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12-06-1995
Patients often aren't informed of danger
The electrodes were placed on her head. With the push of a button, enough electricity to light a 50-watt bulb passed through her skull.
Her teeth bit hard into a mouth guard. Her heart raced. Her blood pressure soared. Her brain had an epileptic-style grand mal seizure. Then, Ocie Shirk had a heart attack.
Four days later, on Oct. 14, 1994, the 72- year-old retired health department worker from Austin, Texas, was dead of heart failure - the leading cause of shock-related death.
After years of decline, shock therapy is making a dramatic and sometimes deadly comeback, practiced now mostly on depressed elderly women who are largely ignorant of shock's true dangers and misled about shock's real risks.
Some lose already fragile memories. Some suffer heart attacks or strokes. And some, like Ocie Shirk, die.
A four-month USA TODAY investigation found: The death rate for elderly patients who receive shock is 50 times higher than patients are told on the American Psychiatric Association's model consent form. The APA sets the chance of dying at 1 in 10,000. But the death rate is closer to 1 in 200 among the elderly, according to mortality studies done over the past 20 years and death reports from Texas, the only state that keeps close track.
Shock machine manufacturers greatly influence what patients are told about shock's risks.
Virtually all "educational" videos and brochures shown to patients are supplied by shock machine companies. And the APA's 1-in-10,000 death rate estimate is attributed to a book written by a psychiatrist whose company sells about half the shock machines sold each year.
Shock therapy is strongly regaining favor among psychiatrists as a treatment for depression. Although exact figures are not kept, one indication of the trend comes from Medicare, which paid for 31% more shock treatments in 1993 than it did in 1986.
The elderly now account for more than half of the estimated 50,000 to 100,000 people who receive shock each year, with women in their 70s getting more shock than any other group. In the 1950s and 1960s, young male schizophrenics got most shock therapy.
Shock therapy is the most profitable practice in psychiatry, and economics strongly influences when shock is given and who gets it.
In Texas, the only state that keeps track, 65-year- olds get 360% more shock therapy than 64-year-olds. The difference: Medicare pays.
Shock treatment may shorten the lives of the elderly, even if it doesn't cause immediate problems.
In a 1993 study of patients 80 and older, 27% of shock patients were dead within one year compared to 4% of a similar group treated with anti-depressant drugs. In two years, 46% of shocked patients were dead vs. 10% who had the drugs. The study, by Brown University researchers, is the only study of long-term survival rates in the elderly.
Doctors rarely report shock treatment on death certificates, even when the connection seems apparent and death certificate instructions clearly indicate it should be listed.
For this story, USA TODAY reviewed more than 250 scientific articles on shock therapy, watched the procedure at two hospitals and interviewed dozens of psychiatrists, patients and family members.
Outside of medical journals, accurate information about shock is sketchy. Only three states make doctors report who gets it and what complications occur. Texas has strict reporting requirements; California and Colorado less stringent rules.
The information that is available raises serious questions about how shock therapy is practiced today, particularly on the elderly.
"We've learned nothing from the mistakes of my generation," says psychiatrist Nathaniel Lehrman, 72, retired clinical director of Kingsboro state mental hospital in New York. "The elderly are the people who can least stand" shock. "This is gross mistreatment on a national scale."
A changing image
Monday, Wednesday and Friday morning is shock therapy time in hospitals across the country.
Most patients get a total of six to 12 shocks: one a day, three times a week until the treatment is finished. Patients generally receive a one- or four-second electrical charge to the brain, which causes an epileptic-like seizure for 30 to 90 seconds.
The American Psychiatric Association information sheet for patients says: "80% to 90% of depressed people who receive (shock) respond favorably, making it the most effective treatment for severe depression." Psychiatrists who do shock therapy also are convinced of its safety.
"It's more dangerous to drive to the hospital than to have the treatment," says psychiatrist Charles Kellner, editor of Convulsive Therapy, a medical journal. "The unfair stigma against (shock) is denying a remarkably effective medical treatment to patients who need it." Psychiatrists say shock therapy is a gentler procedure today than it was in its heyday in the 1950s and 1960s, when it was an all-purpose treatment for everything from schizophrenia to homosexuality.
And advocates say it's nothing like its portrayal 20 years ago in the movie One Flew Over the Cuckoo's Nest, which showed electroshock being used to punish mental patients.
The movie helped send shock therapy into decline and prompted laws across the nation making it hard to give shock treatment without the patient's written consent.
Because of abuse in the past, shock is seldom done now at state mental hospitals, but mostly at private hospitals and medical schools.
The language is softer today, too, reflecting an effort to change shock's image: Shock is "electroconvulsive therapy" or, simply, ECT. The memory loss that often accompanies it is called "memory disturbance." These changes come as doctors expand shock's reach - to high-risk patients, to children, to the elderly - altering the profile of who gets shock therapy so much that the typical patient now is a fully insured, elderly woman treated for depression at a private hospital or medical school.
Someone like Ocie Shirk.
Died in recovery room
Shirk, a widow coping with recurring depression, already had one heart attack and suffered from atrial fibrillation, a condition that causes rapid heart quivers.
On a Monday at 9:34 a.m., Oct. 10, 1994, she received shock therapy at Shoal Creek Hospital, a for-profit psychiatric hospital in Austin. She had a heart attack in the recovery room. Four days later, she died of heart failure.
Yet shock therapy isn't mentioned on Shirk's death certificate, despite repeated instructions on the form to include every event that may have played a role in the death.
The medical examiner confirms that shock should have been on the death certificate. "If it happens so close after (shock) therapy, it definitely should be listed," says Roberto Bayardo, Austin's medical examiner.
Gail Oberta, chief executive of Shoal Creek Hospital, declines comment on Shirk. But she says, "When I checked all our records and went through all the reviews we do, there were no deaths related to ECT." A Texas Department of Health investigation found Shirk's treatment didn't meet the required standard of care because her medical records did not include a current medical history or physical that would let doctors accurately assess shock therapy's risks. The hospital agreed to correct the problem.
In addition to Shirk, state records show two other patients died after shock therapy at Shoal Creek. Asked about these deaths, Oberta repeats: "We could find no correlation between deaths of patients and receiving ECT at this facility." Getting to the facts behind shock-related deaths is very difficult even in Texas, which in 1993 became the only state with a strict law on shock therapy. The law, passed after lobbying from shock opponents, requires all deaths that occur within 14 days of shock therapy be reported to the Texas Department of Mental Health and Retardation.
In the 18 months after the Texas law took effect, eight deaths - including the three at Shoal Creek - were reported out of the 2,411 patients who received shock therapy in the state. About half those who received shock were elderly.
Six of the eight dead patients were older than 65.
Stated another way: 1 in 197 elderly patients died within two weeks of receiving shock therapy. The state does not release enough information to know if shock caused the deaths.
Nationally, record-keeping is almost nonexistant.
The Centers for Disease Control reports shock therapy was listed on death certificates as a factor in only three deaths over the five years ending 1993 - a number so low that it contradicts even the most favorable estimates of shock mortality.
The CDC records shock-related deaths under a category called "Misadventures in Psychiatry." "For obvious reasons, doctors are reluctant to list anything that falls into this category," says Harry Rosenberg, head of mortality data at the CDC, "even though we encourage them to be forthright."
Elderly deaths: 1 in 200
The American Psychiatric Association shock therapy task force report has been the bible of shock practice since its publication in 1990. It says 1 in 10,000 patients will die from shock therapy.
This estimate is included on the APA's model "informed consent" form, which patients sign to prove they've been fully informed of the risks of shock treatment.
The source for this estimate: A textbook written by psychiatrist Richard Abrams, president and co- owner of shock machine manufacturer Somatics Inc. of Lake Bluff, Ill.
Somatics is a private company. Abrams won't say how much of the company he owns or how much he earns from it.
"I don't know where they got that (estimate) from," Abrams says of the 1-in-10,000 death rate.
When pointed to page 53 of his 1988 textbook Electroconvulsive Therapy, where the death rate appears twice, Abrams notes that the number was dropped from the 1992 edition.
His updated textbook states the death rate differently, but Abrams agrees it amounts to the same thing.
Abrams' revised book says a death will occur once in every 50,000 shock treatments. He says it's fair to assume that the average patient gets five treatments, making the death rate about 1 in 10,000 patients. Five shocks is average because some patients stop their treatment early.
Abrams' figures are based on a study of shock deaths that psychiatrists report to California regulators. But USA TODAY found that shock deaths are significantly underreported in California and elsewhere.
At a recent professional meeting, for example, a California psychiatrist told how shock therapy caused a stroke in one of his patients. The man, in his 80s, died several days later. But the death was never reported to state regulators.
Consistently, the studies of elderly death rates conflict with the 1-in-10,000 estimate: A 1982 Journal of Clinical Psychiatry study found one death among 22 patients aged 60 and older. A 71-year-old woman had "cardiopulmonary arrest 45 minutes after her fifth treatment. She expired despite intensive resuscitative efforts." Two men in the study, ages 67 and 68, suffered life- threatening heart failure but survived. Seven more had less serious heart complications.
A 1984 Journal of American Geriatrics Society study - often cited as proof of shock therapy's safety - found 18 of 199 elderly patients developed serious heart problems while receiving shock. An 87-year-old man died of a heart attack.
Five patients - ages 89, 81, 78, 78 and 68 - suffered heart failure but were revived.
A 1985 Comprehensive Psychiatry study of 30 patients age 60 and older found one death. An 80-year-old man had a heart attack and died several weeks later. Four others had major complications.
A 1987 Journal of the American Geriatrics Society study of 40 patients age 60 and older found six serious cardiovascular complications but no deaths.
A 1990 Journal of the American Geriatrics Society study of 81 patients age 65 and older found 19 patients developed heart problems; three cases were serious enough to require intensive care. None died.
These studies looked only at complications that occurred while a patient was undergoing a series of shock treatments; long-term mortality rates were not considered.
Taken together, the five studies found three of 372 elderly patients died. Another 14 suffered serious complications, but survived. These results are similar to a study of shock therapy deaths done in 1957 by David Impastato, a leading shock researcher of the time.
He concluded: "The death rate is approximately 1 in 200 in patients over 60 years of age and gradually decreases to 1 in 3,000 or 4,000 in younger patients." Impastato found heart problems were the leading cause of shock-related death, followed by respiratory problems and stroke - the same pattern as in recent studies.
"The claim that 1 in 10,000 people die from shock is refuted by their own studies," says Leonard Roy Frank, editor of The History of Shock and a shock opponent. "It's 50 times higher than that." But Abrams, who has reviewed the studies, calls it "irrational and incomprehensible" to attribute so many of the deaths to shock itself. Even if a patient has a heart attack minutes later - as Ocie Shirk did - Abrams says, "it may very well not be ECT-related." Duke University psychiatrist Richard Weiner, chairman of the APA task force, also believes studies show the 1-in-10,000 estimate is accurate and disagrees the elderly death rate could be as high as 1 in 200.
"If it were anywhere near that high, we wouldn't be doing it," Weiner says. He says health problems, not age, cause the appearance of a higher death rate among elderly.
Still, some doctors who consider shock therapy a relatively safe treatment are concerned about the complications in elderly patients.
"Almost every death in the literature is an elderly person," says William Burke, a University of Nebraska psychiatrist who's studied shock and the elderly. "But it's hard to hazard a guess on a death rate because we don't have the data."
Shock is profitable The financial incentives of performing shock may be driving the increase in its use.
Shock therapy fits well into the economics of private insurance. Most policies don't pay for psychiatric hospital stays after 28 days. Drug therapy, psychotherapy and other treatments can take much longer. But shock therapy often produces a dramatic effect in three weeks.
"We're looking for more bang for the buck in health care today. This treatment gets people out of the hospital fast," says Dallas psychiatrist Joel Holiner, who performs shock.
It is also the most profitable procedure in psychiatry.
Psychiatrists charge $125 to $250 per shock for the five- to 15-minute procedure; anesthesiologists charge $150 to $500.
This bill for one shock at CPC Heritage Oaks Hospital in Sacramento, Calif., is typical: $175 for the psychiatrist.
$300 for the anesthesiologist.
$375 for use of the hospital's shock therapy room.
The patient got a total of 21 shocks, costing about $18,000. The hospital charged another $890 a day for her room. Private insurance paid.
Those figures add up. For example, a psychiatrist who does an average of three shocks a week, at $175 per shock, would increase his or her income by $27,300 a year.
Medicare pays less than private insurance - the payment varies by state - but it is still lucrative.
Before turning 65, many people are uninsured or have insurance that does not cover shock. Once someone qualifies for Medicare, the chance of getting shock therapy soars - as the 360% increase in Texas shows.
Stephen Rachlin, retired chairman of psychiatry at Nassau County (N.Y.) Medical Center, believes shock therapy is useful treatment. But he worries that financial rewards may influence its use.
"The rate of reimbursement by insurance is higher than anything else a psychiatrist can do in 30 minutes," he says. "I'd hate to think it's done solely for financial reasons." Psychiatrist Conrad Swartz, co-owner with Abrams of Somatics Inc., the shock equipment manufacturer, defends the financial rewards.
"Psychiatrists don't make much money, and by practicing ECT they can bring their income almost up to the level of the family practitioner or internist," says Swartz, who performs shock himself.
According to the American Medical Association, psychiatrists earned an average of $131,300 in 1993.
A doctor says 'no'
Michael Chavin, an anesthesiologist from Baytown, Texas, participated in 3,000 shock sessions before he stopped two years ago, worried he was hurting elderly patients.
"I began to get very disturbed by what I was seeing," he says. "We had many elderly patients getting repeated shocks, 10 or 12 in a series, getting more disoriented each time. What they needed was not an electroshock to the brain, but proper medical care for cardiovascular problems, chronic pain and other problems." In Chavin's view, when the cardiovascular system is dramatically stressed in the elderly, doctors risk triggering a fatal decline.
"As an anesthesiologist, what I do for three to five minutes can have serious consequences later," Chavin says. "But psychiatrists cannot bring themselves to admit any harm from ECT unless the patient gets electrocuted to death on the table while being videotaped and observed by a United Nations task force.
"These deaths are telling us something. Psychiatrists don't want to hear it." Chavin, then chief of anesthesiology at Baycoast Medical Center, stopped doing shock in 1993, reducing his income by $75,000 a year.
He says he feels ashamed that his waterfront home and pool were partially financed by what he considers to be "dirty money." In spite of his growing doubts, Chavin didn't quit doing shock right away. "It was hard to give up the income," he says.
First, Chavin turned away patients. "I'd tell the psychiatrist: 'This 85-year-old woman with high blood pressure and angina is not a good candidate for repeated anesthesia.' " Then, to confront his doubts, he began looking at the research on shock therapy. "I found it was done by psychiatrists who do electroshock for a living," Chavin says.
He finally quit doing shock and another anesthesiologist took over. Two months later, on July 25, 1993, a patient named Roberto Ardizzone died from respiratory complications that began as he received shock therapy.
The hospital stopped doing shock altogether.
By Dennis Cauchon, USA TODAY