|
Tuesday, March 20, 2001
My Turn: ECT Editorial Casts Shadow on Author and
JAMA's Credibility
by Leye Jeannette Chrzanowski
Copyright © The Disability News Service, Inc.
Is Electroconvulsive therapy (ECT) now safe and
effective as indicated in a March 14, 2001,
editorial published in the Journal of the American
Medical Association (JAMA)? The author, JAMA's
Deputy Editor Richard Glass, MD, asserts ECT is
effective, safe, and no longer abused, and thus time
to bring ECT out of the shadows. Glass fails to sway
ECT critics. They are incensed that JAMA would
publish such a questionable report, and remain
unconvinced ECT is the harmless panacea he
describes. Critics assert Glass's editorial makes
erroneous assumptions, excludes important
information, and ignores people who have experienced
adverse effects after receiving ECT. They conclude
ECT remains ineffective, abused and unsafe.
What is ECT?
According to the National Institutes of Mental
Health (NIMH), ECT, sometimes more commonly referred
to as shock treatment, involves producing a seizure
in the brain of a patient under general anesthesia
by applying electrical stimulation to the brain
through electrodes placed on the scalp. According to
NIMH, "Repeated treatments are necessary to achieve
the most complete antidepressant response." People
of all ages receive ECT -- even young children.
The Effects
ECT has been known to cause epilepsy, brain damage,
memory loss, stroke, heart attacks and even death.
Glass asserts ECT earned a bad reputation in the
mid-20th Century, when shock treatments were abused
and overused. He also blames the movie One Flew Over
the Cuckoo's Nest for contributing to an "erroneous
view of ECT as a punitive, painful, and assaultive
procedure used by authorities to control
inconvenient creativity."
"That reputation was enhanced by the immediate
adverse effects of bitten tongues and even fractured
bones and teeth caused by the induction of
generalized seizures, and the painful effects of
electroshocks administered without anesthesia when
they did not successfully induce a seizure with loss
of consciousness," he writes.
"Richard Glass makes some very erroneous assumptions
in this editorial, and it leaves me wondering if he
really knows ECT research at all," says freelance
journalist Juli Lawrence, MA, BS, BA, who received
ECT in July 1994 for severe depression. Lawrence
also operates an Internet Web site
http://www.ect.org , which contains a vast amount of
ECT information. She accumulated the articles and
journal entries -- both pro and con -- after
spending years researching ECT.
"He lists a few reasons that ECT is controversial,
but ignores what every ECT researcher tends to
ignore -- patient feedback. That has been the modus
operandi of the entire ECT industry from the
beginning, although it seems to be currently in
vogue to say, `Well, yes, we admit ECT was misused
in the past, but it's fixed today,'" adds Lawrence.
"It is disturbing that such a respected source as
the Journal of the American Medical Association sees
fit to describe ECT as `an effective and safe
treatment,' given the fact that a significant number
of people have been permanently disabled by it," says
Joseph A. Rogers, executive director of the National
Mental Health Consumers' Self-Help Clearinghouse in
Philadelphia.
To bolster his opinion, Glass relies on the most
recent task force report by the American Psychiatric
Association (APA) committee on electroconvulsive
therapy. First published in 1990, the 2001 edition
of The Practice of ECT: Recommendations for
Treatment, Training, and Privileging concludes ECT
is a safe and effective treatment for severe major
depression. Glass writes the committee noted that
after receiving ECT, people may experience "a
variable but usually brief period of
disorientation," or some retrograde amnesia
immediately after the ECT seizure is induced, which
usually decreases with time. Glass adds that some
people may experience a persistent loss of memory of
events that happened directly before and after they
received the ECT. Anterograde amnesia, forgetting
learned information, may also occur during and
following ECT, but is resolved in a few weeks,
according to Glass.
"Importantly, there is no objective evidence that
ECT has any long-term effect on the capacity to
learn and retain new information," writes Glass.
"The APA fact sheet claims that ECT is `no more
dangerous than minor surgery under general
anesthesia, and may at times be less dangerous than
treatment with antidepressant medications,'" adds
Rogers. He asserts APA wrongly refers to ECT as "a
safe, practically painless procedure" and brain
damage a "myth." Rogers says APA minimizes memory
problems. "Research to the contrary is ignored," he
asserts.
If APA considers brain damage a myth, then it
ignores the results of its own task force survey.
Some 41 percent of psychiatrist responded, "Yes",
and only 26 percent said, "No," when asked, "Is it
likely that ECT produces slight or subtle brain
damage?"
"As a neurologist and electroencephalographer, I
have seen many patients after ECT, and I have no
doubt that ECT produces effects identical to those
of a head injury," wrote Sydney Samant, MD, in
Clinical Psychiatry News, March 1983. Samant
concluded that ECT "in effect may be defined as a
controlled type of brain damage produced by
electrical means."
In the American Journal of Psychiatry, September
1977, John M. Friedberg, MD, writes, "The potency of
ECT as an amnestic exceeds that of severe closed head
injury with coma. His report, "Shock Treatment, Brain
Damage, and Memory Loss: A Neurological Perspective,"
concluded, "It is surpassed only by prolonged
deficiency of thiamine pyrophosphate, bilateral
temporal lobectomy, and the accelerated dementias,
such as Alzheimer's."
"One reason psychiatrists are unaware that ECT is
causing memory loss is that they do not test for
it," wrote Peter Sterling, MD, in a January 2000
letter to the editor of Nature. Sterling who works
in the department of neuroscience, at University of
Pennsylvania, wrote, "Memory loss could be monitored
by questioning patients before ECT about early events
in their lives and then re-questioning them following
each series of ECT. When this was done 50 years ago,
memory losses were marked and prolonged. However, no
effort has been made since to routinely perform this
simple test."
The late Marilyn Rice, founder of the Committee for
Truth in Psychiatry, an organization of
approximately 500 former ECT recipients was forced
to give up her career as a government economist
after ECT wiped out her knowledge of economics.
Lawrence says that ECT wiped out a year and a half
of memories before she received ECT, and eight
months of memories after her shock treatment. She
believes it's important to look at ECT from every
angle, and offers both perspectives on her Web site.
Still, she is not convinced ECT is an effective
treatment for depression, but only offers a brief
respite.
Glass' editorial does not warn that ECT may cause
heart damage or even death.
Last year's controversial U.S. Surgeon General's
Mental Health: A Report of the Surgeon General,
endorsed the use of ECT, but warned, "However, a
recent history of myocardial infarct, irregular
cardiac rhythm, or other heart conditions suggests
the need for caution due to the risks of general
anesthesia and the brief rise in heart rate, blood
pressure, and the load on the heart that accompany
ECT administration."
"In a large retrospective study of 3,288 patients
getting ECT in Monroe County, New York, ECT
recipients were found to have an increased death
rate from all causes," reports Moira Dolan, MD, in
The Effects of Electroconvulsive Therapy, a review
of scientific literature on the subject.
She also reports, "The first three years of mandated
recording of death within 14 days of ECT in the state
of Texas yielded reports of 21 deaths," according to
a 1996 report filed by Don Gilbert, Commissioner,
Texas Department of Mental Health and Mental
Retardation. "Eleven of these were cardiovascular,
including massive heart attacks and strokes, three
were respiratory, and six were suicides..."
"In this issue of The Journal, Sackeim et al report
the results of a multicenter, randomized controlled
trial that addressed the important clinical problem
of preventing relapse following a course of ECT,"
Glass writes.
"He fails to mention that in the JAMA study,
patients were given an electrical charge so high
(double the maximal output) that special machines
had to be manufactured, and that this kind of charge
is allowed only in research, not in contemporary US
practice," counters Lawrence. "Even with that
doubled dose, the response rate was dismal. Out of
the 290 persons who completed a full ECT series at
this high electrical rate, 24 weeks later only 28
were considered to be `in remission' from
depression."
Informed Consent
"In his editorial, Dr. Glass does add that some ECT
recipients have reported `devastating cognitive
consequences' and says that this should be
`acknowledged in the informed consent process,'"
adds Rogers. "Unfortunately, he does not note that
the opportunity for truly informed consent rarely
exists now, since many hospitals base their informed
consent information on sources such as the American
Psychiatric Association fact sheet, which
whitewashes the risks of ECT."
In 1998, the U.S. Department of Health and Human
Services released the Electroconvulsive Therapy
Background Paper prepared by Research-Able, Inc., a
Vienna, Virginia, contractor for the Center for
Mental Health Services (CMHS). This report indicated
that some 43 states regulated the administration of
ECT. Nevertheless, its authors concluded that
despite state laws regulating the practice of ECT,
"physicians and facilities comply neither with the
letter nor the spirit of the laws, nor with
professional guidelines." The Wisconsin Coalition
for Advocacy, for example, reviewed records and
conducted in-depth interviews at a psychiatric
hospital in Madison, and uncovered...
* coercion to obtain patients' consent;
* failure to honor the requests of people who
refused treatment;
* failure to provide patients with sufficient
information about the procedure to allow them to
make an informed decision; and
* absence of consent to treat people who were
mentally unable to give consent.
"The American Psychiatric Association's own consent
form doesn't even mention the high relapse rate, and
mentions memory loss and cognitive damage as
something rare and nearly freakish," adds Lawrence.
Has the abuse and overuse of ECT has declined over
the years?
"One only has to look in the courtrooms of New York
and spend an hour talking with Paul Henri Thomas, a
man who has received as many as 70 forced
electroshocks and is fighting against 40 more,"
asserts Lawrence.
"Or visit the courtrooms in Michigan, where it is
against state law to give involuntary ECT to a
person who does not have a guardian; yet in the last
year, two hospitals and two judges have ignored state
law and done it anyway. And you might talk to
prominent [British] psychiatrist Dr. Carl
Littlejohns, who is a proponent of ECT. Last year he
criticized the American practice of ECT saying it was
not standardized at all, and called it `most
unsettling.' Or talk to the thousands of ECT
survivors who say they have devastating, permanent
damage and were lied to about the longevity of ECT
on depression," advises Lawrence.
The National Mental Health Consumers' Self-Help
Clearinghouse's policy is that potential ECT
recipients have a right to be educated about the
benefits and dangers of the controversial procedure
before they make up their minds about it.
The Financial Factor
Many ECT proponents including some cited by Glass do
not disclose they may have a financial conflict. For
example, he cites Richard D. Weiner, MD, Ph.D., who
heads Duke University Medical Center's
Electroconvulsive Therapy Service and the APA task
force on ECT which petitioned the Food and Drug
Administration to lower its classification of ECT
machines in 1982.
"As a paid `consultant' to shock machine companies,
Weiner designs virtually all of the shock machines
in the United States," asserted Linda Andre, head of
the New York City-based Committee for Truth in
Psychiatry in 1999. "He admits getting money from
shock machine companies but says it's deposited in
his `research' account."
Andrew D. Krystal, MD, director of Duke's Sleep
Disorder Center, an associate of Weiner's who is
frequently cited in pro-ECT journals received
$150,036 in funding from the NIMH in fiscal year
1998 to conduct research on improving ECT's
effectiveness.
"In this issue of The Journal, Sackeim et al report
the results of a multicenter, randomized controlled
trial that addressed the important clinical problem
of preventing relapse following a course of ECT,"
writes Glass.
Harold A. Sackeim, Ph.D., is chief of the department
of biological psychiatry at the New York Psychiatric
Institute, where he directs the ECT research program
and co-directs the Late Life Depression Research
Clinic. The ECT machines Sackeim used in the
research Glass cites above were donated by MECTA,
Corporation, one of two US companies that
manufacture these devices. MECTA reputation is less
than stellar. In 1989, the MECTA, Model D machine
was used to give ECT to Imogene Rohovit. As a
result, she sustained permanent brain damage and
could no longer work. The Iowa nurse and her family
successfully sued METCA for an undisclosed amount.
Electroconvulsive Therapy authored by Richard
Abrams, MD, a professor of psychiatry at the Chicago
Medical School, is the primary reference used by ECT
practitioners. Abrams, a member of the editorial
board of Convulsive Therapy, has authored numerous
articles and books, and lectured extensively on the
subject of ECT. Glass does not mention this highly
esteemed ECT expert by name, however, APA's 1990
task force report relies heavily on Abrams' ECT
expertise. Abrams also rarely mentions his interest
in ECT goes beyond his practice, writings and
lectures.
"Somatics, Inc. was founded in 1983 by two
internationally recognized ECT experts and
professors of psychiatry for the purpose of
manufacturing and distributing the ThymatronÅ
brief-pulse electroconvulsive therapy instrument,"
reads a statement on the company's Web site. Missing
from the site are the names of the two psychiatrists
-- Abrams, and Conrad Swartz, MD, Ph.D., a professor
at the University of South Carolina, an ECT
practitioner, who writes extensively about ECT, and
also designs ECT machines and other related devices.
For years, Abrams failed to disclose his financial
interest in the company. He did not disclose it in
his pro-ECT article, "The Treatment That Will not
Die," published in the academic journal Psychiatric
Clinics. When journalist David Cauchon interviewed
an editor at Oxford University Press, the publisher
of his book, she claimed Abrams had never disclosed
his financial interest in Somatics. Cauchon reveals
this information in his article "Doctor's Financial
Stake in Shock Therapy" published in USA Today,
December 6, 1995. (A financial disclosure is now
included.)
"Abrams says it's ridiculous to think his ownership
of a shock machine company may create a conflict of
interest," wrote Cauchon. In the article, Arthur
Caplan, director of the Center for Bioethics at the
University of Pennsylvania, chides Abrams and Swartz
for failing to disclose their financial interest in
Somatics, when they lecture or write about ECT.
Caplan told Cauchon Abrams and Swartz should
"absolutely, without a doubt, disclose their
ownership in all their publications," and also on
informed consent forms.
Psychiatrists find insurance programs, including
federal programs such as Medicare and Medicaid, are
willing to pay for less costly shock treatments than
for psychotherapy sessions.
"With the insurance companies there isn't a limit
[for ECT] like there is for psychotherapy," Gary
Litovitz told Sandra Boodman in an interview for her
article, "Electric Shock...It's Back" published in
The Washington Post, September 24, 1996. "That's
because it's a concrete treatment they can get their
hands around. We have not run into a situation where
a managed care company cut us off prematurely,"
stated the medical director of Dominion Hospital, a
private 100-bed psychiatric facility in Falls
Church, Virginia.
"The number of shock treatments in Ontario's
community hospitals has more than doubled in the
last ten years, Ministry of Health statistics now
show," writes Maria Bohuslawsky in The Ottawa
Citizen, March 19, 2001. She reports that 40 percent
of the 2,087 people who received shock treatment from
1996-1997, were older people -- a growing trend.
Bohuslawsky writes that those on both sides of the
ECT issue agree that "the trend is partly due to a
push for shorter hospital stays: As a short-term
treatment, electroshock works faster than
antidepressant drugs."
The People Factor
"Neither congressional hearings nor other government
proceedings have ever heard from shock survivors and
other opponents of shock in representative numbers,"
states the National Council on Disability in From
Privileges to Rights: People labeled With
Psychiatric Disabilities Speak for Themselves, a
2000 report the federal agency prepared for the
president and Congress. "More often, the proponents
of shock have either authored the reports or had
major involvement in writing them, often without
disclosing conflicts of interest (such as financial
involvement with the manufacturers of shock
machines), while opponents of shock treatment have
been excluded from the process."
"Dr. Glass says it's time for ECT to come out of the
shadows," asserts Lawrence. "I've got news for him --
it's out, but not always in the positive light he
seems to want. Every day I hear from new people who
now consider themselves survivors of ECT. When these
patients try and talk to their doctors about their
complaints, they are simply ignored or met with
scorn. That's what is in the shadows, and it's
because the industry refuses to recognize their
experiences."
ECT critics raise legitimate concerns which Glass
omits from his editorial. The absence of such
information, which practitioners and the public have
a right to know, casts a dark shadow on Glass's
editorial and the Journal of the American Medical
Association's credibility.
|