Shock Therapy...IT'S BACK - Is Shock Therapy Suicide Preventive?

Written by SANDRA G. BOODMAN The Washington Post

"Texas collects data no one else collects," said Steven P. Shon, the department's medical director. The state, however, does not require an autopsy in these cases. "We need to be very careful" of attributing these deaths to ECT, he added. "Unless there's an autopsy, there's no way to make a causal connection."

Records show that four deaths were suicides, all of which occurred less than one week after ECT. One man died in an automobile accident in which he was a passenger. In four cases the cause of death was listed as cardiac arrest or heart attack. One patient died of lung cancer. Two deaths were complications of general anesthesia. In eight cases there was no information on the cause of death. At least two-thirds of patients were over 65, and in nearly every case treatment was funded by Medicare or Medicaid.

Suicide Preventive?

One of the most common reasons cited by doctors for performing ECT is that it prevents suicide. The report of the 1985 NIH Consensus Conference states that "the immediate risk of suicide" that can't be managed by other treatments "is a clear indication for consideration of ECT."

In fact there is no proof that ECT prevents suicide. Some critics suggest that there is anecdotal evidence that the confusion and memory loss after treatment may even precipitate suicide in some people. They point to Ernest Hemingway, who shot himself in July 1961, days after being released from the Mayo Clinic where he had received more than 20 shock treatments. Before his death Hemingway complained to his biographer A.E. Hotchner, "What is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business? It was a brilliant cure, but we lost the patient."

A 1986 study by Indiana University researchers of 1,500 psychiatric patients found that those who committed suicide five to seven years after hospitalization were somewhat more likely to have had ECT than those who died from other causes.

The researchers, who also reviewed the literature on ECT and suicide, concluded that these findings "do not support the commonly held belief that ECT exerts long-range protective effects against suicide."

"It appears to us that the undeniable efficacy of ECT to dissipate depression and symptoms of suicidal thinking and behavior has generalized to the belief that it has long-range protective effects," concluded the researchers in an article in Convulsive Therapy, a journal for ECT practitioners.

Another factor in ECT's growing popularity is economic, suggests Tampa psychiatrist Walter E. Afield. It can be summed up in one word: reimbursement.

"Shock is coming back, I think, because of the change in psychiatric reimbursement," said Afield, former a consultant to Johns Hopkins Hospital who founded one of the nation's first managed mental health care companies. "[Insurers] no longer will pay psychiatrists to do psychotherapy, but they will pay for shock or for medical tests."

"We're being pushed as a specialty to do what's going to pay," said Afield, who is not opposed to ECT, but to its indiscriminate use. "Finances are dictating the treatment. In the old days when insurance companies paid for long-term hospitalization, we had patients who were hospitalized for a long time. Who pays the bill determines what kind of treatment gets done."

The growing popularity of ECT concerns some psychiatrists. "It's better than it used to be, but I have grave reservations about it," said Boston area psychiatrist Daniel B. Fisher, who has never recommended ECT for a patient. "I see it now being used as a quick and easy and not very lasting solution and that worries me."

Questions About Memory Loss Persist

Does ECT cause long-term memory loss?

The model consent form drafted by the American Psychiatric Association and copied by hospitals says that "perhaps 1 in 200" patients report lasting memory problems. "The reasons for these rare reports of long-lasting memory impairment are not fully understood," it concludes.

Critics such as David Oaks, director of the Support Coalition of Eugene, Ore., an advocacy group composed of former psychiatric patients, say that the 1 in 200 statistic is a sham. "It's totally fictional and without scientific justification and is designed to be reassuring," said Oaks. Complaints about long-term memory loss are widespread among patients, Oaks said. Some insist that ECT wiped out memories of distant events, such as high school, or impaired their ability to learn new material.

Harold A. Sackeim, chief of biological psychiatry at the New York State Psychiatric Institute and a member of the APA's six-member shock therapy task force, says that the 1 in 200 figure is not derived from any scientific studies. It is, Sackeim said, "an impressionistic number" provided by New York psychiatrist and ECT advocate Max Fink in 1979. The figure will likely be deleted from future APA reports, Sackeim said.

No one knows how many patients suffer from severe memory problems, said Sackeim, although he believes that the number is quite small.

"I know it happens because I've seen it," he said. He attributes such cases to improperly performed ECT. Yet even when properly administered, Sackeim notes that greater memory loss is more likely after bilateral treatment -- when electrodes are attached t o both sides of the head -- rather than one side. Because doctors believe bilateral ECT is more effective, it is administered more often, experts say.

While blaming ECT for memory problems is understandable, it may not be accurate, noted Larry R. Squire, a neuroscientist at the University of California at San Diego.