More shocking news about ECT.

As though we need more.

ECT is back in the news this week, with the publication of a paper from the UK studying its long-term effects. Unlike most papers in psychiatry, where the message is buried under a blizzard of statistics, this was a narrative account, i.e. sitting down with the patients and letting them talk around a few basic questions. This is valid: we can either study large numbers of patients superficially, or a small number in depth. Critics are usually quick to dismiss this type of study on the basis that it is subjective and (shudder) emotional and yes, that’s exactly what it is. A narrative account is a semi-structured enquiry into the patient’s emotional reaction to the physical effects of a treatment. The goal is to find points important to the patient, on the basis that what the patient believes has a value not captured by statistical studies.

The objection that narrative studies are emotional contains its own rebuttal: do you know anything that humans do that doesn’t have a large emotional content? Start wars, for example? Get married? That’s probably the biggest single decision in your life, and unless you’re a billionaire or a crown prince marrying for advantage, reality doesn’t enter it. Build massive fortunes? Mr Musk, whose fortune recently reached $400billion, was pissed off recently when a court rejected his claim that his companies owed him another $57billion, on top of his usual shiploads of money.

Emotion defines us but, under the (poorly understood) positivist influence, modern psychiatry tries to put it in the same class of events as blood counts and bowel sounds. In particular, psychiatry actively denigrates anybody who takes an “emotional” approach to studying psychiatry’s disasters, where emotional means “reaching conclusions we don’t like.” That, as I know very well, invites the label “antipsychiatry,” even though no psychiatrist has ever defined it as anything other than “being nasty to us.” So a thorough-going “emotional” study of the sorely neglected topic of long-term, severe adverse effects of ECT demands attention.

The authors interviewed seven people who had had ECT between six months and twenty years before, who were well enough to cope with the interview and who identified at least one major side effect. Each one had an initial interview, of 55-100 minutes and another of up to 85 minutes. Most were conducted by video. There were six women and one male, mostly in their forties, who had received a mean of 47 sessions of ECT (range 4-189), all for depression. Oddly, they had all been given bilateral ECT, which is known to produce more profound memory loss and, to my knowledge, is hardly used now (but I never used ECT so I could be wrong).

The paper provides brief sketches of each patient’s experience of the process of ECT, with lack of information a prominent feature:

Flora was assured that ECT was not dangerous and that memory loss would be temporary. She consented, fearing repercussions if she refused.

Paula experienced a complex traumatic childhood ... Paula consented to ECT. However, she did not feel she had a choice.

(Rose) I didn’t even know it would give me a seizure.

Informed consent means informed consent, as in my review from some years ago:

Ideally, all patients advised to have ECT should be told that while their psychiatrist advises it, other psychiatrists in the same town would not; while, in some countries, it is so severely restricted that the question (of being given ECT) would not arise [2].

Following ECT, patients reported quite severe confusion and disorientation but the real problems didn’t emerge until they went home:

For all participants, returning home from hospital following ECT and trying to re-establish their lives confronted them with the realization that cognitive abilities were impacted, short-term memory had significantly reduced in capacity, and autobiographical memories had disappeared.

Over time, defects and impairments emerged, in particular, loss of short-term memory and loss of chunks of personal memories, e.g. several people mentioned that entire blocks of memories of important people (parents, grandparents, children) had simply disappeared. Needless to say, this has a severe impact on the sense of self. Others were unable to continue with their previous work or career choices. Most patients felt that the treatment had caused brain damage, which several understood to mean they had moved closer to age-related cognitive decline. Three patients had been tested for brain damage, which was confirmed on scans and psychometric testing. Most felt their sense of self-worth and their sense of how other people perceived them had been affected. Socially, it was difficult to meet people whom they should have remembered but couldn’t, or meeting new people while knowing they would not be able to retain memories of them. In particular, the effects of memory loss often took weeks or months to develop so that, if questioned soon after ECT, patients would have given more positive reports than they later realised was the case.

None of this is new. In 2009, Ian McPhee, a Sydney anaesthetist who had been given ECT, said:

The consequences [of ECT] were dire. Retrograde memory loss was profound. I was devastated and searched for answers where my treating doctors could give none … . I was left then to claw back a life only half remembered [3].

Mainstream psychiatrists are convinced ECT is safe and effective, but this impression is gained by the very simple expedient of not asking about longer-term effects. My study started with claims made by the RANZCP: that it is “useful, essential, irreplaceable, effective, valuable, clinically indicated, important and necessary,” and harmless, while opposition to it is neurotic, “irrational,” out-dated, and not scientific. Using figures provided by the ECT industry itself, each of these claims has been rebutted but the message is ignored. We can start with its basic purpose: “shock therapy” was invented with the specific intent of causing widespread, low grade brain damage. That was how it came into being, just on a hundred years ago.

Psychiatrists had long believed that profound fear was a good way to treat mental disorder. Benjamin Rush, one of the signatories of the US Declaration of Independence and regarded as the “father” of American psychiatry, wrote: “Terror acts powerfully upon the body, through the medium of the mind, and should be employed in the cure of madness.” The earliest forms of shock treatment involved chemicals which induced a profound state of terror in patients before they had a succession of convulsions but this was regarded as beneficial. ECT was developed because it was much quicker and more reliable than chemicals or insulin in producing seizures, but its risks have always been minimised by psychiatrists who use it. So why use it? My survey [2] showed there are only three reasons a psychiatrist would use ECT:

1. “I am firmly committed to the concept of depression as a genetically determined, biological disease of the brain and, as such, I believe that physical methods of management are irreplaceable.”

2. “I have tried everything I can but I have reached the limit of my skill set. I don’t know what else to do.”

3. “It pays well.”

Reason 1 is unjustified; nobody has ever proven that depression is a biological disease of the brain. Reason 2 says only that the psychiatrist should get another opinion, from somebody who doesn’t use it. Reason 3 says all we need to know. In 2018, when that paper was written, the Medicare rebate for ECT was about $70.00 which I thought was pretty good money for something that took about two minutes at the absolute most, and involved practically no intellectual effort by the psychiatrist. However, since then, the rebate for ECT (Item 14224) has leapt to the astounding sum of $175.15. The pay went up by 125% but the effort involved didn’t change, it still requires about as much intelligence as opening a can of beer, but it points to something that drives me to distraction. Last week, the ABC carried yet another article on the long-running “crisis” in mental health: “Mental health system a 'nightmare' for vulnerable Australians and needs urgent fixes, AMA warns,” it shrieks. More money is desperately needed, more beds, more staff, more of everything. Sorry to be a stick-in-the-mud, but the problem is not lack of money, it is misallocation

Let’s look at a couple of recent articles on ECT, the first from the US on the topic of ECT in children and adolescents [4]. Bearing in mind that American public health stats are notoriously unreliable, which the authors acknowledged, they found that in 2019, 315 minors (19 and under) were given ECT as in-patients, or 0.03% of paediatric admissions. One reason to question the figure was that they received an average of only two sessions each, when adults normally get about eight, so they probably got a lot more as out-patients after discharge. The figures were not evenly distributed: it was much more common in the north-east of the country, and among families from wealthy city postcodes (zip codes) with private insurance. Children were in hospital an average of twenty days, which set their families back an average of … $88,778 (range $49,571 to $181,860). By any estimation, that is a lot of money, of which the researchers were aware:

As a result, further research that might reduce the cost of hospitalizations involving ECT, for instance reducing the time between admission and administration of first ECT, has the potential for substantial healthcare cost savings ... Commercial insurance and higher income were associated with higher odds of ECT administration, which invites further study of potential socioeconomic barriers to treatment.

That is, let’s find ways of making this a bit cheaper so more kids can benefit from ECT. A study of ECT in adults from Australia comes to the same conclusion:

Variations in ECT were strongly associated with healthcare access, with private patients twice as likely to receive ECT than their public counterparts, suggesting a need to explore ECT accessibility [5].

This group didn’t give any costs for ECT in private hospitals, probably because private hospitals will not release this information. The only figure I have is from early 2019, when ECT was still $70.00 a shot. The patient was quoted a total of $620 per session, covering the psychiatrist, the anaesthetist and the hospital’s theatre fee. With all the hospital fees, a course of twelve ECT would have cost about $54,000, a lot less than in the US but still a heap of money. However, that included about a 200% mark-up on the actual Medicare rebate, i.e. everybody was charging up to three times the recommended fee. That was good money, except it will now be much higher, which is a bit of a problem if you’re urging everybody to get more ECT.

In both papers, the authors fretted over the fact that so many deserving people just couldn’t afford ECT: “Here we have all these cases of depression who are missing out, so we have to find a way of spreading it around.” In the US, a sizeable fortune is spent on one lucky child which means, of course, that the next twenty mentally troubled children get nothing. Based on their figures, I can suggest something to the authors of both papers which obviously didn’t occur to them: if public patients with exactly the same mental problems as the wealthy can get by without ECT, surely everybody can? Instead of bleating how we need to remove “potential socioeconomic barriers to treatment” to increase “ECT accessibility,” why don’t we turn the other way and just get rid of it? Shocking as it may sound, if the poor can manage without having their heads scrambled, so can the rich. The easiest way of dealing with the inequity of distribution of funds is to stop wasting so much on private psychiatrists and their wealthy patients in luxurious private hospitals. $175 for pressing an electrode against an unconscious patient’s head for thirty seconds? Jesus wept.

I don’t know how this massive fee increase came about, I don’t remember seeing notice of an enquiry but you can be sure of one thing: no critics were invited to give evidence. To me, it’s starting to look like a racket. According to Wikipedia, the definition of racketeering is:

A type of organised crime in which the perpetrators set up a coercive, fraudulent, extortionary or otherwise illegal coordinated scheme or operation to repeatedly or consistently collect a profit.

Psychiatry is coercive, there’s no question about that, as was mentioned several times in the narrative study above [1]: “(Flora) consented, fearing repercussions if she refused.” “… (Paula) did not feel she had a choice.” “Dean experienced low mood following a cancer diagnosis … (he) did not consent.”

Is psychiatry fraudulent? It is an established fact that nobody has ever shown that depression is a biological disease of the brain [6]. Similarly, nobody has been able to produce a copy of their vaunted “biopsychosocial model,” the inevitable conclusion being that it doesn’t exist [7]. On that basis, all talk of this model being “...the predominant theoretical framework underpinning contemporary psychiatry ... a relevant and useful component of training and practice ... " (Moore, E. correspondence, Nov. 20th 2023) appears to be fabrication. To my primitive, black-and-white way of thinking, psychiatry is teetering on the brink of a fraudulent enterprise.

Extortion is the use of threats to gain a benefit. Patients are frequently told they must agree to ECT or they will be detained and will get it as an involuntary patient. Strictly, this is the crime of “demanding with menace” as most patients do not want the stain of an involuntary detention to appear on their records. To me, demanding patients agree to ECT under threat of detention, and then charging them $175 or much more is immoral, even if not frankly illegal. If ECT is so important, let’s follow the Norwegian model where it is free, but is only given by government hospitals. As a result, Norway uses very little ECT (Norwegians rank seventh on the world happiness scale). One thing we can be sure of: doubling the ECT fee will quickly treble the rate of ECT.

Is psychiatry coordinated? Well, they have lots of conferences and publish lots of papers to make sure everybody except troublemakers is on the right page, so that sounds coordinated to me. For example, the US researchers said: “Suicidal ideation is a marker for severe and life-threatening disease” (p98). What they’ve done is strip away the emotional content, leaving just a bare signpost sticking up out of the desert of the patient’s life. Feeling suicidal says only that the patient is immensely distressed, and distress isn’t a disease, but categorising it as a “marker” makes it sound terribly biological, as does their use of the word “disease.” Their sentence actually begs the question, i.e. it assumes the truth of that which requires proof, which is a hallmark of pseudoscience.

“Repeatedly or consistently collecting a profit”: 189 sessions of ECT (see above) is fairly consistent. I met a lady who had been given 342 sessions of ECT with no measurable benefit to her. If the patient doesn’t get better, as she didn’t, or even commits suicide after ECT, as Ernest Hemingway did, there’s no refund. So is ECT a crime? Only where it’s banned. In India, it’s banned for children under sixteen, and they cope. I would say that the reason it isn’t a crime in more jurisdictions is just because the people who profit from it control the narrative.

The Australian paper concluded: “More socioeconomically advantaged patients with greater health literacy may exercise a higher demand for ECT due to greater understanding and acceptance of ECT…” [5, p818]. That is, the reason clever, rich people get more ECT is because they’re smart enough to know what’s good for them, and can pay to get to the front of the queue. OK, so why do women get two thirds of ECT in most countries? By that reasoning, women are just so much smarter than men. Despite all the talk, ECT remains something male psychiatrists do to distressed, middle-aged to elderly, middle and upper class women for profit. How is that science, especially as that demographic has the lowest suicide rate in the community? The fact that ECT is given mainly to older, rich, white women with private insurance has nothing to do with science and everything to do with gouging the group who are most likely to pay and least likely to object.

At this point, it is usual for the “shock jockeys” to start prattling on about how they have patients who come in every few months or a year for the ECT they love. Firstly, anecdotes don’t prove anything. Second, there are plenty of people who prefer oblivion, so that proves nothing. There are entire industries devoted to selling oblivion, such as alcohol, drugs, gambling, reality television, computer games, and so on. Third, the people giving all the ECT don’t actually ask patients about any damage they have suffered. There isn’t any room on the Hamilton Rating Scale for Depression for memory loss. That’s why narrative studies are so important, they ask what the patients think is important, rather than the psychiatrist deciding beforehand.

Faced with these objections, their next step is to start assailing the researchers, spluttering that they are “biased and anti-psychiatry” and nobody should listen to them. Ad hominem attacks are the pits but anybody who criticises psychiatry needs to get used to them. In the case of the joint authors of this narrative study, it won’t work. As PhD clinical psychologists, their credentials are impeccable. In particular, Prof. David Murphy has a lifetime of experience in dealing with chronic pain and disability, more than the great majority of psychiatrists, so the usual carping critics can safely be ignored. We await developments but the development I would like to see would be a clear account by mainstream psychiatry of why the state of distress known as depression is a biological aberration of the brain that can only be managed by physical methods, especially one developed for the purpose of causing brain damage. That ECT does just that, as the paper by Shipwright and Murphy makes crystal clear, should come as no surprise.

(For a bit of history on the pseudoscientific gibberish that has been used to justify “shock treatments,” see [8]. The author was a highly-regarded and influential psychiatrist in the UK, who worked almost until he died, in 1982).

References:

1. Shipwright E, Murphy M (2024). Long-Term Adverse Effects After Electroconvulsive Therapy (ECT): A Narrative Analysis Exploring People’s Experiences, Meaning-Making, and Coping. Qualitative Health Research, DOI: 10.1177/10497323241303391.

2. McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104. DOI: 10.1891/1559-4343.19.2.91 .

3. McPhee, I. (2009). When doctors get sick. Radius (Sydney University), pp. 10-13. Retrieved from http:// sydney. edu. au/ medicine/ news/ pubs/ radiuscontents/ 2009/ March/ 22_ 1_ coverstory. Pdf.

4. Lucarelli J et al (2023). The use of electroconvulsive therapy for children and adolescents in general hospitals: A 2019 kids’ inpatient database analysis. General Hospital Psychiatry https://doi.org/10.1016/j.genhosppsych.2023.03.012 .

5. Chen T et al (2024) Factors associated with electroconvulsive therapy treatment for adults with serious psychiatric conditions in Australia. Australian & New Zealand Journal of Psychiatry, 58: 809–820. DOI: 10.1177/0004867424126606.

6. McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18. 10.1891/1559-4343.15.1.7.

7. McLaren N (2023). The Biopsychosocial Model and Scientific Deception. Ethical Human Psychology and Psychiatry, 25: 106-118.doi:10.1891/EHPP-2023-0008.

8. Skottowe, I (1939). Shock Therapy: A Plea for Proportion in Psychiatry. Proceedings of the Royal Society of Medicine. 32:843-852. https://journals.sagepub.com/doi/10.1177/003591573903200750