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ECT is frequently used and retains enormous support within the medical profession. Despite recent scientific blows to their "treatment," electroshock advocates remain determined, powerful, and influential. Anyone 10 doubts this need only read the September 12, 2007, issue of the Journal of the American Medication Association (JAMA) titled "Interest Surging in Electroconvulsive and Other Brain Stimulation Therapies" (Lamberg, 2007 [805]). Beneath a photo of health professionals hovering over unconscious ECT patient, the caption reads, "Although studies have demonstrated that electroconvulsive therapy (ECT) is an effective and safe treatment for severe major depression, inaccurate perceptions of ECT contribute to lingering stigma and fear regarding its use." This positive and even promotional attitude flies in the face of decades of research and heartrending patient testimonials. The publication of this puff piece at this time is probably intended to counter yet one more recently published scientific study that demonstrated the damaging effects of electroshocks to the brain (Sackeim et al., 2007 [1118]).
Beginning in 1979 with the publication of my book Electroshock: Its Brain-Disabling Effects, followed by many other book chapters and scientific reports, I have marshaled innumerable studies, bolstered by my clinical experience, to show that electroconvulsive therapy (ECT) causes permanent brain dysfunction and damage, including widespread memory and cognitive deficits. I have also evaluated evidence that contrary claims that ECT prevents suicide, ECT is ineffective and actually causes or contributes to suicide.
Since the 1997 edition of this book, my task has been lightened research from the heart of the ECT establishment confirming that ECT causes permanent brain damage and dysfunction with widespread cognitive deficits and that ECT greatly elevates the suicide risk, especially in the first week following treatment. In addition, a recent review of controlled clinical trials for ECT demonstrated once again that the so-called treatment is ineffective. And finally, for the first time in history, an ECT malpractice case has been won in court.
Since the ECT literature almost never provides clinical cases that describe the damage caused by the treatment, I will begin with a case from my own clinical practice.
Sarah Williams was 55 years old when her husband died of a sudden heart attack in the early spring. She managed to teach music in high school for the remainder of the year, but by the summer, her "blues" worsened. She lost weight, had difficulty staying asleep at night, and even lost her zest for visiting with her grown children. Her oldest daughter Jeannette, became concerned and in June took her to a psychiatrist. On the first visit, he put her on a tricyclic antidepressant, doxepin, that made her feel too groggy, so she stopped taking it. Then he put her on Prozac which made her feel agitated. She was now both depressed and agitated and her psychiatrist admitted her to a hospital for ECT.
Jeannette was very reluctant to submit her mother to ECT, but was convinced by the doctor and a video film that shock was the effective modality for depression. Jeannette and her mother were that the electrical current and the grand mal convulsion that it produced were virtually harmless. The electrodes would be placed on only one of the head (unilateral ECT), with the latest modifications to prevent injury.
Mrs. Williams herself protested about having electricity passed through her brain, and she wondered why no one seemed to want to with her about her feelings. Didn't psychiatrists do talking therapy anymore? But she was willing to accept anything that promised an end to the hopelessness that pervaded her life. She especially wanted to stop being burden to her daughter Jeannette.
After the first shock treatment, Mrs. Williams developed a headache and stiff neck. She was somewhat nauseated. By the third treatment, given every other day, she was confused and could not recall her daughter's previous visit. Her daughter was reassured by the doctor that this was "normal" for ECT, that all the effects were temporary, and that it would be best if she did not see her mother until the series of 10 ECTs was completed.
The nurse's notes from the hospitalization showed increasing "complaints" of memory difficulties by Mrs. Williams as the treatments progressed in number. However, after the eighth ECT, she stopped communicating about anything. The doctor's progress note at this point stated, "Improved. No longer complaining of feelings of depression." The nurse's progress note indicated, "No complaints. Sits quietly."
By the 10th treatment, Mrs. Williams could not find her way around the ward. The head of occupational therapy noted that the patient was too "disoriented and confused" to participate in the music and art activities.
When Jeannette visited her mother again at the conclusion of the treatments, she hardly recognized her. The expression on her mother's face was bland and indifferent, rather than pained. Sometimes her mother got a silly, almost goofy look that especially upset Jeannette. Her mother had always been so serious and dignified. To her daughter's dismay, her mother could not remember any of the events of the previous summer, including the visits to the psychiatrist. She could not remember who had come to her husband's funeral the previous April. She could not remember much about teaching for two semesters during the school year.
Mrs. Williams stayed in the hospital for 1 week after the completion of the ECT. At that time, her insurance ran out, and she was discharged me. Her discharged diagnosis was "major depression in remission".
Jeannette could see that her mom looked confused as she drove her home. She did not seem to recognize the neighborhood where she had lived for 30 years and raised her children. At home, her mother could not d the coffee or the sugar. She did not recognize the blender that Jeanette had bought her the previous Christmas.
A week later, Jeannette went to see the psychiatrist with her mother. The psychiatrist reassured her that he had never seen a case of permanent memory loss following electroshock, except for memory blanks for the period immediately around the shock treatment.
In September, 2 months after the ECT, Mrs. Williams tried to return to teaching but quit after 2 weeks. She could not remember the books or teaching materials she had been using for several years. The principal, who had started at the school a year earlier, looked like a stranger to her. She had trouble recognizing most of her previous students, including some who had been in music class with her for several years.
For the first time in her life, Mrs. Williams found she was having difficulty hearing music in her head. She was slow reading music and was distraught that she could not learn new pieces by heart anymore. She felt like a beginner in music, except she could not learn as well as a beginner. She wanted to die and became suicidal for the first time in her life.
Jeannette took her mother back to the psychiatrist, who insisted t none of these problems could be from the shocks administered to her mother's head. He said that Mrs. Williams was depressed and need, more ECT. Instead, Jeannette took her mother home to live with her.
It was now January, and her mother was not getting any better. Mom was a changed person. Her personality was gone. So was her vitality. She could not remember the simplest things such as a phone call message a list of three items to get at the grocery store.
Jeannette took her mom to the university medical center for evaluation. Lengthy neuropsychological testing over a 2-day period indicated that her mother had major impairments in anterograde memory (learning and recalling new material) and in retrograde memory (remembering past events). Some of her memory losses extended back several years. She had difficulty concentrating, and there were impairments of abstract reasoning. Formerly very quick mathematically, she was now poor at simple calculating. Her overall IQ had dropped 20 points. She became very fatigued and frustrated from the effort of trying so hard on the tests.
The neuropsychologist described the pattern as typical of traumatic brain injury, but after a consultation with Mrs. Williams's former psychiatrist, he avoided any suggestion that the deficits could have been caused by a series of electroshocks to the brain. Brain wave studies showed that Mrs. Williams had abnormal slow waves on her electroencephalogram (EEG) consistent with brain injury to the right frontal lobe and the anterior portion of the right temporal lobe (the two sites of electrode placement). A brain scan (MRI) showed possible atrophy in the same region.
To this day, Mrs. Williams's psychiatrist states that he has never seen a case of permanent memory loss, or any other permanent neuropsychological deficits, following ECT. He did not report the case in the literature to the Food and Drug Administration (FDA), or to the manufacturer of the shock machine.
Mrs. Williams remains chronically depressed and refuses to go any doctors for anything. She lives with her daughter, who supports financially.
Cases like Mrs. Williams's have become increasingly common psychiatry relies more and more exclusively on drugs and ECT. The last decade has seen a resurgence in the promotion and use of ECT, called electroshock, or simply shock treatment. For a brief time before the 1997 edition of this book, the press had taken note of the escalating controversy surrounding its use (Boodman, 1996 [156]). A critical article Cauchon (1995) [265] in USA Today was followed up by a remarkable editorial ("Patients, Public Need," 1995), declaring that "the long-term effects e devastating. They include confusion, memory loss, heart failure, in some patients, death". In more recent years, the shock doctors have been working hard to promote this barbaric treatment and have received less criticism from the media.
ECT is a treatment that originated in Italy in 1938 for producing convulsions in psychiatric patients. At the time, it was thought that convulsions induced by a variety of methods, including insulin coma and stimulant medication, were useful in treating psychiatric disorders, especially schizophrenia.
Nowadays, ECT is recommended for major depression, usually other approaches have failed. However, some doctors quickly resort to it. Probably more than 100,000 patients a year in the United Sates are shocked. The majority are women, and many are elderly. Advocates of shock have resisted the creation or maintenance of state registers for shock treatment, so most of the data on the frequency of its use are relatively old. In California, for example, two-thirds of shock patients were reported to be women, more than half of whom were 65 or older (Department of Mental Health, 1989). Data (1989-1993) from Vermont concerning ECT showed that 77% of shock patients were female (W. Sullivan, personal communication, 1996). 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, shocked 35 women and 1 man were 80 and older. Overall, the hospital shocked 112 women and 26 during those 5 years.
The use of ECT tends to vary from institution to institution. At s Hopkins, for example, a biologically oriented center, 20% of the inpatients may be on a regimen of ECT at any one time (Wirth, 1991 [1349]). The data was obtained under oath in a deposition, and I'm unaware of more recent data, but shock treatment in general has increased in usage since then.
Beginning in 1979, when I published Electroshock: Its Brain-Disabling Effects [175], through the 1997 edition of Brain-Disabling Treatments in Psychiatry [198], and even until 2006, during my most recent trial testimony in an ECT malpractice case, I have had to marshal sophisticated, detailed, scientific arguments to show that shock treatment causes permanent memory loss and cognitive dysfunction. In presenting my evidence and my conclusions, I had to overcome uniform disapproval and disagreement from the electroshock establishment that dominates the scientific course. Even psychiatrists who rejected ECT in their own practices would not risk standing up in opposition to the powerful ECT lobby.
Then something remarkable happened. In 2007, a team led by 101 time, staunch electroshock advocate Harold Sackeim et al. [1118] published follow-up study of patients given electroshock. The researchers found that the patients were devastated with widespread losses not only in memory, but also in cognitive functioning-the ability to think and learn.
Sackeim et al. (2007) [1118] followed up 347 patients given the range currently available methods of electroshock, including the supposedly newer and most benign forms, and confirmed that electroshock causes permanent brain damage and dysfunction. The patients were selected from the community, that is, from patients in the real world of clinical practice rather than from an experimental study.
When tested 6 months after the last ECT, each form of treatment was found to cause lasting memory and cognitive dysfunction. The losses extended far beyond the erasure of memories surrounding a few months before and after the treatment. Many patients never recovered normal memory function. They described difficulties learning new things and suffered measurable losses on testing in "global cognitive status". Although the authors avoided straightforward language, the patients were suffering from permanent brain damage affecting global mental function.
The results of the Sackeim et al. (2007) [1118] study were highly statistically significant (p < .0001 on 10 of 11 tests and p < .003 on the 11th). Adding to the evidence for permanent brain damage, many of the patients also had persistent EEG abnormalities 6 months after the treatments had ended. Although the older shock techniques were the most damaging, they were also the most commonly used in the community, and the newer technologies also produced significant lasting deficits in memory and cognitive function.
Despite Sackeim's vigorous opposition to my views over the many years, his study (Sackeim et al., 2007 [1118]) cited my 1986 scientific article "Neuropathology and Cognitive Dysfunction From ECT" published in the Psychopharmacology Bulletin [182], noting that "critics contend ECT invariably results in substantial and permanent memory loss".
Remarkably, the detailed Sackeim et al. (2007) [1118] study leaves out some of the most important details, such as exactly what proportion of patients suffered from each of the various deficits in memory and overall cognitive functioning. The tone of the article implies that just about everyone suffered from deficits; they are treated as one catastrophic group. But the a11-important details were not disclosed. The extraordinarily low p-value on the cognitive testing (p < .0001) provided a strong indicator that the devastation was widespread, involving the vast majority of patients.
Sackeim et al. (2007) [1118] also failed to address the real-life impact of these losses on individual patients and did not provide any clinical vies. Stating that shock treatment permanently reduces memory and cognitive function, and describing it statistically, failed to capture the manner in which the "treatment" destroyed the minds of these patients wrecked their lives. That is why I opened the chapter with the story of Sarah Williams.
Did his own research at last induce Harold Sackeim to make public statements withdrawing his previous wholehearted support for ECT? To the contrary, shortly after the publication of his paper I began to receive nom the media asking me to respond to promotional claims by Dr. Sackeim in support of a supposedly new and improved form of ECT that sounded very much like the same old thing. One is left to wonder 'drives so many mental health professionals in such an unrelenting, remorseless fashion to damage the brains of their patients.
ECT is frequently justified as treatment of last resort in cases at high for suicide. But research uniformly shows that ECT has no beneficial effect on the suicide rate. Indeed, the most thorough study available, published in the British Journal of Psychiatry in 2007, found an overall increased rate of suicide in patients previously given ECT (Munk-Olsen, 2007 [962]). In addition, "patients treated with ECT in the past week had a greatly increased risk of suicide compared with other patients (RR = 4.82, 95% CI 2.22-10.95)" (p. 437, emphasis added).
The authors are proshock and minimized the importance of their concerning increased suicide, not even mentioning it in the title. Furthermore, they failed to make clear that this data wholly contradicted the main justification for giving shock treatment: that it is supposedly the quickest and most effective way of preventing acute suicidal activity. 8d, without evidence the authors repeated the old saw that "suicidal intent in patients with depression is rapidly relieved by ECT" (p. 438).
Munk-Olsen et al. (2007) [962] based their observation on ECT-induced suicidality on a review of all inpatient admissions to a Danish hospital from 1976 to 2000 where 95% of the treatments were unilateral, indicating that the more modern techniques were used. Although the total number of patients given ECT was not provided, the numbers were considerable, given that 149 patients died by suicide during the study period.
All ECT studies involving larger numbers of patients are conducted by doctors who favor the treatment and therefore have access to the data, and invariably they minimize or misrepresent negative results. Munk-Olsen et al. (2007) [962] are typical in this regard, not including any research critical of ECT in their bibliography. The study found that mortality from natural causes was also elevated during the first 7 days after ECT but overall, it was decreased, especially for respiratory diseases. How there is no discussion of death due to ECT treatment itself, including anesthesia, which in itself poses a significant risk (Lagasse, 2002 [803]).
In a blatantly misleading fashion, a series of negative studies were cited by the American Psychiatric Association (APA; 1990b [40]) task force report as showing a positive effect. For example, a retrospective study by Avery and Winokur (1976) [74] found no improvement in the suicide rate compared to matched controls who had no shock treatment: "In the present study, treatment was not shown to affect the suicide rate" (p. 1033). Yet it was presented in the 1990 task force report as supporting that position that ECT results in "a lower incidence of suicide" (p. 53). The task force also mentioned three other studies as supporting a beneficial effect on suicide. However, two of them (Avery et al., 1977 [75]; Milstein et al., 1986 [931]) specifically found no such beneficial effect, and the third (McCabe, 1977) did not even deal with suicide. Meanwhile, unmentioned were two retrospective studies of relatively large populations of ECT patients and matched controls in which ECT had no effect on the suicide rate (Babigian et al., 1984 [83]; Black et al., 1989 [145]).
I have rarely seen so much outright fabrication in the psychiatric literature as I have seen in regard to ECT and lobotomy (for more details see Breggin, 1979 [175], 1981a&b [177][178], 1982 [179]). Perhaps because these treatments are so violent and devastating, the doctors who perpetrate them, much like other perpetrators of violence (Breggin, 1992a [191]), are especially prone to hide or to lie about the harmful effects of what they are doing.
Overall, there is little or nothing in the literature to suggest that ameliorates suicide, whereas a significant body of literature confirms that it does not, and the most thorough study shows that it increases the all suicide rate, including a major increase within the week after the last ECT. Once again, treatment opinions are not driven by empirical data. Instead, empirical data is ignored, distorted, or misrepresented to confirm treatment opinions.
My own clinical impression also confirms that ECT increases the suicide risk for many patients. After ECT many patients profoundly miss memories of significant past events in their lives and feel overwhelmed by their inability to learn and to remember as well as they once did. Many feel as if their personalities and identities have been destroyed. As a result, they often feel deeply betrayed by their doctors. Inevitably some grow increasingly hopeless and suicidal. 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 (Hotchner, 1966 [632]).
As they attempt to recover from the treatment, ECT patients frequently find that their prior emotional problems have now been complicated by 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.
Many shock survivors have told me that reading my articles and books about ECT was a life-affirming experience for them. Instead of reacting with more despair to the confirmation of their ECT-induced brain age and disability, they have felt understood and empowered for the first time. Mental health professionals should be advised that it is both 'cal and beneficial to acknowledge to patients in a supportive, empathic manner that they have been injured by the treatment.
Ross (2006) [1107] recently reviewed the sham ECT literature: "The author reed the placebo-controlled literature on electroconvulsive therapy (ECT) for depression. No study demonstrated a significant difference been real and placebo (sham) ECT at 1 month posttreatment." This was crowning summary of considerable prior research confirming that ECT is ineffective.
Rifkin (1988) [1087] noted that the claim is frequently made that ECT is more effective and works more rapidly than drugs in the treatment of depression. He found 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 (1986) [322], 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 (1986) [322] critical review, which was presented large conference of shock advocates, is not cited in the APA report on ECT. Instead, the APA (1990b) [40] task force's proposal for a "sample patient information sheet" declared that "ECT is an extremely effective form of treatment" (p. 160).
At the June 1985 Consensus Conference on ECT, critics and a advocates of ECT debated the issue of efficacy. The advocates were unable come forth with a single 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 the treatment had no positive effect after 4 weeks confirmed the brain-disabling principle since 4 weeks is the approximate time for recovery from the most mind-numbing effects of the ECT-induced acute organic brain syndrome or delirium.
The Consensus Conference panel concluded in its report that ECT had no documented positive effect beyond 4 weeks. Acute brain damage and dysfunction, with a high probability of permanent adverse effects, are inflicted upon the patient in order to achieve a brief period traumatically induced emotional blunting or euphoria. ECT is a wholly irrational, unjustifiable treatment.
For several decades, I have been a medical expert in lawsuits against doctors and hospitals for causing permanent brain damage with electroshock treatment. I have also been an expert in product liability suits against the manufacturers of the machines. A number of the suits against doctors, hospitals, and shock manufacturing companies were resolved, often substantial settlements for the victims. But on several occasions, when cases against doctors went to trial, they were lost. The cases in which I testified were not the only ones that failed to win a jury verdict. Until 2006, not a single electroshock malpractice case had ever been won court anywhere in the world.
Why were the cases lost in trial? There are no easy answers. In several of the cases in which I was involved, our side presented two, three, and even four medical experts who confirmed that shock causes brain damage. At the same time, the defendants could always find well-known professors of psychiatry to defend the treatment as essentially harmless and enormously beneficial. Probably it has been hard for juries to disentangle totally conflicting evidence from critics and advocates of the treatment. In addition, critics like me refuse to send patients for shock treatment and of course, we do not administer it to patients, so the advocates can present themselves as the only experts with the "clinical experience". In addition, it must be hard for juries to believe that so many doctors and so many medical groups would support a treatment that routinely damages the brain. They must find it hard to believe that doctors would simply lie about the damaging effects of their treatments. Finally, victims of shock treatment often remain irritable and angry for the rest of their lives, suffering from the emotional instability and poor impulse control associated with brain damage and dysfunction. As a result, they sometimes present unsympathetically when they testify before juries.
Finally, in 2006, an electroshock case was won against a physician. But even then, the verdict was quirky. The jury found the prescribing physician negligent. He was the one who initially recommended the treatment. But it exonerated the physicians who administered the treatment, even though they broke numerous standards, including giving the treatment on an outpatient basis on a much more frequent basis than is usually done in the hospital. I thought the doctors who carried out the treatment in such an excessive and cavalier manner were far more to blame than the doctor who recommended it.
The case involved a nurse who believed she had previously benefited the treatment. This time, the series of closely packed treatments obliterated her nursing training and her personal memories extending years and caused continued memory and cognitive dysfunction. I cannot explain why this case was won, while so many others have been lost. In most of the prior ECT trials, I was one among several experts testifying on behalf of the victim; but this time I was by myself. How, the patient's psychotherapist, an empathic and courageous woman, described the devastating effects of the treatment on her client. The attorney was excellent; but I have worked with good attorneys on earlier shock suits. A key defense expert in many cases, Max Fink (see subsequent discussion), was not called to the witness stand, and this probably hampered the doctors' case. Fink had admitted in deposition that he had read the victim's medical record but that he had already decided to testify on behalf of the doctors that they had done nothing wrong. It seemed to compromise his credibility and perhaps kept the defense from calling him to the stand. Whatever the reasons for this victory, in the future, medical experts who are critical of shock treatment will now be armed with Sackeim et al.'s (2007) [1118] research, creating a major breach in the professional wall of silence about shock's damaging effects.
In 1979, the FDA classified shock devices as demonstrating "an unreasonable risk of illness or injury" (see Food and Drug Administration [FDA], 1990 [459]). This would have required animal testing for safety. However, under pressure from the APA, the FDA gave notice of its intent to reconsider its original decision and to reclassify ECT machines as safe. The APA's (1990b) [40] task force report was timed to come out in the midst of the FDA's political squirming over ECT.
The FDA's (1990) [459] final report reads remarkably like the APA's (1990b) [40] report, including the mistaken or false citations mentioned earlier in this chapter. Although no large animal studies have been done with shock vices since the 1950s (some have been done with rats) and although those earlier large animal studies consistently demonstrated brain damage (see subsequent discussion), the FDA panel recommended defining ECT devices as safe for depressed patients. It did so ambivalently, recommending that the approval be delayed until the establishment of engineering safety standards for the machines. The approval process continues to be delayed by the lack of approved standards, and ECT exists in a kind c FDA limbo, which has not discouraged psychiatrists from using it.
I have reviewed what the FDA has made available through the Freedom of Information Act as its complete file on ECT. There are dozens of recommendations from state-funded and private patient rights and advocacy groups to ban ECT, and hundreds more from patients who feel that they have been permanently damaged by the treatment. It is astonish' that the FDA has ignored or rejected such an avalanche of official recommendations and personal reports and protests.
In recommending the approval of ECT as safe and effective, the FDA ignored a most remarkable situation. Before being put on the mark, the ECT machines, such as the commonly used MECTA, were not tested for safety on animals or humans. There were no systematic or controlled studies to evaluate their impact on the living brains of animals or humans. The FDA simply took the word of organized psychiatry and ECT advocates that the treatment is safe and effective. Once again I am left to wonder if we are dealing with a treatment that is so egregiously abusive that the perpetrators, including the APA and the FDA, feel compelled hide the facts from the public.
The political nature of the APA (1990b) [40] task force report is reflected in the membership of the panel that wrote it. The chairperson, Richard Weiner, was APA's official representative in defense of ECT at the FDA hearings and has for some time been APA's chief spokesperson on subject. Two of the other six members are psychiatrist Max Fink and psychologist Harold Sackeim, whom we have already met as among the nation's most zealous promoters of the treatment. Fink (1994 [438], 1995 [439]) has actively pressed for the increased use of shock treatment for children and adolescents. Sackeim et al. (1993) [1117] wrote an article calling for a return to much higher electrical doses, given the "old-fashioned way," with bilateral electrode placement (see subsequent discussion) to increase the intensity of the shocks.
By contrast, the task force (APA, 1990b [40]) sought no input from the several patient organizations that oppose the treatment, and none from psychologists, psychiatrists, neurologists, and other professionals who are critical of it.
The APA (1990b) [40] task force report, in its acknowledgments, thanked the manufacturers of electroshock machines for their contributions; company advertising handouts are listed as useful sources of public information; and the names, addresses, and phone numbers of these companies are provided in the report. The task force is particularly positive toward Somatics Inc., whose sole function is to manufacture the electroshock machine Thymatron. Somatics Inc. is acknowledged for providing "input into the guidelines". Under the heading "Materials for Patients and Their Families," the task force cited a pamphlet by Richard Abrams and Conrad Swartz and a videotape by Max Fink, both of which are advertising materials for Thymatron and can only be obtained by writing to the manufacturer.
The report (APA, 1990b) [40] nowhere mentions any link between Thymatron and Richard Abrams, who would appear to be the task force's most valued expert. One of Abrams's articles is recommended under "Materials for Patients and Their Families" and another under "Materials for Professionals". Nine of his publications are cited in the report's general bibliography, making him by far the most heavily represented author. Abrams is also listed among those individuals who "provided comment on the draft of the ECT Task Force Report". However, his most interesting affiliation is unmentioned: Abrams owns Somatics Inc. In a deposition in which he was a medical expert (DeToma v. Brohamer, 1991 [355]), as a result of my prompting the defense attorney to ask the question, Abrams had to acknowledge under questioning that Somatics Inc. is source of 50% of his income.
Women have always been the main victims of the most destructive psychiatric treatments, including lobotomy. In recent decades, older women have become the major population for ECT, despite the absence of controlled studies on safety or efficacy in the elderly.
One of the most remarkable reports in the ECT literature was published by Warren (1988) [1315], who studied 10 women post-ECT, including their family relationships. Many of the women thought that the purpose of the treatment was to erase their memory. While some felt it was help to forget painful memories, they "uniformly disliked the loss of everyday memory, as well as associated effects such as losing one's train of thought, incoherent speech, or slowness of affect. What specifically was forgotten varied from matters of everyday routine to the existence of one or more of one's children". Warren is not a physician and perhaps without knowing about the specific clinical syndrome, she described mild to moderate dementia caused by closed-head injury in the form of ECT.
According to Warren, family members sometimes approved of the memory loss. One husband said, "They did a good job there," referring to his wife's loss of memory concerning their past marital conflicts. A patient who had been molested by her mother's brother believed that her mother wanted her to have "the full treatment" to "make me forget all those things that happened".
Three of the 10 women lived in dread of ECT for years afterward, but were afraid to express their angry feelings for fear of being sent back to the hospital for involuntary shock treatment. In my clinical experience, this is a realistic fear. Doctors frequently respond to complains about the treatment by deciding that the patient is in need of more treatment. Repeated "treatment" can usually be relied on to put an end to protests.
Shock treatment has been used even more blatantly to erase memories and even the personalities of patients, usually women. H. C. Tien, in the early 1970s, described the use of unmodified ECT to erase the personalities of women, then to "reprogram" them as more suitable wives-with their husbands' help ("Electroshock,", "From Couch to Coffee Shop," 1972). World-renowned Canadian psychiatrist D. Ewen Cameron at McGill University, in part utilizing secret funds from the Central Intelligence Agency, used multiple ECTs to obliterate the minds of his patients and then to reprogram them (Cameron et al., 1962 [251]; more details on the Tien and Cameron controversies, see also Breggin, 1979 [175], 1991b [189]).
As already noted, elderly women have become the most frequent target of ECT. The elderly, of course, have more fragile brains and are especially sensitive to biopsychiatric interventions, even relatively mild doses of drugs. In addition, many elderly already suffer from memory dysfunction due to a variety of causes, making them especially vulnerable to the worst effects of ECT.
Against all common sense, the APA (1990b) [40] task force advised that can be used "regardless of age" (p. 15) and cited the successful treatment of a patient aged 102 (pp. 71-72). It did warn, however, that "some elderly patients may have an increased likelihood of appreciable memory deficits and confusion during the course of treatment" (p. 72).
The aged are, in fact, gravely at risk when exposed to any form of head trauma, including electrically induced, closed-head injury from ECT. There are a growing number of reports of special dangers to the elderly that were not mentioned in the APA (1990b) [40] or FDA (1990) [459] reviews (Figiel et al., 1990 [433]; Pettinati et al., 1984 [1030]). In a curious twist, an article by Burke et al. (1987) [241] was listed in the bibliography of the APA report but cited in the actual discussions of the elderly. Burke et al. [241] found a high (35%) of complications among the elderly. They noted, "Common complications in the elderly include severe confusion, falls, and cardiorespiratory problems" (p. 516).
In a study involving 3 times as many women as men, Kroessler and Fogel (1993) [790] produced data indicating that ECT can cause a devastating decline in longevity:
"This is a longitudinal study of 65 patients who were 80 years old or older at the time they were hospitalized for depression. Thirty-seven were treated with ECT and 28 with medication. Survival after 1, 2, and 3 years in the ECT group was 73.0%, 54.1%, and 51.4% respectively. Survival after 1, 2, and 3 years in the non-ECT group was 96.4%, 90.5%, and 75.0% respectively." (p. 30)
These are extraordinary findings, indicating a very high increase in mortality in the elderly who received ECT. The authors, however, argued that the patients receiving ECT were more physically ill and hence at greater risk of dying. They provided no data to justify this speculation or otherwise explain such a vast difference in mortality.
In the Kroessler and Fogel (1993) [790] study, the tragic lethality of ECT was compounded by its lack of efficacy. ECT patients were much more frequently rehospitalized for depression than non-ECT patients (41% vs. 15%). The recurrence rate of depression was more than twice as high among the ECT patients compared to the non-ECT patients (54.1% vs. 25%). Lasting recovery from depression was much lower in ECT patients (22% vs. 71%). If psychiatry were practiced in a rational manner, a study like this would have brought a halt to giving ECT to the elderly.
Elderly women are particularly vulnerable to being diagnosed with depression, with the associated risk of having ECT imposed upon them. Older women often have many reasons - psychosocial and economic, some of them rooted in the ageist and sexist attitudes of our society - for feeling depressed. Often, these women need improved medical care, social services, family involvement, and loving care from friends and volunteers. Too often, their depression is being caused or aggravated multiple medications for elevated hypertension or elevated cholesterol that can cause feelings of fatigue and depression. Even the so-called antidepressants that have been given to them prior to ECT can cause suicidal depression and an overall worsening of their mental state. Instead of ECT, they need their medications and their overall health care reevaluated, along with all of their basic needs. Meanwhile, they typically do not have the strength to resist a doctor's proposal that they undergo electroshock. There may be no family members available or willing to protect them. One thing the elderly do not need is more brain cell death, mental dysfunction, and memory deficits.
I have been a consultant or a medical expert in several suits in which psychiatrists have tried to administer electroshock against the will of elderly women who had no family to defend them. Each time, the doctors, have backed down or, as in the case of Lucille Austwick, they have lost in court (Boodman, 1996 [156]). However, many other elderly women are pro ably getting shocked involuntarily without their situation gaining pub attention. In addition, in my experience, many seemingly voluntary patients are badgered or misled into taking the treatment.
After one or more shock treatments, ECT routinely produces delirium or an acute organic brain syndrome. Abrams (1988) [7], although an advocate of the treatment, has himself observed that
"a patient recovering consciousness from ECT understandably exhibits multiform abnormalities of all aspects of thinking, feeling, and behaving, including disturbed memory, impaired comprehension, automatic movements, a dazed facial expression, and motor restlessness." (pp. 130-131)
At times, patients are so organically impaired following ECT that they will sit around apathetically on the ward, unable to engage in any activities. On occasion, the patients' neurological dilapidation from routine ECT will reduce them to lying 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 following ECT is normal and harmless.
Given that ECT routinely produces acute, marked brain dysfunction, there can be no real disagreement about its damaging effects. The only legitimate question is, "How complete is recovery?" Even without all the confirmatory evidence presented in this chapter, basic neurology warns that it will frequently be incomplete.
Neurology recognizes that relatively minor head trauma-even without delirium, loss of consciousness, and seizures associated with ECT frequently produces chronic mental dysfunction and personality deterioration (Bernat et al., 1987). 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 an alleged means of improving mental function. ECT is electrically induced closed-head injury.
The symptoms of mild to severe closed-head injury were listed in detail by Fisher (1985) [445]. They include impairment of every area of mental, emotional, and behavioral function, and confirm that the multiple adverse effects of ECT on the mind and brain are classic symptoms of closed head injury. McClelland et al. (1994) [900] described the postconcussive syndrome in terms of
"the emergence and variable persistence of a cluster of symptoms following mild head injury. Common to most descriptions are somatic symptoms (headache, dizziness, fatiguability) accompanied by psychological symptoms (memory and concentration difficulties, irritability, emotional lability, depression and anxiety)."
The authors observed that between one-third and one-half of head injury victims experience this symptom cluster over the first few weeks and a "substantial minority" continue to experience it for months or a year or more.
Head injury victims, including post-ECT patients, frequently develop an organic personality syndrome with shallow affect, poor judgment, irritability, and impulsivity. They seem "changed" or "different" to people around them, much as lobotomy patients often seem to their families. Sometimes they become slightly clumsy, moving awkwardly or dropping things. Often they have "lapses" where they cannot think or cannot voice their thoughts. Sometimes their handwriting deteriorates. Headaches frequently begin with the traumatic treatment and may recur indefinitely.
Many post-ECT patients suffer from irreversible generalized mental dysfunction with apathy, deterioration of social skills, trouble focusing attention, and difficulties in remembering new things. I have worked with a number of them who suffer from dementia, confirmed by neuropsychological testing. Several have developed partial complex seizures or psychomotor epilepsy, permanently abnormal EEGs, and atrophy on brain scans. Many have been deprived of the experience of years of their lives, their professional careers, and their mental ability following ECT (Breggin, 1979 [175], 1981a [177]).
Many deaths were reported in association with ECT in the first few' cades of use. An extensive autopsy series indicated that many suffered from trauma to the brain resulting in visible pathology (Impastato, 1957 [647]). Advocates for ECT have claimed the death rate is very small or nearly nonexistent; but I have suspected that deaths are simply no longer reported. For example, I know of deaths of ECT recipients in the Baltimore - Washington, DC, area that have gone unreported.
There has been some epidemiological confirmation of the probability of a significant death rate. A law passed in Texas in the early 1990s required the reporting of death within 2 weeks after ECT. From June 1993 through August 1994, 8 deaths were reported among nearly 1,700 patients subjected to shock treatment. Controversy surrounds causation, and critics of ECT attempted without success to obtain more autopsy details (Smith, 1995 [1195]).
Electroshock specialists almost never seriously consider the memory deficits of their patients. In case after case that I have evaluated for clinical or forensic purposes, I have been the first doctor to take the symptoms seriously, let alone to take a complete inventory of memory losses and ongoing mental difficulties. I have previously outlined a method for evaluating memory deficits from ECT (Breggin, 1979 [175]).
The recent study by Sackeim et al. (2007) [1118] described earlier in the chapter should put to rest the question of whether or not ECT causes permanent cognitive dysfunction and memory loss. However, psychiatry has a long history of ignoring negative research about its treatments.
For example, the APA (1990b) [40] task force report, like the FDA (1990) [459] report, disregarded all of the relevant research on memory loss, except for Freeman and Kendell's (1986) [489] study, which the task force mentions and then grossly misrepresents. That study asked patients to assess their memory function a year or more after electroshock treatment. The authors themselves remarked that the study was biased toward a low reporting of memory dysfunction because the patients were interviewed the same doctor who had treated them. Nonetheless, 74% mentioned "memory impairment" as a continuing problem, and "a striking 30% felt that their memory had been permanently affected". In defiance of the facts, the APA (1990b) [40] task force cited Freeman and Kendell (1986) [489] as indicating that "a small minority of patients, however, report persistent deficits".
Squire and Slater's (1983) [1210] study, also omitted by the APA (1990b) [40] task force, found that 7 months after treatment, patients reported an average loss of memory spanning 27 months. Squire, in a personal communication to me at the June 1985 Consensus Conference on ECT, explained that one patient lost the recollection of 10 years of her life. He told me that he felt it was not necessary to report this in his actual publication.
The Consensus Conference on ECT (1985) used Squire and Slater's (1983) [1210] results to conclude that "on average, patients endure memory loss ending from 6 months prior to the treatment to 3 months afterward". These data, while serious enough in themselves, are misleading. The data reported at 7 months following treatment, cited in the above paragraph, are more likely to be accurate. The brain cannot regenerate lost brain cells or lost memories. With the passage of more time, there is little likelihood of increased improvement, but much likelihood of a growing tendency to deny the losses.
The APA (1990b) [40] task force also ignored older controlled clinical studies by Janis (1948 [665], 1950 [666]; Janis et al., 1951 [667]) showing extensive, permanent loss of important personal memories and life history following routine ECT. Janis (1948 [665], 1950 [666]; Janis & Astrachan, 1951 [667]) interviewed 19 patients before and after routine ECT, and 11 control patients with similar diagnoses in the same hospitals. The results 1 month postshock were striking: Every shock patient had significant memory losses. Many patients were unable to recall 10-20 life experiences which had been available to recall prior to electroshock treatment.
Janis (1950) [666] followed up five of the patients at 2.5-3.5 months later. Most of the lost memories remained lost. Another follow-up 1 year later owed continuing losses (see review in Breggin, 1979 [175]).
The data generated by Janis (1948) [665] confirmed the importance of ECT spellbinding with denial and anosognosia. Patients tended to minimize or even confabulate to cover up their memory losses, rather than to exaggerate them. One patient, for example, in his pre-ECT interview, reported that he had been unable to work for several months prior to coming to the hospital. The historical facts were confirmed by the family. But after 12 ECTs, he was unable to recall the period of unemployment. Instead, he claimed that he worked right up to his hospitalization. As Janis confirmed, patients often do not complain spontaneously to doctors about their memory loss; they tend to deny it.
Not only was Janis's research left out of the 1990 APA report [40], but over the years, his work has been wholly misrepresented by shock advocates. Two of the more important reviews commonly read during my psychiatric training actually cited Janis as evidence that ECT did not harm memory (reviewed in Breggin, 1979 [175]). I
In 1986, Weiner et al. [1327] attempted to measure the loss of personal subjective recollections following ECT because these are "most consistent with the nature of memory complaints by ECT patients themselves". The memory inventory in the study spanned several years prior to the shock treatment. The group found "objective personal memory losses" that lasted through the 6-month duration of the study.
In an earlier article by a team that also included Weiner (Daniel et al., 1982 [329]), there was emphasis on the potentially injurious effect the patient and the patient's family of losing autobiographical memories. The authors observed that "autobiographical memory failures, if ad across a course of ECT, may produce gross autobiographical men gaps that may be disconcerting to a patient and a patient's family cause the patient's sense of continuity with his or her own past may be disrupted" (p. 923).Yet their subsequent study, in which they demonstrated the existence of the autobiographical memory losses, failed mention how distressing they can be (Weiner et al., 1986 [1327]).
One of the newer techniques of shock treatment-multiple monitored electroconvulsive therapy (MMECT)-employs four electroshocks, in one session, while recording EEG, electrocardiogram, and vital signs. Barry Maletzky, an advocate of the treatment, is one of the few who have asked patients in detail about their memory function following ECT. After pointing out that psychological testing has sometimes failed to confirm cognitive deterioration (Maletzky, 1981 [867]), he observed,
"However, if one listens to what patients say who are treated with either conventional ECT or MMECT, subtle cognitive deficits, not easily tested, are discussed. Some patients will mention deficits only if careful inquiry is pursued. Most will not identify these problems even if asked, thus indicating that either they are absent or so subtle as to be imperceivable to the patient." (p. 180)
Maletzky (1981) [867] then goes on to describe a series of 47 MMECT patients who were interviewed 3-6 months after ECT treatment. Thirty-six percent identified a cognitive problem, including difficulty finding their way around, recalling past events in sequence, and understanding TV shows. In another ECT follow-up study by Maletzky (1981) [867] reported be same book, patients were given a questionnaire and interviews and 23% reported "long-term memory deficits". The problems described by Maletzky's patients extend beyond memory dysfunction to substantial cognitive deficits such as a math student's loss of his ability to do computations in his head.
Devanand et al. (1994) [356], in their review, skated over the surface of the many cognitive studies, dismissing most of them, failing to mention any of the Janis studies, ignoring follow-up studies indicating that patients frequently experience permanent memory loss, and raising no issues about the improbability of full recovery from traumatic acute organic brain syndromes. Appearing in the American Journal of Psychiatry amid wing controversy surrounding ECT, Devanand et al.'s (1994) [356] review was seemingly intended as an establishment response to criticism. For this reason n, I shall examine its conclusions at relevant points in this chapter.
The recent study by Sackeim et al. (2007) [1118] that found widespread, persisting generalized cognitive dysfunction provides proof that ECT causes brain damage. There is also an extensive literature confirming brain damage from ECT. The damage is demonstrated in many large animal studies, human autopsy studies, brain wave studies, and an occasional CT scan study.
Animal and human autopsy studies show that shock routinely causes widespread pinpoint hemorrhages and scattered cell death. While the damage can be found throughout the brain, it is often worst beneath the electrodes. Since at least one electrode always lies over the frontal lobe, it 10 exaggeration to call electroshock an electrical lobotomy.
In 1976 [493], Friedberg published the first review of brain damage from ECT. This was followed by my own detailed critiques (Breggin, 1979 [175], 1981a [177], 1986 [182]). None of these studies and none of the reviews on brain mage were mentioned in the 1990 APA task force report [40].
The original animal studies are from the 1940s and 1950s, but they are still valid. Several of them were elegant by any scientific standard. The model for these studies was conducted by Hans Hartelius on cats a published in 1952 [602] in a book-length publication titled "Cerebral Changes Following Electrically Induced Convulsions".
In the double-blind microscopic pathology examination, Hartelius (1952) [602] was able to discriminate between the eight shocked animals and the eight nonshocked animals with remarkable accuracy. The experimental animals showed vessel wall changes, gliosis, and nerve cell changes:
"The vessel wall changes found more frequently and more distinctly in the animals subjected to ECT consist of characteristic sac-like dilatations of the perivascular spaces, which in some cases contain histiocytic elements. The glial reaction, of the progressive type, consists of an increase in the number of the small glial elements in the parenchyma and satellitosis beside the nerve cells. The nerve cell changes observed are in the form of various stages of chromophobia, frequently with coincident nuclear hyperchromatism. The arrangement of such cells is mainly focal."
The changes were statistically significant. Confirming their basis in sound pathology, the abnormalities were found most heavily in the animals given the greater numbers of ECTs, were most dense in the frontal lobe, and were correlated with increased age of the animal (implying increased vulnerability).
Hartelius (1952) [602] was cautious in his determination of irreversibility. He required the detection of shadow cells and neuronophagia (the removal of dead or diseased nerve cells by phagocytes). On the basis these findings, he concluded, "The question whether or not irreversible damage to the nerve cells may occur in association with ECT must therefore be answered in the affirmative."
Hartelius (1952) [602] used relatively small doses of ECT. In fact, amount of electrical energy he used was a fraction of that currently applied to the heads of shock patients. In general, however, animals are less susceptible to electroshock trauma to the head than humans and require more intensive electrical currents to achieve the same degree of damage. If given the doses used in clinical practice, the damage to the cats would almost certainly have been even greater.
Ferraro et al. (1946 [431], 1949 [430]), of Columbia University and the New York State Psychiatric Institute, conducted controlled studies involving clinical doses of ECT on rhesus monkeys. The researchers used regular ECT machines, smaller-sized electrodes to fit the monkey heads, restraint to keep the heads from banging, and the minimally necessary dose of electricity to cause a convulsion, thereby approximating the intensity of current and voltage used to treat human beings (Ferraro and Roizen, 1949 [430]). The total energy dose was less than that routinely used in modern ECT.
In the 1946 study [431], Ferraro and Helfand administered ECT three times per week to the monkeys in relatively short courses of 4 to 18 in number. As a result of only 4 ECT, one animal had microscopic findings: "Here and there in the cerebral cortex there were some areas of rarefaction [cell loss]." After 12 ECT, another showed "small areas of rarefaction" as well as other evidence of cell deterioration and death. Another, again after 12 ECT, displayed "slight rarefaction of nerve cells and a few acellular areas in the front lobes". In addition to areas of cell death, they also found cells in various states of degeneration, loss of myelin sheaths, glial proliferation, dilated blood vessels, microscopic effusions of blood, petechial hemorrhages, and other neuropathology that they associated with the ECT. The pathological findings were roughly proportional to the numbers of ECTs. Their overall findings were very consistent with, although more severe than, those reported by Hartelius in cats.
In their 1949 study [430], Ferraro and Roizin, used larger numbers of ECTs (32-100). Although excessive by some standards in psychiatry, many patients in fact receive such larger numbers of shock treatments, usually spread over a number of years. After the fewest electroshocks, the researchers found evidence of cell death in the form of "moderate nerve cell rarefaction" and "acellular areas, again proportionate to the current intensity and the number of ECT". Photographs of the microscopic findings were reproduced in both papers.
Alpers and Hughes (1942a) [28] studied the effects of ECT on cats and found evidence of subarachnoid hemorrhages and scattered punctate hemorrhages in the brain. They correlated this damage with autopsy findings in two human cases (Alpers and Hughes, 1942b [29]). Alpers (1946) reviewed the literature on ECT experiments involving animals, including additional studies of cell death in dogs (Neuberger et al., 1942 [978]) and rabbits (Heilbrunn et al., 1942 [611]). Alpers noted that even studies that claimed to show little or no effects from ECT in fact often provided evidence of cellular abnormalities and even cell death in the brain.
Neither the Hartelius (1952) [602] study nor any of the other studies using large animals cited in this section were included in the 1990 APA [40] task force report on ECT. An oversight such as that cannot occur by chance but instead must have reflected a conscious attempt to withhold vital information about the dangerousness of ECT.
The Russians carried out a variety of neuropathology studies on animals subjected to clinical ECT to determine if there is permanent brain damage. Babayan [82] called for a ban on the treatment in 1985, citing work the USSR Academy of Medical Sciences as "convincing proof ... pointing to grave changes in the central nervous system, the nerve cells, the glial-tissue apparatus" (p. 37). At another institute, studies of the brains of animals led to a "drastic reduction in the use of electroshock therapy in clinical practice" (p. 134). Babayan [82] compared the treatment to lobotomy.
There have been no studies of large animals using modified ECT under clinical conditions, even though this so-called new form of ECT was developed in the 1960s. Meldrum and Brierley (1973) [916] studied drug-induced (bicuculline) lengthy seizures in baboons and found widespread ischemic (due to lack of blood flow) changes. Meldrum et al. (1973) repeated their earlier experiment, now employing modified ECT, and found similar but lesser ischemic changes in neurons. They concluded that modifying the ECT gave some incomplete protection. However, the seizures were very long. Meldrum et al. (1974) [917] once again studied the impact of drug-induced (allylglycine) seizures in baboons under modified conditions. They used 13 animals, and in 8, the seizures were brief, recurring 6-63 times in 2-11 hours, followed by recovery. The short-duration seizures produced no detectable pathology.
Templer (1992) [1248] reviewed the question of ECT and permanent brain damage. In regard to animal studies, he focused on Hartelius (1952) [602] and also pointed out that animals given artificial ventilation (modified ECT) in other studies also had "brain damage of somewhat lesser magnitude".
While few psychiatrists are willing to admit in public that ECT causes brain damage, a large survey of the APA membership, conducted with anonymity in the 1970s, showed that 41% of the respondents agreed with the statement "It is likely that ECT produces slight or subtle brain damage". Only 26% responded that it did not (APA, 1978 [33]).
As noted previously, Devanand et al. (1994) [356] published an article titled "Does ECT Alter Brain Structure?"19 They concluded that animal studies do not show brain damage. They did this by dismissing the best studies. Hartelius (1952) [602], for example, was criticized for applying a series of four ECTs, with each one spaced at 2 hours. But there is no reason to assume that this method is more damaging than larger numbers of shocks spaced over longer intervals. As currently used, multiple-monitored ECT inflicts four shocks within the space of an hour or so. In addition, it is extremely misleading of Devanand et al. (1994) [356] to focus on that one group of animals. Some of Hartelius's animals, for example, were given one ECT per day for 4 days, others were treated "with clinical frequency (three per week), and many showed evidence of brain damage.
Devanand et al. (1994) [356] dismissed Ferraro and Roizen (1949) [430] for using a "large number of ECSs [electroconvulsive shocks] relative to clinical practice," but in fact, many patients are given 32 or more treatments, sometimes in one series, more often in several. Ferraro et al. (1946) [431], Utilizing fewer shocks, were dismissed on the speculation that the current went through the brain stem.
Devanand et al. (1994) [356] did not deal with the fact that almost every study using large animals, by their own table, showed damage. My review indicated that even purportedly negative studies, on actual reading, indicated harmful effects (Breggin, 1979 [175]). For example, Devanand et al. (1994) [356] described Lidbeck's (1944) three dogs as developing "minimal perivascular and ischemic changes". They left out that in two of the four animals, "nerve cells were shrunken and there was a decrease in the number of stainable granules" (Lidbeck, 1944 [839]). Nor did they mention that of the animals developed blood clots in its brain.
Even if Devanand et al. (1994) [356] had valid points to make, criticizing a raft of animal studies that show damage cannot be used as a method for proving the safety of ECT. To be ethical and scientific, shock advocates would have to produce carefully conducted, large-animal studies that show no damage. In fact, the only studies that Devanand et al. (1994) [356] found acceptable were performed on rats, rather than dogs, cats, and primates, whose brains are more akin to humans and more sensitive to damage. In comparison to monkeys, cats, and dogs, rats, with their smaller brains and thick skulls, are notoriously resistant to head trauma.
The prospects of more modern ECT being safe are nil. The newer methods add the risk of anesthesia, often complicated by multiple psychiatric drugs administered simultaneously. The electrical trauma must be sufficient to cause a grand mal seizure. Grand mal seizures, when repeated and especially when as severe as those caused by ECT, are in themselves harmful to the brain. Nor are modern variations in current intensity necessarily more benign because, in order to cause a seizure with the weaker currents, exposure time is often increased by 10-fold or more over earlier ECT methods. Also, in order to overcome the anticonvulsive effects of the sedatives administered to put the patients to sleep, modern ECT often inflicts more intense electrical energy on the brain than the older animal studies and older forms of ECT (see the section "Modified ECT"). Perhaps most obvious and important, the study by Sackeim et al. (2007) [1118] shows that the effects of modern ECT continue to be devastating.
In addition to demonstrating safety, shock advocates would also have to prove efficacy through double-blind clinical trials comparing ECT to sham or placebo in which the subject is put to sleep without the actually administering the shock. Thus far, placebo-controlled trials have failed to show any significant superiority of ECT over sham ECT.
There has been contradictory evidence of ECT damage in brain scan studies, most of which have been carried out by staunch advocates of the treatment. Using CT scans, Weinberger et al. (1979) [1326] found that chronic patients with schizophrenia who had ECT had more enlargement of their ventricles (cerebral atrophy) than those who had no ECT. Stretching exonerate ECT, they declared, "Either ECT further enlarged the ventricles of the patients treated with it, or it was used with greater frequency patients who tended to have larger ventricles." In another CT study, Calloway et al. (1981) [250] found a correlation between frontal lobe atrophy and ECT in 41 "elderly depressives".
Coffey et al. (1991) [292], using MRI, studied 35 patients before and after ECT. The follow-ups were 2 or 3 days after and 6 months after. In five subjects, they found "an apparent increase in subcortical hyperintensity". Coffey, a strong ECT advocate who has performed shock on many patients, dismissed his own finding as "most likely secondary to progression of ongoing cerebrovascular disease during follow up". I have seen several other patients with very similar post-ECT MRI findings.
Pande et al. (1990) [1018] found no MRI pathology in seven ECT patients. However, the studies were performed I week after the last ECT so that late-maturing pathology would not have been discovered. Bergsholm et al. (1989) [133] found no pathology on MRI in 40 patients, with the exception of a 69-year-old man, who suffered a dilatation of the left temporal horn, which the authors dismissed as unrelated to ECT.
Devanand et al. (1994) [356] reviewed the brain scan literature and found the evidence for brain damage unconvincing. They accepted Coffey et al.'s (1991) [292] unsubstantiated claim that the four damaged patients had progressive cerebral vascular disease, rather than ECT pathology. They dismissed studies showing damage.
In reality, brain scans are not an appropriate instrument for measuring ECT brain damage. None of the damage found in the large-animal studies-such as small areas of dead and dying cells and small pinpoint hemorrhages scattered throughout the brain-would show up on brain scans, which cannot detect damage at a microscopic level until it is massive enough to result in gross atrophy or tissue shrinkage. To use brain scans to show that ECT is harmless is a scientific scam. On the other hand, in my medical-legal work I have on occasion seen patients whose before-and-after brains scans did detect atrophy following ECT.
For the past 40 and more years, a modified form of ECT has been standard, involving sedation with a short-acting barbiturate, muscle paralysis with a curare derivative or similar drugs that prevent activation of muscles of the body, and artificial respiration with oxygen. The purpose of these modifications was not, as some advocates claim, to reduce memory loss and brain damage. Muscle paralysis was intended to prevent fractures from severe muscle spasms, while the artificial respiration kept the paralyzed patient breathing.
The modifications used in contemporary ECT make it clear that ECT-induced convulsions are far more severe than the spontaneous convulsions in grand mal epilepsy. Patients with spontaneous seizures of unknown origin, or with seizures due to brain injury, rarely break their limbs or their vertebrate during the convulsion. The muscle spasms are not intense enough to produce these dramatic effects. Yet these fractures were common with unmodified ECT.
Shock advocates claim that newer modifications have made the treatment much safer and that its negative public image is unfairly based on the older methods. However, the most basic modifications-anesthesia, paralysis, and artificial respiration-are not new at all. I prescribed and administered this kind of modified treatment more than four decades ago (1963-1964) as a resident at Harvard Medical School's main psychiatric teaching facility, the Massachusetts Mental Health Center.
The public's so-called "mistaken" image of ECT is, in reality, based on modern modified ECT, which has been around for a long time. As mentioned earlier, it is actually more dangerous than the older forms. The electrical currents must be more intense to overcome the anticonvulsant effects of the sedatives that are given during modified ECT (Breggin, 1979 [175]). Too frequently, the patient is routinely given a sleeping medication or tranquilizer the night before, further increasing the brain's resistance to having a seizure. Although ECT experts recommend against it, commonly patients are prescribed multiple psychiatric drugs at the same time. In addition, patients are exposed to the added risk of anesthesia. Other modifications include changes in the type of electrical energy employed and the use of unilateral shocks applied to the nondominant (nonverbal) side of the brain. However, the efficacy of these modifications remains controversial among shock advocates and, as a result, older methods continue to be used much or even most of the time (Sackeim et al., 2007 [1118]).
Since the APA (1990b) [40] task force does not exclusively endorse the modified forms of ECT, the claim that modern ECT is somehow much safer is again undercut. Besides, as already emphasized, some ECT advocates give excessive doses-beyond the dose required to produce a convulsion. Sackeim has advocated using electrical doses so large that the safety controls on the machines have to be disabled (Sackeim et al., 1993 [1117]).
There is no reason to believe that shocking the nonverbal side of the brain is less harmful. As Blakeslie (1983) [146] confirmed, damage and dysfunction on the nonverbal side are more difficult for the individual to recognize or describe (see discussion of anosognosia in chapter 1). But the defects are no less devastating. Injury to the nonverbal side impairs visual memory, spatial relations, musical and artistic abilities, judgment and insight, intuition, and personality. Because of the victim's difficulty perceiving damage to the nondominant side of the brain, and because it impairs judgment and insight, modified nondominant ECT is probably more spellbinding. Meanwhile, it is ironic that biopsychiatry promotes sacrificing the nonverbal side of the brain, while humanistic psychology is emphasizing its importance to the full development of human potential.
Beginning with Cerletti and Bini, who introduced electroshock in 1938 in Italy, many advocates of the treatment have not wanted to make the treatment less harmful to the brain. They have considered brain damage necessary for the cure and often spoke openly about it (Cerletti, 1940 [268]; reviewed in Breggin, 1979 [175]).
Fink, himself a member of the 1978 [33] and 1990 [40] APA ECT task force for decades argued and demonstrated scientifically that ECT's "therapeutic" effect is produced by brain dysfunction and damage. He pointed out in his 1979 textbook that "patients become more compliant and acquiescent with treatment" (p. 139). He connected the so-called improvement with "denial," "disorientation" (p. 165), and other signs of trauma brain injury and an organic brain syndrome. This is a direct confirmation of the brain-disabling treatment and the use of iatrogenic denial authoritarian psychiatry.
Fink was even more explicit in earlier studies. In 1957, he stated that the basis for improvement from ECT is "craniocerebral trauma". In 1966 [436], Fink cited research indicating that after ECT, "the behavioral changes related to the degree of induced trauma" (p. 475). Referring to the multi abnormalities produced in the brain following ECT, he wrote, "In these regards, induced convulsions in man are more similar to cerebral trauma than to spontaneous seizures" (p. 481). He stated that improvement depends on the development of an abnormal EEG and other changes in the brain and spinal fluid typical of trauma and compared ECT to "cerebral trauma" (p. 48). Fink (1966) [436] cited Tower and McEachern (1949) [1261], correctly stating that they "concluded that spinal fluid changes in induced convulsions were more like those of craniocerebral trauma than those spontaneous epilepsy". He then gave further evidence for this comparison between ECT and traumatic brain injury.
Up to at least 1974 [437], Fink continued to propose that ECT has its effect by traumatizing or damaging the brain. He began his discussion by noting that psychiatric treatments have often been "drastic" and then cited, among other examples, heat and burning, bleeding, water immersion, and craniotomy. He then went on to present several axioms of ECT, including the connection between the supposed therapeutic effect and traumatic changes in the brain. He spoke directly of the producing "cerebral `trauma' " (p. 9) reflected in EEG slow wave activity. He compared induced convulsions to "craniocerebral trauma" (p. 10). He attributed improvement to the increased use of "denial" by the patient and to the development of "hypomania" (p. 14)-both clinical signs of profound irrationality caused by brain damage and dysfunction.
Psychiatry's more recent emphasis on proving that ECT is harm has developed in response to scientific criticism of the damaging effects made by me and by others, such as neurologist John Friedberg (1976 [493], 1977 [494]) and shock survivor Leonard Frank (1979 [482], 1980 [483], 1990 [484], 2001 [486]). Thus, the APA (1990b) [40] task force report, despite Fink's participation, made no such comparisons between head injury and ECT; instead, the report dismissed any suggestion that the treatment is severely traumatic. In depositions and trial testimony in defense of doctors who give ECT, Fink now takes the position that ECT causes no brain damage.
The 1990 APA task force [40] report noted that low-dose unilateral ECT is often less effective than forms of ECT that deliver more electrical energy. This observation tends to confirm the brain-disabling principle that so called therapeutic efficacy is a function of the degree of treatment-induced damage.
Sackeim et al. (1993) [1117] covertly revived the concept promoted by ECT pioneers that a therapeutic response depends on inflicting brain damage and dysfunction. They advocated bilateral ECT - the most obviously aging method - using a dose of electricity 2.5 times that required to induce a convulsion in the patient. I evaluated a case in which a doctor followed Sackeim et al.'s published recommendation and gave his patient the increased dosage. The patient suffered severe, irreversible memory loss and chronic mental dysfunction, rendering her permanently unable to work at her previously high intellectual level.
Psychiatric drugs are nowadays frequently justified on the grounds that they correct biochemical imbalances. Like Prozac, shock treatment is said to work by enhancing serotonin (e.g., Abrams, 1988 [7]). Accepting this rationale requires ignoring the more gross damage being done: The shocked brain is so traumatized that the patient is rendered too confused and blunted to feel any subtle emotions. Even psychosurgery is nowadays sometimes justified on the grounds that it corrects biochemical imbalances. One advocate looks forward to delivering serotonin "psychosurgically" to "serotonin-depleted sites" in the brain (Rodgers, 1992 [1092], p. 106).
ECT provides a prototype for the concept of iatrogenic helplessness and denial, and spellbinding (chapter 1). Controlled studies of ECT show that any therapeutic effect evaporates after 4 weeks-the approximate time it takes to recover from the most severe symptoms of organic brain syndrome or delirium. Except for psychosurgery, ECT provides the most extreme example in which the psychiatrist denies the damage he is doing to the patient, and then utilizes the effects of that damage to produce a less emotionally aware, less autonomous, and more manageable patient. As Max Fink's earlier work openly described, through brain damage and the exercise of medical authority, patients are pushed deep into denial about the harm done to them as well as about their still unresolved personal problems. This is an example of profound spellbinding intentionally inflicted on the patient under the guise of treatment.
Consistent with other victims of central nervous system damage, most ECT patients minimize or deny their real losses of mental function. This denial of mental dysfunction in brain-damaged patients is call anosognosia (discussed in chapter 1). While damage to either side of the brain can produce anosognosia, it seems more common following damage to the nondominant side (in right-handed individuals, the right is usually nondominant). In electroshock treatment, at least one electrode lies over the nondominant side. In contemporary ECT, both electrodes are frequently placed over the nondominant side. As already noted, damage to the nondominant side of the brain impairs judgment and insight without the patient realizing it, making the treatment very spellbinding.
Nondominant shock starkly illustrates the principle of iatrogenic helplessness and denial: The doctor damages the brain in such a way to confound the patient's ability to perceive the resulting dysfunction.
Advocates of ECT are well aware that shock patients suffer from anosognosia and denial and therefore cannot fully report the extent their memory losses and mental dysfunction. Yet these same advocates claim that patients exaggerate their post-ECT problems.
Interviews with family and friends of patients often disclose that they are painfully aware of the damage done to their loved ones. Often, the psychiatrist is the only one who consistently and unequivocally denies the patient's damaged state.
The 1978 APA [33] task force report labeled electroshock treatment controversial. The 1985 Consensus Conference on ECT report stated, "Electroconvulsive therapy is the most controversial treatment in psychiatry" and referred to 45 years of dispute surrounding issues such as efficacy and "possible complications". In the opening sentence of the introduction to Abrams's (1988) book [7], Fink referred to the "more than 50 years of controversy" surrounding ECT.
Since my 1979 book [175], I have hammered at the right of patients to know that ECT is a controversial treatment, and I have cited the previous quotations in medical-legal reports and testimony. Many survivors of shock treatment, such as David Oaks of MindFreedom and Leonard Frank, have made similar points. Perhaps as a result, the 1990 APA task force report said not a word about controversy. ECT is presented as if no one in the profession has ever criticized it. Psychosurgery remains the only treatment surrounded by more controversy than ECT, but it is used much less frequently (Breggin et al., 1994b [220]). The two treatments are closely related in many ways. Electroshock can be understood as "closed-head electrical lobotomy".
The most significant challenge to ECT within the medical profession was launched by neurologist John Friedberg (1976) [493], whose book for laypersons was followed by a journal review (Friedberg, 1977 [494]). Friedberg's publications were quickly followed by a volume edited by Leonard Frank (1978) [481] and a book by this writer (Breggin, 1979 [175]). Reviews of ECT-induced damage to the brain and mind have continued to be published in professional journals (Cameron, 1994 [252]; Frank, 1990 [484]; Templer, 1992 [1248]). Templer and Veleber (1982) [1250], for example, summarized their review of literature:
"Some human and animal autopsies reveal permanent brain pathology. Some patients have persisting spontaneous seizures after having received ECT. Patients having received many ECTs score lower than control patients on psychological tests of organicity, even when degree of psychosis is controlled for."
"A convergence of evidence indicates the importance of the number of ECTs ... .Our position remains that ECT has caused and can cause permanent brain pathology."
Boyle (1986) [164] reviewed the literature and stated,
"In conclusion, there is considerable empirical evidence that ECT induces significant and to some extent lasting brain impairment. The studies cited above are but a few which suggest that ECT is potentially a harmful procedure, as indeed are most naturally occurring episodes of brain trauma resulting in concussion, unconsciousness and grand mal epileptic seizures. Accordingly, the continued use of ECT in psychiatry must be questioned very seriously." (p. 23)
After hearing evidence presented to the Food and Drug Administration's Respiratory and Nervous System Device Panel, consumer representative Susan Bartlett Foote (1983) [478] reported back to the FDA that
"evidence of the safety and efficacy of ECT devices remains controversial and conflicting. The `new evidence' submitted [by the American Psychiatric Association] petition did not, by any means, eliminate the unanswered or troubling questions surrounding safety and efficacy of the machines." (p. 2)
Consider that all of this was published before Sackeim et al.'s (2007) [1118] study showing permanent harm to the brain and mind caused by ECT. Psychiatry has ignored the decades of research that long ago should have brought the treatment to a halt.
Survivors of shock treatment have become an increasingly active force. In addition to writing and appearing in the media, many who have undergone ECT continue to protest at national psychiatric conventions and shock symposia and even chain themselves to the gates and doors so-called "shock mills".
More than 30 states have passed legislation to monitor ECT, limits on the number of treatments or the age at which it can be given, and require second opinions and informed consent. Four states have banned its use on children, most recently Texas. While efforts to quire informed consent have proved almost impossible to enforce in face of psychiatric resistance, they have raised further questions about the use of shock treatment. However, critics of shock have relatively little clout or funding compared with the American Psychiatric Association and organized shock advocates, who have fought continuously against any monitoring or any restraint of ECT; little progress in reform has made in recent years.
The most dramatic threat to shock treatment became known as the"Berkeley ban". Ted Chabasinski, who had been subjected to electroshock as a child, organized a grassroots citizens' movement in support of a referendum to ban ECT in Berkeley, California. After the proposition was overwhelmingly approved by the electorate, the psychiatric establishment, led by the APA, intervened and had the ban overturned court. But the survivors could claim a partial victory-a so-called "power outage" of 41 days at Herrick Hospital, the city's only ECT facility, in the winter of 1982.
California again became the center of public criticism of electroshock. Inspired by a coalition of former patients and concerned professionals, Angela Alioto, a member of the San Francisco Board of Supervisors held hearings on ECT. About two dozen "shock survivors" testified about permanent damage to their brains and minds. Although both sides had ample time to organize, no shock patients showed up to offer testimonials in favor of the treatment (Breggin, 1991b [189], 1991c [190]; Frank, 1991 [485]).
The recommendations of Alioto's committee were adopted by the city's governing body and signed by Mayor Art Agnos on February 20, 1990. The resolution declared the opposition of the Board of Supervisors the "use and financing" of ECT in San Francisco (Figueroa, 1991 [434]). It also called for the state legislature to develop more strict requirements for informed consent, including the exposure of potential patients to live or videotaped presentations by critics of the treatment. The resolution, which followed the recommendations made in my testimony at the Alioto hearings, was not legally binding. While the resolution has been an important moral and educational victory for electroshock opponents, its actual impact was negligible.
David Oaks is the executive director of MindFreedom (http://www.mindfreedom.org), the leading survivor organization in the world fighting for psychiatric patient rights and resisting psychiatric abuses. He edits the group's magazine, organizes protests against psychiatric abuses like electroshock treatment, and in general inspires reform-minded professionals and victims alike.
The 1990 APA [40] task force report represented a disillusioning and disappointing watershed for my own reform activities around ECT. I had long argued that ECT was an ineffective, dangerous, anachronistic treatment that should be abandoned by modern psychiatry. Yet, despite the urging many victims of ECT, I refused for many years to endorse public or legislative efforts to ban it. It was my position that the practice of medicine and the rights of patients were better served by insisting on informed consent-and by holding liable those psychiatrists who fail to convey to their patients the controversial nature of ECT and its potentially damaging effects. Unfortunately, the 1990 APA report [40] and the APA's political pressuring of the FDA demonstrated that organized psychiatry was determined not to inform professionals or patients about the risk of ECT. Despite the disclaimer tucked away on its copyright page, the APA report provided a shield for those who recommend and administer ECT -an "official" conclusion that there is no serious risk of harm. Doctors who prescribe or recommend ECT can try to hide behind this report when their injured patients protest to them or bring legal actions.
In the environment created by the APA, informed consent for ECT became a mirage. Therefore, after much initial hesitation, I decided to endorse public efforts to ban ECT. I believe that all concerned mental health professionals should support the banning of ECT.
Given that even the APA and the FDA published fraudulent claims about the harmlessness of ECT, it is fair to conclude that patients are rarely if ever going to be given informed consent by doctors who advocate the treatment. Because ECT promoters like Max Fink, Richard Abrams, and Harold Sackeim are considered believable authorities by their colleagues, practicing psychiatrists feel safe in telling their patients that ECT is relatively harmless and very effective.
I have read sworn testimony by many shock doctors, reviewed the medical charts of their patients, and seen the "consent" forms that they give to their patients-and I have never seen a case in which a patient was given adequate information about the treatment's brain-damaging effects. If they were informed about the results of animal experiments or the results of Sackeim et al.'s (2007) [1118] recent research, all but the most self destructive patients would refuse the treatment. Because ECT patient will never be given informed consent, the only alternative is a ban on the treatment. Some patients do feel "helped" by ECT. Often, they have been so damaged that they cannot judge their own conditions. They suffer from ECT spellbinding, as well as iatrogenic denial and helplessness. But should a treatment be banned when some people believe they are helped by it? In fact, it is commonplace in medicine and psychiatry to withdraw treatments and devices that have caused serious harm to a small percentage of people, even though they may have helped a very large percentage. The risk of serious injury to a few outweighs helping many. In the case of ECT, a large percentage of people are being harmed, and there is little evidence that any are being helped.
Based on the original large-animal studies that demonstrated ECT induced brain damage, organized psychiatry should have banned the "treatment" decades ago. Even without the animal studies, Sackeim et al.'s (2007) [1118] demonstration of permanent ECT-induced memory loss and other cognitive deficits consistent with dementia should have been sufficient to stop all use of the treatment. This chapter has also reviewed, mountain of additional research confirming that ECT damages both the brain and the mind.
There is no need to advocate for additional research. Why damage the brains of more animals and more people? The facts have been conclusively established. Shock treatment physically damages the brain, irreversibly impairs mental function, and ruins the lives of many if not most patients who are subjected to it. On top of that, controlled clinical trials comparing ECT to sham ECT show no advantage to the treatment. ECT should be utterly discarded as a useless, damaging relic from psychiatry's more violent past.
Unfortunately, psychiatry shows not the slightest inclination to rein its compulsion to damage the brains of its patients in the name of "treatment". Sackeim et al.'s (2007) [1118] study aroused no concern whatsoever within the profession. Psychiatry's more abusive treatments, such as ECT, will never be stopped by psychiatry itself. ECT will have to be stopped by forces outside the profession including public outrage, court decisions prohibiting its use, and legislation banning it.