DOES ELECTROSHOCK WORK?

WITHIN THE PSYCHIATRIC profession, proponents of electroshock treatment talk about ECT as if it has been unequivocally proven safe and effective by years of clinical practice and controlled experiment. According to New York psychiatrist Leonard Cammer, one of the founders of the International Psychiatric Association for the Advancement of Electrotherapy (IPAAE), one can only speculate on “the unconscionable motives” of ECT’s detractors; attacks on the treatment have been mounted by demagogic politicians, a biased and ignorant press, and some renegade members of the psychiatric profession who misguidedly act on the basis of “metaphysical belief rather than on scientific data. All such attacks accomplish, Cammer writes, is to cause sick people to “avoid treatment and choose to live with chronic morbidity or die by suicide.”

Perhaps the most impressive block in the edifice of psychiatric confidence in ECT is the report of a task force of the American Psychiatric Association, published in 1979 (ECT promoters Fred H. Frankels and Max Fink headed the task force

The report states that the treatment is scientifically valid -different from, for example, psychosurgery, which it calls experimental – and that 85 percent of the psychiatrists answering the Task Force’s questionnaire considered ECT effective for treating one or more psychiatric disorders.

Fred Hapgood, writing in Atlantic Monthly soon after the report was issued, remarked, “It is somewhat alarming to see a group of physicians clinging to a standard of harm so high that the Four Horsemen of the Apocalypse could ride under it. Is there ’incontrovertible scientific evidence’ that permanent damage must result if someone smokes three packs a day? Or drives while drunk? Or shoots himself?”

The answer to Hapgood’s rhetorical questions, of course, is no. But it can be argued that a small risk of some permanent harmful effects from ECT, even if it were proven, would be fully justified by the proven lifesaving and disease-curing effects of the treatment for the majority of those treated. This is certainly the viewpoint of many of the psychiatrists interviewed for this story

“You must remember that depression is not a benign condition,” says Michael Schlesser, M.D., of Parkland Memorial Hospital. “People suffering from severe depression are in great pain, and they are in real danger of killing themselves or of dying from medical complications that grow out of their psychiatric condition. ECT is proven effective by the overwhelming weight of evidence in the literature.”

The fact is that damage, particularly memory disturbances that persist long past the weeks or months usually predicted by psychiatrists, is well documented: One 1975 study found that 67 percent of patients who received bilateral ECT reported noticeable memory change. The researcher went on to say that this “subjective” experience of memory loss was hard to substantiate. He suggested that either the patients were imagining their memory loss or that the tests were improperly designed. Pro-ECT researchers have fastened on such research to deny that any memory loss occurs after ECT. But patients continue to say otherwis

But even if such memory loss were easily documented, wouldn’t the use of ECT still be justified for some dangerously ill patient

Not unless the treatment is valid. And that, despite the assertions made by the APA Task Force and other pro-ECT partisans, has never been established. The task force report suggests the rigorous standard by which criticisms of ECT are judged within the scientific community- “incontrovertible scientific evidence.” It is a valid test of evidence. But when the same standard is applied to the evidence supporting the use of ECT for even the most carefully defined psychiatric cases, the purported scientific validity of the treatment short-circuits, leaving only observer bias, flawed research and a burnt-out theoretical basis.

According to Ugo Cerletti, leader of the team of psychiatrists in the state hospital in Mussolini’s Rome who first used electricity to induce convulsions in humans as therapy, ECT was based on a theoretical misconceptio

The first patient chosen for experimental electroshock was an engineer from Milan, sent to the hospital for “observation”-not treatment, and certainly not to be experimented on -by the police, who had found him wandering around a train station. The experiment, without the subject’s consent or any legal authorization, would be illegal by modern U.S. standards and was morally questionable, as even Cerletti admitted. Cerletti later explained that he was following the lead of Ladislaus Von Meduna, a Hungarian psychiatrist who hypothesized on the basis of limited clinical observations that epilepsy was somehow antagonistic to schizophrenia, and that by inducing grand mal seizures in patients one could cure schizophrenia.

The fact that it was later proven that epileptics can indeed be schizophrenic hardly fazed the psychiatric world. Since then four or five dozen theories have been advanced to explain the workings of ECT on the mind and body, but none of them has stood careful examination. No matter,psychiatrists like Cammer and Fink argue from their clinical experience -the treatment works on the patients.

But the clinical experience of psychiatrists is not necessarily scientific, either. It is subjective, a characteristic it shares with the clinical experience of those practitioners who have reported cancer cures with laetrile and other pseudo-medicines.

What has been proven over and over is that with the use of now-standard methods for the scientific evaluation of what is called clinical experience, the theoretical predisposition of the clinician-researcher is almost always proven -that is, he finds what he wants to find, whether it’s there or not.

To achieve proof of an idea by widely accepted scientific standards, one must test the idea and arrange some way to screen such a theoretical predisposition – called observer bias -out of the results.

One way of doing so is the one routinely applied to psychotropic drugs before they are marketed. In such tests, one group of people is given the medication under examination. Another group, the control group, is also included in the study. The two groups must be closely matched with respect to age, sex, background, race,

medical history, illness and a host of other factors, so that they differ only in the fact that members of the control group are not given any of the test medicatio

Control-group members are not given the test-medication, but since people who are given no treatment are not comparable to those who are given some treatment, the control group is commonly given -unknown to them – a placebo. The placebo is a substitute that resembles the test medication as closely as possible, but has no medicinal properties. In effect, the test medication is being measured against “the placebo effect” -the tendency of patients to get well when they think they are being given a medically valid treatment.

The results of the test must be collected and evaluated, using criteria that, again, exclude outside factors. Just as it is important to keep the control group ignorant (or “blind”) about the placebo, it is important to keep the evaluators blin

Although double-blind placebo controlled studies, as tests of this sort are called, are now required under the regulations governing the sale of drugs in this country, no such study was done to test the efficacy of ECT before it gained widespread use.

According to its proponents, ECT “towers” among the “heroic” therapies for depression, and its strongest suit is for “abolishing the impulse to suicide.” Max Fink, M.D., for example, a respected psychiatric researcher into ECT effects, in a 1977 article in the American Journal of Psychiatry, quotes two studies as proving that ECT decreases the incidence of suicide and shortens hospitalizations of patients, and that it is a more effective treatment than psychotherap

The first study, published in 1948 by P.E. Huston and L.M. Locher, compared two groups of patients with manic depressive psychosis, the first given ECT. Psychiatrists C.G. Costello and G.P. Belton, a second research team, reexamined the results of this study in a 1940 text and pointed out that this is not a controlled study -it is a “retrospective” study, comparing two groups of patients who were not even in the hospital at the same time. Patients in the control group were in the hospital for periods between 1930 and 1938, and the ECT-group patients were in the hospital from 1940 to 1943.

“Actually,” Costello and Belton comment, “11 out of 52 control patients who recovered from their initial depressions relapsed [in 14 years] as did 11 out of 54 experimental or shock patients [in four years] who initially recovered. Perhaps a more appropriate concluding statement could have been that shock therapy does not appear to reduce the probability of recurrence of depression

In his 1977 paper in the American Journal of Psychiatry, Fink also mentions a second study that “reported nine deaths in 109 patients treated by psychotherapy alone, compared with one death in 88 patients treated with ECT

The article in question was published in 1954 by three researchers named Ziskind, and it hardly provides the proof Fink claims it doe

“Fink’s description [of the Ziskind study] is wholly in error,” writes anti-ECT psychiatrist Peter Breggin. “Only 30 of the patients were treated with ECT; the remaining 58 patients received metrazol therapy. Because no distinction was made in the findings between the ECT group and the metrazol group, which had almost twice as many patients, there is no way to use this study to prove anything about ECT

Since Costello and Belton’s book was published in 1976, three placebo-controlled studies of the efficacy of ECT have been done in the U.S. and Britain. In each, ’he control patients were sedated, just like the ECT patients, and taken through the same procedures before and after the treatment period, with the difference that the contol patients did not receive a convulsion electrical charge. In both studies the improvement ratings were supposedly carried out by “blind” personnel. Two out of three found that ECT was no more effective than the fake ECT treatment.

Peter Breggin disputes the validity of these findings, however. “There is no way to do an ECT-placebo procedure which would fool a trained evaluator,” he says.”The effects of real ECT are impossible to hide. The only way to fake it would be to drop the members of the control group on ’heir heads once for each time the first group gets ECT

Breggin says that the supposed therapeutic effects of ECT are nothing but the substitution of brain insult for psychiatric symptoms – unhappy people are made”slap-happy” by the treatment, he sayPsychiatrists disable their patients, aPersist in thinking of this as improvement.% disabling the brain we render tPatient less able to feel or think, and he acts more docile-that is considered a cure, Breggin say.

One unquestioned effect of ECT is monetary: As a medical treatment it is a form of therapy for which insurance companies will pay, even when they are much less willing to pay for ill-defined interventions such as psychotherapy. sam Shaw a spokesman for Blue Cross/Blue Shield of Dallas, the state’s largest medical insurance carrier, says his company provides a multitude of possible policies. But the most common type of policy will pay for a maximum of $1,000 for psychotherapy he says, and allows for up to three months of hospitalization for a mental condition The going rate for that, he says, is about $5,000

The use of ECT, according to the overwhelming weight of the available evidence -as opposed to the subjective “clinical experience” of its promoters-holds little benefit for patients. Indeed, what the evidence suggests again and again is that patients who are considered candidates for ECT should be given a fake ECT placebo treatment and only given the riskier ECT if the placebo fails. The evidence, however, seems to have gotten lost in the shuffle of insurance forms.