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"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 he 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 words.
But some published studies have found that shock treatment can be risky, particularly for elderly patients with significant medical problems. They include the following:
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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.
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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.
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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.
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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.
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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.
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