Commentary on ECT Study - Top Researcher Admits ECT
Causes Permanent Amnesia and Cognitive Deficits
Category: ECT
Information and ECT Effects and Statistics and Studies
and Patient Info and Informed Consent
by Linda Andre
Director, CTIP
The Cognitive Effects of Electroconvulsive Therapy in Community
Settings
NIMH-funded research study published in the January 2007 issue of
Neuropsychopharmacology
Author and primary investigator: Harold Sackeim
Funding: NIMH grants
#35636, Affective and Cognitive Consequences of ECT, funded since
1981 for a total of approximately ten million dollars so far (grant
has been renewed through 2009)
#59069, ECT Practices in Community Settings—Evaluating Outcomes,
funded since 1999 for a total of approximately 3.5 million dollars so
far
Summary: After 25 years and millions of dollars of federal funding to
research the adverse cognitive effects of ECT—25 years in which not
one single longterm followup study was ever published—self-
proclaimed "world expert" on ECT Harold Sackeim has now reversed his
position, admitting that ECT routinely causes permanent memory loss
and deficits in cognitive abilities. His new study—the first to be
published in which he followed patients as long as six months, and
one of his only studies to use controls—validates a generation of
patient reports of permanent iatrogenic disability, and disproves
Sackeim's previously published claims that these reports were simply
symptoms of mental illness. Other findings: there is no evidence that
ECT increases intelligence, as Sackeim has previously claimed; and
women are much more likely than men to experience severe permanent
amnesia.
Significance: Harold Sackeim has been called the Pope of ECT, and for
good reason. He's published more on ECT than anyone in the world, has
received more money to research it than anyone in the world, and is
the author of the American Psychiatric Association's patient
information statement and consent forms, which are used by most
hospitals in America. Through his writing, teaching, testimony—and
positions on peer review, editorial, and funding boards, including
NIMH grant review panels—he has more influence on what the profession
and the public believe about ECT than anyone in the world. What
Harold says goes.
Conclusion: This study could have been done at any point in the past
25 years. If it had, a generation of patients could have been warned
of the likelihood of permanent significant memory and cognitive
deficits before, instead of finding out after, ECT. In fact, there is
evidence—from Harold's own statements—that over the years he has in
fact conducted studies following up ECT patients for a long as five
years…but never published the results. Why not? Why did it take 25
years and over ten million dollars to validate what patients have
been saying all along? In other words: What did Harold know, when did
he know it, and why wasn't it revealed?
Quotable quote from the study: This study provides the first evidence
in a large, prospective sample that the adverse cognitive effects can
persist for an extended period, and that they characterize routine
treatment with ECT in community settings.
For a detailed critique, see below.
For the past 25 years, patients who received electroconvulsive
therapy (ECT) have been told by the nation's top ECT doctor that the
controversial treatment doesn't cause permanent amnesia or cognitive
deficits and, in fact, improves memory and increases intelligence.
Psychologist Harold Sackeim of Columbia University also taught a
generation of ECT practitioners around the world that permanent
amnesia is so rare it could never be studied. Sackeim was the
popularizer if not originator of the position that former patients
who said the treatment erased memory were simply mentally ill and
thus not credible.
His newest and perhaps last ECT research study disproves his
tenaciously held claims about the treatment's harmlessness. It is, in
effect a stunning self-repudiation of a 25-year research career…one
in which he accepted federal research money with one hand and
consulting fees from shock machine companies with the other.
See, for instance, the key finding:
This study provides the first evidence in a large, prospective sample
that the adverse cognitive effects can persist for an extended
period, and that they characterize routine treatment with ECT in
community settings.
Similarly, from the abstract:
Despite ongoing controversy, there has never been a large scale,
prospective study of the cognitive effects of electroconvulsive
therapy
Sounds like the research team is congratulating itself for being "the
first," as if they'd made a discovery before anyone else, doesn't it?
You might think that…if you didn't know that Sackeim has held the
only available NIMH research grant to study ECT's adverse effects,
titled "Affective and Cognitive Consequences of ECT," continuously
since 1981…and if you didn't know what Sackeim promised the federal
government in his original application for grant funding:
"The major objective of the proposed research is to examine the
effects of bilateral and right unilateral electroconvulsive therapy
on affective and cognitive functioning. The consequences of the two
treatment modes will be studied in regard to neuropsychological
functions that have previously not been studied…Drug-free inpatients
presenting major unipolar depressive disorder will be tested before,
during and after treatment and a matched normal control group will be
tested at comparably spaced times."
Instead of doing this, however, he used his grant money largely to
compare different types of ECT to each other, not to examine the
effects of ECT; and only less than a handful of his 200+ published
studies used normal controls, an absolute necessity to isolate the
effects of ECT.
Why did it take 25 years to conduct one large, long-term controlled
follow-up study? And in the absence on this research, why did Harold
so confidently assure professionals, patients, legislators, and the
public that ECT was safe?
A closer look at the study shows us that, in fact, Harold and his
team are still not being honest with us, still not revealing all they
know. They tried their damnedest not to find out what ECT really does…
but failed. Here they reveal only the minimum information they had to
concede after using every trick in the book to bias their research in
favor of not finding negative effects of ECT.
What tricks did they use here?
1) The assumption that ECT does not cause permanent amnesia and
cognitive deficits was built into the design of the study. How so?
The study allowed subjects who'd had ECT before, as recently as two
months prior, to be counted as the "before ECT" patients–meaning
before this course of ECT. It assumed that any effects of ECT resolve
within two months. 43% of the subjects had had prior ECT, so that at
least half of the data involved comparing the effects of ECT to the
effects of more ECT–not isolating the effects of ECT.
2) The outcome measures used to measure amnesia and cognitive
function are irrelevant and inadequate to measure the known effects
of ECT. Yet even deliberately using measures that would result in
underestimating deficits, these deficits were still found to be
profound and persistent!
For a critique of the tests used by Sackeim, see Robertson and
Pryor's article, Memory and cognitive effects of ECT: informing and
assessing patients, in Advances in Psychiatric Treatment (2006), vol.
12, p. 228-238. For example, the Mini Mental Status exam used by
Sackeim is a test that screens for dementia, the grossest and most
glaring form of cognitive disability, and is useless for detecting
the kinds of deficits caused by ECT.
Sackeim uses a memory test he invented himself, the Autobiographical
Memory Inventory. This test is unpublished, not publicly available,
not validated, and is not used except by ECT advocates. Robertson and
Pryor note that the majority of questions are not relevant to the
types of information forgotten by ECT survivors, nor can the test
detect amnesia beyond a one-year period. A string of references in
Sackeim's new article attempt to provide support for the claim that
the AMI "has shown strong reliability and validity as a measure of
retrograde amnesia." Not only do they not show this, but all the
referenced articles were written by Sackeim himself!
3) Patient IQs were estimated pre-ECT using a method that
underestimates intellectual ability especially with much higher than
average IQs; no attempt was made to ascertain actual IQ. No one
looked at these patients' IQs post-shock to see what happened to
them; why not?
Sackeim et al. conclude, based on inaccurate assumptions and no data
from these or any other patients, that "Individuals with greater
premorbid abilities can better compensate for the impact of ECT on
cognitive functions" (references claiming to support this point have
nothing to do with ECT but are articles about an unproven theory
of "cognitive reserve").
Even if the researchers didn't choose to seek out survivors of ECT
who once had very high IQs, or to respond to the many survivors of
formerly superior IQs who have contacted them, there is a substantial
record of accounts by persons who had extremely high or genius IQs
who have spoken and written publicly of the devastating effects of
having those IQs lowered by ECT (Jonathan Cott, Linda Andre, Anne
Donahue, and Marilyn Rice are four such individuals.) None of these
accounts suggests that people with "greater premorbid abilities" have
an easier time after ECT; in fact, they strongly suggest the opposite.
In addition to these tricks, the researchers used one of the most
reliable methods of biasing results: concealing data.
1) "A substantial number of secondary cognitive measures" are said to
have been administered along with the named tests, yet the
researchers nowhere reveal what they were and what the results were.
2) The names of the seven facilities in the New York City
metropolitan area are not revealed. While this isn't necessary for
evaluating the results of the study, it means the facilities with the
worst outcomes can't be held publicly accountable, nor can the
millions of city residents protect themselves from the worst
offenders.
3) The results of the cognitive tests on the 24 control subjects are
not revealed, nor is how they compared to the people who had ECT.
It's a very big deal for the Sackeim team to use matched normal
controls; in 25 years and hundreds of studies they have not done so.
Normal controls are essential to ethical and valid research. This
article states that "The comparison sample completed the same
neuropsychological battery at time points corresponding to the
assessment period in patients." But you search in vain to find out
how the controls did on the five named tests of memory and cognitive
functioning and the unnamed "secondary measures", and how they
compared to the ECT patients immediately and six months after ECT.
It's not in the text, and it's not in the tables. So why have the
controls take the tests at all, if you're not going to reveal the
results?
Only one thing is revealed: The normal controls did much better than
the bilateral ECT patients on the (flawed) measure of amnesia:
"The average decrement in AMI-SF scores in patients treated
exclusively with BL ECT was 3.4 and 2.8 times the amount of
forgetting seen in the healthy comparison groups at the post-ECT and
6-month time periods, respectively, suggesting that the deficits were
substantial."
4) Sackeim does not reveal—has never revealed in hundreds of
published articles—his financial ties to the shock machine companies
Mecta and Somatics. Yet in sworn testimony, Sackeim admits he has
worked for Mecta for at least twenty years. He designs their shock
machines for them. Not only is disclosure required by journals such
as Neuropsychopharmacology (ironically, the subject of a recent
scandal in which authors and even the journal's editor did not reveal
their ties to another company which has hired Sackeim, Cyberonics),
it is also required by state law (because Sackeim is an employee of
New York State) and federal law (because Sackeim accepts NIMH money).
Sackeim flaunts these laws by not disclosing the money he makes from
the shock machine manufacturers.
This article is a damning critique of work done over 25 years (and at
the expense of millions of taxpayer dollars) by this very team of
researchers.
If you know that Sackeim's been funded for decades to do this
research and chose not to do it, the following statements read very
differently than the researchers intended. Instead of self-
congratulation, they read as condemnation.
"Empirical information about ECT's long-term effects derives mainly
from small sample studies conducted in research settings, with follow-
up intervals limited to two months or less…These studies could not
adequately assess the severity and persistence of long-term deficits."
The use of small samples and short-term follow-up characterizes all
of Sackeim's work until now, and was their choice, deliberately made
so as not to know (officially) about "the severity and persistence of
long-term deficits." These researchers single-handedly had the
wherewithal to address these belatedly-acknowledged flaws in their
own research at any time since 1981.
"We conducted the first large-scale, prospective study of cognitive
outcomes following ECT."
Why the first study only after 25 years? What of the generation of
patients—two and a half million people according to their own
estimate—who have received shock in those years without knowing the
long-term consequences?
"Severity of depressive symptoms showed little relationship with the
cognitive measures. At the post-ECT time point, none of the 11
measures were related to concurrent HRSD scores. Findings were also
negative for 8 of the 11 measures at the six-month follow-up."
Translation: patients aren't just imagining or lying about their
cognitive and memory deficits because they're crazy. Yet in many
published articles written on the NIMH dime, and over and over in
public testimony and in court, that is exactly what Sackeim and
Prudic have claimed. And they have influenced countless others to
believe it.
DAMNING FINDING #1: amnesia is substantial and permanent
"The average decrement in AMI-SF scores in patients treated
exclusively with BL ECT was 3.4 and 2.8 times the amount of
forgetting seen in the healthy comparison groups at the post-ECT and
6-month time periods, respectively, suggesting that the deficits were
substantial."
"At the six-month time point, there continued to be a significant
relationship between the number of BL ECT treatments and the extent
of retrograde amnesia."
"Greater amnesia for autobiographical events was significantly
correlated with the number of ECT treatments received 6 months
earlier."
DAMNING FINDING #2: cognitive deficits are substantial and permanent
"Compared to baseline performance, at the postECT time point the
total patient sample showed deficits in the mMMS, sensitivity of the
CPT, delayed recall of the BSRT, delayed reproduction on the CFT…"
(All are measures of memory and cognitive ability).
"This study provides the first evidence in a large, prospective
sample that the adverse cognitive effects can persist for an extended
period, and that they characterize routine treatment with ECT in
community settings."
DAMNING FINDING #3: ECT permanently affects reaction time
"Although psychomotor function is of practical importance with
respect to driving and other motor activities, the impact of ECT on
this domain has rarely been examined…"
(Once again: Whose fault is that?)
"The fact that relative reaction time deficits were observed at the 6-
month follow-up indicates a persistent change in the speed of
information processing, motor initiation, or response levels…The
findings here raise the concern that this form of stimulation has
deleterious long-term effects of elemental aspects of motor
performance or information processing."
DAMNING FINDING #4: Bilateral ECT is no good
"For decades, BL ECT represented the gold standard with respect to
ECT efficacy…A majority (of US ECT practitioners) administer mainly
or exclusively BL ECT…
There appears to be little justification for the continued first-line
use of BL ECT in the treatment of major depression."
(More than 90% of the ECT given in the U.S., and at least as high a
proportion in other countries, is bilateral.)
DAMNING FINDING #5 They lied when they wrote in the APA consent form
that ECT improves your memory
What this team has said in numerous published articles—and what
Sackeim wrote into the American Psychiatric Association guidelines on
ECT, the "bible" used by all rank and file shock doctors—that ECT
improves memory and intelligence, is not true.
"It is noteworthy that most cognitive parameters were substantially
improved at 6-month follow-up relative to pre-ECT baseline,
presumably because of the negative impact of the depressed state on
baseline performance…It cannot be concluded, however, that the extent
of improvement in any group returned to premorbid levels."
DAMNING FINDING #6: A much greater percentage of women than men are
damaged by ECT than men: 81% vs. 18%.
"There was a gender difference, with a greater preponderance of women
(81.6%) compared to men (18.4%) in the persistent deficit group."
No doubt Sackeim and his handlers will try to "spin" this study as a
scientific breakthrough, and hold him up as a reformer and patient
advocate. Nothing could be farther from the truth.
Where is the apology to the generation of people who were lied to,
who will never regain their memories and their cognitive abilities
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