Debate rages over safety of ECT, or shock therapy, used on elderly|
Saturday, September 28, 2002
TORONTO (CP) - Marianne Ueberschar checked herself in to the city's Centre for Addiction and Mental Health two years ago suffering from suicidal depression.
Like many older women entering psychiatric wards in Canada, Ueberschar, now 69, was offered electroconvulsive shock therapy, or ECT. She refused, and fought a legal battle with the institution to prevent it from administering the treatment.
"I said I don't want my brains fried, thank you very much," says Ueberschar, who was discharged five months later without having been hooked up to electrodes to induce a generalized seizure.
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Invented in the late 1930s, the treatment for mental disorders involves passing an electric current through the brain.
It has its supporters and detractors.
ECT is endorsed by the Canadian Psychiatric Association, the American Psychiatric Association, the American Medical Association, the U.S. Surgeon General, and the U.S. National Institute for Mental Health, or NIMH.
According to an article posted on the Toronto mental health centre's Web site, people have no substantial reason to fear the procedure because it doesn't cause "structural brain damage" and it has "come a long way from its first unmodified use in 1938, when it was administered without anesthesia and muscle relaxant."
A vocal minority of doctors, however, says the treatment is inherently unsafe for the elderly.
"It causes them to have memory problems when they've already got memory problems to start with. It causes increased cardiovascular risks. It causes falls which can lead to death when they break their hips," says Dr. Peter Breggin, a psychiatrist and author, speaking on the phone from his office in Bethesda, Md.
"It is ridiculous to give a brain-damaging treatment to people who are already having cognitive difficulties due to an aging brain."
The topic has also provoked a great deal of debate in New York State over the past year. In March, a standing committee of the New York Assembly released the results of a year long review that concluded elderly people were more likely to receive ECT.
Permanent cognitive deficits, memory loss, and premature death were among the increased risks from ECT faced by older people, said the report, which called for special safeguards for the elderly.
"The use of this controversial method of treatment is deeply disturbing, particularly when you consider that its use results in damage to the brain and lapses in memory," said Assemblyman Felix Ortiz, who is preparing a bill which would provide more protection for the elderly.
"The use seems almost ironic when you consider how many children and grandchildren wish there was a way they could save the memories of their parents and grandparents from diseases such as Alzheimer's."
ECT fell out of favour in the 1960s and '70s in the U.S., as psychiatrists increasingly turned to antidepressant medication, but has gradually made a comeback.
The American Psychiatric Association notes in its 2001 Task Force report that elderly people became the primary recipients of ECT across the U.S. in the 1980s.
"Individuals aged 65 and over received ECT at a higher rate than any other age group. Indeed, the overall increase in the use of ECT between 1980 and 1986 was fully attributable to its greater use in elderly patients," states the report.
"Further evidence for increased use of ECT in the elderly comes from a survey of Medicare Part B claims data between the years 1987 and 1992."
The Canadian Psychiatric Association hasn't published a comprehensive national survey of ECT use on the elderly, but partial statistics from several provinces suggest a similar situation in Canada.
About 13 per cent of the population here is over 65.
In British Columbia, people 65 years of age and over comprised 44 per cent of the 835 patients receiving ECT in 2001.
In Ontario, patients 65 and over accounted for 28 per cent of the 13,162 ECT treatments given in general hospitals and community psychiatric hospitals in 2000-01, and 40 per cent of the 2,983 ECT treatments given in provincial psychiatric hospitals in 1999-2000.
In Quebec last year, 2,861 of the 7,925 ECTs administered (about 36 per cent) were to people over age 65.
Figures from Nova Scotia for 2001-02 show a total of 408 ECT treatments, including 91 on people over 65.
Dr. Kiran Rabheru, the head of the geriatric psychiatry at the Regional Mental Health Centre of London, Ont., says the treatment is often safer for elderly depressed people than antidepressant medication or no treatment at all.
"These are people who are so severely ill that without the treatment they would almost certainly die of the illness much faster and more certainly than with the risks," says Rabheru.
"Where someone actually comes in at death's door, and you give them a couple of ECTs, they start to eat, they start to drink, they become a lot less suicidal."
But he acknowledges it's more hazardous to older patients.
"The risks are definitely greater," says Rabheru, whose institution provided 79 per cent of its ECT treatments to patients over the age of 65 in 1999-2000, the last year for which statistics are available.
"Because they're more frail. Their cardiovascular systems are compromised, their respiratory systems are compromised. So the risks are definitely higher, no question about it. And there are people who have cognitive impairment, who have cardiac problems as a result of anesthesia."
Dr. Lee Coleman, a psychiatrist and author based in Berkeley, Calif., says "risk-benefit" analyses of ECT overstate the benefits and underestimate the hazards.
"What they never talk about is the people who commit suicide because they're afraid of the treatment that is about to be forced upon them. That definitely happens," says Coleman in a phone interview.
In a 1999 Journal of Clinical Psychiatry article, Dr. Harold Sackeim, a leading advocate of the treatment in the U.S., wrote: "Little, if any, evidence supports a long-term positive effect of ECT on suicide rates."
Keith Welch, a former president of the patients' council at the Queen Street Mental Health Centre in Toronto, now part of the CAMH, says he suffered a series of strokes and several years of memory loss after receiving ECT in the 1970s.
He feels that elderly patients are being damaged by ECT.
"When the seniors first go in, they're very active. Maybe a little upset, you know, because it could be a family problem, something like that. Then, maybe a month later, they're walking around like zombies. They don't know what's going on, Some of them can't even change their clothes after they get shock treatments," says Welch, 59.
"I always stop and figure, you know, someday I'm going to be as old as them too. What if the same thing happens to me?"
Don Weitz, 71, who has actively campaigned against ECT for years, notes that more older women than men receive the therapy in Ontario.
"Elderly women are such easy targets," he says.
"When part of the medical profession targets an age group of 60-plus, it's a form of elder abuse," says Weitz, an ex-insulin shock patient who lives in Toronto.
"The reason the elderly get so much ECT is because they are less likely to refuse. People as they get older generally automatically do what the doctor says without question. 'Shock docs' can make hundreds of dollars a day just by pressing a button."
Dr. David Conn, head of psychiatry at the Baycrest Centre for Geriatric Care in Toronto, says any notion that psychiatrists give ECT to the elderly to make money is incorrect.
"From a physician's perspective, you've got to get up early in the morning to give the treatments, and I'd prefer to stay in bed," says Conn, who adds that ECT is a "lifesaving" treatment for elderly people who suffer from suicidal depression but who are unable to tolerate antidepressant medication.
"There's no great advantage to physicians giving the treatment except that if you want your patients well, it works."
Treatments are usually administered in the morning because patients have to fast beforehand.
In December 2000, Dr. Jaime Paredes made headlines with his concerns about increased use of ECT at Riverview Hospital in Port Coquitlam, B.C., after doctors began receiving an extra $62 or so per treatment from the provincial health-care plan.
At the time, Riverview spokesman Alastair Gordon defended the increase, saying that the institution was receiving referrals from other hospitals and there was growing medical acceptance of ECT as a "treatment of choice for geriatric patients suffering from depression."
A review panel commissioned by former health minister Corky Evans found that ECT "delivery" at the hospital was of high quality, but the lack of a detailed database on outcomes meant there was no way to evaluate the results, or to determine why the number of treatments had jumped so dramatically.
Paredes resigned under pressure from his position as president of Riverview's medical staff in December 2001.
"The medical plan is impressed with an administrator who shortens patients' hospital stay and even if an ECT patient is readmitted fairly soon, he counts as a new admission, rather than the same patient having a long stay," Paredes said in an interview.
Earlier this year, Riverview was in the news again when Michael Matthews, a 70-year-old patient who had received 130 ECT treatments over a three-year period, made the front page of the Vancouver Sun.
"I don't like it. They hurt, I don't want it," Matthews told a reporter for the Sun, which ran a close-up photo of Matthews' head which was covered in cuts and bruises from a fall he said was caused by ECT-induced confusion.
The B.C. Public Guardian and Trustee's office and the B.C. Provincial Health Services Authority have both launched probes into Matthews' ECT treatments.
Paredes, who was Matthews' doctor for several years before his ECT treatments began, says numerous elderly ECT recipients at Riverview are suffering from the same type of ECT-induced mental deterioration plaguing his former patient.
"There are many, many others. And nobody wants to talk (about) them. Because the relatives are always concerned that they're going to be blamed for allowing this to happen. And the patients, most of the time they are not in a condition to talk at all," says Paredes, who adds that he is not opposed to the appropriate use of ECT.
Dr. Nirmal Kang, the head of ECT services at Riverview, declined to discuss the Matthews case due to confidentiality, but he defended his hospital's ECT safety record in a telephone interview.
"From 1996, God forbid, we haven't had a single fatality related to ECT complications," said Kang.
That ECT can cause death from medical complications is conceded by proponents, but the frequency of ECT fatalities is hotly disputed.
Sackeim, an APA Task Force member and NIMH researcher, says elderly people have only a "somewhat higher" death rate than the APA's general mortality estimate of one in every 10,000 ECT patients, or 0.01 per cent.
"Just in general, the rate of mortality in ECT is low," says Sackeim from his office at the New York Institute of Psychiatry.
Opponents of ECT, like Dr. John Breeding, a Texas psychologist, say the actual death rate among elderly electroshock recipients is closer to one in 200 patients, or 0.5 per cent, judging from the number of post-ECT pathology reports filed in the 1990s in his state, the only jurisdiction in North America requiring the reporting of all deaths occurring within 14 days of ECT.
The current CPA position paper on ECT cites a general treatment complications rate for all ages of one in 1,400 treatments, or 0.07 per cent.
And the APA report says "reports of stroke (either hemorrhagic of ischemic) during or shortly after ECT are surprisingly rare."
Opponents say this overlooks strokes which occur as long-term complications in the elderly, as detailed in a 1994 case report by Dr. Patricia Blackburn, and disregards other types of ECT-related brain damage in older people, such as atrophy of the frontal lobes, found in a 1981 CAT scan study of 41 elderly patients by Dr. S.P. Calloway and a 2002 MRI study by Dr. P.J. Shah.
"(It's) a big lie ECT doesn't cause brain damage," Dr. John Friedberg, a California neurologist, told New York Assembly hearings on ECT in May of last year.
"One picture will refute that," he said, referring to an MRI scan published in the November 1991 issue of Neurology of a 69-year-old woman who suffered an intracerebral hemorrhage after ECT.
The 2001 APA report does include a reference to the woman's brain scan but the sample patient information booklet appended to the report nevertheless says "brain scans after ECT have shown no injury to the brain."
Dr. Barry Martin, head of ECT services at the CAMH in Toronto and a peer reviewer of the 2001 APA report, said it would be a "waste of time" to respond to the opponents' arguments because Breggin and Friedberg suffer from a "lack of credibility."
"The 'other side' is so inflammatory and out of touch with the realistic benefit of this treatment that it interferes with people getting effective treatment," Martin said. "Frightens people and their families unduly."
He said transient memory loss is well worth the price to someone who recovers from depression after undergoing ECT.
"The memory loss usually recovers over a period of weeks to several months," he said.
"There may be some permanent loss for some events both before and after the treatment. But for the ability to learn and retain new information, the actual memory mechanism recovers fully. If it didn't, ECT would not be allowed in treatment."
And Rabheru has noted some financial benefits to the health-care system.
"With the current economic constraints, governments and third party payers are under constant pressure to reduce expensive inpatient stays to a minimum, but also to provide optimum quality of psychiatric care," he wrote in a June 1997 article in the Canadian Journal of Psychiatry.
"C/MECT has been clearly shown to reduce inpatient stays in numerous studies."
C/MECT is continuation or maintenance ECT, and consists of ongoing treatments after the original course of six to 12 treatments is completed.
A report commissioned at arm's length by Health Canada, the provinces and territories, and released in January 2001, says government should become involved.
The study by Dr. Kimberly McEwan and Dr. Elliot Goldner of the University of British Columbia department of psychiatry recommended that health authorities begin measuring the percentage of ECT recipients who suffer strokes, heart attacks, respiratory problems and other recognized complications of the treatment.
Meanwhile, back in New York state, the standing committee's report has urged the U.S. Food and Drug Administration to conduct an independent medical safety investigation of ECT machines.
"The FDA has never tested ECT devices to ensure their safety," the report noted.
On May 30, the New York Assembly passed a resolution calling for an FDA investigation.
Health Canada, like the FDA, has never conducted medical safety tests of ECT machines, nor has it required the ECT machine companies themselves to submit safety and effectiveness data.
"No performance and maintenance standards exist for ECT machines. The Bureau of Medical Devices has not tested ECT machines since there have not been any reported problems. The bureau has never inspected shock machines," wrote Dr. A.J. Liston, then assistant deputy minister of health, in a Feb. 4, 1986 response to questions raised by Weitz.
Health Canada spokesman Ryan Baker says there are no plans to conduct a medical safety investigation of the only ECT machine currently licensed for sale in Canada, the Somatics Thymatron, which was "grandfathered" into use without the submission of safety and effectiveness data sometime prior to 1998, when the current medical devices regulations were enacted.
"A lot of these questions come down to the practice of medicine, like the use of these devices. And Health Canada doesn't regulate that. We regulate the sales," says Baker.
In early years of ECT, most doctors didn't use it on seniors
Most doctors disapproved of the use of electroshock therapy on the elderly during the first era of the treatment, which began in 1940, when the "miracle cure" for mental disease was imported to America from Italy by Dr. David Impastato.
That so-called first era lasted until the late 1950s, when the treatment, also known as ECT, began to be supplanted by the new psychiatric drugs.
Impastato warned psychiatrists in 1940 not to shock patients over the age of 60, and his advice was generally heeded.
"The majority of physicians continue to be opposed to the application of electric convulsive therapy during the senium (sixty years and over)," reported Dr. Alfred Gallinek, a New York psychiatrist, in 1947.
An adventurous minority ignored Impastato's advice, however, with sometimes catastrophic results. In a 1957 survey, Impastato found that electroshock recipients over the age of 60 had a 15 to 40 times higher ECT fatality rate than younger patients (0.5 per cent to one per cent as opposed to 0.025 per cent to 0.033 per cent).
In Canada, where ECT was introduced in 1941, a similar split occurred.
Dr. A.L. Mackinnon, of The Homewood Sanitarium in Guelph, Ont., noted in 1948 that seniors comprised only seven per cent of his institution's electroshock recipients. Dr. John J. Geoghegan, of the Ontario Hospital at London, Ont., on the other hand, reported electroshocking seniors regularly with "excellent" results in 1947.
Still others tried it and regretted it.
"Shock therapy is dangerous therapy," warned Dr. Lorne Proctor, a Toronto psychiatrist, in 1945, after a 65-year-old man suffered a paralysing stroke from electroshock.
"The possibility of cerebral hemorrhage following stimulation of the frontal lobes by this technique is real."
Similarly, Dr. G.W. Fitzgerald, of the Regina General Hospital, reported the death of a 59-year-old farmer from ECT in 1948.
Dr. George Sisler, of the Winnipeg Psychopathic Hospital, reported the electroshock deaths of a 50-year-old farmer in 1949 and a 60-year-old office worker in 1952.