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Among the small fraternity of electroshock experts, psychiatrist Richard
Abrams is widely regarded as one of the most prominent.
Abrams, 59, who retired recently as a professor at the University of Health
Sciences/Chicago Medical School, is the author of psychiatry's standard
textbook on ECT. He is a member of the editorial board of several psychiatric
journals. The American Psychiatric Association's 1990 task force report
on ECT is studded with references to more than 60 articles he has authored.
Abrams, whose interest in ECT dates back to his residency in 1960s, has
served on the elite committee that planned the National Institutes of Health's
1985 consensus conference on ECT. In addition he has long been a sought-after
expert defense witness on behalf of doctors or hospitals sued by patients
who allege that ECT damaged their brains.
What is less well known is that Abrams owns Somatics, one of the world's
largest ECT machine companies. Based in Lake Bluff, Ill., Somatics manufactures
at least half of the ECT machines sold worldwide, Abrams said. Most of
the rest are made by MECTA, a privately held company in Lake Oswego, Ore.
Yet Abrams's 340-page textbook never mentions his financial interest in
Somatics, the company he founded in 1983 with Conrad Melton Swartz, 49,
a professor of psychiatry at East Carolina University in Greenville, N.C.
Neither does the 1994 instruction manual for the device written by Abrams
and Swartz, the company's sole owners and directors, which contains extensive
biographical information.
Financial ties between device manufacturers, drug companies and biotech
firms "are a growing reality of health care and a growing problem," said
Arthur L. Caplan, director of the Center for Bioethics at the University
of Pennsylvania School of Medicine.
For doctors "the questions that such financial conflicts of interest generate
are, do patients get adequate full disclosure of options or are you skewing
how you present the facts because you have a financial stake in the treatment
and you personally profit from it every time it's used?" Caplan asked.
"It's especially disturbing with ECT because it's so controversial" and
public mistrust of the treatment is so great, he added.
Abrams said his publisher at Oxford University Press knew about his ownership
of Somatics. "No one ever suggested I list it," said Abrams. "Why should
it be?" Abrams said he has disclosed his directorship of Somatics after
several medical journals began requiring information about potential conflicts
of interest. Caplan said that a growing number of medical journals are
requiring disclosure of payments greater than $1,000.
Abrams said he sees "no specific conflict" between his role as an ECT expert
and his ownership of a company that makes shock machines. He said he has
not decided whether to list his ownership in the third edition of his book,
which is due out next year.
Abrams declined to say how much he has earned from Somatics. Approximately
1,250 machines, priced at nearly $10,000, have been sold to hospitals worldwide,
he said. Between 150 and 200 machines are sold annually, according to Abrams.
Somatics also sells reusable mouthguards for $29, which are designed to
minimize the risks of chipped teeth or a lacerated tongue.
Swartz, 49, declined to be interviewed. Last year USA Today reported that
he considered his financial interest in Somatics to be "a non-issue." Swartz
is quoted as saying that the company was founded to provide better machines
and to "advance ECT."
"Psychiatrists don't make much money and by practicing ECT they can bring
their income almost up to the level of the family practitioner or internist,"
Swartz is quoted as saying. Swartz also said that the profits from Somatics
are comparable to having an additional psychiatry practice. (Last year
psychiatrists earned an average of $132,000, according to the American
Medical Association.)
Abrams and Swartz are not the only ECT experts with financial ties to the
industry.
Max Fink, 73, a professor of psychiatry at the State University of New
York at Stony Brook, whose passionate advocacy is widely credited with
reviving interest in ECT, receives royalties from two videos he made a
decade ago. Fink is one of six ECT experts who served on the APA's 1990
ECT task force, which drafted guidelines for the treatment.
In 1986 he made two videos about ECT, one for patients and their families,
the other for hospital staff. Each sells for $350 and is used by hospitals
that administer ECT. Fink said that Somatics paid him $18,000 for the rights
to the videotapes; he said h e receives 8 percent of the royalties. He
declined to disclose how much money he has earned from the videos.
Duke University's Richard D. Weiner, 51, chairman of the APA task force
on ECT, appears on a MECTA videotape. Weiner said he served as a consultant
to the company about 10 years ago but has not "received any money directly"
for his services. Instead MECTA deposited between $3,000 and $5,000 in
a university account that Weiner controls which, according to a Duke spokesman,
is earmarked for "research support and other educational functions."
Harold A. Sackeim, director of ECT research at New York's Columbia-Presbyterian
Hospital, is also a member of the APA task force on ECT. Sackeim, who has
consulted for both MECTA and Somatics, says he has not accepted cash payments
from the manufacturers because he does not want to be perceived as "benefiting
personally" from ECT. Instead both companies have made payments to his
lab. Sackeim estimates that his lab has received about $1,000 from Somatics
and "several tens of thousands of dollars" from MECTA.
Ethicist Caplan said that he believes such donations raise fewer ethical
questions than do direct payments to a doctor or an equity interest in
a company. Even so, he said, it is up to physicians who receive such payments
to disclose this to the public an d especially to prospective patients.
"There needs to be full disclosure in writing and the information needs
to be repeated over and over again," Caplan said. "Doctors need to give
patients the opportunity to ask questions if they want, not to make those
decisions for them by saying they won 't be interested."
Changes in Population and
Insurance Make Elderly Women Most Common Patients
Forty years ago, the typical ECT patient resembled Randall P. McMurphy,
the antihero immortalized by actor Jack Nicholson in "One Flew Over the
Cuckoo's Nest." Like McMurphy, ECT recipients tended to be under 40, male
and impoverished -- patients confined to state mental hospitals, often
against their will.
These days the typical ECT patient is an elderly white woman -- clinically
depressed, and usually middle or upper middle class -- who has signed herself
into a private hospital. Because she is over 65 her bill is paid, in whole
or in part, by Medicare, the federal government's insurance program for
the elderly.
The profound shift in the demographics of ECT reflects several factors,
experts say. Among them are the dramatic growth of the nation's elderly
population and of Medicare; a growing awareness by doctors of the problem
of geriatric depression, and the push by insurers that psychiatrists provide
more fast-acting "medical" treatments and less talk therapy.
A 1990 report by the American Psychiatric Association concluded that advanced
age is no bar to ECT; it cited the case of a 102-year-old patient who received
the treatment. Because some psychiatrists believe shock therapy works faster
and is less risky than drugs, it is increasingly being administered to
elderly patients. Frank Moscarillo, director of ECT at Washington's Sibley
Hospital, said the typical patient at his hospital is over 60. His oldest
patient was 98, "a little old lady" in Moscarillo's word s.
But some published studies have found that shock treatment can be risky,
particularly for elderly patients with significant medical problems. They
include the following:
A 1993 study by Brown University psychiatrists of 65 hospitalized patients
over age 80 found that those who received ECT had a higher mortality rate
up to three years after treatment than did a group treated with medication.
Of 28 patients who received drugs, 3.6 percent were dead after one year.
Of 37 patients who got ECT, 27 percent were dead within a year. The authors
concluded that the differences in death rates were not primarily due to
ECT, but to the fact that ECT patients had more serious physical problems.
A 1987 study of 136 patients by researchers at Washington University in
St. Louis found that complications after ECT, including severe confusion
and heart and lung problems, increased with age.
A 1984 study by doctors at New York Hospital-Cornell Medical Center found
that geriatric patients developed significantly more complications, not
all of them reversible, after ECT than did younger patients. Problems included
irregular heartbeats, heart failure and aspiration pneumonia, which occurs
when an anesthetized patient inhales vomit into the lungs. All three conditions
can be fatal.
A 1982 study of 42 ECT patients at New York's Payne Whitney Clinic found
that 28 percent developed heart problems after ECT. Seventy percent of
patients previously known to have cardiac problems experienced complications.
Even so, all of the researchers concluded that the potential benefits of
ECT for depressed elderly patients tend to outweigh the risks. Shock, they
say, is effective in quickly treating life-threatening dehydration or weight
loss caused by severe depression.
Instances of involuntary
electroshock
At the same time, there is concern that the elderly are particularly vulnerable
to inappropriate or dangerous treatments.
Last year the Illinois Appellate Court ruled that ECT was too risky and
not in the best interests of Lucille Austwick, an 82-year-old nursing home
patient who suffers from dementia and chronic depression.
The state's highest court reversed the decision of a lower court in Chicago
that had ordered Austwick, a retired telephone operator, to undergo as
many as 12 ECT treatments at Rush-Presbyterian-St. Luke's Hospital against
her will. Austwick, who has no family, had previously been declared incompetent
by a court.
In a strongly worded opinion the judges detailed contradictions in the
testimony of Austwick's psychiatrist, who said he had sought a court order
"because medication therapy would take a long time [and] he felt it would
be better to get [the patient] out of here [the hospital] rather than stay
here and spend time and money."
In Wisconsin, the state agency that protects the rights of the mentally
ill last year issued a report detailing nine cases in which patients at
St. Mary's Hospital in Madison received ECT against their will or without
proper informed consent.
All but one of the patients was over 60 and female. Two were coerced into
having ECT, the report by the Wisconsin Coalition on Advocacy stated. In
another case the hospital threatened to get a court order to administer
shock over a spouse's objections, investigators said.
The agency concluded that "medical and nursing practices surrounding ECT
at St. Mary's psychiatric unit may not consistently reflect the minimum
standards required by state law and relevant professional standards."
Hospital officials denied that St. Mary's had violated patients' rights.
They noted that regulatory officials had not taken any action. The hospital
made changes in its ECT consent documents, but not as a result of the commission's
report, officials said.
Discovered in 1938, Electroshock
Has Fluctuated in PopularityEven its most ardent defenders agree that ECT
arouses primitive fears: of being struck by lightning, of Dr. Frankenstein's
experiments, of electrocution and the electric chair.
"ECT is something that just because of its nature doesn't look good," said
Richard D. Weiner, chairman of the American Psychiatric Association's 1990
task force on ECT and an associate professor of psychiatry at Duke University
Medical Center. "You're talking about putting electricity on top of somebody's
head."
"ECT is a bizarre treatment," agreed Harold A. Sackeim, chief of the ECT
service at New York's Columbia-Presbyterian Hospital. "In terms of its
surface features, it has a horrific aspect to it."
For thousands of years, the notion of using electricity to treat illness
has held a fascination for doctors. In 47 A.D. Roman healers applied electric
eels to the heads of headache sufferers. In the 1920s and '30s American
and European psychiatrists began treating some mental illnesses by inducing
epileptic-like convulsions through massive doses of insulin and other drugs.
They discovered that some patients showed dramatic, albeit temporary, improvement.
ECT was discovered somewhat by accident in 1938 after an Italian psychiatrist
adapted a pair of tongs used to stun hogs before slaughter and applied
them to the temples of a 39-year-old engineer from Milan, shocking him
out of a delirious state in which h e spoke only gibberish.
By the 1940s insulin coma and electric shock treatments were widely used
in American mental hospitals, especially the overcrowded public institutions
that housed as many as 8,000 patients and as few as 10 doctors.
Historical accounts are replete with examples of shock used to subdue and
punish patients, sometimes under the guise of treatment. Particularly troublesome
patients received hundreds of shocks, often several in a single day.
"ECT stands practically alone among the medical/surgical interventions
in that misuse was not the goal of curing but of controlling the patients
for the benefits of the hospital staff," medical historian David J. Rothman
of Columbia University told an NIH consensus conference in 1985. "Whatever
the misuse of penicillin or coronary artery bypass grafts, the issue of
staff convenience was not nearly as prominent as with ECT."
The invention of Thorazine and other antipsychotic drugs led to a decline
in the use of ECT. So did published accounts of abusive treatment. The
most famous was "One Flew Over the Cuckoo's Nest," Ken Kesey's 1962 novel
based on his experiences in an Oregon state mental hospital, which in 1975
was made into a movie starring Jack Nicholson.
By the mid-1970s ECT had fallen into disrepute. Psychiatrists increasingly
turned to drugs, which were cheaper and easier to administer and aroused
less opposition. In addition, a series of landmark cases involving the
abuses of shock therapy helped form the basis for patients' rights and
informed consent legislation.
The late 1980s marked a resurgence in the use of ECT, and in recent years
ECT opponents in a few states have tried to restrict or ban the treatment.
In 1993 the Church of Scientology, which opposes psychiatric treatment,
and several groups of anti-ECT activists helped persuade Texas lawmakers
to bar ECT for children under 16 and to require hospitals to report deaths
within 14 days of treatment.
Last year a bill to ban ECT was the subject of a two-day public hearing
before a Texas legislative committee that heard testimony from 58 witnesses.
That bill died in committee but its sponsors predict it will be resurrected
next year when the legislature reconvenes.
FAMOUS PATIENTS WHO HAD
ECT:
* Ernest Hemingway fatally shot himself after being released from the Mayo
Clinic, where he had undergone ECT.
* James Forrestal, the first U.S. secretary of defense, committed suicide
in 1949. Forrestal, 57, had received a series of insulin coma treatments,
a precursor of ECT.
* Poet Sylvia Plath described her shock treatments in her 1971 book, "The
Bell Jar." She wrote, "with each flash a great jolt drubbed me till I thought
my bones would break and the sap fly out of me like a split plant."
* Former Sen. Thomas Eagleton (D-Mo.) was forced to relinquish his spot
as vice presidential candidate on the Democratic ticket in 1972.
* Performer and political activist Paul Robeson underwent a series of ECT
treatments in London in 1961.
* At 17, rock star Lou Reed was given shock treatments designed to "cure"
his homosexuality at a New York state mental hospital.
* Film actress Frances Farmer received shock treatments while confined
to a state mental hospital in Washington.
* New Zealand writer Janet Frame described her harrowing experiences with
ECT in a 1961 autobiography.
* Former Boston Red Sox outfielder Jimmy Piersall wrote that ECT helped
pull him out of a serious depression in the early 1950s.
* Vaslav Nijinksy, the famed ballet dancer, underwent a series of insulin
coma treatments in Europe in the 1930s.
* Writer Zelda Fitzgerald underwent insulin coma treatments, a precursor
of ECT, at a North Carolina hospital.
* Literary critic Seymour Krim, a chronicler of the Beat Generation, received
ECT in the late 1950s.
* Movie actress Gene Tierney underwent eight shock treatments in 1955,
according to her autobiography.
* Pulitzer prize-winning poet Robert Lowell was hospitalized repeatedly
for manic depression and alcoholism.
* Film star Vivien Leigh, pictured in "Gone with the Wind," received shock
treatments.
* Talk show host Dick Cavett had a series of ECT treatments in 1980. "In
my case, ECT was miraculous," he wrote.
* Robert Pirsig described his experiences with ECT in his 1974 best-selling
book, "Zen and the Art of Motorcycle Maintenance."
* Piano virtuoso Vladimir Horowitz received shock treatments for depression
and later returned to the concert stage.
* Concert pianist Oscar Levant described his 18 ECT treatments in his book
"Memoirs of an Amnesiac."
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