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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Additional intellectual prolonged losses after ECT
- Judith Ronat (20 June 2003)
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Problems with this review
- Chester A Pearlman (23 June 2003)
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Valuing memory loss
- Keriata Stuart (23 June 2003)
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Does underlying depression, or ECT itself, cause amnesia after ECT?
- Jeremy Seymour (23 June 2003)
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Re: Valuing memory loss
- Chester A Pearlman (24 June 2003)
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Re: Does underlying depression, or ECT itself, cause amnesia after ECT?
- Linda Andre, none (24 June 2003)
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Still arguing....
- Sue Kemsley (24 June 2003)
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What would high quality collaborative research on ECT deficits look like?
- Linda Andre, (none) (25 June 2003)
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How many times do they have to say it?
- susanne stevens, n/a (25 June 2003)
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Nothing New Here
- anthony t frais (28 June 2003)
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Re: How many times do they have to say it?
- William Plummer (2 July 2003)
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Re: Re: How many times do they have to say it?
- Linda Andre, N/A (3 July 2003)
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Re: Re: Does underlying depression, or ECT itself, cause amnesia after ECT?
- Janice Campbell (4 July 2003)
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Re: Re: How many times do they have to say it?
- Sue Kemsley (5 July 2003)
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Allowances for clustering.
- William Plummer (6 July 2003)
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Electronconvulsive therapy causes memory loss, say patients
- Campbell McInroy (21 July 2003)
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Editor's reply
- Richard Smith (21 July 2003)
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ECT works for acute depression as it makes you lose your recent memory.
- Yasuo Ishida, St. Louis, MO 63ll7 (18 August 2003)
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Re: Additional intellectual prolonged losses after ECT
- Sissy Perry (24 September 2003)
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Judith Ronat, Medical Director Rosner Community Mental Health Center of Rishon L'Zion
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Three points: In addition to memory loss, my patients have complained about inability to memorize new material. An example was a pianist who could no longer learn to play by heart. Many years ago, Berton Rouche wrote a piece (in the New Yorker Magazine) about a high level researcher working for the US Government who complained that she had lost the ability to think abstractly. Clinicians are not a homogeneous group. Clinicians who have no personal, professional interest in proving that ECT is harmless might use different measures and come to different conclusions than those who have such interest. Judith Ronat Competing interests: None declared |
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Chester A Pearlman, Clinical Professor, Boston Univ School of Medicine 21 Elba St. Boston MA 02446
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The review is seriously flawed by obsolete information (much of it >20 years old) and failure to consider advances in technique that have increased patient satisfaction and reduced cognitive side effects. The UK ECT Review Group was critical of current procedures in the United Kingdom. Thus, there may be problems that do not occur in places without such deficiencies. For a recent discussion, cf. my editorial.1 1. Pearlman C. Electroconvulsive therapy in clinical psychopharmacology. J Clin Psychopharmacol 2002;22: 345-6. Competing interests: None declared |
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Keriata Stuart, Student, Master of Public Health University of Otago
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This study is a sad reminder both of how differently lay people (including patients) and clinicians can view the world, and of how much clinicians' views continue to be privileged. As a non-medical researcher, it would never have occurred to me that it was possible to define "memory loss" excluding the loss of a person's autobiographical memories. Surely the memories of one's wedding, the birth of a child, or of scoring the winning goal in the game, are core elements of one's perceived identity. To most of us - including members of the Royal College of Psychiatrists, I believe - their loss would be as irreplaceable and shattering as an amputation. While the benefits of ECT may well outweigh the costs, presenting a false picture of possible outcomes is likely to lower patients' faith in the procedure rather than increase it. Competing interests: None declared |
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Jeremy Seymour, Consultant in Old Age Psychiatry Nether Edge Hospital, Sheffield S11 9BF
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Rose et al(1), as part of a wider systematic review, aggregated 7 studies and found that 29 - 55 % of patients treated with Electroconvulsive Therapy (ECT) reported persistent memory loss, which the authors assert is "clinically important". Carney and Geddes, in the accompanying editorial(2), report that this commissioned review on patient experience was influential in formulating NICE Guidance on ECT. However, only one of their 7 studies used a control group, and that 20 year old study had other methodological flaws, particularly in the samples used(3). Anyone who has spoken to patients recovered or partially recovered from major depression, or has suffered with it themselves, knows that major depression itself can cause amnesia and other cognitive impairments - this is supported by a substantial literature(4). Was the retrospective report of amnesia therefore caused by ECT, or by the depressive illness itself? Until a prospective, randomised controlled trial is performed, this question cannot be answered, and the aggregated retrospective data of Rose et al is of very limited value. This is not evidence-based medicine at its best. References (1) Rose D, Wykes T, Leese M, Bindman J, Fleishmann P. Patients perspectives on electroconvulsive therapy : systematic review. BMJ 2003; 326 : 1363-65. (2) Carney S, Geddes J. Electroconvulsive therapy. BMJ 2003; 326 : 1343-44. (3) Squire L R, Slater P C. Electroconvulsive therapy and complaints of memory dysfunction : a prospective three-year follow-up study. Br J Psychiatry 1983; 142 : 1-8. (4) Abas M A, Sahakian B J, Levy R. Neuropsychological deficits and CT scan changes in elderly depressives. Psychol Med 1990; 20 : 507-20. Competing interests: None declared |
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Chester A Pearlman, Clinical Professor, Boston Univ. School of Medicine 21 Elba St. Brookline, MA 02445
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Neither the review nor the responses regarding memory loss mentioned the most sophisticated study of this subject: Lisanby SH, Maddox BA, Prudic J et al. The effects of electroconvulsive therapy on memory of autobiographical and public events. Arch Gen Pschiatry 2000;57: 581-90. They found no change from baseline or normal controls in autobiographical memory two months after ECT. The accompanying comment by Weiner R. 57: 591 -2 noted examples of isolated and highly variable loss of autobiographical memory. While there was more impairment of memory for public events, especially with bilateral ECT given thrice weekly, no evidence of inability to relearn this information has been reported. Competing interests: None declared |
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Linda Andre, none New York NY 10025, none
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First, the "memory loss" sometimes associated with depression is a temporary attentional deficit, not total or near-total amnesia (Sternberg DE, Jarvik ME. Memory functions in depression. Arch Gen Psychiatry 1976; 33:219-224; Steif BL, Sackeim HA, Portnoy S, Decina P, Malitz S. Effects of depression and ECT on anterograde memory. Biological Psychiatry 1986;21: 921-930). Someone who's depressed may have trouble remembering some things about the period of depression; someone who's had ECT may very well not remember ever being depressed at all. The memory loss caused by ECT is quantitatively and qualitatively different from the dysfunction associated with depression (Squire LR, Bouzoukis J, Self-ratings of memory dysfunction: different findings in depression and amnesia. Journal of Clin and Exp Neuropsychology 1988;10(6): 727-738), as anyone who's experienced both depression and ECT knows (Donahue A. Electroconvulsive therapy and memory loss: a personal journey. Journal of ECT 2000; 16(2): 133-143). Depression does not affect memories of the period when one was not depressed, unlike ECT, and never erases months or years of life completely. With ECT, patients don't just lose memories of the period when they were depressed, but also memories of when they were not. It is clear to me from all accounts that the years I forgot were the best of my life. There is quite simply no evidence that persons who experience depression but have never had ECT experience the characteristic amnesia and memory/cognitive deficits reported by persons who have had ECT. Second, persons who have experienced ECT and who are not depressed or otherwise symptomatic, including those who never again experience depression, have permanent memory loss (Freeman CP, Weeks D, Kendell RE. ECT II: Patients who complain. Br J Psychiatry 1980; 137:8-16; Squire LR, Slater PC. Electroconvulsive therapy and complaints of memory dysfunction: a prospective three-year follow-up study. Br J Psychiatry 1983;142: 1-8). It's hard to understand why contemporary researchers haven't designed a study in which the memory and cognition of persons who have had ECT but who are free of psychopathology and drugs have been tested. This would be the scientific way to test the "they're just depressed" theory. However, one researcher gave me some insight into the reason: he told me such a study would be impossible because (he believes) by definition no one who has had ECT can ever recover. Competing interests: The writer is a survivor and unpaid researcher of ECT. |
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Sue Kemsley, None None
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Psychiatrists knew the truth about ECT right from the beginning. This for example was written in 1946 (although there are many people who have had ECT in recent years who will recognise their own experience in this description): "The dangers of shock treatment, apart from physical injury, are several. There is a possibility of damage to the brain substance. Furthermore, convulsions not only result in amnesia for the fits, but also in large memory gaps which may extend far back into the past. For skilled workers and those whose livelihoods depend on intellectual effort there is a real loss of efficiency. Another recorded phenomenon is a mood swing from depression to hypomania or even acute excitement. Occasionally, improvement persists only whilst the treatment is being given. This implies the administration of maintenance shocks for long periods with no promise of permanent benefit." (Beccle 1946) So why are we still arguing? Because they have been trying to cover up the truth ever since and trying to persuade us that memory loss is a figment of patients' illness. If half as much effort had been put into trying to find ways to reduce the memory loss (and persuading all psychiatrists to adopt them) or into an honest debate about the circumstances in which unavoidable damage may be acceptable, then perhaps ECT wouldn't be so controversial and we wouldn't need NICE as an umpire. Beccle, HC. Psychiatry. London: Faber and Faber Ltd, 1946. Competing interests: None declared |
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Linda Andre, Committee for Truth in Psychiatry New York NY 10025, (none)
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SURE is right to recommend further study of the extent of permanent amnesia by the methods used by Irving Janis (Journal of Nervous and Mental Disease 1950; 111). Survivors of ECT as well as professionals have been calling for a replication of his work for decades, using a narrative approach and an unstructured interview. Most strikingly, he published excerpts from transcripts of the before-and-after interviews which are chilling to read and leave no doubt as to the seriousness of the losses experienced by these patients which persisted as long as he studied them (one year). Instead of this sensible approach, U.S. ECT researchers have designed checklists focusing on very old, overlearned biographical facts---the kind of information survivors know is least likely to be forgotten. When a survivor has lost her college education, it is little solace that she remembers her first grade teacher's name. Or else the tests are so trivial that losses are not taken seriously. If you give a test that shows a patient cannot recognize Princess Diana, you need not report that she has forgotten her own husband and children (Warren CAB. Electroconvulsive therapy, the self, and family relations. Research in the Sociology Of Health Care 1988). In the United States, there is a contemporary archive of reports from survivors of ECT at the government's Food and Drug Administration (#82P- 0316). Only a handful of hundreds of patients report satisfaction with their outcomes; others tell in detail not only of permanent amnesia and its effects on their lives, but of permanent deficits in memory and cognitive function. We hear so much about the costs of untreated depression. Read the FDA files, which are public, and in which so many survivors report careers permanently ended by ECT (just as in the Roueche article mentioned by the previous responder). When benefits are temporary and adverse effects permanent, it is the treatment which is more costly to patients and to society. A full investigation of ECT's longterm effects is essential to any cost-benefit analysis of this procedure---and is necessary so that patients may give or withhold fully informed consent. But U.S. government research grants are monopolized by investigators who are financially conflicted [1]; all of the available research funding to study "cognitive consequences of ECT" is locked up for the next decade by the man who designs the Mecta ECT machines. His team (and others) chooses hopelessly irrelevant tests like the MiniMental Status Exam and paired- words and then proclaims that survivors have no cognitive deficits or even that ECT raises IQ. For instance, if a person remembers that oranges do not move about searching for food she is said not to have memory deficits. But those who have used more discerning tests have found deficits (ref. 27). Meanwhile survivors, terrified by functional losses, have sought out- --individually and at our own expense--- the type of full neuropsychological evaluation these researchers should be doing. When these results are pooled (as they are at the FDA, and as we have done informally for years) not only are they indicative of brain injury but they show the same pattern of deficits in a way that would seem highly unlikely to be due to chance. Of particular concern are dramatic losses of 30 to 40 points in IQ---losses that, if they appear at all in the professional literature, have been made to disappear by various techniques like reporting mean scores and overanalyzing data (i.e., Squire L. A Stable Impairment in Remote Memory, Neuropsychologia 13, 1975). Survivors have the knowledge of ECT memory and cognitive deficits and how to measure them; professionals largely control the resources that make it possible to study them and to publish the results. Rose shows us that what is needed is exactly the "genuinely collaborative high quality research" Carney calls for. But who is willing and able to do this work free of financial and career conflict? And who will pay for it? [1] VAPA Task Force Report on ECT, 2001,"The Practice of Electroconvulsive Therapy" Competing interests: The writer is a survivor and unpaid researcher of ECT. She has spent nearly twenty years listening to persons who have had ECT. |
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susanne stevens, retired cardiff cf 24 3pf, n/a
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This is an admirable piece of research but it is yet another which in many respects repeats what those on the rceiving end of ECT have been saying for decades. When it is known to cause as much repugnance,harm and distress why is there still such a stubborn need to retain it? S. Bhat (psychiatrist in 'geriatric psychiatry' in the May edition of the Journal of Psychiatry has suggested that the main group for whom it should be retained are elderly and frail people because they cannot tolerate antidepressants as well as others. He is concerned that trainees will not receive enough practice in giving ECT. ECT could still be given against a person's will unless very strong personal directives are complied with by psychiatrists. At the end of a life elderly people often have no family or other advocates, at least it is possible to put an advance directive on file. Competing interests: None declared |
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anthony t frais, co.director leeds
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It appears that the Rose review (1) does in truth, add very little to that which is already known on the subject. Not that it is the fault of this particular research group. They have undertaken to carry out this review as specified and funded by another party. But it does seem a shameful waste of time, energy and talent which could have been better directed in producing a much needed fresh survey using questions designed to go some way in answering any uncertainties about patients perspectives on ECT treatment not adequately covered by older reviews. Better information can only serve to help prospective patient users and indeed, their consultants in treatment decisions. Until such time, a reminder that depression is a crippling, debilitating and life-threatening illness. ECT may have some undesirable side effects - a minority of patients being more adversely affected than others. However, is this so very different to some of the more damaging side effects of standard anti-depressant drug treatment which may even lead to,as has been alleged,suicide. As ECT can also be a life saver, (2) it should be left on the table as a treatment option for those patients considered to be suitable candidates. 1. Rose D, Wykes T, Leese M, Bindman J, Fleishmann P. Patients perspectives on electroconvulsive therapy : systematic review. BMJ 2003; 326:1363-65. 2. The UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003;354:1369. Competing interests: None declared |
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William Plummer, Consultant Psychiatrist St Martin's Hospital, Canterbury, Kent CT1 1AZ
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Sir, Susanne Stevens may or may not be re-assured to know that in the United Kingdom ECT can not be given without a patient's explicit informed consent unless certain rigorous safeguards are complied with. If a patient were not willing to undertake this treatment no responsible psychiatrist would even consider ECT unless they believed it could be a life-saving treatment in a question of life or death. For example, in patients who are so depressed that they are no longer eating or drinking. In situations like this, antidepressants would take too long to work (Antidepressants take at least two weeks. The effect of ECT is much quicker and can be immediate.) and may not be given reliably by mouth. The patient would need to be assessed by two doctors, one of whom is independent of the unit where the psychiatrist works, and a social worker. The nearest relative must be identified and consulted unless there are genuine reasons why this cannot be done. If all are in agreement that the patient were 1)suffering from a mental illness, 2)that as a result of this they were at risk to their life or health and 3)that the illness is of a nature and degree that warrents treatment in hospital, then the patient could be detained in hospital under the provisions of the mental health act. This would allow most treatments to be given without the patients's consent, but not ECT. In order to give ECT there is a further safeguard. The patient must be examined by a specialist appointed by the Mental Health Act Commissioners. Only after this second opinion is obtained, and only if the second opinion doctor agrees that ECT can be given will the treatment be given. I must emphasise that these safeguards apply to anyone who cannot give explicit consent for treatment, even if other evidence suggests that they would normally give consent (such as willingly having had ECT in the past). In the face of an explicit refusal to have ECT, whether given as an advance directive or at the time it is suggested, I personally would be reluctant to prescribe it, even in extreme circumstances, as long as I was assured that the patient's decision was based on an informed understanding of the benefits and side-effects of the treatment. I must add, however, that under the proposed legislation for a new Mental Health Act, whose introduction into Parliament has been delayed, many of these safeguards would be removed. I myself would not welcome this. Competing interests: I am a consultant psychiatrist. I have used ECT in circumstances similar to the current NICE guidelines, but am not a strong advocate for it. |
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Linda Andre, N/A USA 10025, N/A
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William Plummer wrote: "I personally would be reluctant to prescribe it, even in extreme circumstances, as long as I was assured that the patient's decision was based on an informed understanding of the benefits and side-effects of the treatment. " Here is the crux of the matter: patients and doctors disagree on the benefits and "side"effects of ECT; doctors believe they are right and patients are wrong, and then their patients viewpoint is equated with "lack of insight and understanding" is used to justify forced ECT. Forced ECT is common in the U.S. and this is exactly why played out in a publicized trial in New York State. Doctors of Paul Henri Thomas testified that he was not competent to consent to ECT because he believed it would harm him. (He had had previous ECT). The same doctors testified that they "knew" studies by the US Food and Drug Administration had proven ECT safe (there are no such studies), or because they read this in some textbook. Those who dismiss the SURE study as "nothing new" don't understand how it may change the balance of what is officially "known" about ECT in favor of what has always been known by patients. This will hopefully have an impact in the U.K. and far beyond. If the SURE study had been available earlier, I would have given it to the attorneys in the Thomas case. Oh---what happened to the patient in that case? There was no decision. After testifying that nothing else but shock could save him, the doctors decided he had gotten better on his own, and he was released without treatment. Competing interests: The writer is a survivor and unpaid researcher of ECT. |
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Janice Campbell, N/a N/a
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A recent article in the American Journal of Psychiatry states, “The role of depression in causing a reversible dementia or pseudodementia has been known for a long time.” (1) As Seymour remarks, “this is supported by a substantial literature.” (2) But what the article in question adds is a longer-term perspective, enabling its authors to report that the type of cognitive decline (after a stroke) which is amenable to reversal with successful treatment of the causative depression is distinguished by the fact of its reversibility. Insofar as the depression for which ECT (electroconvulsive therapy) is given results in cognitive changes of the reversible variety – what Andre terms “a temporary attentional deficit” (3) – such changes really shouldn’t be complicating assessment of impairment following ECT. For one thing, blaming continuing depression undermines the idea of ECT as an effective treatment for depression. Logically, neither it nor anything else may be described as effective if cognitive impairment following treatment persists. This is what Rose et al. state is being claimed by up to 55% of recipients – a figure reflecting 20-year-old reportage by Squire and Slater. They noted, “About half the patients prescribed bilateral ECT subsequently felt that their memory had never returned to normal; and even when all the patients prescribed bilateral ECT were considered as a group, ECT changed the quality or pattern of memory complaints in a lasting way.” (4). Andre also states, “The memory loss caused by ECT is quantitatively and qualitatively different from the dysfunction associated with depression (Squire LR, Bouzoukis J, Self-ratings of memory dysfunction: different findings in depression and amnesia. Journal of Clin and Exp Neuropsychology 1988;10(6): 727-738).” (3) The article in Am. J. Psychiatry (2003) lends support to the understanding that there are two distinct kinds of cognitive dysfunction. Seemingly, in “patients with early and sustained remission of depression, there was rapid improvement of cognitive function, which was maintained over 2 years,” whereas “cognitive deterioration due to ischaemic brain damage does not improve between 1 month and 24 months poststroke.” (1) If depression after stroke is treatable, why do psychiatrists who promote ECT find it so difficult to ensure rapid remission of depression in order to maximise the cognitive functioning of patients – which would also render the supposedly rare instances of cognitive damage attributable to ECT easy to spot? At present, depression and ECT are deemed to interact in ways too complex to make establishing causation of the cognitive decline feasible. However, the article to which I refer concludes, “Cognitive impairment due to post-stroke depression is reversible and can be quantified separately from cognitive impairment on the basis of the location and extent of ischemic brain damage.” (1) In short, research which focused on cognition and depression indicates that it is possible to assess the cognitive dysfunction of depression separately from impairment due to brain damage. So surely ECT psychiatrists should be capable of distinguishing the cognitive effects of the one from those related to the other, similarly employing appropriate neuropsychological testing to quantify the two types of cognitive deterioration as these occur post-ECT. 1. Kenji Narushima et al. Does Cognitive Recovery After Treatment of Poststroke Depression Last? A 2-Year Follow-Up of Cognitive Function Associated With Poststroke Depression. Am. J Psychiatry 160: 6, June 2003, 1157-1162 2. Seymour S. Does underlying depression, or ECT itself, cause amnesia after ECT? Rapid Responses, BMJ, 23 June 2003 3. Andre L. Re: Does underlying depression, or ECT itself, cause amnesia after ECT? Rapid Responses, BMJ, 24 June 2003 4. Squire L R and Slater P C. Electroconvulsive Therapy and Complaints of Memory Dysfunction: A Prospective Three-Year Follow-up Study. Brit. J. Psychiatry (1983), 142, 1-8 Competing interests: None declared |
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Sue Kemsley, None None
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The degree to which William Plummer's "rigorous safeguards" (detention under the Mental Health Act and a visit from a psychiatrist from the Mental Health Act Commission's panel) protect patients is debatable since these "second opinion" psychiatrists very seldom refuse to authorise ECT. But in any case there are some people in the UK who are given ECT without their consent and without even these safeguards. Every year in England about one hundred informal patients are given ECT without their consent and a further 300 patients are detained but are given ECT before a visit from the MHAC psychiatrist. William Plummer says he would be reluctant to give ECT to someone who is explicitly refusing it, but there are other psychiatrists who do not show such reluctance. Nearly half of the 2000 or so people a year in England and Wales who are given ECT without their consent under section 58 of the Mental Health Act (that is, after a visit from the MHAC psychiatrist) are in fact considered to be "capable but refusing" rather than incapable. (1) Scotland's new mental health legislation will give capable patients the right to refuse ECT. (2) The government in London however rejected calls (from, for example, the Richardson Committee on reform of the Mental Health Act and the majority of responses to the government's consultation document including the response from the Royal College of Psychiatrists) for a similar right for patients in England and Wales. Guidance from the National Institute for Clinical Excellence meanwhile appears confused. While they say that "valid consent should be obtained in all cases where the individual has the ability to grant or refuse consent" and that "the wishes of the patient must be of paramount importance", they then make an exception for individuals detained under the Mental Health Act, which rather defeats the purpose. Earlier this year a woman who was threatened with ECT took her case to the High Court. The case was never heard, since the hospital decided that she no longer needed ECT. (3) 1) Mental Health Act Commission, 1999, Eighth biennial report. London: Stationery Office. 2) Scottish Parliament official report, 20 March 2003, column 19734. 3) http://news.bbc.co.uk/1/low/health/2777301.stm Competing interests: None declared |
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William Plummer, Consultant Psychiatrist St Martin's Hospital, Canterbury, Kent. CT1 1AZ
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I have some technical questions which I hope the authors of this paper will clarify when they make a reply to this correspondence. In the statistical analysis, tests for heterogeneity showed good evidence of heterogeneity between studies in answers to wheher ECT was helpful and whether the subject would have it again. In view of this, it is necessary to allow for clustering in the logistic regression which was carried out to examine associations between these outcomes and the methodological quality of the studies. No mention of this is made in either the printed or electronic form of the paper. It is very easy to allow for clustering in STATA by using the 'cluster()' option in logistic regression and more sophisticated analyses can be carried out by using 'xtlogit'. Can the authors kindly confirm that this was, in fact, done? In view of the correlations between the various measures of methodological quality, can these all be included together in a logistic regression model to give mutually adjusted measures of association with the study outcomes? Or are the results reported already adjusted in this way? The authors of this study assigned a percentage value for the main outcome measures to each of the studies they identified in their literature search. In some cases they would have had to exercise little choice or judgement - where there were simple study designs consisting of a few questions with binary outcomes. In other cases, much more subjectivity and judgement had to be used in assigning a percentage value. Where many questions were used in the original study the authors of the present study had to decide which questions were relevant and how to combine relevant questions into a single overall measure. Where the outcome was a Likert scale, or more complex scale, a cut-off point had to be determined. It is clear that where the authors had little choice in assigning a percentage value the results favour ECT and the more choice they have, the results are less and less favourable to ECT. This association is statistically significant. The obvious interpretation of this would be that the authors are biased against ECT. To challenge this suggestion, the authors need to establish the objectivity of their assessments by publishing the results of the reliability studies which they carried out for this investigation. It would also be helpful if they could triangulate their results with some other objective measures of outcome. For example, how do their judgements for each study compare with the conclusions of the authors of the original papers on which this present study is based? Competing interests: I have a research interest in the use of statistical methods in studies where clustering occurs. |
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Campbell McInroy, Retired Glasgow G66 1EP
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When was this picture [accompanying the paragraph for This week in the BMJ] taken? It appears to depict circumstances that are old enough to be "historic", and it would be appropriate in a museum of medical treatments. When illustrating a treatment currently in use, you should choose an up to date picture, not one that is old fashioned and gives rise to subtle negative spin. "Spicing up" of this kind is a deception and wrong. CAMPBELL McINROY Competing interests: None declared |
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Richard Smith, editor BMJ
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Dr McInroy objects to the use of a picture taken in 1942, but I'm not sure that everybody would agree. We use pictures primarily to break up the monotony of the text. Our first requirement of pictures is that they be visually strong. Even this requirement can be hard to achieve, particularly when the pictures are small. Secondly, we want the picture to be relevant, and again this can be surprisingly hard to fulfil. Thirdly, we like the picture to add extra useful information. This requirement is best achieved with graphs, but they tend to be visually weaker. The picture to which Dr McInroy object fulfils all three criteria. It fulfils the third requirement in that it gives a sense of how ECT used to be applied. Dr McInroy argues that use of such a picture is deceptive and wrong, but I don't agree. I think that it will be obvious to everybody that this is a historical picture, and I can't believe that it will have a very powerful effect on how people interpret the study that we reported. Certainly people have strong opinions about ECT, but I find it hard to believe that use of this picture will make much difference to anybody's beliefs. Competing interests: See text of letter |
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Yasuo Ishida, none 6744 Clayton Rd #302, St. Louis, MO 63ll7
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Dear Editor: That electroconvulsive therapy (ECT) causes memory loss (D Rose et al BMJ 2003; 326:1363-5) is not at all surprising. I encountered ECT many years ago as a senior medical student. My mentoring psychiatrist labeled ECT as ‘brain frying. ‘No textbook offered satisfactory explanation how it worked. Therefore, over the years, I have developed my own theory of ECT as ‘crude’ treatment as it relates to memory loss. Consider Domain I - a see of information bits. With an energy input of a certain amount, these bits are arranged into some patterns depending on the kind of memory required; e.g., telephone number: 32l-9876 may require a simpler scheme, while facial recognition a much more complex designs. (Domain II) With an additional energy input, these strands are wound into various segments of a Master bobbin. (Domain III) With ECT, these processes are reversed, i.e., the stored memory is lost as the strands are unwound, and information bits are separated. If acute depression is caused by recent events, then, by erasing corresponding memory by ECT, depression may be ‘cured ‘. These bobbin-segments may be intertwined. The deep memory is more difficult to unravel by external means, but internally a short-circuit may develop. Chronic brain illness may expose memory of childhood by unwinding interposing layers, but it will take time and or much force. In summary, ECT may be effective for acute depression caused by recent events which are ‘stored’ as recent memory bit-strands. Competing interests: None declared |
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Sissy Perry, patient 27549
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Am treatment resistant bipolar 1; was in a suicidal depression in late 2001 and had ECT as a last resort. It was not successful. I, too, am a pianist; can no longer memorize or play to performance level. Long- term and short-term memory in all areas still affected. ANY doc who recommends ECT for a patient should have to undergo treatment him/herself so that memory side effects will be understood! Competing interests: None declared |
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