ECT procedure making $$$

Doc driven

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    Thanks for your time. I do not know if I even believe in this type of procedure. However, I have heard that psychiatrists doing it make tons of money, and I just wanted to hear opinions for my own knowledge. I am just curious. Thanks
     

    TheWowEffect

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      Thanks for your time. I do not know if I even believe in this type of procedure. However, I have heard that psychiatrists doing it make tons of money, and I just wanted to hear opinions for my own knowledge. I am just curious. Thanks

      Let's first explore what makes you a non-believer in ECT?:D
       

      Doc driven

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        I am not saying I am a non believer. I said this because I know absolutely nothing about it. I will be starting DO school in August, and I am interested in psychiatry. I was just asking a doctor the other day about their salaries. He said the psychiatrists doing the procedures are the ones making money. I am just asking to learn more.
         
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        Doc driven

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          Just out of curiosity, how much a year do the psychiatrists who do this usually make? Do they only do this type of procedure or can they mix their practice up and do a variety of things- like some therapy, prescription of meds and ECTS? What's the maximum you have heard in earnings? I appreciate your knowledge; it's interesting.
           

          OldPsychDoc

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            It's not that much more lucrative than seeing a few more med visits in a day. Most psychiatrists who do this are doing it as staff of a hospital. I've only heard of a very few places where they can keep it going all day, or even all morning. In our hospital we might have 3-4 inpatients getting the treatments M-W-F, and 6-8 outpatients on T-Th in a typical week. So yes, it is a procedure, and you do get to bill for your physician services, but the RVUs are essentially equivalent to a high-complexity office visit.
             

            erg923

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              I think its interesting to note that every neuroscientist I've ever met is pretty strongly opposed to ECT, however, most psychiatrists and psychologists support its use in appropriate cases. I have seen it pushed in cases where the person is already mildly demented....which is like playing with fire in my opinion.
               

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                I think its interesting to note that every neuroscientist I've ever met is pretty strongly opposed to ECT, however, most psychiatrists and psychologists support its use in appropriate cases.

                Not to state the obvious, but it's probably b/c neuroscientist don't work in a clinical setting with patients.
                 

                erg923

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                  Not to state the obvious, but it's probably b/c neuroscientist don't work in a clinical setting with patients.

                  Haha...well I think thats a little too obvious though. Most were neuroscientists who worked in clinical settings as researchers and were very much aware of the effects, procedure, and research on ECT treatments. I would think of anyone who is qualified to research and understand the neurological and neurobiological effects of ECT treatment....it would be neuroscientists.
                   

                  OldPsychDoc

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                    Haha...well I think thats a little too obvious though. Most were neuroscientists who worked in clinical settings as researchers and were very much aware of the effects, procedure, and research on ECT treatments. I would think of anyone who is qualified to research and understand the neurological and neurobiological effects of ECT treatment....it would be neuroscientists.

                    I have to disagree--having worked in both settings.
                    Until you have seen a hand-wringing, pacing, delusionally depressed melacholic restored to a sane, articulate, delightful person after 2-3 ECT-induced seizures (and actually seen how boring the procedure is when done right), you cannot be said to understand ECT.
                    Bottom line: it works, it works fast, and it works dramatically in many patients who have tried and failed many meds. So much so that it is a bigger risk to continue the infinite reiteration of empirical medication trials in these patients.
                     

                    Chimed

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                      Haha...well I think thats a little too obvious though. Most were neuroscientists who worked in clinical settings as researchers and were very much aware of the effects, procedure, and research on ECT treatments. I would think of anyone who is qualified to research and understand the neurological and neurobiological effects of ECT treatment....it would be neuroscientists.

                      Yes, of course. I'm not sure why you haven't meant a neuroscienist that doesn't support using ECT in appropriate cases. I was only pointing out that sometimes people in academics are out of touch with clinical practice. This is probably even more true in treatment resistant patients where there is often less evidence to guide treatment.

                      "If you want evidence-based practice, you need practice-based evidence"
                      -Larry Green
                       

                      erg923

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                        I have to disagree--having worked in both settings.
                        Until you have seen a hand-wringing, pacing, delusionally depressed melacholic restored to a sane, articulate, delightful person after 2-3 ECT-induced seizures (and actually seen how boring the procedure is when done right), you cannot be said to understand ECT.
                        Bottom line: it works, it works fast, and it works dramatically in many patients who have tried and failed many meds. So much so that it is a bigger risk to continue the infinite reiteration of empirical medication trials in these patients.

                        Well yes, I agree. But again, I think that's pretty obvious. I was referring more to them understanding the "HOW" and "WHY" question. And what it is really doing to the brain. Noone looking at the literature can argue that it doesn't work in terms of reducing symptoms. That is very clear. What is less clear is "WHY" it works, and what exactly its doing to functional neuroanatomical systems and subsystems. The literature is much less clear on this.
                         
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                        Faebinder

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                          I have to disagree--having worked in both settings.
                          Until you have seen a hand-wringing, pacing, delusionally depressed melacholic restored to a sane, articulate, delightful person after 2-3 ECT-induced seizures (and actually seen how boring the procedure is when done right), you cannot be said to understand ECT.
                          Bottom line: it works, it works fast, and it works dramatically in many patients who have tried and failed many meds. So much so that it is a bigger risk to continue the infinite reiteration of empirical medication trials in these patients.

                          Exactly, it's nothing short of amazing. :thumbup:
                           

                          strangeglove

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                            Well yes, I agree. But again, I think that's pretty obvious. I was referring more to them understanding the "HOW" and "WHY" question. And what it is really doing to the brain. Noone looking at the literature can argue that it doesn't work in terms of reducing symptoms. That is very clear. What is less clear is "WHY" it works, and what exactly its doing to functional neuroanatomical systems and subsystems. The literature is much less clear on this.

                            Is the literature that much clearer on the mechanism of action of antidepressants?
                             

                            MDVertigo

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                              Quick read - Shocked by Kitty Dukakis wife of former Massachusetts Governor and pres. candidate Michael Dukakis. It's her personal experience with alternating chapters of history and light data. a good start.
                               

                              Hurricane

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                                Quick read - Shocked by Kitty Dukakis wife of former Massachusetts Governor and pres. candidate Michael Dukakis. It's her personal experience with alternating chapters of history and light data. a good start.

                                There's a documentary that's based on the book too. They filmed some of it here. :)
                                 

                                toby jones

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                                  Do we know about the longer term side effects?

                                  One theory is that it disrupts memory for the events leading up to the episode. Memory loss is a fairly common side effect and it could well be that the memory loss is responsible for the benefits.

                                  What kinds of longer term effects does it have on memory? I know that patients often report memory disruption that they put down to the ECT but that is often written off...

                                  We know that bi-lateral has been known to disrupt language processing, for example. And we don't test to check whether people are processing language on the left or right hemisphere before doing uni-lateral ECT - do we? We just assume that they are left hemisphere processors...
                                   

                                  Faebinder

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                                    Do we know about the longer term side effects?

                                    One theory is that it disrupts memory for the events leading up to the episode. Memory loss is a fairly common side effect and it could well be that the memory loss is responsible for the benefits.

                                    What kinds of longer term effects does it have on memory? I know that patients often report memory disruption that they put down to the ECT but that is often written off...

                                    We know that bi-lateral has been known to disrupt language processing, for example. And we don't test to check whether people are processing language on the left or right hemisphere before doing uni-lateral ECT - do we? We just assume that they are left hemisphere processors...

                                    You have to weigh the risk of memory loss (which is not that severe) compared to living almost like a human vegetable. Forget a month of your life and move on like a normal person or stay a non-functioning, melancholic person living in a delusional world?
                                     

                                    toby jones

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                                      > You have to weigh the risk of memory loss (which is not that severe) compared to living almost like a human vegetable. Forget a month of your life and move on like a normal person or stay a non-functioning, melancholic person living in a delusional world?

                                      Well when you put the issue like that the choice is obvious :)

                                      The issues are: Is the memory loss really not that severe? Are we fairly sure that people don't suffer from more pervasive memory loss? I'm talking about a more perminent disruption to abilities such as categorisation and language processing.

                                      How bad are the majority of people before ECT is considered as a viable option? How long are they depressed for (depression tends to pass even if untreated)? For the clinicians making a lot of $$$ doing ECT procedures would their threshold on severity be lower by any chance? If they are NEVER going to get better then of course the choice is obvious. But who gets to make that decision?

                                      How many people who have a course of ECT have a course of ECT at some later point in time? It might be that ECT is a quick fix solution that doesn't do much to prevent later episodes (whereas if the person had therapy or similar they would come to understand what kinds of things triggered their episodes and how to better manage their triggers in order to prevent relapse).

                                      I do think it is important not to disintegrate into polarities of it 'always' or 'never' being justified. I just worry that it isn't justified as much as it is performed. Especially when clinicians stand to earn big bucks in doing the procedure.
                                       

                                      Faebinder

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                                        > You have to weigh the risk of memory loss (which is not that severe) compared to living almost like a human vegetable. Forget a month of your life and move on like a normal person or stay a non-functioning, melancholic person living in a delusional world?

                                        Well when you put the issue like that the choice is obvious :)

                                        The issues are: Is the memory loss really not that severe? Are we fairly sure that people don't suffer from more pervasive memory loss? I'm talking about a more perminent disruption to abilities such as categorisation and language processing.

                                        How bad are the majority of people before ECT is considered as a viable option? How long are they depressed for (depression tends to pass even if untreated)? For the clinicians making a lot of $$$ doing ECT procedures would their threshold on severity be lower by any chance? If they are NEVER going to get better then of course the choice is obvious. But who gets to make that decision?

                                        How many people who have a course of ECT have a course of ECT at some later point in time? It might be that ECT is a quick fix solution that doesn't do much to prevent later episodes (whereas if the person had therapy or similar they would come to understand what kinds of things triggered their episodes and how to better manage their triggers in order to prevent relapse).

                                        I do think it is important not to disintegrate into polarities of it 'always' or 'never' being justified. I just worry that it isn't justified as much as it is performed. Especially when clinicians stand to earn big bucks in doing the procedure.

                                        You make it sound like it's a million dollar procedure and physicians are dying to do it. In medicine, the need to do a procedure is not always 100%. You trust a physician to weigh the need and benefit over the adverse effects and the risks. Are you asking for a guarantee that the physician is 100% trustworthy? Isn't that like asking for a guarantee that it wont rain tomorrow despite the weather report saying 80% unlikely?

                                        Pick your physicians wisely but once you do... listen.
                                         

                                        Anasazi23

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                                          > You have to weigh the risk of memory loss (which is not that severe) compared to living almost like a human vegetable. Forget a month of your life and move on like a normal person or stay a non-functioning, melancholic person living in a delusional world?

                                          Well when you put the issue like that the choice is obvious :)

                                          The issues are: Is the memory loss really not that severe? Are we fairly sure that people don't suffer from more pervasive memory loss? I'm talking about a more perminent disruption to abilities such as categorisation and language processing.

                                          How bad are the majority of people before ECT is considered as a viable option? How long are they depressed for (depression tends to pass even if untreated)? For the clinicians making a lot of $$$ doing ECT procedures would their threshold on severity be lower by any chance? If they are NEVER going to get better then of course the choice is obvious. But who gets to make that decision?

                                          How many people who have a course of ECT have a course of ECT at some later point in time? It might be that ECT is a quick fix solution that doesn't do much to prevent later episodes (whereas if the person had therapy or similar they would come to understand what kinds of things triggered their episodes and how to better manage their triggers in order to prevent relapse).

                                          I do think it is important not to disintegrate into polarities of it 'always' or 'never' being justified. I just worry that it isn't justified as much as it is performed. Especially when clinicians stand to earn big bucks in doing the procedure.


                                          A. Psychiatrists don't make "big bucks" doing ECT. In the majority of cases, it's a small bonus a physician may get as a salaried position while working in an inpatient setting. Some are paid per procedure, but the majority of cases are Medicare/Medicaid, which hardly justifies the procedure alone. I've never known a psychiatrist to do this procedure for money. I would argue the opposite, in fact.

                                          B. ECT is underused. It's not justified enough only because it's not used as often as it should be. Link to an article. It's old but still relevant and holds true.
                                           

                                          atsai3

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                                            Thanks for your time. I do not know if I even believe in this type of procedure. However, I have heard that psychiatrists doing it make tons of money, and I just wanted to hear opinions for my own knowledge. I am just curious. Thanks

                                            ECT is more or less a break even proposition for a medical center. And psychiatrists can make more by doing 20-minute med checks. With the caveat that this is a limited and selective sample size, most of the ECT attendings around here say that one of the reasons they find ECT so satisfying is because they are taking care of the most ill, most med-refractory patients that the rest of the world has washed its hands of.

                                            -AT.
                                             
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                                            toby jones

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                                              > You trust a physician to weigh the need and benefit over the adverse effects and the risks.

                                              That is one view of medicine (paternalism over autonomy).

                                              Another view of medicine is that you trust the physician to present the data on the potential adverse effects and the risks and the benefits in a comprehensible fashion such that the patient is able to weigh them for themselves - to provide informed consent as to what should be done in other words.

                                              (Autonomy over paternalism).
                                               

                                              Faebinder

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                                                > You trust a physician to weigh the need and benefit over the adverse effects and the risks.

                                                That is one view of medicine (paternalism over autonomy).

                                                Another view of medicine is that you trust the physician to present the data on the potential adverse effects and the risks and the benefits in a comprehensible fashion such that the patient is able to weigh them for themselves - to provide informed consent as to what should be done in other words.

                                                (Autonomy over paternalism).

                                                Sure, if the patient is able to make their own decisions. IF they are this hunk of none moving none responding flesh that doesnt respond to medical therapy. Autonomy goes down. You get a relative to come intervene and make the decision, and sometimes that's impossible but when it happens they usually decide that living as a hunk of flesh for a month on the ward is torture and the ECT is a quick fix that works when meds dont.

                                                It doesn't sound like you have seen any of those extremely depressed patients on the wards.

                                                Someday we might even be able to do partial ECTs focusing on parts of the brain. Hence the deep brain stimulation.
                                                 

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                                                  > You trust a physician to weigh the need and benefit over the adverse effects and the risks.

                                                  That is one view of medicine (paternalism over autonomy).

                                                  Another view of medicine is that you trust the physician to present the data on the potential adverse effects and the risks and the benefits in a comprehensible fashion such that the patient is able to weigh them for themselves - to provide informed consent as to what should be done in other words.

                                                  (Autonomy over paternalism).
                                                  As much I enjoy reading your philosophically inclined posts, toby_jones, I have to disagree with you on this one.

                                                  Faebinder made the important point in his reply: many patients undergoing ECT are not capable of informed decision-making. The only thing to add is that most patients (those that are actually able to provide informed consent) that are offered ECT, take it any day over the miserable existence in the depressive fog.
                                                   

                                                  toby jones

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                                                    If the patient is unable to provide informed consent then there is the issue of whether a family member or an ethics board (for example) or a doctor gets to make the decision.

                                                    The poster suggested that the doctor should weigh the pros and cons and convey the decision they had reached.

                                                    I just meant to convey that that is ONE view of a doctors place in medicine. ANOTHER view of a doctors place in medicine is that it is their role to convey the relevant information to the relevant decision makers such that they could come to an informed decision.

                                                    Who gets to decide whether or not a patient is or is not able to provide informed consent? I didn't think that was a doctors place either, though I do understand that a doctor gets to provide expert testimony as to mental state.

                                                    What are the laws on providing ECT without the patients consent in the USA? I know that this is illegal in New Zealand - though I think the family can stand in as proxy or a judge can stand in as proxy. In New Zealand I'm pretty sure that doctors don't get to make the informed consent decision. The doctors role is to convey the information to some other body.

                                                    Perhaps things are different in the USA...
                                                     

                                                    michaelrack

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                                                      Who gets to decide whether or not a patient is or is not able to provide informed consent? I didn't think that was a doctors place either, though I do understand that a doctor gets to provide expert testimony as to mental state.
                                                      ...

                                                      The doctor makes the decision, or at least determines if it's an issue. Any time a doctor treats a pt (whether it is with a medication, surgery, or a procedure like ECT) he makes an implicit determination of capacity. Obviously, the doc is going to put a lot more thought into it for an 80 year old being evaluted for a CABG than a 20 year old who is in the office for an ear infection (in which case the doc probably won't even consciously think about the issue). The more risky the procedure, the higher the standard for capacity is.
                                                      If capacity to make medical decisons is in question, then the attending will either do a formal evaluation or refer to another physician for an evaluation of capacity. Usually a judge is not involved, especially in inpatient settings- can you imaging a judge going into a hospital to evaluate whether a gorked out 85 year old who is tearing out his IV lines is competent to consent to urgent surgery?? In most cases like this, if the doc finds a patient to lack capacity, a social worker will find a family member to make medical decisions.
                                                      As far as ECT, the attending psychiatrist usually will evaluate for capacity. If he finds the patient to lack capacity, then it often is necessary to get the legal system formally involved, but this varies from state to state.
                                                       

                                                      toby jones

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                                                        Thanks. Turns out I was wrong about the situation in NZ...

                                                        I did find this:

                                                        > ... evidence has shown that ECT can result in persistent or permanent memory loss (Lisanby et a. 2000; McElhiney et. Al. 1995; Sackeim et al. 2000). For some people this may include loss of people and place names. It may include a disruption of your memory around loved ones or meaningful events in your life.

                                                        http://www.namiscc.org/Recovery/2004/ECT.htm

                                                        Even the manufacturer brochures allowed for this...
                                                         

                                                        worriedwell

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                                                          Thanks. Turns out I was wrong about the situation in NZ...

                                                          I did find this:

                                                          > ... evidence has shown that ECT can result in persistent or permanent memory loss (Lisanby et a. 2000; McElhiney et. Al. 1995; Sackeim et al. 2000). For some people this may include loss of people and place names. It may include a disruption of your memory around loved ones or meaningful events in your life.

                                                          http://www.namiscc.org/Recovery/2004/ECT.htm

                                                          Even the manufacturer brochures allowed for this...

                                                          If you've ever seen a catatonic patient, on the brink of death get ECT and then have a miraculous recovery, you would realize that ECT is an incredibly important life saving procedure. Every procedure in medicine has risks, that doesn't mean that we have to be terrified of the potential side effects. ECT definitely carries some risk of permanent memory impairment, deal with it. We deal with it for every other medical procedure. You clearly care a lot about the rights of patients but it is just extremely impractical and not reality based to claim that therapy is equivalent to ECT when you actually see it clinically. Doctors care about helping their patients and they have an obligation to consider all options, especially ones that are extremely effective, have a generally low side effect profile, and are rapidly acting. And people believe it is underutilized compared to medication because of all the side effects of the medication. The only reason it is so feared is because of the prior sloppy way that ECT (again not different from other fields of medicine as they evolved) was practiced and the bias against psychiatry, otherwise it would be in use further and its a damn shame too. I hope they find ways to perfect TMS as this will be a great step forward in treating mental illness.
                                                           

                                                          Faebinder

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                                                            Thanks. Turns out I was wrong about the situation in NZ...

                                                            I did find this:

                                                            > ... evidence has shown that ECT can result in persistent or permanent memory loss (Lisanby et a. 2000; McElhiney et. Al. 1995; Sackeim et al. 2000). For some people this may include loss of people and place names. It may include a disruption of your memory around loved ones or meaningful events in your life.

                                                            http://www.namiscc.org/Recovery/2004/ECT.htm

                                                            Even the manufacturer brochures allowed for this...

                                                            Didn't we all state this above? that you may lose some past memories? :thumbdown:

                                                            Tell you what... If ever a relative of yours is in the wards, feel free to say no to ECT and leave them in the wards till you find a solution. Please make sure you arrange for someone to come feed them and change them daily that way the system doesnt pay for your choice as well. I feel like I am arguing with someone who has never seen extremes of depression resistant to medical therapy.
                                                             
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                                                            Anasazi23

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                                                              Thanks. Turns out I was wrong about the situation in NZ...

                                                              I did find this:

                                                              > ... evidence has shown that ECT can result in persistent or permanent memory loss (Lisanby et a. 2000; McElhiney et. Al. 1995; Sackeim et al. 2000). For some people this may include loss of people and place names. It may include a disruption of your memory around loved ones or meaningful events in your life.

                                                              http://www.namiscc.org/Recovery/2004/ECT.htm

                                                              Even the manufacturer brochures allowed for this...

                                                              There's a high rate of mortality in performing a CABG. However, the risk of dying without it is higher. Catatonic or unresolving depression also carries a mortality risk that is much higher than that of ECT, which remains a very safe procedure. If you're going to criticise psychiatry for performing this procedure, then you need to do the same for the incapacitated stroke patient that receives TpA in the ED.
                                                               

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                                                                I thought about posting this anonymously, but maybe it carries more weight coming from someone sorta known? Anyway, speaking from personal experience of almost a decade ago...

                                                                The memory loss from ECT can be terrifying. It's not just retrograde but, for the time that you're still getting ECT, anterograde as well. If you've seen Memento, it's a little like that. Subjectively, it's worse than suicidal depression, and worse than the rest of the experience of being in a locked unit. Even worse? When it doesn't do a damned thing for the depression. Every time, you go under hoping that this time you won't wake up, and then you wake up sobbing that you're still alive. Eventually you figure out that you need to lie and say you're feeling better or they will never let you out and never stop doing ECT on you.

                                                                At least in my case, you get the memories back, eventually, so later you can remember the experience of the ECT suite in vivid detail, and recall the other fun activities of unit life. But you become hyper-aware of every little normal human slip in memory, and probably over-ascribe any memory problems to the ECT, and wonder if your brain was permanently damaged.

                                                                I understand why it's used (frustration, desperation, patient's perceived best interest) but I think the memory loss needs to explained fully and then taken seriously and sympathetically. Being told "so you've forgotten the past six months, big deal" is not helpful. Consent, I agree, is a problematic concept here, because when you're talking to someone who wants to die, maybe they're consenting because they're hoping for a fatal complication. But fully informing someone is still important.

                                                                I'm curious, for those who are seeing it used often, how often do you see it fail? Do the memory problems bother people more if they're higher functioning to begin with?
                                                                 

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                                                                  > If you've ever seen a catatonic patient, on the brink of death get ECT and then have a miraculous recovery, you would realize that ECT is an incredibly important life saving procedure.

                                                                  I think that the efficacy and risks of ECT need to be assessed on the basis of randomised double blind control trials on a representative patient population rather than on the basis of one or two or ten or one thousand cases that are taken to be salient for illustrating a particular theoretical view.

                                                                  > it it is just extremely impractical and not reality based to claim that therapy is equivalent to ECT when you actually see it clinically.

                                                                  I didn't claim that.

                                                                  > Doctors care about helping their patients

                                                                  I didn't deny that.

                                                                  > ...they have an obligation to consider all options, especially ones that are extremely effective, have a generally low side effect profile, and are rapidly acting.

                                                                  But this is precisely what people are querying.

                                                                  > The only reason it is so feared is because of the prior sloppy way that ECT (again not different from other fields of medicine as they evolved) was practiced and the bias against psychiatry, otherwise it would be in use further and its a damn shame too.

                                                                  The point is: The history of past practices is NOT the only reason that there are concerns with the procedure. The point is: There are present side-effects coming up in trials such that the risks may be greater than is often supposed, and the efficacy might be less than is often supposed.

                                                                  > Didn't we all state this above? that you may lose some past memories?

                                                                  I'm not sure that losing names of significant others or losing ones ability to categorise objects falls under the 'some past memory' category. These might be better thought of as ongoing problems with memory formation. The point is that it has often been reported that the memory loss is more significant than is commonly supposed. The qualitative nature of it while a person is in a course of treatment (as one poster has suggested). Past memories for names of faces and names of objects and also experiences that were acquired well before a year before the procedure was undertaken. Abilities to acquire new names for people and categories. These sorts of memory problems are far more significant than 'a little memory loss for the 6 months prior to the treatment and most people reacquire them later anyway'.

                                                                  (On a seperate note would this reaquitition of memory after ECT meet the definition of 'repression' that there was that prize for? Yeah, ECT was developed after the 1700's, but I wonder if these kinds of cases would be ruled out on the grounds that there was cerebral injury / trauma).

                                                                  > If ever a relative of yours is in the wards, feel free to say no to ECT and leave them in the wards till you find a solution. Please make sure you arrange for someone to come feed them and change them daily that way the system doesnt pay for your choice as well.

                                                                  What is the efficacy of ECT? 60%? Less than? How about relapse? Maybe ward management would be even less of an issue if we simply enduced coma for a time...

                                                                  I'm sorry you feel frustrated that other people don't share your faith in ECT. I do hope that for your patients and for your patients families sake that you will be able to accept a 'no' to this particular variety of treatment (as for any other) and respect their decision while still doing what you can to help. Instead of thinking that 'you can't help people who won't help themselves (ie do as you say)'. I do worry about issues of paternalism vs autonomy sometimes... I'm sorry you think that is 'impractical'. The trouble is that while you don't have to expliclitly consider these issues pragmatism requires you to adopt a position. Better to adopt one on the basis of reflection rathe than out of obliviousness, I would have thought...
                                                                   

                                                                  Anasazi23

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                                                                    Hospitals, for better or more likely, worse, are rabid about certain things being done properly.

                                                                    ECT is one of them (restraint and seclusion are another). In my personal clinical experience, a large portion of patients have family involment when it comes to making a decision about ECT. In all of these cases, risks, including memory impairment, are discussed. Many times, patients and families refuse. In many of these described cases, their hosptial stay is dramatically extended (which also carries a morbidity risk).

                                                                    There have been many meta analyses of ECT vs. other antidepressant trials and vs. placebo (sham) ect. Virtually every study shows a large effect size in efficacy favoring ECT.

                                                                    Yes, memory impairment can be signifianct. Again in my experience however, it's short-lived and is generally less of a concern than that of the debilitating depression preceding it.

                                                                    Again, I can't help but think that people like to go after ECT and psychiatry practice in general because they feel they can understand it. This argument doesn't exist for the cranky diabetic who is having a BKA since people don't claim to understand how exactly to amputate a leg, or are less privy to the medical complications that untreated gangrene can cause.
                                                                     

                                                                    Faebinder

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                                                                      > If ever a relative of yours is in the wards, feel free to say no to ECT and leave them in the wards till you find a solution. Please make sure you arrange for someone to come feed them and change them daily that way the system doesnt pay for your choice as well.

                                                                      What is the efficacy of ECT? 60%? Less than? How about relapse? Maybe ward management would be even less of an issue if we simply enduced coma for a time...

                                                                      Whoa, induce coma? :scared: Easy there cowboy, lets not potentially kill the patient by doing something more dangerous yet has no proven benefit against their disease. I hope you were joking.

                                                                      I'm sorry you feel frustrated that other people don't share your faith in ECT. I do hope that for your patients and for your patients families sake that you will be able to accept a 'no' to this particular variety of treatment (as for any other) and respect their decision while still doing what you can to help. Instead of thinking that 'you can't help people who won't help themselves (ie do as you say)'. I do worry about issues of paternalism vs autonomy sometimes... I'm sorry you think that is 'impractical'. The trouble is that while you don't have to expliclitly consider these issues pragmatism requires you to adopt a position. Better to adopt one on the basis of reflection rathe than out of obliviousness, I would have thought...

                                                                      It's all easy until it's your brother/mother/sister/spouse/father/child sitting in the wards for over 2 months and failed every medical drug there is. Want to try a fourth drug sir or ECT or sit tight in the psych wards and do nothing? Is it worth sacrificing another 2 months of your life rethinking? I can't tell you where the threshold is but I sure hope you realize there is one. I.E. How much are you willing to lose of your life in the psych wards before you are willing to try an ECT?

                                                                      Lets just say we agree to disagree regarding the practicality of doing an ECT on someone who has been on the wards for a couple of month with ZERO improvement and no baseline function. Fortunately, it's not up to us to make the decision, it's up to the patient and the family.
                                                                       

                                                                      PeeWee137

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                                                                        I think that the efficacy and risks of ECT need to be assessed on the basis of randomised double blind control trials on a representative patient population rather than on the basis of one or two or ten or one thousand cases that are taken to be salient for illustrating a particular theoretical view.

                                                                        how can you blind ECT?
                                                                        people say the same thing about osteopathic manipulation. they dont want to know anything about it until they see the big double-blind studies proving its worth. i dont get it.
                                                                         

                                                                        billypilgrim37

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                                                                          how can you blind ECT?
                                                                          It's easy to blind ECT. You simply put a patient under general anesthesia, and don't induce a seizure. The problem is that it is unethical to give someone placebo when a treatment (ECT) has already been proven to work. It's similarly easy to blind OMT, but there are no osteopaths willing (or properly trained) to perform the trials. If the acupuncture folks have figured out effective blinding methods (which they have), then you can blind almost anything.

                                                                          Toby, the risks and benefits of ECT have been EXTENSIVELY described in the literature. There are no magic studies in the works that are suddenly going to show ECT to be more harmful or less effective than we already believe it to be. At least not meaningfully so. For one, it would be impossible to actually perform a study like that, at least in the US, because NIMH surely has zero interest in wasting money reproving what past research has already proven without a doubt to anyone in the field.

                                                                          The ethical dilemmas associated with ECT are not that different from deciding to give someone clozapine. If you're not throwing your hands about clozapine clinics, but are questioning our motives for judicious use of ECT, you're not going to make much sense to us.

                                                                          Clozapine isn't as sexy, I guess.
                                                                           

                                                                          toby jones

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                                                                            > NIMH surely has zero interest in wasting money reproving what past research has already proven without a doubt to anyone in the field.

                                                                            But psychiatrists are some of the most vocal advocates for its abolition. (I'm not necessarily agreeing with them - just saying that there IS still controversy from within the field).

                                                                            There are lots of things that are problematic. The efficacy of SSRI's (compared to placebo) and the extent and frequency of side effects like agitation, suicidal ideation etc. (Should we not have looked again at the data for efficacy in children? Didn't 'everybody know' that it was okay to prescribe SSRI's to kids???) Kind of like how the extent and frequency of the side effects of the older generation anti-psychotics (tardive dyskinesias and dementias) is something that is only just starting to be accepted within the profession now. Even less acceptance of problems with SSRI's, I think. ECT is problematic, too.

                                                                            Given history... It is fairly unsurprising. Not such a problem for psychiatry... A bit of a problem for medicine more generally... People stand to make big bucks and there you go...

                                                                            I found this. Don't necessarily agree with everything... But a refreshing change in bias...


                                                                            http://www.ect.org/wp-content/uploads/2006/09/shock-treatment.pdf
                                                                             

                                                                            toby jones

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                                                                              > people say the same thing about osteopathic manipulation. they dont want to know anything about it until they see the big double-blind studies proving its worth. i dont get it.

                                                                              It is called 'evidence based medicine'. It consists in a hierarchy of different kinds of evidence that we can have in support of something and it tells us which are 'best'. The 'best' method of acquiring evidence (according to medicine) is the randomized double blind control trial.

                                                                              Surely you don't mean to question that... I mean really, you don't think that psychiatry / medicine shouldn't be based in evidence - do you?

                                                                              ;-)

                                                                              (There is MUCH controversy over this ranking of ways of acquiring evidence. Part of the problem is that one simply can't run double blind randomized control trials in order to investigate certain things. Try hiding whether you are giving someone therapy - for example. So... According to current evidence based standard there will be better evidence for meds than for therapy...
                                                                               

                                                                              Faebinder

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                                                                                > NIMH surely has zero interest in wasting money reproving what past research has already proven without a doubt to anyone in the field.

                                                                                But psychiatrists are some of the most vocal advocates for its abolition. (I'm not necessarily agreeing with them - just saying that there IS still controversy from within the field).

                                                                                There are lots of things that are problematic. The efficacy of SSRI's (compared to placebo) and the extent and frequency of side effects like agitation, suicidal ideation etc. (Should we not have looked again at the data for efficacy in children? Didn't 'everybody know' that it was okay to prescribe SSRI's to kids???) Kind of like how the extent and frequency of the side effects of the older generation anti-psychotics (tardive dyskinesias and dementias) is something that is only just starting to be accepted within the profession now. Even less acceptance of problems with SSRI's, I think. ECT is problematic, too.

                                                                                Given history... It is fairly unsurprising. Not such a problem for psychiatry... A bit of a problem for medicine more generally... People stand to make big bucks and there you go...

                                                                                I found this. Don't necessarily agree with everything... But a refreshing change in bias...


                                                                                http://www.ect.org/wp-content/uploads/2006/09/shock-treatment.pdf

                                                                                Alright, last reply for me, otherwise I am wasting breath here on this thread. The article is a review written by a single person (not peer reviewed in a scientific journal) and posted on a biased website of a person who had an ECT. That's not the proper way to provide evidence for the cease of a therapy. You are better served off by doing a metaanalysis and submitting it to a journal for review and publishing it. 1 non-peer reviewed article only says that you are biased against the subject. (BTW, I never ordered or did a ECT myself yet defend it because of the amazing results I witnessed and the published data).

                                                                                And with this I conclude there is no point to this discussion. If you dont want an ECT, simply refuse it. Best of luck.
                                                                                 

                                                                                michaelrack

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                                                                                  Again, I can't help but think that people like to go after ECT and psychiatry practice in general because they feel they can understand it. This argument doesn't exist for the cranky diabetic who is having a BKA since people don't claim to understand how exactly to amputate a leg, or are less privy to the medical complications that untreated gangrene can cause.

                                                                                  I think the average person knows much more about how to amputate a leg than how ECT is administered and its theoretical basis. The average person probably also knows more about gangrene. Amputation has been performed for thousands of years, ECT for less than a century.
                                                                                   

                                                                                  Anasazi23

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                                                                                    I think the average person knows much more about how to amputate a leg than how ECT is administered and its theoretical basis. The average person probably also knows more about gangrene. Amputation has been performed for thousands of years, ECT for less than a century.

                                                                                    I disagree. While someone may think they know about how to amputate a leg, they know nothing about treating vascular complications of diabetes. ECT is called "shock treatment" by the general public. Everyone knows what "memory loss" is. Nobody knows, however, who might be eligible for a fem-pop based on ABI results.

                                                                                    What I'm trying to get at is the concept that scientologists, mothers, and the general lay person feels that they are qualified to critique the science and practice of psychiatry. They don't do the same for the drug company profit in the general uselessness of statins in mortality studies. That's just not understandable by the general public. "Shock treatment" has been in famous movies, and holds a place in popular culture because it looks so outrageous. There are people out there that think we're doing this because it makes us money (ridiculous), and there are people who rail against psychotropic medication use as though psychiatrists are hiding in alleys pulling people into dark corridors from the shadows and forcing medications on people. Never mind the fact that it's these people who are presenting themselves to us for medical help when they've exhausted all their resources. People choose to not understand the doral raphe nucleus and its role in psychiatry. They just want to consider and debate the horrible injustices of tying people to the bed and forcing electroshock treatment on them, because it's outwardly outrageous and goes against the grain of 'helping medicine.' If we started putting leeches on people to drain wounds, we'd have the newspapers clamiring for our heads. Psychotropics, however? Mind-numbing zombifying elixers that suck the human sole from their victims.

                                                                                    Psychiatry remains with one foot in the dark ages because people can't advance from this.
                                                                                     

                                                                                    TheWowEffect

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                                                                                      How many times have we heard patients and their family members/parents/guardians saying they want to try "holistic" treatments for their OCD/depression/anxiety. I am sure there won't be many people out there saying the same thing for a gangrene.

                                                                                      Psychiatrists need to stop saying that we don't know enough about brain functioning and mental illness. We have to stop being too laid-back and start learning about neuroscience and educating our patients about tremendous advances we have made.

                                                                                      Too many times, we don't want to make an effort to learn about all the new advances because it's easy to dismiss these things as esoteric. It's just easy to maintain the status quo and keep doing the same old things.

                                                                                      Need of the hour is to do the hard thing and learn how glutamate is involved in schizophrenia; learn that pretty soon there will be biomarkers for mood disorders. Next time, someone tells me they don't know how lithium works or why SSRIs take a while to start working, I want to tell them to please go to pubmed and do a simple search. These are just few of the ways how we psychiatrists take the easy way out.

                                                                                      Toby Jones, I am sure you are well informed about the various theoretical underpinnings of mental health but the point is that it does not matter here. For academic reasons, it might be fascinating to read about various theories and opinions but all this fascinations flies out of the window when that woman with severe clinical depression is sitting in your office. When that grandiose manic is dancing around the ward or when that schizophrenic has that fearful look on his face. What takes precedence is to find out the best option available to treat this person.

                                                                                      A huge reason for this unnecessary debate in psychiatry is that everybody and their grandmother think that they know more about it than anyone else. A big part of this debate is also trying to explain psychiatry from the point of view of philosophy. My dear friends, enough of trying intellectualize mental health. We have to send out a message that this is medicine of brain function and not just behavioral health. It's time to believe in the potential of neuroscience. The burden is on this new generation of psychiatrists to get the field out of anachronistic thinking, and move forward.
                                                                                       

                                                                                      toby jones

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                                                                                        Just a couple of things.

                                                                                        The link I posted should be assessed by its merits. The person is up-front about saying that their intention in systematically critiquing the studies (offering a peer review of the literature) is for the purposes of claiming that there is evidence that ECT isn't terribly effective and that it causes significant memory troubles to a court of law. Guess some disgruntled client sued their psychiatrist. Because their psychiatrist didn't warn them of such things and as such they weren't in the position to offer INFORMED consent. This is of course what a paralegal has to say from ONE side. It would be interesting to read what a paralegal has to say from the OTHER side. It would be interesting to know who won the case.

                                                                                        People keep coming back to 'but when you have a patient in front of you...' But precisely what is at issue here is the efficacy and potential harm of this way of 'treating' patients.

                                                                                        To say that 'its just because of past practices that people are concerned today' is a way of UNDERMINING and IGNORING the significant concerns that people have about PRESENT practices.

                                                                                        I wasn't terribly surprised to see that a persons post about her experience with ECT was completely ignored. But don't forget there are many many others who have said similar things and they really do start to add up.

                                                                                        The efficacy is being questioned. up to 80% of people who are treatment naieve. The APA doesn't approve ECT as a first line treatment though, does it? For people who are treatment resistent around 30-50%. Are these people with depression (ECT is often advocated for that). Nah, most of them were schizophrenic... The efficacy is correlated with the most significant memory / brain impairment. Better efficacy for bi-lateral and many times the seizure induction threshold (though important to note that they haven't really tested the level that the majority of clinicians deliver it at). Positive benefits seem to remit with time. Hard to do follow up because a number kill themselves or refuse follow up (so those who are most negatively impacted are screened out). Follow up studies don't do follow up past 6 months because that is when the highest relapse kicks in.

                                                                                        All this is by way of questioning the EFFICACY of PRESENT practices.

                                                                                        There is a lot that goes on in medicine that the general public doesn't know about. In some instances I think they would fuss if they knew. But once again, the problems with ECT aren't restricted to the 'general public' who are misinformed. They aren't restricted to people who believe in UFO's. There are significant concerns here.

                                                                                        I hope that people don't find out about this that hard way (might be interesting to read what information a paralegal managed to garner from the perspective of saving ones own butt if nothing else).
                                                                                         

                                                                                        toby jones

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                                                                                          > If we started putting leeches on people to drain wounds, we'd have the newspapers clamiring for our heads.

                                                                                          Actually... This leeches are used quite a lot. Sterile hospital leeches to be sure. I think that this is fairly common knowledge and nobody is fussing.

                                                                                          > How many times have we heard patients and their family members/parents/guardians saying they want to try "holistic" treatments for their OCD/depression/anxiety. I am sure there won't be many people out there saying the same thing for a gangrene.

                                                                                          Guess you haven't seen the 'stop smoking' (environmental intervention) messages on Australian (for example) cigarette packages. My favourite is 'smoking causes gangrene' with a picture of a gangrenous foot covering 10% of the front and 90% of the back of the pack.

                                                                                          > Psychiatrists need to stop saying that we don’t know enough about brain functioning and mental illness.

                                                                                          Trouble is... We simply don't know much at all. We still know stuff all about neural mechanisms. I'm surprised you seem to think we know so much about them...

                                                                                          > learn how glutamate is involved in schizophrenia; learn that pretty soon there will be biomarkers for mood disorders.

                                                                                          Biomarkers? You mean aside from the behavioural symptoms that we have already (and that internal markers need to be calibrated against??)
                                                                                           

                                                                                          michaelrack

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                                                                                            I disagree. While someone may think they know about how to amputate a leg, they know nothing about treating vascular complications of diabetes. ECT is called "shock treatment" by the general public. Everyone knows what "memory loss" is. Nobody knows, however, who might be eligible for a fem-pop based on ABI results.

                                                                                            Most people don't know who would be elgible for ECT based on mental status exam results, neuropsychological testing, lab work up, and pt history. I agree that most people don't know about one of the indications for amputation (severe vascular compromise due to DM), but they probably don't know either that Parkinson's disease can respond to ECT (at least I hope that was the correct answer to one of the questions on last week's Psychosomatic Boards).

                                                                                            Most people know that severe depression can be treated with ECT, and they also know that infected extremity wounds sometimes have to be amputated (military surgeons have been doing this for thousands of years).

                                                                                            Most non-physicians don't know how to perform ECT, but they could probably learn by reading a survival first aid manual or perhaps a book about medicine during the civil war how to perform an amputation. Sometimes psychiatric patients perform self-amputation, though I have never known a psychiatric patient to perform ECT on himself.

                                                                                            I guess what I am trying to say is that I disagree with your amputation analogy. I do agree with your main point that people feel qualified to criticise psychiatry and psychiatric treatment and not other medical specialties.
                                                                                             

                                                                                            TheWowEffect

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                                                                                              Guess you haven't seen the 'stop smoking' (environmental intervention) messages on Australian (for example) cigarette packages. My favourite is 'smoking causes gangrene' with a picture of a gangrenous foot covering 10% of the front and 90% of the back of the pack.

                                                                                              You are talking about prevention, and not treatment here, Dr. McLaren.
                                                                                               
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