Woman loses 30 years of memories after electroconvulsive therapy
Richland County (SC) Circuit Court
A 55-year old woman with a history of depression underwent successful electroconvulsive therapy (ECT) after her husband and father died. Six months later she became depressed, and a new psychiatrist referred her to his partner for additional ECT treatments.
The partner administered outpatient ECT at a hospital daily for 10 days. The referring psychiatrist wrote in the patient’s chart that the patient experienced memory loss and severe cognitive problems during the initial ECT regimen but did not report this development to his partner and allegedly encouraged the patient to continue ECT.
After the second round of ECT treatments, the patient suffered brain damage and lost all her memories from the past 30 years—including the births of her children and her job skills—leaving her unable to work.
In court, the patient claimed ECT should be administered no more than three times a week, and the referring psychiatrist should have told his partner about the patient’s memory problems.
- The case was settled for $18,000
Dr. Grant’s observations
Although this case concerns ECT, the claim is based on negligence—that is, the psychiatrist did not fulfill his duty to care for the patient. The negligence claim focused on how the treatment was implemented, not whether ECT was appropriate for this woman’s depression.
ECT’s response rate ranges from 50% to 60%1 among patients who did not respond to one or more antidepressant trials. Symptomatic improvement usually is faster with ECT than with pharmacotherapy2 when ECT is administered three times per week. Mortality rates with ECT are similar to those associated with minor surgery.1
In addition to being an effective and safe treatment for depression, ECT rarely is a basis for malpractice. One study found that only 4 (0.2%) of 1,700 psychiatric malpractice claims filed between 1984 and 1990 concerned ECT’s side effects, complications, or appropriateness.3 Few patients who receive ECT file a malpractice claim because most are satisfied with the treatment; approximately 80% of ECT patients say they would consent to ECT again.4,5 In fact, one might consider withholding ECT from severely depressed patients grounds for malpractice.
Although safe and effective, ECT could present health risks that you need to discuss with patients. In particular, cognitive problems such as delirium and impaired attention and memory may result.1
Cognitive impairment risk in ect
ECT’s more severe cognitive side effects stem from:
- bilateral electrode placement
- sine wave stimulation
- suprathreshold stimulus intensity
- administration >3 times per week
- large numbers of treatments, usually >20 in an acute treatment course
- some medications, such as lithium carbonate and anticholinergics6
- pre-existing neurologic diseases such as Alzheimer’s or Parkinson’s disease.1
The magnitude of retrograde amnesia often is greatest immediately after treatment. Patients are more likely to forget public information such as current events than personal information.10 The effects usually subside over time, and older memories are more likely to be recovered than more recent ones. ECT can cause permanent memory loss, particularly after bilateral electrode placement, suprathreshold stimulus intensity, sine wave stimulation, or large numbers of treatments—usually more than 20.
6 steps for obtaining informed consent before ECT
Ensuring adequate informed consent when delivering ECT or before referring a patient for treatment can help prevent a malpractice claim. Although specific requirements for ECT consent vary by jurisdiction, follow these general principles:1
- Provide the patient adequate information. Explain the reasons for ECT, describe the procedure including choice of stimulus electrode placement, offer alternative treatments, and explain the risks, benefits, anticipated number of treatments, relapse risk, and need for continuing treatment.
- Make sure the patient is capable of understanding and acting reasonably on this information and knows he or she can refuse treatment at any time.
- Tell the patient that a successful outcome is not guaranteed.
- Describe the likelihood and potential severity of major risks associated with ECT, including mortality, cardiovascular and CNS problems, and minor side effects such as headache, muscle aches, or nausea.
- Be sure the patient understands that consent is voluntary and can be withdrawn. The patient should know that he or she is also consenting to emergency treatment.
- Tell patients about possible behavioral restrictions—such as needing a friend or family member to monitor the patient or not being able to drive a car—that may be necessary during evaluation, treatment, and recuperation.