Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Peter Gøtzsche’s book, Critical Psychiatry Textbook. In this blog, he discusses the poor body of research for the efficacy of ECT and the common effect of amnesia, which indicates brain damage. Each Monday, a new section of the book is published, and all chapters are archived here.
Electroshock, also called electroconvulsive therapy (ECT), was highly praised in the textbooks. One book recommended ECT or pulsating electromagnetic fields (PEMF) for treatment-resistant depression,16:275 and another book noted that ECT must always be considered for this condition.17:364
It was claimed that ECT stimulates the formation of new neurons and the maintenance of the dendrite tree,16:558 and the development of new neurons in hippocampus.17:746 A third book noted that no acute or permanent brain damage had been demonstrated in the many scanning studies, and that a few studies suggest that the neurogenesis in the hippocampus increases.18:245
The truth is that the brain reacts to harm by producing new neurons.11 A harmful effect was therefore praised as being beneficial, which is common in psychiatry. There were no references.
One book claimed that it has not been possible to detect brain damage; that retrograde amnesia is difficult to interpret and difficult to distinguish from problems triggered by the disease; that some studies suggest a slight memory loss a year after ECT whereas other studies do not find it; and that long-term symptoms experienced by the patients after ECT are extremely rare and not with certainty related to it.17:745 By using the word “experienced,” the author downgraded what the patients tell their psychiatrists about the harms of ECT.
In another book, the same author claimed that brain damage has never been diagnosed after ECT while noting that almost all patients get amnestic symptoms in a treatment series.16-556 This is full-blown cognitive dissonance. If amnesia after ECT is not a sign of brain damage, what is it then? How can anyone argue this way? People who become amnestic after a concussion are told it is because they had a brain damage.
The author explained that the anterograde amnesia recovers two weeks later while retrograde amnesia is more uncertain. He noted that some studies suggest a slight memory loss 6-12 months later whereas prolonged experiences of inconveniences are extremely rare. This author, a professor of psychiatry, ignored the facts when asking if the problems were due to ECT or the disorder.
Other authors also denied the facts. They noted that, rarely, a few patients experience “subjective inconveniences” in the form of lacunas in retrograde memory and claimed that it is difficult to judge if they are harms of ECT because patients with severe depression also often have such lacunas.18:244
The memory problems are not just subjective (which is the standard script: Blame the victim, not the treatments); they have been verified in numerous studies.
Elsewhere in this book, the authors wrote about a short-term memory dysfunction, and that thorough studies with imaging methods had not shown damage to the nerve tissue.18:231
This is just incredible. ECT causes memory loss in most patients573-575 and permanent memory loss in some patients, which means irreversible brain damage.96,121 ECT furthermore kills some patients,573 which means that every single brain cell is dead.
The organised denial of the harms caused by ECT was astounding. My translation of the above is: We psychiatrists do not worry about the memory problems we cause; the patients already had memory problems before we electroshocked them; the memory problems patients tell us about are not real (only “subjective”); and we need not pay attention to what the patients tell us anyway because they are mentally ill. In my view, psychiatrists are too dangerous to have around.
The descriptions of what ECT does to people are among the most dishonest I encountered when reading the five textbooks, and this also applies to the postulated benefit. We are told that ECT is extremely effective against severe depression;18:231 and that it can be lifesaving.18:244 This agrees poorly with the information in the same book that, usually, 8-16 shocks are given.18:244 ECT is also used in patients with mania to prevent delirium acutum.18:114
It was claimed that 80% of patients with affective disorders respond to ECT,17:360 but there was no control group and no reference.
Here is an account of the facts.7:207 In the Cochrane review of ECT for patients with schizophrenia, which is from 2005,576 more people improved on ECT than on placebo or sham ECT, risk ratio 0.76 (0.59 to 0.98), but this finding is unreliable. It was barely statistically significant; the trials were small (only 392 patients in 10 trials); the larger the trial, the smaller the effect, which suggests that negative trials exist that haven’t been published; and the authors only excluded trials from their review if more than 50% of the patients were lost to follow-up, which is far too generous. Other researchers have concluded that all the sham ECT trials are grossly flawed.577
The Cochrane authors reported that, using the Brief Psychiatric Rating Scale, ECT was better than sham ECT, but there were only 52 patients in the analysis, and we have no idea how many patients or data that were missing or why. Further, the difference was only 6 on a scale that goes to 126, which is not a clinically relevant effect (see Chapter 7, Part One about a similar lack of a relevant effect of psychosis pills).
Even more worrying, ECT was considerably less effective than psychosis pills, e.g. twice as many patients weren’t improved in the ECT group, risk ratio 2.18 (1.31 to 3.63).
The authors didn’t draw firm conclusions about any short-term benefit, and there was no evidence for a long-term benefit.
A 2003 review found that ECT was more effective than simulated ECT for depression (6 trials, 256 patients, effect size -0.91 (-1.27 to -0.54), corresponding to a Hamilton score difference of 10, and ECT was also better than drugs (18 trials, 1,144 patients, effect size -0·80 (-1.29 to -0.29).578 This looks impressive, but these are short-term effects; the quality of the trials was poor; most trials were small; the results would likely change materially if a few neutral studies were identified; the trials rarely used outcomes relevant for clinical practice; and the data suggested that ECT caused cortical atrophy in the brain. The authors advised that the trade-off between making ECT optimally effective in terms of amelioration of depressive symptoms and limiting the cognitive impairment should be considered.
Psychiatric researchers often avoid saying in plain language what they found and what it means, as it would be threatening to the psychiatric guild. They should have said that it is uncertain if ECT for depression does more good than harm, particularly as it caused brain damage and as only short-term studies were evaluated. Systematic reviews have failed to find benefits beyond the treatment period, both for schizophrenia and for depression.573,578
Many psychiatrists believe ECT can be life-saving, but there are no reliable data in support of this belief,573,578 whereas we know for sure that ECT can be deadly. A systematic review found a death rate of about 1 per 1000,573 which is 10 times higher than what the American Psychiatric Association says. When I lectured in Brisbane in 2015, a mother told me that the psychiatrists killed her son with ECT but they resuscitated him. When he woke up, he had severe burns and the next two to three months he couldn’t say anything people could understand. He is permanently brain damaged and his social skills are very poor; he cannot live on his own.
In 2003, the UK Royal College of Psychiatrists’ fact sheet stated that more than 80% of depressed patients respond well to ECT and that memory loss is not clinically important.575 We do not ask a hairdresser if we need a haircut. The patients disagreed and the lowest satisfaction levels were obtained in studies led by patients rather than by psychiatrists.
If we want to know the truth about psychiatric drugs and electroshock, we need to listen to the patients and not to the psychiatrists.121 One Danish patient couldn’t remember even the commonest things, like the name of the Danish capital, after she was electroshocked.121 She was permanently brain damaged by electroshocks she should never have received because her problem was that she had been sexually abused as a child. She didn’t have any psychiatric disorder. Her book is a frightening account of what is wrong with psychiatry.121
Studies of ECT using routine neuropsychological tests have concluded that there is no evidence of persistent memory loss, but what is measured is typically the ability to form new memories after treatment (anterograde memory). Reports by patients of memory loss are about the erasing of autobiographical memories, or retrograde amnesia, and they are damning.575 With a strict definition of memory loss, between 29% and 55% of the patients are affected. With looser criteria, the range goes from 51% to 79%.
Other studies also show that ECT may cause permanent brain damage.573 In the 1940s, it was acknowledged that ECT “works” because it causes brain damage and memory deficits, and autopsy studies consistently found brain damage, including necrosis.
It is blatantly dishonest to say, as the psychiatrists who authored a Cochrane review of depressed elderly did,579 that, “Currently there is no evidence to suggest that ECT causes any kind of brain damage, although temporary cognitive impairment is frequently reported” and that “ECT seems to be a safe procedure”.
The 2010 official guidance for general practitioners in Denmark on depression was even worse. It stated that, “Many have an unfounded fear of ECT treatment, although there is no evidence that the treatment causes brain damage; in fact, there is strong evidence that new nerve cells are formed in response to treatment.”580
ECT “works” by making people confused and by destroying their memories, which are what define us as humans, but doctors describe this as positive. They also described lobotomy and the many other harmful treatments they used in the past as positive.1
As illustrated by the case in Brisbane, what happens in practice is far from what should happen. This has been studied systematically. Repeated audits by the Royal College of Psychiatrists showed that many hospital trusts failed to adhere to the college’s standards.575 One audit found that only a third of ECT clinics met the standards.578 There are also huge variations in clinical practice and in rates of usage.573,575,578
In Denmark, forced treatment with ECT quadrupled in just seven years in the 1990s, but forced treatment is immensely unpleasant; the patients are very scared; it often elicits colossal bitterness and anger; and it is perceived by the patients as a breach of trust.581
There is a very moving documentary about Mette Askov, a Danish nurse who had heard voices since she was eight years old and was a psychiatric patient for 15 years.582 She was diagnosed with paranoid schizophrenia and received vast amounts of medicine, 150 electroshocks and a disability living allowance. She was stigmatised and surrounded by prejudice but after she reclaimed her own life and left psychiatry, she achieved some of her greatest goals. Her story illustrates so well what the psychiatrists’ abuse of forced treatments lead to. Even when they so clearly don’t work, the psychiatrists continue to use them.
I have heard many stories where psychiatrists describe miraculous improvements and grateful patients. I was once asked at a meeting after my lecture about drugs what my view was about a woman who was so depressed that she could hardly be contacted but asked for a glass of water after an electroshock.8:87 I said that since this was an anecdote, I would reply with another anecdote. I examined a newly admitted man, an unconscious alcoholic, and as I needed to rule out meningitis, I tried to insert a needle in his back to tap cerebrospinal fluid for microscopy and culture. It was very difficult to get in and I hit his bone several times. All of a sudden, the drunkard exclaimed loudly: “Bloody hell, stop stinging me in the back!” Had I caused a miracle with my needle and cured the guy? No. Odd things happen all the time in healthcare. Could I have woken up the deeply depressed woman with my needle? Who knows, but maybe?
Some psychiatrists I have met have never used electroshock. This barbaric treatment should be made illegal, just as lobotomies were. In particular, no one should be forced to get electroshocks against their will.
To see the list of all references cited, click here.
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