Electroconvulsive Therapy: An Exchange

To the Editors:

In his otherwise fairminded and brilliant synthesis and review of recent trends in the neuroscience of altered brain functioning [“The New Brain,” NYR, March 14], Israel Rosenfield has been, in my view, unduly critical of Nancy Andreasen’s endorsement of electroconvulsive therapy (ECT) as a treatment for melancholia, and blind to its usefulness as a tool for understanding the brain.

Dr. Andreasen’s advocacy of ECT [in The Broken Brain] is hardly radical. In a recent survey of 3,000 randomly selected psychiatrists the American Psychiatric Association (Task Force Report #14, Electroconvulsive Therapy, APA Press, 1978, pages 2–3) found that clearly two-thirds were favorably disposed toward ECT’s use with only 2 percent totally opposed to it in any situation.

Granting that we are not fully knowledgable about the mechanism of action of ECT, it is far from being a “desperate measure.” In two recent reviews of the efficacy of ECT in treating depression, Raymond R. Crowe (New England Journal of Medicine, July 19, 1984, pages 163–157) and Philip G. Janicak and colleagues (American Journal of Psychiatry, March, 1985, pages 297–302) conclude from the results of rigorous scientific studies that ECT is clearly superior to all other available forms of treatment of severe depression. This effect appears to be all the more impressive because most of the patients had failed to respond to drug treatment or psychological therapy prior to initiating ECT. These scientific studies confirm practicing clinician’s anecdotal reports of ECT’s literally life-saving benefit to the desperately suicidal and depressed.

Finally, Professor Rosenfield has not conveyed to the reader recent research in the actual application and biological effects of the ECT procedure itself; he implies nothing more is known now than 50 years ago when the treatment was introduced. The use of modern integrated electrical circuitry and placement of the treating electrodes on the patient’s non-dominant cerebral hemisphere greatly reduce the degree of memory impairment without apparent change in efficacy. Many other lines of research are elucidating the effects of the electrical current on the very neurotransmitter systems felt to be deranged in depression. For example, a series of papers by Markku Linnoila and colleagues (Archives of General Psychiatry, 1983, pages 677–680; 1983, pages 1015–1017; and 1985, pages 688–692) have demonstrated the effects of ECT, lithium carbonate, and the antidepressant drugs on norepinephrine, dopamine, and serotonin. It appears that ECT acts similarly to these other treatments for depression.

Although ECT remains a controversial treatment, it must remain available for selected patients while new knowledge is generated to reduce its side effects and to completely understand its action.

William H. Nelson, MD

The University of Connecticut Health Center

Farmington, Connecticut

To the Editors:

In Israel Rosenfield’s review of new books on the brain, he raises the question of the permanent damage to that organ that may be done by electroconvulsive therapy (ECT). This is the psychiatric treatment that consists of a series of brain seizures triggered by electric shocks. Rosenfield’s discussion of this “desperate measure” is on the mark, so far as it goes, but I believe it should be supplemented by a report on the drama concerning ECT brain damage that has been unfolding at the Food and Drug Administration (FDA) for the better part of a decade.

The FDA first became involved with ECT when it acquired responsibility for screening all types of medical devices for safety. This was by legislation in 1976. The new law automatically brought ECT devices (shock machines) and the treatment they produce under security.

The law had different but consistent provisions for new and existing devices. New medical devices coming on the market were to be given a “premarket approval” investigation before they could be sold; while existing devices were to be placed in one of three risk classes, I, II, and III, with those in the highest risk class being subject to the same “premarket approval” investigation as a new device coming on the market. If a Class III device didn’t pass that investigation, it was to be taken off the market. Further sale would be prohibited.

What happened with respect to ECT devices was that FDA identified eight “risks to health” in ECT, including brain damage and memory loss, and in 1979 placed ECT devices in Class III by a firm regulatory action known as “final rule.”

The American Psychiatric Association (APA) vigorously objected to this placement and, in 1982, at the end of a liberal grace period, forestalled a premarket approval investigation by petitioning the FDA to change the classification of the devices to Class II. In this petition the APA was supported by the National Institute of Mental Health (NIMH). The NIMH is the government agency that holds the purse strings of brain science, but it itself has never conducted or sponsored an investigation of ECT for the possibility or extent of brain damage. NIMH is staffed largely by members of the APA and it shares the APA’s unwillingness that an investigation along these lines should be made by the FDA.

A public hearing was held on the APA’s petition in November of 1982 and a rather ambivalent panel of advisers recommended granting it, though with some strings attached. FDA expressed its intention of following the panel’s recommendation, but, to the continuing consternation of the APA, it has not yet done so. The matter remains up in the air, with shock machines still in Class III.

Meanwhile the FDA has been concerned with ECT in another but related way.

In 1979, at the same time ECT devices were placed in Class III, the FDA approached consumer protection from also the aspect of informed consent. It announced that it was considering sponsoring a statement of information about ECT that would be required to be given to prospective patients.

Subsequently two different statements have been proposed to the FDA for this purpose—one by the APA and one by the Committee for Truth in Psychiatry. The latter body is an organization of former ECT patients. The two statements differ principally in what they have to say about brain damage and permanent memory loss. Both statements are under consideration by the FDA at the present time.

How these two issues—the one concerning sale of shock machines and the one concerning informed consent—will be resolved, may be decided this summer by a “Consensus Development Conference” on ECT that the National Institute of Health is holding on June 10–12. At any rate, the FDA is saying informally that it will take action on the two ECT issues after it sees the consensus arrived at by this conference.

Unfortunately, the conference is not intended to address or debate the basic scientific facts about ECT. Rather, it has been planned by the National Institute of Mental Health, and is intended to arrive at a consensus of views among practitioners and proponents of ECT. That there exists disagreement with these views will be recognized by an hour during which critics of ECT will be allowed to speak….

Marilyn Rice

Arlington, Virginia

Israel Rosenfield replies:

My comments on Dr. Andreasen’s view of ECT were based in part on the following passage in her book:

Most patients who receive ECT have some memory loss for the period when they were receiving treatment. They may also have some difficulty remembering a few things that occurred just before the treatments began. These memory problems clear up completely after the ECT is stopped, however, and there is no evidence of any long-term effects on learning or memory.

Dr. Andreasen’s unequivocal claim that there is no long-term memory loss following ECT is hardly established fact. I suspect that proper testing will reveal permanent damage. Dr. Nelson’s letter suggests that he, too, believes that ECT can cause some permanent memory loss. I do not believe my criticism of Dr. Andreasen should be modified on this point.

The subject is very controversial and I referred readers to the symposium in Behavioral and Brain Sciences, mentioned in my review, in which a wide range of views is presented. I think the consensus of that symposium would be in general agreement with Dr. Nelson’s letter. I recognize the usefulness of ECT in treating severe depression, though I hope such procedures will be better understood (or replaced) in the future. It remains questionable whether recent studies of ECT have given us any new insights into the nature of depression. Dr. Nelson cites evidence that ECT affects certain neurotransmitters believed to be important in depression. This is interesting so far as ECT is concerned, but I do not see how it gives us any new understanding of depression. The studies fail to discuss the effects of ECT on neurotransmitters that are not implicated in depression.

In my review I suggested that depression may be related to attempts to piece together “solutions” to psychological problems through a series of memory searches. If this is true, it would not be surprising that memory loss is the reason ECT is effective in treating depression. Following treatment, memories of the most recent events are recovered last. It is these memories that are likely to have precipitated the depressive crisis. This pattern of recovery may permit unconscious and conscious search procedures to find “new” solutions to old problems, along the lines I suggested in my review.

Marilyn Rice’s letter suggests that a serious professional controversy over the effects of ECT remains to be resolved. The administrative history she outlines should be cautionary to those who uncritically accept assurances about the safety of ECT.

I should add that I have the same reservations about other antipsychotic and anti-depressant therapies that I have about ECT. Therapeutic usefulness, or necessity, should not be confused with understanding.