Wednesday, September 30, 2020

Comments by drtobywatson

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  • I also spoke to them about this issue, and have posted their response to my letter below:

    Minister for Mental Health; Disability Services; Child Protection
    Ourref: 43-10519/83
    Toby Watson, [email protected]

    Dear Mr Watson

    Thank you for your recent correspondence to the Minister for Mental Health,
    regarding the Mental Health Bill 2013. The Bill was introduced into Parliament on 23
    October 2013 and represents a significant step forward for mental health reform in
    Western Australia.

    The Bill has been developed over a 10 year period and has involved extensive
    consultation from a range of stakeholders including people with a lived experience of
    mental illness, families, carers, clinicians and non-government organisations. During
    the consultation process on earlier drafts of the Bill, over 1,300 written submissions
    were received and 40 forums held across the state were attended by 600 people.
    This feedback, both written and verbal, has been vital and developing and shaping
    this important piece of legislation.

    The Bill makes significant improvements upon the Mental Health Act 1996, which is
    the current legislation in Western Australia. This includes strengthening the rights of
    people experiencing mental illness and providing for greater family and carer
    involvement with the treatment and care of their loved ones. It also provides new
    levels of rights protection, providing processes and safeguards around involuntary
    treatment to protect some of society’s most vulnerable people.

    I note that you have raised some specific concerns regarding the clauses which
    regulate the use of electroconvulsive therapy and psychosurgery on children and the
    involvement of parents. Please be assured that the Bill provides stringent
    safeguards in these areas, considerably greater than those in the current Act.

    Electroconvulsive therapy
    Electroconvulsive therapy, or ECT, is a form of medical treatment for severe
    depression, bipolar disorder and psychotic illnesses such as schizophrenia. It may
    be recommended by a psychiatrist when symptoms are severe or other forms of
    treatment, such as medication or counselling are ineffective.

    Under the current Act, ECT can be performed on an involuntary patient if it is
    recommended by the treating psychiatrist and approved by a second psychiatrist.
    The current Act does not differentiate between adults and children. As such, a child
    of any age could potentially receive ECT.
    1
    7th Floor Dumas House, 2 Havelock Street, West Perth Western Australia 6005
    Telephone: +61 8 6552 6900 Facsimile: +61 8 6552 6901 Email: [email protected]

    ECT is not a common treatment for children, in any case, the Biii bans the use of
    ECT on children under the age of 14. As an additional safeguard, the Mental Health
    Tribunal (Tribunal) is required to give approval before ECT can be provided to a
    child.

    Whether or not a child has the capacity to consent to receive ECT is a decision to be
    determined by the patient’s psychiatrist. The Bill creates a presumption that children
    do not have decision making capacity. However, this can be reversed where a child
    demonstrates that they do have capacity. This is the same position as for general
    health, where a child needs medical treatment.

    Where the child does not have capacity, the decision to provide informed consent for
    ECT lies with their parent or guardian. Conversely, a child with capacity may
    consent to ECT, which may not be reflective of their parent or guardian’s wishes.
    The Bill requires that any decision regarding a child must take into account the views
    of their parent or guardian, including a decision surrounding ECT. In determining
    whether or not to approve an application for a child to receive ECT, the Tribunal
    must consider the views of the child’s parent or guardian.

    Psychosurgery
    Under the current Mental Health Act 1996, psychosurgery may be performed with
    the informed consent of the patient in addition to the approval of the Mental Health
    Review Board.

    Psychosurgery has not been performed in Western Australia since the 1970’s.
    However, there is evidence of emerging forms of treatment which meet the definition
    of psychosurgery and require regulation. In particular, one treatment being
    undertaken in other jurisdictions is Deep Brain Stimulation. There is mounting
    evidence that this treatment is beneficial in treating illnesses such as depression and
    obsessive compulsive disorder. It is considered to be inappropriate for Government
    to deny a person access to a treatment which may greatly assist them, provided
    appropriate safeguards are in place.

    The position in the Bill is similar to the current Act, with extra safeguards.
    Psychosurgery can only be provided with the informed consent of the patient in
    addition to the approval of a specially constituted Tribunal.

    There are other additional safeguards in relation to children. The current Act does
    not differentiate between children and adults, meaning that psychosurgery could
    potentially be performed on a child of any age. Based on clinical advice, the Bill
    prohibits psychosurgery on a child under 16 years. In deciding whether or not to
    approve psychosurgery, the Tribunal must have regard to the views of the child’s
    parent or guardian, amongst other matters.
    2
    Other provisions for the protection of children
    The current Act does not make reference to children at all. There are numerous
    provisions in the Bill which protect children, for example:
    • Requiring the child’s personal support person/s (anticipated to be the child’s
    parent or guardian) to be:
    o notified about an incident of detention, admission, discharge, and
    similar matters;
    o informed about treatment and care; and
    o involved in treatment decisions and treatment, support and discharge
    planning.
    • The views of the child’s parent or guardian to be considered at all times.
    • The wishes of the child to be considered at all times.
    • The best interests of the child to be a primary consideration (taking into
    account the safety of other people, which cannot be ignored).
    • Requiring an advocate from the Mental Health Advocacy Service to contact a
    child within 24 hours of involuntary admission.
    • Requiring the Tribunal to review a child’s involuntary status within 10 days of
    admission.

    I hope that the above in formation some use. If you require any further information
    on the Bill, I encourage you to visit the Mental Health Commission’s website
    http://www.mentalhealth.wa.gov.au/

    Yours sincerely
    Dawn FitzGerald
    Chief of Staff to the
    MINISTER FOR MENTAL HEALTH
    21 NOV 2013
    3

  • Below is ISEPP’s letter by Dr. Toby Watson (www.psychintegrity.org) to the Health Ministry of Australia, helping inform them of the dangers of ECT. With ISEPP’s help, this ban has taken effect ! Way to go ISEPP ! Don’t just read about mental health issues, join ISEPP today and help teach the world:

    —– Original Message —–
    From: Toby Watson PsyD – Office
    To: [email protected] ; [email protected]
    Sent: Tuesday, November 05, 2013 11:27 AM
    Subject: ECT and Psychosurgery Legislation- Research Says No Safety and Long Term Benefit

    Dear Honorable Ministers Morton and Hames,

    I recently learned from a researcher friend in Australia, Dr. Brian Kean, PhD, that there is a new mental health act being proposed that would allow minors to engage in electro-convulsive shocking (ECT) and psychosurgery without parental consent. I have special expertise and interest in the area of ECT, as I have given testimony to the United State Federal Drug Administration (FDA) on this specific topic, whereby, the FDA has upheld the supported request to keep the stringent classification upon these devices. As Clinical Director of an outpatient mental health center here in the United States, as the Past Chief Supervising Psychologist for the State of Wisconsin-USA, Department of Corrections-KMCI, and as the past Executive Director for the International Society for Ethical Psychology and Psychiatry, have been able to witness first hand the long term after-effects of ECT. I ask that you please read the summary of peer reviewed research on the safety and effectiveness of ECT, because you deserve to have all the information.

    In 1979, the FDA categorized the ECT device as a Class III, high risk device, meaning that it’s benefits have not been shown to outweigh its risks, and that it presents a “potential unreasonable risk of injury or illness.” It ruled that brain damage and memory loss were risks of the procedure. Thirty plus years later and most recently within the past few years, the FDA upheld it’s decision to keep the Class III listing, as no evidence has accumulated to disprove these findings. Rather, there has been a stream of continued evidence in the research demonstrating significant harmful effects.

    There are seventy years of reports of permanent extensive amnesia and memory dysfunction in a large percentage or majority of patients. [i] Reviewing the evidence to date, in 1985 the NIMH Consensus Conference on ECT found that the average loss was eight months of life and that the majority of ECT patients had chronic memory impairment three years after “treatment”. [ii] Then in 2003, the first-ever systematic review of all the evidence to that date found at least 33% of ECT patients experienced permanent memory loss. [iii] An even more recent prospective study found that at least 45% of patients experienced permanent amnesia, and 40% reported loss of intelligence. [iv]

    The research on permanent amnesia can be summarized as follows: researchers have mostly avoided conducting any long term, six months or longer studies, but whenever they have looked for permanent memory deficits, they have found them. There have been only two long term (e.g. six month) studies of amnesia done in the past 33 years, and both, despite serious methodological problems, show that permanent extensive amnesia is common. [v] One found “provocative evidence for autobiographical memory loss lasting at least six months” and the other, the largest study of memory ever done, concluded “adverse effects can persist for an extended period, and (usage) characterizes routine use of ECT in community settings.”

    In seven decades there here have been only two methodologically sound randomized controlled clinical trials investigating whether ECT is more effective than drugs, and neither of these studies compared shock to drugs currently in use today. [vi] Interestingly, it has never been compared to other forms of true treatment, such as psychotherapy.

    In 1992 and again in 2006 researchers systematically reviewed the literature on real vs. sham ECT (pretending they gave someone ECT when in fact they did not), and concluded the studies show no advantage for real ECT. [vii] Even the most recent American Psychiatric Association Task Force report, though it asserts ECT’s efficacy, did not cite a single study showing real ECT having a superior outcome to a sham ECT, when treating depression.

    In 1985, the NIMH found there was no evidence for any benefit of ECT lasting more than four weeks, and there are no studies since 1985 showing any longer benefit other than Huuhka, Viikki, Tammentie’s study published in the Journal of ECT in April 2012. Huuhka et al acknowledged the relapse rate of short term c/mECT for depressed patients is 40-60% even with anti-depressant medication continuing, and for patients with more severe pathology (e.g. schizophrenia, bipolar), patients were even more likely to relapse within 8-12 months.

    Another large recent study indicated approximately one half of patients had no significant improvement to ECT, even in the very short term, and the majority who relapsed within one and six months later were suffering long term adverse effects, while overall only 10% were in remission. [viii] And another more recent study found claims of 70-90% efficacy to be wildly inflated, with the actual rates from 30 to 46%; however, these positive outcomes were measured only in the few days immediately after ECT. [ix]

    Despite claims repeatedly made that ECT is safe and effective for severe depression and helps with suicide, research shows that ECT has no protective effect against suicide either in the short or long term. [x]

    In one of the very few studies ever performed, researchers in 1985 found that ECT patients committed suicide more frequently than those who had not received ECT, even when level of depression was taken into account. [xi]

    Finally, in the January 2007 journal Neuropsychopharamacology researchers highlighted in a large scale study how current ECT techniques used still produce cognitive effects immediately and after six months post ECT. [xii] They state ECT produces “pronounced slowing of reaction time” and significant “persisting retrograde amnesia”. Dr. Harold Sackheim, the chief researcher had been a strong ECT advocate.

    Recall, prior to modern brain imaging technology, dozens of human and animal autopsy studies documented brain damage from ECT. In the modern era, brain scan studies of psychiatric patients show a correlation between treatment with ECT and cerebral atrophy. The very few studies which set out to investigate the question of ECT’s effects on brain structure are both seriously methodologically flawed and inconclusive (i.e. they did not use normal controls, and allowed patients who had previously had shock to be considered as “before shock” or non shock subjects.)

    Therefore, in summary researchers John Read and Richard Bentall in 2010 set out to conduct a large literature review and meta-analysis review of over 100 studies on the efficacy of ECT when compared to sham-placebo ECT. [xiii] They concluded:

    Controlled studies show minimal support for effectiveness of ECT for depression or ‘schizophrenia’; however, ONLY
    a) during treatment,
    b) for some patients,
    c) on some measures,
    d) and only by psychiatrists, not other raters.
    • There was no evidence of any benefits beyond the short treatment period.
    • There are no placebo-controlled studies showing ECT prevents suicide.
    • There is persistent evidence of permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and evidence of significant increased risk of death by ECT.’

    They concluded by stating:

    “Given the strong evidence (summarized here) of persistent and for some, permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and the evidence of a slight but significant increased risk of death, the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified.”

    Given the above, and that at least 55% of patients who had ECT would not recommend it nor want it do to them again [xiv], I think it is relevant to NOT support allowing minors to use ECT. This seems to be a growing consensus around the world, because in February 2013, the United Nations Special Report on Torture, Mr. Juan Mendez recommended an “absolute ban on forced and non-consensual medical interventions against persons with disabilities, including non-consensual administration of psychosurgery, electroshock and mind-alternating drugs such as neuroleptics, [and] the use of restraint and solitary confinement, for both long and short-term application.” http://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_English.pdf
    Children’s parents need to be fully informed of risks and of any decisions their child may make. The decision to use ECT always carries a life-long consequence, and most often the risk are under-reported by practitioners who are paid to use these machines. Children are unable to appreciate the extreme nature of such intervention, and given the developing nature of their brains, ECT should never be used on anyone under the age of 18. Given they will likely be already vulnerable due to their mental suffering and age, it is imperative they make mental health decisions with parental consent, and any biological intervention only after every possible other option has been fully exhausted to it’s fullest extent. Please say NO to the pending legislation because children need protection from my mental health industry.

    Regards,

    Dr. Toby Watson, Psy.D.
    ISEPP Past Executive Director, Current Board Member
    Associated Psychological Health Services-Clinical Director
    2808 Kohler Memorial Drive, Suite 1, Sheboygan, WI 53081
    920-457-9192 920-918-7377

    Dr. Brian Kean, PhD, ISEPP International Executive Director
    Dr. Charles Ruby, PhD, ISEPP Board Chairman

  • I almost forgot…they also state right away:
    “Violence is reported with command hallucinations: 48% experienced harmful or dangerous actions and this increased to 63% in medium secure units and was significantly higher, 83%, in the forensic population.2”

    But, what the study had as a confounding variable was that for inclusion into the study you had to: 1) have 6 months of command hallucinations, BUT 2) a history within that time of being violent! Thus, the reported violence was not a typical group of patients, but those who were already known to be violent…within the past 6 months. Thus, they showed that past violence is a great predictor of future violence, not that Sz patients are prone to violence.

  • Just a quick comment. The paper was great, but the beginning has a few distorted facts and poor research cited. Mentally “ill” people may be slightly more violent than the general public when looking at multiple studies. The paper above cites one study from Sweden, with a higher rate (13% vs 5% of general public).

    Over ninety percent (90%) “of persons with mental illness have no history of violence….through media sensationalism (it sells papers) the cases that do occur stand out in peoples minds.” Serper, M, Bergman, A. (2003) Psychotic Violence: Methods, Motives, Madness, Psychosocial Press of Madison, CT.

    Monahan, J. and Shah, S. Dangerousness and commitment of the mentally disordered in the United States. Schizophrenia Bulletin, 15: 541-553. Reprinted in: Social and Clinical Psychiatry, 1991, 1: 56-70 [in Russian]. Monahan found people Diagnosed Sz and Bipolar were no more violent than general population, unless problems with substance abuse or psychopathology. Also found by:

    Cirincione, C., Steadman, H., Robbins, P. and Monahan, J. Schizophrenia as a contingent risk factor for criminal violence. International Journal of Law and Psychiatry 15: 347-358.

    Elbogen, E.B. & Johnson, S.C. (2009). The intricate link between violence and mental disorder. Archives of General Psychiatry, 66, 152-161. “mental illness suggests a lower probability of violence”

    Fazel S, Gulati G, Linsell L, Geddes JR, Grann M (2009) Schizophrenia and Violence: Systematic Review and Meta-Analysis. PLoS Med 6(8): e1000120. doi:10.1371/journal.pmed.1000120

    The paper above was correct that the GREATER risk of violence is from those who have dual diagnosis, i.e., individuals who have a mental disorder as well as a substance abuse disorder.
    Swanson, 1994; Eronen et al, 1998; Steadman et al., 1998.

    Fazel, et al (2009) did a meta-analysis of the 20 studies between January, 1970 and February, 2009 that assessed the risk of violence of 18,423 individuals diagnosed as Schizophrenia or other psychoses, which they compared with the level of violence in the general population of 1,714,904. Eleven of the studies reported on the affect of comorbid substance abuse. The authors found that there was no significant difference between people with Schizophrenia and those with other psychotic disorders. People with psychoses were slightly more likely to exhibit violence than the general population, and significantly more likely to commit homicides, though the homicide probability was only 0.3% for either psychosis or substance abuse. However, “the increased risk of violence in schizophrenia and the psychoses comorbid with substance abuse was not different than the risk of violence in individuals with diagnoses of substance use disorders. In other words, schizophrenia and other psychoses did not appear to add any additional risk to that conferred by the substance abuse alone [pp. 7-8].” Further, substance abuse markedly increased the risk of violence for people with comorbid psychotic and substance abuse disorders.

    These findings are consistent with those of the MacArthur violence risk assessment research, particularly the finding that people with psychoses but without substance abuse do not have a high level of violence, while those who abuse alcohol or other drugs do have a significantly higher risk of violence. According to Martin Grann, Ph.D., one author of the 2009 study, “people with schizophrenia are not dangerous…. If a person is an alcoholic or a drug addict, he is less likely to be violent if he also has schizophrenia. So, in this context, you could say schizophrenia is actually protective” (quoted in Cassels, C. (2009, August 31). Substance abuse main driver of violence in Schizophrenia, psychoses. Medscape Medical News. Retrieved from http://www.medscape.com September 10, 2009).

    The NIMH MacArthur study found that recently discharged psychiatric patients were not statistically more dangerous than people in the communities they were discharged to, and those same patients were not more dangerous even if they had threat/control delusions. “…[T]he presumed risk of violence associated with delusions per se does not justify hospitalization of a patient….” This multi-year study of over 1,000 patients found a number of violence risk factors and provided an “odds ratio” table for the first year discharge, indicating the increase in probability for a given factor (male=1.51, i.e. 51% more likely to be violent than females when other factors removed).

    The assessment used was the Classification of Violence Risk (COVR), an interactive software program-interview that provides an estimate on future violence. Patients were followed for 20 weeks after discharge and measured violence towards others by official police and hospital records, patients’ self-report, and by collateral contacts (e.g. family). COVR can be found at: P.A.R., 800 331 8378: http://www.parinc.com.

    Hare PCL:SV > 12 4.05
    Chart diagnosis of Antisocial Pty. Dis. 3.11
    Violent fantasies about escalating harm 2.80
    Substance disorder, no major disorder 2.47
    Father ever used illegal drugs 2.40
    Recent violent behavior 2.32
    Frequent violent fantasies 2.23
    Any arrest for a crime against a person 2.11
    Violent fantasies while with target 2.08
    Serious adult arrest 2.04
    Substance abuse at time of admission 2.01
    Violence at time of admission 1.97
    Violent fantasies 1.94
    Violent fantasies focused on 1 person 1.91
    Father ever intoxicated (alcohol) 1.87
    Any arrest besides crime against person 1.80
    Father ever arrested 1.79
    Involuntary hospitalization 1.78
    Any head injury w/loss of consciousness 1.69
    Homelessness 1.66
    Frequency of adult arrests 1.60
    Mother ever used illegal drugs 1.54
    Perceived stress 1.54
    Seriousness of physical child abuse 1.51
    Male gender 1.51
    Major disorder and substance abuse 1.47
    Personality disorder only 1.46
    Nonviolent aggression at admission 1.44
    Command hallucinations 1.43
    Any head injury w/o loss of conscious. 1.43
    Mother ever intoxicated (alcohol) 1.41
    Suicide attempt 1.31
    Unable to care for self 1.29
    Frequency of abuse as a child 1.25
    Diagnosis of “other psychosis” 1.00
    Diagnosis of depression 0.92
    Any delusions 0.74
    Diagnosis of Mania 0.74
    Diagnosis of Schizophrenia 0.38

    Applebaum P, Robbins P, and Monahan , Violence and Delusions: Data from the MacArthur Violence Risk Assessment Study, by J. Am J Psychiatry 2000; 157:566-572.

    Monahan, J., Steadman, H.J., Silver, E., Appelbaum, P.S., Robbins, P.C., Mulvey, E.P., Roth, L.H., Grisso, T., & Banks, S. (2001). Rethinking risk assessment: The MacArthur Study of Mental Disorder and Violence. New York: Oxford University Press. . “mental illness suggests a lower probability of violence.”

    Monahan, J, Steadman, H., Robbins, et al. (2005). An actuarial model of violence risk assessment for persons with mental disorders. Psychiatric Services, 56, 810-815.

    Walsh E, Buchanan A, Fahy T., Br J Psychiatry. 2002, Violence and schizophrenia: examining the evidence. Jun;180:490-5. full text: http://bjp.rcpsych.org/cgi/content/full/180/6/490 Section of Forensic Mental Health, Institute of Psychiatry, Denmark Hill, London. [email protected]
    The proportion of societal violence attributable to schizophrenia is small.
    METHOD: A review of population-based studies on the epidemiology of violence and schizophrenia. Population-attributable risks for violence in schizophrenia were calculated.
    RESULTS: Recent good evidence supports a small but independent association. Comorbid substance abuse considerably increases this risk. The proportion of violent crime by people Diagnosed with schizophrenia falls below 10%. CONCLUSIONS: Strategies aimed at reducing this small risk require further attention, in particular treatment for substance misuse.

    Kindly,
    Toby Watson, PsyD
    [email protected]
    ISEPP Past Exec. Director, http://www.psychintegrity.org

  • Two thoughts…1st, great job Bruce. Below is the research conducted on ECT. I have placed the citations in order below of appearance. I highlighted this work in another blog response, and will start blogging for Mindfreedom soon…

    In 1979, the FDA categorized the ECT device as a Class III, high risk device, meaning that it’s benefits have not been shown to outweigh its risks, and that it presents a “potential unreasonable risk of injury or illness.” It ruled that brain damage and memory loss were risks of the procedure. Thirty plus years later and most recently within the past two years, the FDA upheld it’s decision to keep the Class III listing, as no evidence has accumulated to disprove these findings. Rather, rather there has been a stream of continued evidence in the research demonstrating significant harmful effects.

    There are seventy years of reports of permanent extensive amnesia and memory dysfunction in a large percentage or majority of patients. Reviewing the evidence to date, in 1985 the NIMH Consensus Conference on ECT found that the average loss was eight months of life and that the majority of ECT patients had chronic memory impairment three years after “treatment”. More recently, the first-ever systematic review of all the evidence to that date (2003) found that at least one-third of ECT patients experienced permanent memory loss. An even more recent prospective study found that at least 45% of patients experienced permanent amnesia, and 40% reported loss of intelligence.

    The research on permanent amnesia can be summarized as follows: researchers have mostly avoided conducting any long term, six months or longer, studies, but
    whenever they have looked for permanent memory deficits, they have found them. There have been only two long term (e.g. six month) studies of amnesia done in the past 33 years, and both, despite serious methodological problems, show that permanent extensive amnesia is common. One found “provocative evidence for autobiographical memory loss lasting at least six months” and the other, the largest study of memory ever done, concluded “adverse effects can persist for an extended period, and (usage) characterizes routine use of ECT in community settings.”

    In seven decades there here have been only two methodologically sound randomized controlled clinical trials investigating whether ECT is more effective than drugs, and neither of these studies compared shock to drugs currently in use today. Interestingly, it has never been compared to other forms of treatment.

    In 1992 and again in 2006 researchers systematically reviewed the literature on real vs. sham ECT and concluded the studies show no advantage for real ECT. Even the most recent American Psychiatric Association Task Force report, though it asserts ECT’s efficacy, did not cite a single study showing real ECT having a superior outcome to a sham ECT, when treating depression.

    In 1985, the NIMH found there was no evidence for any benefit of ECT lasting more than four weeks, and there are no studies since 1985 showing any longer benefit other than Huuhka, Viikki, Tammentie’s study just published in the Journal of ECT (Apr., 2012). Huuhka et al acknowledged the relapse rate of short term c/mECT for depressed patients is 40-60% even with anti-depressant medication continuing, and for patients with more severe pathology (e.g. schizophrenia, bipolar), patients were even more likely to relapse within 8-12 months.

    Another large recent study indicated approximately one half of patients had no significant improvement to ECT, even in the very short term, and the majority who relapsed within one and six months later were suffering long term adverse effects, while overall only 10% were in remission. And an even more recent study found claims of 70-90% efficacy to be wildly inflated, with the actual rates from 30 to 46%; however, these positive outcomes were measured only in the few days immediately after ECT.

    Despite claims repeatedly made that ECT is safe and effective for severe depression and helps with suicide, research shows that ECT has no protective effect against suicide either in the short or long term. In one of the very few studies ever performed, researchers in 1985 found that ECT patients committed suicide more frequently than those who had not received ECT, even when level of depression was taken into account.

    Finally, in the January 2007 journal Neuropsychopharamacology researchers highlighted in a large scale study how current ECT techniques used still produce cognitive effects immediately and after six months post ECT. They state ECT produces “pronounced slowing of reaction time” and significant “persisting retrograde amnesia”. Dr. Harold Sackheim, the chief researcher had been a strong ECT advocate.

    Recall, prior to modern brain imaging technology, dozens of human and animal autopsy studies documented brain damage from ECT. In the modern era, brain scan studies of psychiatric patients show a correlation between treatment with ECT and cerebral atrophy. The very few studies which set out to investigate the question of ECT’s effects on brain structure are both seriously methodologically flawed and inconclusive (i.e. they did not use normal controls, and allowed patients who had previously had shock to be considered as “before shock” or non shock subjects.)
    The literature on permanent memory loss from the 1940s through 2009 is summarized in L. Andre, op. cit.
    ‘ “Consensus Conference: Electroconvulsive Therapy,” Journal of the American Medical Association 254 (15), (1985, October 18), 2103-2108.
    D. Rose, P. Fleischmann et al, “Patients’ Perspectives on Electroconvulsive Therapy: Systematic Review,” British Medical Journal 326 (7403), (2003, June 21), 1363-1367.
    M. Philpot, C. Collins et al, “Eliciting Users’ Views of ECT in Two Mental Health Trusts with a User Designed Questionnaire,” Journal of Mental Health 13(4), (2004, August), 403-413.
    R. Weiner et al, “Effects of Stimulus Parameters on Cognitive Side Effects,” Annals of the NY Academy of Sciences 462 (1986), 315-325; H. Sackeim, J. Prudic et al,“The Cognitive Effects of Electroconvulsive Therapy in Community Settings,” Neuropsychopharmacology 32 (2007), 244-254.
    A. Rivkin, “Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness” (book review), New England Journal of Medicine 358(2), (2008, January 10), 204-205.
    G. Shepard, S. Ahmed, “A Critical Review of the Controlled Real vs. Sham ECT Studies in Depressive Illness,” paper presented at the First European Symposium on ECT, Graz, Austria, March 1992. C. Ross, “The Sham ECT Literature: Implications for Consent to ECT,” Ethical Human Psychology and Psychiatry 8(1), (2006), 17-28.
    H. Sackeim, R. Haskett et al, “Continuation Pharmacotherapy in the Prevention of Relapse Following Electroconvulsive Therapy,” Journal of the American Medical Association 285(10), (2001, March 14), 1299-1307.
    J. Prudic, M. Olfson et al, “Effectiveness of Electroconvulsive Therapy in Community Settings,” Biological Psychiatry 55 (2004), 301-312.
    V. Milstein, J. G. Small et al, “Does Electroconvulsive Therapy Prevent Suicide?” Convulsive Therapy 2(1), 1986, 3-6.
    T. Munk-Olsen, P. Videbech et al, “All-Cause Mortality Among Recipients of Electroconvulsive Therapy,” British Journal of Psychiatry 190 (2007), 435-439.
    H. Huuhka, M. Viikki, T. Tammentie et al, “One-Year Follow Up After Discontinuing Maintenance Electroconvulsive Therapy,” Journal of ECT (April 24, 2012).

    Harold A. Sackeim, et al., “The Cognitive Effects of Electroconvulsive Therapy in Community Settings, Neuropsychopharamacology (2007) 32: 244-254.

  • Great work. I have testified in numerous cases as an expert witness, and I am happy to say that in about 70% of these, the commitments are stopped or reversed. The little research that is there is quite clear about the lack of evidence. I will begin to blog about how psychologists and other professionals should begin to market themselves as professionals who will help inform the courts about what is needed. So often Judges are begging and thanking me for the testimony, as they have wanted someone like me to highlight there must be another way.
    Enjoy the read…
    Toby

    There are few studies that have attempted to determine the effectiveness of Outpatient Commitment Orders (OPC) by comparison to the tens of thousands of OPC ordered. In one of the first thorough reviews of empirical studies of OPC, Dr. Kathleen Maloy concluded in 1992, there was “almost no valid empirical evidence in support of the effectiveness of involuntary outpatient commitment vis-à-vis treatment compliance, success in the community for people with severe and persistent mental illness.”
    Maloy, Analysis: Critiquing the Empirical Evidence ; Does Involuntary Outpatient Commitment Work? Mental health Policy Resource Center (1992).

    This acknowledgement by Maloy in 1992 led Duke University researchers in North Carolina in 1999 and 2001 to examine if OPC reduced hospitalizations. They, and Swartz and his colleagues, concluded “outpatient commitment had no clear benefit unless it was sustained for at least six months and accompanied by high-intensity community services and supports”, and there were no significant differences in hospitalizations between the non OPC controls and those under commitment at the one year mark.
    Swartz MS, Swanson JW, Hiday VA, et al: A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services 52: 325-329, 2001.
    Swartz MS, Swanson JW, Wagner HR, et al: Can involuntary outpatient commitment reduce hospital recidivism? Finds form a randomized trial with severely mentally ill individuals. Am J. of Psychiatry 156: 1968-1975, 1999.

    In turn, the Bellevue Outpatient Commitment Study was conducted in 2001, which was the only controlled study that explicitly provided and offered enhanced community services to both groups. They reviewed if commitments were necessary for individuals to continue with treatment if they were offered it without the OPC. They concluded “individuals provided with voluntary enhanced community services did just as well as those under commitment orders who had access to the same services.” Researchers found no additional improvement in patient compliance with treatment, no additional increase in continuation of treatment, and no differences in hospitalization rates, lengths of hospital stay, arrest rates, or rates of violent acts.
    Steadman HJ, Gounis K, Dennis D, et al: Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services 52:330-336, 2001

    This lead Drs. Kirsley and Campbell, who were highlighted by the Cochrane Database of Systematic Reviews, the gold-standard of peer reviewed psychiatric research, to look at the number of outpatient commitment orders (OPC) it would take then to prevent one re-hospitalization. They concluded “it takes 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent a future arrest.” Thus, 84 people would need to be subjected to a non-required forced treatment program in order to reduce just one re-hospitalization.
    Kisely S, Campbell LA, Preston N. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. The Cochrane Database of Systematic Reviews 2005, Issue 3.

    This was confirmed by researchers not only here in the United States, but across the world as well. In 2007, at the Institute of Psychiatry in Maudsley, UK, they conducted “the most comprehensive and through review of outpatient commitments” and concluded, “it is not possible to state whether or community treatment orders (CTOs) [the equivalent to OPC] are beneficial or harmful to patients.”
    Churchill, R., International experiences of using community treatment orders, by the Institute of Psychiatry at the Maudsley (UK), Section of Evidence based Mental Health-Serv. Research Dept., March 2007.

    Then more recently in April, 2012, researchers in Israel tracked 163 (51%) schizophrenia patients compulsory admitted to the hospital and 157 (49%) patients that left the hospital against medical orders. There was no difference in baseline clinical symptoms, demographics or outcome measures, and the non hospitalized group did not lead to any significant difference in rehospitalization, incarceration or length of stay for those that were rehospitalized.
    Krivoy, A. Fischel, T, Zahalka, H et al Outcomes of compulsorily admitted schizophreni patients who agreed or disagreed to prolong their hospitalization. , Comprehensive Psychiatry, Apr., 2012 (in press).

    In Contrast, the State of New York began investing their own OPC, under Kendra’s Law and the Assisted Outpatient Treatment (AOT) program; however, their results were mixed, whereby the New York State Office of Mental Health in 2005 and later 2009 stated the AOT drastically reduced hospitalization, homelessness, arrest, incarcerations and adherence to medication compliance ; whereas, non contracted independent researchers in 2004 had just indicated that their sample of the AOT group and control group “did not differ significantly (with) rates of hospitalizations, homelessness, dangerousness and arrest/incarcerations.” One additional major conclusion was that the AOT forced treatment group was significantly “less satisfied” with treatment than those not under commitment.
    Duke University School of Medicine et. al. (June 2009). New York State Assisted Outpatient Treatment Program Evaluation.
    Perese, E.F. , Wu, Y.-W. B., & Ranganathan R. (2004). Effectiveness of Assertive Community Treatment for Patients Referred under Kendra’s Law: Proximal and Distal Outcomes International Journal of Psychosocial Rehabilitation. 9 (1), 5-9.

  • Your right Stephan, Lilly’s claim back in 2004 was that although 5 of the 9,000 people who took Cymbalta back then killed themselves, but the company saw no connection. “We have not been able to discern any signal between duloxetine and suicide,” an Eli Lilly spokesman told the NY Times back in Feb. of 2004.

    The suicide rate for all Americans at that time was 10.8 per 100,000, according to the Surgeon General Report. This means 5 suicides would be expected in a group of 46,000 people, not in a group of 9,000. In a group of 9,000, one person would be expected to commit suicide, which suggested Lilly’s own trials showed that Cymbalta was likely causing subjects to kill themselves at FIVE times the expected rate.

    The rates are suicides per 100,000 are per year though, and presumably Cymbalta trials took much less than a year. Thus, you likely would have seen an even higher rate if the clinical trials had run for patients over a full year, as up/down regulation of the neurotransmitter system causes the super-sensitivity to feeling depressed and manic/psychotic.

    According to the Surgeon General Report back then, the suicide rate for those 15 to 19 years of age was 9.7 per 100,000. That meant a group of about 50,000 of that age normally would be required to find 5 suicides. The presence of young people in the Lilly trials should be offsetting the presence of those with depression symptoms, again resulting in Cymbalta trials participants killing themselves at about 5 times the expected rate.

  • In case anyone wonders what research or evidence is out there on outpatient commitments…here are the studies. if there is any more…send them over to me at [email protected].
    Kindly,
    Dr. Watson

    There are few studies that have attempted to determine the effectiveness of Outpatient Commitment Orders (OPC). In one of the first thorough reviews of empirical studies of OPC, Dr. Kathleen Maloy concluded in 1992, there was “almost no valid empirical evidence in support of the effectiveness of involuntary outpatient commitment vis-à-vis treatment compliance, success in the community for people with severe and persistent mental illness”.[1]

    This acknowledgement by Maloy in 1992 led Duke University researchers in North Carolina in 1999 and 2001 to examine if OPC reduced hospitalizations. They, Swartz and his colleagues, concluded “outpatient commitment had no clear benefit unless it was sustained for at least six months and accompanied by high-intensity community services and supports”, despite no significant differences in hospitalizations between the non OPC controls and those under commitment at the one year mark.[2] [3]

    In turn, the Bellevue Outpatient Commitment Study was conducted in 2001, which was the only controlled study that explicitly provided and offered enhanced community services to both OPC and non OPC groups. They reviewed if commitments were necessary for individuals to continue with treatment if they were offered it without the OPC. They concluded “individuals provided with voluntary enhanced community services did just as well as those under commitment orders who had access to the same services”. Researchers found no additional improvement in patient compliance with treatment, no additional increase in continuation of treatment, and no differences in hospitalization rates, lengths of hospital stay, arrest rates, or rates of violent acts.[4]

    This lead Drs. Kirsley and Campbell, who were highlighted by the Cochrane Database of Systematic Reviews, the gold-standard of peer reviewed psychiatric research, to look at the number of outpatient commitment orders (OPC) it would take then to prevent one re-hospitalization. They concluded “it takes 85 OPC orders to prevent one readmission, 27 to prevent one episode of homelessness and 238 to prevent a future arrest”.[5] Thus, 84 people would need to be subjected to a non-required forced treatment program in order to reduce just one re-hospitalization.

    This was confirmed by researchers then in 2007 at the Institute of Psychiatry in Maudsley, UK, whereby they conducted “the most comprehensive and through review of outpatient commitments” at that time. They concluded, “it is not possible to state whether or community treatment orders (CTOs) [the equivalent to OPC] are beneficial or harmful to patients”.[6]

    In Contrast, the State of New York began investing their own OPC, under Kendra’s Law and the Assisted Outpatient Treatment (AOT) program; however, their results now appear mixed, whereby the New York State Office of Mental Health in 2005 and later 2009 stated the AOT drastically reduced hospitalization, homelessness, arrest, incarcerations and adherence to medication compliance[7] [8]; however, non contracted independent researchers in 2004 had indicated that their sample of the AOT group and control group “did not differ significantly (with) rates of hospitalizations, homelessness, dangerousness and arrest/incarcerations”. One additional major conclusion was that the AOT forced treatment group was significantly “less satisfied” with treatment than those not under commitment. [9]

    ——————————————————————————–

    [1] Maloy, Analysis: Critiquing the Empirical Evidence ; Does Involuntary Outpatient Commitment Work? Mental health Policy Resource Center (1992).

    [2] Swartz MS, Swanson JW, Hiday VA, et al: A randomized controlled trial of outpatient commitment in North Carolina. Psychiatric Services 52: 325-329, 2001.

    [3] Swartz MS, Swanson JW, Wagner HR, et al: Can involuntary outpatient commitment reduce hospital recidivism? Finds form a randomized trial with severely mentally ill individuals. Am J. of Psychiatry 156: 1968-1975, 1999.

    [4] Steadman HJ, Gounis K, Dennis D, et al: Assessing the New York City involuntary outpatient commitment pilot program. Psychiatric Services 52:330-336, 2001

    [5] Kisely S, Campbell LA, Preston N. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. The Cochrane Database of Systematic Reviews 2005, Issue 3.

    [6] Churchill, R., International experiences of using community treatment orders, by the Institute of Psychiatry at the Maudsley (UK), Section of Evidence based Mental Health-Serv. Research Dept., March 2007. http://www.iop.kcl.ac.uk/news/downloads/final2ctoreport8march07.pdf

    [7] N.Y. State Office of Mental Health (March 2005). Kendra’s Law: Final Report on the Status of Assisted Outpatient Treatment.

    [8] Duke University School of Medicine et. al. (June 2009). New York State Assisted Outpatient Treatment Program Evaluation.

    [9] Perese, E.F. , Wu, Y.-W. B., & Ranganathan R. (2004). Effectiveness of Assertive Community Treatment for Patients Referred under Kendra’s Law: Proximal and Distal Outcomes International Journal of Psychosocial Rehabilitation. 9 (1), 5-9.

  • I have no doubt this comes in response to:
    growing evidence that the atypicals may be exacerbating the problem of early death. Although the atypicals may not clamp down on dopamine transmission quite as powerfully as the old standard neuroleptics, they also block a number of other neurotransmitter systems, most notably serotonin and glutamate. As a result, they may cause a broader range of physical ailments, with diabetes and metabolic dysfunction particularly common for patients treated with Zyprexa. In a 2003 study of Irish patients, 25 of 72 patients (35%) died over a period of 7.5 years, leading the researchers to conclude that the risk of death for psychotic patients had “doubled” since the introduction of the atypical antipsychotics. Morgan, M, et al. “Prospective analysis of premature morbidity in schizophrenia in relation to health service engagement.” Psychiatry Research 117 (2003):127-35.

    In addition, how could patients not die sooner from the host of other side effects of standard neuroleptics, such as increased incidence of blindness, fatal blood clots, arrhythmia, heat stroke, swollen breasts, leaking breasts, obesity, sexual dysfunction, skin rashes and seizures, and early death.
    Arana, G. “An overview of side effects caused by typical antipsychotics.” Journal of Clinical Psychiatry 61, supplement 8 (2000):5-13.
    Waddington, J. “Mortality in schizophrenia.” British Journal of Psychiatry 173 (1998):325-329.
    Joukamaa, M, et al. Schizophrenia, neuroleptic medication and mortality. British Journal of Psychiatry 188 (2006):122-127.

    Schizophrenia patients now commit suicide at 20 times the rate they did prior to the use of neuroleptics, and when researcher’s compared typical hospital treatment with anti-psychotic medications against non-psychiatric psychological interventions over an 11 month period, pure psychological interventions were less likely to produce suicides (3 suicides compared to none in the pure psycho-social treatment group).
    Healy, D et al. “Lifetime suicide rates in treated schizophrenia.” British Journal of Psychiatry 188 (2006):223-228.
    Diekman, A., Whitaker, L. “Humanizing the Psychotherapy Ward: Changing from Drugs to Psychotherapy.” Psychotherapy: Theory, Research, and Practice. 16 (2): 204-214.

    Lastly, during a 17 year follow up study that involved 99 people diagnosed with psychosis, 39 of the patients died; however, when researchers accounted for age, gender, somatic diseases, bloodpressure, cholesterol, body mass index, smoking, exercise, alcohol, education and other premature death factors, the relative risk was 2.50 times greater (95% confidence level) if the patient took just one neuroleptic at baseline.
    Joukamaa, M., Heliovaara, M., et al. “Schizophrenia, neuroleptic medication and mortalityl” British Journal of Psychiatry (2006) Feb: 188: 122-127.

  • Emma, not sure which “significance” you are referring to…that all were on Rxs, that anxiety may be a confounding variable, or that they have a test that might correlate 100% of the time with a Dx of Sz. The Rxs confounding variable indicates that maybe the test of eye mvt really is able to differentiate those ‘normals’ from those who take neuroleptic drugs…not those Dx Sz. The anx. confounding variable likewise might indicate that really what the ocular test is picking up on is not a difference of normals and Sz patients, but normals and those with high anxiety…which happen to inculde those Dx Sz. Lastly, the test does seem to be picking up on something…what not sure exactly what yet, as they would need to have a bit more control, higher N’s and more replication. Interesting work though. I may be missing something that Kermit could comment on…as i did not read the study fully.