Electroshock: scientific, ethical, and political issues by Peter R. Breggin M.D.

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http://www.breggin.com/Electroshockscientific.pdf

 

International Journal of Risk & Safety in Medicine 11 (1998) 5–40 5

IOS Press

 

Electroshock: scientific, ethical, and

political issues

Peter R. Breggin

 

Abstract. Electroconvulsive treatment (ECT) is increasingly used in

North America and there are attempts to promote its further

use world-wide. However, most controlled studies of efficacy in

depression indicate that the treatment is no better than placebo

with no positive effect on the rate of suicide.

ECT is closed-head electrical injury, typically producing a delirium

with global mental dysfunction (an acute organic brain

syndrome). Significant irreversible effects from ECT are demonstrated

by many studies, including: (1) Inventories of autobiographic

and current events memories before and after ECT; (2) Retrospective

subjective observations on memory; (3) Autopsy

studies of animals and some of humans. ECT causes severe and

irreversible brain neuropathology, including cell death. It can

wipe out vast amounts of retrograde memory while producing permanent

cognitive dysfunction.

Contemporary ECT is more dangerous since the current doses are larger

than those employed in earlier clinical and research

studies. Elderly women, an especially vulnerable group, are becoming

the most common target of ECT. Because of the lopsided

risk/benefit ratio, because it is fundamentally traumatic in nature,

because so many of the patients are vulnerable and unable to

protect themselves, and because advocates of ECT fail to provide

informed consent to patients – ECT should be banned.

Introduction

The use of electroconvulsive treatment (ECT), also called electroshock

treatment (EST), has been

escalating in the United States and Canada. Europe has not yet

experienced a significant increase in the

usage of ECT or in the controversy surrounding it. However, ECT seems

to be used in most European

psychiatric centers. With the growing emphasis on biological

approaches in psychiatry, as well as the

emphasis on cost efficiency, the North American trend will probably

begin to take hold in Europe in

the near future. In the meanwhile, ECT advocates are making an

international effort to encourage the

treatment throughout the world. For example, the First European

Symposium on ECT was held in Austria

in March 1992 and drew representatives from 13 European countries, as

well as Russia, Israel, Canada,

and the United States [107]. A team of three Americans – Max Fink,

Harold Sackeim, and Richard

Weiner – made a special presentation to the meeting. Their efforts are

central to the current promotional

campaign for ECT and their publications will be cited throughout this

paper.

The controversy surrounding ECT in the United States led to three

institutional responses that have

affected the future of ECT throughout the world. First, in 1985 the

National Institute of Mental Health

(NIMH) and the National Institutes of Health (NIH) held a joint

Consensus Conference aimed at establishing

some agreement among mainstream professionals about the status of ECT.

Second, in 1990 the

*This paper is modified and greatly expanded from chapter 8 of my 1997

book, Brain Disabling Treatments in Psychiatry:

Drugs, Electroshock and the Role of the FDA. I wish to thank Springer

Publishing Company for permission to use the original

material from that book. I also want to thank Alex Laris, Steve

Baldwin, and Leonard Roy Frank for their help in updating the

material.

**Peter R. Breggin, M.D., is director of the International Center for

the study of Psychiatry and Psychology (ICSPP), 4628

Chestnut Street, Bethesda, Maryland 20814. Further information about

Dr Breggin, ICSPP, electroshock and other psychiatric

treatments, can be found on two Web sites: www.breggin.com. and

www.ICSPP.org.

0924-6479/98/$8.00 Ó 1998 – IOS Press. All rights reserved

6 P.R. Breggin / Electroshock: scientific, ethical, and political issues

Food and Drug Administration (FDA) decided for the first time to

review the safety of ECT machines.

Third, still in 1990, the American Psychiatric Association (APA)

issued a lengthy report aimed at convincing

the FDA not to require the testing of ECT machines. The APA report was

successful in this

regard and became the basis for the FDA's final report. The APA's

report was also aimed at stifling controversy

and protecting psychiatrists from lawsuits being brought by patients

claiming brain injury from

ECT. The conclusions of the Consensus Conference [63], the Food and

Drug Administration [89], and

the American Psychiatric Association [8] will be referred to

throughout this analysis, often to compare

their conclusions to the actual scientific data.

The ECT controversy has also been addressed by various agencies and

bodies in Canada [74,128,142]

and in England [150], usually in less detail and with reliance on

opinions generated in the United States.

Current ECT usage in America and Europe

Nowadays ECT is most commonly recommended for major depression. Some

doctors recommend it

when other approaches have failed but others quickly resort to it as a

treatment of choice. On occasion

the treatment is also prescribed for other disorders, especially acute

mania.

ECT was originated in Italy in 1938 by Bini and Cerletti who observed

the effects of electric current

in rendering slaughter house pigs into a state of unconsciousness.

That the electrical shocks did not

actually kill the pigs led the doctors to try it on human beings [3,

p. 6; 57]. The first human subject

understandably feared that he was indeed about to be slaughtered. When

the first shock did not render

him unconscious, he beseeched the doctors, " Not again, it's

murderous! " [3, p. 6]. Cerletti himself [57]

translated the victim's plea as " Not another one! It's deadly! "

In the United States, and probably elsewhere, the use of ECT tends to

vary from institution to institution.

At Johns Hopkins, for example, a biologically oriented psychiatric

center, 20% of the inpatients

may be on a regimen of ECT at any one time [182, p. 9]. Many other

hospitals in the US do not even

offer ECT.

Probably more than 100,000 patients a year in the United States are

electroshocked. The majority are

women and many are elderly. In California, for example, two thirds of

ECT patients are reported to be

women, more than half of whom are 65 or older [165]. Data (1989–1993)

from Vermont concerning

ECT showed that 77% of ECT patients were female [168]. For all sexes,

58% were at least 65 years

old and 20% were at least 80 years old. During this time, one Vermont

hospital, Hitchcock Psychiatric,

electroshocked 35 women and one man who were 80 and older. Overall,

the hospital electroshocked

112 women and 26 men during those 5 years.

Pippard [142] commented " The use of ECT in England has shown a more or

less steady decline for

many years: : : " . He surveyed ECT in all 35 National Health Service

hospitals and five private clinics

in the North East Thames and East Anglian Regions. He found that many

of the hospitals used older

machines and operated them according to the doctors' personal habits

rather than " rational strategy " in

regard to stimulus settings and other treatment variables. (Wise [183]

recently found that 70% of ECT

machines in Britain and Wales remain below standard.) Pippard

discovered that ECT usage had fallen

55% in North East Thames Region since 1979 while it risen by 20% in

the East Anglian region.

Pippard found a wide variation in usage from hospital to hospital, and

district to district. In the County

of Suffolk in East Anglia, " In the year toMarch 1990, 3580

applications of ECT were given, a rate of 6.50

per 1000 of population. In East Suffolk the rate was 8.32 per 1000. "

In one of the inner London health

districts, few patients other than the elderly received ECT. The

overall rate was 0.68/1000 population.

While ECT has been slightly on the decline in Great Britain,

successful efforts to escalate its use in

the United States are likely to spread abroad. A review by Allan Scott

[156], consulting psychiatrist at

P.R. Breggin / Electroshock: scientific, ethical, and political issues 7

the Royal Edinburgh Hospital, draws heavily on the American experience

and recommends, " Electroconvulsive

therapy (ECT) is an effective and important treatment for severe

depressive illness and for

other depressive illnesses that have not responded to drug treatment. "

Except to dismiss brain damage

from ECT, Scott does not mention any adverse effects, even memory

loss. A.G. Hay and Scott [109],

in part to counter this author's concerns about ECT-induced brain

damage (the British publication of

Breggin [39]), presented a single case of a woman who had received a

total of 125 treatments over

several years. The follow-up evaluation, which showed no mental

decline, involved an IQ test and the

Clifton Assessment Procedure for the Elderly. The evaluation was

conducted by one of the co-authors.

This single-case clinical report bears more on the rising enthusiasm

for ECT than upon ECT's supposed

safety.

Canadian authorities have not published data concerning the use of

ECT. However, in reply to inquiries

from Don Weitz [104,181], some data has been released. Weitz obtained

the estimates for ECT administered

in Ontario's general and community psychiatric facilities, and

provincial psychiatric hospitals.

Outpatient ECT was not included. During the year 1994–1995, 12,865

individual ECT treatments were

administered to approximately 1,800–2,000 patients. Payments to all

physicians in Ontario in general

and community hospitals (not provincial psychiatry hospitals) for the

year 1993–1994 showed that almost

twice as many women as men received ECT [136]. Women received 6,221

ECTs and men received

3,236. Fifteen youngsters age 15–19 were treated with ECT.

With advancing age, there was a tendency for women to become

increasingly over-represented. The

figures for the numbers of individual ECT treatments for women and men

in each age group were as

follows: age 60–64, 352 women, 342 men; age 65–69, 632 women, 240 men;

age 70–74, 655 women,

430 men; 75–79, 592 women, 179 men; 80–84, 318 women, 97 men; 85 and

older, 102 women, 94 men.

Stromgren [167] compared electroconvulsive therapy usage in Nordic

countries – Sweden, Norway,

Denmark, Finland, and Iceland – in 1977 and in 1987. The surveys were

sent to departments of psychiatry

in each country. The percentage of departments using ECT in 1987 in

order of frequency were:

Sweden (98%), Denmark (97%), Norway (82%), Iceland (67%), and Finland

(57%). Departments that

were unlikely to use ECT – child and adolescent, forensic, and drug

addiction services – were excluded

from the survey.

The number of units using ECT in Nordic countries was unchanged

between 1977 and 1987 but

there was a slight decrease in the absolute number of treatments

given. This small decline was variously

attributed to the decreasing numbers of beds, treatment by non-medical

professionals, and the increasing

use of psychopharmacology.

In the most commonly used diagnostic category in the Nordic countries,

endogenous depression, all

but 4 of 216 departments used ECT. However, the frequency of use had

declined. In 1977, 22% of departments

used ECT frequently (more than 25%) for endogenous depression, but in

1987 only 15% used

it frequently. Overall, the report found that " ECT is still regarded

as being an important useful treatment "

and that during the 1980s, its value " has become obvious to an

increasing number of psychiatrists in the

Nordic countries " .

A survey of 20 general hospitals with psychiatric units and

psychiatric hospitals in Barcelona, Spain in

1993 found that 12 of 20 (60%) practiced ECT [24]. Reports from around

Europe suggest at least some

interest in ECT since the early 1980s, including Belgium [163,164],

Germany [73], Poland [58], as well

as Israel [49].

In addition to the US, England, and Canada, ECT has generated

considerable controversy in Ireland

[158] and especially in Australia [16–21,31,120,139,140]. Writing in

the Australian and New

8 P.R. Breggin / Electroshock: scientific, ethical, and political issues

Zealand Journal of Psychiatry, Durham [70] laments the criticism of

ECT, as well as a " distinct prejudice "

against the treatment manifested in recent legislation. The

controversy surrounding ECT will be

addressed in more detail later in this paper.

1. Efficacy studies

1.1. Is there any basis for the claims?

Rifkin [149] noted that the claim is frequently made that ECT is more

effective and works more

rapidly than drugs in the treatment of depression. He located nine

controlled studies comparing the two

treatments, but they were badly flawed. He could find no conclusive

evidence that ECT was better than

antidepressant treatment.

Crow and Johnstone [64], in a review of controlled studies of ECT

efficacy, found that both ECT and

sham ECT were associated with " substantial improvements " and that

there was little or no difference

between the two. Crow and Johnstone concluded, " Whether electrically

induced convulsions exert therapeutic

effects in certain types of depression that cannot be achieved by

other means has yet to be clearly

established " (p. 27).

Crow and Johnstone's critical review, which was presented at the

largest conference of ECT advocates

in recent years, is not cited in either the APA or FDA reports on ECT.

Instead, the APA task force's

proposal for a " Sample Patient Information Sheet " declares that " ECT

is an extremely effective form of

treatment " [9, p. 160].

At the Consensus Conference on ECT [63], critics and advocates of ECT

debated the issue of efficacy.

The advocates were unable to come forth with a single controlled study

showing that ECT had a positive

effect beyond 4 weeks. Many studies showed no effect, and in the

positive studies, the improvements

were not dramatic. That ECT had no positive effect after 4 weeks

confirms the brain-disabling principle

(see ahead), since 4 weeks is the approximate time for significant

recovery from the most obvious mindnumbing

or euphoric effects of the ECT-induced acute organic brain syndrome.

The Consensus Conference panel stated in its report that ECT had no

documented positive effect

beyond 4 weeks. This is, of course, critical in weighing the

risk/benefit ratio.

1.2. Does ECT reduce the risk of suicide?

ECT is frequently justified as treatment of last resort in cases at

high risk for suicide. Sackeim [153],

for example, claims " When confronted with a psychiatric or medical

emergency – for instance, the acute

risk of suicide – ECT can save lives " (p. 39).

Despite the claims of advocates, research uniformly shows that ECT has

no beneficial effect on the suicide

rate. In a misleading fashion, the negative studies are cited by the

task force report, the FDA report,

and others as showing a positive effect. For example, a retrospective

study by Avery and Winokur [10]

found no improvement in the suicide rate compared to matched controls

who had no electroshock treatment:

" In the present study, treatment was not shown to affect the suicide

rate " (p. 1033). Yet it is

presented in the 1990 task force report as supporting the position

that ECT results in " a lower incidence

of suicide " (p. 53). The task force also mentions three other studies

as supporting a beneficial effect on

suicide. Two of the studies [11,135] specifically found no such

beneficial effect. The third [129] did not

even deal with suicide.

P.R. Breggin / Electroshock: scientific, ethical, and political issues 9

In two other retrospective studies of relatively large populations of

ECT patients and matched controls,

ECT had no effect on the suicide rate [13,28]. Overall, there is

little or nothing in the literature to suggest

that ECT ameliorates suicide, whereas a significant body of literature

confirms that it does not.

My own clinical experience indicates that ECT increases the suicide

risk for many patients. It is well

known, for example, that Ernest Hemingway attributed his suicide to

despair over ECT ruining his memory

and rendering him unable to write [112, p. 308].

As they attempt to recover from ECT, patients frequently find that

their prior emotional problems have

now been complicated by ECT-induced brain damage and dysfunction that

will not go away. If their

doctors tell them that ECT never causes any permanent difficulties,

they become further confused and

isolated, creating conditions for suicide.

2. Acute brain dysfunction caused by ECT

2.1. The production of delirium (acute organic brain syndrome)

After one or more treatments, ECT routinely produces delirium or an

acute organic brain syndrome.

Richard Abrams [3], although an advocate of ECT, has observed that:

: : : a patient recovering consciousness from ECT might understandably

exhibit multiform abnormalities

of all aspects of thinking, feeling, and behaving, including disturbed

memory, impaired comprehension,

automatic movements, a dazed facial expression, and motor restlessness

(p. 214).

Abrams' accurate description, including the " dazed facial expression " ,

would indicate even to a layperson

that the patient has suffered a severe head trauma. The existence of

" multiform abnormalities of all

aspects of thinking, feeling, and behaving " should raise warning flags

about the potential for complete

recovery. It should also remind us that not only memory but all mental

processes are severely disrupted.

The severity of the trauma should signal that it's dangerous to repeat

this procedure again and again with

the inevitable deterioration of the patient's condition. Finally, in

trying to ascertain how ECT " works " , it

should direct us, first and foremost, to suspect the traumatic impact

on the brain rather than to speculate

about the correction of some subtle, undetected biochemical imbalance.

This is a treatment that creates

abnormalities rather than correcting them.

The acute reaction to routine ECT often reaches the proportions of a

neurological catastrophe. Max

Fink [82] wrote of ECT:

A more prominent neurological sequel to seizures is the change in

mental state and the development

of an organic mental syndrome. Although there is a relationship

between the number and frequency

of seizures and the change in sensorium, an organic psychosis may

occur with few treatments (4 citations).

The syndrome may include disorientation, amnesia, agnosia,

confabulation, aphasia, apraxia,

and delirium, the latter being seen principally as the postseizure

emergence of delirium (3 citations)

(p. 131).

Fink's description of severe neurological dilapidation amplifies all

the issues discussed in regard to

Abrams' summary of ECT effects. It would seem extremely unlikely to

find a complete recovery in most

patients after such a traumatic assault on the brain.

At times, patients are so neurologically impaired following ECT that

they will remain prone and

apathetic for days at a time, sometimes incontinent of urine and

feces, and unable to communicate or

to carry out routine self-care. On occasion, the patient's

neurological dilapidation from routine ECT

10 P.R. Breggin / Electroshock: scientific, ethical, and political issues

will reduce the person to curling up in a fetal position for many

hours. In malpractice suits in which

I have been a medical expert for plaintiffs, psychiatrists for the

defense have claimed that this kind of

neurological collapse is normal and harmless following ECT.

A review of the literature by Calev, Gaudino, Squires, Zervas, and

Fink [86, p. 510] confirms that ECT

can acutely disrupt not only memory but " perceptual, language and

other cognitive functions " , especially

if the stimulus intensity is relatively high.

An apparently rare complication is the production of status

epilepticus. Scott and Riddle [157] suggest

that it may be more frequent than usually estimated because it can

occur without obvious motor

manifestations following ECT.

A team led by Christina Sobin [160] recorded variations in

" orientation recovery " after ECT. The dose

of electricity varied from amounts necessary to cause a convulsion

(low-dose) to suprathreshold doses

(high dose). Recovery after low-dose bilateral ECT (40.0 min recovery

time) and after high-dose bilateral

ECT (37.2 min) were essentially the same. Recovery from high-dose

right unilateral (19.2 min) was much

shorter than for either bilateral group and low-dose right unilateral

(11.1 min) was even shorter.

Retrograde amnesia as measured by the recovery of autobiographic

memories was also worse following

bilateral ECT. Two months after one course of ECT, " Longer duration of

acute disorientation

was also associated with greater persistent retrograde amnesia " (p.

198). The authors conclude that both

the initial disorientation and retrograde amnesia are " overlapping

phenomena " – a function of the same

ECT-induced brain dysfunction.

Given that ECT routinely produces acute, global brain dysfunction –

and that this dysfunction is obviously

associated with persisting retrograde amnesia – there can be no real

disagreement about the

existence of damaging effects. The only legitimate question is: " How

complete is recovery from the

initial trauma? "

2.2. ECT as closed-head electrical injury

For more than a decade, neurologists have recognized that relatively

minor head trauma – without the

delirium, loss of consciousness, and seizures associated with ECT –

frequently produces chronic mental

dysfunction and personality deterioration [25]. If a woman came to an

emergency room in a confusional

state from an accidental electrical shock to the head, perhaps from a

short circuit in her kitchen, she would

be treated as an acute medical emergency. If the electrical trauma had

caused a convulsion, she might

be placed on anticonvulsants to prevent a recurrence of seizures. If

she developed a headache, stiff neck,

and nausea – a triad of symptoms typical of post-ECT patients – she

would probably be admitted for

observation to the intensive care unit. Yet ECT delivers the same

electrical closed-head injury, repeated

several times a week, as a means of improving mental function. ECT is

electrically induced closed-head

injury.

Interestingly, the results of lightning injuries are basically similar

to those of ECT and other forms of

electrical injury to the head [146]. Obvious impairments of language

or consciousness are rare, but " impairments

of attention, concentration, verbal memory, and new learning are very

frequently identified "

(p. 279).

The symptoms of mild to severe closed-head injury are listed in detail

by J.M. Fisher [87]. They

include impairment of every area of mental, emotional, and behavioral

function, confirming the multiple

adverse effects of ECT on the mind and brain. McClelland et al. [130]

describe the postconcussive

syndrome in terms of the following:

 

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