Introduction
This article continues my examination of the risks and harms of electroconvulsive therapy.
Electroconvulsive therapy is also called ECT, electroshock therapy, electroshock treatment, shock treatment, and electroshock. It may be called shock therapy, although there are additional types of shock therapy, such as insulin shock therapy. It is a psychiatric treatment in which electricity is transmitted through the brain to produce a supposedly therapeutic seizure. It is often performed involuntarily, that is, against the will of the patient. This is currently legal in Connecticut and many other places.
My first article on this subject, dated January 14, 2012, was the story of my personal experience at the Institute of Living and an entreaty to three Connecticut politicians to ban involuntary shock therapy in the state. I mailed that article to them as well. The second article, dated November 21, 2012, was a summary of references about trauma and memory dysfunction caused by electroshock.
I may sound like I’m flogging a dead horse. However, it is important to continue this discourse, because I have recently learned that State Representative Sandy Nafis and State Senator Paul Doyle have heeded my entreaty. They have introduced a bill in the General Assembly, Proposed Bill 5298, that would end involuntary shock therapy in Connecticut. This is a pivotal step. Yet the recent massacre at Sandy Hook Elementary School has stirred people to make involuntary psychiatric treatment easier, which may put pressure against this important bill. Therefore, I feel even greater responsibility to report on the risks and harms of electroshock.
In psychiatric research articles about ECT, there are some common mantras. It is commonly stated that the treatment is safe and effective. There is also an implication that opposition to ECT is irrational or misinformed.
Psychiatrists may even view patient antagonism toward electroshock as a symptom of mental illness, as some psychiatrists already view denial of illness by certain people with certain illness diagnoses as a symptom of the illness. In a related sentiment in a January 29 Hartford Courant article, Harold I. Schwartz, Psychiatrist–in–chief of the Institute of Living, was quoted saying, “Chronic schizophrenia and certain other chronic and severe mental illnesses are often marked by denial of illness. The failure to recognize illness and the need for treatment … is a function of the disease's impact on the brain – not unlike the stroke victim who is unable to recognize that one side of the body is paralyzed. […] in our efforts to protect autonomy we are acting to protect the decision making of individuals whose capacity for autonomous decision making has been severely impaired by mental illness.” Schwartz has authority to deem patients legally incapable of informed consent to shock therapy, as a “head of the hospital” according to Connecticut law Chapter 319i, Sec. 17a-543(c).
In this article, I summarize more research that contradicts opinions of the psychiatric establishment about electroconvulsive therapy.
Risks to Memory and Cognition
In a study published in July 2007 in the Journal of Psychiatry & Neuroscience, researchers Glenda MacQueen et alia did a memory assessment of a group of healthy comparison subjects, a group of patients with bipolar disorder who had undergone a course of ECT at least six months prior to the assessment, and a group of similar bipolar patients who had never undergone electroshock (pages 241–242). The subjects were matched for age and sex. The assessment included the California Verbal Learning Test, the Continuous Visual Memory Task, and a computerized process dissociation task examining recollection and habit memory.
There were several exclusion criteria, including substance abuse, treatment with transcranial magnetic stimulation, closed head injury, a reading deficit, untreated medical illness (such as hypertension), and current mania or depression (242). Patients were aged 30–65. There were 20 test subjects per group (243). Illness burden between the two patient groups was about the same (243–244).
Both the bipolar patients who had been electroshocked and the bipolar patients who never been electroshocked exhibited significant impairment in verbal learning and recollection, in contrast to the age and sex–matched healthy subjects (245). However, patients who had been electroshocked had worse performance on the California Verbal Learning Test than patients who never had ECT (246).
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In a study published in 2008 in the periodical Neuropsychiatric Disease and Treatment, researchers Miriam Feliu et alia examined the effects of electroshock on neuropsychological test performance. Using archival methods, they reviewed the records of 46 patients with major depression before and after ECT.
The testing was comprised of the Short–Term Memory Questionnaire (STMQ), the Levin Selective Reminding Test (Levin), and the Logical Memory and Visual Reproduction subtests from the Wechsler Memory Scale (WMS–R). They report, “On a verbal list–learning test (Levin), there was a significant decrease in long–term storage and immediate recognition memory following ECT.” Other aspects of memory were also undermined.
Ironically, in the STMQ, the patients generally were unable to recognize the changes in their memory functioning. Feliu et al concluded, “Contrary to the established literature, patients indicated memory deficits both before and after receiving ECT, but did not report a significant change in their subjective ratings of memory functioning. Indeed, there was a slight trend towards improved memory functioning, despite the objective neuropsychological data indicating significantly lower recognition and delayed recall.”
Disconcerting Changes to Rat Biochemistry
Márcio Búrigo et alia had a study published in the periodical Neurochemical Research in July 2006. They studied the activity of creatine kinase in rats after electroconvulsive shock (ECS), an analog of ECT in humans. They note, “Creatine kinase is a crucial enzyme for brain energy homeostasis, and a decrease of its activity has been associated with neuronal death” (877). They describe how creatine kinase is important in the metabolism of tissues that consume high amounts of energy, such as the brain, skeletal muscle, and the heart (878).
The rats used were adult male Wistar rats (878). One group of six rats was given a single acute shock and another group of six received eight chronic ECS every other day. There was also a sham (control) group that didn’t get electroshocked. The rats were decapitated. From each brain, the hippocampus, striatum, and cerebral cortex were dissected out. Samples were tested using a creatine kinase activity assay.
It was found that creatine kinase activity was inhibited (decreased) in both rat groups that had ECS.
Although the authors echo pro–ECT sentiment that such changes may be related to electroconvulsive therapy’s supposed therapeutic effect, they also speculate that the change may be related to the cognitive impairment caused by electroshock (879–880).
An interesting paragraph in the Discussion section states:
It is known that a diminution of creatine kinase activity may potentially impair energy homeostasis, contributing to brain damage. In this context, creatine kinase inhibition has also been observed in neurodegenerative and mental diseases, such as Alzheimer’s disease and schizophrenia. Besides, it has been demonstrated that the enzyme is also inhibited in animal models of some inborn errors of metabolism affecting the brain. Finally, it would be expected that reduced functional brain activity may result in cognitive deficits.
Doubtful Efficacy
In a study published in February 2004 in the periodical Biological Psychiatry, researchers Joan Prudic et alia examined 347 patients treated with electroshock therapy, in order to assess how medicinally effective the treatment was upon their mental illness.
In their introduction, Prudic et al note several research articles concluding that electroconvulsive therapy is highly effectual, saying the estimated rate of remission for patients who undergo ECT is 70–90% (301). However, they also note, “Medical treatments frequently do not perform as well in routine practice as in controlled clinical trials.” Their study was unusual in the fact that it was not a controlled clinical trial, but instead examined patients in diverse community settings, possibly providing a more realistic indication of the medicinal efficacy of ECT.
The patients in the study were given extensive neuropsychological testing before their courses of ECT, immediately afterward, and at a 24–month follow–up point (302). Contrary to the cited clinical trials indicating that ECT causes a high rate of remission from mental illness, this study concluded that only 30.3–46.7% of the subjects went into remission. Among the participants deemed to have gone into remission after ECT, 64.3% were considered to have relapsed at the follow–up point (309–310).
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In a study published in 2003 in the British Medical Journal, researchers Diana Rose et alia did a review of 27 research articles about patient opinions of electroconvulsive therapy (1363). They analyzed the amount of patients giving positive responses that they think ECT is helpful or that they would choose to have electroshock therapy again.
Rose et al explain that people who have electroshock report more negative responses about perceived benefit in patient–led studies than they report in clinical studies (1364). In their Discussion section, they state, “This study still reports lower rates of satisfaction than any of the clinical studies. Our findings suggest the difference may be attributed to a tendency for clinical studies to take place soon after treatment, to use medical assessors in clinical settings, and to use brief questionnaires with low complexity for responses.”
The authors cite the 1995 Fact sheet on ECT published by the Royal College of Psychiatrists, which states that more than eight out of ten depressed patients who undergo ECT respond well to electroshock. Contrary to that figure, Rose et al conclude, “The current statement for patients from the Royal College of Psychiatrists that over 80% of patients are satisfied with electroconvulsive therapy and that memory loss is not clinically important is unfounded” (1363).
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A study was published in 2010 in the periodical Epidemiologia e Psichiatria Sociale. The authors are John Read of the Department of Psychology at the University of Auckland and Richard Bentall of the Department of Psychology at Bangor University in Wales. Read and Bentall reviewed studies of electroshock therapy and simulated–ECT, “in which the usual general anaesthesia is administered but the electric shock is not” (333). They note that their review includes all the studies cited in the recent book Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness, authored by Edward Shorter and David Healy. The book by Shorter and Healy, they say, supports the conclusion that ECT is “a safe and effective treatment.”
Their review is comprehensive, covering many studies on rate of efficacy, whether electroshock treatment prevents or causes suicide, the general effect on rate of mortality, and possible memory dysfunction and brain damage. The References section at the end of the article consists of about two and a half pages of sources in double columns per page.
In the Summary section, Read and Bentall state, “These placebo controlled studies show minimal support for effectiveness with either depression or ‘schizophrenia’ during the course of treatment (i.e. only for some patients, on some measures, sometimes perceived only by psychiatrists but not by other raters), and no evidence, for either diagnostic group, of any benefits beyond the treatment period. There are no placebo–controlled studies evaluating the hypothesis that ECT prevents suicide, and no robust evidence from other kinds of studies to support the hypothesis. […] Given the strong evidence (summarised here) of persistent and, for some, permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and the evidence of a slight but significant increased risk of death, the cost–benefit analysis for ECT is so poor that its use cannot be scientifically justified.”
Bibliography
Author: Diana Rose, Til Wykes, Morven Leese, Jonathan Bindman, Pete Fleischmann. Article: Patients’ perspectives on electroconvulsive therapy: systematic review. Periodical: British Medical Journal. Volume: 326. Date: June 21, 2003. Pages: 1363. Web address: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC162130/.
Author: Glenda MacQueen, Caroline Parkin, Michael Marriott, Helen Bégin, Gary Hasey. Article: The long–term impact of treatment with electroconvulsive therapy on discrete memory systems in patients with bipolar disorder. Periodical: Journal of Psychiatry & Neuroscience. Volume: 32. Issue: 4. Date: July 2007. Pages: 241-249. Web address: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1911194/.
Author: Joan Prudic, Mark Olfson, Steven C. Marcus, Rice B. Fuller, Harold A. Sackeim. Article: Effectiveness of Electroconvulsive Therapy in Community Settings. Periodical: Biological Psychiatry. Volume: 55. Issue: 3. Date: February 1, 2004. Pages: 301–312. Web address: http://www.ncbi.nlm.nih.gov/pubmed/14744473.
Author: John Read, Richard Bentall. Article: The effectiveness of electroconvulsive therapy: A literature review. Periodical: Epidemiologia e Psichiatria Sociale. Volume: 19. Issue: 4. Date: 2010. Pages: 333–347. Web address: http://www.breggin.com/ECT/ReadAndBentall_ECT_2010.pdf.
Author: Márcio Búrigo, Clarissa A. Roza, Cintia Bassani, Gustavo Feier, Felipe Dal–Pizzol, João Quevedo, Emilio L. Streck. Article: Decreased Creatine Kinase Activity Caused by Electroconvulsive Shock. Periodical: Neurochemical Research. Volume: 31. Issue: 7. Date: July 2006. Pages: 877–881.
Author: Miriam Feliu; Christopher L. Edwards; Shiv Sudhakar; Camela McDougald; Renee Raynor; Stephanie Johnson; Goldie Byrd; Keith Whitfield; Charles Jonassaint; Heather Romero; Lekisha Edwards; Chante Wellington; LaBarron K. Hill; James Sollers, III; Patrick E. Logue. Article: Neuropsychological effects and attitudes in patients following electroconvulsive therapy. Periodical: Neuropsychiatric Disease and Treatment. Volume: 4. Issue: 3. Date: 2008. Pages: 613–617. Web address: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526376/.
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