Title: Electroshock and Informed Consent. Subject(s): INFORMED consent (Medical law); ELECTROCONVULSIVE therapy Source: Journal of Humanistic Psychology, Winter2000, Vol. 40 Issue 1, p65, 15p, 1bw Author(s): Breeding, John Abstract: Informed consent is a vital issue in all forms of medicine, especially in psychiatry, where patients are often in extremely vulnerable states of mind, customary practice involves high risk to patients, and the law allows for abrogation of traditional civil rights based on judgments of perceived mental incompetence. This article addresses informed consent related to the practice of electroshock. The author argues that genuine informed consent for electroshock is nonexistent because psychiatrists deny or minimize its harmful effects and, as long as the threat--overt or covert--of involuntary treatment exists, there can be no truly voluntary informed consent. The author discusses four primary ways psychiatry violates informed consent in electroshock practice and presents an outline of important information to know about electroshock. An annotated review of the research is provided to back up each of the author's assertions about medical effects and lack of efficacy of electroshock. ELECTROSHOCK AND INFORMED CONSENT Summary Informed consent is a vital issue in all forms of medicine, especially in psychiatry, where patients are often in extremely vulnerable states of mind, customary practice involves high risk to patients, and the law allows for abrogation of traditional civil rights based on judgments of perceived mental incompetence. This article addresses informed consent related to the practice of electroshock. The author argues that genuine informed consent for electroshock is nonexistent because psychiatrists deny or minimize its harmful effects and, as long as the threat--overt or covert--of involuntary treatment exists, there can be no truly voluntary informed consent. The author discusses four primary ways psychiatry violates informed consent in electroshock practice and presents an outline of important information to know about electroshock. An annotated review of the research is provided to back up each of the author's assertions about medical effects and lack of efficacy of electroshock. Genuine informed consent for electroshock is nonexistent because electroshock psychiatrists deny or minimize its harmful effects. For example, the American Psychiatric Association (APA) (1990) states, "In light of the available evidence, `brain damage' need not be included [in the consent form] as a potential risk" (p. 68). In addition, in all but one state, electroconvulsive therapy (ECT) may be legally forced on nonconsenting individuals who are adjudicated mentally unqualified to give their consent. The undergirding of psychiatry is coercive. Society generally respects the right of citizens to refuse treatment of physical illnesses, however life-threatening, except for "mental illness." As long as the threat (overt or covert) of involuntary treatment exists, there can be no truly voluntary informed consent. There are many ways in which informed consent is violated; I will mention four. First, there is denial and minimization of harmful effects. The official APA literature and the typical hospital brochure are both travesties of truth. The consent form example provided by the APA (1990) in The Practice of Electroconvulsive Therapy states that the death rate for ECT is "approximately one per 10,000 patients treated" (p. 157). Publicly available statistics collected between 1993 and 1996 by the Texas Mental Health Department show that the rate is 50 times higher. As noted above, the APA suggests that patients need not be advised of ECT's potential risk. The APA gives no credence to the numerous human autopsies, brainwave studies, animal studies, clinical observations, and reports from ECT subjects clearly demonstrating ECT's brain-damaging effects (see Appendix B). In 1994, St. David's Hospital in Austin, Texas, gave an information sheet to ECT candidates that stated ECT was safe for pregnant women. The second reason I argue that informed consent exists only in name is that even minimal and inadequate guidelines for the administration of ECT are routinely and systematically violated. For example, a report by the Wisconsin Coalition for Advocacy (1995) thoroughly documents pervasive and systematic violations of that state's informed consent guidelines on ECT. A study by Benedict and Saks (1987) of the regulation of professional behavior with regard to ECT in Massachusetts showed that "approximately 90% of ECT patients received treatment inappropriately, suggesting that the regulation of ECT administration is ineffective" (p. 247). It is interesting that the authors also reported that "the more familiar a psychiatrist was with threatened or instituted lawsuits involving ECT, and the more likely a lawsuit was thought to be, the greater was his or her departure from the guidelines" (p. 252). A third point with regard to how informed consent principles are violated is rarely mentioned. Dr. Fred Baughman, a retired neurologist, in a letter to United States Attorney General Janet Reno, points out that the legal obligation under informed consent is to provide patients with all the information relevant to their decision making--not just about the treatment in question but also about their condition. Psychiatric patients are never told that their alleged disease is theoretical or metaphorical. To quote Baughman (personal correspondence, September 10, 1998), To say or even imply that what the patient has is biologic and a disease when there is no such proof (as in all psychiatric "diseases") is conscious deception and abrogates informed consent. That this has become the standard of practice in psychiatry does not excuse it. The abrogation of informed consent is de facto medical malpractice. Fourth, and pragmatically crucial, is simply that people become victims of this so-called "treatment" at a time in life when they are extremely vulnerable. At vulnerable times, individuals desperately need to trust and rely on others for help. Reaching out, they need complete safety and support. Their only hope, in this desperate state, is to trust the wisdom and guidance of the professionals to whom they turn for help. Informed consent is a superlative principle, but, in practice, it is not a protection. Nevertheless, for educational purposes, I provide here an example of what authentic informed consent would involve. I encourage you to copy and share this form with others. An annotated review of the research by Moira Dolan, M.D., provided to back up each of my assertions about medical effects and lack of efficacy, is in Appendix B. AUTHENTIC INFORMED CONSENT FOR ELECTROSHOCK You are being asked to consider undergoing the psychiatric procedure of electroshock, commonly referred to as electroconvulsive therapy (ECT). It is your right, according to Texas state law, to be fully informed about the nature and effects of this procedure. This is so that should you choose to receive electroshock, your consent will be authentic, based on full knowledge and awareness. Of course, you also have the right to refuse the procedure. Prerequisites to Informed Consent State of Mind A fundamental requisite of genuine informed consent is mental competence. This means that prospective patients are able to understand this information and make a decision. At minimum, 1. Patient is free from the influence of any and all mood-altering substances, including legally prescribed psychotropic medications. 2. Patient is evaluated by a nonpsychiatric physician, preferably a neurologist. A mental-status examination is required to reveal a well-oriented mind and adequate functioning of higher level decision-making processes. 3. Patient is functionally literate: able to read and comprehend this written material. Alternatively, he or she is able to clearly understand the communication of this material to him or her by audiotape. State of Body A complete physical examination by a nonpsychiatric physician, preferably an internist, is recommended. The internist should evaluate for, and inform the patient and psychiatrist of, the potential of the individual to sustain physical complications of ECT treatment. This is analogous to what an internist does in a preoperative evaluation for surgery. Your Condition You are labeled as "mentally ill," diagnosed with a particular "disease" for which ECT is being recommended as "treatment." ECT is being justified as a "treatment" based on the assertion that your "disease" (probably called depression, but possibly some other "disease" such as bipolar disorder or schizophrenia) is a biologically or genetically based illness. Your label of "mentally ill" and diagnosis of "major depression" or other "mental illness' is entirely hypothetical, based on subjective reports and observations of mood and behavior. There is no evidence of disease, chemical imbalance, or anything physically or chemically abnormal to validate your diagnosis with a medical illness. What It Is The Procedure Electroshock involves the attachraent of electrodes to the temples outside one (unilateral) or both (bilateral) frontal lobes and the administration of electricity to the frontal lobes of the brain. Intensity of voltage may vary from approximately 70 volts to approximately 600 volts. Duration of the electrical current may vary from 0.5 to 4 seconds. Administration of ECT also varies enormously in number of treatments, from one to literally hundreds, over time. A typical course of treatment involves 6 to 12 sessions. Multiple monitored ECT is a variation that consists of three treatments in I session, spaced about 5 minutes apart, with 3 sessions in I week; thus, nine treatments in I week. In making your decision, it is important that you know the following: 1. The natural electrical activity of the brain is measured in millivolts, or thousandths of a volt. Thus, the power of ECT is literally hundreds of thousands of times greater than natural brain electrical activity. 2. The ECT procedure involves a level of electricity that can range from the minimum level required to induce a convulsion to 40 times greater than that level (Sackeim, Devenand, & Prudic, 1991). The official APA recommendation ranges from 1.5 to 3 times the level required to induce a convulsion (APA, 1990). Drugs Administered Prior to electroshock, you will be given the following: É general anesthesia, É tranquilizers, and É muscle relaxants. Each of these drugs has a wide range of effects on your body, mind, and emotions, including but not limited to the possible adverse reactions that are listed below. You can look up this information at the library in the Physicians Desk Reference (PDR) (1999) or at your local pharmacist's office in Drug Facts and Comparisons (1999). Anesthesia (i.e., Methohexital Sodium). Possible adverse reactions include circulatory depression, hypotension, peripheral vascular collapse, convulsions in association with cardiorespiratory arrest, respiratory depression, cardiorespiratory arrest, skeletal muscle hyperactivity, injury to nerves adjacent to injection site, seizures, emergence delirium, restlessness, anxiety, nausea, abdominal pain, pain at injection site, salivation, and headache. Tranquilizer (i.e., Valium). Possible adverse reactions include excessive sleepiness and drowsiness, confusion, restlessness, depression, crying, sobbing, delirium, hallucinations, dizziness, blurred vision, depressed hearing, unsteady gait, hypertension, hypotension, skin rash, nausea, and vomiting. Muscle Relaxant (i.e., Succinylcholine Chloride). Possible adverse reactions include skeletal muscle weakness; profound and prolonged skeletal muscle paralysis resulting in respiratory insufficiency and apnea, which require manual or mechanical ventilation until recovery; low blood pressure; flushing; heart attack; bronchospasm; wheezing; injection site reaction; and fever. Prior to granting consent for ECT, a patient will be provided a list of drugs to be administered for ECT and a complete list of the effects described in the PDR. FDA Classification The Federal Food and Drug Administration (FDA) classifies ECT machines as Class III devices. This means that ECT is an experimental procedure, classified in the highest risk category by the FDA. Class III means that the machine has not gone through the rigorous FDA testing required of medical devices, including safety testing and efficacy assessments. Possible Medical Effects of ECT É death, É brain damage, É cardiovascular complications, É extra risks of the three above categories for the elderly, É seizures and epilepsy, and É memory loss. Note Because ECT is a high-risk, experimental procedure and because of the possibility of permanent brain damage, you may want to consider magnetic resonance imagery (MRI) brain scans before and after this procedure. Having a pre-ECT MRI and post-ECT MRI is one way to measure the possible physical effects of ECT on your brain. Negative Emotional Effects É terror, É shame, É helplessness, and É hopelessness. Many individuals who have undergone ECT report horrific emotional distress resulting from this procedure (see Appendix A for contacts with outlets for the voices of outspoken survivors of electroshock). Physical and mental debilitation, together with intense fear, shame, and hopelessness, often make life and recovery a tremendous challenge for people who undergo this procedure. Lack of Efficacy Research indicates the following: 1. No lasting beneficial effects of ECT (Breggin, 1997; Rifkin, 1988). 2. Sham-ECT (where an individual is anesthetized and told he or she will receive ECT but actually does not) has the same short-term outcomes as actual ECT (Crow & Johnstone, 1986). 3. ECT does not prevent suicide. Suicide rates for those receiving ECT are no lower than non-ECT patients with similar diagnostic profiles (see Appendix B). Financial Disclosure The cost of ECT varies significantly. Cost of the procedure itself may vary from $100 to $300 per treatment for the psychiatrist's services. "Hidden" costs include fees for the anesthesiologist and the surgery suite (up to $800 combined per session), room and board at the hospital (usually $800-$1,300 per day at a private psychiatric hospital), psychotherapy charges by the psychiatrist (average $100-$150 per hour), consultant fees, and charges for whatever drugs are administered. Depending on the setting and whether you are inpatient or outpatient, there will be variable fees for the "operating room" and the hospital. Patients will receive and sign a full financial disclosure of all costs, in writing, prior to consent for this procedure. EDITOR'S NOTE: As the U.S. Surgeon General will soon issue a statement giving blanket approval to the use of ECT, many mental health consumers and activists are alarmed and angry. For information about this ongoing controversy, see these Web sites: www.MindFreedom.org and www.ect.org/statements/apa/contents.html. REFERENCES American Psychiatric Association. (1990). The practice of electroconvulsire therapy: Recommendations for treatment, training and privileging (task force report). Washington, DC: Author. Benedict, A., & Saks, M. (1987, Summer). The regulation of professional behavior: Electroconvulsive therapy in Massachusetts. Journal of Psychiatry and Law, 15, 247-275. Breggin, P. (1997). Consensus conference on ECT. In Brain-disabling treatments in psychiatry: Drugs, electroshock, and the role of the FDA. New York: Springer. Crow, T., & Johnstone, E. (1986). Controlled trials of electreconvulsive therapy. Annals of the New York Academy of Sciences, 462, 12-29. Drug facts and comparisons. (1999). St. Louis, MO: Wolters Kluwer. Physician's desk reference (53rd ed.). (1999). Montvale, NJ: Medical Economics. Rifkin, A. (1988). ECT versus tricyclic antidepressants in depression: A review of evidence. Journal of Clinical Psychiatry, 49(1), 3-7. Sackeim, H., Devenand, D., & Prudic, J. (1991). Stimulus intensity, seizure threshold and seizure duration. Psychiatric Clinics of North America, 14, 803-843. Wisconsin Coalition for Advocacy. (1995). Informed consent for electroconvulsive therapy: A report on violations of patients' rights by St. Mary's Hospital, Madison, Wisc. (Available from Wisconsin Coalition for Advocacy, 16 N. Carroll St., Madison, WI 53703) Reprint requests: John Breeding, 2503 Douglas St., Austin, TX 78741; e-mail: john@wildestcolts.com. APPENDIX A Additional Resources Breggin, P. (1991). Shock treatment is not good for your brain. In Toxic psychiatry: Why therapy, empathy, and love must replace the drugs, electroshock, and biochemical theories of the new psychiatry. New York: St. Martin's. Breggin, P. (1997). Electroshock and depression. In Brain-disabling treatments in psychiatry: Drugs, electroshock, and the role of the FDA. New York: Springer. Dendron, published by David Oaks. (Available from P.O. Box 11284, Eugene, OR 97440; 503-341-0100) This is the best newspaper available on mental health system oppression. David Oaks is also the contact for Support Coalition International, an umbrella group of organizations devoted to the work of mental health liberation. Dolan, M. (1999). Electroshock annotated bibliography. (Available from Electroshock Review, P.O. Box 4085, Austin, TX 78765 [$3.00]) Frank, L. (Ed.). (1978). The history of shock treatment. (Available from Leonard Frank, 2300 Webster St., San Francisco, CA 94115 [$12 postpaid]) Frank, L. (1990). Electroshock: Death, brain damage, memory loss, and brainwashing. Journal of Mind and Behavior, 11, 489-512. Friedberg, J. (1976). Shock treatment is not good for your brain. San Francisco: Glide. Friedberg, J. (1977). Shock treatment, brain damage and memory loss: A neurological perspective. American Journal of Psychiatry, 134, 1010-1013. Psychiatry, Victimizing the Elderly. (Available from the Citizens Commission on Human Rights [CCHR], 6362 Hollywood Blvd., Suite B, Los Angeles, CA 90028; 800-572-2905 [in Texas]; 800-869-2247 [outside of Texas]) This is a booklet by CCHR, a private nonprofit organization whose sole purpose is to investigate and expose psychiatric violations of human rights. Shock Waves, edited by Linda Andre. (Available from the Committee for Truth in Psychiatry, P.O. Box 1214, New York, NY 10003; 212-473-4786) This is an important newsletter for information related to ECT. www.banshock.org. This is a Web site devoted to granting access to information with regard to electroshock treatment and attempts to ban or restrict its use. It has many links to other useful sites. APPENDIX B Electroshock Annotated Bibliography by Moira Dolan, M.D. Effects of Electroconvulsive Therapy (ECT): A Review of the Scientific Literature(n1) DEATH In a large retrospective study of 3,288 patients getting ECT in Monroe County, NY, ECT recipients were found to have an increased death rate from all causes. Babigian, H., et al. (1984). Epidemiologic considerations in ECT. Arch Gen Psych, 41, 246-253. Survival of 65 patients hospitalized and treated for depression was evaluated by researchers at Brown University. They reported that the 37 patients who received ECT had survival rates of 73.0% at 1 year, 54.1% at 2 years, and 51.4% at 3 years. By contrast, depressed patients who did not receive ECT had survival rates of 96.4%, 90.5%, and 75.0%, at 1, 2, and 3 years, respectively. Kroessler, D., & Fogel, B. (1993). Electroconvulsive therapy for major depression in the oldest old. Am J Geriatr Psych, 1(1), 30-37. The risk of death was doubled in depressed patients who got ECT, in a 7-year follow-up study of 188 patients. O'Leary, D., & Lee, A. (1996). Seven year prognosis in depression--Mortality and readmission rates in the Nottingham ECT cohort. British Journal of Psychiatry, 169, 423-429. The first 3 years of mandated recording of death within 14 days of ECT in the state of Texas yielded reports of 21 deaths. There were 11 cardiovascular deaths, including massive heart attacks and strokes; 3 respiratory deaths; and 6 suicides. Gilbert, D. (Commissioner). (1996). Texas Department of Mental Health and Mental Retardation. (n1.) Dr. Dolan periodically updates this research review. It may be obtained by sending $3.00 to Electroshock Review, P.O. Box 4085, Austin, TX 78765. BRAIN DAMAGE More than 20 years ago, Cotman reported in Science that ECT disrupts (protective) protein production by brain cells. More recent studies show that electric shocks to the brain also cause an increase in the production of inflammatory proteins inside brain cells. Cotman, et al. (1971). Electroshock effects on brain protein synthesis. Science, 178, 454-456. Marcheselli, et al. (1996). Sustained induction of prostaglandin endoperoxidase synthase-2 by seizures in hippocampus. J Biol Chem, 271, 24794-24799. C. Edward Coffey, M.D., a leading proponent of ECT, conducted a study at Duke University Medical Center and the Durham VA Hospital that looked at the brain scans (by magnetic resonance imaging [MRI]) of patients before and after ECT. Out of the 35 patients studied, 8 had changes on MRI after shock. That is 22%, or greater than i in 5, with anatomic brain effects. Among those with the brain changes, I patient suffered a stroke and 2 had new abnormal neurologic signs on exam within 6 months of ECT. Coffey, C. E., et al. (1991). Brain anatomic effects of ECT. Arch Gen Psych, 48, 1013-1021. Weinberger looked at the effects of ECT on the brains of schizophrenics by comparing brain CT scans of those who had had ECT with schizophrenics who had never received shock. He documented that cerebral atrophy (brain shrinkage) was significantly more common in those who had ever been shocked. Weinberger, et al. (1979). Structural abnormalities in the cerebral cortex of chronic schizophrenic patients. Arch Gen Psych, 36, 935-939. Another CT scan study, done by Calloway, looking at a similar group, confirmed that frontal lobe atrophy (brain shrinkage) was significantly more common in ECT recipients. Calloway, et al. (1981). ECT and cerebral atrophy: A CT study. Acta Psych Scand, 64, 442-445. Andreasen used MRI scans to demonstrate a strong correlation between the number of previous ECT treatments and enlarged ventricles (loss of brain tissue). Andreasen, et al. (1990). MRI of the brain in schizophrenia. Arch Gen Psych, 47, 35-41. A study in England compared the brain CT scans of 101 depressed patients who had received ECT to 52 normal volunteers. They found a significant relationship between treatment with ECT and brain atrophy. In fact, ECT recipients were twice as likely to have a measurable loss of brain tissue in the front area of the brain and three times as likely to experience loss of brain tissue in the back of the brain. "Most significantly, the brain abnormalities correlated only with ECT, and not with age, alcohol use, gender, family history of mental illness, age at the time of psychiatric diagnosis, or severity of mental illness (Dolan, 1986). Dolan, R. J., et al. (1986). The cerebral appearance in depressed subjects. Psychol Med, 16, 775-779. An animal study sought to discover whether giving supplementary oxygen during shock would prevent brain damage; the researchers also gave vitamin E to lessen the effects of damaging "free radical" molecules that get released during a shock seizure. They found no difference in the brain-damaging effects of ECT-induced seizures when oxygen and vitamin E were given. These findings disprove the claim that modern ECT methods (complete with anesthesia and oxygen) are any less damaging to the brain than uncontrolled seizures. Manoel, et al. (1986). Brain damage following repeated electroshock in cats and rats. Rev Rom Neurol Psych, 24, 59-64. CARDIOVASCULAR COMPLICATIONS ECT-induced seizures cause a rapid rise in blood pressure; at the same time, the brain experiences a significant reduction in blood flow. Webb, et al. (1990). Cardiovascular response to unilateral ECT. Biol Psych, 28, 758-766. Rosenberg, et al. (1988). Effects of ECT on cerebral blood flow. Convulsive Therapy, 4, 62-73. A Mayo clinic study of 34 elderly patients receiving shock found an 18% incidence of serious heart arrhythmias during treatment: 4 had ventricular tachycardia requiring IV lidocaine and 2 had supraventricular tachycardia requiring IV beta blockers. An additional 2 patients had other cardiogram changes. Tomac, T., & Rummans, T. (1997). Safety and efficacy of electroconvulsive therapy in patients over age 85. Am J Geriatr Psych, 5, 126-130. After his eighth ECT, a 57-year-old man died of heart rupture. Ali, P. B., & Tidmarsh, M. D. (1997). Cardiac rupture during electroconvulsive therapy. Anesthesia, 52, 884-895. Physicians from Tulane University Medical School reported on a 69-year-old woman who developed brain hemorrhage during ECT. She was also left with epilepsy. This was, as expected, associated with further deterioration in her mental status from her baseline depression. They conclude that the fragile vessels of the elderly may make some patients a particularly high risk for ECT. Weisberg, et al. (1991). Intracerebral hemorrhage following ECT. Neurology, Nov, 1849. EXTRA RISKS IN THE ELDERLY In an analysis of 34 persons over the age of 85 who were subjected to ECT, researchers at the Mayo clinic documented that 79% suffered treatment complications, including a 32% incidence of confusion and delirium, a 67% incidence of transient high blood pressure, and an 18% incidence of serious heart arrhythmias during treatment. There were 2 patients with other cardiogram changes, 3 patients who took falls, and i patient with a hip fracture due to a fall. Tomac, T., & Rummans, T. (1997). Safety and efficacy of electroconvulsive therapy in patients over age 85. Am J Geriatr Psych, 5, 126-130. ECT enthusiast, Dr. Coffey, and his associate, Dr. Figiel, found that 10 out of 87 (11%) elderly patients getting ECT for depression remained delirious between ECT sessions for no discernible medical reason other than the ECT itself. (Italicized words are those of the study authors.) They documented by brain MRI scans that 90% of these unfortunate patients had lesions in the basal ganglia areas of the brain, and 90% had moderate to severe white matter lesions. Figiel, Coffey, et al. (1990). Brain MRI findings in ECT-induced delirium. J of Neuropsych and Clin Sci, 2, 53-58. Kroessler and Fogel's (1993) study on death rates was done on the "oldest old": depressed patients at least 85 years of age. Mortality rates were significantly greater for those who received ECT, compared to those who did not. Kroessler, D., & Fogel, B. (1993). Electroconvulsive therapy for major depression in the oldest old. Am J Geriatr Psych, 1(1), 30-37. EPILEPSY In a review of the literature on the well-known ECT complication of epilepsy, researchers calculated "that the age-adjusted incidence of new seizures after ECT was fivefold greater than the incidence found in the nonpsychiatric population (Devinsky & Duchowny, 1983). Devinsky, O., & Duchowny, M. S. (1983). Seizures after convulsive therapy: A retrospective case survey. Neurology, 33, 921-925. Persistent brain wave disruption to the point of status epilepticus has been reported to occur following ECT. Individual reports by Drs. Weiner and Varma, on different patients, describe acute disorientation and deterioration of intellectual function immediately following ECT. This was found to be due to ongoing epileptic brain wave forms that were initiated by the ECT. Weiner, R. D. (1980). Prolonged confusional states and EEG seizure activity following ECT and lithium use. Am Journal Psych, 137, 14521453. Varma, N. K. et al. (1992). Nonconvulsive status epilepticus following ECT. Neurology, 42, 2263-2264. MEMORY LOSS Publicly available data from the state of California's Department of Mental Health reveals that more than 99% of ECT recipients complain of memory loss 3 months following treatment, with the average number of ECT sessions being five to six. Lazarow, A. (Chief). (1996). Office of Human Rights, California Department of Mental Health. In a chapter on the cognitive effects of ECT in a psychiatry textbook, Sackheim indicates that cognitive effects (disordered thinking), particularly amnesia, can be long lasting after shock. Sackeim. (1992). In Moos et al. (Eds.), Cognitive disorders: Pathophysiology and treatment. The conclusion that amnesia can be a long-lasting effect of shock is arrived at by both Squire and Weiner, in separate studies. Squire, et al. (1981). Retrograde amnesia and bilateral ECT: Long term follow-up. Arch Gen Psych, 38, 89-95. Weiner, et al. (1986). Effects of stimulus parameters on cognitive side effects. Ann NY Acad Sci, 462, 315-325. LACK OF EFFICACY In the large New York study cited earlier, the death rates from suicide among depressed patients given ECT were slightly higher at the 1-year mark. By 5 years, the suicide rate was the same for depressed patients who got ECT as for those who did not. Babigian, H., et al. (1984). Epidemiologic considerations in ECT. Arch Gen Psych, 41, 246-253. In a University of Iowa study of treatment effectiveness, 1,076 depressed patients were categorized according to whether they received ECT, high doses of antidepressant medications, low doses of antidepressant medications, or neither (neither ECT nor medications). Long-term follow-up revealed that all groups had the same suicide rates, indicating that the incidence of suicide is not affected by treatment. The authors concluded, "Therefore, active biological treatments, such as ECT, may not be deemed as `lifesaving' now as in the past" (Black et al., 1989). Black, et al. (1989). Does treatment influence mortality in depressives? Ann Clin Psych, 1, 165-173. The same findings are documented in three other studies: ECT does not prevent suicide in depressed patients. Eastwood, et al. (1976). Seasonal patterns of suicide, depression, and ECT. Br J Psych, 129, 472-475. Babigian, et al. (1984). Epidemiological considerations in ECT. Arch Gen Psych, 41, 216-253. Milstien, et al. (1986). Does ECT prevent suicide? Convulsive Therapy, 2, 3-6. By John Breeding JOHN BREEDING, Ph.D. is a licensed psychologist in private practice in Austin, Texas. A significant part of his work involves counseling and consulting with parents and children. He also works with adults in psychotherapy, including many who are self-identified as psychiatric survivors. He is active in challenging various aspects of psychiatric oppression, in particular the practices of electroshock and the use of psychiatric drugs with school-age children. His book, The Wildest Colts Make the Best Horses, is a forceful and informative challenge to the use of stimulant drugs with millions of our children. Dr. Breeding has been on the advisory board of the World Association of Electroshock Survivors and has been active in the effort to ban electroshock in the state of Texas. His website, www.wildestcolts.com, is a valuable resource on psychiatry-related issues.