ECT Experts' Ties to Shock Machine Industry|
Among the small fraternity of electroshock experts, psychiatrist Richard Abrams is widely regarded as one of the most prominent.
Abrams, 59, who retired recently as a professor at the University of Health Sciences/Chicago Medical School, is the author of psychiatry's standard textbook on ECT. He is a member of the editorial board of several psychiatric journals. The American Psychiatric Association's 1990 task force report on ECT is studded with references to more than 60 articles he has authored. Abrams, whose interest in ECT dates back to his residency in 1960s, has served on the elite committee that planned the National Institutes of Health's 1985 consensus conference on ECT. In addition he has long been a sought-after expert defense witness on behalf of doctors or hospitals sued by patients who allege that ECT damaged their brains.
What is less well known is that Abrams owns Somatics, one of the world's largest ECT machine companies. Based in Lake Bluff, Ill., Somatics manufactures at least half of the ECT machines sold worldwide, Abrams said. Most of the rest are made by MECTA, a privately held company in Lake Oswego, Ore.
Yet Abrams's 340-page textbook never mentions his financial interest in Somatics, the company he founded in 1983 with Conrad Melton Swartz, 49, a professor of psychiatry at East Carolina University in Greenville, N.C. Neither does the 1994 instruction manual for the device written by Abrams and Swartz, the company's sole owners and directors, which contains extensive biographical information.
Financial ties between device manufacturers, drug companies and biotech firms "are a growing reality of health care and a growing problem," said Arthur L. Caplan, director of the Center for Bioethics at the University of Pennsylvania School of Medicine.
For doctors "the questions that such financial conflicts of interest generate are, do patients get adequate full disclosure of options or are you skewing how you present the facts because you have a financial stake in the treatment and you personally profit from it every time it's used?" Caplan asked.
"It's especially disturbing with ECT because it's so controversial" and public mistrust of the treatment is so great, he added.
Abrams said his publisher at Oxford University Press knew about his ownership of Somatics. "No one ever suggested I list it," said Abrams. "Why should it be?" Abrams said he has disclosed his directorship of Somatics after several medical journals began requiring information about potential conflicts of interest. Caplan said that a growing number of medical journals are requiring disclosure of payments greater than $1,000.
Abrams said he sees "no specific conflict" between his role as an ECT expert and his ownership of a company that makes shock machines. He said he has not decided whether to list his ownership in the third edition of his book, which is due out next year.
Abrams declined to say how much he has earned from Somatics. Approximately 1,250 machines, priced at nearly $10,000, have been sold to hospitals worldwide, he said. Between 150 and 200 machines are sold annually, according to Abrams. Somatics also sells reusable mouthguards for $29, which are designed to minimize the risks of chipped teeth or a lacerated tongue.
Swartz, 49, declined to be interviewed. Last year USA Today reported that he considered his financial interest in Somatics to be "a non-issue." Swartz is quoted as saying that the company was founded to provide better machines and to "advance ECT."
"Psychiatrists don't make much money and by practicing ECT they can bring their income almost up to the level of the family practitioner or internist," Swartz is quoted as saying. Swartz also said that the profits from Somatics are comparable to having an additional psychiatry practice. (Last year psychiatrists earned an average of $132,000, according to the American Medical Association.)
Abrams and Swartz are not the only ECT experts with financial ties to the industry.
Max Fink, 73, a professor of psychiatry at the State University of New York at Stony Brook, whose passionate advocacy is widely credited with reviving interest in ECT, receives royalties from two videos he made a decade ago. Fink is one of six ECT experts who served on the APA's 1990 ECT task force, which drafted guidelines for the treatment.
In 1986 he made two videos about ECT, one for patients and their families, the other for hospital staff. Each sells for $350 and is used by hospitals that administer ECT. Fink said that Somatics paid him $18,000 for the rights to the videotapes; he said he receives 8 percent of the royalties. He declined to disclose how much money he has earned from the videos.
Duke University's Richard D. Weiner, 51, chairman of the APA task force on ECT, appears on a MECTA videotape. Weiner said he served as a consultant to the company about 10 years ago but has not "received any money directly" for his services. Instead MECTA deposited between $3,000 and $5,000 in a university account that Weiner controls which, according to a Duke spokesman, is earmarked for "research support and other educational functions."
Harold A. Sackeim, director of ECT research at New York's Columbia-Presbyterian Hospital, is also a member of the APA task force on ECT. Sackeim, who has consulted for both MECTA and Somatics, says he has not accepted cash payments from the manufacturers because he does not want to be perceived as "benefiting personally" from ECT. Instead both companies have made payments to his lab. Sackeim estimates that his lab has received about $1,000 from Somatics and "several tens of thousands of dollars" from MECTA.
Ethicist Caplan said that he believes such donations raise fewer ethical questions than do direct payments to a doctor or an equity interest in a company. Even so, he said, it is up to physicians who receive such payments to disclose this to the public an d especially to prospective patients.
"There needs to be full disclosure in writing and the information needs to be repeated over and over again," Caplan said. "Doctors need to give patients the opportunity to ask questions if they want, not to make those decisions for them by saying they won 't be interested."
Changes in Population and Insurance Make Elderly Women Most Common Patients
Forty years ago, the typical ECT patient resembled Randall P. McMurphy, the antihero immortalized by actor Jack Nicholson in "One Flew Over the Cuckoo's Nest." Like McMurphy, ECT recipients tended to be under 40, male and impoverished -- patients confined to state mental hospitals, often against their will.
These days the typical ECT patient is an elderly white woman -- clinically depressed, and usually middle or upper middle class -- who has signed herself into a private hospital. Because she is over 65 her bill is paid, in whole or in part, by Medicare, the federal government's insurance program for the elderly.
The profound shift in the demographics of ECT reflects several factors, experts say. Among them are the dramatic growth of the nation's elderly population and of Medicare; a growing awareness by doctors of the problem of geriatric depression, and the push by insurers that psychiatrists provide more fast-acting "medical" treatments and less talk therapy.
A 1990 report by the American Psychiatric Association concluded that advanced age is no bar to ECT; it cited the case of a 102-year-old patient who received the treatment. Because some psychiatrists believe shock therapy works faster and is less risky than drugs, it is increasingly being administered to elderly patients. Frank Moscarillo, director of ECT at Washington's Sibley Hospital, said the typical patient at his hospital is over 60. His oldest patient was 98, "a little old lady" in Moscarillo's word s.
But some published studies have found that shock treatment can be risky, particularly for elderly patients with significant medical problems. They include the following:
A 1993 study by Brown University psychiatrists of 65 hospitalized patients over age 80 found that those who received ECT had a higher mortality rate up to three years after treatment than did a group treated with medication. Of 28 patients who received drugs, 3.6 percent were dead after one year. Of 37 patients who got ECT, 27 percent were dead within a year. The authors concluded that the differences in death rates were not primarily due to ECT, but to the fact that ECT patients had more serious physical problems.
A 1987 study of 136 patients by researchers at Washington University in St. Louis found that complications after ECT, including severe confusion and heart and lung problems, increased with age.
A 1984 study by doctors at New York Hospital-Cornell Medical Center found that geriatric patients developed significantly more complications, not all of them reversible, after ECT than did younger patients. Problems included irregular heartbeats, heart failure and aspiration pneumonia, which occurs when an anesthetized patient inhales vomit into the lungs. All three conditions can be fatal.
A 1982 study of 42 ECT patients at New York's Payne Whitney Clinic found that 28 percent developed heart problems after ECT. Seventy percent of patients previously known to have cardiac problems experienced complications.
Even so, all of the researchers concluded that the potential benefits of ECT for depressed elderly patients tend to outweigh the risks. Shock, they say, is effective in quickly treating life-threatening dehydration or weight loss caused by severe depression.
Instances of involuntary electroshock
At the same time, there is concern that the elderly are particularly vulnerable to inappropriate or dangerous treatments.
Last year the Illinois Appellate Court ruled that ECT was too risky and not in the best interests of Lucille Austwick, an 82-year-old nursing home patient who suffers from dementia and chronic depression.
The state's highest court reversed the decision of a lower court in Chicago that had ordered Austwick, a retired telephone operator, to undergo as many as 12 ECT treatments at Rush-Presbyterian-St. Luke's Hospital against her will. Austwick, who has no family, had previously been declared incompetent by a court.
In a strongly worded opinion the judges detailed contradictions in the testimony of Austwick's psychiatrist, who said he had sought a court order "because medication therapy would take a long time [and] he felt it would be better to get [the patient] out of here [the hospital] rather than stay here and spend time and money."
In Wisconsin, the state agency that protects the rights of the mentally ill last year issued a report detailing nine cases in which patients at St. Mary's Hospital in Madison received ECT against their will or without proper informed consent.
All but one of the patients was over 60 and female. Two were coerced into having ECT, the report by the Wisconsin Coalition on Advocacy stated. In another case the hospital threatened to get a court order to administer shock over a spouse's objections, investigators said.
The agency concluded that "medical and nursing practices surrounding ECT at St. Mary's psychiatric unit may not consistently reflect the minimum standards required by state law and relevant professional standards."
Hospital officials denied that St. Mary's had violated patients' rights. They noted that regulatory officials had not taken any action. The hospital made changes in its ECT consent documents, but not as a result of the commission's report, officials said.
Discovered in 1938, Electroshock Has Fluctuated in Popularity
Even its most ardent defenders agree that ECT arouses primitive fears: of being struck by lightning, of Dr. Frankenstein's experiments, of electrocution and the electric chair.
"ECT is something that just because of its nature doesn't look good," said Richard D. Weiner, chairman of the American Psychiatric Association's 1990 task force on ECT and an associate professor of psychiatry at Duke University Medical Center. "You're talking about putting electricity on top of somebody's head."
"ECT is a bizarre treatment," agreed Harold A. Sackeim, chief of the ECT service at New York's Columbia-Presbyterian Hospital. "In terms of its surface features, it has a horrific aspect to it."
For thousands of years, the notion of using electricity to treat illness has held a fascination for doctors. In 47 A.D. Roman healers applied electric eels to the heads of headache sufferers. In the 1920s and '30s American and European psychiatrists began treating some mental illnesses by inducing epileptic-like convulsions through massive doses of insulin and other drugs. They discovered that some patients showed dramatic, albeit temporary, improvement.
ECT was discovered somewhat by accident in 1938 after an Italian psychiatrist adapted a pair of tongs used to stun hogs before slaughter and applied them to the temples of a 39-year-old engineer from Milan, shocking him out of a delirious state in which h e spoke only gibberish.
By the 1940s insulin coma and electric shock treatments were widely used in American mental hospitals, especially the overcrowded public institutions that housed as many as 8,000 patients and as few as 10 doctors.
Historical accounts are replete with examples of shock used to subdue and punish patients, sometimes under the guise of treatment. Particularly troublesome patients received hundreds of shocks, often several in a single day.
"ECT stands practically alone among the medical/surgical interventions in that misuse was not the goal of curing but of controlling the patients for the benefits of the hospital staff," medical historian David J. Rothman of Columbia University told an NIH consensus conference in 1985. "Whatever the misuse of penicillin or coronary artery bypass grafts, the issue of staff convenience was not nearly as prominent as with ECT."
The invention of Thorazine and other antipsychotic drugs led to a decline in the use of ECT. So did published accounts of abusive treatment. The most famous was "One Flew Over the Cuckoo's Nest," Ken Kesey's 1962 novel based on his experiences in an Oregon state mental hospital, which in 1975 was made into a movie starring Jack Nicholson.
By the mid-1970s ECT had fallen into disrepute. Psychiatrists increasingly turned to drugs, which were cheaper and easier to administer and aroused less opposition. In addition, a series of landmark cases involving the abuses of shock therapy helped form the basis for patients' rights and informed consent legislation.
The late 1980s marked a resurgence in the use of ECT, and in recent years ECT opponents in a few states have tried to restrict or ban the treatment. In 1993 the Church of Scientology, which opposes psychiatric treatment, and several groups of anti-ECT activists helped persuade Texas lawmakers to bar ECT for children under 16 and to require hospitals to report deaths within 14 days of treatment.
Last year a bill to ban ECT was the subject of a two-day public hearing before a Texas legislative committee that heard testimony from 58 witnesses. That bill died in committee but its sponsors predict it will be resurrected next year when the legislature reconvenes.
FAMOUS PATIENTS WHO HAD ECT:
* Ernest Hemingway fatally shot himself after being released from the Mayo Clinic, where he had undergone ECT.
* James Forrestal, the first U.S. secretary of defense, committed suicide in 1949. Forrestal, 57, had received a series of insulin coma treatments, a precursor of ECT.
* Poet Sylvia Plath described her shock treatments in her 1971 book, "The Bell Jar." She wrote, "with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant."
* Former Sen. Thomas Eagleton (D-Mo.) was forced to relinquish his spot as vice presidential candidate on the Democratic ticket in 1972.
* Performer and political activist Paul Robeson underwent a series of ECT treatments in London in 1961.
* At 17, rock star Lou Reed was given shock treatments designed to "cure" his homosexuality at a New York state mental hospital.
* Film actress Frances Farmer received shock treatments while confined to a state mental hospital in Washington.
* New Zealand writer Janet Frame described her harrowing experiences with ECT in a 1961 autobiography.
* Former Boston Red Sox outfielder Jimmy Piersall wrote that ECT helped pull him out of a serious depression in the early 1950s.
* Vaslav Nijinksy, the famed ballet dancer, underwent a series of insulin coma treatments in Europe in the 1930s.
* Writer Zelda Fitzgerald underwent insulin coma treatments, a precursor of ECT, at a North Carolina hospital.
* Literary critic Seymour Krim, a chronicler of the Beat Generation, received ECT in the late 1950s.
* Movie actress Gene Tierney underwent eight shock treatments in 1955, according to her autobiography.
* Pulitzer prize-winning poet Robert Lowell was hospitalized repeatedly for manic depression and alcoholism.
* Film star Vivien Leigh, pictured in "Gone with the Wind," received shock treatments.
* Talk show host Dick Cavett had a series of ECT treatments in 1980. "In my case, ECT was miraculous," he wrote.
* Robert Pirsig described his experiences with ECT in his 1974 best-selling book, "Zen and the Art of Motorcycle Maintenance."
* Piano virtuoso Vladimir Horowitz received shock treatments for depression and later returned to the concert stage.
* Concert pianist Oscar Levant described his 18 ECT treatments in his book "Memoirs of an Amnesiac."