Friday, September 18, 2020

Comments by rational_moderation

Showing 11 of 11 comments.

  • Clearly there is a range of possible total energies, influenced by a variety of factors. My point is that all things being equal, sine-waves would deliver greater energy (~3x). It’s a little hard to understand these low values because the references I linked to clearly say that the average energy required to induce a seizure is 47 joules (vs. 18 joules for pulses). That would lead one to think, on average, the minimum energy one could use would be 47 joules. Unless one was taking pains to avoid going over the seizure threshold, I’d assume the energy would often be much higher than that. I do think much much less care was taken with ECT 60 or 70 years ago and I would be shocked if the energy didn’t go significantly higher.

    I’m wondering if there is something missing here, for example maybe the total energy was lower, but because of the setup back then it delivered greater charge than would be delivered with similar energy on a modern machine. Either that, or these are just atypical examples where the energy was especially low. Unless we have all the parameters of the machine, I’m not sure we will ever definitively conclude the dose delivered in mC for these examples from many decades back. From my perspective, the statements about energy used then and now from experts is more compelling. I don’t think there is a broad conspiracy to miscalculate or misstate this basic and falsifiable fact about the physics of ECT.

    Anyway, it’s been an enjoyable back and forth. Thanks for not getting mad and calling me names. None of this probably changes our respective opinions about the treatment as a whole. I think there is some concerning misinformation floating around and there is a real danger of polarization that promotes extremism. I’m sure a lot of people would embrace that, but I don’t think it helps the case for reforming psychiatry. Nor does it lend itself to people with different views being willing to listen to this “anti-psychiatry” perspective. It’s not a comment about you specifically Bramble. Like I said, I appreciate the efforts you’ve gone to in order to prove your position and I trust it was with the goal finding the truth. Nonetheless, I still think you are wrong 🙂

  • Oops, sorry Bramble, my response accidentally ended up at the bottom of the comment thread. I’ll repost it here to maintain continuity of our back and forth:

    Bramble, you’re not really answering any of the meaningful questions which would cast doubt on your assertion. I think that the energy values from that article may be inaccurate or at least atypical. See ‘The Clinical Science of Electroconvulsive Therapy’ by Edward Coffey, 1993 (page 34) – full link to this page in the book below.

    For your convenience I’ll paste in the relevant bit:

    “It is well established that sine-wave devices may deliver much larger amounts of energy than pulse devices, yet they have not been shown to be more efficient at eliciting seizures than carefully administered brief pulse treatments (for review, see Weaver and Williams 1982). This means that the patient is often exposed to a more intense electrical stimulus with sinusoidal waveforms, even when the electrical dose is at or near seizure threshold. Further support for this idea comes from a study by Weiner (1980), in which he compared the effects of stimulus waveforms on seizure threshold. He found that brief pulse ECT as associated with an average seizure threshold of 18.0 J and that patients receiving sine-wave stimuli had an average seizure threshold of 47.0 J. Thus, on average, sine-wave stimuli required nearly three times as much electrical stimulus energy to elicit adequate seizures as brief-pulse stimuli. ” (link at bottom)

    As I mentioned similar statements are found throughout the literature. Moreover, it just makes rational sense when considering the waveform and is consistent with a number of studies which demonstrate fewer cognitive side effects when using brief or ultra-brief pulses as compared to sine-wave stimuli.

    Perhaps the patient in your article had an unusually low seizure threshold or because of his skull defect they were using lower energy? I don’t really know, but if this one example is what you’re basing this on, I don’t think it’s a very strong case. I’ve provided a fair amount of proof, I think you would need a more detailed explanation or reference to convince me or anyone else of your position in light of this. Modern brief pulse ECT uses much less energy than sine-wave ECT.

    http://books.google.com/books?id=8IxAO4wySBkC&pg=PA34&lpg=PA34&dq=typical+energy+in+sine+wave+ECT&source=bl&ots=6A2F9SopaT&sig=pxQQSqDto-tiEPvxAE4dQpgVA-g&hl=en&sa=X&ved=0ahUKEwjHrLv9mPXYAhURwmMKHc_PAD8Q6AEIWzAI#v=onepage&q=typical%20energy%20in%20sine%20wave%20ECT&f=false

  • You mostly just said the same thing again though. Albeit providing some references. I feel like you’re just ignoring the questions you don’t want to answer… You can use this number, 5.7, but what evidence do you have that the assumptions you make are accurate? As you say, “all else isn’t equal: other parameters have changed.” I don’t think you can just assume that relevant variables are identical in 1950, everything would have been different. If you show me something that gives charge calculations for 1950s ECT then I’ll buy it and will apologize for being wrong. However it’s got to make sense.

    Why is sine-wave ECT considered obsolete in most of the developed world if what you say is true? Kellner himself says that sine-wave ECT uses excessive energy and this is the reason it is obsolete. Help me understand why everyone but you is mistaken.

    Some may find this irrelevant and want to “moderate” me, but I’ve been nothing but civil. Anyone who suggests I be silenced isn’t helping their credibility. What would you say to someone who feels like they benefited from ECT? “You’re wrong, be quiet, you can’t have it ever again, it’s banned?” I doubt ECT will disappear completely, unless something replaces it. For people like my sister, who was suicidal and catatonic I have zero doubt that it was helpful. It seems wrong to take it away from at least people like her, because otherwise they might die. I guess no one will believe this story, but I’m obviously not the only one telling this perspective.

    I definitely don’t see making any headway on banning ECT unless there can be some consensus developed about what is true and what isn’t. I’m becoming skeptical that this is the place where that can happen. Perhaps this is a place where people only want to have their own viewpoint repeated back to them. Anyway, I appreciate that Bramble has engaged with me on this, but I wonder whether anyone here is open to adjusting their point of view in even a very modest way.

  • Can you explain how you are converting directly from energy to charge? As you alluded to they aren’t the same thing, i.e. not like converting between miles and kilometers. They are related, but you’d have to make some assumptions and you’ve not given enough information to do that. You can’t just take energy in joules from a 1950s publication and assume it relates directly to how you convert between joules and millicoulombs for a modern machine. A further point is that energy delivered will depend on other factors since most of the energy is used to overcome resistance in the actual electrodes, tissue and skull (not the brain). You’re actually making something complex appear super simple and it isn’t, charge is the accepted metric to use for comparing and that’s not even completely straightforward.

    Aside from that, when I suggested something pretty general, a source was immediately demanded. You give some really specific numbers without any source. The bit of the text I referenced specifically says the charge with sine wave ECT is far greater. I’ve read it a few times in other places too, so that’s why I’m skeptical.

    Here are a couple other reasons: 1) The other aspect of brief pulses is that they are more efficient at driving neuronal responses. Neurons have a refractory period between action potentials and so any energy delivered during the refractory period is wasted in terms of driving a seizure. Therefore, if there is a certain seizure threshold, you necessarily must deliver greater energy with a sine wave than with pulses to elicit the same seizure. 2) I have a hard time understanding why a device would be engineered to convert sine waves to brief pulses if it wasn’t an improvement in some way. It’s obviously more technically challenging than just using current from the wall, so why do it if it was going to deliver more charge and cause worse side effects? Then further why is it being repeated in scientific articles that less charge is delivered if that’s not true? Maybe your position is that it’s the same (ie not any improvement), but multiple people were repeating the idea that modern ECT is way stronger and much worse and that’s what I responded to as a potential inaccuracy 3) You mention that sine-wave ECT was still practiced in New York as recently as 2001 as though that’s is a bad thing (maybe I’m misinterpreting?). However, based on what you’re saying wouldn’t it be better to use sine-waves? If it’s true as was suggested that modern ECT is more charge, more dangerous, more damaging then it would seem better to use an older design. If sine-wave ECT is largely considered obsolete, where does the idea come from that it is no longer appropriate to use it at all?

    I anticipate that my position will be unpopular, but a family member of mine received ECT and I think it saved her life. I’ve read a lot about it since and have come across this site only recently. I’m not trolling anyone, just trying to square what I’ve learned in my own reading with what’s being said here by some apparently reasonable people. I’m not a huge supporter of ECT really, but I come from a more libertarian perspective and don’t think it should be outlawed. All interventions to treat dire conditions come with risks, I won’t get into it, but in my sister’s case it was a matter of life or death. The ECT did help her and she has no ill effects, I don’t think she would be alive now if it wasn’t available. Maybe psychiatry is abusing ECT and using it as a torture weapon in some cases, I can’t really know that, but if it can sometimes help when the alternative is death, then I think it should be available. That’s another debate entirely, but suffice it to say accurate information should not be the enemy of reasonable opinions on either side of a question.

  • In response, this is the first thing I came across when I just googled it now. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990832/

    The most relevant bit is below. I’m sure I could have found a better explanation of how this has changed, but in a hurry right now. Basically the total energy delivered is proportional to the area under the curve, so a sine wave will in general deliver far greater energy than brief pulses. I guess you could alter the pulse parameters to have equivalent energy to a smaller sine wave, but I don’t think that’s what is happening. If someone can show that I’m wrong I’d be interested to see the evidence for that though. Bramble – it seems like you know what you’re talking about, but I don’t think that’s true. Not saying modern ECT doesn’t cause the problems you describe with memory, but I don’t think it’s as bad as if you got ECT in 1950.. Again, open to being proved wrong.

    From the article:
    “There are two important categories of electroconvulsive therapy (ECT) devices: constant voltage, sinusoidal wave devices and constant current, brief-pulse devices. The sinusoidal wave devices are currently considered obsolete for the following reasons.[1]

    Current flows almost continuously with the sinusoidal waveform. As a result, far more electrical charge is delivered than is necessary to trigger the seizure. The extra charge may not increase efficacy but does increase the cognitive adverse effects of the treatment. In contrast, with constant current, brief-pulse ECT devices, current is delivered in short pulses. The seizure which is triggered can be as effective as that with sinusoidal wave ECT, and is associated with less cognitive adverse effects.”

  • I’ve looked into it a little Stephen. You don’t have to take my word for it, I just think it’s important to be accurate when discussing these things. The establishment has a way of writing off opinions when they see an inaccuracy. Please don’t take offense, I wasn’t intending to make an argument in support of shock.

  • Hi Steve, you bring up some great points, thanks.

    I have to disagree with you though that “no one” would deny that genes are involved. This is what I’m struggling with because a lot of what I’m seeing seems to suggest that genes have zero impact (or close to it, see my response above). Of course the idea that the environment has no impact would be equally ludicrous. I’m just not that sure a lot of people are arguing that genes explain all or most of so-called psych disorders either though.

    As far as the bone analogy, I’m not so sure. What if a small number of people were breaking bones during regular activities. Let’s say your kid broke his leg just playing soccer without a clear cause. At first you might say that’s just a weird fluke, but what if the next week they broke their arm just swinging on the monkey bars? If it was my kid I’d be worried there was something wrong and want them to have some sort of medical evaluation. It doesn’t seem crazy to me to say that could be caused by a “weak bone syndrome”. I’m no expert, but I believe a condition like that does exist. Where do you draw the line between that and people who are just slightly more likely to break bones in a car accident? I have no idea, but I think drawing the line somewhere is a reasonable way of conceptualizing it if it’s an obvious issue.

    Whether we should spend a lot of money trying to figure out the cause of these bone issues is another question. Your feeling that this might be a poor use of resources seems reasonable to me. I would also agree with devoting resources to protecting sensitive people or helping with the healing of any resulting injuries.

  • Hi Nancy, thanks for your response!

    Perhaps I wasn’t being clear in my thought process. I was trying to think of an example where both genes and environment have an obvious contribution. It seems self-evident to me that experiences alter the brain, as you eloquently described. It’s less clear to me that we don’t inherit to some degree our own unique susceptibilities to stressors. It seems like this question is getting all entangled with the idea that genes determine things or are the only or main cause of so-called psych disorders. I agree that it doesn’t look like that to me at all.

    You said, “no study has pinned down any genes responsible for these conditions. If we take schizophrenia for example, genes appear to explain only about 0.001 percent of outcomes”

    Maybe I’m missing something, but I’d like to gently suggest that isn’t what the linked article says. They say 10 out of 8000 cases was due to this one particular gene. A very small number for sure, as you say .001%. Taking this at face value though it suggests that a gene is involved in this very small percentage of cases (I don’t know if the evidence for this is good or not). If I understand correctly, this doesn’t mean that genes as a whole explain .001% of outcomes. These gene scientists haven’t been very successful at finding specific genes that cause so-called psychiatric disorders. However, does that mean many different factors of small effect in our DNA can’t explain the tendency of some people to respond to stress in different ways?

    As you mention, it looks like the brain is highly sensitive to the environment and its structure and chemistry is constantly changing. I’m not under the impression that most psychs or scientists would argue with that… (maybe I’m wrong). My sense is that some assume that any discussion of inherited sensitivities to stress is tantamount to saying genetics is the only or main cause of so-called psych disorders. My observation alone indicates to me that stressors are not the only thing that determines behaviors or “symptoms” that are being called disorders. As you say, the brain (and genome for that matter) are immensely complex. If that’s true, I can’t figure out what the other factors are if they aren’t our inherited tendencies. I see that we are all unique and very different from each other, doesn’t some of this come from our parents (similar to height or weight).

    -Jerry

  • Wait, I don’t think the problem is the press not having scientific training. After all the original findings that these journalists are reporting on are actually from the scientific community. They are often peer reviewed by other scientists. So if the press had similar scientific credentials they would likely be even more supportive of the main findings of the work right? The truth is that the interpretations of those on this forum are still a minority opinion in science. Until the majority of scientists agree, it’s unlikely that much will change about psychiatry or public opinion of its so-called disorders.

  • So this is what I want to know. When bad things happen to people in the world and in relationships, it seems like that affects people differently. While some develop psychosis, others may become depressed or do OK in spite of the trauma. If different individuals respond differently to stress, why could that not be partly due to their genetic makeup?

    I’m trying to understand, but it just seems like for so many other things it seems clear that genes play a role. Things like height or weight for example, seem to me like they run in families, but are also influenced by something like nutrition. Why would so-called psychiatric problems be different? I’m really struggling with how it seems so obvious to some here that genes don’t have anything to do with it.