Wednesday, 31 July 2013

ECT: This is shocking

A recent BBC Newsnight feature asked: “Why are we still using electroconvulsive therapy?” It’s an important question. While crude psychiatric ‘treatments’ from the early-mid 20th century like surgical lobotomies and insulin coma therapy have been recognised for what they really are (dangerous and barbaric) and have been withdrawn from use, electroconvulsive therapy (ECT) has managed to survive.

I first came across ECT back in 1975 when I saw it portrayed in the film One Flew Over the Cuckoo’s Nest. I was at that time working in a small psychiatric unit where the psychiatrist-in-charge was making radical changes - including the removal of bars from the windows and developing a more home-like milieu. His contextual understanding of mental and emotional troubles had a profound influence on my life.

Then, within a few years of seeing One Flew Over the Cuckoo’s Nest, ECT came nearer home as I had the unpleasant experience of accompanying one of my parents to a London hospital for repeated ECT treatments. The whole process was depressing (for both of us) and erased important memories from my parent without any hint of lifting the depression. Since then I have known many people who have endured multiple ECT ‘treatments’.

ECT ‘works’ by inducing a grand mal seizure. This is shocking; there’s no getting away from that. Prof Steven Rose describes it like this: “ECT puts a blast of electricity across the brain, temporarily disrupting communication, killing some cells, erasing recent memory and generally inserting a large clumsy spanner into the brain’s machinery…for any neuroscientist, the thought of such a massive, if brief, intervention into the delicate workings of the brain must be a cause of concern, however well intentioned the therapeutic goals might be”.[1]

This ‘treatment’ inevitably raises ethical issues; not least, when used against a person’s wishes, as still happens here in the UK. But there is another ethical issue: what if a psychiatrist would rather not subject a patient to ECT?  This matter was raised by the Critical Psychiatry Network in a letter to the Royal College of Psychiatry (RCPsych). The request (signed by Dr Joanna Moncrieff and Dr Rhodri Huws) asks “that the College consider dropping the obligation for trainees to conduct ECT during their training.” Now that’s an interesting request.

It is understandable that some psychiatrists would want to take an ethical position against having to administer ECT; rather like doctors are able to opt out of conducting abortions. What is striking is the immediate displeasure by the President of the RCPsych and the strength of the refusal by the follow-up letter ten months later on by the Dean.

I have never thought about it quite like this before, but insisting that all trainee psychiatrists perform ECT must surely act like a filtering system – potentially screening out some very able and conscientious people who are loyal to the “Do no harm” principle underpinning medical ethics; perhaps the very people able to compassionately respond to those suffering with mental and emotional pain.

A willingness to reflect on what we are doing (or asked to do) and why we are doing it is of course essential for progress. This reminds me of R.D. Laing’s experience: “As a young psychiatrist in general hospitals and psychiatric hospitals, I administered locked wards and ordered drugs, injections, padded cells and straightjackets, electric shocks [ECT], deep insulin comas [drug-induced comas] and the rest… I went around in a white coat, with stethoscope, tendon hammer and ophthalmoscope sticking out of my pockets, like any other doctor.  Like them, I examined patients clinically…It looked the same as the rest of medicine, but it was different.  I was puzzled, and uneasy.  Hardly any of my psychiatrist colleagues seemed puzzled or uneasy.  This made me even more puzzled and uneasy.” (Wisdom, Madness & Folly 1985)

In the US, ECT machines are Class III medical devices (Class III includes devices “which present a potential, unreasonable risk of illness or injury”). Any Class III device does of course have to be approved by the FDA for safety and efficacy – though this has been side-stepped by the makers of shock-machines. This is because “Electroshock machines were ‘grandfathered’ into the system when the FDA assumed jurisdiction over medical devices in 1976 (source)”. At long last the FDA is currently requesting this data, but no deadline has been set. This means that the device makers are in fact relying on the clinical literature to infer safety and efficacy. That’s amazing, and alarming. Since Congress ordered the FDA to have shock machines tested back in 1990, the makers and others with vested interests have been dragging their feet to avoid the necessary safety tests (source). In fact, they have even tried to have the Class III status revoked so as to be exempt from Class III conditions.

Early in 2010 Prof David Cohen made clear and definitive recommendations to the FDA concerning the evaluation of ECT devices. Please see his letter to the FDA here, which is made available with his permission. As for any evidence that full and adequate testing is being carried out – still waiting, and waiting.

And yet, in spite of this, shock-machine makers make some very bold claims for success, such as “providing up to an 80% response rate”.  Another maker boasts a similar treatment success: “ECT is an exceptionally effective medical treatment, helping 90% of patients who take it”. And not surprisingly, they promote their devices as safe with assertions like: “the safety of these devices is unparalleled, and as such these devices are an advance that will impact the safety and effectiveness of the ECT treatment.” It is surely time they were made to provide robust data to defend such claims.

But what about brain damage from the use of RCT? The maker, Somatics, make another bold claim in answer to this question: “The available evidence speaks strongly against this possibility.” There are, however, those who would strongly contest this. Traumatising the brain, even with the best of intentions, has got to be hazardous. I also understand that “In rare cases, ECT can cause heart rhythm problems” too. (source)

We know that a single general anaesthetic carries serious risks (hence the patient signs a disclaimer). And even if the estimate of “about five deaths for every million anaesthetics given in the UK” is an accurate one, this is still a risk, especially as some people have 20 or more ECT treatments – each under general anaesthetic.

I wonder if there are any long-term follow up studies showing any possible links to ECT use and later onset dementia, especially bearing in mind the recent research (see The Guardian report here) that raises the possibility that general anaesthetics (especially in older people) may significantly increase the risk for dementia.

Although there are claims of short-term benefit from ECT, this does not prove that ECT is curative. Interestingly, “there is an intriguingly high sham [placebo] ECT response rate in some of the studies” (Rasmussen KG, 2009). Also, I surmise that some people will likely misconstrue the iatrogenic “postictal bliss” - sometimes reported by people following a seizure - with a diminishing or lifting of depression.

What surprises me is that there aren’t more law suits against the makers of these devices – though attorney Kendrick Moxon reports a number of cases. There is another account of litigation here.

Should ECT be banned? I guess you have already made up your own mind on this.  According to attorney Kendrick Moxon,“ECT remains at best, an experimental or theoretical ‘therapy’.” I concur with him that the manufacturers should be made to “prove the safety and efficacy of any ECT devices before more patients are subjected to this damaging treatment.” Otherwise, this long-standing human experiment should be drawn to a rapid close. But “what about individual choice?” you may say. Maybe there’s always a counter argument.

Since electro-convulsive therapy (ECT) was first used 75 years ago there have always been both supporters and critics. ECT continues to have the power to divide as most people seem to either strongly defend its use or to vehemently oppose it. And when it comes to choice: here in the UK trainee psychiatrists have no choice to opt out of administering ECT; some patients are still forced to undergo ECT for their ‘good’; but the makers of shock-machines seem to be a law unto themselves and have chosen, so far, to avoid adequately demonstrating that their machines are safe and effective. Shocking.

Mick Bramham is an Existential Psychotherapist based in Dorset, UK.
He has a particular interest in ethical issues and also how our lives are shaped by the society, circumstances and culture in which we live.
He trained at Regent's College London, and is a member of the Society for Existential analysis. 
Although he has serious concerns about the inappropriate and excessive use of mental health medications, he supports the freedom to choose (to take or not to take these drugs) and the right to be fairly informed of their limits and the risks. He offers support for people who are considering reducing or coming off psychiatric drugs.
He has a long-standing interest in non-clinical (and non-coercive) responses to mental and emotional distress.
You can read more about his work and find his contact details here. You can follow Mick on Twitter @MickBramham

[1] Rose, S. (2006) The 21st Century Brain. UK: Vintage Books

Monday, 15 July 2013

Deep brain stimulation: Treating or tampering with our brains?

A history of trial and error

Tampering with the brain is inevitably fraught with risks. Everything seemed fine when Henry Molaison awoke from the operation to treat his epilepsy. But all wasn’t well: his ability to form new memories was severely impaired. In the words of Benedict Carey: “For the next 55 years, each time he met a friend, each time he ate a meal, each time he walked in the woods, it was as if for the first time”.

When it comes to mental health, there is a history of trial and error with the development and use of brain treatments. The surgical lobotomy (pre-frontal leucotomy) which was widely practiced in the 1950s is one such example, where the aim was to modify the brain to change moods, thinking, and behaviour. Most people will agree, that despite early optimistic reports on its use, it was a crude and disastrous failure that left many people “debilitated by serious brain damage” (Nuffield report p. 3).

Over the years many mental health drugs have been marketed under the pretext that they might correct imbalances in brain function or structure. They do, however, create all manner of unwanted ill-effects and carry serious risks too. What’s more, there is a view that they create rather than correct chemical imbalances in the brain[1]. To those with an entrepreneurial spirit - this apparent failure to consistently, successfully and safely modify the brain to address psychiatric concerns - may seem like a beckoning gap in the market place.

Novel neurotechnologies such as Deep brain stimulation

New procedures (“novel neurotechnologies” as they are often called) are currently being developed to try and adjust how the brain functions. These are already attracting considerable interest and investment. One such novel neurotechnology is Deep brain stimulation (DBS), in which electrodes are implanted deep within the brain and are then connected to a battery that is implanted in the chest. Then an electric current (modulated by a remote control device) is delivered to a specific location within the brain. It is sometimes compared to a heart pacemaker. Well, that’s the theory. [...]

Tuesday, 7 May 2013

From DSM-5 to RDoC - From bad to worse?

A personal crisis can remind us of our frailty and increase the wish for a sense of order and meaning; consequently, it can be reassuring when a doctor frames our difficult-to-define experiences in a clear and organised way by using familiar diagnostic criteria - usually beginning with "You are suffering from ..."

Though we may welcome some semblance of order during mental or emotional distress, it is not reassuring to know that the producers of DSM-5 have failed to come up with the scientific evidence to support the diagnostic categories that form the basis of this code book. In truth, these are simply just one way of trying to understand our personal struggles and crises (I write more about this here). Furthermore, the limits and risks of the DSM-5 have been loudly trumpeted by many people, including Dr Allen Frances, such as here in the New Scientist.

With the precise timing akin to an experienced actor entering the stage, Dr Insel (Director of the National Institute of Mental Health – NIMI) has announced that they (NIMI) have the answer. They are developing another new classification system (the Research Domain Criteria, RDoC) that will, he asserts, be far superior and have a more robust scientific basis. And with reference to DSM-5, Dr Insel concludes: “The weakness is its lack of validity”.

When I read Dr Insel’s report, some things didn’t ring true. I mention just one: he explains that the research for this new classification system “began with several assumptions”, including the one that “mental disorders are biological disorders involving brain circuits”.

It’s elementary, isn’t it - if science is an open and unbiased (as far as possible) quest for knowledge (and truth) - research cannot be based on narrow and rigidly predetermined assumptions without prejudicing the outcome. Dr Insel is in effect saying “we have decided mental disorders are biological disorders involving brain circuits, and on this basis we will introduce a new diagnostic approach and treatments to match.” It’s certainly wilful, but I don’t see this as science. As Dr Insel says of DSM-5, here again with RDoC the same applies: “the weakness is its lack of validity”. [...]

Tuesday, 30 April 2013

A time to grieve, a time to console, and a time to profit?

Eli Lilly and Co. are not slow to seize a business opportunity. As the American Psychiatric Association has opened up the way for the excessive diagnosing and treating of grief (through DSM-5), Eli Lilly has, it seems, a drug ready and waiting in the wings - Cymbalta.

In reality grief is not a sickness waiting for a cure; rather, it is a natural response to the loss that is an unavoidable part of life. And sadly, the older we get the more likely we are to experience the loss of family and friends.

With this in mind there are those who think that medication is an answer to the experience of grief in the elderly. In fact, the antidepressant Cymbalta (duloxetine) has been trialled as a “treatment on grief” - assuming that grief could really be treated. Dr John Shuster was the principal investigator in this drug trial of Cymbalta - sponsored by Eli Lilly. And as with most trials, it was a mere 8 weeks – not long enough to accurately assess the side-effects. In passing, it is worth mentioning that out of 44 patients referred and screened for this trial, 26 were enrolled and only 18 actually completed (3 dropped out because of the drug side-effects).  [You can read the trial specifications here.]

It seems that Eli Lilly are ahead of the game in testing Cymbalta for “bereavement-related depression” - now that DSM-5 has changed the diagnostic guidelines so that many more people are likely to be medicated for feeling down following a bereavement. As you may realise, the previous guidelines (DSM-IV) had a 2 month “bereavement exclusion” built in - to delay the experience of grief from being hastily diagnosed and medicated as depression.  But the whole notion of trying to put a time-scale on grieving seems to me quite absurd. I touch on this in my blog on grief here, “No stranger to Grief”. [...]

Thursday, 25 April 2013

There it is again – depression and chemical imbalances in the brain

There it is again. Why oh why do people still keep on perpetuating this very tired (and tiresome) old myth – the one about depression being a direct result of an imbalance in brain chemistry which is then corrected by antidepressants? I say this because I stumbled across this in a health website the other day: “Antidepressants help correct chemical imbalances in your brain by affecting certain brain chemicals called neurotransmitters.”

Why does this matter, you may ask? It matters for various reasons. First, it matters as people deserve the truth and it isn't just or helpful to oversimplify the facts to mislead people.  I say more about chemical imbalances and depression here. Second, it turns our attention away from addressing the concerns and situations that might be getting us down.  That’s why I write about the importance of the context of our lives here. Third, it can make people feel pressurised into thinking they need a drug to correct this so-called chemical imbalance, when in reality, antidepressants can actually create all manner of chemical imbalances, possibly leading to, for example: disrupted sleep, mood swings, mania, feelings of depression, sexual problems, and even suicidal feelings or violent thoughts and actions too. That’s not to say that some people may not find them helpful some of the time.

I also read in that article that: “Antidepressants are not habit forming (addictive).” A quick search on the internet will soon reveal countless people struggling to come off antidepressants such as Seroxat (US Paxil) as they can be so difficult to stop. I call that “addictive” even though a person is unlikely to crave them in the same way as someone might crave some of the street drugs. I mention the addictive power of antidepressants here (number 20 in my list of “20 Reasons To Be Cautious About Antidepressants”).

Yesterday I wrote down a few thoughts about trust and betrayal in my blog here. Being mislead about mental health drugs is also a betrayal of trust. It’s only right that we are clearly told what these drugs do and do not do, and to be clearly told about their limitations and the risks – so then we can make more informed choices. Fair?

“I'm not upset that you lied to me, I'm upset that from now on I can't believe you.”
― Friedrich Nietzsche

Monday, 22 April 2013

Should a mum-to-be continue with antidepressant drugs whilst pregnant?

A few thoughts on "There's a Pill for That" by Anne Kingston, here.

It can be a difficult decision to make. Should a mum-to-be continue with antidepressant drugs whilst pregnant? In this press article conflicting views are presented. What about the risks of the mother’s depression? What about the risks of the drugs to the unborn child?

As you will see, in this article some doctors claim the drugs are 100% safe; however, others contest that antidepressants can cause all manner of damage to the unborn child, including damage to the developing brain, heart defects, an increased risk of miscarriage and even autism.

In this article Dr Healy is quoted as saying that “there’s no good data suggesting untreated depression is more dangerous to mother and child than SSRIs [antidepressants]”. He also warns that “Women often aren’t told about addiction risks or the difficulty of withdrawal, which creates problems if they become pregnant.” And yet, even the makers of Seroxat (US Paxil) have issued an advisory that this drug may pose “an increased risk” of cardiovascular defects when taken in the first trimester.

Though not mentioned in this article, I quote Dr Adam Urato, assistant professor of obstetrics and gynaecology at Tufts University School of Medicine, in Boston:
“We are witnessing a large-scale human experiment. Never before have we chemically altered human foetal development on such a large scale…Many of the experts in this area receive funding from the anti-depressant majors. These experts continue to downplay the risks of these agents and to promote the benefits of their use in pregnancy.”
I mention some of the risks (including birth defects) of antidepressants here.

As antidepressants are so widely prescribed many mums-to-be will be taking them when they become pregnant.  Some doctors may then advise a careful withdrawal from these drugs to reduce the chance of risk to the unborn child. But this Dutch study indicates that the risk of birth defects continues 6-9 months after stopping these drugs.

Mick Bramham is an Existential Psychotherapist based in Dorset, UK.
He has a particular interest in ethical issues and also how our lives are shaped by the society, circumstances and culture in which we live.
Although he has serious concerns about the inappropriate and excessive use of mental health medications, he supports the freedom to choose (to take or not to take these drugs) and the right to be fairly informed of their limits and the risks. He offers support for people who are considering reducing or coming off psychiatric drugs.
He has a long-standing interest in non-clinical (and non-coercive) responses to mental and emotional distress. You can read more about his work and find his contact details here.

Sunday, 21 April 2013

Medicine at its best - Defeating polio

A report just out in the British Medical Journal announces that the world could be free of polio by 2018. In fact, one prediction is that the last case may be in 2014. This is wonderful news as medicine excels in eradicating such a terrible disease.

Polio was not unusual here in the UK when I was a child. A neighbour’s child contracted polio when I was just 4 years old. At that time I became suddenly very ill, reached a temperature or 106 F (that’s a colossal 41.1 C) and was of course delirious. As it was assumed that I too had polio I was rushed into what was then termed an “isolation hospital”. 

Fortunately (in comparison), it transpired that I had a serious case of measles and had not been infected with the polio virus - and was thus spared its crippling effects - and fully recovered.

I have clear memories of the hospital. I was behind a glass screen so visitors could only view me at a distance. I recall a small multi-coloured plastic train on my bed-side locker, an aunt peering through the window, and the fact that all my toys had to be destroyed when I left as this was an isolation hospital.

I say a lot in my web site about the risks of medications and how drug companies can have their sights set more on profits than the public’s health. But with the polio vaccine this is surely a time to celebrate! 

(The image shows a 14th century BC Egyptian with what appears to be a polio disability, courtesy of Wiki)