Coronary’ cuts to heart of Tenet scandal

Some books are good enough to keep me in a chair reading eight hours straight, but not many of them are medical-legal nonfiction. “Coronary: A True Story of Medicine Gone Awry” was riveting.

The book, about the 2002 FBI investigation into Tenet Healthcare and accusations of unnecessary heart surgeries at Redding Medical Center, was released Jan. 9. Local bookstores can hardly keep it in stock.

“Coronary” is paced like a thriller, but this long-form journalism is a factual account packed with details. It captures well the tone and history of the region, and recounts the stunning effect the scandal had on the medical community, patients and California’s north state at large.

The author lived in Redding almost a year, conducting hundreds of interviews and collecting millions of details. It’s as comprehensive a story of what happened as we’ll probably ever get, complete with heroes, villains and unsuspecting innocents.

I’ve heard and read a bit of bizarre commentary about the book; flippant, dismissive chatter by people who appear to have prejudged the book without reading it. Weird. Some folks never let facts get in the way of an opinion.

I met Steve Klaidman and his wife, Kitty, on two or three occasions while they were here, and found them to be warm and intelligent people who seem genuinely fond of Redding. Soft-spoken and careful, Steve, 68, is the picture of gentle concern.

In the author’s note, he says he has been interested in America’s health care industry for more than 20 years.

Of his initial consideration of the
Tenet-RMC events as a book, he writes: “My interest was in systemic flaws in American medicine, not criminal fraud. But the more I thought about it the more obvious it seemed to me that vulnerability to fraud was a major systemic flaw in American medicine. … My previous book, Saving the Heart,’ had dealt with cardiac medicine and I knew that two well-qualified clinicians could evaluate the same patient’s disease and reach very different conclusions about how it should be treated or even if it needed to be treated. Suppose the cardiologists and cardiac surgeons in Redding were guilty of no more than being aggressive practitioners who believed they were practicing good, up-to-date medicine and their local colleagues were simply … behind the curve? Well, it didn’t take me too long to recognize there was a book in that, too. This story was not just about medicine, it was also about justice, irrespective of whether the victims were patients or doctors.”

The book has received high marks, and a Business Week review says, “Klaidman never forgets that, at its core, this is a tale of a company that seems to have cracked under pressure from Wall Street to continually boost profits.”

Americans are at the mercy, ultimately, of a giant medical machine. Parts have our best interests at heart. Other parts will grind our bones to make their bread.

York uni expert calls for radical rethink for therapies

The Press (York)
Jan 19 2007

AN EXPERT in mental health at the University of York has called for a radical reform of psychological therapies across the country.

Professor David Richards, of the university’s Department of Health Sciences, said despite being “both effective and highly valued” by patients, no more than one per cent of people with anxiety or depression receive such therapy.

But, in a seminar to the Dr Foster Ethics Committee, he argued traditional treatments were not the answer.

Prof Richards said: “People with common mental health problems such as depression and anxiety tell us they want help which is convenient, acknowledges their own strengths and is culturally appropriate.

“We are now pioneering ways of helping people by recruiting new workers from the same culture, the same class and the same community as the people they serve. These workers operate in the community, with the community and for the community.”

In a pilot scheme in Doncaster, Prof Richards and his team have designed a new method of helping people with anxiety and depression. Within 24 hours of seeking help they are phoned by a new case manager, who organises a recovery programme based on education and self-help.

Almost all the treatment is delivered on the phone, making it quicker and more convenient for patients. More than 300 patients a month are being dealt with by the service.

He said: “In all public services, people have demanded greater visibility and higher quality. The police service and traffic management are examples where new support officers have been a resounding success. Our case managers are the community support officers of psychological therapy.

“The NHS now faces a choice between a system which will perpetuate existing inequalities versus a system which will embed psychological therapies in people’s own communities. It is a choice between investment in a system which has failed us in the past versus investment in change.”

The Baseball Player Who Used His Celebrity to Bring Mental Illness Out into the Open

The Baseball Player Who Used His Celebrity to Bring Mental Illness Out into the Open Royals and the Reich’ Reveals Fateful History of Nazi Princes

History News Network
Jan 15 2007

By Barron H. Lerner

Dr. Lerner is a historian and physician at Columbia University’s Mailman School of Public Health. This article draws on his new book, When Illness Goes Public: Celebrity Patients and How We Look at Medicine (Johns Hopkins, 2006).

In 1952, a major league baseball player did calisthenics and hula dances in the outfield and mocked pitchers when he got on base. When the team sent him to the minors, he climbed into the stands to lead cheers for himself, ran around wearing only an athletic supporter and sprayed home plate with a water pistol when an umpire called him out.

The player was Jimmy Piersall. His book, entitled “Fear Strikes Out,” helped to expose the realities of mental illness, a condition that had previously been a source of whispers and embarrassment. Interestingly, it was in Chicago that Piersall, then a member of the Boston Red Sox, first went public.

Born in Connecticut in 1929, Piersall excelled in baseball, football and basketball in high school. But his problems had already begun. He was incredibly high-strung and suffered from headaches.

The Red Sox took note of the high school phenom and signed him to a minor league contract in 1948. By 1952, his solid hitting and acrobatic play in the outfield made him a prime candidate for the major leagues.

However, the Red Sox originally chose to play Piersall at shortshop, something that upset him. As the season progressed, he acted more and more bizarrely.

Today, such behavior would probably quickly be diagnosed as pathological. But at the time, mental illness was very much in the closet. Families quietly sent sick relatives to large institutions where conditions were often terrible.

Finally, in July 1952, Piersall agreed to go to a private sanitarium. From there he was sent to Westborough State Hospital in Massachusetts.

After he was discharged as “recovered” two months later, Piersall pieced together what had happened. He had been diagnosed as having manic depression, now known as bipolar disorder, in which periods of excitability and high energy alternate with profound sadness. He had received both psychotherapy and electro-shock treatment, the latter of which had caused memory loss.

The Red Sox and their fans waited anxiously to see whether Piersall would play baseball again. And he did, rejoining the team as an outfielder in 1953.

Journalists covered Piersall’s story cautiously, pursuing few details. But in 1954, a Chicago man named Don Slovin, who ran a group called “Fight Against Fears,” convinced Piersall to tell his story on a local television show hosted by newspaper columnist Irv Kupcinet.

The response was dramatic. Piersall received letters from hundreds of Chicago residents with mental illness, one of whom thanked him for being “a source of inspiration to anyone who has gone through an experience similar to yours.”

This episode led to a two-part series in the Saturday Evening Post, entitled “They Called Me Crazy—And I Was!” and the subsequent publication of “Fear Strikes Out” in 1955, both of which brought Piersall’s story to the broad public. In these writings, coauthored with sportswriter Al Hirshberg, Piersall was quite frank, even discussing his shock therapy, which was commonly seen as barbaric.

With the release of a movie version of “Fear Strikes Out” in 1957, Piersall’s story achieved even more attention. Critics liked the film, admiring it for its honest portrayal of mental illness as a real disease that deserved treatment. Piersall also approved, although he chided Anthony Perkins, the actor who played him, for “throwing like a girl.”

Piersall did well until 1959, when he was traded to the Cleveland Indians. Unhappy with his new manager, he began to behave as he had in 1952, fighting with umpires and spraying bug repellant in the outfield.

Piersall insisted that his illness was not relapsing. The fans, who loved his antics during slow games, largely agreed. Perhaps his teammate Vic Power summarized the situation best. “He said he wasn’t crazy anymore,” Power said, “but he still was sick.”

After his retirement in 1967, Piersall became active in the Chicago baseball scene, hosting a sports talk show and broadcasting White Sox games on radio. Despite taking lithium, a pill that effectively treats manic depression, he continued to have emotional outbursts and fights with colleagues.

Ironically, over time, Piersall, who is now 77, has increasingly obscured aspects of his disease and treatment. For example, he has analogized mental illness to breaking a limb, an easily fixable medical problem. And he has stressed the role of self-help in curing psychological distress: “You can cure it, or you can lick it, if you want to.” Given the chronic, waxing and waning nature of most mental illnesses, these statements are misleading. And Piersall has developed a dim view of mental health professionals. Psychologists, he has said, “talk too much” and “do nothing.”

Still, Jimmy Piersall’s main legacy should be as someone who went public with his mental illness long before such revelations became fashionable. In so doing, he paved the way for athletes and others to deal with a serious medical problem openly and without shame.

Books prescribed to patients in UK

Wiltshire Times
Jan 15 2007

PATIENTS are being prescribed self-help books by GPs to complement more traditional treatments, thanks to an innovative new scheme in Wiltshire.

Designed to help patients cope with common psychological and emotional difficulties such as anxiety, depression and stress, it enables health professionals to prescribe highly recommended self-help books.

Books on Prescription is a partnership between Wiltshire County Council and Wiltshire Primary Care Trust.

The books have been chosen by doctors, psychologists and counsellors from those which have proved useful to patients in similar schemes across the country. The doctor issues a prescription’ for the recommended book, which the patient then takes to their local library.

All the county’s main libraries hold copies of the books, or they can be requested free of charge from any Wiltshire library.

The scheme falls within Wiltshire County Council’s goal to be the healthiest county by 2010.

Head of primary care psychology in Avon and Wilts Mental Health Partnership, Dr Liz Howells, said: “There is good evidence to support this scheme and it means GPs have more options to offer their patients.”

Tessa Cozens from Wiltshire Libraries said: “It is easy to borrow a book on prescription, even if you are not already a library member. Simply hand in your prescription and say you need to join.

“Think of your library as you would your local pharmacy – a place where you get a friendly, professional and confidential service,” she added.

For more details on any of Wiltshire County Council’s services, please visit www.wiltshire.gov.uk.

Shock therapy revived as treatment for depression

By Elise Kleeman Staff Writer
Pasadena Star-News
01/13/2007

PASADENA – Patricia Wedberg’s overwhelming depression arrived quietly and without cause.

In April, her family noticed she wasn’t herself and seemed tired and run down. In May, she lost her appetite. By the end of July she could no longer function at work. In mid-August she tried to take her own life by suffocation.

When September arrived, Wedberg said, “I was down to 90 pounds, skin and bones, and I was pacing around the house.”

“They put me on different things. I was on Prozac, and that seems to work for a lot of people, but it didn’t seem to work for me,” she said. “My husband was at his wit’s end.”

Fortunately for Wedberg, an article in Newsweek magazine about Kitty Dukakis’ book, “Shock,” caught her husband’s eye. In that book, Dukakis, wife of former Massachusetts governor and presidential candidate Michael Dukakis, talks about the treatment that rescued her from her own severe depression – electroconvulsive therapy, or ECT.

Wedberg’s husband took her to Huntington Hospital in Pasadena for treatment.

“I thank the doctors down there for saving my life,” she said last week from her home in Bishop, where she once again leads a happy and active life. “For me, ECT was the answer. I know it’s not for everyone, but it brought me back to life.”

“\ universally acknowledged to be the most effective treatment in serious depression,” said Charles Kellner, chief of psychiatry at University Hospital in Newark, N.J. Between 65 percent and 90 percent of patients see their depression lift completely after a course of treatment, he said.

But, Kellner said, it’s also “a very serious treatment that should be reserved for major illness.”

During electroconvulsive therapy, doctors administer anesthesia and heavy-duty muscle relaxants and, while the patient is asleep and immobile, send a small current through the front of the brain.

“We’re talking about enough electricity to light up a 60-watt bulb for about a second,” said Richard Meadows, a registered nurse who administers Huntington’s ECT program.

The short jolt sets off a wave of electrical chaos – a controlled grand mal seizure usually lasting 30 seconds to a minute.

Then everything returns to normal, and within 10 minutes of receiving the anesthesia, the patient wakes up. After about an hour and a half of monitored recovery time the patients – who are often treated on an outpatient basis – can go about their day.

Treatments are generally given three times a week until a patient’s depression lifts, which takes eight sessions on average, Kellner said.

“There’s no way this is the power of suggestion,” Meadows said. “They have appetite, they become engaging, they no longer have the depressing thoughts, the suicidal thoughts.”

At first the changes are subtle, but “usually five to six treatments and then they’ll make comments,” Meadows said. “One man told me `You know, I turned the corner at treatment number seven’ – they put a number on it.”

There are side effects, though – which range from mild headaches after the procedure to short term memory loss affecting weeks or months before the treatments.

Dukakis, wife of the 1988 Democratic presidential candidate Michael Dukakis, said she has no memory of the trip to France she took shortly before her first treatment five and a half years ago; Wedburg’s memory is spotty for a few months before ECT, and neither can remember the details of their hospital stays.

But for both of them, the trade-off was worth it.

“All I can say is I have a new life,” said Dukakis, who will speak at Huntington Hospital on Wednesday about her experience.

For many, ECT is still stigmatized, with some Web sites offering outreach for “ECT victims” and calling it “a crime against humanity.”

Much of that condemnation, doctors said, stems from its portrayal in the film “One Flew Over The Cuckoo’s Nest,” in which Jack Nicholson is reduced to a shuffling, drooling shell of himself after a painful shock contorts his body.

“Enough is enough – that was 1975,” Kellner said.

Hospitals that administer ECT are now strictly regulated, and careful monitoring and medication prevent patients from injury and pain.

And over the last five years, Kellner said, the tide has begun to turn.

“The fact that ECT remains an accepted treatment in every major psychiatric facility has become more widely known,” he said. “It’s pretty clear that ECT is making a comeback.”

LR Frank on coercive psychiatry

Leonard Roy Frank has published an excellent commentary on a recent article by Dr. Thomas Szasz on Barely a Blog: Read it here.

Professional accounts of electroconvulsive therapy: A discourse analysis

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

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

Available online 8 January 2007.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(Nurse A, Psychiatric Nurse: lines 364ˆ367)

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

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

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

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

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

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

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

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

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

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West (1981) E.D. West, Electrical stimulation therapy in depression: A double blind controlled trial, British Medical Journal 282 (1981), pp. 355ˆ357. Abstract-MEDLINE | Abstract-EMBASE

Wetherell (1998) M. Wetherell, Positioning and interpretative repertoires: Conversation analysis and post-structuralism in dialogue, Discourse and Society 9 (1998), pp. 387ˆ413.

Willig (1999) C. Willig, Introduction. In: C. Willig, Editor, Applied discourse analysis: Social and psychological interventions, Open University Press, Buckingham (1999), pp. 1ˆ21.

Willig (2001) C. Willig, Introducing qualitative research in psychology, Open University Press, Buckingham (2001).

Wood & Kroger (2000) L.A. Wood and R.O. Kroger, Doing discourse analysis: Methods for studying action in talk and text, Sage, London (2000).

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

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

Doc who strangled nanny is locked up; he’d had ECT

Oct 7 2005

By James Glover, Liverpool Echo

MEDICAL chiefs were never warned that killer doctor Abdalla Eltom was suffering mental problems.

The Sudanese surgeon was yesterday locked up indefinitely after he admitted killing his children’s nanny at the family home in Park View, Thornton.

Liverpool crown court heard the 52-year-old surgeon strangled 48- year- old Premawatnie Dolamullage with a necktie after he stopped taking medication for a mental disorder.

Father- of- three Eltom worked in the casualty department of Ormskirk general hospital, but gave up his job suffering from severe depression after he sent home a patient in April 2002 who later died.

But the General Medical Council (GMC), the body which licences doctors and surgeons to practise in Britain, would not necessarily have been notified of this and would not have known that Eltom was taking medication and was not mentally stable.

A GMC spokesman said: “We were never made aware of any concerns over the doctor.”

Eltom came to believe he had contracted HIV and that his food was inedible and dirty and he was put on anti-depressants.

After receiving electroconvulsive therapy his condition appeared to improve and he stopped taking his medication in January.

But on January 25 he snapped, murdered his nanny in the sitting room of his home and then walked into Crosby police station to announce: ” I ‘ ve killed someone – I’ve strangled her.”

It was more than a week after the killing when police were finally able to name Eltom’s victim because they could not find a relative who could confirm her identity.

Miss Dolamullage did not have any relatives in this country so police had to contact the authorities in Sri Lanka, who were still struggling to cope with the aftermath of the tsunami disaster, to try to find a family member who could identify the nanny.

Eltom was charged with murder, but admitted manslaughter on the grounds of diminished responsibility.

Ahmed Nadim, defending, told the court: “This is a tragedy for the victim, her family, for the defendant’s family and for the defendant.”

Judge Mr Justice Royce sentenced Eltom to an indefinite hospital order.

UK: Landmark judgement for suicide victim

Editor’s note: This man, who committed suicide after a workplace accident, had ECT just three months before his suicide. According to an ect.org editor in the UK, the employer’s lawyers originally considered pursuing the hospital, but changed their minds.

——————-

Corr v IBC – Court of Appeal Judgment.
Date:     19 Sep 2006
Text     Corr v IBC – Court of Appeal Judgment.

LANDMARK JUDGEMENT IN THE COURT OF APPEAL FOR SUICIDE VICTIM

The claimant was a Maintenance Engineer employed by IBC. He sustained injuries as a result of an accident at work on 22 June 1996. He was almost decapitated, in the event he sustained severe head injuries, underwent several operations including the reconstruction of his right ear, he suffered tinnitus, severe headaches, Post-Traumatic Stress Disorder and severe depression. His severe depression led to him committing suicide in May 2002. Following the suicide his employers, IBC Vehicles, alleged that there was no duty to protect against suicide and that in any event the suicide was not foreseeable. They also sought to blame the treating health trust although later discontinued their action in that regard. The case proceeded to the High Court in April 2005. The trial Judge found that an employer’s duty of care did not extend to the prevention of suicide and that the suicide was too remote. The Claimant’s widow was awarded approximately £85,500 and on our advice appealed to the Court of Appeal in December 2005 on the basis that the judgment was wrong and that the claimant’s widow should be entitled to claim for dependency representing an award for loss of her husband’s future income and pension. The claimant was represented by the TGWU who also funded the appeal. This case was of significant importance both to victims of suicide and for the law in general in that it was the first employers’ liability case heard in England since 1957 when under the old law; it was held that a defendant should only be liable for “foreseeable” damage. The Court of Appeal after hearing extensive arguments by both parties’ representatives overturned the High Court ruling by a majority decision. It held that the claimant’s suicide was symptomatic of depression and that as his “depression” was foreseeable that was sufficient. Further, given our unchallenged psychiatric evidence, namely that one in ten sufferers of severe depression go on to commit suicide, it was also held that the suicide was in any event foreseeable. The court increased the initial award to £633, 000 which is very satisfying given that Mr. Corr left a widow and two young children. This case demonstrates the real benefits of union membership which helped bring about a change in the law and justice for the victim and his family.

Gay victims of Franco era to win compensation

By Graham Keeley in Barcelona
28 December 2006
The Independent

In the dying days of General Francisco Franco’s dictatorship, Antoni Ruiz found out for himself what thousands of others had already suffered for being gay.

Antoni, then just 17, from Valencia, eastern Spain, told his mother he was homosexual and his family sought advice from a nun. “She went straight to the police and I was arrested and sent for trial,” said Mr Ruiz.

“I spent three months in prison. I was raped there and in the police cells and psychologically tortured by both the guards and the prison doctor.”

Now, 31 years later, Mr Ruiz and a dwindling band of others who suffered General Franco’s ruthless repression of homosexuals, may finally be offered compensation by the state.

The Spanish government may offer money to those who were sent to mental hospitals, tortured, imprisoned or who suffered a lifetime of persecution. The Spanish Justice Minister, Juan Fernando López Aguilar, is considering granting victims a pension of €800 (£540) a month, plus a one-off €12,000 payment for what they suffered under the regime. It could be introduced in two months.

Many homosexuals were prevented from working under the Franco dictatorship because of their “criminal” records, meaning they never contributed enough money to receive more than the minimum pension.

Mr Ruiz, president of the Association of Ex-Social Prisoners, said the move would be a victory. “This is not just about economic compensation but remembering homosexuals who suffered under unjust and dictatorial laws,” he added. A few hundred survivors will see the payments – many of the thousands victimised have since died.

During Franco’s homophobic dictatorship, gays were jailed or locked up in sinister mental institutions known as “correction camps”. With echoes of the Nazi atrocities against gays, they were given electric shocks in the belief that this would rid them of their homosexual urges. Inmates were forced to watch pornographic films featuring women in an effort to show them a sex life that was deemed “natural” by the conservative authorities.

As part of their nationalist, Catholic ideals, the Franco regime and its Falangist supporters considered homosexuals a threat to the “macho” Spanish male.

General Queipo del Llano, who broadcast to the nation, once said: “Any effeminate or introvert who insults the movement will be killed like a dog.”

The most famous gay man killed by the regime was the poet and playwright Federico Garcia Lorca, who wrote Blood Wedding and The House of Bernarda Alba. Considered a subversive, he was executed by a Nationalist firing squad in Granada in 1936.

Homosexuality was designated as an offence under the “law against delinquency and criminals” introduced in 1954. But towards the end of Franco’s regime, it was increasingly viewed as an illness rather than a crime. In 1968, the psychologist Lopez Ibor said: “Homosexuals should be seen more as sick people than as criminals. But the law should still prevent them proselytising in schools, sports clubs and army barracks.” Jail terms of up to three years were imposed under laws covering “public scandal” or “social danger”.

Homosexuals, almost all of them men, were packed off to mental hospitals, where some were given electric-shock therapy.

Lower middle class or working-class gays without powerful friends in the regime to protect them were the main victims. For others, the situation was different. The historian Pablo Fuentes said: “It is not uncommon to hear homosexuals from the upper classes and the aristocracy speak about the Franco period as a great time.”

Many gay people who suffered at the hands of the regime are reluctant to raise the issue because of the horrors it brings back or because they still fear society’s attitudes.

Even after Franco died, persecution of gays continued. They could be jailed until 1979. And although thousands of political and other prisoners were pardoned in 1976, gay people were made to serve their sentences. In 2001, Spain finally pledged to wipe clean the criminal records of gays convicted under Franco.

The present Socialist government legalised same-sex weddings and gay adoption in 2005, against opposition from the conservative opposition and the Roman Catholic Church.

Pedro Zerolo, president of Spain’s Federation of Gays and Lesbians, said: “What we want is a declaration of moral rehabilitation for those people who had part of their lives stolen by the state.”

Psychiatry’s electric evolution A new shock therapy or the same old charges?

San Francisco Chronicle

Dec 24 2006

Telling a friend I was starting Kitty Dukakis’ new book sparked a disagreement. Was it rubbing alcohol she used to drink? Or vanilla extract? A happy debate: We were both right.

One might be tempted to say Dukakis self-medicated by treating her storied long-term depression with booze and pills. But she had plenty of help from some of the country’s leading doctors, who enabled decades of her addiction to amphetamines.

Dukakis’ book, “Shock: The Healing Power of Electroconvulsive Therapy,” alternates what folks in Alcoholics Anonymous call a “drunk-a-logue” — Dukakis’ finely honed tale of a life punctuated by overdoses, blackouts and trips to treatment centers — with journalist Larry Tye’s history of electroconvulsive therapy, “psychiatry’s most controversial treatment.”

The Dukakis shining through these struggles with depression is warm, funny, vulnerable and considerably more engaging than her uptight husband of 43 years, former Massachusetts governor and 1988 presidential contender Michael Dukakis. Her description of unraveling under the media klieg lights is downright courageous.

Let’s face it, when celebrities get together to divvy up diseases, neither mental illness nor alcoholism often gets a taker. Appreciating the depths of Dukakis’ despair is the key to understanding why she would seek out the treatment that became her salvation and even promote it, even though it stole significant slices of her memory.

“Electroconvulsive therapy has opened a new reality for me. … It has given me a sense of control, of hope,” she writes.

Shock’s authors are on a mission to rescue this therapy from stigma that haunts it to this day, even as psychiatry has embraced it as a mainstream therapy and some 100,000 patients are said to undergo it each year in the United States.

It was an Italian neurologist, Ugo Cerletti, who determined that electric shocks could be used to “tame” mental patients by causing convulsions. Cerletti first determined the amount of electricity needed to induce a seizure, but not kill, a pig or a dog in a series of experiments that would give a PETA member a lifetime of nightmares.

He first made the leap to a human in 1938 when he administered 110 volts to a 39-year-old man who had been found wandering a train station in Milan, muttering incomprehensibly.

In the early decades of the therapy’s use, electrical shocks were administered to fully conscious patients. They lost consciousness, experiencing seizures and muscle spasms so violent as to routinely break bones. Confusion and memory loss was a common side effect.

To understand how such a brutal treatment gained sway in the 1940s and ’50s, it is worth noting that competing treatments included lobotomy, as well as other means intended to induce shock or coma as a therapy, such as insulin or the drug Metrazol.

But there was arrogance and sloppiness in its use, too. Doctors tried electroshock therapy on patients as young as 2 and as old as 102, seldom following them adequately or conducting proper clinical research, making it difficult to sort out the long-term impacts. Treatment was often given over patients’ objections or with scant attention to informed consent. The therapy became popular for treating schizophrenia, although, under more rigorous scrutiny, it was later determined not to be helpful.

Some doctors shocked with abandon, resorting to electroshock therapy for indications as questionable and slippery as “antisocial behavior,” “maladjustment” and homosexuality.

The use of shock for punishment rather than therapy also undermined its future.

Such was the case for the therapy’s most famous patient, albeit a fictional one. Randall Patrick McMurphy was the bete noir of Nurse Ratched in Ken Kesey’s 1962 novel, “One Flew Over the Cuckoo’s Nest.” The gruesome electroshock McMurphy received in “Cuckoo’s Nest” left the impression that he had been shocked into submission, but it was actually a lobotomy that reduced him to the catatonia seen at the movie’s end.

For Dukakis and Tye, that was your grandfather’s electroshock therapy. They say today’s version is neither an abomination nor a “Clockwork Orange” instrument of social control, but rather an invaluable treatment all too often denied to poor people and people of color.

Today, electroshock therapy is reserved for a more discreet set of circumstances. Depression is the most common indication, especially where antidepressant drugs and psychotherapy have failed and when suicide is a risk or psychosis and catatonia are complicating factors. Now, shocks are briefer; administering them on only one side of the brain is thought to spare memory. The patients receive anesthesia and muscle relaxants, and don’t remember undergoing what is a much calmer looking procedure.

Of course, one might wonder why a book seeking to destigmatize the practice is entitled “Shock” when modern practitioners prefer the “electroconvulsive therapy” of the subtitle.

“We debated it. Ultimately we decided it is the term most people recognize and understand. It might help sell the book and reach people in need. Sometimes embracing a stigmatized term is a way of deflating it,” said Tye in a recent phone interview.

“Shock” chronicles how the Bay Area was the crucible for much of the political debate over electroconvulsive therapy, profiling some of its harshest foes, Ted Chabasinski and Leonard Frank. They remain implacable critics of the procedure, even in its modern guise, maintaining that psychiatrists still understate long-term side effects, driven at least in part by a profit motive.

The debate fueled by California “psychiatric survivors” peaked in 1982, when they succeeded in placing electroshock therapy on the ballot in Berkeley. Residents voted 2-to-1 to ban the procedure within city limits, but the measure was quickly overturned in court.

Chabasinski, 69, a Berkeley attorney, is the very definition of a psychiatric survivor. A line on his Web bio summarizes his mental health experiences: “Shocked, Inpatient, Outpatient, Forced Treatment, Raped, Restraints, Tortured, Solitary Confinement.” With his natural mother incarcerated, Chabasinski was in foster care from birth. “The doctors had decided I was mentally ill before I was even born; hereditary views of mental illness were very much the fashion,” he said in a recent interview.

Chabasinski received electroshock therapy from Dr. Lauretta Bender at New York City’s Bellevue hospital in one of the first experiments involving children. He was 6 years old and would spend the next few years in what amounted to psychiatric solitary confinement.

Frank, 74, a longtime Pacific Heights resident, edits successful books of quotations for Random House. Born in Brooklyn, he landed in San Francisco after college and an Army stint. He was happy to hang out in North Beach and in no particular hurry to find a job. Distressed by his beatnik “lifestyle,” his parents had him involuntarily committed to a psychiatric hospital where he received 50 insulin coma treatments and 35 electroshocks in 1962 and 1963.

The impact on Frank’s memory was “like wiping a wet eraser on a chalkboard,” he said. He no longer remembered that JFK had been elected. More troublesome yet was the ablation of much of his Wharton School college education. Finally released from the hospital, “I decided I would spend my life fighting this,” he recounted in a recent interview in which he shared excerpts from his online “electroshock quotationary.”

Although Chabasinski and Frank and their fellow psychiatric survivors were unsuccessful in banning electroshock therapy, they were able to persuade California legislators to pass some of the strictest laws in the country regulating the practice.

Before administering the treatment in California, a psychiatrist must assert that other options have been exhausted. A second opinion must be secured from a physician who doesn’t use electroshock, and the episode must be reported to state authorities. Although “Shock” laments the California regulations as reducing the procedure’s availability throughout the state, one local practitioner embraces them.

Dr. Robert Dolgoff practices psychiatry at Alta Bates Summit Medical Center in Berkeley and teaches at UCSF. Much of his practice consists of referrals for electroconvulsive therapy.

“We are proud of what we do; we help incredibly vulnerable people,” said Dolgoff. His busy office is in the basement, not to hide it but because “that is the space we got.” Not all of the patients referred to Dolgoff for the treatment end up receiving it because he believes it is truly a measure of last resort.

“All of our patients have tried at least two drug regimens before coming to us for ECT. But it is much more typical for them to have tried four, five or six different drugs and still be suffering,” Dolgoff said.

Dolgoff acknowledges that some patients will experience memory loss for some of the time surrounding the procedure; discussing this risk is a key part of the informed consent process. But do extremely depressed patients have the wherewithal to weigh all the factors? “That is where the second opinion is helpful,” Dolgoff said. California also requires a court order for the therapy to be administered against a patient’s will.

Dolgoff said he rarely receives referrals for court-ordered electroconvulsive treatment, but when he does there is a good reason. “You have to understand that by this point patients are dying because they are so depressed that they are basically unwilling or unable to eat. ECT offers the prospect of a much more rapid turnaround than antidepressant drugs.”

Electroconvulsive Therapy Causes Permanent Amnesia and Cognitive Deficits

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

———–

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

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

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

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

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

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

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

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

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

———————————————————-

Other publications that have picked up the story:

Dec 22 2006:

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

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

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

Medical News Today
Dec 22 2006

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

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

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

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

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

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

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

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

Tenet Healthcare (THC) Announces Settlement With IRS

StreetInsider.com
Nov 22, 2006

Tenet Healthcare Corporation (NYSE: THC) has reached a settlement with the Internal Revenue Service to resolve certain disputed issues in connection with the audit of its tax returns for the fiscal years 1995, 1996 and 1997. As part of the settlement, the company said it expects to make a payment in the fourth quarter of 2006 of approximately $80 million representing taxes and interest owed under the settlement.

The company expects the settlement announced today will not have a material impact on income from continuing or discontinued operations after taking into account the impact of the deferred tax valuation allowance.

New Zealand: First Report of Director of Mental Health

29 November 2006
Scoop Independent News

First Annual Report of the Office of the Director of Mental Health released
The first annual report by the Office of the Director of Mental Health has been released today by the Ministry of Health.

The publication provides a record of the work the office does and reports on some of the activities of District Inspectors of Mental Health and the Mental Health Review Tribunal. It is part of the office’s accountability to the sector and will be of significant interest to many people, including mental health service users and their families, those who work in the sector, and advocacy groups. It will also contribute to improved standards of care and treatment for people with a mental illness.

“We are proud of this work and believe it is an enormous achievement. The report reflects the importance we place on transparency and accountability to the sector and the wider public. We hope to build on this information in subsequent reports and include trend data,” says Dr David Chaplow, Director of Mental Health and Chief Advisor Mental Health.

The report is divided into three sections. The first section looks at how the office operates and the legislation it is guided by. The second section describes the work carried out by the office in 2005 and the third section provides information on the use of the Mental Health (Compulsory Assessment and Treatment) Act 1992, electroconvulsive therapy treatments and deaths of people subject to the Act. An appendix provides historical background on compulsory treatment in New Zealand.

For the first time raw data on the use of compulsory treatment is being published. It shows marked variations between district health boards.The data has not been analysed and the differences could be due to a range of reasons, such as the differences in the nature of their populations, service coverage or clinical practice.

Information on the numbers and outcomes of Special and Restricted-Patient’s leave and change of legal status applications considered by the Health Minister are also included.

“We have not captured all the data we would like, for example statistics on the use of force, serious adverse incidents and seclusion are not included because the earlier data is not reliable enough,” Dr Chaplow says.

” However, District Health Boards now have more robust reporting procedures in place and as a result we expect to be able to include trend data in future annual reports.”

The report also includes research looking at the outcomes for Special Patients found not guilty of a crime, by reason of insanity, over the last three decades. The work followed an indication by the Law Commission that it intended to review section 23 of the Crimes Act 1961, which relates to insanity.

“Our research found that following discharge in to the community, people acquitted on the grounds of insanity are reconvicted of violent crimes at a very low rate, although readmission to hospital is more common,” Dr Chaplow says.

During 2005 there were 23 deaths recorded for people subject to the Mental Health (Compulsory Assessment and Treatment) Act 1992, of which six were suspected suicides.

Full report