What accounts for the huge increase in the number of children diagnosed with attention deficit hyperactivity disorder (ADHD) and the use of Ritalin? Dr. Lawrence Diller analyzes the explosive growth of the ADHD diagnosis and Ritalin use.

I've practiced behavioral pediatrics in an affluent San Francisco suburb for over twenty years. In that time I've evaluated and treated nearly 2500 children for a variety of behavior and performance problems. I never imagined during my early years of practice that one diagnosis would so come to dominate not only my work, but America's children in general.

That diagnosis is attention deficit hyperactivity disorder, or ADHD.

A Diagnosis on the Rise

I had always encountered hyperactive children or kids who performed poorly at school. Stimulant drugs, the best known of which is Ritalin(methylphenidate), have always been one of the interventions I used to help these children and their families. These children were mostly boys, aged six to thirteen. But in the early 1990's, I began to see with increasing frequency a new type of ADHD candidate. These children were both younger and older than the previous group that met my criteria for ADHD and received Ritalin. There were also many more girls. Some of them weren't even kids. Older teenagers and adults (initially the parents of the children I evaluated for ADHD) wondered whether they too had ADHD.

But most strikingly, these new candidates for the ADHD diagnosis were far less impaired in terms of behavior and performance than my earlier patients. Many of these children behaved quite well in my office. Many were getting passing grades, even B's, at school, but were not "meeting their potential." Most of these children tended to have their biggest problems at school, or only at home when it came to doing homework.

Did Tom Sawyer have ADHD?

Boys still predominated over girls in the number presenting for evaluations for ADHD. But their problematic behaviors could just as well be viewed as an extreme of the normal variations one attributes to the male gender. Indeed, I began to wonder if boyhood, at least in my community, had become a disease. I mused if Mark Twain's Tom Sawyer walked into my office in the late 1990's whether or not he too after several visits might also leave with a prescription for Ritalin.

Ritalin production up 740 percent

I became interested in the ADHD epidemic I was witnessing and quickly learned that my experience wasn't unique. Stimulants are, by far and away, the predominant medical treatment for ADHD and are prescribed overwhelmingly for only that indication. In that sense, they serve as a marker for how much ADHD is being diagnosed in the population. Because stimulants are abusable, the Drug Enforcement Administration (DEA) tightly monitors and controls their legal production and distribution in the U.S. The DEA's records showed that between 1991 and 2000, annual production of methylphenidate rose by 740 percent, or over fourteen tons produced per year. Production of amphetamine, the active ingredient of Adderall and Dexedrine, two other stimulants used for ADHD, multiplied twenty-five fold during the same period. In the year 2000, America used eighty percent of the world's stimulants.

Most of the other industrialized countries use Ritalin at one-tenth the American rate. Only Canada, which uses half our per capita rate, comes close to using stimulants the way we do.

Many have hailed the increase of Ritalin use in our country as simply a treatment catching up to a previously under-diagnosed condition. Others are alarmed at this unprecedented rise in the diagnosis of ADHD and Ritalin use in America. Whether good or bad, this large rise in Ritalin use tells us a great deal about the way we view and address problems of children's behavior and performance at the beginning of the 21st century.

Patterns of Prescription

The answer to the question "Is Ritalin over-prescribed or under-prescribed?" is "Yes". It depends on the community you assess, and its threshold for the ADHD diagnosis and Ritalin use. Ritalin use rates from DEA data (reported in several research studies and most recently by the Cleveland Plain Dealer's county-by-county national survey) widely vary within the U.S.—from state to state, community to community and even school to school.

For example, Hawaii perennially is the state with the lowest per capita Ritalin use in the nation. Hawaiians typically use Ritalin at one-fifth the rate of the highest using states, which tend to be eastern states like Virginia or Midwestern states like Michigan. There are various "hot spots" of Ritalin use. The best documented is a three-cities cluster in the southeast corner of Virginia, where one in five white boys was taking Ritalin at school (G.Lefever, ET AL, American Journal of Public Health, September, 1999). Overall rates were probably higher than twenty-five percent since many children only take medication at home before the start of the school day. The DEA maintains that virtually every state has pockets of high use rates that are centered near a college campus or clinic that specializes in the evaluation and treatment of ADHD.

Racial/ethnic disparities

At the same time, there are areas where Ritalin is hardly used at all, especially in rural areas (the Cleveland Plain Dealer featured a county in New Mexico) and within the inner city.

Socioeconomic differences or unequal access to care are not the only reasons for differences in diagnosis and stimulant use rates. There are clear ethnic differences between who does and doesn't use Ritalin. African American children are conspicuously absent in the ADHD/Ritalin epidemic. Missing too are children from Asian American families, though the reasons for the under-representation are different for both groups.

On average, neither group tends to trust or utilize mental health services as frequently as white Americans. Many Asian American families simply raise their children differently in the early years, employing stricter standards and techniques compared to their white American counterparts. Many African Americans seem especially suspicious of a neurological label of ADHD to account for their children's problems, which may be partly attributed to poor schools and neighborhood environments. African Americans in urban communities are also uneasy about what they perceive to be similarities between Ritalin and crack cocaine, which devastated black communities in the 1990's. These opinions were expressed by the NAACP Legal Defense Fund when public hearings were held by the DEA over decontrolling Ritalin in the mid-nineties.

Indeed, the ADHD/Ritalin epidemic appears to be a primarily white middle-upper middle class phenomenon. The best demonstration of these ethnic-racial disparities comes, ironically, from HealthCanada, a federal department responsible for helping Canadians maintain and improve their health. The data and its conclusions were debated in an article and a series of letters in the Canadian Journal of Medicine. They examined Ritalin use rates in two large cities in British Columbia separated only by a short ferry ride. Victoria, a highly homogeneous white middle class community, used Ritalin nearly four times as much as Vancouver, a far more cosmopolitan, polyglot city with large numbers of people of Asian descent. All families were enrolled in a national health plan, which covered visits for ADHD, so access to care cannot explain this striking difference.

Neurological factors

Neurological factors alone, felt to be the basis of the official ADHD diagnosis, do not account for the extreme variation in Ritalin use. While children with severe impulsivity and hyperactivity exist in all populations in every country of the world, these are not the majority receiving stimulant medication in America today. Rather, economic, social and cultural factors are strongly implicated in the real world diagnosis of ADHD and who does and doesn't get Ritalin.

An Explanation

Why this huge increase in the use of Ritalin during the 1990's? I propose a number of factors involved in the explosive growth of the ADHD diagnosis and Ritalin use. By the early 1990's we, as a society, accepted the notion that poor behavior and performance in children are caused by a brain disorder or chemical imbalance. American psychiatry over the previous twenty years turned 180 degrees from the previous Freudian model, which blamed Johnny's mother for all of his problems, to a biological model of mental illness, which blamed Johnny's brain and genes.

The Prozac connection

The success and popularity of the anti-depressant Prozac, which was introduced in the late 1980's, cemented the notion of the brain-behavior connection in the public's imagination.

Prozac made taking a drug for an emotional problem in adults more acceptable and paved the way for the increased use of a psychiatric drug, Ritalin, in children.

Living in a pressure cooker culture

In my mind, a "living imbalance" rather than a chemical one has fueled Ritalin demand. In general, academic standards among the middle class have increased, and children are expected to reach certain milestones earlier and earlier. Children at three are often expected to know the alphabet and their numbers, children at five are expected to know how to read, children in third grade are learning multiplication and division, and so on. These are the expectations middle and upper middle class children face today.

The expectation is also that every child attains at least a four-year college degree in order to compete in the marketplace and survive economically in a post-technological world. By talent or temperament, many children are found wanting, and wind up taking Ritalin.

Changing parental habits

Nearly eighty percent of mothers now work outside the home, leaving many more young children in full-day childcare and many more school age children alone at home in the afternoons. Both parents are working longer hours to maintain their economic position, leaving them exhausted, and perhaps guilty at the end of their day when they finally get to see their kids.

Parents are further handicapped by current styles of American discipline of children.

"Politically correct" parenting practices propose that by effectively talking to children, conflict and punishment can be avoided. The fear of damaging a child's self image by even short-term immediate punishment is a significant handicap for parents today, as this type of direct, immediate discipline is a major motivator for children, especially for children with ADHD-type personalities. Of course ineffective discipline alone does not explain the explosion of ADHD diagnoses, but it is one piece of the puzzle. When children's behavior continues to be out of control, and punishment is not an option, then using a medication becomes very appealing.

Managed care, media, and the pharmaceutical industry

Until the last few years, average class sizes were increasing even as curricula demands rose for the general classroom teacher. No wonder teacher complaints are often the catalyst that leads to an ADHD evaluation. Managed health care only exacerbated economic pressures, especially on pediatricians and family doctors, resulting in less time in evaluations and treatment and a rise in the "quick fix" of Ritalin. Media tended to exaggerate the ubiquity of the ADHD diagnosis ("Does your child have this hidden disorder? Do you?"). Testimonials that recount the power of the Ritalin intervention belie the often complex courses and treatments necessary for myriad children's problems that get lumped under ADHD diagnosis.

The pharmaceutical industry's influence has been profound, both in determining the kinds of ADHD studies funded and published and in their drug promotions, advertising first to doctors (Adderall) and most recently directly to consumers (Concerta).

Federal educational disability law

All these factors were in place by the early 1990's and Ritalin production in the U.S., which has remained stable throughout the 1980's, took off beginning in 1991. The spark that set off all these socially combustible materials and led to the Ritalin boom was the change in the Federal educational disability law, IDEA. In 1991, IDEA was amended to include ADHD as a covered diagnosis for special educational services at school. Once parents (and teachers) learned that they could get help for their kids at school, they flocked to their doctors seeking the ADHD diagnosis and along the way received Ritalin for their children.

Nothing surprising about the effectiveness of stimulants

Ritalin "works." Stimulants in one form or another have been used for treating children's behavior for over sixty years. But the effects of Ritalin are not specific to treating ADHD.

Ritalin improves everyone's ability—child or adult, ADHD or not—to stick with tasks that are boring or difficult. Ritalin decreases everyone's impulsivity and therefore decreases motor activity. There is nothing paradoxical about low dose stimulants' effects on "calming" hyperactive kids. Higher doses "wire" both ADHD kids and normal adults: except children tend to dislike the experience of the higher doses while teens and adults can abuse the drug.

Conclusion

I'm not against the use of Ritalin in children. I am against Ritalin as a first and only choice for a wide variety of children's performance and behavior problems. Ritalin works but it is not a moral substitute for, or equivalent to, better parenting and schools for children. My role as a physician is to ease suffering. After a proper evaluation and an attempt to address issues of family and learning as best as possible, I will prescribe Ritalin if the child continues to significantly struggle.

But as a physician who prescribes medication for children, it is also my role to alert others about the economic, social and cultural factors that are involved in the ADHD diagnosis and Ritalin use in our country. To not raise alarm would make me complicitous with values and factors I feel are harmful to children and their families.

The huge rise in Ritalin use in our country is telling us we should reexamine our demands on our children and the resources we offer them, their families and their schools. It is a message we should heed not only for children with the ADHD diagnosis who take Ritalin but for all of America's children. We should be paying attention.

Originally published at Healthology.com, August 20, 2001
Copyright © 2001 Healthology, Inc.

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Electroconvulsive therapy's return stirs debate on use

George Ebert is not certain how many of his memories are missing. He can recall that during a 1971 tour of Ohio with his family, his mental state first began to deteriorate. He recalls hurriedly trying to "cleanse" his life by throwing away most of his belongings, and attempting to hitchhike in the middle of the night from Columbus to Texas with his son in tow on a search for God.

It was at an Ohio psychiatric hospital that same year that Ebert had his first experience with electroconvulsive therapy, then known as electroshock. The 15 treatments with the device, he said, left him temporarily unable to perform the simplest tasks and permanently unable to remember patches of his life.

"Afterwards, I was given a container of milk and I could not figure out how to hold it, and given a spoon and I didn't know what it was for," said Ebert, 58, an Oswego native who now runs the Mental Patients Liberation Alliance, an advocacy group in Syracuse that opposes the procedure.

ECT, long derided as a primitive and disruptive treatment for mental illness, has recently returned to the psychiatric mainstream, bringing calls for the state to monitor its use more closely than almost any other medical procedure. Though the treatment's technology has advanced significantly, state lawmakers, doctors and patients are now engaged in a vigorous debate that has dredged up the lingering stigma from ECT's early days.

Most of the machines may have changed since the time when Ebert received the treatment, but the issue of informed consent, what patients know about ECT's effects and whether they can be compelled to undergo it, has persisted.

The criticism has been exacerbated by a 1997 study of community hospitals in New York City, Westchester and Nassau counties. The study, by the New York State Psychiatric Institute based at Columbia University, found that 11 percent of patients were treated with outmoded ECT machines such as the one used on Ebert.

Underscoring the absence of government oversight of ECT, state regulators said they do not know where these antiquated machines are, or even how many people receive ECT treatment throughout New York in any given year. Individual complaints about ECT, as with any other medical procedure, are handled by either the state Commission on Quality of Care or a national commission that accredits hospitals.

Texas and Vermont have imposed severe restrictions on ECT. But the push for greater oversight in New York and elsewhere concerns doctors who say it will discourage hospitals from using the treatment.

"The truth of the matter is that this is now a very routine ," said Dr. Charles Kellner, professor of psychiatry and neurology at the Medical University of South Carolina. "Some of them would die by suicide if people are denied access to this."

Nationally, as many as 100,000 people receive ECT every year, according to the American Hospital Association. New York's Office of Mental Health tallies only how many people in state hospitals receive the treatment -- 134 last year.

The treatment has evolved since Ebert's family had him committed 30 years ago. Now, ECT is primarily administered to those who do not respond to medications. For years it has been recommended as a method of last resort. Physicians target electricity to the brain until the patient experiences a seizure. Some doctors believe the electricity alters existing electrical impulses in the brain to correct any chemical imbalance.

The first generation of ECT devices, called sine wave machines, were used liberally to treat a wide range of mental illnesses for decades. Proponents and opponents alike agree that, until very recently, the treatment was overused to control unruly patients. Crude in comparison to more modern versions, the early machines sent out intense bursts of electricity that often produced memory loss. The improved machines deliver less electricity in more brief pulses, causing less cognitive damage.

Until 1980, sine wave devices were the only machines on the market and today still evoke the images of the earliest electroshock treatments administered without muscle relaxants or anesthesia to soften the effects of the seizure.

The machines were immortalized in the 1975 film "One Flew Over the Cuckoo's Nest," where the patient played by Jack Nicholson thrashes uncontrollably during electroshock treatments.

"It's receiving a kind of attention that probably isn't driven by science questions but has generated a lot of emotional reaction," said Dr. John Oldham, chief medical officer for the New York State Office of Mental Health and director of Columbia University's psychiatric research institute. "It has been sensationalized."

But the introduction of newer machines has not quelled controversy about ECT. In one well-publicized case in 1999 on Long Island, Paul Henri Thomas challenged Pilgrim Psychiatric Center's right to administer the treatment against his will. Pilgrim had to go to court to proceed with the treatment. The hospital won the case in March, but Thomas has appealed and until it is resolved, the hospital is barred from treating him with ECT.

"It happens to be a procedure that is involved per patient in more court cases than any other," said Martin Luster, chairman of the state Assembly's Mental Health Committee. "There may be legitimate cases raised in terms of medications. We have not received the same outpouring of concern over medications as we have over ECT."

Luster (D-Trumansburg) has proposed legislation that would require every hospital in the state to inform patients about the benefits and side effects of ECT. Luster's bill also would require hospitals to obtain patients' written consent and routinely report the number of treatments to state regulators. In addition, hospitals would need to have alternative treatment nearby in case of an emergency.

But psychiatrists warn of the consequences of bringing a medical debate to the Legislature. In Texas, groups of ECT watchdogs, including the Church of Scientology, lobbied so successfully that state lawmakers entertained an outright ban of the procedure. Lawmakers ultimately prohibited doctors from performing ECT on anyone under 16 and required multiple recommendations before allowing the procedure on anyone over 65. They also required more stringent reporting practices and a separate consent form each time ECT is administered.

"For a legislature to intercede in a medical practice would inhibit its continued research," said Max Fink, an attending psychiatrist at Long Island Jewish Medical Center in New Hyde Park and a vocal ECT proponent. "ECT is an effective treatment that has saved many lives its availability is very spotty. State, municipal and many private hospitals do not have it available."

ECT advocates dispute that the existing sine wave devices pose any threat, though they agree the machines should not be used. Harold Sackeim, one of the authors of the 1997 study that found several machines still in use, called it "a small issue."

Sackeim would not disclose the location of the machines, citing confidentiality of the hospitals that participated in the study. Newsday contacted 40 hospitals for this story; none said they use sine wave machines.

Oldham said the sine wave machines, while less preferable than newer devices, still deliver valuable treatment with minimal side effects. "The evolution of transitioning to improved medical and surgical equipment is a process," Oldham said. "Hospitals can't immediately drop everything they've got. They have to do it in a planned, budgeted way."

Continued use of even a few machines has further galvanized opponents, who say it is representative of the greater problem of insufficient standards for ECT. Sackeim's study found that procedures vary from hospital to hospital, including how often a patient's memory is evaluated after treatment.

"The American Psychiatric Association has been warning people not to use sine wave for 20 years or more, but they're still there," said Linda Andre, who underwent the treatment in 1981. Andre, 41, of Manhattan, added that an independent agency was necessary to regulate ECT. She said psychiatrists "didn't do anything" to get rid of the sine wave machines before, and warned against having psychiatrists "police" themselves: "You can't put these kinds of things in their hands."

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A WATCHDOG group says mental patients at Hillside Hospital in Queens are being abused - mentally.

Since January, about a dozen patients have been coerced into receiving electroshock treatment under the threat of being shipped off to inferior state-run facilities.

"It's not physical abuse - it's mental abuse," said Dennis Feld, the deputy chief for the Mental Hygiene Legal Service, a state-funded watchdog group that represents all mental patients.

"What they are doing is frightening them."

Patients' treatment teams - which are made up of psychiatrists, psychologists, therapists, social workers and even nurses - are ganging up on our sick and vulnerable, Feld charges.

"They go a little further than just saying, 'You don't want to take this [electroshock therapy]? It's OK,' and moving on," said Feld, who is considering filing a class-action lawsuit. "They're really pushing it."

Feld claims that at least five patients have already been transferred for refusing to receive electroshock treatment.

A Hillside spokesperson didn't respond to repeated telephone messages.

The watchdog group began eyeing alleged electroshock abuse at Hillside when the hospital tried to strong-arm spunky 65-year-old Wilfredo Hernandez, of Brooklyn.

Hillside, with Hernandez's consent, zapped his 38-year-old mentally retarded daughter, Nina, 21 times. When Hernandez refused to allow the doctors to continue, they allegedly threatened to legally take custody of his daughter and get a court order to zap her again.

But one day - that's one day - after The Post reported Hernandez's plight, Hillside doctors decided Nina didn't need electroshock treatment anymore. In fact, they said she didn't need the hospital's services at all anymore. She was discharged Friday.

Hernandez, a deacon at a Borough Park Catholic church, is thinking about forming a parents group to combat forced electroshock at Hillside.

"I'm worried about the patients who don't have family members to defend them," Hernandez said.

Vera Hassner-Sharav, the president of the city's Citizens for Responsible Care and Research, called the alleged coercion practice at Hillside "unconscionable."

She said the only recognized use of electroshock is for patients with severe clinical depression who haven't responded to any other form of treatment.

Zapping Nina Hernandez, who doesn't suffer from depression, is "contrary to accepted medical standards put forth by the American Psychiatric Association" and, therefore, "that makes it experimental," Hassner-Sharav said.

Feld charges the pressure to zap patients at Hillside began 1997, when Dr. Max Fink, the godfather of electroshock, moved his research and teaching activities to Long Island Jewish Medical Center, which is affiliated with Hillside.

Published studies show Hillside has participated in several federally funded electroshock experiments.

Fink said he had retired from the electroshock business to write books, and at first distanced himself from Hillside. He's listed as a "research faculty" member on the hospital Web site.

When pressed, a flustered Fink said, "If he [Feld] alleges we are doing something wrong, he should go to court and sue the pants off the place."

Maybe Feld should. A lawsuit might teach these doctors not to play with electricity and the lives of patients who trust them.

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New York State Assembly, May 18, 2001

My name is Linda Andre, and I am a survivor of ECT. I had a fairly typical experience. Five years of my life were permanently erased as if they had never happened, including most of my college education; I lost 40 points off my IQ; and I've been left with permanent disabling memory and cognitive deficits. I have brain damage from ECT, and it's very similar to what happens to persons who suffer traumatic brain injuries from other causes such as car crashes. Let me hasten to say that I received what's often falsely called the "new and improved" ECT and that every doctor who consulted on my case agreed and will tell you to this day that my treatment was state of the art and done according to the specifications of the APA. Since 1985, I have been the New York Representative of the national organization of persons who've received ECT, the Committee for Truth in Psychiatry; in 1992, I became the Director of our organization.

I'd like to add that although I'm not a doctor, I passed the CME test that supposedly qualifies doctors to give shock. I've got the certificate to prove it.

The reason why there was and is a need for a national organization of ECT survivors is that there are big problems with this treatment, as you're hearing today. In a nutshell, the problem is that patients aren't truthfully informed of the known permanent adverse consequences of ECT, including permanent extensive memory loss and permanent brain damage. The industry, much like the tobacco industry, won't acknowledge these effects and ex-mental patients haven't got the political clout to make them.

Throughout the history of ECT, there has been conflict between doctors and patients. This conflict is at the very heart of the Paul Henri Thomas case, and the other forced shock cases in New York. What survivors know to be true about ECT, and what doctors believe, are opposed and are irreconcilable. Survivors and shock doctors cannot both be right. I sat through the Thomas court hearings, and I heard the doctors say that they considered Paul incompetent because he did not agree with their assessment of the risks and benefits of shock. I heard what the doctors said, and I don't agree with them either, nor would any of the members or our organization. I guess that makes all of us incompetent as well. Paul came to his conclusions by experiencing ECT. His doctors said they formed their opinions on ECT by reading a book. (There isn't major book on ECT that isn't written by a doctor with financial ties to the shock machine industry, as an owner, shareholder, grantee or consultant to these companies.) Paul's doctors believed things that are not true, such as that the FDA has performed safety trials of ECT; but then what matters in these hearings is not so much what is true as who has the power to define the truth.

Our group organized because we all had ECT without informed consent, we all suffered permanent memory loss, and we want to protect future patients from suffering tragically preventable amnesia and disability. Our one and only mission is to advocate for truthful informed consent, and we've done that over the past sixteen years in a wide variety of forums. In fact, Marilyn Rice, the founder of our group, testified before the New York Assembly at your first hearings on ECT in 1977. We called ourselves the Committee for Truth in Psychiatry to emphasize that we are for informed consent, not against ECT. Marilyn liked to say, "I'm not against ECT, I'm against lying about ECT."

In my position as Director of CTIP I've been in contact with literally thousands of ECT survivors from around the world over the past decade. I keep up with the industry research on ECT; I attend and present at psychiatric conferences; I write and publish on ECT; I consult with agencies such as the Center for Mental Health Services. I've worked with states which have passed or tried to pass laws to protect patients. This last includes an unsuccessful reporting bill in New York State in the early 90s, and reporting bills that were successful in Texas and Vermont. But CTIP's biggest accomplishment has been getting the Food and Drug Administration to acknowledge the risks of ECT, including brain damage and memory loss.

The FDA regulates ECT because the machines used to give it are considered medical devices. It is somewhat limited in its authority because ECT machines were in use before the FDA gained jurisdiction over medical devices in 1976. FDA was mandated by law to place the shock machines in one of its three medical devices categories, Class I, Class II, or Class III. Briefly, Class I would be an over-the-counter device, Class II one which is safe if used according to certain standards or safeguards, and Class III one which presents an unreasonable risk of injury or harm and cannot be made safe. To classify a device, FDA weighs its risks against its benefits. At the end of my presentation, I will tell you what the FDA says about shock machines. But first I will do what the FDA did, and give you an overview of what we know about ECT's risks and benefits.

ECT patients have been reporting permanent adverse memory and nonmemory cognitive effects ever since shock began in 1938. The nature and frequency of these reports has not changed in over 60 years. Let me explain that the so-called modifications of ECT have had no effect on these permanent adverse effects. You may have heard claims that oxygenation, muscle paralyzers, so-called brief pulse ECT, or unilateral ECT have solved the problems with memory loss and brain damage. But all of these modifications were in use by the 1950s, and none of them eliminated or minimized ECT's effects on memory and on the brain. You may also have heard that today's ECT uses "less electricity" than in the 50s, 60s, 70's, and 80s. The opposite is true. Today's ECT devices are the most powerful in history. Each new generation of machine is designed to put out more electricity than the one before it. This means, for example, that a person getting shocked today is probably getting more electricity through her brain than I did in 1984.

In the early decades of ECT, doctors were frank about sacrificing the brains, intellects, and careers of their patients in the hope of a temporary respite from depression. Since about 1975, the beginning of what I call the public relations era of ECT----that is, the period when organized psychiatry decided to deny there was any problem with ECT itself in favor of claiming there was simply an image problem with ECT---they have attempted to deny or cover up memory loss and brain damage, just as they have stopped writing up ECT deaths.

Even so, it is accurate to say that when researchers looked for the type of memory and cognitive deficits survivors report, and used measures that were relevant to these deficits, they have found them. There are just a handful of studies that follow ECT patients up for the long term, asking about memory. But the studies that have done this--followed patients for six months, a year, three years, and in one very brief and limited study, seven years---have all found that the majority of these patients still have amnesia and memory disability. There is nothing to support the industry's claim that memory or memory ability returns to normal shortly after ECT. In fact, patients tested as long as twenty years after ECT had brain damage verified by sensitive neuropsychological tests.

Outside of these of studies, which were done before 1990, no one has been interested in following up ECT survivors to document the permanent effects of ECT---except ECT survivors. Let me explain that survivors and others have had to step in because of the lack of ethical and scientific research, and this is something you may want to look into in further hearings because New York State is where the biggest problem is. You may know that one institution, the Psychiatric Institute, gets a large percentage of the total NIMH money that is available for mental health research. When it comes to ECT research money, the percentage is much greater. Millions and millions of dollars have been granted to one investigator in this lab, Dr. Harold Sackeim, to study ECT, including the adverse effects of ECT. Because Sackeim's had a lock on this money for 20 years, because his money is renewed automatically for as long as he wants it without his proposals having to compete with other grants, and because he sits on the panel which decides who gets funded, other researchers aren't able to get grants to do research in this area. Dr. Sackeim is on the American Psychiatric Association's Task Force on ECT, and he's the spokesman for industry, the one whose name is always given out to the media. His entire career has been built on promoting ECT. That's an ethical and scientific problem. But there's an even bigger legal problem: his research has been done in violation of federal law which requires disclosure of conflict of interest. While he's been getting millions of NIMH dollars, he's also been a consultant for, and received grant money from, the companies that make most of the shock machines in America, and he has never disclosed this financial conflict. That is illegal.

I also need to add that Dr. Sackeim, along with other New York ECT promoters such as Dr. Fink, and the other doctors of the APA's Task Force on ECT, are on record at the Food and Drug Administration as opposing an impartial safety study of the effects of ECT on the brain. They have successfully lobbied over a period of nearly two decades to prevent such a study by the FDA. So it is not only that these men monopolize the research funding and decide the research agenda; they also work to actively prevent anyone but themselves from researching ECT.

I hope you will look into this, and into other problems in this research as well, such as fraudulent informed consent, the "disappearing" of study participants with adverse outcomes, the fudging or falsification of data. All of this is documented. I bring it to your attention because there is no way to understand the dearth of valid and scientific research on longterm effects of ECT without placing it in this larger context.

So if the research money is monopolized by Sackeim and a handful of others with a personal financial and career stake in promoting ECT, how do we know what we know about the nature and prevalence of its adverse effects?

We know because of the research that was done prior to the public relations era, and in fact even up until the early 80s. There are dozens of brain anatomic studies of both humans and animals, autopsy studies where cells have been counted, solid scientific studies which have been replicated by other studies, showing brain damage from ECT. The industry tries, dishonestly, to discredit this research but there are too many studies. In fact, though they're either ignored or miscited by ECT proponents, there human MRI studies showing brain atrophy from ECT. There are also well-designed memory studies which have never been either discredited or replicated by the ECT industry, documenting the nature, extent, and permanence of ECT amnesia.

I refer you to the excellent presentation given by neuroanatomist Dr. Peter Sterling in 1977, in which he describes the mechanism by which ECT inevitably produces brain damage. The brain hasn't changed since 1977, and ECT hasn't changed except for the fact that today's ECT machines put out many times more electricity than those in use is 1977.

The permanent effects of ECT on the brains, memories, and lives of survivors are documented in the files of the FDA. The FDA has been collecting data from ECT survivors for nearly 20 years. Its docket on ECT, Docket #82P-0316, consists of about 40 volumes, each several inches thick, and I have read all of them. This is a public record and anyone making policy on ECT should look at it. There are several hundred reports from persons who have had ECT. They come from persons who had ECT at different institutions, at different times and in different places, but the similarity of the reports from these hundreds of survivors who don't know each other is unmistakable. They describe permanent amnesia and memory disability---the daily experience of living with a poorly functioning memory. Some have sent in laboratory tests documenting brain damage. They talk of losing jobs, forgetting the existence of children, becoming a permanently diminished human being. There are hundreds of reports of educations and careers ended, families destroyed. Many reports go into great detail about the nature of ECT disability, such as the fact that new learning after ECT doesn't stick. These people want something done about what happened to them. They beg the FDA to conduct an impartial safety investigation of ECT's effects on the brain.

There are exactly fourteen letters from patients who have anything good to say about ECT. Five were sent in by these patients' shock doctors, some of these written on hospital stationery, probably with the shock doctor literally looking over the patient's shoulder, telling them what to say. Four of the letters report memory loss.

That's fourteen letters in nineteen years from ECT patients who had positive experiences, versus several hundred who report negative, harmful, or devastating results.

This is and was not meant to be a scientific study but it is what we have to go on, and it has some advantages over a conventional study which would, after all, include patients all treated by the same doctor in the same institution, and would only include one or two dozen people. The ECT reporters had ECT in every decade, by every imaginable technique and type of machine, by every type of doctor, in every state and even some foreign countries. It's not possible to dismiss them by claiming they "just" had a bad doctor, or the wrong type of ECT.

Because of the absence of valid and scientific studies by impartial doctors, and the seeming political unlikelihood that such studies will ever happen, survivors of ECT have had to take the lead in designing and implementing our own research. In the past several years there have been four large studies which focused on amnesia and memory disability. All of these went to a heterogeneous group of survivors, from people who'd had ECT in the past year to those who'd had it twenty years ago. One was done in the US by Juli Lawrence, an ECT survivor and member of the Center for Mental Health Services Advisory Board; three were done in England. The findings of all of these independent studies have been strikingly similar.

In my own study which I designed, I sent an questionnaire commonly used to assess brain injury, slightly modified to include the most common ECT symptoms, to our members, and every one of the 51 people who responded reported having at least some of the symptoms. Two-thirds had become unemployed due to ECT. 90% said they wanted and needed help with their cognitive and memory deficits, and had been unable to get it.

The United Kingdom Advocacy Network, a patients rights group in England, surveyed 308 survivors of ECT, one-third of whom had received forced shock. 60% of women and 46% of men found ECT damaging or not helpful. 73% reported permanent memory loss. 78% said they would never agree to ECT again.

Juli Lawrence's study of 41 survivors found that 70% had not been helped by ECT. 83% reported permanent memory loss, in some cases up to 20 years of amnesia. 64% reported permanent problems with memory functioning. 43% said ECT had caused permanent changes in cognitive abilities.

ECT Anonymous is the sister group to the Committee for Truth in Psychiatry in the UK. It is entirely made up of ECT survivors. They designed an extensive survey which as of 1999 has been completed by about 225 people. 82% reported permanent memory loss; 81% reported permanent memory disability; 50 to 80% reported permanent impairment in various cognitive abilities; 73% reported that ECT was not helpful in any longterm way. 76% were never able to return to their previous occupations.

MIND is a British charity which might be compared to our Mental Health Associations. In 2001, they published their survey of 418 ECT survivors. One-third had ECT against their will. 84% reported permanent adverse effects, including amnesia and cognitive deficits. 43% of the total found ECT unhelpful, damaging or severely damaging, and 65% said they would not have it again.

There is another adverse effect even more chilling than losing years of your life, and that is death. We don't have accurate national figures on deaths from ECT, because we don't collect any national statistics on ECT. Those that you may have heard are either an industry projection based on very old numbers (like the claimed "100,000 people get ECT a year) or a complete fabrication (like the death rate claimed by the APA). Only six states are required to report deaths from ECT, and not all of them have up-to-date figures. Texas is one state that has kept statistics in recent years, and they show a death rate of 1 in 200. In 1998, Illinois reported a death rate of 1 in 550. Yet patients are never told of these statistics.

A large retrospective study of 3,228 ECT patients in Monroe County, New York found that ECT recipients had an increased death rate from all causes. Another large study corroborated the fact that ECT survivors die sooner than mental patients who haven't had ECT. There is research to show that ECT survivors relapse more quickly than patients who were treated with drugs, and are much more likely to commit suicide. There is research that suggests that ECT survivors are more likely to develop Alzheimer's disease. There is no research on other longterm adverse effects of ECT, such as its longterm effects on the heart. If someone such as myself develops a heart condition at an early age, a condition for which there is no risk factor or family history, is this a result of ECT? No one's even looking into this.

To summarize what we know about adverse effects: 100% of persons who have ECT experience permanent memory loss, and a majority experience significant, extensive loss. Memory lost to ECT doesn't "return". NIMH looked at what the industry says and estimated that the average period permanently lost to ECT is eight months. That's an underestimate, as you'd expect. It is frequent, not rare, for persons to lose many years of their life to ECT, and for this loss to be permanently disabling. ECT commonly causes many of the other permanent effects typical of brain injuries, including loss of intelligence, permanently impaired memory functioning, and other cognitive problems which is sum amount to preventable disability.

What about efficacy? Are there benefits to ECT that can justify these risks?

Let's look at what the industry itself says. You may have heard a claim that ECT prevents suicide or saves lives. It doesn't. There is not one study to prove this. In fact, the industry-designed research shows the opposite: ECT has no effect on suicide, at least as far as preventing it. There are many, many studies that document suicide after ECT, often when researchers attempt to find their patients a month or three afterwards and can't find a certain percentage of their patients because they've killed themselves. Ernest Hemingway is just the most famous example of a suicide caused by ECT.

In 1985, NIMH looked at the published research---again, this is research largely done by the industry itself---and concluded that there was no evidence that ECT has any beneficial effects that last longer than four weeks. In 1992, two British psychiatrists presented a paper at an international conference, evaluating all the studies that had been done up to then---there have been none since---which compared real ECT to what's called sham ECT (anesthesia alone without electricity). They concluded that there is no evidence that real ECT is superior to fake ECT. Remember, in both cases all that was being evaluated was ECT's efficacy in depression, the condition for which is it supposedly most effective; ECT is commonly used for other conditions for which it is considered less effective, as in the case of Paul Henry Thomas.

ECT's lack of efficacy is a big public relations problem for the industry. In 2001, the industry's leading spokeman Harold Sackeim published a paper looking at what happens to patients who've had ECT. This study was based on research done from 1992 to 1998, and I remind you that this research was done in violation of federal law. I have also examined the grant file for this study, and I can tell you that the actual results reported to NIMH do not match the results revealed to the public in the published study. I can't tell you why, or what happened to the patients who were disappeared, except to ask you to look into it.

The point here is not that this study is good science, or that you should believe what it says, but that it was the best that the most prominent and best-funded spokesman of the ECT industry, using millions of our tax dollars, could come up with.

Of the roughly 290 people who were shocked for this study, half did not respond to ECT at all. That's a 50 percent response rate for the very definition of state-of-the-art, 21st century ECT. But in fact Dr. Sackeim cheated a bit, because he uses the special shock machines that he designs to put out twice as much electricity as patients normally get. This, as Sackeim would tell you, boosted the response rate higher than it would have been in clinical use----but it was still only 50%. (Correspondingly, when a study focuses on cognitive effects and not efficacy, researchers are able to turn down the electricity to less than is given in normal practice.)

Of the roughly 150 people who responded to ECT, only about 25 (we don't know the exact number because Sackeim says different things in different places) were free of depression six months after shock. An equal number, about 21, had become so depressed again that they had more shock within six months. That's a total of only about 10% of the total who had any benefit from shock that lasted as long as six months.

The study notes that most patients who relapsed did so very quickly. This is consistent with earlier studies. NIMH reviewed these studies and concluded that there is no scientific evidence that any benefit of ECT lasts longer than four weeks.

It has been noted by numerous scientists that this extremely brief period of well being is entirely consistent what is seen in other types of brain injuries, and with the theory that ECT "works" by causing an acute organic brain syndrome.

In contrast to benefits, the adverse effects of ECT are permanent. At any length of time at which survivors have been followed up post-ECT, the vast majority report a stable retrograde amnesia for months or years. When survivors have been tested with instruments sensitive to brain injury at any length of time post-ECT, they have exhibited stable and permanent deficits in intelligence, memory ability, abstract thinking and other cognitive functions, and the pattern of impairment is consistent among survivors no matter when or where they had ECT. All of the adverse effect reports collected by the FDA are of permanent, enduring deficits. The effects of electricity on the human brain have not been mitigated by any claimed improvements or refinements by the industry. There is a great deal of variance among individual ECT patients, because the amount of electricity received varies greatly and cannot be controlled by even the most modern devices, due to human physiology and the nature of electricity. There is no way to predict who will be most devastated by ECT.

ECT's morbidity rate is 100%. It commonly results in permanent disability, and lifetime Social Security payments, in adults who previously were able to work. Its mortality rate, based on very spotty statistics, may be as high as 1 in 200. ECT has not been shown to be more effective than no treatment at all, and even the most biased estimate of its longterm efficacy rate is only 10 to 40%.

You would be right if you guessed that the FDA has placed the ECT device in its Class III, High Risk category. FDA warns that the benefits of ECT do not outweigh its risks and that its risks include brain damage and memory loss.

If ECT were a drug just coming on to the market, it would not be allowed to be used.

If safety trials of a drug showed that the drug caused permanent amnesia, disability, and brain damage in even a small fraction of those who have experienced these effects due to ECT, that drug would be pulled off the market.

Would it surprise you at this point to learn that there have never been any safety trials of the ECT device? There have not. None of the manufacturers of the devices have ever conducted a single safety test. (When manufacturers, in their ads, say their devices are safe, they mean safe for the treating psychiatrists and nurses!) Even in 1997, when the FDA belatedly called for them to submit safety information, they did not submit one shred of evidence, because there is none. They knew there would be no consequences for not submitting the required information, and there have been none. If the ECT device didn't have the powerful lobby of the American Psychiatric Association behind it, it would be pulled off the market.

You may rightly ask why ECT continues to be used given its terrible track record. There are many reasons. One is the historical quirk that ECT was invented in fascist Italy, at a time and place where there were no protections for patients and no regulation of industry, that it continued to be used free of the restrictions and protections we take for granted in this country, and that today it is still largely immune from such restrictions and protections. We can't even get the most basic information about the use of ECT in New York State today, such as how much it's done!

In 1976 the APA formed its Task Force on ECT, and since then ECT has been kept alive largely by vigorous sustained effort on the part of a dozen men who design the machines, conduct the research, consult for the companies, and otherwise owe their highly paid lifestyles to ECT. New York State is home to two men in particular who have staked everything on ECT and have everything to lose if it is discredited. It's the shame of our state and part of the reason all attempts at patient protection here have failed so far. Both men are or were state employees. No wonder OMH is so invested in the forced shock of Paul Thomas, Adam Szyszko, and so many others.

Fink and Sackeim and a few others around the country are so busy promoting ECT, lying to the media, conducting big ticket how-to-do-shock seminars, etc., because if they let up on their public relations campaign for a minute ECT would collapse under the weight of all the scientific evidence against it.

Did I mention how enormously profitable it is? Medical journals recommend setting up "ECT suites" to bolster incomes threatened by managed care. Insurance companies pay for ECT without asking questions, and that's not an accident; the proponents of ECT, such as Dr. Fink, are consultants to the insurance companies. Psychiatrists who do ECT make an average of twice the income of those who don't use it, and they can achieve this increase in income by working only the few hours a week it takes to give a bunch of treatments. It's easy to set up an ECT practice; all you have to do is pay about a thousand dollars to Drs. Fink, Sackeim, Weiner, etc.; go to the seminar for a few hours, pass the test and you're considered qualified to do ECT. This practice bears further scrutiny by the Assembly.

As a society, we allow things to be done to mental patients that would be unconscionable if done to persons without psychiatric labels. Hatred and fear of mental patients is so ingrained among the general population, and so unquestioned, it's never recognized for what it is, except by those of us who are on the receiving end of it every day. Getting a psychiatric label is like having a curse placed on you: from this day on, as long as you live, you will not be believed. You may dismiss my testimony and that of my peers, if you wish, as the ravings of an irrational crazy person, without compunction, because it's socially acceptable for you to do so. You may place less value on the brain and life of Paul Henri Thomas than you would on your own, and that again is socially acceptable. You may even do these things without conscious awareness that you are doing them. This is how shock and forced shock came to be, and how they continue.

Along these lines, I warn you not to derail these hearings into a general discussion of mental patient competency---as happened to some extent in 1977. Too often, the discussion on informed consent to shock ends when someone assumes that the real issue is that mental patients lack capacity to consent to anything. First of all, that's not true in the vast majority of cases. Second, it implies that the problem with shock resides in the patient, and not the industry. In 2001, the sharpest, most alert, most intelligent and competent patient cannot give informed consent to ECT, because there is nowhere in New York State or in the country where that patient will be informed of the true risks and benefits of shock. The patient is deceived by the assurances provided by the shock industry that shock is effective, that memory loss is trivial and rare, that memory comes back...the lies propagated by the APA's small Task Force of career ECT promoters. Until the day when the most competent patient can give informed consent to shock, no one can.

There is one more reason why ECT continues to exist. Psychiatrists need it. There are always going to be people whom they cannot help, and the more the field comes to rely exclusively on biological theories of mental illness and biological treatments, the more true this will be. There must be something psychiatry can hold out to those it has failed (and it is they who have failed, despite their practice of referring to their patients as "treatment failures")---something drastic and dramatic, something absolutely certain to have a dramatic effect in the short term, some last resort that can get the patient out of the hospital in the time allotted by the insurance companies and make the psychiatrist look like a hero. If a patient's brain is damaged in the process, that is a small price to pay (for the psychiatrist). Psychiatry offers brain damage as treatment because it has nothing else to offer. It is bankrupt. I am sure that if psychiatry could come up with something else besides ECT that fit the need for the last-resort treatment, it would get rid of shock. It's been trying for decades and hasn't come up with anything. Dr. Sackeim and others who have tried to develop (and profit from) drugs to eliminate the adverse effects of ECT have been unsuccessful. He's currently experimenting with giant magnets. But psychiatry's not going to admit ECT is brain damage until it has something else to offer. It puts saving face ahead of saving patients' brains.

Contact information:
Linda Andre
Committee for Truth in Psychiatry
P.O. Box 1214
New York, NY 10003

212 665-6587
ctip@erols.com

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Some time back The Westend Weekly published a story about Wayne Lax. He is anti electro shock and has joined a growing world wide group who are trying to get the practice banned. There are conflicting attitudes toward these treatments. Most of the doctors (but not all) still insist it is effective and not barbaric.

The patients who have received these treatments, again with exceptions, say they have lost years of their lives, have long lasting or permanent memory loss and want it stopped. Wayne, along with many others take every chance to speak with anyone who will listen and give their accounts of horrible ordeals some encounter.

Wayne has had his story published in many periodicals and newsletters. He was interviewed extensively by the BBC both for booklets and for an upcoming documentary which will be shown at a future date. The London, England based BBC has interviewed people from all over the world in regards to shock treatments and the lasting effect they have. Wayne was so angry when he recovered that he used his anger to try and help others. He has lawsuits against doctors in Kenora and Thunder Bay which are still pending.

Despite the fact that these doctors said he would never be able to live on his own he now sits on the Board of Directors for Changes Recovery Homes, Kenora; a regional representative for the Northwest Ontario Patient Council and is a member of Sunset Country Psychiatric Survivors, The Association for Community Living, People Advocation for Change and Empowerment and many other associations that deal with good mental health. He was in Fort Frances last week for Mental Health Week.

Wayne maintains there are reasons for people taking medication and he does recognize there are some very good psychiatrists, but the use of shock treatment in combination with powerful drugs is not the answer for some of the problems. He has a real concern for the fact that many facilities for patients with mental disorders are being closed or amalgamated. He is afraid the inexpensive use of shock treatments will increase to maintain compliance enabling institutions and hospitals to discharge these patients sooner.

He asked if the big new super jails the Province is building might end up warehousing former mental patients. He cited a statistic where women and the elderly, particularly elderly women, have been the prime targets of electroshock. In Canada and the USA, approximately 70% of shock survivors are women. 45% -50% are over 60 years old and several are 80 years and older. Although psychiatrists claim that depression or "clinical depression" is the main indication to administer electro-shock, people with other conditions such as anxiety, mania, post-partum depression, alcoholism, schizophrenia and dementia have also undergone electroshock.

Wayne's story is included in a new book by Scott Simmie, "The Last Taboo," a collection of stories by the famed journalist who was featured in a documentary for the CBC. This book may be available at the local Library soon. There are other books on the subject such its Remembrance of Patients Past by Geoffrey Reaume, who was diagnosed with paranoid schizophrenia in his teens and is himself a former psychiatric patient. Mr. Reaume is a Hannah post-doctoral fellow at the Institute for the History and Philosophy of Science and Technology, University of Toronto. Another book which I have read is Wendy Funk's What Difference Does it Make. This was the answer she got from her doctor when she told him the shock treatments were robbing her of her past.

Wayne had with him a plaque he received recently. It is the "Courage to Come Back Award," given by the Centre for Addictions and Mental Health Foundation. The Honorary Chair, Silken Laumann, is the Olympian who displayed courage to come back in the Olympics. She states, "your extraordinary courage is an inspiration to us all." He was nominated for this award by his sister, Joyce Roller of Thunder Bay. Joyce is one of the people who stood by Wayne and supported his fight to get well.

Wayne is very busy these days, traveling to speak and meet with anyone that needs and wants his help. It is what continues to make him well. He is also busy trying to piece together his past with the help of his records and recollections of his family and patients of the facility he formerly was admitted to. With over 100 admissions he has a lot of people to talk to.

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The fatty oil found in salmon, cod and other fish, already touted for its effectiveness in combating heart disease and arthritis, may also alleviate the symptoms of manic depressives, researchers said on Thursday. In what experts described as a limited but landmark study of how a naturally occurring dietary ingredient can affect the brain, researchers found that patients suffering from manic depression given capsules containing fish oil experienced a marked improvement over a four-month period.

"The magnitude of the effects were very strong. Fish oil blocked the abnormal signalling (in the brain) which we think is present in mania and depression,'' lead researcher Andrew Stoll, the director of the pharmacology research laboratory at Harvard University's McLean Hospital, said in a telephone interview.

The study, published in the American Medical Association's Archives of General Psychiatry, comprised 30 patients diagnosed with bipolar disorders, which are characterised by chronic bouts of mania and depression.

Roughly half the subjects received fish oil supplements and half got capsules containing olive oil, a placebo. They underwent psychological testing at two-week intervals during the four-month study.

The chemicals in the fish oil believed to be at work on the subjects' brains were omega-3 fatty acids, which are present in certain types of fatty fish such as salmon and cod. They are also found in canola and flaxseed oil.

Among the many health benefits sometimes attributed to omega-3 fatty acids are smoothing blood flow through constricted arteries of heart disease patients, lubricating painful joints in rheumatoid arthritis sufferers, cutting women's risk of breast cancer, preventing an intestinal inflammation known as Crohn's disease, and even ridding the body of cellulite.

But there has been little done on the effect of omega-3 fatty acids on the human brain.

Stoll said omega-3 fatty acids boost levels of the neurotransmitter serotonin in the brain -- similar to the effect of popular anti-depressants such as Prozac -- although the mechanism by which either works remain uncertain.

He said previous research on animals showed that omega-3 fatty acids replenished the "lipid bilayer'' surrounding the body's cells, including brain cells, where receptors reside that receive signals from chemical transmitters.

Stoll theorised that diets in Western industrialised countries are low in fish and other foods containing omega-3 fatty acids, a deficiency that can be compensated for by consuming fish oil or flaxseed oil supplements.

Patients in the study received up to seven capsules daily with concentrated fish oil from menhaden, a type of Atlantic herring, containing a total of nearly 10 grams of fatty acids.

"If you're treating depression and bipolar disorder, you have to think of it as a medicine and take an adequate amount,'' Stoll said. He suggested that omega-3 fatty acids might be taken as an adjunct to anti-depressant drugs or lithium, which is commonly prescribed to treat bipolar disorders.

In a commentary on the study that was published in the journal, three researchers from Case Western Reserve University said it had "substantial limitations'' partly because of its small size, but called it "a landmark attempt.''

"Methodology aside, the fact remains that this is, I think, a critical study looking at the role of agents which are naturally occurring substances that are well tolerated -- patients nowadays have a high affinity for taking the most effective, least toxic agent they can find,'' Dr. Francisco Fernandez, chairman of the department of psychiatry at Loyola University Medical Centre, told Reuters.

"It suggests that these agents may be effective in bipolar disorders, maybe equivalent to psychotropic agents," he said, describing the effect of the omega-3 fatty acids as setting off a "cascade of chemicals'" that aid cell functioning.

The drawback is that no drug company was likely to throw its resources behind studies of fish oil, because it cannot be patented and profited from. Fernandez and the other researchers suggested government-financed research.

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Non-stimulant, Amoxetine, for treating ADHD appears to be safe and effective - providing alternative to stimulants for treatment of ADHD.

An experimental drug could offer an effective nonstimulant alternative for treating attention-deficit/hyperactivity disorder (ADHD), according to Dr. David Michelson, who spoke here at the 154th annual meeting of the American Psychiatric Association.

Atomoxetine is more effective than placebo for treating ADHD and may be more easily tolerated, said Michelson, medical director at Eli Lilly, the company responsible for the drug's development. In a presentation of several studies funded by Eli Lilly that involved adults and children, he and his colleagues concluded that atomoxetine was superior to placebo in controlling ADHD symptoms.

ADHD is characterized by impulsiveness, difficulty with academic and social functioning, and short attention span. It is most frequently treated with the stimulant drug Ritalin.

In one study in which some patients were given Ritalin, investigators found some evidence that atomoxetine is more easily tolerated. For example, atomoxetine does not appear to be associated with insomnia.

"Atomoxetine seems to work by blocking the norepinephrine transporter and doesn't involve the dopamine receptors directly,'' he told Reuters Health. "Therefore, it has a different mechanism of action than the stimulants commonly used to treat ADHD.''

"Clinicians and parents have been looking for alternatives to stimulants for the treatment of ADHD for years,'' Dr. Christopher Kratochvil, assistant professor of psychiatry at the University of Nebraska, told Reuters Health. "There are concerns about side effects, and about reports of children and adolescents using it recreationally. We're looking for an alternative class of medications that will be effective and have a different side effects profile than stimulants. Indications are that atomoxetine is not an abusable drug.''

In addition, stimulants are not effective for every patient with ADHD. For example, children with ADHD who have other conditions, such as anxiety disorder, may be more effectively treated with a nonstimulant alternative, said Kratochvil, who was an investigator in the study. He has also worked as a consultant for Eli Lilly and other companies.

In his experience, Kratochvil said, atomoxetine has been a safe and effective treatment for the management of this condition. Phase III studies of atomoxetine are ongoing, and Eli Lilly is preparing to submit an application to the Food and Drug Administration for approval of this drug for the treatment of ADHD later this year, Kratochvil told Reuters Health.

Large study shows Luvox is safe and effective in treating anxiety disorders in children and adolescents.

A multi-site study to evaluate treatments for anxiety disorders in children and adolescents, funded by the National Institute of Mental Health (NIMH), found that a medication was more than twice as effective as the placebo, or sugar pill. The research trial, which cost $1.7 million, involved 128 children and adolescents ages 6 to 17 over a period of eight weeks. Symptoms improved in 76 percent of those randomly assigned to take the medication, compared to only 29 percent of those in the placebo group. The study, "Fluvoxamine (Luvox) For The Treatment Of Anxiety Disorders In Children And Adolescents," is being published this week in the New England Journal of Medicine.

Although anxiety disorders affect an estimated 13 percent of children and adolescents during any given six-month period, making them the most common class of psychiatric disorders in that age group, the disorders are often not recognized, and most who have them do not receive treatment.

Common signs of anxiety disorders in children are excessive worrying about ordinary activities, such as going to school or summer camp, taking a test or performing in sports. At times, there are physical symptoms such as palpitations, sweating, trembling, stomachache, or headache. There may be avoidance of certain situations that are perceived by the child to be sources of anxiety. This avoidance can cause social withdrawal. When these symptoms cause extreme distress and interfere with the functioning of the child in usual activities, a child is diagnosed as having an "anxiety disorder."

These disorders are properly recognized through a careful evaluation that includes direct examination of the child, a parent interview and a collection of past history. Anxiety disorders cause significant suffering and functional impairment in the affected children. While not all of them will continue to suffer from these disorders into adulthood, some will, and early treatment may help prevent future mental health problems, including suicide attempts.

Researchers used four inclusion criteria to select participants for the study, including a clinician-rated scale that was developed for the study to assess symptoms of the targeted disorders. The participants also had to go through several weeks of extended evaluation, during which time supportive psychotherapy was initiated. Only children who had not adequately improved at the end of that period were entered into the medication study. This was done to avoid exposing to medications children who might have improved with simple support and encouragement.

NIMH director Steven E. Hyman said, "This ground-breaking study is a big step forward in our understanding of how to treat children and adolescents with anxiety disorders. More research is still needed, however, to compare the efficacy of existing therapies, including cognitive-behavior therapy, to, or in combination with, medication."

The medication used in this new study, fluvoxamine, is one of the class known as selective serotonin re-uptake inhibitors (SSRIs), which is used to treat depression and anxiety disorders in adults. This medication has also been approved for treatment of obsessive-compulsive disorder in adults and children age 8 and above. Children and adolescents with a current diagnosis of obsessive-compulsive disorder were among those excluded from the study, which focused on those with at least one of three other anxiety disorders that typically occur together: generalized anxiety disorder, separation anxiety disorder, and social phobia.

"Although physicians often prescribe fluvoxamine for children and adolescents with these three anxiety disorders, this is the first rigorous examination of this medication's safety and efficacy in treating them," said Daniel Pine, one of the researchers on the study. "Each child or adolescent whose functioning is impaired by anxiety disorders should be carefully evaluated by a professional who is familiar with childhood anxiety disorders to determine the best course of therapy for that particular child." Dr. Pine is now Chief of Development and Affective Neuroscience and Child and Adolescent Research in the NIMH's Intramural Mood and Anxiety Disorders Program.

No severe side effects from the medication occurred in the study, although 49 percent of the study participants who were taking it had stomachache compared to 28 percent of the children and adolescents on placebo. The medication was also associated with greater increases in children's levels of activity than was the placebo. The side effects, however, were usually mild, and only five of the 63 children in the medication group discontinued treatment as a result of these adverse events, as compared with one of the 65 children in the placebo group. Most of the participants were under age 13. Half were boys. About 65 percent were white and about 35 percent were from minority ethnic groups.

The study was conducted at five sites of the Research Units of Pediatric Psychopharmacology (RUPP) network, which is funded by NIMH. The RUPP network is composed of research units devoted to conducting studies to test the efficacy and safety of medications commonly used by practitioners to treat children and adolescents (off-label use) but not yet adequately tested.

Source:

• NIMH, April 25, 2001

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Men who suffer from eating disorders have higher rates of depression, anxiety disorders and alcohol abuse than their peers do, study findings suggest.

These men with eating disorders, are also more likely to report problems in their marriage and feel dissatisfied with life in general, researchers report in the April issue of the American Journal of Psychiatry.Women and Depression

However, it is not clear whether these findings reflect factors that predispose a person to an eating disorder or are consequences of anorexia and bulimia.

In an interview with Reuters Health, lead author Dr. D. Blake Woodside, of the University of Toronto in Canada, called anorexia and bulimia "extremely soul-destroying" disorders. Individuals with eating disorders "are very unhappy" and are more likely to experience difficulty in their relationships, he explained.

The findings are based on information from 62 men and 212 women with eating disorders and more than 3,700 unaffected men. Nearly 15% of anorexic and bulimic men reported that they had been depressed at some point in their lives and 37% said they had been diagnosed with an anxiety disorder.

In contrast, only 5% of men without an eating disorder reported depression and about 17% said they had ever suffered from an anxiety disorder, the report indicates. More than 45% of men with eating disorders said they had been alcohol-dependent at some point in their lives, compared with about 20% of their peers.

Men with eating disorders also reported less satisfaction with their leisure activities, housing, income and family life, the authors point out.

Nearly 26% of anorexic and bulimic men said they had more than one marital conflict a week compared with roughly 10% of their peers, and about 63% of anorexic or bulimic men said they were currently living with their spouse, compared with 83% of men without eating disorders.

"Men with eating disorders showed striking differences from men without eating disorders," Woodside and colleagues conclude. "The extent to which these differences are effects of the illness or possible risk factors for the occurrence of these illnesses in men is not clear."

In other findings, eating disorders appeared to be clinically similar in both sexes, the researchers note.

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Discover the history of the ADHD diagnosis along with DSM-IV diagnostic criteria for Attention-Deficit/Hyperacivity Disorder (ADHD).

The Diagnostic and Statistical Manual of Mental Disorders includes standardized diagnostic criteria for many psychiatric disorders. First published by the American Psychiatric Association in 1952, the manual is used as a resource by the majority of mental health professionals. In its earlier editions, many clinicians considered the DSM merely a tool for researchers. Now, in an era of managed care, clinicians are often forced to rely on the standardized criteria in the DSM in order to remit insurance claims. And its impact goes even further. If a condition is acknowledged by the DSM, it can be credibly used in a legal defense, or in a disability claim. In the case of ADHD, a diagnosis can mean that a child is entitled to receive special educational services from his or her school district.

In its 50-year history, the DSM has been significantly updated four times--in 1968, in 1980, in 1987, and in 1994. It wasn't until the second edition was published in 1968 that a disorder resembling ADHD appeared in the DSM. The "hyperkinetic reaction of childhood" was defined as a type of hyperactivity. It was characterized by a short attention span, hyperactivity, and restlessness.

In the third edition of the manual (DSM-III) published in 1980, the name of this childhood disorder was changed to Attention Deficit Disorder (ADD), and its definition was expanded. The new definition was based on the assumption that attention difficulties are sometimes independent of impulse problems and hyperactivity. Therefore, the disorder was redefined as primarily a problem of inattention, rather than of hyperactivity. In keeping with this approach, two subtypes of ADD were presented in DSM-III--ADD/H, with hyperactivity, and ADD/WO, without hyperactivity.

The inclusion of ADD/WO has been the subject of debate ever since. When the third edition of the manual was revised in 1987 (DSM-IIIR), the name of the disorder and its diagnostic criteria had been overhauled, once again emphasizing hyperactivity. The authors now called it Attention Deficit Hyperactivity Disorder (ADHD), and consolidated the symptoms into a unidimensional disorder, without any subtypes at all. This definition did away with the possibility that an individual could have the disorder without being hyperactive.

After the publication of the DSM-IIIR, a variety of studies were published supporting the existence of ADD without hyperactivity, and the definition was changed again in the fourth, and most recent, edition of the manual published in 1994 (DSM-IV). The authors did not change the name ADHD, but the symptoms were divided into two categories--inattentive and hyperactive/impulsive--and three subtypes of the disorder were defined: ADHD, Primarily Inattentive; ADHD, Primarily Hyperactive/Impulsive; and ADHD, Combined Type.

The DSM-IV listing attempts to describe the typical manner in which ADHD manifests in affected children--when symptoms appear, when parents and caretakers can reasonably expect the symptoms to attenuate, and what factors may complicate the diagnosis of ADHD.

The DSM-IV urges clinicians to use caution when considering an ADHD diagnosis under certain circumstances. The manual notes, for example, that it is difficult to diagnose ADHD in children who are younger than 4 or 5 years of age because the variability in normal behavior for toddlers is much greater than that of older children. It also recommends that evaluators use caution in diagnosing adults with ADHD solely on the adults' recollection of symptoms they experienced as a child. This "retrospective data," according to the DSM-IV, is sometimes unreliable.

Below are the current diagnostic criteria for ADHD, taken from the text-revised edition of the DSM-IV, which was published in the summer of 2000. Note that this excerpt comprises only a fraction of the DSM-IV's entry on ADHD.

Diagnostic Criteria For Attention-Deficit/Hyperacivity Disorder (DSM IV)

(A) Either (1) or (2):

(1) six (or more) of the following symptoms of inattention have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level;

Inattention

• often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities
• often has difficulty sustaining attention in tasks or play activities
• often does not seem to listen when spoken to directly
• often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behavior or failure to understand instructions)
• often has difficulty organizing tasks and activities
• often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework)
• often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools)
• is often easily distracted by extraneous stimuli
• is often forgetful in daily activities

(2) six (or more) of the following symptoms of hyperactivity-impulsivity have persisted for at least 6 months to a degree that is maladaptive and inconsistent with developmental level:

Hyperactivity

• often fidgets with hands or feet or squirms in seat
• often leaves seat in classroom or in other situations in which remaining seated is expected
• often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)
• often has difficulty playing or engaging in leisure activities quietly
• is often "on the go" or often acts as if "driven by a motor"
• often talks excessively

Impulsivity

• often blurts out answers before questions have been completed
• often has difficulty awaiting turn
• often interrupts or intrudes on others (e.g., butts into conversations or games)

(B) Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.

(C) Some impairment from the symptoms is present in two or more settings (e.g., at school [or work] and at home).

(D) There must be clear evidence of clinically significant impairment in social, academic, or occupational functioning.

(E) The symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia, or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood Disorder, Anxiety Disorder, Dissociative Disorder, or Personality Disorder).

Sources:

• DSM-IV-TR. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association.
• Diagnostic and Statistical Manual of Mental Disorders, Wikipedia.

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