ECT procedure making $$$

[Faebinder]

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.[/U]

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Members don't see this ad.

 

[qtpai]

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.

This sort of rhetoric has been used for decades, bordering on nearly half a century, and it has come to little. You can find such calls to "embrace neuroscience" and claims that we will someday have "biomarkers" from the 70s and particularly 80s, in almost exactly this same written/spoken style. It is quite fascinating to observe this still today.

It is precisely because of the advances of neuroscience that psychiatry is in such a conundrum these days. The yesteryear promises of advancement in psychiatric knowledge have proven rather disappointing. We still don't understand the biological basis of schizophrenia or depression, or why antipsychotics or antidepressants "work" (or don't "work," as the latter case has it in clinical trials).

This call against intellectualism is contradictory at best, especially when you invoke the name of neuroscience. A pretty telling sign of this is when neuroscientists have such a difficult time reconciling their differences with psychiatrists. That is precisely why psychiatrists have taken to philosophy and social science. It is neuroscience, psychiatric epidemiology, and so-called ivory tower intellectualism that have cast such rather daunting doubts on the old psychiatric staples. Neuroscience is no salvation but only another difficult, ambivalent, convoluted tunnel that defies anything but nuanced and often uncomfortable interpretation.

I should note, as others have already, that this anti-intellectual, bordering on anti-scientific, stance that I have seen in this thread seems so against the methodology of medicine that it is quite shocking. It certainly seems that "something" should be done when a patient needs help, and no doubt, this should continue to be done. But a little humility should be had when those producing the very knowledge that finds its way somewhat distilled in the hands of practitioners would themselves probably not endorse these sorts of attitudes, which are quite closer to authoritarian than humanitarian.

 

[Anasazi23]

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.

I said if WE i.e. psychiatrists, started using them.


Sorry to sound paternalistic, but the efficacy isn't being questioned by people that know what the hell is going on. It's being questioned by either fringe groups, anti-psychiatry zealots, or non-scientists. We have decades of literature stating that this is a safe and effective procedure. Any procedure has its risks. Ours are relatively mild. Memory loss is squishy and understandable by the public. It makes people sad to think about it and they bring up the loss of images of their grandmother dancing around the christmas tree in december.

We know tons about neuroscience. Not "a little."

I can't wait for biomarkers...that'll be the next big jump forward that launces psychiatry as a medical specialty and takes it out of the hands of the armchair practitioners to a degree.

 

[LadyGrey]

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.

How much neuropsychological testing is typically done before ECT?

I think I can understand the frustration when people object to what is standard practice in psychiatry; you feel like Science or Modern Medicine is under attack, and maybe worry that patients will suffer as a result of inaccurate public perceptions. I know I can feel a similar anger about the parents who choose not to vaccinate. But to lump Toby and anyone else with some skepticism about ECT in with the Scientologists is a bit much. I'm disappointed that a profession that is essentially treating subjective complaints has little interest in looking into the subjective complaints about a treatment. I'm not calling for ECT to be demolished, because the literature does show it to be effective for some, and as a physician I have to submit to the evidence, but I think that calling the side effects of ECT "relatively mild" trivializes the experience of patients.

 

[LadyGrey]

Sorry to sound paternalistic, but the efficacy isn't being questioned by people that know what the hell is going on. It's being questioned by either fringe groups, anti-psychiatry zealots, or non-scientists.

Sorry, not part of any organized fringe, and hardly anti-psychiatry. Pretty sure my degree was in biology and that I worked in a lab for a while, so I thought maybe I counted as a scientist.

Memory loss is squishy and understandable by the public. It makes people sad to think about it and they bring up the loss of images of their grandmother dancing around the christmas tree in
december.

Why does the intelligibility of memory loss to the public make it somehow count for less? It makes "people" sad to think about it; what about you? I'm just curious whether side effects that are "mild" in patients would register as somewhat worse if they were to happen to you, or your friend or colleague or partner?

 

[Faebinder]

How much neuropsychological testing is typically done before ECT?

I think I can understand the frustration when people object to what is standard practice in psychiatry; you feel like Science or Modern Medicine is under attack, and maybe worry that patients will suffer as a result of inaccurate public perceptions. I know I can feel a similar anger about the parents who choose not to vaccinate. But to lump Toby and anyone else with some skepticism about ECT in with the Scientologists is a bit much. I'm disappointed that a profession that is essentially treating subjective complaints has little interest in looking into the subjective complaints about a treatment. I'm not calling for ECT to be demolished, because the literature does show it to be effective for some, and as a physician I have to submit to the evidence, but I think that calling the side effects of ECT "relatively mild" trivializes the experience of patients.

I will illustrate what Anasazi23 was trying to say.

When a diabetic patient controlled via insulin suffers gangrene of the foot, they are treated with antibiotics. The physician continues to do their best until the prognosis is highly morbid/mortal and an amputation is recommended. When an amputation is done, the patient's mobility maybe partially gone and they will need help. Do you find groups ANTI amputations? Do you feel physicians trivialized the side effects of an amputation when they decided to amputate the foot?

Substitute the following:
Diabetes = Depressed
Insulin = SSRIs
Antibiotics = Tricyclics/Intense Psychotherapy/Other options
Gangrene of the foot = catatonic state
Amputation = ECT
Mobility = Memory

Losing a foot (Can't drive, women/men dont wanna date you, need help walking, can't play sports so well etc etc etc) is as drastic as losing memory (forgot grandma, don't remember the person I dated last year, having difficulty memorizing for a month, forgot 1st semester medical school (oh wait you dont need an ECT for that)). Would you not amputate someone who will die from gangrene but you will let a depressed catatonic patient die from suicide or immobility?

Nobody is trivializing anything.

 

[TheWowEffect]

The yesteryear promises of advancement in psychiatric knowledge have proven rather disappointing. We still don't understand the biological basis of schizophrenia or depression, or why antipsychotics or antidepressants "work" (or don't "work," as the latter case has it in clinical trials).

It's obvious you haven't been reading much, or may be reading the wrong (read anti-psychiatry) websites and books.

I should note, as others have already, that this anti-intellectual, bordering on anti-scientific, stance that I have seen in this thread seems so against the methodology of medicine that it is quite shocking. It certainly seems that "something" should be done when a patient needs help, and no doubt, this should continue to be done. But a little humility should be had when those producing the very knowledge that finds its way somewhat distilled in the hands of practitioners would themselves probably not endorse these sorts of attitudes, which are quite closer to authoritarian than humanitarian

Come sit with me in my office and you'll know how humanitarian I or any of my colleagues is. You'll know how many satisfied patients come day in and out thanking me for practicing modern medicine to make their lives better.

Don't expect a group of psychiatrists to cower down when a bunch of anti-psychiatry and quasi-scientology people are quick to dismiss the potential of modern psychiatry.

 

[LadyGrey]

I will illustrate what Anasazi23 was trying to say.

...

Do you find groups ANTI amputations? Do you feel physicians trivialized the side effects of an amputation when they decided to amputate the foot?

Losing a foot (Can't drive, women/men dont wanna date you, need help walking, can't play sports so well etc etc etc) is as drastic as losing memory (forgot grandma, don't remember the person I dated last year, having difficulty memorizing for a month, forgot 1st semester medical school (oh wait you dont need an ECT for that)). Would you not amputate someone who will die from gangrene but you will let a depressed catatonic patient die from suicide or immobility?

Nobody is trivializing anything.

I'm not saying that doing ECT is trivializing how drastic a step it is, which is what you seem to think I was saying. I was objecting to Anasazi23 describing the side effects as "mild." How is that not trivializing it? To me, and to most people, mild side effects are things like being nauseated from your antibiotic.

Your amputation analogy works because they are both drastic, last-resort treatments. I'm not saying I would let someone die from gangrene or from suicide, but I also would not tell the diabetic with gangrene that foot isn't that big a deal, and that he won't really miss it once it's gone.

 

[Anasazi23]

I'm not saying that doing ECT is trivializing how drastic a step it is, which is what you seem to think I was saying. I was objecting to Anasazi23 describing the side effects as "mild." How is that not trivializing it? To me, and to most people, mild side effects are things like being nauseated from your antibiotic.

Your amputation analogy works because they are both drastic, last-resort treatments. I'm not saying I would let someone die from gangrene or from suicide, but I also would not tell the diabetic with gangrene that foot isn't that big a deal, and that he won't really miss it once it's gone.

Permanent memory loss is rare. Compared to the morbidity and mortality of non-treatment, yes. I'll say that memory impairment is a relatively mild side effect. It's most often short-lived, non-permanent, and if it occurs at all, is circumscribed to the time shortly before treatment. Compare that to cardiomyopathy, agranulocytosis and other potentially life-threatening side effects, and I call it mild.


This is my last post on this topic.

http://www.medscape.com/viewarticle/523756

 

[toby jones]

Did anybody actually read the article?

Once again: It is a systematic peer review of the literature on the efficacy of ECT and on the APA policies that are supposed to be sensitive to that literature.

It was written by a paralegal (who is attempting to defend a client by showing that the psychiatrist was negligent in not informing the client to the SUBSTANTIAL risks to memory, and the SIGNIFICANT relapse rate and the data on potential BRAIN DAMAGE).

I thought people might be interested to take a look and check out the primary sources if they would like and then make up their own mind. But more importantly... Have a think about what information needs to be conveyed to a patient in order for them to provide informed consent.

I do understand that psychiatrists have something of an identify crisis about their place in medicine sometimes. But really, if people are going to call everyone who doesn't follow the party line an 'anti-psychiatrist' or maintain that they are ignorant well... I haven't seen such black and white thinking for a long time... And don't forget (thinking about making this my signature but people will misunderstand): Anti-psychiatrists are psychiatrists too.

The amputation / ECT analogy is only as good as whether amputation and ECT are similarly a matter of delivering effective, life saving treatment. Both of those things are precisely at issue, however, so the analogy is simply begging the question (assuming that which is at issue).

I made it clear that I wasn't opposed to ECT in EVERY case but still people like to caricature my position into something that if clearly wrongheaded (all the easier to dismiss it).

ECT was a significant advance for psychiatry's seperation from neurology... They were doing coma therapy around the same time (seems that there is a literature on how inducing a coma with insulun is effective too). And bloodletting... That was meant to (and did) rather successfully help calm people down... Not so surprising when you think about it...

 

[BabyPsychDoc]

Did anybody actually read the article?

Once again: It is a systematic peer review of the literature on the efficacy of ECT and on the APA policies that are supposed to be sensitive to that literature.

It was written by a paralegal (who is attempting to defend a client by showing that the psychiatrist was negligent in not informing the client to the SUBSTANTIAL risks to memory, and the SIGNIFICANT relapse rate and the data on potential BRAIN DAMAGE).

Oh, that just boosted my confidence in the article, without even reading it. How can a paralegal write a systematic peer-review concerning efficacy of a medical treatment - especially when the paralegal has the conflict of interests there?

ECT was a significant advance for psychiatry's seperation from neurology... They were doing coma therapy around the same time (seems that there is a literature on how inducing a coma with insulun is effective too). And bloodletting... That was meant to (and did) rather successfully help calm people down... Not so surprising when you think about it...[/

This statement REALLY smells of scientology for me, personally.

 

[toby jones]

>Description of Ad Hominem

>Translated from Latin to English, "Ad Hominem" means "against the man" or "against the person."

>An Ad Hominem is a general category of fallacies in which a claim or argument is rejected on the basis of some irrelevant fact about the author of or the person presenting the claim or argument. Typically, this fallacy involves two steps. First, an attack against the character of person making the claim, her circumstances, or her actions is made (or the character, circumstances, or actions of the person reporting the claim). Second, this attack is taken to be evidence against the claim or argument the person in question is making (or presenting). This type of "argument" has the following form:

>Person A makes claim X.
Person B makes an attack on person A.
Therefore A's claim is false.
The reason why an Ad Hominem (of any kind) is a fallacy is that the character, circumstances, or actions of a person do not (in most cases) have a bearing on the truth or falsity of the claim being made (or the quality of the argument being made).

>Example of Ad Hominem

>Bill: "I believe that abortion is morally wrong."
Dave: "Of course you would say that, you're a priest."
Bill: "What about the arguments I gave to support my position?"
Dave: "Those don't count. Like I said, you're a priest, so you have to say that abortion is wrong. Further, you are just a lackey to the Pope, so I can't believe what you say."

http://www.nizkor.org/features/fallacies/ad-hominem.html

___________

Or, here is another example:

I don't even need to read the article because they aren't a doctor and so they don't know what they are talking about and they are probably an anti-psychiatrist* anyway!

(Even though anti-psychiatrists are psychiatrists who have criticisms of the current state of psychiatry. Szasz, Breggins etc were trained as psychiatrists, worked on in-patient wards, worked as therapists, prescribed medication etc etc etc. The appropriate ad hominum attack is really 'scientology'. You know, waiting for the UFO's to come back. Clearly anyone who suggests that ECT might not be appropriate as a first line treatment for depression must believe that the UFO's are coming back...)

;-)
___________

It should be noted that much of the literature in the journals exhibits a considerable bias - typically in the other direction as when researchers / clinicians have a financial investment or tie to a particular pharma company or ECT manufacturer (which they often don't disclose). This person was upfront about their bias. What the person has to say should be assessed on its merits. As should those who have financial ties to pharma. While a paralegal isn't qualified to be RUNNING experiments I would think that the critical thinking skills could be useful for offering a review on the findings of the experiements that had been run.

I don't know what happened in the court of law but my feeling was that the information that the paralegal found would be presented in order to question the claim that a competent psychiatrist wouldn't know about the considerable risks to memory etc in order to adequately inform their patient and / or the patients family of the risks. I don't imagine the judge would have said 'you are a lawyer, what do you know? The doc said he didn't know and since he is a doc he must be competent (the opposite of an ad hominum - an appeal to authority).

The primary sources are referenced so if one is dubious one could in fact chase up the primary sources oneself.

 

[billypilgrim37]

The primary sources are referenced so if one is dubious one could in fact chase up the primary sources oneself.

Or I could just look up a Max Fink-Mickey Taylor article while sipping the wonderful Kool-Aid of psychiatry.

The paralegal's article doesn't go as well with sangria, which is of course the final arbiter of all evidence's true value.

 

[Shalom77]

Here's a review of ECT published in the UK in their Health Technology Assessment program which is peer reviewed. I think it can lend some support to Toby's position and is more reputable than the "paralegal paper."

http://www.hta.ac.uk/execsumm/summ909.shtml

They review the randomized controlled trial evidence as well as evidence from 6 systematic reviews on ECT treatment.

It's pretty clear that the evidence for efficacy and cost effectiveness is no where near the quality claimed in this thread. In certain subgroups (adults older than 65) there's little evidence at all.

In fact the reviewers had a hard time making any conclusive statement about cost effectiveness given the numerous questions of about the long term impact of ECT both in terms of effectiveness and impact on quality of life.

I agree there is evidence that certain kinds of ECT are effective in the short term although if one reads this articles analysis of real vs. sham ECT in depression - it's not a ringing endorsement of efficacy. "The efficacy of real versus sham ECT is unclear. ...

When all the results are pooled (as in the UK ECT Group analysis


51), real ECT is more effective than sham ECT. However, when the results are analysed separately, real unilateral ECT is not more effective than sham

ECT and it is unclear whether bilateral ECT is more effective than sham ECT." (pg. 71) ​

​

​

AND few RCT trials look at even 6 month outcomes. And the few randomized controlled trials that have have found no difference in terms of HAMD ratings or quality of life. Patient satisfaction with ECT also appears to decrease the longer one goes out from the intial treatment. There's a huge difference between an effective treatment and a treatment that's effective in the short term but not a 6 months.​

Unlike medical students and residents who might be impresed with the impressive short term improvement in the impatient setting, individuals and families have to live with the illness long term. Also different people make different judgements about the tradeoffs of more rapid short term improvement/potential for memory/cognitive loss. I certainly don't want a psychiatrist making the judgment that what's a little cognitive/memory loss (a potential gross underestimate) compared to getting the "hunk of flesh" aka my beloved relative out of the hospital sooner - when I know that my beloved relative is a almost 100% cerebral person for whom cognitive/memory effects would be highly distressing. The review notes that patients will make different trade-offs between benefits and risks which are complex and that there's no one right trade-off for patients. This certainly is an argument for more complete informed consent and less psychiatric paternalism when it comes to ECT. (only about 50% of patients feel they received adequate information about ECT.)​

The review notes the types of memory loss (typically autobiographical) that patients find most distressing are not captured by the tests used in most clinical trials which likely accounts for the low rate found in RCTs compared to the almost 30% rate of patient reported memory loss at 6 months. (For this discussion they rely most on this systematic review on patient perspectives of ECT: http://www.bmj.com/cgi/reprint/326/7403/1363 ) This article has interest tables/charts showing that differences in reported patient satisfaction in clinician vs. patient advocacy group lead studies, as well as time from ECT.​

Despite these shortcomings, I do think that ECT has a place and is an appropriate treatment in certain cases.​

It would be nice if someone had studied whether determining dominance or other testing could help reduce the side effects - but even with the lack of studies in this area - I do think that determining brain dominance is important and would certainly advocate for that in the case of a relative.​

What I disagree with is
1) the cavalier attitude towards informed consent and potential memory/cognitive effects which have clearly NOT been adequately studied especially in the long term. Not to mention this is one aspect that patients who had ECT feel that they were NOT adequately informed about.​

2) the claim that psychiatrists need to stop saying they don't know enough about brain function - per this review - there is no agreement about how ECT works and there still needs to be more studies on the mechanism of ECT.​

Personally, I would run away from any psychiatrist who claimed to know how the brain worked. A sure sign that the person is not to be trusted. (No referrals from me. Fortunately, there are many honest and realistic psychiatrists out there.) I may not be a psychiatrist, but I do a lot of reading in neuroscience and that is a clearly false statement. There is much more that we don't know about the brain and its function than what we do know.​

3) the use of clinical anectodes as evidence - that if one had only seen how these people who the resident/med student knew in the hospital had amazingly improved with ECT we would be as pro ECT as those who are on this thread. That's not evidence. Perhaps it would be more accurate to say that evidence is on the same level as all the anectodes from the many people who claim permanent harm and little benefit from ECT.

4) The claims that ECT is cost effective (clearly not proven), is so well studied that studies are no longer needed (clearly false), claims about efficacy without even mentioning that there is little evidence for long term efficacy, the apparent efficacy vs. side effects trade off, discussion about how its efficacy in certain important subgroups (older adults, treatment resistant depression) has not been studied in a rigourous way, and the higher risk of relapse.​

One doesn't have to be a scientologist to think that a more nuanced view is needed than has been presented by the "pro-ECT" people on this thread. Unfortunately between the ECT is evil people (I have argued against this view in another setting) and the non nuanced proECT view it can be quite difficult to find balanced information on ECT particularly information which is publically accessible and appropriate for patients.​

 

[TheWowEffect]

the claim that psychiatrists need to stop saying they don't know enough about brain function - per this review - there is no agreement about how ECT works and there still needs to be more studies on the mechanism of ECT.

Personally, I would run away from any psychiatrist who claimed to know how the brain worked. A sure sign that the person is not to be trusted. (No referrals from me. Fortunately, there are many honest and realistic psychiatrists out there.) I may not be a psychiatrist, but I do a lot of reading in neuroscience and that is a clearly false statement. There is much more that we don't know about the brain and its function than what we do know.

Well, we certainly know a enough about how brain works to be able to provide decent psychoeducation to our patients, which in most cases is all they need. While you may be reading a lot of neuroscience, 4 years of medical school and a residency teaches us a lot more about what is relevant and what is not for our patients. Reading and clinical application are two vastly different things. So, good luck referring patients to your trustworthy psychiatrists because I do fine with I get and will get.

 

[Shalom77]

I have been through medical school and I have clinical experience as a licensed physician, thank you very much.

It's possible to provide psychoeducation to one's patients without overstating the amount we understand about the brain and how it works.

The most highly qualified and knowledgable physicians in my experience are the ones who are aware of what is not known and who are able to admit that to their patients.

 

[TheWowEffect]

I hope you would have learnt during all your training that twisting someone's statement and blaming that they are claiming to know all about how brain works is not the really best thing to do. I am fully aware of mine and medical science's limitations, and would advise you to refrain from making your wild judgements about me.

 

[Shalom77]

I'm sorry you took my comment so personally. I didn't even think of you when I made it.

 

[TheWowEffect]

I'm sorry you took my comment so personally. I didn't even think of you when I made it.

I understand. This thread overall has been quite provocative and some miscommunication can be expected.

 

[BabyPsychDoc]

>Description of Ad Hominem

>Translated from Latin to English, "Ad Hominem" means "against the man" or "against the person."

>An Ad Hominem is a general category of fallacies in which a claim or argument is rejected on the basis of some irrelevant fact about the author of or the person presenting the claim or argument. Typically, this fallacy involves two steps. First, an attack against the character of person making the claim, her circumstances, or her actions is made (or the character, circumstances, or actions of the person reporting the claim). Second, this attack is taken to be evidence against the claim or argument the person in question is making (or presenting). This type of "argument" has the following form:

>Person A makes claim X.
Person B makes an attack on person A.
Therefore A's claim is false.
The reason why an Ad Hominem (of any kind) is a fallacy is that the character, circumstances, or actions of a person do not (in most cases) have a bearing on the truth or falsity of the claim being made (or the quality of the argument being made).

>Example of Ad Hominem

>Bill: "I believe that abortion is morally wrong."
Dave: "Of course you would say that, you're a priest."
Bill: "What about the arguments I gave to support my position?"
Dave: "Those don't count. Like I said, you're a priest, so you have to say that abortion is wrong. Further, you are just a lackey to the Pope, so I can't believe what you say."

http://www.nizkor.org/features/fallacies/ad-hominem.html

___________

Or, here is another example:

I don't even need to read the article because they aren't a doctor and so they don't know what they are talking about and they are probably an anti-psychiatrist* anyway!

(Even though anti-psychiatrists are psychiatrists who have criticisms of the current state of psychiatry. Szasz, Breggins etc were trained as psychiatrists, worked on in-patient wards, worked as therapists, prescribed medication etc etc etc. The appropriate ad hominum attack is really 'scientology'. You know, waiting for the UFO's to come back. Clearly anyone who suggests that ECT might not be appropriate as a first line treatment for depression must believe that the UFO's are coming back...)

;-)
___________

It should be noted that much of the literature in the journals exhibits a considerable bias - typically in the other direction as when researchers / clinicians have a financial investment or tie to a particular pharma company or ECT manufacturer (which they often don't disclose). This person was upfront about their bias. What the person has to say should be assessed on its merits. As should those who have financial ties to pharma. While a paralegal isn't qualified to be RUNNING experiments I would think that the critical thinking skills could be useful for offering a review on the findings of the experiements that had been run.

I don't know what happened in the court of law but my feeling was that the information that the paralegal found would be presented in order to question the claim that a competent psychiatrist wouldn't know about the considerable risks to memory etc in order to adequately inform their patient and / or the patients family of the risks. I don't imagine the judge would have said 'you are a lawyer, what do you know? The doc said he didn't know and since he is a doc he must be competent (the opposite of an ad hominum - an appeal to authority).

The primary sources are referenced so if one is dubious one could in fact chase up the primary sources oneself.

Very educational, though I was merely pointing out that a paralegal is not a peer to a physician, and therefore by definition cannot write a peer-review regarding medical treatments.

 

[Shalom77]

I understand. This thread overall has been quite provocative and some miscommunication can be expected.

Rereading what you wrote, I think we probably are in essential agreement about your basic sentiment as it applies to psychiatry in general which I think is:

Just because there's lots we don't know/haven't known in the past doesn't mean psychiatrists should use that as an excuse not to keep up with what is being learned with the latest research, particularly since these advances in knowledge can help inform treatment.

I think that research in brain function isn't only exciting for pharmacotherapies but also for psychotherapies/other non pharmacological therapies which can clearly also change brain function.

I also think that anything we can do to get away from the term "behavioral health" (ugh!) is a good thing.

As long we don't overstate our knowledge when talking to patients - I agree it can be useful in psychoeducation as well.

I'm not sure I agree though that this will lessen the debate. Particularly with ECT where there's little agreement (even among scientists ) about its basic mechanisms.

 

[TheWowEffect]

There are many things we do in medicine because they are effective, despite not being fully aware of exact mechanism of action. RCTs and evidence-based medicine is important but clinical experience, expert opinion and consensus guidelines are very significant as well, especially when treating an illness as disabling as depression. Having said that, there is vast body of literature supporting the effectiveness of ECT. One or two random papers do not give us the bigger and the real picture.

 

[billypilgrim37]

Not to submit this as evidence or exhibit A, but I think Sherwin Nuland's talk on TED about his personal experience with ECT (they are positive, btw, just to disclose the bias) is one of the best half hours of internet video out there. Some interesting history as well because, well, he's good at writing interesting histories.

http://www.ted.com/talks/view/id/189

Sherwin Nuland writes lots of good books. He's a former Yale surgeon/historian/awesomedood.

Repeat: not submitting this as evidence. Just submitting for your viewing pleasure.

 

[Shalom77]

There are many things we do in medicine because they are effective, despite not being fully aware of exact mechanism of action. RCTs and evidence-based medicine is important but clinical experience, expert opinion and consensus guidelines are very significant as well, especially when treating an illness as disabling as depression.

I agree with this. But clinical experience is also likely to overstate the benefits of treatment due to selection bias. Those who do not benefit are less likely to return to see the clinician. Those who are not benefiting (and who are in a relatively powerless situation) are more likely to lie about benefit to be able to avoid getting the "treatment." Treatments which have short term benefits which do not last are more likely to be seen as effective by clinicians in acute care settings than by family members or individuals.

Having said that, there is vast body of literature supporting the effectiveness of ECT. One or two random papers do not give us the bigger and the real picture.

There's a lot of evidence for short term efficacy but there isn't much at all for long term efficacy. I think that's an important point because the amount of risk I would be willing to take for long term efficacy is greater than for short term efficacy and if there's really no difference in outcome long term between other forms of treatment - I would accept greater short term pain for reduced long term cognitive/memory risk.

There are, however, certainly situations where one needs a rapid short term response and evidence is strongest for use of ECT in these scenarios.

There also seems to be an efficacy/side effect trade off. The more effective forms of ECT also have more side effects.

For situations where a rapid short term response is less vital - I think ECT is a lot more problematic given the uncertainty with respect to long term side effects.

I wouldn't call the HTA/NICE assessment a "random" paper. It's a nice review of the most important systematic reviews/clinical trials.

 

[Shalom77]

Do the memory problems bother people more if they're higher functioning to begin with?

While this study doesn't look at patients subjective reports of distress - on quantitative testing - people with higher premorbid intellection function showed less impairment on tests at 6 months than lower functioning people. The authors theorize that people with higher cogntive function to begin with are more able to compensate for the effects of ECT.

http://www.nature.com/npp/journal/v32/n1/pdf/1301180a.pdf

 

[solumanculver]

Not to submit this as evidence or exhibit A, but I think Sherwin Nuland's talk on TED about his personal experience with ECT (they are positive, btw, just to disclose the bias) is one of the best half hours of internet video out there. Some interesting history as well because, well, he's good at writing interesting histories.

http://www.ted.com/talks/view/id/189

Sherwin Nuland writes lots of good books. He's a former Yale surgeon/historian/awesomedood.

Repeat: not submitting this as evidence. Just submitting for your viewing pleasure.

That talk was inspiring.