by John Breeding, Ph.D.
(A version of this information has just been published in the Journal of Humanistic Psychology, Winter 2000, Vol. 40, No. 1, pp. 65-79).
"This is a crime against the spirit. This is a rape against the
"I open my mouth and the scream surrounds me. My body a lurch and a scream of pain. A firecracker, pain and lights, burning, searing, my bones and my flesh. I am on fire. Shorter than a second. The fragments of a bomb sear my body. Blue-white lights, fiercer than God, going through me É I wondered when they would be over, these ritual burnings. The pain. I would never survive the searing pain. 'Paranoid delusions,' they wrote on my chart. 'She thinks there is a conspiracy to kill her by electrocution.'" (Janet Gotkin) (2)
I deliberately keep this chapter brief because, in my mind, it is a simple issue. Our brains are exquisitely sensitive, and complex -- billions of cells, trillions of connections, more vast and intricate than we can imagine. The most brilliant of our scientists, those who understand more about the brain than any of us, are most humbled and forthcoming about how little they really know about the brain. The most ardent proponents of ECT don't really have a clue as to how it might work. My own point-of-view, like psychiatrist Peter Breggin, neurologist John Friedberg, and others, is that ECT "works" to the extent that it disables the brain.
Psychiatrists call this technique electroconvulsive therapy or ECT. Given that the average ECT procedure induces a level of electricity that is approximately 2 1/2 times greater than that required to induce a convulsion, the term ECT is really a euphemistic misnomer. It is not a "convulsive therapy." Rather, it is systematic brain damage, and the damage is the effect; the more current, the more brain damage. Also known as shock treatment, critics often refer to the procedure as electroshock. Texas, as a result of ardent activism by a coalition of electroshock survivors and concerned allies, is one of the few states to have a systematic reporting system. Official reports on the use of ECT in Texas during fiscal year 1994 included a total of 1,644 patients. (3) The current national estimates are about 100,000 individuals electroshocked each year. After its heyday in the 1940s and 1950s as a means of intimidating and controlling "patients" in state mental hospitals, electroshock lost favor, partly due to the advent of neuroleptic drugs, partly because of the exposure of the horror of it all, as in the popular movie, 'One Flew Over The Cuckoo's Nest'. Most citizens today think that ECT is a relic of bygone days; they tend to be surprised to hear that the practice of ECT is making a resurgence. The American Psychiatric Association is, in fact, working overtime to create an illusion that ECT is no longer even controversial.
The Need for a Backup Treatment
In most psychiatric settings today, the biological model is a given. With this model, for all intents and purposes, there are only two treatment approaches -- drugs and ECT: drugs for starters and ECT for "treatment-failures" or "treatment-resisters." Thus ECT is the only available back-up treatment when the drugs fail to "work." Psychiatrists would find themselves greatly limited were ECT abandoned or abolished -- they'd have nothing else to offer. Society expects psychiatrists to have the answers, and they readily admit to having them. Nothing would more quickly lower their prestige in the public's eyes, and in their own as well, than to acknowledge not having the answers. The British radical psychiatrist, R.D. Laing, pointed out the irony that while society gives great social police power to psychiatrists, it is equally true that psychiatrists have no choice about whether to exercise that power. In granting the power, society insists that it be used. The coercers are coerced, but so thoroughly conditioned they think they are free.
Doctors are trained to be action-oriented. As a doctor, you just don't stand by and do nothing. There is a reason for the absence of alternatives. Successful outcome of non-medical alternatives would threaten their place in the system; why try something new when the old is paying off so handsomely? Belief that only medical methods are effective is thoroughly ingrained in psychiatrists (that's where their identity is coming from); non-medical alternative approaches are considered inadequate, ineffective and impractical.
Electroshock involves the production of a grand mal convulsion, similar to an epileptic seizure, by passing from 70 to 600 volts of electric current through the brain for 0.5 to 4 seconds. Before application, ECT subjects are typically given anesthetic, tranquilizing and muscle-paralyzing drugs to reduce fear, pain, and the risk (from violent muscle spasms) of fractured bones (particularly of the spine, a common occurrence in the earlier history of ECT before the introduction of muscle paralyzers). The ECT convulsion usually lasts from thirty to sixty seconds and may produce life-threatening complications, such as apnea and cardiac arrest. The convulsion is followed by a period of unconsciousness of several minutes' duration. Electroshock is usually administered in hospitals because they are equipped to handle emergency situations which often develop during or after an ECT session.
Contrary to claims by ECT defenders, newer technique modifications have made electroshock more harmful than ever. For example, because the drugs accompanying ECT to reduce certain risks raise the seizure threshold, more electrical current is required to induce the convulsion, which in turn increases brain damage. Moreover, whereas formerly ECT specialists tried to induce seizures with minimal current, suprathreshold amounts of electricity are commonly administered today in the belief that they are more effective.(4) Again, the more current, the more brain damage.
ELECTROSHOCK AND ELDERS
The use of ECT is increasing, and seventy percent of the "treatments" are insurance-covered. The bottom line is that more than 100,000 Americans are being electroshocked each year; half are 65 years of age and older, and two-thirds are women. Psychiatry defends the use of electroshock with our elderly women, arguing they need it because of the intractability of geriatric depression. I call it shameful abandonment and mistreatment of our elders, clear evidence of psychiatry as agent of institutionalized ageism and sexism in our society. It is also interesting that here in Texas, our reporting system revealed a 360% increase in the use of ECT between ages 64 and 65.(5) The only logical interpretation is to see it as a dramatic example of how much economics is really the determining factor in the practice; when patients turn 65, doctors can receive Medicare reimbursement for ECT.
The truth is that electroshock is one of the most dramatic examples ever of iatrogenic (medically-induced) disease. Brain damage, memory loss and mental disability are routine distinguishing results. In addition to obvious physical and mental damage, there are a number of other negative effects of ECT. These include:
1) Suppression of emerging distress material;
When I hear of an individual for whom electroshock is being considered, I always ask, "What is important that he or she not remember and tell about?" Or "What is it that the others do not want to hear or look at?" Often it is abuse, always it is difficult, disruptive, threatening, uncomfortable, painful. Emotional discharge is essential to healing. The distress needs to emerge, the truth needs to be told. Electroshock is an awful, violent assault on individuals, and on the possibility of healing by expressing the truth.
Individuals who have undergone ECT report horrific emotional distress resulting from this procedure. Physical and cognitive debilitation, together with intense fear, shame and hopelessness make life and recovery a tremendous challenge for many people who undergo this procedure. My own clients have reported years of fearful avoidance of medical doctors after undergoing electroshock. The fear is so great that they neglect their physical medical needs, rather than go to a doctor. Electroshock survivors often have recurrent nightmares about the electroshock or about symbolic forms of torture and death. One client recently shared with me that the reading of testimonials from Holocaust survivors was a key to her recovery; she finally found people whose depth of emotional pain and anguish was similar to her own. This helped her to overcome some of the shame and stigmatization, and to begin walking through the isolation that so many psychiatric survivors experience after their "treatment."
The whole effect of ECT is a waking horror.
Electroshock and Informed Consent
Genuine informed consent for electroshock is nonexistent because electroshock psychiatrists deny or minimize its harmful effects. For example, the American Psychiatric Association officially states, "In light of the available evidence, brain damage need not be included [in the consent form] as a potential risk." (6) In addition, in all but one state ECT may be legally forced upon nonconsenting individuals who are said to be or are adjudicated mentally unqualified to give their consent.
There are many ways in which informed consent is violated. First, there is denial and minimization of harmful effects. The official APA literature and the typical hospital brochure are both travesties of truth. The consent form example, provided in 1990 by the APA in The Practice of Electroconvulsive Therapy, states that the death rate for ECT is "approximately one per 10,000 patients treated". (7) Publicly available statistics collected between 1993 and 1996 by the Texas Mental Health Department show that the rate is 50 times higher. As noted above, the American Psychiatric Association recommends that patients need not be advised of ECT's potential risk. The APA gives no credence to the numerous human autopsies, brainwave studies, animal studies, clinical observations, and reports from ECT subjects clearly demonstrating ECT's brain-damaging effects. St. David's Hospital in Austin, Texas in 1994 was giving an information sheet to ECT candidates which stated that ECT was safe for pregnant women.
The second reason I argue that informed consent exists only in name is that even minimal and inadequate guidelines for the administration of ECT are routinely and systematically violated. For example, a 1995 report by the Wisconsin Coalition for Advocacy thoroughly documents pervasive and systematic violations of that state's informed consent guidelines on ECT. (8) A 1987 study by Benedict and Saks of the regulation of professional behavior regarding ECT in Massachusetts showed that "approximately 90% of ECT patients received treatment inappropriately, suggesting that the regulation of ECT administration is ineffective." (9) Interestingly, the authors also reported that "the more familiar a psychiatrist was with threatened or instituted lawsuits involving ECT, and the more likely a lawsuit was thought to be, the greater was his or her departure from the guidelines."
A third point is rarely mentioned by anyone except the likes of Dr. Fred Baughman, a retired neurologist who has charged, in a 1998 letter to United States Attorney General Janet Reno, that "Attention Deficit Hyperactivity Disorder" (ADHD) and Ritalin is the biggest health care fraud in U.S. history. What Baughman has to say about ADHD and Ritalin is equally true for "Depression" and ECT. He points out that the legal obligation under informed consent is to provide the patient with all the information relevant to their decision-making -- not just about the treatment in question, but also about their condition. Psychiatric patients are never told that their alleged disease is theoretical or metaphorical. To quote Dr. Baughman, "To say or even imply that what the patient has is biologic and a disease when there is no such proof (as in all psychiatric 'diseases') is conscious deception and abrogates informed consent. That this has become the 'standard of practice' in psychiatry does not excuse it. The abrogation of informed consent is de facto medical malpractice." (10)
Fourth, and pragmatically crucial, is that people become victims of this so-called "treatment" at a time in life when they are extremely vulnerable. At vulnerable times, people desperately need to trust and rely on others for help. Reaching out, they need complete safety and support. Their only hope, in this desperate state, is to trust the wisdom and guidance of the professionals to whom they turn for help. Informed consent is a superlative principle; it is not a protection in these conditions. So, rather than an informed consent document, I provide below what I consider to be authentic information addressed to a potential candidate for "treatment," for educational purposes, about electroshock. I encourage you to copy and share this information with others. Moira Dolan, M.D., an internal medicine doctor and electroshock researcher, provides an annotated review of the research to back up each of my assertions about medical effects and lack of efficacy, which can be seen in the Appendix.
AUTHENTIC INFORMATION ABOUT ELECTROSHOCK
You are being asked to consider undergoing the psychiatric procedure of electroshock, commonly referred to as electroconvulsive therapy, or ECT. It is your right, according to Texas state law, to be fully informed about the nature and effects of this procedure. Of course, you have a right to refuse the procedure.
Prerequisites to Clear Thinking About Electroshock
STATE OF MIND
A fundamental requisite of good decision making is mental competency. This means that prospective patients are able to understand this information and make a decision. At minimum:
1) Patient is free from the influence of any and all mood-altering
substances, including legally prescribed psychotropic medications.
STATE OF BODY
A complete physical examination by a non-psychiatric physician, preferably an internist, is recommended. The internist should evaluate for and inform the patient and psychiatrist of the potential for the individual to sustain physical complications of ECT treatment. This is analogous to what internists do in a pre-operative evaluation for surgery.
You are labeled as "mentally ill," diagnosed with a particular "disease" for which ECT is being recommended as "treatment." ECT is being justified as a "treatment" based on the assertion that your "disease" (probably called Depression, but possibly some other "disease" such as Bipolar Disorder or Schizophrenia) is a biologically or genetically based illness.
Your label as "mentally ill" and diagnosis as "Major Depression" or other "mental illness" is entirely hypothetical, based on subjective reports and observations of mood and behavior. There is no evidence of disease, chemical imbalance, or anything physically or chemically abnormal to validate your diagnosis as a medical illness.
What It Is
Electroshock involves the attachment of electrodes to the temples outside one (unilateral) or both (bilateral) frontal lobes, and the administration of electricity to the frontal lobes of the brain. Intensity of voltage may vary from approximately 70 volts to 600 volts. Duration of the electrical current may vary from 0.5 to 4 seconds.
Administration of ECT also varies enormously in number of treatments, from one to literally hundreds over time. A typical course of treatment involves 6 to 12 sessions. Multiple Monitored ECT is one variation which consists of 3 treatments in one session, spaced about 5 minutes apart, with 3 sessions in one week; thus, 9 treatments in one week.
Two pieces of information to know are that:
1) The natural electrical activity of the brain is measured in millivolts,
or thousandths of a volt. Thus, the power of ECT is literally hundreds
of thousands of times greater than natural brain electrical activity.
Electroshock is a procedure which involves administration of the following general classes of medication:
1) general anesthesia
Each of these drugs has a wide range of effects on your body, mind and emotions. Listed below is a sample of possible adverse reactions as listed in the Physicians Desk Reference (13):
Anesthesia [i.e. propofol]: circulatory depression, hypotension, hypertension, peripheral vascular collapse, tachycardia, arrythmia, respiratory depression, cardiorespiratory arrest, skeletal muscle hyperactivity, injury to nerves adjacent to injection site, seizures, hysteria, insomnia, moaning, restlessness, anxiety, nausea, abdominal pain, pain at injection site, salivation and headache.(p. 3416)
Tranquilizer [i.e. valium]: drowsiness, fatigue, ataxia, confusion, constipation, depression, diplopia, dysarthria, headache, hypotension, incontinence, jaundice, changes in libido, nausea, changes in salivation, skin rash, slurred speech, tremor, urinary retention, vertigo, blurred vision, hyperexcited states,anxiety, hallucinations, muscle spasticity, insomnia, rage, sleep disturbance.(p. 2736)
Muscle Relaxant [i.e. succinylcholine chloride]: skeletal muscle weakness, profound and prolonged skeletal muscle paralysis resulting in respiratory insufficiency and apnea which require manual or mechanical ventilation until recovery , low blood pressure, flushing, heart attack, bronchospasm, wheezing, injection site reaction, fever.(p. 1091)
You should obtain a list of drugs recommended for ECT, including a complete listing of effects described in the PDR.
The Federal Food and Drug Administration (FDA) classifies ECT machines as a Type III device. This means that ECT is an experimental procedure, classified in the highest risk category by the FDA. Class III means that the machine has not gone through the rigorous FDA testing required of medical devices, including safety testing and efficacy assessments.
POSSIBLE MEDICAL EFFECTS OF ECT
Note: Because ECT is a high-risk experimental procedure and because of the possibility of permanent brain damage, you may want to consider magnetic resonant imagery (MRI) brain scans before and after this procedure. Pre- and post- MRI's are one way to measure the possible physical effects of ECT on your brain.
Many individuals who have undergone ECT report horrific emotional distress resulting from this procedure. Physical and mental debilitation, together with intense fear, shame and hopelessness often make life and recovery a tremendous challenge for people who undergo this procedure.
LACK OF EFFICACY
Research indicates the following:
1) No lasting beneficial effects of ECT. (14)
The cost of ECT varies significantly. Cost of the procedure itself may vary from $100 to $300 per treatment for the psychiatrist's bill. "Hidden" costs include fees for the anesthesiologist and the surgery suite (up to $800 combined per session), room and board at the hospital (usually $800 to $1300 per day at a private psychiatric hospital), psychotherapy charges by the psychiatrist (average $100 - $150 per hour), consultant fees, and charges for whatever drugs you will be administered. Depending on the setting and whether you are in-patient or out-patient, there will be variable fees for the "operating room" and the hospital. You should obtain a full financial disclosure of all costs in writing, prior to decisions about any procedure.
1. Quoted in Frank, L.R., ed., Influencing Minds: A Reader in Quotations.
Feral House, 1995.
Breggin, P. (1991) Shock Treatment is not Good for Your Brain, in
Toxic Psychiatry. New York: St. Martin's Press.
EFFECTS OF ELECTROCONVULSIVE THERAPY: A review of the scientific literature
In a large retrospective study of 3,288 patients getting ECT in Monroe County, NY, ECT recipients were found to have an increased death rate from all causes. Babigian, H., et al. Epidemiologic Considerations in ECT. Arch Gen Psych 1984;4:246-253.
Survival in 65 patients hospitalized and treated for depression was evaluated by researchers at Brown University. They reported that the 37 patients who received ECT had survival rates of 73.0% at one year, 54.1% at two years, and 51.4% at three years. In contrast, depressed patients who did not receive ECT had survival rates of 96.4%, 90.5% and 75.0% at 1,2 and 3 years respectively. Kroessler, D. and Fogel, B. Electroconvulsive Therapy for Major Depression in the Oldest Old. Am J Geriatr Psych 1993;1:1:30-37.
The risk of death was doubled in depressed patients who got ECT in a seven year follow up study of 188 patients.
O'Leary, D. and Lee, A. Seven Year Prognosis in Depression - Mortality and Readmission Rates in the Nottingham ECT Cohort. British J of Psychiatry 1996;169: 423-429.
The first three years of mandated recording of death within 14 days of ECT in the state of Texas yielded reports of 21 deaths. Eleven of these were cardiovascular, including massive heart attacks and strokes, three were respiratory, and six were suicides. Don Gilbert, Commissioner, Texas Department of Mental Health and Mental Retardation, 1996.
Over twenty years ago Cotman reported in Science that ECT disrupts
(protective) protein production by brain cells. More recent studies
show that electric shocks to the brain also causes an increase the
production of inflammatory proteins inside brain cells. Cotman, et
al. Electroshock effects on brain protein synthesis. Science 1971;178:454-456.
C. Edward Coffey, MD, a leading proponent of ECT, conducted a study
at Duke University Medical Center and the Durham VA Hospital which
looked at the brain scans (by MRI) of patients before and after ECT.
Out of 35 patients studied, 8 had changes on MRI after shock. That's
22%, or greater than one in 5, with anatomic brain effects. Among those
with the brain changes, one patient suffered a stroke and two had new
abnormal neurologic signs on exam within 6 months of the ECT.
Weinberger looked at the effects of ECT on the brains of schizophrenics
by comparing brain CT scans of those who had ECT with schizophrenics
who never received shock. He documented that cerebral atrophy (brain
shrinkage) was significantly more common in those who had been shocked.
Another CT scan study done by Calloway looking at a similar group
confirmed that frontal lobe atrophy (brain shrinking) was significantly
more common in ECT recipients.
Andreasen used MRI scans to demonstrate a strong correlation between
the number of previous ECT treatments to enlarged ventricles (loss
of brain tissue).
A study in England compared the brain CT scans of 101 depressed patients
who had received ECT to 52 normal volunteers. They found a significant
relationship between treatment with ECT and brain atrophy. In fact
ECT recipients were twice as likely to have a measurable loss of brain
tissue in the front area of the brain and a tripling of the incidence
of a loss of brain tissue in the back of the brain. Most significantly,
the brain abnormalities correlated only with ECT, and not with age,
alcohol use, gender, family history of mental illness, age at the time
of psychiatric diagnosis, or severity of mental illness. (quoted words
are those of the study authors)
An animal study sought to discover whether giving supplementary oxygen
during shock would prevent brain damage; they also gave vitamin E to
lessen the effects of damaging 'free radical' molecules that get released
during a shock seizure. They found no difference in the brain damaging
effects of ECT-induced seizures by giving oxygen and vitamin E. These
findings disprove the claim that modern ECT methods (complete with
anesthesia and oxygen) are any less damaging to the brain than uncontrolled
ECT-induced seizures cause a rapid rise in blood pressure; at the
same time the brain experiences a significant reduction in blood flow.
A Mayo clinic study of 34 elderly patients receiving shock found an
18% incidence of serious heart arrhythmias during treatment; 4 had
ventricular tachycardia requiring IV lidocaine, 2 had supraventricular
tachycardia requiring IV beta blockers. An additional 2 patients had
other cardiogram changes.
After his eighth ECT, a 57-year-old man died of heart rupture.
Physicians from Tulane University Medical School reported on a 69-year-old
woman who developed brain hemorrhage during ECT. She was also left
with epilepsy afterward. This was, as expected, associated with further
deterioration in her mental status from her baseline depression. They
conclude that the fragile vessels of the elderly may make some patients
a particularly high risk for ECT.
EXTRA RISKS IN THE ELDERLY
In an analysis of 34 persons over the age of 85 who were subjected
to ECT, researchers at the Mayo clinic documented that 79% suffered
treatment complications, including a 32% incidence of confusion and
delirium, 67% incidence of transient high blood pressure, 18% incidence
of serious heart arrhythmias during treatment, 2 patients with other
cardiogram changes, 3 with falls, 1 hip fracture due to fall.
ECT-enthusiast Dr. Coffey and his associate Dr. Figiel found that
10 out of 87 (that's 11% of) elderly patients getting ECT for depression
remained delirious between ECT sessions for no discernible medical
reason other than the ECT itself. (Italicized words are those of the
study authors.) They documented by brain MRI scans that 90% of these
unfortunate patients had lesions in the basal ganglia areas of the
brain, and 90% also had moderate to severe white matter lesions.
Kroessler and Fogel's 1993 study on death rates reported above was done on the "oldest old," depressed patients at least 85 years of age. Mortality rates were significantly greater for those who received ECT, compared to those who did not. Kroessler, D. and and Fogel, B. Electroconvulsive Therapy for Major Depression in the Oldest Old. Am J Geriatr Psych 1993;1:1:30-37.
In a review of the literature on the well-known ECT complication of
epilepsy, researchers calculated that the age-adjusted incidence of
new seizures after ECT was fivefold greater than the incidence found
in the non-psychiatric population. (italicized words are those of the
Persistent brain wave disruption to the point of status epilepticus
has been reported to occur following ECT. Individual reports by Drs.
Weiner and Varma on different patients both describe acute disorientation
and deterioration of intellectual function immediately following ECT.
This was found to be due to ongoing epileptic brain wave forms that
was initiated by the ECT.
Publicly available data from the state of California's Department
of Mental Health reveals that over 99% of ECT recipients complain of
memory loss 3 months following treatment, with the average number of
ECT sessions being 5 to 6.
In a chapter on the cognitive effects of ECT in a psychiatry textbook,
Sackheim indicates that cognitive effects (disordered thinking), particularly
amnesia, can be long lasting after shock.
The conclusion that amnesia can be a long lasting effect of shock
is arrived at by both Squire and Weiner in separate studies.
LACK OF EFFICACY
In the large NY study cited earlier, the death rates from suicide
among depressed patients given ECT were slightly higher at the 1 year
mark. By 5 years the suicide rate was the same for depressed patients
who got ECT as those who didn't.
In a University of Iowa study of treatment effectiveness, 1,076 depressed
patients were categorized according to whether they received ECT, or
high doses of anti-depressant medications, or low doses of anti-depressant
medications, or neither (ECT nor meds). Long term follow up revealed
that all groups had the same suicide rates, indicating that the incidence
of suicide is not affected by treatment. The authors conclude: "Therefore,
active biological treatments, such as ECT, may not be deemed as 'lifesaving'
now as in the past."
The same findings are documented in three other studies: ECT does
not prevent suicide in depressed patients.
Dr. Dolan periodically updates this research review. It may be obtained
by sending $3.00 to Electroshock Review, PO Box 4085, Austin, Texas
John Breeding · 5306 Fort Clark Dr., Austin, TX 78745 · 512-799-3610
Dr. Breeding at: