His New Battle
Patient takes fight against electric shock treatment to court

Paul Henri Thomas, a former Haitian human rights activist, is now an American citizen championing a different cause: the right of psychiatric patients to refuse forced electric shock therapy.

As in Haiti, he counts himself among the oppressed here. Thomas, 49, has been a patient at Pilgrim Psychiatric Center in Central Islip for the past 22 months, where he has received shock therapy between 30 and 50 times.

Pilgrim psychiatrists say he needs to be shocked because he has schizophrenic affective disorder, a form of psychosis that in Thomas' case shows itself through manic, delusional behavior.

Thomas says he's fine. He's not mentally ill, so he doesn't need shock treatment, he says. If anything, Thomas says, shock treatment makes his life worse.

"After the treatment, it is just as if I came back from nowhere," Thomas said during a court hearing Friday. "I am surprised I am myself... It is not a pleasant experience."

The hearing was held to determine whether Thomas is psychologically competent to refuse shock therapy. If state Supreme Court Justice W. Bromley Hall determines he is competent, the focus of the hearing will turn to whether shock treatment is appropriate for Thomas. If Hall decides Thomas is not competent, the hospital may proceed with therapy, despite Thomas' wishes.

Thomas and his plight have become an international cause. Anti-shock therapy Web sites urge viewers to rally behind him.

Friday's hearing took place in a cramped courtroom in Building 69 on the Pilgrim campus. About 30 activists, some from as far away as Syracuse, gathered outside. Although Thomas waived his privacy rights and Hall assured the public it could attend, state Office of Mental Health officials made the activists unwelcome.

Pilgrim police officers made them stand outside in the snow for hours until court was in session and then allowed only five to sit in the courtroom. Pilgrim police also threatened news photographers with arrest if they took pictures on campus. Police followed a group of activists to make sure they were photographed beyond Pilgrim's property line.

Dr. Robert Kalani, Pilgrim's associate medical director and the director of electroconvulsive therapy there, testified that Thomas came to Pilgrim in May 1999 when he became unmanageable at South Nassau Community Hospital in Oceanside.

Thomas' psychiatric problems date to 1977, when he had a breakdown while living in Haiti.

Kalani said shock treatment is appropriate for Thomas because years of taking psychotropic drugs have damaged his liver. Thomas still takes 3,000 milligrams of Depakote and 1,200 milligrams of lithium a day. Depakote and lithium are mood stabilizers.

During questioning by Assistant Attorney General Laurie Gatto, Kalani said Thomas is not competent to decline shock treatment. Evidence of that is Thomas' belief that he's not even mentally ill, Kalani said.

"He does not appreciate the consequences of refusing treatment," Kalani said.

Kalani also said Thomas' illness is apparent in how he communicates. He has "pressured speech" -- he speaks rapidly -- and needs to be frequently redirected or else his answers to questions quickly ramble off the topic. For example, Thomas responded to one question during an interview about how he was functioning by listing his educational background, Kalani said.

But Thomas' attorney, Kim Darrow of the state Mental Hygiene Legal Services, suggested that Thomas gave his education as an example of how well he was functioning.

But Thomas' own sister, Mary Ann Pierre-Louis of Elmont, testified that he cannot function in society. Before his transfer to Pilgrim, Pierre-Louis said, Thomas was out of control.

"He was playing with his feces," she said. "He said he was doing an experiment."

Later during the hearing, Thomas said he didn't recall that, adding that if he had been experimenting with feces he would have known enough to have worn latex gloves.

"My brother is sick," she said. "We know it. My brother is very ill."

Thomas' answers on the witness stand were frequently elliptical, often unrelated to the question and sometimes completely incoherent. At times Darrow struggled to follow his client's answers.

"What are we talking about now?" Darrow said in confusion at one point.

Thomas' speech was slurred and his hands trembled, a result of the psychotropic medicine he took when he was younger, according to his doctors.

But Dr. Ron Leifer, a Syracuse psychiatrist hired by Darrow, testified that he agreed Thomas had no major mental illness.

"If he's suffering from delusions, so am I," Leifer said. "His speech is not disorganized, if you have the patience to listen to him. He always comes back to the point."

Thomas' refusal of shock therapy is well reasoned, Leifer said.

"Shock treatment is very unpleasant, and because he believes he's not mentally ill, it doesn't make any sense," Leifer said.

During cross-examination by Gatto, Leifer stood by his diagnosis and added that everyone suffers from some kind of personality disorder.

The hearing will continue next week.

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Notes Say Shock Treatments Help Man

by Zachary R. Dowdy
Staff Writer
March 13, 2001

The scribblings of doctors and nurses tell a tale of Paul Henri Thomas, a man they say lapsed into delusions and harassed Pilgrim Psychiatric Center staff until he was given a jolt of electric shock therapy.

The contents of the "progress notes" read by Pilgrim's Dr. Robert Kalani at a hearing before State Supreme Court Justice W. Bromley Hall in Central Islip yesterday formed the bulk of the state's claim that Thomas is better off, and more manageable to staff, when he gets regular doses of electroconvulsive therapy.

The notes, dating from the time he was admitted to the facility in May 1999 through last month, consist of dozens of short reports of Thomas displaying "manic behavior," "pressured speech" and "agitation." Soon after shock treatment, though, the notes said, he was "much calmer," displayed "no acting out" and was "no longer manic." State Assistant Attorney General Laurie Gatto asked Kalani about Thomas' treatment and used Kalani's opinion and the progress notes to draw a direct link between Thomas' behavior and the shock treatment, which Thomas vigorously opposes.

Kalani said Thomas, 49, is afflicted with "bipolar mania with psychotic features," though Thomas' disorder had been diagnosed as "schizoaffective bipolar type with psychotic features," Gatto said.

The hearing will determine whether Thomas should be subject to the therapy against his will.

Thomas, whose psychiatric problems date to 1977 when he had a breakdown in Haiti, came to Pilgrim after he became unmanageable at Southside Community Hospital in Oceanside. His plight has become, for some, a symbolic fight for the preservation of a constitutional right to refuse treatment.

His doctors at Pilgrim, however, say he is sick, and unable to determine what is best for himself.

Pilgrim officials, backed by three court orders, won the right to administer the treatment, subjecting Thomas to up to 60 shocks over the past two years.

Thomas' attorney, Kim Darrow of the state's Mental Hygiene Legal Services, said his client has no mental illness and is healthy enough to be released.

He objected each time Kalani began to read through the progress notes that contained illegible signatures. And, in what may have been the most dramatic moment of the hearing, he said some of them were written to make the case that Thomas should continue to receive the treatment.

"These notes are made for the specific purpose of this litigation and should not be admitted as evidence," Darrow said. But his objection, like dozens of others, was overruled by Hall.

Darrow, who did not get a chance to cross-examine Kalani because the court day ended, also argued the notes make "conclusions" and statements that categorize Thomas' behavior without describing what specific acts he allegedly committed.

At a hearing earlier this month, Hall divided the case into two portions: to determine whether Thomas has the capacity to make health decisions for himself and to determine whether the controversial shock treatment is an appropriate method in his case.

The next hearing date could be set as early as today, and Hall said it will likely occur Thursday.

March 16, 2001

Mental Competence in Question Doctors: Man not fit to refuse shock treatment

In June 1, Paul Henri Thomas thought clearly enough to sign a consent form, giving his doctors permission to place electrodes near his temples and send jolts of electricity through his brain as part of his treatment at Pilgrim Psychiatric Center.

He underwent the painful and controversial electro- shock procedure three times, on June 9, 11 and 14. But after that third treatment, he had refused to submit to it again.

That's when his doctors began saying Thomas, 49, no longer had the mental capacity to make decisions on his own, so they obtained a court order to force the electroshock therapy upon him.

The revelation of a kind of Catch-22-the strange circumstance that Thomas was fine when he consented to the procedure but mentally incompetent when he refused it-took center stage at a hearing yesterday to determine whether doctors may again shock Thomas against his will.

Thomas, who has been a patient at Pilgrim since May 1, is challenging the state's application to continue giving him shock treatments-a controversial form of therapy to treat a variety of mental illnesses. Thomas contends he is not mentally ill.

At the third day of Thomas' hearing yesterday, his attorney questioned a witness for Pilgrim.

"In June he was competent to consent and received three treatments, and some time after that he became incompetent. Is that correct?" asked Kim Darrow, an attorney for the state Mental Hygiene Legal Service, which is representing Thomas.

"I'm unable to answer that," responded Dr. Robert Kalani, Pilgrim's associate medical director.

But State Supreme Court Justice W. Bromley Hall swiftly cut off Darrow's line of questioning, saying Thomas' capacity to make decisions about his health may have changed since he consented to the treatment.

"There are a lot of people walking around with capacity for whatever," Hall said in the Central Islip courtroom. "The fact that you have capacity today doesn't mean you will have capacity tomorrow," he added, prompting gasps from Thomas' supporters.

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The proceeding marked the first time Darrow could cross-examine Kalani, who was testifying for Assistant Attorney General Laurie Gatto on Monday.

Gatto had made the case then that Thomas was perceived to be much more manageable during the periods when he was receiving shock treatments.

If Pilgrim officials are successful, they will be able to administer the treatment to Thomas, who is also on mood stabilizing drugs, despite his wishes.

The facility seeks authorization for 40 more shock treatments.

It would be the fourth time they have obtained court approval for the procedure on him. Thomas has already received at least 57 treatments over a two-year span without his consent.

Under questioning by Darrow, Kalani also admitted that on Feb. 1, he signed a form for a court order for additional treatments without first examining Thomas, an act that Darrow said was a violation of state rules regarding treatment of mental illness.

Darrow also said the affidavit submitted to the court for additional shock treatments was only a stock form with spaces for the date, patient's name, name of the doctor and the disorder. It had no specific details concerning the patient.

Darrow asked Kalani how he could sign off on such a form, but Kalani said he based his decision partly on a conversation he had with Thomas' physician.

Testimony ended with Darrow asking Kalani, given that Thomas has called the procedure "torture" and "evil," how has it improved his life.

"Do you think you have improved the quality of life for Mr. Thomas?"

"I think we have," Kalani answered.

The hearing will continue next week.

March 28, 2001

Man Says More Rights Violated

by Zachary R. Dowdy
Staff Writer

In recent weeks, Paul Henri Thomas has become Long Island's most visible and vocal opponent to electroshock treatment, a procedure he has undergone at Pilgrim Psychiatric Center nearly 60 times against his will since he was confined there in May 1999.

His fight against the treatment has spilled into public forums, including news media and the Internet, but most notably state Supreme Court in Central Islip, as he challenges the state's application to give him 40 more shocks.

He has called the procedure a form of "torture," claiming doctors at Pilgrim are violating his constitutional right to refuse the treatment.

Now, Thomas, 49, and his attorneys say Pilgrim officials are violating another basic right-freedom to speak his mind about electroshock treatment-by monitoring his conversations with people who visit him at Pilgrim in Central Islip. And, they say, the restrictions that have been imposed on Thomas are in retaliation for his efforts to publicize his plight.

"Under the guise of seeing whether he is competent to do such things as sign papers or have a conversation, they are providing obstacles for his free communication to the public about his views on what's happening to him," said Dennis Feld, deputy chief attorney for the state Mental Hygiene Legal Service, which is representing Thomas.

Jill Daniels, a spokeswoman for the state Office of Mental Health in Albany, declined to comment, citing ongoing litigation.

Feld, whose agency filed the lawsuit Friday in Federal Court, said Pilgrim officials have placed Thomas under so-called one-to-one observation. That designation means Thomas cannot sign papers or have a conversation with anyone outside of his family or attorneys without a Pilgrim staff member present.

Thomas, who Feld said receives visitors almost daily, seeks a declaration from the court that his rights were violated, an order barring the restrictions, in addition to attorney fees and monetary damages.

The one-to-one designation, Feld said, is normally applied to patients who have been "acting out," or who do not have the mental capacity to sign papers.

The lawsuit comes as State Supreme Court Justice W. Bromley Hall tries to decide whether Thomas has the capacity to refuse the treatment and whether shock treatment is appropriate therapy for him.

April 17, 2001

Judge Continues Electroshock

Saying that expert witnesses for Paul Henri Thomas were "simply not credible," a State Supreme Court justice yesterday gave Pilgrim Psychiatric Center the green light to resume the electroshock treatments Thomas had hoped to stop.

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Justice W. Bromley Hall's seven-page decision comes more than two months after Pilgrim applied for a court order to administer 40 shock treatments to Thomas.

The judge approved the treatments and lifted a temporary injunction blocking three treatments Pilgrim had won the right to give by a previous court order.

Thomas, 49, who emigrated from Haiti in 1982, denies he has a mental illness, but doctors at Pilgrim testified he displays signs of several disorders including schizoaffective disorder and bipolar mania.

He has received nearly 60 electroconvulsive therapy treatments -- most of them against his will -- since he was committed to the institution in May 1999.

Hall's decision, which evaluates the weight of testimony from Thomas, his sister and expert witnesses, came as no surprise, according to the state attorney general's office which represented Pilgrim.

"The intensity of the objection by Mental Hygiene Legal Service [which represented Thomas] is the only thing that was surprising," said Assistant Attorney General Laurie Gatto.

Denis McElligott of the state attorney general's office said Thomas' case shows that electroshock treatments are forced upon a patient only after a thorough legal debate.

"We're hoping that the best thing that comes from this entire situation is the public's understanding that when this is done it is only done pursuant to a court order after a judge has heard all of the testimony," McElligott said.

But Dennis Feld, deputy chief attorney for the state Mental Hygiene Legal Service in Mineola, said Hall discredited Thomas' witnesses, tipping the scales against him. "The decision doesn't come as a surprise with the court discounting our experts' testimony," Feld said. "It leaves very little to be argued and to be guessed as to which way the court would go."

Kim Darrow, an attorney who argued the case for Thomas, was unavailable for comment yesterday.

Feld said his agency would appeal the decision once the attorney general's office drafts an order to administer the treatments.

Hall's decision came after many weeks of testimony from experts who fall on both sides of the controversial electroshock treatment issue.

The hearing was designed to answer two questions: Did Thomas possess the mental capacity to make medical decisions on his own and was this form of treatment, ­it is uncomfortable if not painful for some patients, has caused memory loss and is often followed by relapses -- the best treatment for Thomas?

Pilgrim doctors Robert Kalani, associate medical director, and Andre Azemar, Thomas' psychiatrist, both testified that Thomas badly needed the treatment, partly because drugs that would help him will further damage his liver.

They said he suffers from delusional thinking and is prone to behavior they consider bizarre.

"He has been found sitting on the floor comparing himself with Mahatma Gandhi," Hall wrote. "He was wearing three pairs of pants which he believed provided therapy for him. At the same time he was found, in the ward, wearing layers of shirts which were inside-out, together with jackets, gloves and sunglasses."

Hall dismissed the testimony of Ron Leifer, an Ithaca psychiatrist, and John McDonough, a psychologist, who appeared on behalf of Thomas. Hall said that Leifer was "evasive," and that his testimony was influenced by his opposition to electroshock and involuntary medical treatment altogether. The judge declared McDonough's testimony as "not helpful," saying it was based largely on a widely used intelligence test that measures cognitive ability and that he did not administer tests that measure psychosis or discuss Thomas' alleged illness or electroshock treatment.

The most damning testimony against Thomas, though, may have come from James D. Lynch, an independent psychiatrist who said Thomas has an acute form of bipolar disorder and manic behavior and needs more than the 40 shock treatments to help him function.

Briefs

April 25, 2001

Zachary R. Dowdy; Chau Lam

BRENTWOOD / Pilgrim Patient Wins a Stay Paul Henri Thomas, 49, the Pilgrim Psychiatric Center patient who is challenging the state facility's decision to give him electroshock treatments, will not have to undergo the procedure, at least for now, pending a decision from an appellate court.

On Monday, attorneys for Thomas secured from the Appellate Division a temporary stay of an order signed by State Supreme Court Justice W. Bromley Hall. Hall's order approved Pilgrim's request to administer 40 electroshock treatments.

The stay will remain in effect at least until Monday, the deadline by which Pilgrim officials must file papers with the Appellate Division, said Kim Darrow, an attorney for the state Mental Hygiene Legal Service, which represents Thomas.

After that, a four-judge panel will review the arguments from both sides and decide whether to grant another stay while the court reviews Thomas' appeal.

The stay, granted by Justice David S. Ritter, asks Pilgrim to make a case as to why shock treatments should not be prohibited while the court reviews Hall's order, which was signed April 20.

That order came after a weeks-long hearing in which Thomas challenged an application by Pilgrim in February to administer the 40 shock treatments. Hall ruled that the expert witnesses who testified for Thomas were not credible, saying in conclusion that the treatments are in Thomas' "best interest." Thomas, who Pilgrim doctors say displays signs of mental illnesses ranging from schizoaffective disorder to bipolar mania, has been in the Brentwood facility since May 1999.

He has received about 60 shocks in all, almost all of them against his will. Thomas signed papers consenting to the treatments in June 1999.

He underwent three procedures and then refused them. That's when doctors at Pilgrim sought court approval for the procedure, arguing that Thomas did not have the mental capacity to make medical decisions for himself. -Zachary R.

next: New Self-Help Booklets Promote Recovery For People with Mental Illnesses
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(Shocked! ECT note: Tenet-owned hospitals are in red)

Source: Missouri Certificate of Need program; Bureau of Hospital Licensing; Missouri Department of Health

In St. Louis and St. Louis County, only 16 facilities provide beds for psychiatric patients. SouthPointe Hospital represents nearly 8 percent of the 1,354 beds available.

Hospitals, ranked by number of psychiatric beds:

1. St. Louis Psychiatric Rehabilitation Center, 5300 Arsenal Street, St. Louis, 215.

2. St. Anthony's Medical Center, 10010 Kennerly Road, south St. Louis County, 158.

3. Metropolitan St. Louis Psychiatric Center, 5351 Delmar Boulevard, St. Louis, 111.

4. Veterans Affairs Medical Center, 915 North Grand Boulevard, St. Louis, 117.

5. Barnes-Jewish Hospital, 216 South Kingshighway, St. Louis, 109.

6. SouthPointe Hospital, 2639 Miami Street, St. Louis, 104.

7. St. John's Mercy Medical Center, 615 South New Ballas Road, Creve Coeur, 82.

8. Christian Hospital Northwest, 1225 Graham Road, Florissant, 80.

9. DePaul Health Center, 12303 DePaul Drive, Bridgeton, 78.

10. Hawthorn Children's Psychiatric Hospital, 1901 Pennsylvania Avenue, north St. Louis County, 60.

11. Forest Park Hospital, 6150 Oakland Avenue, St. Louis, 59.

12. St. Louis University Hospital, 3635 Vista Avenue at Grand Boulevard, St. Louis, 47.

13. St. Mary's Health Center, 6420 Clayton Road, Richmond Heights, 44.

14. St. Alexius Hospital, 3933 South Broadway, St. Louis, 41.

15. Missouri Baptist Medical Center, 3015 North Ballas Road, Town and Country, 28.

16. Des Peres Hospital, 2345 Dougherty Ferry Road, Des Peres, 21.

Source: Missouri Certificate of Need program; Bureau of Hospital Licensing; Missouri Department of Health

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~ all articles on depression

February 21, 2001
Riverview Hospital Report

Carried out by:

* Dr. Caroline Gosselin (Head, Dept. of Geriatric Psychiatry, VHHSC) - Chair
* Dr. Elisabeth Drance (Geriatric Psychiatrist, Providence Health Care) - Member
* Ms. Jeanette Eyre (RN and ECT Coordinator, UBC Hospital) - Member
* Dr. Norman Wale (Anesthesiologist, Dept. of Anesthesia, Royal Jubilee Hospital, Capital Health Region) - Member
* Dr. Athanasios Zis (Professor and Head, Dept. of Psychiatry, UBC and VHHSC) -Member
* Mr. Noam Butterfield (PhD candidate, Pharmacology & Therapeutics, UBC) - Secretary and Principle Facilitator
* Mr. Wayne Jones (MHECCU, St. Paul's Hospital) - Statistical Consult

February 21, 2001

Review of ECT Practice at Riverview Hospital February 21, 2001

PURPOSE: The Ministry of Health, Division of Mental Health Services, has appointed a committee to review the current practice of electroconvulsive therapy (ECT) at Riverview Hospital (RVH). The mandate of this review was to determine if patients at RVH are provided with ECT services that are appropriate and safe, and to make Recommendations to improve ECT service.

COMMITTEE COMPOSITION: * Dr. Caroline Gosselin (Head, Dept. of Geriatric Psychiatry, VHHSC) - Chair
* Dr. Elisabeth Drance (Geriatric Psychiatrist, Providence Health Care) - Member
* Ms. Jeanette Eyre (RN and ECT Coordinator, UBC Hospital) - Member
* Dr. Norman Wale (Anesthesiologist, Dept. of Anesthesia, Royal Jubilee Hospital, Capital Health Region) - Member
* Dr. Athanasios Zis (Professor and Head, Dept. of Psychiatry, UBC and VHHSC) - Member

ADDITIONAL CONTRIBUTORS: * Mr. Noam Butterfield (PhD candidate, Pharmacology & Therapeutics, UBC) - Secretary and Principle Facilitator * Mr. Wayne Jones (MHECCU, St. Paul's Hospital) - Statistical Consult

TERMS OF REFERENCE (as outlined by the Ministry of Health): Purpose: To determine if patients at RVH are provided with ECT (electroconvulsive therapy) services that are appropriate and safe, and to make recommendations to improve service.

Issue: ECT practice at RVH has been questioned by Dr. Jaime Paredes, Medical Staff President, in a letter to Honourable Corky Evans, Minister of Health and Minister Responsible for Seniors. Media coverage reflects concern for safety of clients.

Deliverables: The review will determine practices for both in- and outpatient ECT in the following areas and compare with accepted medical practice:

1. Equipment of Physical Design - specifications of the ECT machine (e.g. waves, voltage, monitoring heart rate, e.e.g.s etc) design of the ECT and recovery rooms, safety and anesthetic and ancillary equipment issues.

2. ECT Technique and Anesthesia - issues of technical competence (unilateral versus bilateral; timing of current, wave forms, etc) that are designed to have the therapeutic effect and reduce memory disturbance. Medications including type and dosage of anesthetics used during ECT and physiological monitoring during ECT.

3. Care Plan and Documentation - protocols and guidelines in place for ECT. Clear documentation of Assessment and treatment plan.

4. Preparation and Aftercare - preparation of the patient for the procedure and aftercare including instructions to caregivers.

5. Patient Selection - exclusions for other medical conditions, characteristics of psychiatric conditions including non-responsiveness, urgency, etc. and indications for second opinions and other consultations are addressed. Indications for maintenance ECT.

6. Patient Education/Consent - process for informed consent; consent forms; completed methods of presenting material to patients and families.

7. Staff Training - level of skill and knowledge of staff involved in any aspect of providing ECT.

8. Monitoring and Evaluation - RVH practice of monitoring important aspects of ECT. Trends and comparisons in the use of inpatient and outpatient and maintenance ECT. Monitoring, on a periodic basis the type of equipment, techniques, staff training and patient outcomes.

NOTE: The review is to address system issues as opposed to professional practice of individuals. Individual practice concerns are not the purview of this report and, therefore the review team will refer such issues to appropriate RVH professional bodies and/or provincial practice bodies.

REVIEW PROCESS: Discussions were held over three days with management, medical staff, nursing staff, patients and their families and patient advocacy groups.

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The first site visit was conducted on January 16, 2001, during which the review team members, the terms of reference and the review process were introduced to President/CEO of RVH, Chair of the Board of Trustees, the Clinical Executive Team and ECT staff representatives. Following introductions, meetings were held separately with the following groups:

* ECT physicians (psychiatrists and anesthesiologists) and ECT Nursing Staff
* Coordinator of the ECT program and Manager of the ECT Program
* Vice President, Medicine and Research and Vice President of Clinical Services
* President, Medical Staff Association
* Medical Director and Patients Services Director of the Geriatric
Psychiatry Program and five Medical Staff
* Medical Director and Patient Services Director of the Adult Residential Transfer Program
* Medical Director and Patient Services Director of the Adult tertiary Redevelopment Program
* An open forum was also held for any other Riverview Hospital Staff, patients, families or advocacy groups, to voice any concerns and provide feedback.

During the second site visit on January 17, 2001, time was spent observing patients in the pre-ECT room, in the treatment room, and in the post-anesthetic recovery room, as well as being transferred back to the ward. A discussion was held with families of some of the patients who received ECT treatment this day. A chart review was initiated and additional discussions were held with the following:

* Union of Psychiatric Nurses (UPN, Local 102) Nurse, Aggressive Stabilization Ward and Vice President, UPN
* Five members of Medical Staff Organisation

On January 22, 2001, discussions were held with the following:

* Ten Geriatric physicians * Vice President of Clinical Services

In addition to the three site visits, materials provided by Riverview Medical Staff and Administration were reviewed. Substantial correspondence received by the Minister from a variety of individuals and organisations was forwarded to the team as well.

ASSESSMENT AND RECOMMENDATIONS:

1. Equipment and Physical Design

Assessments: PHYSICAL DESIGN Riverview Hospital houses a newly built ECT suite on the ground floor of Valleyview Pavilion with formal operation underway since December, 2000. This current location was found to be well located with respect to the patient population served. It encompasses a waiting area for patients and families, a treatment room and a recovery room capable of managing 4 post-ECT patients. It is clean, spacious, well lit, and provides a comfortable environment for both recipient and providers of ECT.

ECT EQUIPMENT The ECT suite is equipped with the newest ECT devices available. A Spectrum 5000Q is used for daily ECT. A Thymatron and an older model of MECTA (the JRI) are also in the treatment room for backup in the event of equipment failure.

ANESTHESIA EQUIPMENT a) Stretchers - The stretchers are of current design, safe and sturdy. b) Monitoring Equipment - Blood pressure, heart rate, electrocardiogram, haemoglobin saturation and neuromuscular transmission monitors are all of current design and good quality. c) Suction Equipment - Suction availability, although not through a central system, is adequate. Three such suctioning units were tested and all well functioning.

2. ECT Technique and Anesthesia

ECT TECHNIQUE Assessment: ECT Technique was uniformly praised by all those interviewed, including by those who raised concerns in other domains.

Patients are prepared for ECT in accordance with APA standards i.e.: skin cleansing with alcohol, application of abrasive and non-abrasive conductant gels. Bilateral lead placement is routinely used with the Titration Method dosing strategy according to the protocol devised by Duke University. A standard rubber mouth guard is inserted into the patient's mouth prior to ECT and the anesthesiologist provides jaw support during the delivery of the stimulus itself. The ECT device creates an EEG recording of the convulsion, which is documented on a flow sheet.

It is presumed, given the training the treating psychiatrists have, that EEG morphology is used as an adjunct to the progress report of the patient's physician to determine electrical dosage used for each treatment. We observed the Coordinator of ECT Services deliver ECT for several patients. The remaining five psychiatrists who deliver ECT declined to allow us to observe them - stating that we did not have the authority to do so. They cited receiving advice from the College of Physicians and Surgeons of B.C for their decision. The Coordinator of ECT Services informed us that they have all received ECT training at either Canadian or American programs and practice accordingly.

Recommendation: Although the choice of electrode placement is a subject of continuous research and discussion, recent evidence suggests that the therapeutic outcome of unilateral electrode placement of sufficient electrical intensity is comparable to bilateral ECT, but with reduced cognitive side effects. The choice of electrode placement should be reviewed and updated.

ANESTHESIA Assessment: Oxygen Supply: The provision of oxygen was adequate, although the addition of a pressure gauge to provide "real time" monitoring of supply/pressure would be desirable. Absent also was any conspicuous visual or auditory alarm to be deployed if there should occur a failure in oxygen supply. A large K-cylinder of oxygen as back up supply was readily at hand.

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Drug Supply: Sufficient and appropriate drugs are readily available. Drugs and equipment required for resuscitation are also appropriately stored, labelled, and immediately available. Surveillance and replenishment of dated drugs is an ongoing commitment of Riverview Pharmacy.

Practice: The current practice in the provision of anesthesia for ECT at Riverview Hospital conforms to the "Guidelines to the Practice of Anesthesia, revised edition 2000" as recommended by the Canadian Anesthesiologists' Society. The safe and courteous conduct of anesthesia was apparent, as was the cooperative compassionate approach to patient care.

Recommendations: a) "Real time" monitoring of oxygen supply pressure should be provided. b) Auditory and visual alarms to notify personnel of failure of oxygen supply are also recommended. c) Consideration should be given to the use of "needle-less" supplies for the administration of drugs and/or intravenous fluids. There is no doubt that patients receiving therapy later in the day do benefit from intravenous fluid administration, and such fluids may be given utilizing one of the several "needle-less" products which are currently available. The principle advantage of using "needle-less" supplies continues to be the reduced risk of "needle-poke" injuries.

3. Care Plan and Documentation

Assessment: We reviewed the following documents and guidelines:
* ECT Consent Process (Flow sheet)
* Consent for ECT Treatment (Guidelines)
* Consent for Treatment, Involuntary Patient
* Consent for Treatment, Informal Patient and Outpatient
* ECT - Information for Patients and Families (1997)
* Preparing for ECT - Information for Inpatients (1997)
* Preparing for ECT - Information for Outpatients (1997)
* ECT Information For Students (1996)
* Pre-ECT Nursing Checklist
* ECT Ward Nursing Guidelines
* Request for Consultation (form)
* ECT Service Procedure Manual: Pre-ECT/Pre-Anaesthesia Consultations
* Pre-ECT Medical Checklist
* Medications Used In ECT - A Brief Compendium for Ward Nursing Staff
* ECT Service Procedure Manual: Duties of the Escort Nurse
* ECT Service Procedure Manual: Duties of the Waiting Room Nurse
* ECT Service Procedure Manual: Description of the ECT Treatment Process
* ECT Service Procedure Manual: Clinical Nursing Procedures in the ECT Room
* ECT Service Procedure Manual: Description of the ECT Treatment Process
* Medical Staff Policy & Procedure Manual: ECT (1997)
* ECT Service Procedure Manual: Anaesthesia Procedures in the ECT Treatment Room
* ECT Treatment Room Drug List (1996)
* Communication In the ECT Suite
* ECT Treatment Record
* ECT Nursing Record
* Methicillin Resistant Staphylococcus Aureus Guidelines (MRSA) (1997)
* Management of Patients Infected or Colonized with MRSA and other Multiple Drug-Resistant (MRO) Microorganisms
* ECT Service Procedure Manual: PARR Equipment
* ECT Service Procedure Manual: PAR Nurse Qualifications
* ECT Service Procedure Manual: Clinical Nursing Procedures in the PARR
* ECT Service Procedure Manual: Documentation In the PARR
* ECT Service Procedure Manual: Nurse to Patient Ratio in the PARR
* ECT Service Procedure Manual: Post Anaesthesia Recovery Room
* ECT Service Procedure Manual: Medical Emergency - Code Blue
* ECT Service Procedure Manual: Criteria For Discharging Patients from the PARR
* ECT Outcome Evaluation

Recommendations:
These guidelines are comprehensive and clear and only minor changes are recommended:
a) Aortic Stenosis is not listed in the "Medical Staff Policy and Procedure Manual (1997)" as a relative contraindication
b) The document "CLI-005 Description of the ECT Treatment Process" contains inaccurate information and is poorly written. It needs to be revised and the author and purpose of such a document identified.

4. Preparation and Aftercare

Assessment: Preparation of the patient begins as soon as a decision has been made that ECT is a recommended treatment choice for the patient. The attending physician discusses treatment options with the patient including the possibility of ECT. An "Information for Patients and Families" booklet on ECT is given to the patient and family members if possible, prior to being asked to sign consent for ECT. The patient and family members both have the opportunity to meet with the attending physician to ask questions about the recommended ECT. If the patient is capable of giving informed consent the attending physician will meet with the patient and review and explain the information on the back of the ECT form.

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Patients and families are also encouraged to view a video about ECT as well as visit the ECT suite prior to beginning ECT to meet the Staff, see the facilities and address any concerns they may have about the process.

A pre-ECT nursing checklist is completed prior to the patient leaving the ward (for inpatients) and checked by the waiting room nurse. For outpatients, the waiting room nurse completes the pre-ECT nursing checklist.

The PARR nurses manage the patient's airway, administer oxygen at 6-8L per minute, and monitor the heart rhythm by ECG. They also assess and score the following every five minutes until the patient meets discharge criteria: blood pressure, pulse, respiratory rate, oxygen saturation, level of consciousness and muscle strength. When the patient has met the criteria for discharge from the PARR they are transferred from the stretcher to a wheel chair and returned to the waiting room. The waiting room nurse receives a verbal report from the recovery room nurse of any significant information. This is in turn passed on to the escort nurse or to the person returning the patient to a facility or home. The patient is offered cookies and juice in the waiting room prior to discharge from the ECT suite. Patients returning to their wards will have their vitals assessed and recorded within 30 minutes.

Outpatients are discharged home in the care of a responsible adult.

Concern was raised about the length of time some patients were required to fast prior to receiving their treatment, despite requesting an earlier time slot. The ECT Treatment Team are aware of this and have responded by suggesting methods of keeping patients hydrated (e.g. with intravenous fluids) prior to their treatment. They have also attempted to accommodate these patients as best as possible.

Recommendations: a) Improved communication is necessary to facilitate the issue surrounding fasting patients (i.e. personal contact rather than an answering machine). Without increased resources such as a registered nurse (on site five days per week), this will be difficult to accomplish. b) Riverview needs to expand their discharge information for outpatients and identify staff responsible for providing this information. A checklist would ensure this information has been disseminated (as is already established for inpatients).

5. Patient Selection

PATIENT SELECTION Assessment: There was a lack of pertinent statistics pertaining to ECT at Riverview. Moreover, due to time constraints it was not possible to conduct a systematic chart review to address issues pertaining to patient selection. There is however, no doubt that the number of ECT procedures at Riverview has increased over the last few years and that this increase in ECT procedures is primarily due to an increase in ECT procedures for geriatric patients. There is insufficient information available to draw any firm conclusions regarding the rate of ECT across age and diagnostic groups or the number of treatments per patient. For the same reason, it is not possible to draw any conclusions whether patient selection and utilization are in agreement or at variance with other provincial, national and international data.

Efforts are being made by an internal subcommittee at Riverview to address questions related to appropriate utilization of ECT, and we were pleased to be informed of changes of the composition of said committee to better accommodate the concerns of the Medical Staff for a more objective assessment.

Recommendation: The committee, due to inadequate data, is unable to draw any conclusions regarding ECT patient selection and utilization at Riverview. The committee strongly supports the internal review currently underway under the auspices of the Riverview Medical advisory Committee and cannot underscore enough the need for an independent and objective review process. Although this Review Team cannot speak to Riverview's numbers, nor the appropriateness of patient selection, the Ministry of Health and Ministry Responsible for Seniors needs to extend effort to refine ECT data collection and examine ECT use Province-wide.

SECOND OPINION FOR TREATMENT Assessment: Several staff aired concerns about the process of a second psychiatric opinion. It was pointed out that the bulk of the ECT at Riverview is carried out by Geriatric Psychiatrists for Geriatric patients.

Recommendation: We recommend that second opinions should be done in a more objective manner i.e.: by Adult psychiatrists for geriatric patients. The Geriatric Psychiatrists have agreed with this in principle and have added that it is also crucial for the second opinion to be done by psychiatrist well versed in ECT. They have expressed a desire for Adult Psychiatrists to join the ECT delivery team in the future.

6. Patient Education / Consent

PATIENT EDUCATION Assessment: Patients and families are invited to view a video regarding ECT and are provided with written brochures (appended). They are further referred to Riverview's library for additional information. Attending physicians also spend time preparing patients and their families for ECT. Despite this, at the open forum, some patients, as well as the Patient Advocacy group representative, expressed a concern that often, patients do not fully understand ECT and are scared during their initial treatment.

The family representatives that spoke at the open forum, as well as those interviewed on the second review day, all expressed a sense that they had been given ample relevant information prior to the treatments. They also felt strongly that their input had been valued in the initial decision to proceed with treatment.

Recommendation: While fear of medical procedures and or anesthesia is common, Riverview Staff need to remain sensitive to patients' reactions during a course of ECT and encourage education and support. CONSENT Assessment: We did not witness any consent interviews during our visit. Therefore, our data comes from chart review and discussion with the above-mentioned parties.

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The process being followed for informed consent is well outlined in documents appended here. In addition, the Coordinator of ECT Services stated that ECT was not given without the consent of family, even though that may not formally be required under the Mental Health Act.

In charts reviewed by the team, appropriate consent documents were found in 100% of cases.

The facility has a clear understanding of the effect of the new Guardianship Legislation on consent and has built in new steps to accommodate this.

Involuntary patients may sign consent forms for themselves if their physician considers them to be mentally capable; however, if they are incapable of signing, the Vice President of Medical and Academic Affairs must sign as "Deemed Consent".

Although this consent process is outlined in the ECT Policies and Procedure Manual on all wards, some staff indicated that they are unaware of the VP's decision-making "checklist" in signing "Deemed Consent" for Involuntary patients.

Recommendation: The VP of Medical and Academic Affairs' role in consent for Involuntary patients should be clearly delineated and communicated to staff.

NUMBER OF TREATMENTS IN CONSENT Assessment: Some concern was expressed by a number of physicians that the consent form, being designed for up to fifteen treatments, might influence the number of treatments given. Certain physicians recommended reducing the number of treatments in a course per consent.

Recommendation: The average number of treatments for an index course is normally between six and twelve, however more may be needed. It is advisable that a new informed consent form is signed after a course of twelve treatments or a period of six months.

7. Staff Training

PHYSICIANS Assessment: Since the last review in 1996, the prerequisite training for psychiatrists wishing to carry out ECT has increased significantly. Attendance at the Duke University Course in ECT is recommended, and most of the psychiatrists currently performing ECT have attended this course. All of them endorse it as an outstanding experience which has prepared them well to carry out ECT. Currently, the hospital pays for missed sessional time while the individual pays for their airfare, accommodation, and course registration.

Some psychiatrists have expressed concern that the hospital should fully compensate physicians for attending this course if it is a prerequisite to practising ECT. According to the Coordinator of ECT Services, while the course is strongly recommended, equivalent experiences can be arranged within British Columbia for those who do not wish to attend. The Coordinator of ECT Services is insistent that psychiatrists practising ECT require sophisticated skills, as the patient population at RVH frequently suffers from co-morbid medical conditions.

Consideration is being given to having a separate credentialing process for psychiatrists wishing to practise ECT in order to maintain high standards of practice.

Currently, exposure to the ECT suite and the practice of ECT is not part of the orientation for Physicians.

Ongoing ECT grand rounds are offered annually. However, in our discussions with physicians and nursing staff, questions were raised about the increasing numbers of geriatric patients with dementia who were receiving ECT. There seemed to be limited understanding of the current changing indications for ECT in people with Dementia. Recommendations: a) The criteria for joining the ECT treatment team, as a Psychiatrist, need to be clarified (i.e. what constitutes an adequate "specific training course/lecture" as specified in the Medical Staff Policy and Procedure Manual, 1997). b) All physicians hired at Riverview Hospital should receive an orientation to the ECT suite and the practice of ECT. This should become a formal part of their orientation to aid in their understanding and decision-making about ECT. c) ECT Grand Rounds should continue to occur on an annual basis and should reflect the educational needs voiced by staff. This would be an excellent opportunity to relay new research findings related to ECT.

NURSING Assessment: In-services about ECT have been held and ECT information and procedure binders have been created for each ward. There appears however, to be a lack of ongoing education for Riverview nurses. This concern was voiced by The Coordinator of ECT Services and the nurses from the ECT Treatment Suite. In particular, staff who are rarely involved with patients undergoing ECT should nevertheless be kept abreast of ECT practices at RVH. Recommendation: All nurses at RVH should be required to spend time in the ECT suite to develop thorough knowledge of the indications for and the practice of ECT. In additions, they should be oriented to the current indications for ECT to enhance their ability to participate in team ECT decisions.

8. Monitoring and Evaluation Assessments: a) The ECT program lacks a detailed database. Statistics currently kept are collected manually by staff in the ECT suite. This deficit makes examination of the RV practice of ECT with respect to patient selection and outcome virtually impossible.

We have been made aware by the administration at RVH that a database is not likely forthcoming for at least another year and a half. This hampers both monitoring of clinical practice and research initiatives.

b) While an outcome tool was included in our pre-reading package, it was not found on any of the charts reviewed.

d) Similarly to the Inpatient population, there is little data regarding the use of outpatient ECT at Riverview. Monitoring of the progress of these patients occurs partially in the community, and partially by ECT physicians. There are no dedicated resources for Outpatient ECT.

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Recommendations: a) The ECT program at RV is in need of a database in order to gather statistics that will answer the questions regarding utilization of the practice of ECT. A year and a half delay is unacceptable and needs to be reassessed. b) An appropriate ECT outcome tool needs to be completed for each patient at the completion of the Index Course of ECT and then on an ongoing basis for those patients receiving Maintenance ECT. It should be included and easily identified in the patient chart.

c) Riverview needs to enhance and formalise an outpatient ECT clinic. This would involve an expansion of resources. A full-time ECT nurse coordinator could take on several roles including: i. Enhancing ECT education to patients, families and staff (e.g. managing groups) ii. Participating in planning for further education iii. Liasing with the community referral source for patient management iv. Maintaining outpatient ECT statistics.

Additional resources would also allow for additional ECT days (Tuesday and Thursday). This would reduce the total number of patients treated in one day and therefore reduce the waiting time for patients requiring who must fast prior to treatment.

Additional observations: While Riverview is filled with talented and caring professionals, it appears to struggle in the area of developing a healthy work culture.

In our review, we met with a wide variety of professionals including psychiatrists, nurses, anesthesiologists, general practitioners and administrators. Many described their interdisciplinary relationships with colleagues and other health care providers as thoroughly satisfactory. Others expressed fear that speaking out about controversial subjects leads to retribution by the administration in the form of termination of contracts or demotions.

These are serious allegations. They point to a culture which feels unwelcome of diverse opinions, which threatens people's sense of security, and which is strongly hierarchical. The involvement of the media and letters to the health minister may be reflections of this culture.

Riverview Hospital needs to foster an improved quality of internal communication and provide manifestation of respect for individuals' freedom of expression.

Concluding Remarks:

ECT delivery at Riverview Hospital is of high quality. Protocols and guidelines for safe and effective application are in effect. A Reasonable and acceptable informed consent process is in place which is in keeping with current legislation. There are some areas for improvement such as revising second opinion protocols, updating education for Riverview Staff, and expanding resources for outpatient ECT.

Although questions have arisen pertaining to ECT utilization, the lack of trust that such issues will be fairly addressed within the organization has caused this issue to become public. The staff, patients, and families of Riverview Hospital have experienced distress as a result of adverse publicity. There is a need for Riverview Hospital and other health care professionals to improve public understanding about ECT.

The number of ECTs at Riverview Hospital has increased. Data explaining this increase are currently unavailable and therefore conclusions regarding utilisation cannot be made at this time. A comprehensive Province-wide database, including appropriate outcome measures, is essential.

February 21, 2001 Riverview Report

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Many women suffer with both major depression and anxiety. Here's why and the difficulties that come with treating comorbid anxiety and depression in women.

1. Major depression in women is twice as common as in men - lifetime prevalence 21% for women. At age 10, the incidence difference begins to differ between the sexes, and peaks by mid to late adolescent.
2. Women are more likely to have an increase in stressors prior to the depression diagnosis than men. Anxiety, panic, somatic complaints, increased appetite, weight gain, guilt, and decreased sexual desire are more apt to be seen in women that men. Comorbid psychiatric disorders are more common. Women attempt suicide more often than men but men are more apt to be successful with the attempt.
3. Why is depression more common in women than men? May be due to genetic transmission or difference in brain structure. Depression is also associated with reproductive function. There are many psychosocial risk factors. Lack of work outside the home may be a risk factor, along with marital conflict (women three times more apt to be depressed in an unhealthy marriage than men) and the presence of young children in the home.
4. Depression and anxiety together usually results in more treatment difficulties - often with the need for higher med dosing with longer duration of med use.
5. Women with anxiety have much more panic and phobia problems than men. Posttraumatic stress disorder in women is more common along with a history of sexual abuse in women with PTSD.
6. Tricyclic antidepressants can have significant side effects once at therapeutic doses to treat depression. The lethal potential is greater than with the SSRI's as well.
7. Panic disorder in women is associated with a more frequent relapse when the meds are discontinued. SSRI's are effective as this is most thought to be due to a serotonin deficiency. Starting at low dose and then titrating up to the mid or higher end of the dosing schedule for any given ssri is the recommended way to go. Beginning a benzodiazepine with the SSRI initially can be acceptable, but it is important to let the patient know that this is a temporary medication.
8. Cognitive therapy is a valuable adjunct to medication use and should not be forgotten.
9. Premenstrual dysphoric disorder (PMDD) - premenstrual and cyclical with mood symptoms (irritability is the hallmark), along with other typical depressive symptoms. Women with postpartum depression, history of mood changes when on bcp's have a higher incidence of PMDD. The theory of this is that there is a decrease in serotonin function. There is also serotonergic dysregulation.
10. Treatment of PMDD - one a day multivitamin plus calcium, diet modification with smaller and more frequent meals with higher carbohydrates and less fat, nsaids can be effective for the dysmenorrhea, and consideration for SSRI medications. The SSRI's work "immediately" to treat the PMDD as they effect serotonin levels immediately. Some may already be on an SSRI and can "bump up" the dose for the one to two weeks of PMDD symptoms. The low dose of an SSRI may be all that is needed to treat the PMDD especially if there is no other comorbid condition such as anxiety or depression
11. Postpartum depression (PPD) can also be well treated with SSRI's. Treatment for a minimum of one year is suggested. There can be an increase in conduct disorders and depression in children of women with untreated postpartum depression. Women with a previous history of PPD do better when given meds prophylactically shortly after the birth or even before birth (ssri's are category C, however -so one must weigh the risks and benefits) if the mother has a history of the depression beginning before the child is born. Minimal case reports of problems noted in babies breastfeeding whose mothers are on an SSRI medications.
12. Depression during the perimenopause: commonly seen together. Early menopause is risk factor, as is surgical menopause.

The Concise Guide to Women's Mental Health is a book that can be obtained from the American Psychiatric Association to get additional advise in medication prescribing in breastfeeding or pregnant women.

Source: Annette Smick, M.D. (Marquette General Hospital), Feb. 2001

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Anxiety and work is a little discussed topic. Stress, yes. But not anxiety. Yet work has much anxiety associated with it. Our success or failure rests on our ability to deal with the unknown. Doubts about our individual competence run through us all. Some of the tasks we have to perform may be unpleasant, distressing, or irritating.

In the last fifty years, a growing field of inquiry has focused on how these anxieties get handled in organizations. A seminal study was produced by Isabel Menzies Lyth (1959) on a consulting project she did with an English teaching hospital. The presenting problem was the concern voiced by senior staff that student nurses' training was driven more by work demands of the hospital than the training needs of nurses. What she discovered was an extremely high level of distress and anxiety within the nursing staff - so high in fact that about one third of student nurses left each year of their own volition.

Her initial observation was that the work of nursing is itself exceptionally anxiety-producing. Nurses work with people who are ill or dying. Wrong decisions can have devastating consequences. Nurses must respond to the distressed family of the patient. Many tasks are distasteful or repulsive.

She also observed that the way work was organized seemed directed at containing and modifying this anxiety. For instance, there was a dominant belief that if the relationship between nurse and patient were close, the nurse would experience more distress when the patient was discharged or died. Work practices encouraged distance. Nurses were required to perform a few specialized tasks with a large number of people, thereby restricting contact with any one patient. Calling patients by their condition - "the liver in bed 14"- rather than their proper name was common. Similarly, the weight of responsibility for making a final decision was mitigated in a number of ways. Even inconsequential decisions were checked and rechecked. Tasks were "delegated" up the hierarchy, with the result that many nurses were doing work well below their competence and position. In some cases subordinates were reticent to make decisions; in others guidelines were not in place to implement delegation.

These procedures appeared analogous to individual defense mechanisms. While they protected the nurses from their original anxieties, they created new ones. For instance, nurses and student nurses in particular, were given lists of simple tasks over which they had little discretion on how to perform them. Consequently they would wake patients to give them sleeping pills! They woke patients early in the morning to wash their faces before the doctors arrived, despite feeling that they would be better off sleeping. In interviews, nurses expressed guilt that they had in fact practiced bad nursing even though they carried out procedures to the letter. They knew they were not caring for patients' needs, but the system's needs.

Menzies Lyth argued that substantial parts of the hospital organization constituted social defenses (Jaques, 1955) that helped individuals avoid anxiety. The nursing management made no direct attempt to address the issue of the anxiety-provoking experiences and develop nurses' capacity to respond to anxiety in a psychologically healthy way. They did not, for instance, acknowledge that a patient's death affected nurses or provide support to deal with this and other distress. Instead, the rationale developed that a "good nurse" was "detached".

Menzies Lyth proposes that an organization is influenced by four main factors: (1) its primary task, including related environmental pressures and relationships. (2) the technologies needed to perform the task, (3) the need of members for social and psychological satisfaction, and (4) the need for support in dealing with anxiety. She argues that the influence of task and technology is often exaggerated, and that the power of psychological needs of members is generally underestimated as an influencing force. Task and technology are the framework- the limiting factors. Within those limits, the culture, structure, and mode of functioning are determined by psychological needs.

If support for anxiety is not provided, people will still find ways to insure that their anxieties are eased. The process will, however, be unconscious and covert, and the defenses developed against anxiety will become embedded in the organization's structure and culture. As we saw with the nurses, these defenses may work counter to the needs of the primary task. They may not make sense. But they are an aspect of the organization's reality to which everyone must adapt or leave.

So if we look at any organization's processes and culture, do they make more sense from a rational productivity perspective, or can they be better explained as social defenses? What about governmental bureaucratic procedures? What about the current culture of heavy work loads and long hours? As with the nursing practices, both are well in place with many people complaining about them.

The striking point arising from Menzies Lyth's study is how deeply vested we all are in the way things are done. Those of us who work to introduce change into organizations must be sensitive to how dependent we all are on social defenses. We must recognize the active function that many dysfunctional processes fulfill in the psychological lives of members if we are to keep ourselves grounded in the reality of how difficult change is to achieve.

References

Menzies Lyth, Isabel. "The Functioning of Social Systems as a Defence against Anxiety", in Containing Anxiety in Institutions, Free Associations, London, 1988. pp 43-85.

Jaques, "Social Systems as a Defense against Persecutory and Depressive Anxiety", in New Directions in Psychoanalysis, Klein, Heimann, and Money-Kyrle, Eds., Tavistock Publications, London, 1955. pp 478-498.

© 2001 All rights reserved. The authors are Brian Nichol and Lou Raye Nichol or call (919)303-5848.

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Description of body dysmorphic disorder, BDD behaviors and treatment of body dysmorphic disorder.

Body Dysmorphic Disorder, (BDD) is listed in the DSM-IV under somatization disorders, but clinically, it seems to have similarities to Obsessive-Compulsive Disorder (OCD).

BDD is a preoccupation with an imagined physical defect in appearance or a vastly exaggerated concern about a minimal defect. The preoccupation must cause significant impairment in the individual's life. The individual thinks about his or her defect for at least an hour per day.

The individual's obsessive concern most often is concerned with facial features, hair or odor. Body Dysmorphic Disorder often begins in adolescence, becomes chronic and leads to a great deal of internal suffering.

The person may fear ridicule in social situations, and may consult many dermatologists or plastic surgeons and undergo painful or risky procedures to try to change the perceived defect. The medical procedures rarely produce relief. Indeed they often lead to a worsening of symptoms. BDD may limit friendships. Obsessive ruminations about appearance may make it difficult to concentrate on schoolwork.

Other behaviors that may be associated with BDD

• Frequent glancing in reflective surfaces
• Skin picking
• Avoiding mirrors
• Repeatedly measuring or palpating the defect
• Repeated requests for reassurance about the defect.
• Elaborate grooming rituals.
• Camouflaging some aspect of one's appearance with one's hand, a hat, or makeup.
• Repeated touching of the defect
• Avoiding social situations where the defect might be seen by others.
• Anxiety when with other people.

BDD tends to be chronic and can lead to social isolation, school dropout major depression, unnecessary surgery and even suicide.

It is often associated with social phobia and OCD, and delusional disorder. Chronic BDD can lead to major depressive disorder. If it is associated with delusions, it is reclassified as Delusional disorder, somatic subtype. Bromosis (excessive concerns about body odor) or Parasitosis (concern that one is infested by parasites) can classically be associated with delusions.

Other conditions that might be confused with BDD: Neglect caused by a parietal lobe brain lesion; anorexia nervosa, gender identity disorder.

Milder body image disturbances that do not meet criteria for BDD:

• Benign dissatisfaction with one's looks. This does not affect the person's quality of life. 30-40% of Americans may have these feelings.
• Moderate disturbance with one's body image. The person's concerns about appearance cause some intermittent anxiety or depression.

Treatment of Body Dysmorphic Disorder:

It is at times difficult to get an individual with BDD into psychiatric treatment because he or she may insist that the disorder has a physical origin. We prefer that the referring physician call us in advance so that we can strategize on how best to encourage the individual to accept help. Treatment often involves the use of SSRI medications (such as sertraline or fluoxetine) and cognitive-behavioral psychotherapy. In this type of psychotherapy the therapist helps the affected individual resist the compulsions associated with the BDD such as repeatedly looking in mirrors or excessive grooming (response prevention). If the individual avoids certain situations because of fear of ridicule, he or she should be encouraged to gradually and progressively face feared situations. If the individual plans to seek invasive medical/surgical treatment, the therapist should attempt to dissuade the patient or ask permission to talk with the surgeon. The therapist helps the individual to understand how some of his or her thoughts and perceptions are distorted and helps the patient replace these perceptions with more realistic ones. Family behavioral treatment can be useful, especially if the affected individual is an adolescent. Support groups if available, can help.

About the author: Carol E. Watkins, MD is Board-Certified in Child, Adolescent and Adult Psychiatry. She is a well-known lecturer and in private practice in Baltimore, MD.

For more information, read The Broken Mirror by Katharine Phillips, M.D. or The Adonis Complex: The Secret Crisis of Male Body Obsession by Harrison G. Pope Jr. M.D. and Katharine Phillips, M.D.

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Detailed description of agoraphobia with an overview of treatment for agoraphobia.

Agoraphobia is the fear of going out into public places. Agoraphbia can occur with or without panic attacks.

Mary's problems started one day when she was pumping gas. Some rough young men came over and made rude remarks. She was frightened and began avoiding gas stations. The fear increased, and she became unable to do the grocery shopping without her husband. She spent much of her day worrying about anticipated trips out of the house. Within two years, she was housebound. Her husband consulted a psychiatrist who gave him advice on how to persuade Mary to come in for a consultation. The psychiatrist saw them together, educated them about agoraphobia, and prescribed medication. At Mary's next session, she was calm enough to begin the therapeutic work of enlarging her "perimeter of safety." Her husband attended all of the sessions. Between sessions, he helped her with her homework. He would accompany her as she gradually went further from home. When she began to go places on her own, he was coach and cheerleader. She was eventually able to deal with her fears on her own. Mary elected to remain on her medications for a year after her symptoms had gone away. *

In milder forms, agoraphobia may cause an individual to avoid certain situations and jobs. However, in some cases, the fear increases until the individual becomes depressed and housebound. Occasionally one may be too fearful to come in for treatment. This may be a reason for resurrecting the old concept of the physician's house call.

Treatment for Agoraphobia

Individuals with severe agoraphobia should usually start both medication and therapy as soon as possible. Without the medication, such an individual might not be able to make full use of the therapeutic process. People with mild to moderate symptoms might chose a combination approach or therapy alone. Homework between situations, and coaching from family members or therapists help one gradually face the feared situations.

*vignettes are fictional examples

About the author: Carol E. Watkins, MD is Board-Certified in Child, Adolescent and Adult Psychiatry and in private practice in Baltimore, MD.

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J CLIN PSYCHIATRY 43 4
April 1982
JOAN P GERRING. M.D. and HELEN M SHIELDS. M D

Abstract

The authors describe the cardiovascular complications of ECT in 42 patients undergoing this procedure during a one year period at a psychiatric referral center. Twenty-eight percent of the entire group of patients developed ischemic and/or arrhythmic complications following ECT. Seventy percent of the patients who had a history, physical or EKG evidence of cardiac disease developed cardiac complications. On the basis of this data, a high risk category for ECT is defined more precisely than previously. Recommendations are made for managing this high risk category of depressed patients In order to treat them with maximum safety and effectiveness. (J Clin Psychiatry 43:140-143. 1982)

A mortality rate of less than 1% has been consistently reported for patients undergoing electroconvulsive therapy (ECT), the most common side effect being memory impairment. Fortunately this is usually a short term loss which may be minimized with the use of unilateral ECT. With the addition of a muscle relaxant to modify ECT, fractures are no longer the second most common complication. Rather cardiovascular complications have taken this place. In this study we define a psychiatric population with high medical risk to develop cardiovascular complications of varying severity. We emphasize the identification and special care of this group.

Method

The charts of the 42 patients who had undergone a course of electroconvulsive therapy at Payne Whitney Clinic (PWC) during the period July 1, 1975 to July 1, 1976 were reviewed. Five patients had undergone two separate courses of ECT during this time period.

During the year July 1975 to July 1976, 924 patients were admitted to PWC. There were 347 males and 577 females: 42 patients or 4.5% received ECT. The average age of the ten men receiving ECT was 51 years and the average age of the 32 women receiving ECT was 54.7 years. Thirty-three patients (78%) of the group were diagnosed as having an affective disorder. These patients had an average age of 59.4 years and received an average of seven treatments. Seven patients (16%) were diagnosed as schizophrenic. These patients were much younger on the average than the preceding group (29.4 years) and had twice as many treatments per patient.

Seventeen of our patients (40%) presented with cardiac disease. This group included all patients with a history of angina, myocardial infarction, congestive heart failure, abnormal electrocardiogram, hypertension. (Table l)

The standard preparation for ECT during the year July 1, 1975 to July 1, 1976 consisted of a physical examination, hematocrit, hemoglobin and white count, urinalysis, chest x-ray, skull x-ray, lateral spine x-rays, electrocardiogram and electroencephalogram. Medical clearance, if any value was abnormal or the history revealed significant medical problems, was obtained from an internist, cardiologist, or neurologist.

Psychotropic medications were discontinued on the day prior to the first treatment and the patient was fasted overnight. One-half hour prior to a treatment 0.6 mg atropine sulfate was injected intramuscularly. First and second year psychiatric residents were in attendance in the ECT suite. After application of electrodes, the patient was anesthetized with intravenous thiopental, with a mean amount of 155 mg and a range of 100 to 500 mg. Intravenous succinylcholine, with a mean of 44 mg and a range of 40 to 120 mg was used for muscle relaxation. Mask ventilation with 100% oxygen was then begun continuing until the point in treatment when the effects of the succinylcholine were wearing off and the patient could resume breathing without assistance. This usually occurred about five to ten minutes after the dose. Patients with pulmonary disease were to have a baseline set of blood gases, carbon dioxide retainers not being hyperventilated. The modified grand mal convulsion was induced by an electric current that varied from l30 to 170 volts given over a period of 0.4 to 1 second (Medcraft Unit Model 324). In ten of 17 patients with history, physical or EKG evidence of cardiovascular disease, a cardiac monitor or twelve lead EKG machine was used to monitor their rhythm immediately before, during and for a 10-15 minute period following an ECT treatment.

The average systolic blood pressure on admission in the group who did not experience cardiovascular complications was 129 ± 21 mm Hg. The average of the highest systolic blood pressures recorded after the first ECT in this group was 173 ± 40mm Hg. A multivariate analysis was performed on the baseline blood pressure for each patient as recorded on his/her initial physical examination, as well as the highest blood pressure noted after each of the first four ECT treatments (unless the patient had less than four treatments). The systolic and diastolic pressure rise after each of the treatments were separately compared to the baseline blood pressure.

The treatment course for depression consisted of from five to 12 treatments given as three treatments per week. For the treatment of schizophrenic illness, the treatment plan consisted of five treatments per week to a total of 15 to 20 treatments.

Results

During July 1, 1975 to July 1, 1976. 12 of the 42 patients (28%) who underwent modified ECT at the New York Hospital developed an arrhythmia or ischemia following the procedure. In patients with known cardiac disease, the complication rate rose to 70%. This rate may have been even higher had all 17 cardiac patients been monitored. The four cardiac patients with no complications were not monitored so arrhythmias could easily have been missed. The 12 patients who developed cardiac complications of ECT came entirely front this group of 17 cardiac patients (Table 1) with known cardiovascular disease prior to ECT. Six of the cardiac patients had a history of hypertension, four had rheumatic heart disease, four had ischemic heart disease and three had arrhythmias or a history of arrhythmias. Sixteen of the 17 patients had an abnormal electrocardiogram prior to ECT: these included three who had a definite old myocardial infarction, two who had a possible old myocardial infarction, three other patients who had a bundle branch block, four patients with arrhythmias and four others with either left ventricular hypertrophy, left atrial abnormality or first degree heart block. Thirteen of the 17 patients were on a digitalis preparation, six were on diuretics and six were on an antiarrhythmic spent.

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Four of the complications in this series were life threatening events while the rest were largely asymptomatic arrhythmias. These latter included ventricular begeminy (two patients), ventricular trigeminy (one patient), coupled premature ventricular contractions (one patient), premature ventricular contractions (four patients), atrial flutter (two patients), and atrial bigeminy (one patient) (Table 1). The complications were scattered throughout the entire treatment course and were not localized to the initial one or two treatments. Not included as a complication is the hypertensive response immediately following ECT which occurred in the majority of patients. The group of 12 patients with cardiovascular problems who developed cardiovascular complications did not have a significantly greater increase in systolic or diastolic blood pressure after any of the first four treatments as compared to all the other patients.

Arrhythmias were the most common cardiac complication. Of the nine patients who developed an arrhythmia, six had a previous history or EKG evidence of arrhythmia. Four patients developed severe complications following an ECT treatment. Patient E.S. sustained a cardiopulmonary arrest 45 minutes after her fifth treatment. She expired despite an intensive resuscitative effort. Autopsy did not reveal evidence of a recent infarction, but only evidence of an old infarct that had occurred clinically seven months previously. Patient D.S, with a history of infarction seven years prior to admission, showed electrocardiographic evidence of a subendocardial infarction after his first ECT. After transfer and treatment on the medical service, DS. completed a course of seven ECT. A.B. developed hypotension, chest pain, and premature ventricular contractions after his first treatment. In the patient M.O. rapid atrial fibrillation following the second treatment led to severe heart failure. The latter two patients were also transferred to the medical service before resumption of their ECT treatment courses.

Twenty-eight (67%) of the patients in this series were age 50 or older. Although the non-cardiac complications were evenly distributed between the younger and older patients. 100% of the cardiac complications occurred in the age group over 50 with 11 of 12 occurring over age 60. No cardiac complications occurred in the schizophrenic group all of whom were less than 50 years of age, despite the higher number of treatment courses in this group (Table 2).

Fourteen (33%) of the patients had other medical complications temporally related to ECT. The most common non-cardiac complication was a rash seen in six patients. described as urticarial or maculopapular. In two instances patients developed transient laryngospasm following ECT. None of the other non-cardiac complications would be classified as serious. Only one of the 42 patients had both a medical and cardiac complication.

Discussion

Using our review of 42 patients who underwent ECT during one year at a psychiatric referral hospital. we have identified more precisely than previously a group of patients at high risk for the development of cardiovascular complications. This group is comprised of those patients with a known history of angina, myocardial infarction, congestive heart failure, arrhythmias, rheumatic heart disease, hypertension or a baseline abnormal electrocardiogram. It is interesting that all the severe or life threatening complications occurred in patients who had previous myocardial infarctions or congestive heart failure: they appear to be a special subset of the high risk category. Since all the patients in this series with heart disease were over 50 years of age, it is impossible to say whether patients under 50 years of age with heart disease will have the same complication rate.

The cardiovascular complications in this series and in others are probably attributable to the physiological changes that accompany ECT. Autonomic nervous system activity is triggered by the electric shock. During the early phase of the seizure, parasympathetic activity predominates with a fall in pulse rate and blood pressure. This is followed by a sympathetically induced rise in pulse and blood pressure. Pulse rates of between 130 and 190 and systolic blood pressures of 200 or over are common following electric shock even in modified ECT. Atropine has been recommended for all patients undergoing ECT in order to block the excess secretions and reduce the impact of the initial parasympathetic discharge. Unfortunately. there is still a significant rate of arrhythmias subsequent to atropine as shown in our study and in others. Some of these probably result from inadequate vagal blockage and others from unblocked sympathetic stimulation. In addition. succinylcholine has a cholingeric action which may be increasingly severe with successive doses and has been shown to cause hyperkalemia.

Methohexital has been associated with fewer arrhythmias than thiopental which was the short acting barbiturate used in our patient group. Although it is not clear why arrhythmias are fewer with methohexital its use is recommended rather than thiopental for all patients undergoing ECT.

Arrhythmias were the most common complication in our series accounting for ten of the 13 complications. Except for the patient M.O. who developed severe congestive failure secondary to rapid atrial fibrillation, the arrhythmias noted after ECT in this series were benign, terminating within minutes without symptoms or signs of hypotension. congestive heart failure or ischemia. It is possible however that an arrhythmia contributed to the death of E.S.

In a recent study by Troup et al on the incidence of arrhythmias in a group of 15 patients undergoing ECT who were monitored by 24 hour Holter recordings before, during and after ECT, there was no significant difference between the number of premature atrial or ventricular contractions prior to ECT and that noted during or after ECT. The discrepancy between their findings and other reports including the present series may he accounted for by the younger age in their group of patients. The majority were in their twenties with only one patient being over 50. Of equal or greater importance may be the fact that only the one patient over 50 (age 51) had historical, physical and EKG evidence of cardiovascular disease.

In this series two patients developed ischemic complications. Other investigators have previously reported ischemic changes on the EKG during and immediately after the convulsive period. ECT induced ischemic damage is presumably mediated by the marked sympathetic stimulation as evidenced by the rise in pulse and blood pressure. The mild hypoxia, hypercapnia and respiratory acidosis which can complicate ECT may also contribute. There was no statistical correlation between the height of the systolic or diastolic blood pressure rise after ECT and the occurrence of ischemic complications. However, different susceptibilities to the rise in blood pressure may play a role in complications in a given individual.

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A recent report of the task force on ECT protocol emphasized the careful tailoring of both the anesthetic agent and muscle relaxant to the individual patient based on body weight and other medications. It also stressed the use of 100% oxygen via the anesthetic mask for 2-3 minutes before injecting the anesthetic agent in patients with higher risk. On the basis of our data showing that arrhythmias and ischemic events occur more frequently in patients in the high risk category, we suggest that other precautions be taken for ECT in this group to minimize the morbidity and mortality of ECT. The additional precautions should include: 1) medical clearance from an internist or cardiologist familiar with the complications of ECT. 2) cardiac monitoring immediately preceding during and for at least a ten to 15 minute period following ECT. 3) the presence at ECT of personnel trained in cardiopulmonary resuscitation and the emergency management of arrhythmias. 4) an EKG reading before each successive treatment to establish no significant interval change and 5) frequent electrolytes particularly in patients on a diuretic or digitalis therapy throughout the ECT course.

Both suicidal and non-suicidal deaths are higher in the depressed population and ECT is effective in reducing the incidence of both types of deaths. Studies indicate that ECT is superior to tricyclics in rapidity of response and in the percentage of positive responses. ECT exposes the patient to a very short period of risk during which time he is under the direct supervision of trained personnel. In addition tricyclic use has been associated with a variety of cardiotoxicities.

Although the rate of complications for ECT is very low, those that occur most often are cardiovascular in nature. It is hoped that through early identification and management of the group of patients at high risk for these complications that the morbidity and mortality of this extremely effective treatment for severe depression will be lowered even further.

References

1. Impastato DJ. Prevention of fatalities in electroshock therapy. Dis Nerv Syst 18 (Suppl) 34-75, 1955.

2. Turek IS and Hanlon TE: The effectiveness and safety of electroconvulsive therapy (ECT). J Nerv Ment Dis 164:419-431.1977

3. Squire LR and Stance PC: Bilateral and unilateral ECU Effects on verbal and nonverbal memory. Am J Psychiatry 135:I316-1360.1978

4. Kalinowsky LB: The convulsive therapies. In: Comprehensive Textbook of Psychiatry Second Edition. Edited by Freedman AM Kaplan HI and Sadock BJ. Baltimore. The Williams and Wilkins Company. 1975

5. Huston PE: Psychotic depressive reaction. In: Comprehensive Textbook of Psychiatry Second Edition. Edited by Freedman AM. Kaplan HI and Sadock BJ. Baltimore. The Williams and Wilkins Company. 1975

6. Lewis WH Jr. Richardson J and Gahagan LH: Cardiovascular disturbances and their management in modified electrotherapy for psychiatric illness. N EngI J Med 252:1016-1020. 1955

7. Hejtmancik MR. Bankhead AJ and Herrman GR: Electrocardiographic changes following electroshock therapy in curarized patients Am Heart J 37:790-850. 1949

8. Deliyiannis S. Eliakim M and Bellet S: The electrocardiogram during electroconvulsive therapy as studied by radioelectrocardiography. Am J Cardiol 10:187-192. 1962

9. Perrin GM: Cardiovascular aspects of electric shock therapy. Acta Psychiat Neurol Scand 36 (Suppl) 152:1-45. 1961

10. Rich CL. Woodriff LA. Cadoret R. et al: Electrotherapy: The effects of atropine on EKG. Dis Nerv Syst 30:622-626. 1969

11. Bankhead AJ. Torrens JK and Harris TH. The anticipation and prevention of cardiac complications in electroconvulsive therapy. Am J Psychiatry 106:911-917. 1950

12. Stoelting RK and Peterson C: Heart rate slowing and junctional rhythm following intravenous succinylcholine with and without intramuscular atropine preanesthetic medication. Anesth Analg 54:705-709. 1975

13. Valentin N. Skovsted P and Danielsen B: Plasma potassium following suxamethoniurn and electroconvulsive therapy. Acta Anesthesiol Scand 17:197-202. 1973

14. Pitts FN Jr. Desmarias GM. Stewart W. et at.: Induction of anesthesia with methohexital and thiopental in electroconvulsive therapy. N Engl J Med 273:353-360. 1965

15. Troup PJ. Small JG. Milstein V et al: Effect of electroconvulsive therapy on cardiac rhythm, conduction and repolarization. PACE 1:172-177. 1978

16. McKenna O. Enote RP. Brooks H. et al: Cardiac arrhythmias during electroshock therapy Significance, prevention and treatment. Am J Psychiatry 127:172-175. 1970

17. American Psychiatric Association Task Force Report 14: Electroconvulsive Therapy. Washington. DC. APA. 1978

18. McAndrew J and Hauser G: Preventilation of oxygen in electroconvulsive treatment: A suggested modification of technique. Am J Psychiatry 124:251-252. 1967

19. Homherg G: The factor of hypoxemia in electroshock therapy Am J Psychiatr) 1953

20. Avery D and Winokur G Mortality) in depressed patients treated with electroconvulsive therapy and antidepressants. Arch Gen Psychiatry 33:1029-1037. 1976

21. Buck R. Drugs and the treatment of psychiatric disorders. In the Pharmacological Basis of Therapeutics (Fifth Edition) Edited by Goodman LS and Gilmar, A. New York. Macmillan Publishing Co. Inc. 1975

22. Jefferson J: A review of the cardiovascular effects and toxicity of tricyclic antidepressants. Psychosom Med 37:160-179.1975

23. Moir DC. Cornwell WB. Dingwall-Fordyce et al. Cardiotoxicity of amitriptyline. Lancet: 2:561-564. 1972

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Prepared for the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Mental Health Services

March 1998
Prepared pursuant to CMHS Contract No. 0353-95-0004

RESEARCH-ABLE, INC., 501 Niblick Drive, S.E., Vienna Virginia 22180

TABLE OF CONTENTS

PURPOSE

INTRODUCTION

I. HISTORY

II. ECT AS A METHOD OF TREATMENT

Administration of ECT
Risks
Theories Regarding Mechanism of Action
Conditions for Which ECT Is Used
Importance of Patient Consent to Treatment

III. CONSUMER AND PUBLIC ATTITUDES REGARDING ECT

Introduction
Basis of the Opposition to ECT
Questions Regarding Persons Giving Voluntary Informed Consent
Opponents of ECT
Proponents of ECT and Informed Consent

IV. LEGAL PERSPECTIVES AND STATE REGULATION

V. RESEARCH PRIORITIES IDENTIFIED BY 1985 NIMH CONSENSUS DEVELOPMENT CONFERENCE ON ECT

SUMMARY

APPENDIX A - Interviews with Representatives of Organizations

PURPOSE

The Center for Mental Health Services (CMHS) periodically issues reports on topics of concern to the mental health field and to the American public. Part of the CMHS's responsibility is to develop and disseminate information on the delivery of services to persons with mental illness and their families.

This report on electroconvulsive therapy (ECT) summarizes the following information:

1. the current state of knowledge regarding this treatment;
2. consumer and public views;
3. relevant laws and regulations; and
4. priority research tasks.

INTRODUCTION

ECT, a treatment for serious mental illness, involves the production of a generalized seizure through application of a brief electrical stimulus to the brain. Since ECT was first used in Italy more than 50 years ago, the procedures associated with ECT have been improved. Better methods have been developed in regard to anesthesia, the delivery of electrical current, and patient preparation and consent.

Broad agreement exists within the medical-psychiatric community about the effectiveness and safety of ECT for the treatment of people with certain mental illnesses. However, some of those to whom ECT has been administered, are greatly concerned about its possible misuse and abuse. They are also concerned about what they perceive to be a failure to protect the rights of patients. Their concern may be heightened both because treatment side effects (e.g., post-treatment confusion and memory loss) are not uncommon, and because scientists have yet to clarify precisely how ECT works to relieve symptoms. ECT is used primarily for people with severe depression. (1) The treatment is usually provided in the psychiatric units of general hospitals and in private psychiatric hospitals. According to a 1995 report, (2) per capita utilization rates of ECT vary widely across the United States, and an estimated 100,000 patients received ECT during 1988-1989.

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I. HISTORY

In 1938, Ugo Cerletti, an Italian neuropsychiatrist, applied electric shock to the brain of a person with a serious psychiatric illness. According to reports, the man's condition improved dramatically, and within 10 years, this treatment was employed widely in the United States.(3) In the 1940's and 1950's, ECT was used mainly for persons with severe mental illness residing in large mental institutions (mainly State hospitals). The 1985 Report of the National Institute of Mental Health (NIMH) Consensus Development Conference on ECT (4) described these early efforts:

"ECT was used for a variety of disorders, frequently in high doses and for long periods. Many of these efforts proved ineffective, and some even harmful. Moreover, the use of ECT as a means of managing unruly patients, for whom other treatments were not then available, contributed to a perception of ECT as an instrument of behavioral control for patients in institutions for chronically mentally ill individuals."

In 1975, the blockbuster movie, One Flew Over the Cuckoo's Nest, based on the 1962 novel by Ken Kesey, dramatically reinforced fears regarding ECT, at least for the movie-going public. More recently, at legislative hearings in Texas, (5) opponents of ECT buttressed their concerns about its safety and effectiveness with testimony about the results of Internet surveys. (6)

In the early years, many fractures and even a number of deaths were associated with the use of ECT. (7) Over the years, however, ECT has changed. The technology associated with ECT has been improved, virtually eliminating previous risks. (8) Safer methods of administration have been developed, including the use of medications, muscle relaxants, and an adequate supply of oxygen throughout treatment.

It is believed that the largest category of people receiving ECT are elderly, depressed women who are inpatients in general or private psychiatric hospitals. (9) Most States do not require physicians to report ECT use; therefore, annual estimates of the number of patients receiving this treatment are speculative. What scientific data do exist suggest a great deal of regional variation in its use -- more so than for most other medical and surgical procedures. (10)

The absolute number of individuals receiving ECT appears to have decreased. Public complaints, coupled with litigation, have caused many public institutions to become increasingly uneasy about its use, and State regulation has served to reduce its administration in public hospitals. Moreover, the revolution in psychopharmacology since the 1960's, has played a role in lowering the number of patients receiving ECT. Today, the procedure is most often administered only after other treatment alternatives have been tried and found to be unsuccessful.

While patient concern about ECT has a long history, the growing prominence of the consumer rights movement has, in recent years, brought the issue to increasing public attention. The concept of informed consent for treatment is becoming more widely understood and accepted by patients and their families. Opponents who argue for a total legislative ban, assert that ECT causes long-term memory loss and is frequently administered without having been explained adequately. Such arguments have led many States to require patients to give consent before ECT can be administered (See Section IV below).

II. ECT AS A METHOD OF TREATMENT

Administration of ECT

ECT involves the use of controlled electrical currents of one to two seconds in duration that induce a 30-second seizure. Generally, the procedure involves attaching two electrodes to the scalp, one on each side of the head, although physicians sometime place the electrodes on only one side of the head. Often, two or three treatments are given weekly for several weeks. In its early years, ECT was administered to patients without prior medication. Today, however, anesthesia, muscle relaxants, and electroencephalographic (EEG) monitoring during and following treatment, enable the physician to closely check patient reactions. Thus, involuntary movement from ECT-induced seizure normally consists of a slight movement of the fingers and toes. (11)

Risks

Some patients who have received ECT report long-term side effects from the treatment. Memory deficits have been reported even three years post-treatment, although most seem to occur around the period immediately prior to and following the procedure. While not minimizing the significance of adverse side effects, most members of the medical community maintain that the duration of such side effects is relatively brief:

"It is.. .well established that ECT produces memory deficits. Deficits in memory function, which have been demonstrated objectively and repeatedly, persist after the termination of a normal course of ECT. Severity of the deficit is related to the number of treatments, type of electrode placement, and nature of the electric stimulus... The ability to learn and retain new information is adversely affected for a time following the administration of ECT; several weeks after its termination, however, this ability typically returns to normal." (12)

Theories Regarding Mechanism of Action

While many theories have sought to explain the therapeutic effects of ECT, a determination of the precise mechanism of action awaits further research. (13) The medical community generally believes that something associated with the seizure itself, rather than a psychological factor such as patient expectation, causes neurophysiological and biochemical changes in the brain that account for the decrease or remission of symptoms. Permanent changes in brain structures have not been found in either animal studies or in autopsies performed on the brains of persons who had ECT at some time in their lives. Furthermore, studies in which animals have been subjected to much stronger and more protracted electric shock than those used during ECT, have not detected structural or biochemical brain changes. (14)

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Conditions for Which ECT Is Used

Because beneficial psychopharmacological drugs are easier to administer, less expensive, and not as controversial as ECT, such interventions are usually attempted prior to employing ECT. ECT is generally considered only for persons with severe or psychotic forms of affective disorders (depression or bipolar illness) who either have failed to respond to other therapies or are considered to be at imminent risk of suicide. Since an antidepressant may not become fully effective for several weeks after treatment begins, the rapidity of symptom relief associated with ECT may make it the treatment of choice for people who cannot safely wait for alternative treatments (such as people who are suicidal). (15) ECT can make the patient accessible to the efficacious effects of medications and psychotherapy. (16) Clinicians also report that ECT can reduce the duration of episodes of mania and major depression, (17) and if used promptly, may help to shorten hospital stays of people with recurrent major depression. (18)

The Agency for Health Care Policy and Research, in a recent clinical practice guideline, (19) suggests ECT is appropriately used for selected patients with serious depressive disorders.

"It is a first-line option for patients suffering from severe or psychotic forms of major depressive disorder, whose symptoms are intense, prolonged, and associated with neurovegetative symptoms and/or marked functional impairment, especially if these patients have failed to respond fully to several adequate trials of medication. Electroconvulsive therapy may also be considered for patients who do not respond to other therapies, those at imminent risk of suicide or complications, and those with medical conditions precluding the use of medications...."

"However, ECT should be considered cautiously and used only after consultation with a psychiatrist, because ECT:

• Has not been tested in milder forms of illness.
• Is costly when it entails hospitalization.
• Has specific and significant side effects (e.g., short-term retrograde and anterograde amnesia).
• Includes the risks of general anesthesia.
• Carries substantial social stigma.
• Can be contraindicated when certain other medical conditions are present.
• Usually requires prophylaxis with antidepressant medication, even if a complete, acute phase response to ECT is attained."

No general agreement exists within the medical community regarding the utility of ECT in the treatment of schizophrenia. Although a number of clinical studies suggest ECT is effective in treating people with schizophrenia, (20) they are not definitive.

Further research is also needed to determine whether ECT reinforces the effects of neuroleptic drugs. Clinicians find most ECT patients benefit from the use of supportive drug and/or talk therapy once ECT has alleviated the worst depressive or other symptoms. Recent scientific reports suggest major mood disorders among pregnant women can safely be treated with ECT if appropriate steps are taken to decrease risks to both mother and child. (21,22)

Importance of Patient Consent to Treatment

In the wake of the ongoing controversy surrounding ECT, the medical community has become increasingly sensitive to the importance of obtaining informed voluntary consent from patients before initiating treatment. State laws and regulations, as well as professional guidelines, (23) spell out in detail, the nature of such consent. They suggest or require that the medical provider educate the patient and his/her family using written and audio-visual materials as well as verbal explanations, before the patient signs a consent form. (24) Required or suggested consent forms generally specify the following kinds of information:

1. the nature of the treatment;
2. the likely benefits and possible risks of treatment;
3. the number and frequency of treatments to be undertaken;
4. alternative remedies; and
5. stipulations that patients retain the right to withdraw consent at any time during the treatment process.

In the case of an individual whose cognitive functioning and/or judgment may be impaired by psychiatric illness, it may be difficult to be certain of fully informed voluntary consent (see the discussion of legal aspects in Section IV below).

The 1985 NIMH Consensus Development Conference on ECT (25) commented on the issue of informed and voluntary consent:

"When the physician has determined clinical indications justify the administration of ECT, the law requires, and medical ethics demand, the patient's freedom to accept or refuse the treatment be fully honored. An ongoing consultative process should take place. In this process, the physician must make clear to the patient the nature of the options available and the fact the patient is entitled to choose among these options."

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III. CONSUMER AND PUBLIC ATTITUDES REGARDING ECT

Introduction

Douglas G. Cameron (26) of the World Association of Electroshock Survivors, addressing the Public Health Committee of the Texas House of Representatives in an April 1995 public hearing to consider a ban on ECT, captured the strong feelings of many ECT opponents with the following statement:

(ECT is) "An instrument which has injured and destroyed the lives of hundreds and thousands of people since its inception and continues to do so today."

Despite support from Cameron and others, proposed legislation to outlaw ECT was not enacted by the Texas legislature.

Comments contained in a two part series in USA Today (27) typify how some of the popular press view ECT:

"After years of decline, shock therapy is making a dramatic and sometimes deadly comeback, practiced now mostly on depressed elderly women who are largely ignorant of shock's true dangers and misled about shock's real risks."

A study (28) based on an Internet survey of ECT recipients choosing to respond, quotes some as saying:

"(ECT was) the worst thing that ever happened to me, and:

"Destroyed my family."

Citizens of Berkeley, California, in a 1982 local referendum, voted to "outlaw" the use of ECT. However, 40 days later, the courts ruled the result of the referendum to be unconstitutional.

The views of ECT opponents are balanced by people such as talk show host Dick Cavett who found ECT "miraculous," (29) and writer Martha Manning who felt as if she got 30 IQ points back once the depression lifted. However, she lost forever some memories before and during ECT. (30)

Although few studies of patient attitudes about ECT have been reported in the literature, a consistent finding among them has been the relationship between good ECT response and favorable attitudes. (31) In a controlled study, Pettinati and her colleagues reported that six months after ECT treatments, most of the patients studied said they would agree to ECT in the future if they were to become depressed again. (32)

Basis of the Opposition to ECT

When it comes to evoking strong feelings for and against a therapy, ECT may be unique among the broad range of current medical and psychiatric treatments. Dramatic impressions and portrayals of its horrors are juxtaposed against the rapid relief and remission of symptoms it often provides. These antithetical pictures combine to keep the controversy raging. The ways in which ECT was used and administered in the past are probably major factors in the continuing dispute. Reports of serious injury such as fractures and/or death resulting from the administration of ECT are now extremely rare. (33) However, the occurrence of these adverse effects in the past continues to promote public concern. Memory loss is the most frequent complaint of ECT recipients. Although its proponents agree that patients may suffer short-term memory deficits (particularly for the periods immediately preceding and following treatment), substantial disagreement exists about the nature, magnitude, and duration of such deficits.

Questions Regarding Persons Giving Voluntary Informed Consent

The patients' rights movement in the 1970's and 1980's heightened public and professional awareness regarding protection of the rights of persons with mental disorders, and the most emotionally-charged concerns about ECT probably center on questions of informed consent. (34) Are patients being fully informed and educated about the nature of ECT, the risks and benefits involved, and the availability of alternative, less intrusive treatments? Have they been told they can withdraw consent at any time during the treatment process? Is it clear that duress or inappropriate pressure has not been used to obtain agreement to the treatment? Is it clear that ECT is not being used to punish or control unruly patients?

Substantial ethical and legal issues may arise in regard to the involuntary administration of ECT. A report from the Wisconsin Coalition for Advocacy (35) indicates that such issues remain problematic in at least some hospitals in the State. The Coalition, which serves as the designated State Protection and Advocacy agency for persons with mental illness, responded to complaints regarding violation of the rights of patients on the psychiatry unit of a hospital in Madison. They reviewed treatment records and conducted in depth interviews that uncovered clear evidence of:

1. coercive practices to obtain patients' consent and failure to honor patients' refusal of treatment;
2. failure to provide sufficient information to patients for informed consent; and
3. consent to treatment by patients who were not mentally competent at the time they gave consent. (36)

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Professional organizations such as the American Psychiatric Association have proposed guidelines (37) to educate patients and their families about informed patient consent to ECT, and a substantial number of States have passed laws regulating the practice of ECT. Still, there may remain instances in which physicians and facilities comply neither with the letter nor the spirit of the laws, nor with professional guidelines. When noncompliance occurs, it increases public distress about the use of ECT.

Opponents of ECT

While some opponents of ECT seek a total prohibition of its use, others focus on situations that may involve less than fully informed, fully voluntary consent.

David Oaks, editor of Dendron News for the Support Coalition International, emphasizes the importance of informed consent, "Our position on TEC as a treatment option is pro-choice - if the patient wants it, that's his or her decision, but they must understand there is no proof of sustained efficacy." (38)

Peter Breggin, a psychiatrist in private practice, strongly opposes the use of ECT. He characterizes the effects of ECT as "brain injury." (39)

Leonard R. Frank, a writer often cited by ECT opponents, received combined insulin coma-electroshock in early 1962. He charges, "... ECT as routinely used today is as least as harmful/...[[[;overall as it was before changes in the technology of ECT administration were instituted." (40)

Linda Andre, Director of the Consumer Rights Advocacy Group, the Committee for Truth in Psychiatry, states that all ECT involevs involuntary treatment. Her organization, whose 500 members have experienced ECT, asserts that all patients receiving ECT are under some form of coercion. They maintain that ECT causes permanent head injury (brain damage). Recently, Andre stated, "Forced shock is the most profound violation of the human spirit imaginable. The use of force is a second injury superimposed upon the damage of the shock itself." (41)

The National Association for Rights Protection and Advocacy is a non-profit organization composed of mental disability program administrators, paralegals, professionals, lay advocates, and consumers of mental health services. Its director, Bill Johnson, believes most members of the organization are opposed to the use of ECT and involuntary treatment. He stated, "Our members are against forced treatment laws. People should make their own choices, they have the right to choose. We try to empower people who have been labeled." (42)

Proponents of ECT and Informed Consent

While no organizations have been established which are dedicated exclusively to retaining ECT as a treatment choice, representatives of the organizations identified below have expressed support for the position that ECT remain an option.

The National Depressive and Manic-Depressive Association (NDMDA), an organization of persons who have experienced depressive or manic-depressive illness and their families and friends, "strongly supports the appropriate use of electroconvulsive therapy." (43)

The National Alliance for the Mentally Ill (NAMI), a grassroots organization composed of families and friends of people with mental illness and people recovering from mental illness, does not endorse any particular treatment or services. However, it recognizes the efficacy of ECT and of medications such as Clozopine and Prozac, and is opposed to measures intended to limit the availability of recognized effective treatments provided by appropriately trained and licensed practitioners. (44)

The National Mental Health Association, a non-profit organization of citizens concerned about the promotion of mental health and the prevention, treatment, and care of mental illness, supports the use of ECT in life-threatening situations (suicide), and for the treatment of severe affective disorders that do not respond to other treatments. (45)

The National Association of Protection and Advocacy Systems (NAPAS), the membership organization of State protection and advocacy agencies, has Federal authority and funds to investigate abuse and neglect of persons with mental illness. While NAPAS has not adopted a formal position on ECT, it strongly supports the importance of full and informed patient consent. (46)

IV. LEGAL PERSPECTIVES AND STATE REGULATION

Forty-three States have enacted legislation that in some way regulates the use of ECT. (47) Most of the State statutes directly address the administration of ECT; others regulate psychiatric treatment generally without specific reference to ECT. The most common approach, adopted in 20 States, requires either informed patient consent before the administration of ECT, or in the absence of informed consent, court determination of patient incompetency. There is substantial variation among requirements from one State to another.

Debate continues about the need to protect patients' rights and the use of effective, albeit invasive, treatments such as ECT. (48) The argument is made that overly protective regulation can result in urgently needed treatment being substantially delayed. Most States regulate the administration of ECT, and require a judicial determination of incompetency before involuntary administration of ECT can begin. (49)

The issue of informed consent has been a significant focus of litigation, legislation, and regulation in recent years. Three key questions have been raised:

1. Does the individual have the capacity to form a reasonable judgment? (For example, to what extent is a person's capacity to give informed consent to ECT treatment compromised, or even eliminated, by the condition for which the ECT is being recommended?);
2. Was consent obtained under circumstances free of coercion or threat? (For example, did the patient consent freely or did the patient feel threatened with court proceedings or isolation? Under what circumstances does the physician's "opinion" unduly influence the informed voluntary consent of the patient?); and
3. Was sufficient information about the risk and availability of less invasive therapies provided to the patient as part of the education and consent process? (This last question is particularly complex involving, among other concerns, the uncertainty regarding the precise nature and duration of short and long term memory loss associated with ECT).

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As with all medical treatments, administration of ECT is governed by State laws and regulations. Some States permit "substitute consent" by a spouse, a guardian, or an attorney-in-fact through a power of attorney. Other States take a more restrictive approach requiring that only the patient can give consent for treatment. (50)

Courts generally have ruled that a patient who has been involuntarily committed does not, per se, lack capacity to provide informed consent. Only under the most extreme conditions have the courts ruled that the right to refuse treatment is compromised by a depressive condition. The courts also generally do not permit a "substituted judgment" either by the court or a guardian. (51)

V. RESEARCH PRIORITIES IDENTIFIED BY 1985 NIMH CONSENSUS CONFERENCE

The National Institute of Mental Health Consensus Development Conference on Electroconvulsive Therapy, convened in June 1985, identified five priority research tasks : (52)

1. Initiation of a national survey to assemble basic facts about the manner and extent of ECT use, as well as studies of patient attitudes and responses to ECT;
2. Identification of the biological mechanisms underlying the therapeutic effects of ECT and the memory deficits that may be associated with the treatment;
3. Better delineation of the long-term effects of ECT on the course of affective illnesses and cognitive functions, including clarification of the duration of the therapeutic effectiveness of ECT;
4. Precise determination of the mode of electrode placement (unilateral vs. bilateral) and the stimulus parameters (form and intensity) that maximize efficacy and minimize cognitive impairment;
5. Identification of patient subgroups or types for whom ECT is particularly beneficial or toxic.

While many studies of ECT have been undertaken since the 1985 Consensus Development Conference on ECT, the issues regarding brain damage and memory loss have not yet been fully explored or understood. Consumer groups continue to express a strong desire for broader surveys of patients' experiences with ECT because the few published studies to date have relied on small and/or self-selected samples.

SUMMARY

This report describes the current situation concerning ECT, and has attempted to capture the broad spectrum of opinions and views about its use.

APPENDIX A

INTERVIEWS WITH REPRESENTATIVES OF ORGANIZATIONS

In order to present a broad range of opinions about ECT, representatives of five citizen/consumer organizations with particular interest in ECT were interviewed. The interviewees were all asked the following questions:

• What position does your organization hold on the use of ECT?
• What do you think about involuntary administration of ECT?
• What is your position on the effectiveness of ECT?
• What do you feel about ECT as a treatment option?
• In general terms, how has your organization been involved with ECT since 1985?
• Can you tell me some of the experiences of your members?
• From the perspective of the consumer, what do you think are the overall benefits and risks of ECT?
• What would you say are the key issues for this report?
• Specifically, what should be done in terms of future research?
• What alternative treatments would you recommend?
• What do you see should be looked at in terms of the education for health care personnel involved with ECT? For the consumer? For the family of the consumer?

Response of Organizations

Support Coalition International (David Oaks).

"Our by-laws state that we are against coercion. Many of our members are outright opposed to the use of ECT. We are a coalition of 45 groups in six countries opposed to fraudulent informed consent... We feel there is a high rate of forced electroshock. The treatment is so intrusive. No means no. We are pro-choice, but insist on informed choice."

"Doctors should offer empowering sustainable options such as peer groups, emphasizing real life needs of persons -- housing, community and employment Our position on ECT is that if the patient wants it, it's his or her decision, but they must understand there is no proof of sustained efficacy ... (The treatment) is unproven, unsustained and unregulated by the government."

---

"The Support Coalition was founded in 1990 ... Forced ECT may involve less than five percent of all cases, but it is the litmus test to see if the Federal government is responsive to consumer empowerment. No consumer/survivor organization endorses forced ECT."

"Our members tend to be folks with negative experiences. They have experienced devastating, poignant, persistent memory loss ... Many members have personally experienced great problems ... Our members have lost memories of weddings, the birth of children, the ability to play musical instruments, they can't remember videos, vacations."

"I have met some individuals who feel they have benefited from the treatment They may experience a temporary lift for a four-week period. This is not really recovery."

"Forced ECT is the key issue. There have been more comments on this than on any other issue. It destroys trust and safety; it's a violation, a profound violation to the core of one's being. We are disappointed that CMHS (Center for Mental Health Services) has been slow to acknowledge and deal with this concern ... Another important issue is fraudulent informed consent. There is much more of this than the American Psychiatric Association (APA) claims. Deaths also are much more frequent than the APA states."

"Consumers and their families need to know the full range of hazards. People aren't told memory problems can last as long as three years ... Consumers should have a legal advocate present when they make decisions about treatment . . .They must have education on other alternatives and the right to refuse."

National Association for Rights and Advocacy (NARPA) (Bill Johnson)

NARPA is a non-profit organization composed of mental disability program administrators, paralegals, professionals, lay advocates, and ECT survivors.

"We are opposed to involuntary treatment on moral and ethical grounds and are the only professional organization that takes this position ... We oppose the resurgence of involuntary administration ... The psychiatric profession usually minimizes the risks and overstates the successes of ECT."

"If ECT is done against the will (of the patient), it is totally immoral. The procedure is a lot safer than it was, but nevertheless it remains violently intrusive."

Respondent stated that NARPA has a large number of anti-shock activists among its members and most would seriously question the efficacy of shock treatments. He considers the following issues important: 1) An independent study of ECT, of its effectiveness and failures; 2) Ensuring consumers are fully informed about its pros and cons when they make treatment choices; and 3) Obtaining information about the profits hospitals and physicians make from ECT.

National Depressive and Manic-Depressive Association (NDMDA) (Donna DePaul- Kelly)

NDMDA consists of persons who have experienced depressive [unipolar] or manic- depressive [bipolar] illness and their families and friends. Excerpts from a NDMDA statement on ECT follow:

"Electroconvulsive therapy is a safe and effective treatment for certain patients with serious psychiatric illness. NDMDA strongly supports an individual's right to receive any safe and effective treatment for psychiatric illnesses, including electroconvulsive therapy, and therefore strongly opposes any laws or regulations which interfere with patients' access to competently administered electroconvulsive therapy (ECT)."

"Access to ECT, as well as all medical care, must be subject to complete, continuing informed consent. Consent must be obtained through a sincere effort, free from explicit or implicit coercion by the physician or the facility. The patient's right to withdraw his/her consent at any time during the course of treatment must be protected. If the patient is incapable of consenting to treatment, the appropriate local legal procedures must be invoked."

Respondent reported that she had heard from a lot of consumers that ECT works when other treatments do not and:

"ECT can get you to a place where other treatments will then begin to work. Consumers have told me that the memory lost from ECT isn't nearly as much as the memory lost when they were severely depressed -- sometimes they've lost weeks of their memory [to depression]. Most of the people we hear from have had a good experience with ECT."

Respondent identified informed consent and overcoming the negative reputation of ECT as the two key issues.

National Association of Protection and Advocacy Systems (NAPAS) (Curt Decker)

NAPAS is an organization that has members in every State and territory that have Federal authority and resources to represent and investigate abuse and neglect in relation to mental illness.

NAPAS does not have a formal position on the use of ECT. However, the organization is leery about the administration of ECT and supports:

"... full and informed consent. We are very concerned about involuntary administration and believe it is a violation of persons' rights. We are not medical people. We have heard from consumers that claim memory loss and we have worked with groups of consumers who have tried to ban ECT. But we have no position on this ... I have heard from people who have had ECT and experienced severe memory loss. They are very angry and bitter. From the larger perspective, it plays into the issue of forced treatment ... ECT is really a flash point for many consumers ... One of the key issues is moving away from involuntary and forced treatment. Consumers need to be able to look at various treatment options so they can be more comfortable about ECT... There should be an opportunity to choose an 'advance directive' which is an agreement that a person makes in advance when they are more lucid and stable. This would make it easier for families and care givers because the consumer is actually making the decision that they okay certain treatments, in advance of when they are in an episode where they no longer can make a decision."

---

Respondent indicated that research is needed on long term effects, positive as well as negative:

"Some people seem to respond only to ECT. Any treatments that are less daunting or undignified would be desirable ... ECT is a flash point for consumers. Health care professionals want to use what is readily available and take the easy way out, particularly in difficult situations. They have to be more sensitive to the issues of rights and choices ... They need to have better empathy with the feelings of families in this regard ... From a research standpoint, it is important to know how ECT is being used, how often and why, and to make sure it is not being abused."

National Alliance for the Mentally Ill (NAMI (Ron Honberg)

NAMI is a grassroots organization composed of families and friends of persons with mental illnesses and persons recovering from mental illnesses. Excerpts from a NAMI statement related to ECT follow:

"NAMI does not endorse any particular treatment or services. While not endorsing any particular form of treatment as a matter of policy, NAMI believes that access to treatments for individuals with mental illnesses that have been recognized as effective by the FDA and/or the NIMH should not be denied. NAMI therefore opposes measures that are intended to or actually do limit the availability and rights of individuals with mental illnesses to receive Clozaril (Clozopine), Fluoxetine (Prozac) and/or electroconvulsive therapy (ECT) from appropriately trained and licensed practitioners. These treatments are being singled out by NAMI because of ongoing efforts by various individuals and organizations to limit the rights of individuals with mental illnesses to receive them."

"In accordance with scientific evidence, we feel ECT is an effective, sometimes lifesaving treatment. I know many that feel ECT has saved their lives. That is not to say it has not been inappropriately used, especially in the 1940's and 1950's. But the treatment should be available to people who do not respond to other treatments. We are opposed to efforts to ban ECT. This would be an inappropriate and grave injustice to those who really need it ... Involuntary administration rarely happens. Given the controversial history and the dramatic nature of the treatment, most of those using it are extremely cautious ... People who need it most may not be in a position to accept the fact they need it. Involuntary administration should be the very last resort. There should always be a surrogate acting for the patient. Every step should be taken to minimize any consideration of involuntary ECT."

"We feel strongly that it should be among the treatment options. We are aware of side effects and short-term memory loss. We don't minimize these, nor downplay the fact that it is a powerful and dramatic treatment. On the balance, though, the benefits and detriments show evidence on the positive side. It may produce short-term memory loss, and may be permanent regarding the events surrounding the actual treatment. However, there is no evidence that the severe memory loss is permanent."

"The majority of our members feel it is important not to make this a political issue. As far as alternative treatments go, less invasive treatments should be tried for major depressions. ECT should be used only when people don't respond to traditional treatments. Persons should be fully apprised of the risks and benefits of the treatment. Significant family members in care giving roles should be fully informed regarding benefits and potential detriments."

1.Consensus Conference. Electroconvulsive Therapy. JAMA 254:2103-2108, 1985.
2 Hermann RC, Dorwart RA, Hoover CW, Brody J. Variation in ECT Use in the United States. Am J Psychiatry 152:869-875, 1995.
3. Goodwin FK. New Directions for ECT Research. Introduction. Psychopharmacology Bull 30:265-268, 1994.
4. Consensus Conference. op. cit.
5. Hearings before Public Health Committee, Texas House of Representatives. April 18, 1995.
6 Lawrence J. Voices from Within: A Study of ECT and Patient Perceptions. Unpublished Study, 1996.
7. Consensus Conference. op. cit.
8.Consensus Conference. op. cit.
9. Hermann et al. op. cit.
10. Hermann et al. op. cit.
11. American Psychiatric Association. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. A Task Force Report. Washington, DC: The Association, 1990.
12. Consensus Conference. op. cit.
13. Sackeim HA. Central Issues Regarding the Mechanisms of Action of Electroconvulsive Therapy: Directions for Future Research. Psychopharmacology Bull 30:281-308,1994.
14. Devanand DP, Dwork AJ, Hutchinson ER, Boiwig TG, Sackeim HA. Does ECT Alter Brain Structure? Am J Psychiatry 151:957-970, 1994.
15. Depression Guideline Panel. Clinical Practice Guideline Number 5, Depression in Primary Care, Vol. 2., Treatment of Major Depression. DHHS Publication No. 93-0551, Washington, D.C.: Superintendent of Documents, U.S. Government Printing Office, 1993.
16. Harvard Women's Health Watch. November 1997, p 4.
17. Grinspoon L and Barklage NE. Depression and Other Mood Disorders. Harvard Medical School Mental Health Review. 4:14-16, 1990.
18. Olfson M, Marcus 5, Sackeim HA, Thompson J, Pincus HA. Use of ECT for the Inpatient Treatment of Recurrent Major Depression. Am J Psychiatry 155:22-29, 1998.
19. Depression Guideline Panel. op. cit.
20 American Psychiatric Association. op. cit.
21 Miller U. Use of Electroconvulsive Therapy During Pregnancy. Hospital and Community Psychiatry 45: 444-450, 1994.
22. Walker R and Swartz CM. Electroconvulsive Therapy During High-Risk Pregnancy, General Hospital Psychiatry. 16:348-353, 1994.
23 American Psychiatric Association. op. cit.
24. Psychiatric Association. op. cit.
25 Consensus Conference. op. cit.
26. at Hearing before Public Health Committee, Texas House of Representatives, April 18, 1995.
27. Cauchon D. Controversy and Questions, Shock Therapy. USA TODAY December 5, 1995.
28. Lawrence J. op. cit.
29. Boodman SG. Shock Therapy: It's Back. The Washington Post September 24, 1996.
30. Boodman SG. op. cit.
31. Pettinati HM, Tamburello BA, Ruetsch CR, Kaplan FN. Patient Attitudes Toward Electroconvulsive Therapy. Psychopharmacology Bull 30:471-475,1994.
32.Pettinati et al. op. cit.
33. Consensus Conference. op. cit.
34. SB et al. Informed Consent in the Electroconvulsive Treatment of Geriatric Consumers. Bull Am Acad Psychiatry Law 19: 395-403, 1991.
35. Wisconsin Coalition for Advocacy. Informed Consent for Electroconvulsive Therapy; A Report on Violations of Consumer's Rights by St. Mary's Hospital. Unpublished Study, Wisconsin Coalition for Advocacy, Madison, Wisconsin 1995.
36. Wisconsin Coalition for Advocacy. ibid.
37. Psychiatric Association. op. cit.
38. Oaks D. Personal Communication, 1996.
39. Breggin P. Toxic Psychiatry: Why Therapy, Empathy and Love Must Replace the Drugs, Electroshock and Biochemical Theories of the New Psychiatry. St. Martins Press, NY, NY 1991.
40. Frank LR. Electroshock: Death, Brain Damage, Memory Loss, and Brain-Washing. J Mind andBehavior 2:489-512,1990.
41. Andre L. Personal Communication, 1996.
42. Johnson B. Personal Communication, 1996.
43. DePaul-Kelly D. Personal Communication, 1996.
44. Honberg R. Personal Communication, 1996.
45. Nokes M. Personal Communication, 1997.
46. Decker C. Personal Communication, 1996.
47. Johnson SY Regulatory Pressures Hamper the Effectiveness of Electroconvulsive Therapy. Law and Psychology Rev 17:155-170, 1993.
48. Leong GB. Legal and Ethical Issues in ECT. Psychiatr Clin North Am 14:1007- 1021,1991.
49. Parry J. Legal Parameters of Informed Consent Applied to Electroconvulsive Therapy. Mental and Physical Disability Law Reporter 9:162-169, 1985.
50. Levine S. op. cit.
51. Levine S. op. cit.
52. Consensus Conference. op. cit.

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Distribution of a pamphlet on electroconvulsive therapy (shock treatment) published by the Mental Health Division of the Health Department of West Australia, has been discontinued, following a complaint.

The pamphlet which was supplied to the public from six State operated shock facilities, the Guardianship and Administration Board, the Office of the Public Advocate and elsewhere, contained false and misleading information which served to recklessly misguide the most vulnerable members of the community, and their family and friends.

The pamphlet which carried the government seal, described ECT as a "small electric current," even though the strength of current in ECT, induced a grand-mal seizure and the Australian Safety Standards gives no such value as "small" to electric current.

The pamphlet also claimed that "There is no medical evidence that the brain is damaged," even though the medical literature is littered with such instances from both the historic use and the modern method of ECT. In fact, there is a small added risk of brain damage in the modern method, from the anesthetic alone.

The pamphlet and its content which "helps answer questions" was being used by psychiatrists in the process of obtaining 'informed consent' while avoiding the obligation of a truthful disclosure.

As of October 2001, the pamphlet "Electroconvulsive therapy" catalogue No: HP6824 - has been given the official status, "OBSOLETE"

For what it is worth, we are assured by the Health department today by phone, that they will not be publishing any information in the future on the topic of ECT.

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