel and corporate integrity program director, she was personally responsible for investigating alleged violations of any federal program legal requirements and for reporting to HHS the existence and status of any such internal inquiry.
That factual assertion hardly seems debatable. It has, however, given rise to a new theory of liability under the FCA. DOJ’s ardor in this case quite clearly was fueled by the alleged failure to follow through on the corrective measures and by the vigorous defense of the qui tam action.
Perhaps this aggressive pursuit of compliance and legal officers under the Act will be confined to exceptional circumstances involving a confluence of aggravating factors. Case-specific facts notwithstanding, all compliance and legal officers operating in regulated industries should review this decision carefully. The imposition of a CIA is a serious matter, as is the subsequent submission of contractually mandated compliance reports. Furthermore, the potential consequences of a privilege waiver in a settlement agreement must be analyzed comprehensively before negotiations are concluded.
Added: December 7, 2007 in
note: a “Hageseth” is being used around the Internet in the same way “a Lewinsky” is. (A Lewinsky is now an accepted synonym for oral sex, as in Monica Lewinsky and Pres. Bill Clinton.) A Hageseth is defined as a “psychiatrist who has an inappropriate sexual relationship with a patient or recent patient.”
I only report it, folks.
KING 5 News and KREM.com Staff reports
SPOKANE – A lawsuit filed in Superior Court in Spokane Monday claims a Spokane psychologist used his position to seduce a patient.
According to the complaint, the Dr. John Moulton committed multiple acts of malpractice and negligence while treating a female patient.
Malpractice cited in the legal complaint against Moulton includes: seeing the patient outside of treatment sessions, buying her alcoholic beverages, consuming alcohol with her, and other boundary violations and negligent acts of both a sexual and non-sexual nature.
Among the allegations detailed in the complaint, Dr. Moulton sent emails to the patient where he admitted to her that he acted like an abusive predator: “I have acted like an abusive predator, which may be the most despicable kind of person there is.”
The alleged malpractice began after the patient, who suffered from severe depression, checked herself into Spokane’s Sacred Heart Medical Center in April of 2005. The hospital assigned Moulton to be treating psychiatrist. During this two-week hospital stay, the psychologist administered a series of nine electro-shock treatments to patient.
Following discharge from the hospital, the patient returned to her family in Alaska. On June 1, 2005, she again traveled to Spokane and re-entered Sacred Heart for additional treatment for depression. Again, Dr. Moulton was assigned to be her treating psychiatrist, and according to the patient’s attorney, Michael S. Kolker, who said it was during the second hospital visit that Moulton told the patient he had feelings for her.
Upon her discharge from Sacred Heart on June 12th, Moulton arranged for the patient to spend time at an in-patient facility in Lake Chelan for continuing treatment for her depression. According to Kolker, Moulton drove the patient to the Spokane airport for the flight to Lake Chelan, and kissed her before she boarded the plane.
On June 23, 2005, the patient returned to Spokane to stay at the home of her brother for continued outpatient treatment with Moulton, whose boundary violations and acts of malpractice continued.
According to Kolker, for nearly a month while he was supposed to treat the patient for depression, Moulton saw the patient almost daily outside of therapy sessions. He took her out to bars and restaurants, consumed alcohol with her, fondled and kissed her.
“When a psychiatrist does it to a patient, it’s not dating and it’s not a relationship. It’s a boundary violation and it is abusive,” said Kolker.
Moulton then told the that he loved her and tried to convince her that she was in love with him. They made plans for the future. The suit said Moulton did all of this, knowing the patient was married and the mother of three children. He also knew she was on medication and had giving her multiple sessions of electro shock therapy.
In August, the patient’s husband discovered Moulton’s malpractice and confronted him. According to allegations in the complaint, Moulton sent the patient and her husband a number of emails in which he admitted and apologized for his misconduct. Excerpts of some of those emails are included in the complaint.
The complaint further alleges that Moulton’s negligent conduct caused the patient exacerbated depression, pain and suffering and two suicide attempts.
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Added: November 19, 2007 in
New Zealand Herald
November 06, 2007
By Chris Barton
It happens more often than you’d think. A person arrives at a mental health unit in a psychotic state and is immediately put into a seclusion room.
Mental health consumer adviser Vicki Burnett tells the story of patient A. “When psychotic, she thought she was on fire and her hands were on fire. Put into a seclusion room, all the walls appeared to her to be on fire. I can’t think of anything worse or more terrifying.”
Why, asks Burnett, when someone is struggling with reality, lock them into a stark empty space with nothing to anchor them to the real world? “That’s not low stimulus, it’s worse than low stimulus because there is nothing – there is no reality.”
The sticking point for this story is getting a photo of a seclusion room. No one is keen to provide an image of this unpalatable reality that harks back to the days of the padded cell. Locking people up in solitary confinement is not a good look for enlightened, recovery-based mental health services in the 21st century.
We can get a description. “A seclusion room is a bare room with a plastic mattress on the floor and a disposable potty that’s made out the same stuff that egg cartons are,” says Burnett.
We know, too, the effect of being put in seclusion. Anne Helm, a member of the Confidential Forum for Former In-Patients of Psychiatric Hospitals, says: “If you are in a seclusion cell you have feelings of worthlessness, of loss of dignity and, at the very time when you are most fragile, you are removed from any human contact. It’s counterproductive to what people generally need.”
For the first time, we also know just how much this outmoded practice is still being used in mental health units around the country today.
Data just made public by the office of the director of mental health shows that 477 people were locked in seclusion rooms during the last quarter of last year. The bulk (383) were in adult mental health units, 59 were in forensic (crime related) services and 18 in child and young persons facilities. Data for those over the age of 65 was incomplete, but it appears most mental health units for the elderly do not have seclusion rooms.
Maori are more often secluded than other ethnic groups, accounting for 186 of the 477 locked up. Most stays (82 per cent) were shorter than one day. The longest recorded was 30 days.
There were 1514 seclusions in adult services during the quarter, indicating the same people are secluded multiple times – about four times on average. There is a wide variation in the data from district health boards (DHB). Tairawhiti (Gisborne), Canterbury and Bay of Plenty had the highest incidence of locking people up, and Auckland, Waitemata and Capital and Coast were among the lowest.
“Seclusion is a worry to us,” says the mental health director for the Ministry of Health, Dr David Chaplow. “We want it to start trending down and we want to really minimise, possibly even extinguish, the use of seclusion.”
The worry for the ministry is unavoidable evidence that the practice has no therapeutic purpose and that its continued use may breach fundamental human rights – and expose mental health services, already tainted by a legacy of inhumane practices, to further compensation claims.
Chaplow says the latest statistics are one of the steps in setting a benchmark for acceptable practice. At present, the use of seclusion is allowed under the Mental Health Act for the “care” or “treatment” of the service user, or protection of other users in the ward. It’s operation is outlined in the ministry’s Restraint Minimisation and Safe Practice Standard (2001), which is about to be updated.
With only three months of reporting, not too much can be read into the wide variation of figures by district. Tairawhiti, for example, which has the highest number of seclusion events (120 for the quarter) is a six-bed unit with two seclusion rooms.
Its statistics have been looked at by the mental health district inspector, who has reported that the use of seclusion in each of the cases was justified.
But Chaplow says that when the full figures for last year come out such discrepancies will be weighed against the wider picture. “If we do have DHBs wildly out of step, we’ll be saying to them they had better have a look at this.”
He points to reasons for the variations, including data being skewed by one or two difficult patients, demographic differences, ward design, staff training and differences in seclusion practices.
“In the past, it would not be uncommon for people to be secluded as a type of punishment. We are rigorously combating that in our training.”
Burnett is not so sure the message is getting through. “I think seclusion rooms are a threat to people and I think they are used as a threat: ‘If you don’t settle down we’ll have to put you into seclusion.”‘
She argues that it’s not necessary to lock someone in a room to reduce stimuli and says the ministry shouldn’t be approving any new buildings that have seclusion rooms.
Although the ministry wants the use of seclusion minimised in mental health services, many – including the Mental Health Foundation, the Mental Health Commission and the Mental Health Advocacy Coalition – want its routine practice eradicated. “We would like to see it become unacceptable as a norm to use seclusion – and if it is used, there has to be a thorough justification and explanation,” says Judi Clements, chief executive of the Mental Health Foundation. Clements says that, aside from seclusion, other statistics in the director’s report raise concerns, such as that 224 patients were treated with electroconvulsive therapy (ECT) last year and that 17 per cent of the treatments given did not have consent.
Seventy per cent of the recipients were women, most aged in the 64 to 84 age age group.
“We need to keep asking, what place does compulsion have in an environment that is moving towards a more enlightened approach towards people with mental illness?” says Clements.
Being forced to accept assessment and intervention against their will is a common complaint among mental health service users, and seclusion – forced restraint and imprisonment – is a prime example.
Psychiatrist David Codyre, also a member of the Mental Health Advocacy Coalition, agrees. He sees no evidence that seclusion is of any benefit and much confirmation from consumers that it is harmful and a significant breach of human rights. “It is no longer sustainable to say this is a necessary evil,” says Codyre. “It’s an unnecessary evil in the vast majority of cases.”
Codyre says studies show that when staff work in ways that minimise confrontation and maximise reassurance and engagement, the need to use seclusion as an intervention reduces dramatically.
Importantly, when staff work to reduce the use of seclusion, the level of violence in in-patient units, and particularly assaults on staff, reduces in a parallel line. “While seclusion was viewed as a way to keep everyone safe, what it actually was doing was increasing levels of trauma and violence for everyone involved .”
Consumer advocate Burnett sees the use of seclusion as poor nursing practice. “In nearly all instances it could have been avoided by better engagement with the person before that was necessary.”
But not everyone is convinced that it’s possible to totally eradicate seclusion. “That’s a good aim to have – whether it’s realistic I’m not entirely sure,” says Nigel Fairley, Capital and Coast DHB director of area mental health services, a DHB which is among the lowest users of seclusion practices. “The problem with that aim is that it does not recognise that, in some circumstances, there is a therapeutic value for the use of seclusion in that it provides the person a low stimulus environment, which is important at that point in time in their mental health issue.” He sees seclusion as a compulsory time out to deal with risky situations – a last, but legitimate, resort.
One who is determined to see seclusion completely removed is Karla Bergquist, the manager of district mental health services for the Waitemata District Health Board.
“We’re supposed to be providing services for people who have experienced trauma that are supportive and caring and therapeutic,” Bergquist says. “I don’t think that seclusion and restraint fit into those categories.”
The DHB has introduced “trauma informed care” projects, where staff use debriefing and analysis of each incidence of restraint and seclusion to understand why they happened and what could be done differently.
Bergquist says studies show that while initially there may be a small increase in the use of psychotropic medication – sometimes called the chemical straitjacket – when seclusion is removed it’s not a lasting effect. “When you’ve had an option that has been available to you for a very long period of time it’s hard to imagine what life would be like without it.” As to staff reaction to her ideas, “A lot of people say ‘You’re off your head’, but we’ve also got a group who are really passionate about moving towards that goal.”
Helm sees seclusion as part of our institutional legacy and no longer appropriate as a response to distress in the light of what is now call recovery-based practice. “It’s basically used as a behavioural management tool in controlling very complex environments.”
Like most, Helm agrees there are instances – such as for those in drug-induced psychosis – when restraint will be required. But seclusion is usually the result of impaired judgment by overworked, over-stressed staffing regimes where room for more appropriate responses is not possible.
“Solitary confinement might be perceived as therapeutic by the staff, when the recipient is seen as calm and contemplative. Mostly, that’s just the trauma of confinement. It breaks the spirit and sometimes results in long held fears which means the service user doesn’t want to use the service again.”
PUNISHED FOR SOMETHING I HAD NO CONTROL OVER
Big guy Mark tells his side of story
Mark, at the time 28, describes his experience of being put into seclusion in an Auckland mental health unit for three days.
I was diagnosed bipolar schizoaffective. At the time I wasn’t aware I had problems. I thought what I was going through was natural – that it was a spiritual awakening when you start hearing voices. I got hospitalised in February 2003. I had no clue about why I was there. I wanted to escape and one night I did. I took off out the door, jumped the fence and was away.
I got caught and put into the acute service. In the ward I was wrestled to the floor and given an injection to calm me down. I was afraid for my life. I thought they were going to do something to me. I spent the next few days locked up in a daze – you don’t know what time it is. All I recall is waking up and going back to sleep again. Sometimes there would be food and water. It was a lock-up room. It felt like being chucked into prison without a conviction – without any reason for why I was there.
I remember the smell of urine. The room wasn’t cleaned often. The walls were yellowish brown. My bed was just a flat pillow on the floor. They would come and give me another injection. There was nothing to look at all day – except out the window in the door which had a view of the corridor. There was no other window. The lights were on 24/7. The only person I saw was the one who brought the tray in and took away the waste. It’s something you shelve – try to forget about. I felt helpless and kept thinking I had done something wrong to be locked up. It felt like I was being punished for something I had no control over.
At the end of it, in the review, the staff told me the main problem was they thought I would be violent and psychotic and basically because I’m a big guy, they thought it was better to keep me monitored. I was in there for three days. My parents cried when they saw me – they thought going to hospital was the only and best choice for me. They didn’t realise anything like this would have occurred.
Added: November 12, 2007 in
Electroconvulsive Therapy Saves Lives. But 70 Years After It First Gained Currency as a Treatment For Major Depression, ECT Continues to Court Controversy.
By Shirley Wang
Special to The Washington Post
Tuesday, July 24, 2007; HE01
Anthony Mauger woke up at 5 a.m. one morning nearly 10 years ago and heard a message in his head telling him to kill himself. He wrote a goodbye note to his wife, then jumped off the back deck of their Kensington home, falling the 14 feet hard enough to wake her with the sound of his thud.
The 66-year-old organic chemist succeeded only in smashing his knees and skull. After surgery at Suburban Hospital, he was transferred to Potomac Valley Nursing and Wellness Center in Rockville for intensive psychiatric care.
Mauger had been depressed for about six months, his wife, Inge, remembers. His sleep had been poor, and he was making strange claims that he could not go on vacation or walk. The slew of antidepressants Mauger tried made no difference. After four more months watching her husband deteriorate, Inge Mauger was desperate. “Nothing is happening,” she said to his psychiatrist. “Isn’t there anything you can do?”
“We can try ECT,” he replied.
Better known as shock therapy and seared into our collective consciousness as the involuntary procedure depicted in “One Flew Over the Cuckoo’s Nest,” electroconvulsive therapy remains a controversial treatment, often used, as in Mauger’s case, only after other treatments fail. Its popularity has waxed and waned in its 70-year history, but an estimated 100,000 Americans undergo ECT each year, according to a 1995 survey of more than 17,000 psychiatrists, and its use appears to be steady or increasing since then.
The number of treatments in California — one of the few states that have mandatory reporting — increased from about 13,000 to more than 20,000 between 1994 and 2004. Although the District, Maryland and Virginia do not require such reporting, Johns Hopkins Hospital treats about 125 people with ECT annually, a number that has not changed much recently, according to Irving Reti, head of Hopkins’s ECT unit; at Sheppard Pratt outside Baltimore, ECT physician Jack Vaeth says his service does about 60 treatments a week, an increase over the past decade.
While no one fully understands why ECT works, many psychiatrists believe that using an electric current to produce a “grand mal” — or generalized brain — seizure can “reboot” the brain when medications and psychotherapy fail. Just last week, a commentary in the Journal of the American Medical Association (JAMA) suggested that, despite its demonstrated effectiveness, ECT remains underused, primarily because of its stigmatized history.
The treatment is “miraculous” and “lifesaving,” say some patients and doctors, and yet the costs — primarily memory loss — can be significant. Many individuals who believe that ECT kept them alive when they were suicidal also urge caution about its use.
Mauger, as an older individual with “treatment-resistant” depression, is a fairly typical patient. Initially scared, he decided to try ECT weeks after his psychiatrist and wife first urged him to. By the seventh of his 12 treatments, he felt his depression lift.
“He sat up and said, ‘I’m not depressed anymore,’ ” his wife said. “I was amazed.”
His one relapse years later quickly responded to another course of treatment. “I am terrified of what would have become of me without ECT,” Mauger says.
A Long-Term Goal
An acute course of treatment usually comprises eight to 12 sessions, administered two or three times a week at a hospital. Studies show that more than 70 percent of severely depressed patients experience quick improvements. (About 50 to 60 percent respond to antidepressants.)
“ECT is hands-down, for the short term, our most effective treatment for depression,” says Harold Sackeim, professor of psychiatry and radiology at Columbia University.
However, only about half of patients remain well even six months after one course, if given no other treatment afterward. “Acutely helping someone out of a period of depression is very important,” says Sarah Lisanby, chairperson of the American Psychiatric Association Committee on ECT and Related Treatments. “But it’s not the end of the story. The goal is long-term treatment.”
That goal is a priority for researchers. The first randomized, controlled study of maintenance treatment following ECT, published in 2001, found that giving patients a combination of an antidepressant and a mood stabilizer significantly increased the chances that they would not relapse into major depression six months after having ECT.
More recently, a research group found that continuing to give ECT once a week to once a month for six months produced results similar to the combination medication treatment.
“We’re learning how to keep people well after ECT more than we knew before,” said Max Fink, professor emeritus of the Departments of Psychiatry and Neurology at Stony Brook University in New York, who wrote last week’s commentary in JAMA. “You can’t just stop.”
A 20-Minute Procedure
The ECT of today is not the shocking scene depicted in books and movies. The overwhelming majority of patients receive the treatment voluntarily. While I was a clinical psychology intern this year at Western Psychiatric Institute and Clinic in Pittsburgh, the head of the ECT program, Roger Haskett, arranged for my classmates and me to view ECT in action.
At Western, ECT is provided every weekday morning. Patients are wheeled one at a time into the ECT suite, lying on gurneys and in hospital gowns, much like patients about to get any other medical procedure. Many that morning were elderly and female, which is typical of the population that gets ECT, and most appeared calm.
They were given an intravenous anesthesia, which sent them to sleep within minutes. A muscle relaxant coursed through their entire bodies except for one foot, which was wrapped with a blood pressure cuff to keep the muscle relaxant out so the seizure movement could be observed. Five sensors were carefully attached to the patients’ foreheads to measure electrical brain activity, and their temples were cleaned and coated with conducting gel. The patients were also given oxygen, and a bite block was inserted into their mouths right before the electrodes were placed on their heads.
The anesthesiologist, psychiatrist and nurse then confirmed which procedure each patient would get — unilateral (both electrodes on the same side of the head) or bilateral (one electrode on each temple) — and what dosage of current.
The psychiatrist then placed the electrodes against the patient’s head, and the ECT machine sent a jolt of seizure-inducing current. Except for what appears to be a grimace — an automatic result of stimulation of the muscles that run along the sides of the face — and a tensing of the total body, ECT patients do not move during the procedure. There is no flailing about, apart from a slight twitching in the cuffed foot. Yet as a new observer, I found watching the experience a little jarring.
The setup is very efficient; each procedure takes about 20 minutes.
The Memory Issue
What bothers many patients afterward — and is at the core of the continuing controversy about ECT — is memory loss. Some are confused when they wake up; others complain that they cannot remember past events and have at least temporary trouble forming new memories.
Much research has focused on reducing that side effect, but patient experiences vary tremendously, and it is nearly impossible to predict the extent of memory difficulties in individuals, according to Frank Moscarillo, executive director of the Association for Convulsive Therapy, who has conducted ECT at Sibley Hospital since 1968.
Barbara Winkler, 46, of Kennewick, Wash., who had more than 90 sessions of ECT at Yakima Valley Memorial Hospital, cannot recall her wedding, which occurred during the period she was receiving ECT. “It probably saved my life initially,” Winkler said. “But the hardest part is probably the memory loss.”
Others, like Tom Hempel, 59, from Pittsburgh, see memory lapses as “inconveniences.” He jokes about “having an ECT moment.” “I know it was worth it,” he said.
Many in the ECT field say concentration and memory may also be compromised by depression. But it appears clear now that ECT can affect memory for much longer than the two to three weeks after which many physicians say most patients’ ability to remember will return to normal.
Some patients have pointed to inconsistency in information about side effects. Vermont state legislator Anne Donahue, 51, thinks they were not sufficiently emphasized before her first round of treatment in 1995, while the informed-consent form provided to her at a second hospital in 1996 was much more complete and easy to read.
“This is an incredibly vital and valuable treatment, but you have the right to know the risks,” Donahue said.
Although the overwhelming majority of ECT patients in the United States consent to the treatment, legislation governing involuntary ECT varies by state. The criteria are generally strict: A patient must be unable to make the decision, and they must be exhibiting dangerous behavior, such as not eating.
Also, there is no special license that a doctor needs to administer ECT in the United States. The American Psychiatric Association has issued practice guidelines, but in most states there is no regulatory body to see that practitioners adhere to those standards or to review the information on consent forms.
Nor is there any firm rule about when ECT is complete. Memory loss tends to get worse with more closely spaced treatments or larger doses of current, so doctors look for a plateau in improvement, when patients say they feel no additional benefit in symptoms.
“The desire to minimize memory loss while maximizing effectiveness is the holy grail,” said Steve Seiner, director of the ECT service at McLean Hospital in Belmont, Mass., one of the largest such programs in the country. “The goal of ECT is to get them back to their base line.” ·
Shirley Wang, who is completing an internship at Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center, has a degree in clinical psychology
Added: July 25, 2007 in
Our son’s condition kept getting worse, and everything we tried to help him failed. Then we discovered there was one final option: Electroshock therapy.
By Ann Bauer
Jun. 19, 2007
At the age of 3, my older son withdrew, becoming sullen and cross-eyed overnight. He stopped speaking and lost the ability to follow directions, vanishing inside a body that only rocked and swayed and arched away from human touch.
Together with my then-husband, I coaxed this little boy back: reading him poetry, drilling him with flashcards, crawling the floor in circles at his side. And when he returned to us, recovering in a way most autistic children never do, I believed the worst thing that would ever happen to us was done.
So when — after more than a decade of progress — my son began to regress, I didn’t see it. I couldn’t. I called it depression, anxiety, teenage sloth. I didn’t realize the enormity of what was happening until my 18-year-old son could no longer climb a flight of stairs or tie his own shoes. Even then, it took us another year to figure out that he had a condition called autistic catatonia: a second withdrawal, even more cruel and dangerous than the first, which occurs on the far end of childhood.
About a month ago, I wrote a story about my son’s misdiagnosis of schizophrenia during that yearlong period, as well as his frightening response to a couple of commonly prescribed antipsychotic medications, Abilify and Geodon. I cited a New York Times article about psychiatrists in Minnesota (where we live) receiving kickbacks for prescribing exactly those drugs and went on to report that my ex-husband and I finally took our son to Mayo Clinic, where he was correctly diagnosed and appropriately treated. I told how doctors there admitted a mute and feral young man, working in choreographed teams to figure out exactly what he needed, magically finding the person inside and bringing him back again.
What I did not report was that they used electroconvulsive therapy (or ECT) in order to do so.
I had two reasons for omitting this information. First, the point of my original essay was to bring attention to the misuse of antipsychotic drugs in children, adolescents and people of all ages along the autistic spectrum; I believed including the information about ECT (also commonly known as shock treatment) would hijack the piece, drawing attention away from the issues of overprescription and autistic catatonia.
But also, frankly, I didn’t feel like going through a hailstorm of reader outrage and Frankenstein jokes. Because even after seeing the benefits of electroshock for myself, I remained ambivalent about the treatment, protective of my son and simply raw.
So why go public now? Because after that original essay was posted, I received literally hundreds of messages (in fact, I continue to receive them, all these weeks later), from readers who had children, brothers, sisters or friends suffering from something similar. And these people were desperate for answers: How was my son cured? Did it last? And where could they go to obtain the same treatment for their son, daughter, brother, sister or friend.
I was in the process of responding individually to each of these queries when I received a letter from Max Fink, the doctor who had referred us to Mayo — and whose book “Electroshock: Healing Mental Illness” I used to research ECT — asking me to set the record straight. “I recognize the tremendous stigma attached to this treatment,” it said. “But if you wish to help other parents of such adolescents, you should disclose the fact that, despite its stigma, electroshock is one of the most effective treatments in medicine; that it has been in use for more than 70 years; and that its benefit-to-risk ratio [for acute patients] is very favorable.”
Everything he wrote is true.
- – - – - – - – - – - -
Convulsive therapy was introduced to modern medicine in 1934 by the Hungarian neuropsychiatrist Ladislas Meduna. He had observed that delusional patients who suffered spontaneous seizures often were miraculously cured and developed a theory that mental illness and epilepsy were “antagonistic” conditions: Those with the first had a deficit of neuroglia (branched cells that form the network for communication between neurons), whereas those with the second had a surfeit. By inducing seizures with an injection of Metrazol, Meduna believed he could “grow” neuroglia in the addled brain, thereby reversing disease.
Proponents of ECT no longer believe this. In fact, they can’t say exactly why it works, only that it does, swiftly and consistently, in roughly 90 percent of catatonia cases, and 60-70 percent of patients with severe depression, mania and intractable psychosis. Recently, neurologists have begun recommending regular electroconvulsive therapy sessions for patients with movement disorders, such as Parkinson’s, saying that it minimizes tremors and reduces the need for drugs such as L-dopa, which has notoriously negative side effects. (ECT has proved ineffective, however, when used for dysthymia, anxiety, substance abuse and personality disorders.)
The prevailing theory today is that ECT somehow repairs and sensitizes various neurotransmitter receptors, such as the ones that bind to serotonin, dopamine, glutamate and cortisol. But the truth is, no one really knows.
“Think of it like rebooting the brain,” one clinician told me. “You don’t know exactly why your computer isn’t working, but if you shut it off and turn it back on, nine times out of 10, it’ll come back online and function just fine.”
This is small consolation on a chilly, blue morning in May, as I drive to Mayo before dawn and walk through the still-sleeping ward. Inside my son’s room I stand at his bedside, reading the form I’ve been handed, then take a deep breath and sign so the doctors who have assembled six-deep can take him to a surgical suite, put him under a “light” general anesthesia, attach electrodes to his temples, and shock him until he has a seizure. Under any other circumstances, this young man — 19 years old, of normal intelligence, and legally in charge of his own medical decisions — would not need parental consent. But here’s what it means to be clinically catatonic: Though he is burly and muscular, my son’s mind is spinning so fast his body has stopped functioning altogether and he cannot exert enough pressure to use a ballpoint pen. His signature at the bottom of the sheet is illegible.
After I have scrawled my name under his, I hand the paper to my ex-husband who does the same. Then we walk alongside the bed that is being wheeled with effort by two medical students into a large, bright theater. They talk excitedly as we walk: This is the first time they will observe an actual ECT treatment.
Just then, the female student glances in our direction. Her face softens. “We’ll take good care of him,” she says.
And I nod blindly, through stupid, angry tears.
Then my former husband and I stand against a wall while they coax our son onto a fancier gurney, one with long straps that they pull out to their full length and buckle snugly around him. We watch the anesthesiologist lean over his frozen form and slip a needle into his arm. And I remember the day of his tonsillectomy, 13 years ago, when we — still hopeful young parents — held him down, our hands meeting on his Winnie the Pooh gown, while someone lowered a rubber mask over his small face.
Suddenly, there is a problem. “They don’t belong in here!” a voice says, and we are hustled out, into a small waiting room where I sit uncomfortably across from the man to whom I was married for 14 years. “Don’t worry, it’ll be all right,” he says, in lieu of touching me. And again, I nod.
Twenty minutes later, the male medical student comes out to talk to us.
“Your son is fine, everything went well,” he says in a bright voice. “And you should know, we got a really good seizure using the very lowest level of current.”
“Is that better?” I ask. “What does that mean? Is less current safer, or a sign that he’s closer to the surface than we think?”
The boy’s eyes cloud and he looks suddenly bewildered. He pauses, then says, “Honestly, ma’am, I have no idea.”
- – - – - – - – - – - -
By the early 1940s, electrical current had replaced chemical agents to become the standard method for convulsive therapy. Ugo Cerletti and Lucio Bini, the Italian researchers who developed the protocol for “electroshock” by experimenting on animals, were nominated for (but did not receive) a Nobel Prize in medicine.
But ECT’s popularity plummeted briefly in the 1960s when drugs such as imipramine and chlorpromazine were introduced and deemed preferable by most doctors. And it dropped off again in the mid-’70s, when the film “One Flew Over the Cuckoo’s Nest” depicted electroshock as medicalized torture, used by venal healthcare workers to keep mental patients in line. Despite a series of movies and television shows that vilified the therapy — “Law and Order” even did an episode about ECT, called “Cruel and Unusual” — rates crept back up over the next several decades, mostly for patients with drug-resistant forms of mental illness. And by the mid-’90s (the most recent period from which statistics are available), about 100,000 people in the U.S. were being treated annually with ECT.
“One of the major reasons ECT is so controversial is because of the way it’s been portrayed in the media,” says Dr. Teresa Rummans, professor of psychiatry and the former medical director for ECT at Mayo Clinic. “Our challenge is to get people to consider this therapy as an option, despite the negative things they’ve seen in the movies. It’s not a panacea. But for certain people who can’t be helped any other way, it can be life changing, or life saving.”
Today, even anti-ECT activists admit the therapy sometimes works in cases where nothing else has. But there is a debate raging about whether the side effects of ECT — including memory loss and confusion — are temporary or, in the language of the medical establishment, “persistent.” Earlier this year, Harold Sackeim — a professor of psychiatry and radiology at Columbia University — published the results of a 25-year study in the journal Neuropsychopharmacology, confirming that ECT can cause permanent memory loss.
We didn’t turn to this treatment until it was the only option left and our son was so lost, overwhelmed and deluded that his quality of life was entirely gone. I remind myself of this. I’ve read and reread the quote from novelist William Styron — author of the visceral depression memoir “Darkness Visible” — after he underwent ECT in 2000: “I’m writing. I don’t sense any memory loss whatsoever … I would say that my memory is somewhat better than it might have been a year ago.” I remind myself that today electroconvulsive therapy is practiced not only by the Mayo Clinic but also by neurologists and psychiatrists in nearly every well-respected academic and teaching hospital in the country.
Still, I pray that this is not a terrible, irreversible mistake.
After his first treatment, my son is wheeled back to his room. I check him over, anticipating strap marks from where he strained upward during the convulsion, or burn marks on his temples. All I find is a white bandage on the crook of his arm, from where the IV needle went in. He sleeps the rest of the afternoon. When he awakens, he appears confused, but he is able to drink some water. The nurse asks him if he has a headache; he thinks for a few moments then signals “No.”
Drained, my ex and I drive back to Minneapolis together. We’ve told no one what we’d gone to Rochester to do, in fear that some distant relative with a Scientology bent might file an injunction to stop us. Now, the weight of this sits between us and we barely speak.
Eighteen hours later, my husband drives me back to Rochester. It is 10 a.m. on a Saturday. We walk onto the unit and while we are being checked for contraband (anything with a blade, a sharp edge, or a cord), my son ambles out of his room and smiles at us. He raises a hand. “Hey, good to see ya,” he says, and walks — not quickly, but purposefully — into the lounge where three other patients are sitting in front of the TV. “What are you watching?” we hear him ask one of the others.
My husband turns to me, eyes freakishly wide. “Holy cow,” he says, grabbing my hand. “Have you ever seen him move like that?”
And, of course, I have. But it was long ago: before I met this man, before my son became depressed and discouraged, before the catatonia set in.
Later that day, we play hearts and when my son shoots the moon [taking all the heart tricks, plus the queen of spades; a move that requires careful strategy and a straight face], he gathers up all the cards and crows the single word “Yes!” out loud.
It is an eerie, wonderful sound that doesn’t fade for me, even as we are riding home.
In “Flowers for Algernon,” the science fiction novella written by Daniel Keyes in 1959, a retarded janitor named Charlie Gordon undergoes brain surgery and is “cured.” His IQ rises from 68 to the genius range. Then the process begins to reverse and Charlie, now sober and worldly and able to read in several languages, must experience his own deterioration. In the final pages of the novel, after writing a scientific paper detailing the descent, he becomes once again a shambling, childlike man.
Bringing our son home from the hospital is something like this. After seven ECT sessions, he seems ready: still autistic — this is a lifelong condition that no current therapy will change — but clearheaded, affectionate, gentle and ready for real life. On the day of his arrival back home, he writes a new schedule, updates his calendar, washes his clothes. On the second day, he is a little shakier, more tentative; around dinnertime, he begins laughing joylessly, under his breath.
“I can feel the catatonia coming back,” he whispers to me late in the evening. “Please, help me. Make it stop.”
Day 3, he is supposed to return to work and he does, but his supervisor calls midway through the shift to say there is a problem: By the time I arrive, he is standing in place, swaying, tears streaming down his face. He cries for the next 17 hours, taking breaks only to eat, which he does in enormous quantity, telling us he’s trying to erase the sadness and bad thoughts. On Day 4, he pushes through the wall of me and his father, sobbing, saying he is leaving us and leaving his life, then walks away — a shaking, swooning mass topped with a backward baseball cap — into a steadily graying twilight.
Together with two police officers, a paramedic, and our respective spouses, we track him down and take him back to Mayo, where they determine he needs more ECT. This time, however, the response is not so immediate: He lies in his bed, lumpen and rank-smelling, his head lolling. It is only after the third treatment that my son is resurrected again. I call and he answers the phone in his old voice, telling me he’s feeling quite good now and would like to go home again soon. He remembers little of the four days between hospital stays but promises things will be different this time. Better.
That’s when the psychiatrist in charge of his case calls a meeting. We’ve reached a decision-making point, he says. ECT alone is effective but transient. Also, there are residual symptoms of the catatonia: tics, disordered thoughts, twilight around the edges of his mind. The best option is to continue with the ECT three times a week for the duration of his hospital stay and afterward, once or twice a week on an outpatient basis.
In addition, they’d like to try a drug that will bridge the treatments and sustain their effect.
Because our son has responded so badly to medications in the past, all four parents object. But we are told it is the only option, barring constant, lifelong ECT.
“Most people will need something to keep them well after their course of treatment,” says Dr. Rummans. “Electroconvulsive therapy resets the circuits and gets things working. But I think of it the same way as when someone has electroconversion for cardiac arrythmia: They still need medication or surgery afterward to maintain. The brain works similarly to the heart in this respect.”
Here’s what I know: Even given the potential risks and my distrust of its murky track record, ECT has brought my son back to life twice and I am suddenly more afraid of what will happen to him — that inevitable Charlie Gordon-like crumbling — if he is disconnected from the machines.
- – - – - – - – - – - -
It is Memorial Day weekend and our family urges us to get away. “You need to take a break from this,” my father tells me. “Go out of town for a couple days and we’ll take over at Mayo.”
My husband and I throw a change of clothes into a bag, climb onto our Triumph, and ride 12 hours through the Badlands and into the Black Hills. On the morning of the third day — our final one — we go to Bear Butte, the mountain just outside Sturgis, S.D., to which many Native Americans trace their spiritual roots.
We know that bikers have a reputation for desecrating this sacred place. So we are careful: touching nothing, taking nothing, leaving nothing behind.
It is a cool afternoon with clear skies but dampness that licks our cheeks and arms. We climb the rubbly laccolith through trees hung with colorful Indian tobacco ties, bits of cloth representing the six directions: north, south, east, west, above and Earth Mother. When the wind blows, they move like soundless bells.
As we near the top of Bear Butte, a storm gathers and I run ahead. I reach the wooden platform at the peak and stand in the center, watching black clouds scud like ships. Lightning cracks to the north of the mountain. Then, as if in answer, there is a flash from the south. I face east so I can watch both sides of the storm. Up here I am taller than the trees, the highest point between Rapid City and the Wyoming border, inviting one of the bolts to strike. Never has the power of electrical current seemed so clear and there is a part of me that wants to feel it, here in this hallowed place. I imagine the six directions have conspired to tell me something and I must listen, so I look toward the forked branches of light.
My husband arrives then, breathless, climbing the steps of the platform and coming toward me with his arms outstretched.
“Sit,” he orders. And I do. But I keep my head up, feeling the rain on my face and watching the flickering sky.
Added: June 20, 2007 in
By Marie Woolf and Sophie Goodchild
Published: 17 June 2007
A government U-turn tomorrow will herald huge improvements in mental- health treatment for young people. In a series of compromise changes to its controversial Mental Health Bill, the Government will curb the use of electroconvulsive therapy (ECT) on teenagers and ensure they do not have to share wards with adults, who are often disturbed and dangerous.
As the Bill reaches a crunch phase in the Commons, amendments will mean no child under 18 will be givenECT without a second opinion from a doctor. Children must also be treated in an environment appropriate for their age.
The U-turns follow criticism from a powerful coalition of mental health charities, psychiatrists, MPs and peers, who tore apart the Bill with a series of amendments. The Independent on Sunday has highlighted opposition to the Bill for five years.
Ministers are said to be ready for a “dog fight” over parts of the Bill they refused to compromise on, such as the definition of mental illness. The Mental Health Alliance welcomed the changes but said the Bill was still “not fit for the 21st century”.
Added: June 18, 2007 in
Sometimes I really LOVE LIFE!!! This is one of those days.
Letter To Editor from Harold Sackeim
p.s. Hi everybody, I’m crazy busy and will be back in the flow soon.
Added: June 13, 2007 in
Today Israel remembers the Holocaust and honors those who died and survived.
I suggest each person who visits ect.org today take a few moments to learn more about the Holocaust and why the need exists for reminders that it happened.
Many of you visiting, had you lived under the Nazis, would have likely been exterminated too. You (and I) would have been part of the mentally defectives, the less desirables. Most people don’t know that along with six million Jews, a number of Gypsies, homosexuals and other groups considered to be “less than,” mental defectives – persons with mental illness, epilepsy and mental retardation – were systematically exterminated to cleanse the race.
Nearly a quarter million mental defectives died at the hands of the Nazi eugencis program.
The effect of the principles at work here that children call each other names and say “you’re crazy; you’ll be sent to the baking oven in Hadamar”…
…Letter from Dr. Hilfrich, Bishop of Limburg, to the Reich Minister of Justice, August 13, 1941 (Trials of War Criminals Before the Nuernberg Military Tribunals – Washington, U.S Govt. Print. Off., 1949-1953, Vol. I, p. 845-846).
I remember my birthday when I was living in the Soviet Union shortly before it fell apart and visited Kiev. Because it was my birthday, I was given the honor of placing flowers at the memorial of Babi Yar, just outside the city. Babi Yar is the site of yet another massacre by the Nazis, where approximately 100,000 Soviet civilians – many of them Jews – were rounded up over a period of two days and executed.
The first to die were the 700 patients of a psychiatric hospital.
I urge you to visit a photographic tour from several years ago by a small group of psychiatric survivors. The “Freedom from Fear Tour” explores the history of the extermination of “mental defectives” under the Nazis.
Freedom From Fear
Other sites worth visiting:
Yom Ha’Shoah blog roundup
Holocaust Museum in Washington, DC
Deadly Medicine: Creating the Master Race, a new exhibit at the Centers for Disease Control in Atlanta
I leave you with the poem Babi Yar by one of my favorite poets of all time, Yevgeny Yevtushenko.
Babi Yar by Yevgeny Yevtushenko
No monument stands over Babi Yar.
A drop sheer as a crude gravestone.
I am afraid.
Today I am as old in years
as all the Jewish people.
Now I seem to be
Here I plod through ancient Egypt.
Here I perish crucified, on the cross,
and to this day I bear the scars of nails.
I seem to be
is both informer and judge.
I am behind bars.
Beset on every side.
Squealing, dainty ladies in flounced Brussels lace
stick their parasols into my face.
I seem to be then
a young boy in Byelostok.
Blood runs, spilling over the floors.
The barroom rabble-rousers
give off a stench of vodka and onion.
A boot kicks me aside, helpless.
In vain I plead with these pogrom bullies.
While they jeer and shout,
“Beat the Yids. Save Russia!”
some grain-marketeer beats up my mother.
0 my Russian people!
are international to the core.
But those with unclean hands
have often made a jingle of your purest name.
I know the goodness of my land.
How vile these anti-Semites-
without a qualm
they pompously called themselves
the Union of the Russian People!
I seem to be
as a branch in April.
And I love.
And have no need of phrases.
is that we gaze into each other.
How little we can see
We are denied the leaves,
we are denied the sky.
Yet we can do so much –
embrace each other in a darkened room.
They’re coming here?
Be not afraid. Those are the booming
sounds of spring:
spring is coming here.
Come then to me.
Quick, give me your lips.
Are they smashing down the door?
No, it’s the ice breaking …
The wild grasses rustle over Babi Yar.
The trees look ominous,
Here all things scream silently,
and, baring my head,
slowly I feel myself
And I myself
am one massive, soundless scream
above the thousand thousand buried here.
each old man
here shot dead.
here shot dead.
Nothing in me
shall ever forget!
The “Internationale,” let it
when the last anti-Semite on earth
is buried forever.
In my blood there is no Jewish blood.
In their callous rage, all anti-Semites
must hate me now as a Jew.
Added: April 16, 2007 in
March 14, 2006
Bay Area Teen’s Suicide Blamed On Online Pharmacy
by Thuy Vu
PALO ALTO (CBS 5) ― The easy availability of prescription drugs over the Internet is being blamed for the death of a Bay Area teenager.
David McKay still doesn’t know why his son John secretly turned to an online pharmacy to buy the anti-depressant drug Prozac.
“He wasn’t showing symptoms of depression,” McKay said. “The times I saw him, he was very upbeat.”
Last summer, John committed suicide. He was 19 and a nationally known debate champion.
His father’s shock turned to anger when he investigated the online pharmacy his son used: USAnetRx.com. It does not require a faxed or mailed prescription from a licensed physician. A doctor in Colorado signed off on John’s Prozac request without ever talking to him.
“I think if he had proper diagnosis and treatment, he’d still be alive,” David McKay said.
McKay is suing the Web site’s operator and the doctor, Christian Hageseth, whose license was restricted after an improper relationship with a patient. Hageseth told us by phone he has “no comment.”
According to the National Association of Boards of Pharmacy, there are 1,000 Internet pharmacies, yet only 200 of them are considered reputable.
The reputable sites show a seal from the Boards of Pharmacy. But many other sites are reckless.
“Currently, it is too easy to obtain prescription medications over the Internet from these disreputable sites,” said Angie Graham, drug information coordinator at Stanford Medical Center.
Graham says some studies have shown Prozac has serious risks, specifically suicidal thinking and suicidal behavior.
McKay hopes his lawsuit will make it more difficult to obtain Prozac and other prescription drugs.
“I would hope it would send a message to those operating illegally that they’ll be held accountable,” McKay said.
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Added: March 13, 2007 in
What follows are the three most frequently asked questions sent via email:
1. Where can I find a facility that gives ECT?
I don’t have a master list of ECT providers. I am concerned, however, that you would be seeking out ECT on your own. It is unlikely that you would find a clinic or hospital that would give you ECT without a doctor’s recommendation.
This is something that should be discussed with your psychiatrist. Your doctor will know of facilities that perform ECT and will give you a recommendation if s/he feels ECT would be beneficial. If you do not have a relationship with a psychiatrist and wish to have ECT, you will have to find a psychiatrist who will fully evaluate you.
2. I had ECT and it was successful. Why is it necessary to put so much negative information on the web?
I am always curious about one thing when I get this question: if ECT was successful, why are you searching the Internet for ECT information? It seems to me that you would simply accept that it worked and move on to other more interesting pursuits. (I do not doubt your enthusiasm, but it’s something that has always puzzled me – I’m interested in responses!)
That said; why NOT put it on the web? I sincerely believe that patients should be told all sides of the ECT story before making their decision. Anything less is unfair and it’s patronizing.
“Until recently there appears to have been a general reluctance among psychiatrists to admit that ECT could cause memory or other cognitive problems that are severe, persistent and disabling.” This bold statement comes from a recent article in the British medical journal Advances in Psychiatric Treatment. (1)
The majority of people who find their way to ect.org AFTER ECT are at the very least disappointed. At worst, they’re devastated. If they had known before ECT that it causes a number of side effects (with discouraging efficacy and high relapse rates), they could have at least gone into it armed with information and lowered expectations. It’s less devastating to know the possibilities beforehand than to be caught completely blindsided. The latter leaves patients feeling deceived and swindled. That is much of the reason there is so much anger on the part of ECT patients who have a bad outcome. If they had clearly known the risks, they likely would have made the same decision to have ECT, but would not end up feeling so mislead.
Robertson and Pryor emphasized that “prospective patients should be warned of the significant risk of permanent amnesia and the possibility of permanent memory and cognitive disability.” (2)
You may have had a good outcome, but many do not. The negative side of ECT is discussed on ect.org to provide the full set of facts instead of the sanitized version many ECT practitioners choose to supply. Additionally, after a person is left bewildered, with no answers, this site provides a sense of fellowship with others, knowledge that they are not alone.
ECT is NOT a cure and any doctor who sells it as such is guilty of snake-oil salesmanship.
3. I told my doctor I searched the Internet and found information contrary to what s/he told me regarding ECT. His/her response was that the Internet is full of material not based on scientific facts and I should ignore it and stay off the web. Why would s/he be dishonest? What reasons could my doctor possibly have to hide these things from his/her patients?
Two simple answers followed up by more thorough discussion:
1. They are unaware or more commonly, don’t listen to their patients and have their heads in the sand.
2. They are paternalistic and think they know what’s best for you. They know if they provided a full set of facts, some patients would reject ECT.
Neither explanation means that your psychiatrist is a demon or a bad doctor. The very nature of psychiatry is based on paternalism, a view that you are mentally ill and therefore are incapable of decision-making. By removing some of the variables (information), your decision is easier to make. Unfortunately, this point of view is strongly rooted in psychiatry and in the public perception. That doesn’t make psychiatrists bad, just old fashioned and in need of a makeover.
“Persons with mental illness cannot make decisions on their own.” Most are lumped into that category. Yes, there are some individuals who are so ill they cannot function and make a decision. But you are obviously well enough to surf the Internet, to perform a search and find ect.org, and you’re well enough to compose an email to me, type in the email address and operate your computer to send the mail. You’re very likely well enough to make an informed decision, based on ALL the facts, not the selected few chosen by the person in charge.
There is a debate within the ECT industry concerning when ECT should be prescribed. Should it be used early in a depressive episode, or saved for those who are the most severely ill, desperate and treatment resistant? One of the leading psychiatrists in the latter camp once said that if a person is well enough to surf the Internet, he or she is not ill enough to consider ECT. (Many would disagree with that statement, but I toss it out as an interesting observation.)
Without a clue
I did a small research study called “Voices” a decade ago. An unsurprising finding from that study was that when ECT patients tell their doctors that they HAVE suffered devastating memory loss and other side effects, the doctors dismiss their complaints. But there was a highly surprising finding: many of those patients get frustrated at their psychiatrists but feel trying to convince them of the existence of the effects is futile. They move on to a new psychiatrist, or give up on psychiatry completely.
That treating psychiatrist, who has already discounted that they had side effects, never sees the individual again. S/he logically assumes that the person got better and moved on. Another success story! And since the doctor had not listened to the patient’s complaints, those complaints are never registered in the psychiatrist’s mind, and therefore, do not exist.
You can make up a variety of scenarios regarding the psychiatrist’s thinking along that path, but the bottom line is that to the psychiatrist, that patient did not have side effects. It’s a misperception, based on a refusal to acknowledge the patient’s complaints, but the doctor probably genuinely does not know it.
The second scenario is of course knowing the truth, but failing to share it. That sounds a bit more devious that I believe it is. I don’t think it’s a case of an evil doctor knowing and not telling because s/he’s a bad person. I think it’s just more of a case of this paternalism I keep talking about, a view that the doctor knows what’s best for you, so why bog you down with too much information, particularly negative information.
Another possibility is that your doctor simply has not kept up with the literature. What your doctor may consider “scientific fact” may be the statistic that has been quoted for many years, that only 1 in 200 persons suffer severe memory loss. Several years ago, that statistic was shown to be, depending on your point of view, either misleading or an outright lie. Harold Sackeim, considered the King of ECT, admitted it on a television show, although it softened the blow by calling the number “Impressionistic.”
1. of or relating to or based on an impression rather than on facts or reasoning; “a surprisingly impressionistic review bearing marks of hasty composition”; “she had impressionistic memories of her childhood”
In more recent writings and testimonies, Mr. Sackeim has said that now it’s known ECT does, in fact, cause severe memory loss much more often than has been acknowledged. In his defense, he said the industry “Just didn’t know,” and that he has been trying to get industry leaders and doctors in the field to acknowledge what is now known.
For seventy years, patients have been reporting the same complaints, but “they just didn’t know.” Sackeim claims that they only discovered the hard science a few years ago.
The information is now out there, it’s being published, and your doctor’s only excuse will soon be that s/he’s not keeping up with current literature.
If your doctor is promoting ECT as a cure for depression, consider that a red flag and get a second opinion. Even the most enthusiastic ECT cheerleaders will tell you it’s most often a temporary fix, one that will require regular treatments indefinitely.
1. Mangaoang, M. & Lucey, J. (2007) Cognitive rehabilitation: assessment and treatment of persistent memory impairments following ECT. Advances in Psychiatric Treatment, 13, 90-100.
2. Robertson, H. & Pryor, R. (2006) Memory and cognitive effects of ECT: informing and assessing patients. Advances in Psychiatric Treatment, 12,228-237.
Added: March 13, 2007 in
Advances in Psychiatric Treatment (2007), vol. 13, 90-100 doi: 10.1192/apt.bp.106.002899
Cognitive rehabilitation: assessment and treatment of persistent memory impairments following ECT
Maeve A. Mangaoang & Jim V. Lucey
Few tests address the types of memory problem commonly reported after electroconvulsive therapy (ECT). Here, we focus on the importance of neuropsychological assessment in ECT-treated patients and describe a number of tasks that may be useful in measuring the everyday memory problems of such patients with ongoing memory difficulties. At the time of writing, no attempts have been made to rehabilitate patients who experience persistent adverse cognitive effects, but clinicians should be aware of the potential beneficial role of cognitive rehabilitation in the treatment and management of these effects.
In a recent issue of APT, Robertson & Pryor (2006) drew attention to a number of issues regarding the assessment of cognitive function in patients treated with electroconvulsive therapy (ECT). In particular, they highlighted the paucity of tests that are sensitive and relevant to the specific memory problems commonly reported after ECT. Here, Mangaoang & Lucey return to this problem, discussing neuropsychological assessment in ECT-treated patients.
Electroconvulsive therapy (ECT) has been used for many years, but it remains one of the most controversial psychiatric treatments. In recent years, a considerable amount of research has attempted to highlight the efficacy and safety of ECT, in addition to emphasising the overall improvements in current ECT techniques, equipment and standards (Sharma, 2001; Chung, 2002; UK ECT Review Group, 2003; Prudic et al, 2004). However, there also exists a growing body of research consistently reporting the adverse cognitive and psychological consequences of ECT among a substantial minority of patients (Johnstone, 1999; Service User Research Enterprise, 2002; Koopowitz et al, 2003; Rose et al, 2003; Scott, 2005). Although discrepancies exist between clinician-led or hospital-based studies and those undertaken in collaboration with patients regarding the nature and extent of adverse side-effects, there is a general consensus that memory loss (Box 1) is the most frequently and consistently reported side-effect following ECT (Rose et al, 2003). There have been many conflicting accounts of the severity and duration of the memory and other cognitive difficulties (Weeks et al, 1980; Squire et al, 1981; Templer & Veleber, 1982; Squire & Slater, 1983; Lisanby et al, 2000; Brodaty et al, 2000), but to date there has been a distinct lack of routine neuropsychological assessment of individuals receiving ECT at any stage during their treatment.
Designing an assessment battery that is sensitive to the nature of the everyday problems experienced by patients with memory and/or cognitive disability is challenging, and standard neuropsychological tests may not adequately reflect the levels of impairment experienced by patients on a daily basis (Robertson & Pryor, 2006). Thus, the use of novel, personally relevant memory tasks such as those described below may be warranted.
Furthermore, no attempts have been made to provide any form of memory rehabilitation or cognitive retraining to patients who experience persistent memory and other cognitive problems in these areas following ECT. Here we argue that cognitive rehabilitation could be offered to such patients as a means of addressing these difficulties in a constructive way.
The importance of assessment
What is striking from the literature in this area is the lack of routine, formal assessment of patients’ neuropsychological performance following a course of ECT, despite the long-known risk to memory functioning (Squire & Chace, 1975; Squire et al, 1975; Freeman et al, 1980; Squire & Slater, 1983; Robertson & Pryor, 2006). Furthermore, the lack of consistency in the types of measures used to assess patients has made it difficult to clarify the extent and duration of the reported cognitive problems and the impact they may have on the individual’s overall quality of life and sense of self.
In Ireland, for example, there is no published research on the long-term effects of ECT on cognitive functioning among Irish patients. The failure to conduct such assessments means that there may be a significant delay in detecting patients who have experienced a marked decline in memory function.
The importance of assessing and monitoring patients’ cognitive function throughout their treatment has been recognised in guidelines on the commissioning of ECT services within the National Health Service (NHS) (Royal College of Psychiatrists, 1995,1999), and the ECT Accreditation Service (ECT Accreditation Service, 2005) includes assessment and monitoring of cognitive function as standards required for accreditation of a clinic. However, there has been a relative neglect to include such measures in routine clinical practice. It appears that even when they have been explicitly recommended (Freeman et al, 1980; Salford Community Health Council, 1998 ; Royal College of Psychiatrists, 2005) patients who report persistent memory loss have not been systematically followed-up or referred for neuropsychological assessment. As a result, their progress or deterioration over time in terms of cognitive performance has not been monitored.
Monitoring patients’ self-reports of adverse side-effects to ECT has also been recommended by the Royal College of Psychiatrists (1995, 2005) and the National Institute for Clinical Excellence (NICE, 2003). Benbow & Crentsil (2004) have shown the importance of measuring such experiences during treatment, as it allowed the ECT staff to take immediate action to try to relieve the problems. For instance, if patients reported persistent confusion or memory difficulties, staff could change from bilateral to unilateral ECT or increase the interval between treatments.
The failure to adequately provide neuropsychological assessments to patients receiving ECT means that the impact of additional, subsequent episodes of depression and/or future courses of ECT on overall cognitive functioning remains unknown (Robertson & Pryor, 2006). Establishing a baseline of functioning before an individual’s first ECT treatment is extremely important in terms of its association with ‘cognitive reserve’. This concept refers to individual differences in factors such as education and occupation, which may be protective against ECT’s adverse effects on memory functioning (Legendre et al, 2003).
The Society for Cognitive Rehabilitation (SCR; Malia et al, 2004) recommends that a combination of standard and novel tasks to assess current cognitive status should be administered to patients. Objective and subjective self-report questionnaires and collateral information from family or caregivers should be used, and the assessment battery should provide sufficient information to form hypotheses about the underlying cognitive impairments and deficits that interfere with the individual’s cognitive functioning. These recommendations concur with Robertson & Pryor’s (2006) proposal that ECT-treated patients who report ongoing memory disability should be referred for neuropsychological assessment. The purpose of this is both to determine their general cognitive abilities and to measure specific cognitive functions, such as attention, concentration and information processing, that may be related to memory functioning in everyday life (Ponds & Hendriks, 2006).
Making use of assessments results
Rather than merely describing problems, the results of neuropsychological assessments should be explained in terms that the patient can understand and explicitly related back to the functional problems that have been identified (Mateer et al, 2005). They should be interpreted in a holistic way that takes account of the individual’s personality and emotional characteristics and used to inform decisions about preparing a suitable rehabilitation programme (Malia et al, 2004).
Neuropsychological assessment of memory
There are many factors to consider in the neuropsychological assessment of patients receiving ECT. These include the selection or development of appropriate testing materials, the timing of testing sessions (Robertson & Pryor, 2006) and the effects of factors such as mood, metamemory and memory self-efficacy on performance (Mateer et al, 2005; Ponds & Hendriks, 2006). Additional problems, such as limited access to neuropsychology services, financial and time constraints, may have an impact on the number and frequency of assessment sessions that can be undertaken.
Design of appropriate tests
Although Robertson & Pryor (2006) recommend that patients who have had ECT should be assessed with the kind of neuropsychological tests that are used for patients with known or suspected brain injury, they acknowledge some of the problems associated with these traditional, standardised tasks. The main challenge appears to be designing tests that are sensitive to the memory and other cognitive demands placed on patients in their everyday lives. This task is made even more difficult by the realisation that patients with memory disability may not be able to give reliable self-reports of their memory functioning (Cronholm & Ottosson, 1963; Robertson & Pryor, 2006). Rose et al (2003) note that neuropsychological assessment of the extent of memory loss in ECT patients has tended to focus on the ability to form new memories (anterograde memory, Box 1), whereas patients have commonly reported the loss of autobiographical memory (retrograde amnesia, Box 1) following ECT (Coleman et al, 1996; Peretri et al, 1996; Donahue, 2000). However, loss of autobiographical memory does not appear to have been adequately investigated (Robertson & Pryor, 2006). Furthermore, alternative versions of tests may be required to reduce practice effects over repeated assessments.
Timing of testing
As mentioned above, encouraging patients who are undergoing a course of ECT to give self-reports of any adverse side-effects can be beneficial in terms of allowing staff to take immediate actions to reduce or relieve these effects (Benbow & Crentsil, 2004). However, in many studies the premature assessment of memory and overall cognitive functioning following ECT has led to inaccuracies and underestimations of patients’ impairment (Squire & Slater, 1983; Weiner et al, 1986; Coleman et al, 1996; Peretti et al, 1996; Donahue, 2000; Rogers et al, 2002; Robertson & Pryor, 2006). It may take a number of months for patients to gain a more stable view of permanent changes in their memory and cognition (Weiner et al, 1986; Coleman et al, 1996; Donahue, 2000).
A further problem relates to the ambiguity of meaning in the phrase ‘short-term memory loss’. Does it refer to type of memory or duration of loss? Robertson & Pryor (2006) recommend that the phrase ‘temporary memory loss’ should be used when referring to duration. Patients who interpret short-term memory loss in terms of duration may not be inclined to complain about memory difficulties, believing that they are to be expected and will resolve within the ‘short term’. This may lead to an underreporting of memory problems among patients who are assessed only a few days or weeks after the completion of ECT and highlights the importance of scheduling follow-up assessments after the 6-month time point (Service User Research Enterprise, 2002; Robertson & Pryor, 2006).
Effects of mood and emotional valence on performance
Many studies have shown that individuals who are depressed are more likely to recall negative events than positive or neutral ones (Teasdale et al, 1980; Parrott & Sabiny, 1990; Williams et al, 1988; Lemogne et al, 2005). The performance of people without depression on tasks measuring memory and cognition may also be influenced by their current mood. Recently, Beatty et al‘s (2006) study involving healthy adults showed the significance of both current mood and emotional valence (the subjective emotions associated with an event) on participants’ ability to recall events they had experienced over the past year. Therefore, any assessments of cognitive and memory functioning in patients who have received ECT should take account of the individual’s mood at the time of testing and also whether they perceive the event recalled as positive, negative or neutral.
The concept is strongly linked to Mateer et al‘s (2005) theory of metamemory, which is defned as an awareness of one’s own memory processes, knowledge and use of memory strategies, self-perceptions of one’s memory abilities and beliefs about the functioning of ones’ own memory.
Memory self-efficacy and metamemory
According to Ponds & Hendriks (2006), patients’ complaints about their memory do not necessarily reflect memory deficits; furthermore, there may be large discrepancies between the severity of memory disturbances as measured by memory tests and the impact of these problems in daily life. Finding only moderate correlations between self-reported memory problems and objective results on standardised neuropsychological assessments, Ponds & Hendriks introduced the idea of memory self-efficacy (Box 2) to explain this discrepancy. They argue that an individual’s beliefs and perceptions about their memory may be extremely influential in determining their level of engagement and performance during memory assessment. The belief that one has a poor memory may lead to increased dependence on others, avoidance of memory challenges, and a pattern of helplessness and demoralisation when faced with memory difficulties (Elliot & Lachman, 1989). Additional evidence of the impact of self-perceived memory capacity on control of memory efficiency (Cavanaugh & Poon, 1989; Hertzog et al, 1990; Jonker et al, 1997) supports the argument that neuropsychological assessments of patients who have had ECT should take account of the patient’s own metamemory or sense of memory self-efficacy.
Novel tasks for measuring everyday memory
A few years ago one of us (M. M.) was involved in a study of the effects of surgery for temporal lobe epilepsy (Mangaoang et al, 2004). The study team developed tasks for assessing aspects of everyday memory functioning and spatial representation in patients after surgery (Box 3). These have since been administered to large numbers of healthy control individuals of all ages and to people with chronic major depression (McMackin et al, 2005). These tasks, which are outlined in this section, might be considered for use with patients following ECT.
Sensitivity to the nature of the patients’ memory problems
Episodic and autobiographical memory
The Mundane Memory Questionnaire specifically measures personally relevant episodic memory of typical daily events over the previous four consecutive days. Participants are asked to indicate (by circling either ‘yes’ or ‘no’) whether they recall a particular event, for example, watching television or eating lunch. If the event is recalled, they are asked to give additional information such as what programmes they watched or what food they ate. If participants are unable to provide additional details, they are asked to proceed to the next question.
This measure was extremely sensitive to the types of everyday memory problem experienced by the patients in our study of temporal lobe epilepsy (Mangaoang et al, 2004). It differs from questionnaires such as the Everyday Memory Questionnaire (Sunderland et al, 1984), the Prospective and Retrospective Memory Questionnaire (Smith et al, 2000) and the Cognitive Failures Questionnaire (Broadbent et al, 1982) in that it does not require patients to rate their own memory performance, thereby taking account of the observation that some people with memory problems cannot accurately rate the level of their impairment.
The Everyday Memory Interview is based on an interview used by Eldridge et al (1994) in their assessment of the role of schemas in autobiographical memory. In a tape-recorded interview, the participant is asked to describe, in as much detail as possible, their typical day, yesterday and a day in the previous week, in counterbalanced order (to control for order effects or bias). The interview is scored by focusing on the number of basic activities that are recorded for each of the target days. Discourse analyses of the interview content can also be undertaken to measure the frequency of repetition of events, pragmatic problems and the use of verbal tics.
The merit of both the Mundane Memory Questionnaire and the Everyday Memory Interview is that they measure the ability of patients to recall personally relevant events, are straightforward to administer and are free from practice effects. Modified versions of the tasks could also be completed by patients’ caregivers or spouses, should collateral information be desired.
Semantic and phenomenal characteristics
Although both episodic and autobiographical memory have been widely researched, very few studies have used tasks that are concise, distinguish between semantic and episodic information, and control for emotional valence. Semantic information consists of general knowledge: things we know without any connection to personal experience, whereas episodic information refers to details such as time, person, place and emotions about specific personally experienced events. Levine et al‘s (2002) Autobiographical Memory Interview separates the semantic from episodic details of events. Beatty et al (2006) adapted and extended this measure to show how the recall of specific personally relevant events over the previous 12 months was influenced by whether participants construed the events as positive, negative or neutral. The transcribed interviews were analysed in terms of the number of specific episodic details recalled for each type of event, thereby controlling for the emotional valence of the event. This interview can be extended to include events from the less recent past, in order to gain a thorough appreciation of the extent of a patient’s retrograde amnesia.
Beatty et al (2006) also used the Memory Characteristic Rating Scale (adapted from Johnson et al, 1988) in conjunction with Levine et al‘s (2002) Autobiographical Memory Interview to measure the phenomenal characteristics of the different events. The Memory Characteristic Rating Scale uses a seven-point Likert scale to rate the vividness with which participants can recall specific aspects of an event, such as visual and auditory details. This combination of tasks facilitates examination of the association between the emotional valence of an event and the vividness with which different characteristics can be recalled.
The effects of ECT on topographical memory, way-finding and spatial representation are largely unknown. We can find only one self-report of such deficits (Anonymous, 1965). Assessments of patients who have received ECT do not appear to consider the possibility of such impairments, despite their impact on everyday life. In our work on temporal lobe epilepsy (Mangaoang et al, 2004; Roche et al, 2005), we developed a number of tasks (the Landmark Location, Landmark Recognition and Virtual Map tasks) to measure the ability of patients with left or right unilateral hippocampal damage to recognise photographs of well-known Dublin landmarks and to accurately name their location on a modified map of the city. Patients also described in writing the routes they would take to get from one landmark to another on a map of a virtual city. These tasks were extremely sensitive to the everyday way-finding problems experienced by many of the patients, particularly those with right-sided hippocampal damage (Mangaoang et al, 2004) and could potentially be used to identify whether patients treated with ECT experience similar difficulties.
Sensitivity to metamemory and mood
In considering metamemory and memory self-efficacy (Box 2), the study team used a simple memory rating scale, asking patients to rate their own perception of their current memory functioning at the time of assessment on a five-point Likert scale (1 = ‘very bad’, 5 = ‘excellent’).
Patients’ self-reported symptoms of depression can be assessed using the Beck Depression Inventory (Beck et al, 1996). Alternatively, McMackin et al (2005) have used a mood rating scale that asks patients to rate their mood state at the time of assessment on a nine-point Likert scale (1 = ‘worst you’ve ever felt’, 9 = ‘best you’ve ever felt’). Either instrument could be easily incorporated into an assessment battery for patients receiving ECT.
Potential role of memory rehabilitation and cognitive retraining
Although reports have claimed that about one-third of people receiving ECT experience persistent memory loss (Service User Research Enterprise, 2002; Rose et al, 2003; Scott, 2005), it is unclear whether patients receive treatment or assistance from psychiatrists or other mental health professionals to deal with this disability. We do know that some patients turn to sources of help outside psychiatry (e.g. self-help groups) for support (Johnstone, 1999). This failure to attempt to rehabilitate patients may reinforce the negative public image of ECT specifically and psychiatry in general.
Adopting extisting techniques: brain trauma
The importance of carrying out detailed neuro-psychological assessments of patients following ECT in order to identify persistent cognitive problems was recognised over a decade ago (Calev, 1994). Unfortunately, however, even when cases of severe and persistent memory loss are highlighted in the literature, no study has recommended or attempted to provide any kind of rehabilitation or follow-up care. Documenting persistent and severe deficits in memory and cognition is not enough; patients need to be helped to adjust to the major effects that such disabilities may have on their everyday lives. Robertson & Pryor (2006) recommend that tests assessing neuropsychological function of brain-injured patients be used for ECT-treated patients. We would argue that the cognitive rehabilitative techniques that are used with brain-injured patients should also be considered for use with patients experiencing memory and/or other cognitive disability following ECT.
During the past 20 years, the course and nature of cognitive difficulties after brain injury and the key components of rehabilitation have become better understood. The significance of personal background, the range of emotional responses to injury and its consequences, and the role of coping skills in long-term adjustment are now more readily accepted (Mateer et al, 2005).
Cognitive rehabilitation therapy
Cognitive rehabilitation therapy is ‘a systematic, functionally oriented service of therapeutic cognitive activities and an understanding of the person’s behavioural deficits’ (Malia et al, 2004). Its aim is to achieve functional changes by reinforcing or strengthening previously learned patterns of behaviour, or establishing new patterns of cognitive activity or mechanisms to compensate for impaired neurological systems (Bergquist & Malec, 1997). Cognitive rehabilitation therapy has a large evidence base and has been widely researched among patients with acquired brain injury.
Recently, Ponds & Hendriks (2006) have described what appears to be the first formal attempt to offer a rehabilitation programme focusing on memory to patients with epilepsy. However, no attempts have yet been made to extend such treatment to patients who experience memory deficits following ECT.
What rehabilitation could achieve
Designing a rehabilitation programme for patients with memory or other cognitive disability associated with ECT would constitute the first step towards treating these deficits rather than merely reporting them. Such a programme would also acknowledge the individual’s difficulties and the challenges they face in coping with the demands of everyday life.
How it could be done
Baseline and post-treatment neuropsychological assessments could be used to clarify the nature and extent of cognitive difficulties. From there, appropriate steps towards memory rehabilitation and cognitive retraining (see below) could be undertaken in individual and/or group sessions, and could be extended to include the individual’s family or caregivers. Follow-up assessments of progress would allow any changes in cognitive status to be measured and also to monitor the transfer of acquired skills to other areas of functioning such as the social and occupational domains of the individual’s life. In this way it would be possible to determine whether the rehabilitation programme was having a beneficial effect on the patients’ overall quality of life.
Ultimately, successful practical attempts to address the impact of cognitive disabilities on the lives of patients treated with ECT would be welcomed not only by the patients themselves but also by their relatives and caregivers. The provision of such a service might also improve potential patients’ attitudes towards ECT, by reassuring them that, should they develop a persistent cognitive problem following treatment, some form of structured treatment and assistance would be made available to them. This might help the decision-making process for patients who are considering ECT as a treatment option.
Design of a successful rehabilitation programme
There are many factors to consider in the design of a cognitive rehabilitation programme. These include understanding that rehabilitation is a collaborative process, recognising the importance of including family and/or caregivers and being sensitive to the impact that a patient’s level of awareness, meta-memory, mood and motivation can have on their ability to take part in a programme. Premorbid personality and psychological functioning are also extremely important. Therefore, cognitive rehabilitation should involve work on the patient’s psychosocial skills such as coping, anxiety control, self-esteem, self-concept, motivation, locus of control and adjustment (Malia et al, 2004).
Mateer et al (2005) believe that a combination of neuro-rehabilitation, pharmacotherapy and cognitive-behavioural therapy is often needed. Thus, many programmes incorporate multiple interventions such as attention training, memory compensations, skills training, feedback on performance, psycho-education, stress management, confidence-building and psychotherapy aimed at increasing self-awareness, acceptance and adjustment.
Cognitive rehabilitation programmes that take into account the emotional as well as the cognitive aspects of the injury appear to offer patients the best chance of adapting to their altered situations (Mateer et al, 2005). Being aware of the patient’s emotional well-being is extremely important as it may help identify the development of cognitive distortions such as catastrophic thinking (in which the individual imagines the worst possible outcome of events and situations). Catastrophic thinking can occur when an individual has a distorted belief about the implications of a cognitive error or episode of forgetfulness (Mateer et al, 2005). For example, a patient may interpret normal lapses of memory as confirmation of a memory impairment that will never improve. They may have difficulty in distinguishing between a normal memory lapse and a cognitive error that commonly results from a genuine brain impairment and this may reduce the individual’s ability to cope. Cognitive appraisal and beliefs of self-efficacy are increasingly recognised as being crucial to an individual’s ability to manage stress (Lachman et al, 1992; Mateer et al, 2005).
Recommendations for successful rehabilitation
Approaches to successful cognitive rehabilitation consider both general and specific aspects of the patient’s difficulties (Box 4). The general aspects focus on psychoeducation covering the effects of brain damage and cognitive difficulties, the impact of personality changes and emotional reactions, and the perception of cognitive disorders (Malia & Brannagan, 2004; Ponds & Hendriks, 2006). Aspects specific to memory rehabilitation address the types of memory problem that should be targeted for treatment and the best strategies that could be used (Ponds & Hendriks, 2006). Treatment plans should be given to the patient, caregivers or family members and the appropriate hospital staff. Progress on the treatment plan should be reviewed regularly (Malia et al, 2004).
At the earliest possible stage, patients should be fully informed of their cognitive problems and their likely prognosis in terms of cognitive function (Malia et al, 2004; Mateer et al, 2005). Education should take place both in formal educational groups for patients and their careers/families and during regular individual contact with the patient, and it should be seen as an ongoing process (Malia et al, 2004). Group sessions should focus on understanding specific brain injuries and what rehabilitation is all about, cognitive and emotional problems following brain injury, how to cope with the changes experienced and developing a new sense of self.
The Society for Cognitive Rehabilitation (Malia et al, 2004) states that the aim of psychoeducation is to help the patient develop appropriate self-awareness, self-esteem, confidence, feelings of personal control and a trusting, working relationship with the therapist. It believes that the importance of education cannot be overemphasised: without good awareness, much of what is subsequently offered will have no enduring effects on the individual’s life in the outside world.
At present, very few patients and families are informed about the consequences of acquired cognitive deficits for future life or the possibilities to train or restore memory (Ponds & Hendriks, 2006). Creating a realistic perspective about the impact and possibilities for improvement of memory problems is the first important step in every memory treatment programme. Mittenberg et al (1996) showed that giving head-trauma patients a booklet on recovering from head injury had a significant positive effect on the number, duration and severity of reported symptoms (headache, memory, fatigue, concentration difficulties, anxiety, depression and dizziness) at 6-month follow-up.
It is crucial to give patients information on ECT during the consent process (Robertson & Pryor, 2006). Moreover, if the results from neuropsychological assessments indicate a need for intervention, patients should also be given psychoeducation or information booklets such as those given to head-injured patients, as these can be extremely beneficial in helping to alleviate the distress experienced by patients with mild brain damage. The information may also help patients adjust to any persistent cognitive difficulties they experience.
Rehabilitation techniques and strategies
The aim of rehabilitation is not restoration but compensation (Malia et al, 2004). This can be achieved through the use of internal or external rehabilitation strategies and modifications to the environment. Strategies adapted for use with people who have epilepsy have been shown to improve many aspects of their lives, including attention and memory, emotional regulation and psychosocial functioning (Ponds & Hendriks, 2006). Cognitive rehabilitation should improve the individual’s ability to function as independently as possible in the least restrictive setting and its end result must be to improve quality of life and real-life skills (Malia et al, 2004).
Studies investigating memory rehabilitation have focused on alleviating many different aspects of memory difficulties. These include both general memory problems such as learning and retrieval, and specific problems with orientation, dates, names, faces, routes or appointments (Wilson et al, 2001; Boman et al, 2004; Avila et al, 2004). Rose & Brooks (2003) have highlighted the potential role of virtual reality paradigms in memory rehabilitation.
According to Ponds & Hendriks (2006), two general approaches are currently used in memory rehabilitation: drill and practice, and compensatory strategies.
Drill and practice
The patient is encouraged to practice repeatedly specific memory tasks. This leads to an improvement on these tasks only; there is no transfer of benefits to general memory.
This second approach involves teaching the patient compensatory internal and/or external strategies for coping better with everyday memory problems. Internal memory strategies comprise verbal and visual techniques. These encourage the patient to focus on linking isolated items, via associations, and on enriching the ‘to-be-remembered’ information with additional retrieval cues. The success of internal memory strategies may be due to the deeper level of processing and the elaboration of information that this brings about (Ponds & Hendriks, 2006). External memory strategies include devices that are used to store information (e.g. a calendar, diary, voice recorder or portable electronic organiser) or remind people to perform a particular activity at a specifed time (Wilson et al, 2001; Hart et al, 2004; Kapur et al, 2004; Kirsh et al, 2004).
External strategies also include rearranging or making modifications to the individual’s environment, for example always keeping important items such as keys, wallet or purse and diary together in a labelled drawer in the kitchen (Ponds & Hendriks, 2006). Clearly, internal strategies require greater cognitive capacity and insight than external strategies because the strategy has to be remembered at the very time the individual is becoming overwhelmed with the demands of a task (Malia & Brannagan, 2004).
Strategy teaching is an integral part of what is known as ‘process training’ in cognitive rehabilitation (Malia et al, 2004). Process training attempts to stimulate poorly functioning neurological pathways in the brain in order to maximise their efficiency and effectiveness. It aims to overcome damage by using both new, undamaged pathways and old partially damaged ones. Process training involves comprehensive assessment and an analysis of the results of this using a practical cognitive model. Regular reassessment should be undertaken to ensure that the patient is moving towards the agreed functional goals, and the results should determine the direction and progress through the process-training exercises.
Evidence shows that the use of process-training materials designed on the basis of neuropsychological theories and arranged into a structured programme can lead to gains in the majority of patients (Boman et al, 2004). Studies have also highlighted the benefits of using computerised assessment and rehabilitation tools in memory process training (Moore et al, 2001; Tarn & Man, 2004; Cappa et al, 2005).
Why is post-ECT rehabilitation so uncommon?
There are many reasons why no one has yet tried to introduce cognitive rehabilitation for patients who report persistent cognitive difficulties after ECT Until recently there appears to have been a general reluctance among psychiatrists to admit that ECT could cause memory or other cognitive problems that are severe, persistent and disabling. Even when patients show significant impairments in memory functioning, there has been considerable debate regarding the extent to which these may be attributable to ECT as opposed to factors such as depression (Robertson & Pryor, 2006). There has also been a failure to acknowledge the effect these consequences on the patient’s sense of self (Johnstone, 1999).
The delay in implementing in routine clinical practice the guidelines and recommendations for the neuropsychological assessment of patients at any stage during programmes of ECT has been a significant contributory factor. Furthermore, when patients receiving ECT have been assessed, the focus has generally been on documenting deficits rather than suggesting how to treat them. It is possible that psychiatrists have limited knowledge about the types of cognitive problem experienced by patients, how they affect their lives and what could be done to facilitate the recovery of cognitive functions or compensate for persistent deficits. They may also be unaware of the potential role of rehabilitation, what it involves and how it may inform the treatment and management of patients under their care.
However, the main reason for the near absence of post-ECT rehabilitation may be the lack of specialist neuropsychological services available to ECT psychiatrists and treatment teams (Robertson & Pryor, 2006). A psychiatrist may well recognise the merit of rehabilitation programmes but have no one to whom the patient can be referred. In Ireland, neuropsychology services are severely underdeveloped, particularly outside of Dublin. Therefore, the lack of suitably qualified personnel with expertise in this area is a significant problem. Multidisciplinary team approaches that include psychiatrists, neuropsychologists, occupational therapists, social workers and community liaison officers may be an integral part of best practice recommendations in cognitive rehabilitation, but in reality such services may not be available.
All patients should undergo cognitive assessment before their first ECT session. Subsequent comprehensive neuropsychological assessments should be routinely undertaken if patients report memory and cognitive disability following ECT. Assessments should take into account baseline (pre-treatment) functioning and should use tasks that are sensitive to the nature of the patient’s everyday problems and that take account of the influence of patient’s current memory, sense of memory self-efficacy and mood. Reassessment should be scheduled after a sufficiently long interval (more than 6 months after treatment) so that persistent cognitive and memory deficits can be identified. Furthermore, patients’ self-reports of adverse side-effects, particularly those concerning deterioration in memory and cognition while undergoing a course of ECT, should be properly investigated by staff in the ECT clinic (NICE, 2003; Benbow & Crentsil, 2004).
It should now be clear that documenting neuropsychological deficits is not enough; a specific programme of cognitive rehabilitation should be designed and made available to all patients with persistent cognitive difficulties following ECT, and details about this treatment should be included with the information that patients receive prior to treatment. This programme should incorporate methods of training and strategy learning of known efficacy that aim to generalise skills to all domains of the patient’s life. Clinicians should be aware cognitive rehabilitation appears to be most successful when patient’s physical, psychological, social and vocational well-being are considered together and when the programme is extended to include the family or caregivers (Mateer et al, 2005).
Cognitive rehabilitation following ECT offers a constructive way of treating and managing the most commonly reported side-effect, which is currently left untreated. Over time, this acknowledgement of the presence and impact of cognitive disability in ECT-treated patients, together with the education of patients, families and mental health professionals about ways to deal with these difficulties, would lead to better overall adjustment by patients and the development of a new sense of self.
Declaration of interest
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1 Patients currently referred for ECT complete routine neuropsychological assessments:
a following the course of ECT treatments
b prior to receiving the first ECT treatment
c 3 months after the last ECT treatment
d 6 months after the last ECT treatment
e patients do not routinely complete neuropsychological assessments at any stage during treatment.
2 The following are not necessary in neuropsychological assessment of patients receiving ECT:
a the Eysenck Personality Inventory
b recommendations for treatment or rehabilitation of
c tasks measuring ‘real-world’ functioning
d collateral information from the patient’s family or caregivers
e measurement of factors influencing a patient’s ‘cognitive reserve’.
3 Tasks that require patients to self-rate their own memory functioning include:
a the Landmark Recognition Task
b the Mundane Memory Questionnaire
c the Autobiographical Memory Interview
d the Prospective and Retrospective Questionnaire
e the Everyday Memory Interview.
4 Cognitive rehabilitation is least successful when it focuses on:
a compensation for deficit rather than restoration of function
b the cognitive and emotional aspects of brain injury
c including the patient’s family or caregivers in the rehabilitation process
d the drill and practice approach
e the generalisation of acquired skills to the social and vocational domains of the patient’s life.
5 Cognitive rehabilitation techniques have been adapted and used for:
a patients with acquired brain injury
b patients with permanent memory and cognitive disability following ECT
c patients with intellectual (learning) disability
d patients with temporary memory and cognitive problems following ECT
e all of the above.
Maeve Mangaoang is a research psychologist at St Patrick’s Hospital (St Patrick’s Hospital, PO Box 136, James’s Street, Dublin 8, Ireland. Email: firstname.lastname@example.org) and a research associate at the Trinity College Institute of Neuroscience. Her interest in cognitive rehabilitation stems from her current research on electroconvulsive therapy (ECT) as a treatment for major depressive disorder and previous work in experimental neuropsychology among patients with temporal lobe epilepsy. Jim Lucey is a consultant psychiatrist and Head of the ECT Department at St Patrick’s Hospital. He also has a special interest in the treatment of obsessive-compulsive disorder.
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