SHOCK THERAPY IN THE FOR-PROFIT PSYCHIATRY ERA by Fred A. Baughman Jr., MD (3/14/96). [Baughman has contributed original descriptions of diseases to the scientific literature, is a neurologist, pediatric neurologist and medical writer] At New York's famed Mount Sinai Hospital, in the early sixties, a strange situation existed in which neurlogists, not psychiatrists, did electroconvulsive therapy (ECT) or "shock," albeit on patients said by the psychiatrists to need it. It was then, as a resident (trainee) physician in neurology that I assisted attending neurologists in administering "shock." treatments. I held electrodes to patient's heads, electricity passed through their brains producing convulsions indistinguishable from grandmal epileptic siezures of the sort that, as a neurologist, I did my best to prevent with anti-convulsant medications possible--of the sort that invariably cause global injury to the brain manifested by post-siezure memory loss and disorientation lasting minutes, hours or days. It is by virtue of this global injury to the brain, purposely inflicted that depression, and more, is eradicated. Given the resurgence of "shock" treatment and the notable targeting of the elderly, the in-depth report by Dennis Cauchon in USA Today, December 6, 1995, is especially timely. More than 250 scientific articles were reviewed, "shock" treatments were observed first-hand and dozens of psychiatrists, patients and family members were interviewed. It is this writer's opinion that the Cauchon-USA TODAY article is a more balanced view of modern-day "shock" therapy, it's risks and benefits, than one is likely to find in anywhere, including the medical and and psychiatric literature. The elderly are more fragile medically and have frequent cardiac problems increasing their risk for death and injury from "shock therapy. Pre-existing memory deficits (organic brain syndrome) often go undetected with "shock" therapy resulting in the permanent worsening of such deficits. The elderly are less suited as well for the repeated anesthesia required for each of the 6-12 sessions over 2 to 3 weeks. Before his suicide Ernest Hemingway wrote "What is the sense of ruining my head and erasing my memory...and putting me out of business? It was a brilliant cure...but we lost the patient." Five studies reviewed by the author disclosed that 3 of 372 (1/125) elderly patients died while 14 (14/372) or 3.8% suffered serious injury. The results of this review were in agreement with the 1957 study of David Impastato, a leading shock researcher of the time, who concluded "The death rate is approximately 1 in 200 in patients over 60 years of age and gradually decreases to 1 in 3000 or 4000 in younger patients." Neither do those who survive "shock" initially, live long happy lives thereafter. In a 1993 study, 27% of "shock" patients 80 years of age and older, were dead within a year compared to 4% of a similar group treated with medication. At 2 years. 40% of the "shock" treatment group were dead vs. 10% in the medication group. "We've learned nothing from the mistakes of my generation" says psychiatrist Nathaniel Lehrman, 72, retired clinical director of Kingsboro State Mental Hospital in New York. "The elderly are the people who can least stand" shock. " This is gross mistreatment on a national scale." All of this, and still the American Psychiatric Association (APA) insists in their model "informed consent" that the "operative death rate" for "shock" therapy is 1/10,000. To enable patients (or their surrogates) to decide whether to undergo surgery or treatment of any sort, the physician(s) has a legal duty to provide the best available information with which the patient then makes an "informed consent." (Natanson v. Kline, 1960) If the "operative death rate" for shock therapy in the elderly is 1/200 (or thereabouts) but is falsely represented in obtaining "informed consent" to be 1/10,000, such a misrepresentation would be tantamount to medical malpractice. What about the resurgence of "shock" therapy? What factors are at work? The elderly account for more than half of the estimated 50,000 to 100,000 patients who get it each year, with women in their seventies getting more "shock" treatment than any other group. Lest we get the idea that there is an real epidemic afoot, consider the fact that in Texas--the only state that requires close record-keeping on such things--65 year-olds get 360% more "shock" than 64 year-olds. Could it be that the critical difference is that "shock" and all else medical is suddenly so much more reimbursable in 65 year-olds with their Medicare cards? Medicare paid for 31% more shock treatments in 1993 than in 1986. Cauchon and USA TODAY pondered to what extent financial incentives might be increasing the use of "shock." Psychiatrists, they note, charge $125 to $250 per shock for the five to 15 minute procedure with the anesthesiologist getting $300; $375 for use of the hospital shock treatment room and $890 per day for the hospital room. To fully understand the resurgence of "shock" therapy one must understand the origins of the US health care crisis; why health care expenditures overall have risen from $50 billion/ year in 1965 to a $trillion annually today and how, in the process, US medicine has become "dollar (reimbursement)-seeking" instead of "health-seeking." >From 1965 to the present the number of US physicians has grown four times the rate of the population, from 300,000 to 700,000, equating to 40% fewer patients (and less disease) for each physician. Their incomes would have been expected to drop, but did not. By "provider-induced need" that is, by increasing the "volume" and "intensity" of prescribing they have enjoyed a steady 5.5.% yearly increase in average net income to $189,300 in 1993. In this new market-place scheme of things every physician had become a "cost center" and every physician-patient encounter a source of profit-taking . Nowhere is the physician glut more pressing than in psychiatry. With fifty percent of mental health now in managed care and managed care turning to family practitioners, psychologists and social workers to provide such care, some estimate that half of the nation's 36,000 psychiatrists will be out of business when mental health is fully under managed care. Is it any wonder that they invent "diseases" and prescribe--not what the patient needs--but what is reimbursable. 1992 Congressional hearings entitled " How Inpatient Psychiatric Treatment Bilks the System and Betrays Our Trust" heard of hundreds of millions of dollars in fraudulent billings, of thousands of adolescents, children and adults hospitalized for care they didn't need, for periods coinciding with the extent of their insurance benefit; of bounties paid to school and law enforcement personnel and even clergy for referrals; of the targeting of military personnel because of the liberal mental health benefits under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) and of invented psychiatric diagnoses such that "everyone in this room will fit into two or three diagnoses" and that "Every new disease that's defined gets a new hospital program, new admissions, a new system and a way to bilk it..." Where shock therapy and all else in US for-profit medicine and psychiatry is concerned: "Caveat Aeger--Let the patient beware."