ECT at the European Congress of Psychiatry

The words “safe and effective” have become super-glued to electroconvulsive therapy (ECT). But safety and effectiveness are relative concepts. Is ECT safe because you are extremely unlikely to die with the electrodes on your head? Or is it unsafe because it causes memory loss? Is it effective because it can temporarily reduce someone’s score on a checklist of symptoms? Or ineffective because many patients will soon find themselves depressed again?

The chair of the Scottish ECT Audit Network (SEAN), Julie Langan Martin, presented a paper on ECT at the European Congress of Psychiatry. At least, I suppose she did – I have only been able to find the press release.

The headline of the press release says: “Electroconvulsive therapy (ECT) shown to reduce severity of certain mental illnesses”. Reading the body of the press release, it transpires that Langan Martin has gone through a number of SEAN annual reports and found that 2,920 courses of ECT resulted in a mean reduction of their CGI-S score. The CGI-S score simply indicates whether the treating clinicians rate their patients as “much improved”, “very much improved”, etc.

She acknowledges that “confusion was reported in 19% and cognitive side effects in 26.2%” and goes on to conclude: “Our findings from this large naturalistic study across Scotland from over an 11-year period reinforce the widely held, but nonetheless underexplored view, that ECT is both a safe and effective treatment when delivered to appropriate groups of people with severe mental illness.” The issue of cognitive side effects is side-stepped with a nod to “monitoring”.

The “notes to editors” section at the end of the press release does not mention the fact that over 40 per cent of patients given ECT in Scotland over the period in question did not consent to the treatment.

ECT and recovery of orientation

A team of researchers from the Netherlands, led by Sven Stuiver, technical physician at Rijnstate Hospital, Arnhem, have recently published an article in European Psychiatry with the title “Restoration of postictal cortical activity after electroconvulsive therapy relates to recovery of orientation in person, place, and time”.

The researchers studied the EEG of patients following electroconvulsive therapy (ECT) and compared it with the time taken for them to recover clinical orientation in “person (name, birthday), place (name of hospital) and time (age, day of week)”. After one hour most of the patients were reorientated in person, place and time but EEGs were only returning towards baseline, rather than actually reaching it. Knowing who you are and where you are is a good start, but it tells us nothing about how long it takes people to reorientate themselves in their lives.

There are some interesting violin diagrams which show the variation in individual times to reorientation. What the researchers do not say is how long it took patients to recover consciousness following the seizure. Presumably you have to be conscious to answer questions about your name, etc., but it would be nice to know how soon after regaining consciousness people were aware of who they were and where they were.

The authors note that: “The specific order of reorientation in person-place-time is in line with earlier findings and was also observed in patients recovering from closed-head injury. Furthermore, this finding is also in line with observations in patients with dementia, where orientation disappears in counterorder”. In the list of seven authors, neurophysiologists outnumber psychiatrists, which perhaps explains their candour, along with the fact that the research was funded by the Dutch National Epilepsy Fund.

ECT and a Freudian typo

The Electroconvulsive Therapy Service at Providence Alaska Medical Center has produced a brochure for their patients which contains a typically optimistic account of ECT:

“Electrical stimulation and seizure promotes changes in thebrain that reduce symtpoms associated with certain psychiatric disorders and restores health. ECT produces substantial improvement in about 80% of people with severe depression.”

“During the course of treatment, many patients experience short term memory impairment, such as forgetting details of recent conversations or things they just read. This resolves completely within a few weeks after treatment is over. Many patients feel their memory is improved after receiving ECT.”

And so on. But there is a typo that rather spoils this rosy picture of ECT. We are told that ECT is “an FDA aproved treatment that utilizes a small amount of electrocity applied to the scalp to produce a brief seizure in the brain”. Electrocity? That sounds unfortunately like a combination of electric and atrocity.

Lake Alice: the RANZCP apologises

I have written several posts about Lake Alice, most recently here. Selwyn Leeks, the psychiatrist in charge of the child and adolescent unti at the Lake Alice psychiatric hospital, died in January 2022 aged 92, without ever facing action from the authorities. It was only after his death that the Royal Australian and New Zealand College of Psychiatrists (RANZCP) rescinded his fellowship of the College.

Today (20 February 2024) the RANZCP published an apology to the victims of Lake Alice. The apology, when it was delivered in person to survivors, did not go down well. Some survivors walked out of the room as RANZCP president Elizabeth Moore read out the apology. Afterwards, barrister Rosemary Thomson, who spent eight days in Lake Alice as a thirteen-year-old in 1976, said that the the apology sounded like “careful chosen words that just didn’t ring true” and that “At the end of the day the true apology will come from the government … when they pay money, that will be the true apology.” More reactions from survivors can be read in this article from Radio New Zealand.

Even in apologising, ANZCP tried to distance themselves from responsibility: “The barbaric abuse conducted by Leeks at Lake Alice was not psychiatry of any form.” And they couldn’t resist the opportunity for a bit of self promotion: “We are committed to people receiving the best mental health care, guided by evidence and expertise.”

ECT and the disappearing shock

Electric shock + seizure = electroconvulsive therapy (ECT)

It is simple. You give someone an electric shock, they have a seizure, and the result is ECT. That much has not changed since the treatment was invented more than eighty years ago. The machines may be more sophisticated and able to print-out EEG recordings, the patient may be anaesthetised before the electric shock is given and the convulsions dampened with a muscle-paralysing drug, but otherwise it remains the just the same.

So why are psychiatrists so reluctant to use the term “electric shock”? They instead refer to an electric current, or pulses or stimulations. Shock therapy has become neuromodulation. It used to be the case that humans were given ECT or electroconvulsive therapy while animals in laboratories were given ECS or electroconvulsive shock. But even that has now changed to electroconvulsive stimulation.

At the Duke Behavioral Health Center in Durham, North Carolina, they go one step further. The eight psychiatrists (one woman and seven men) in charge tell us that only that ECT uses “a machine” with no mention of currents or pulses or anything else electrical. Perhaps they think that it is enough that the clue is in the name.

“Electroconvulsive therapy is effective for people with treatment-resistant psychiatric and medical conditions and is a clinically proven, safe process that uses a machine to induce seizures in order to improve brain function for people with certain treatment-resistant disorders.”

I was surprised to come across a recent use of the term “shock treatment” to describe ECT on the website of the manufacturers of Ectron ECT machines. According to the website, the Ectonustim Series 6+ model is:

“A reliable and easy to use device used to treat depression with shock treatment. Available with a full range of accessories and consumables.”

Another selling point is “zero-low maintenance costs“.

ECT and a victim of injustice

“After medication did not work, she received 14 treatments of electroconvulsive therapy (ECT)”

Such statements are commonplace in case histories. Often there will be a long list of the various drugs that “did not work” before ECT is used. And guidelines and patient information leaflets on ECT invariably say that it is used when drugs do not work. The Royal College of psychiatrists patient information leaflet for example says:

“ECT will usually be suggested if your condition: … has not responded to other treatments, such as medication…. “

But the above quote does not come from a case history in a medical journal. It comes from a BBC article about the Post Office scandal, which saw hundreds of innocent people convicted of theft or forced to pay back money they didn’t owe because of faults in the Post Office accounting software. What might have worked for the sub-postmaster in the article – and spared her memories – was justice and redress in the place of medication and ECT. She can be seen in a TV interview here (at 5’30).

Colleen Loo explains how ECT works

In an article on the website of the Australian Broadcasting Corporation, professor of psychiatry Colleen Loo explains how electroconvulsive therapy (ECT) works.

She said on a micro level, the procedure caused individual brain cells to regrow and become “plump and healthy” – while on a macro level, it was like “rebooting a computer”.

There has never been a shortage of theories of how ECT works. I wrote here about Major Gordon’s 1948 article Fifty shock therapy theories. And they are being added to all the time. Researchers at the University of California (San Diego) recently proposed a theory that it is all down to the brain’s background noise, while a team in Hefei in China suggest it has something to do with reward-related networks and the default mode network.

Professor Loo continues:

“We know with disorders like depression, the brain gets stuck in patterns of circuit functioning that are different to when people are in normal health.”

These words remind me of how Egas Moniz explained leucotomy in the 1930s. His theory was that, by severing connections between the frontal lobes and deeper parts of the brain, fixed thoughts could be forced to take a different pathway through the brain and become more normal. Plus ça change, as they say.

She finishes by warning people about online misinformation about ECT:

However, Professor Loo said there was still a widespread stigma around ECT, which was only being worsened by online misinformation.”I have to explain to people that these opinions are not actually based in fact,” she said.

Whereas the plump brain cells and rebooting the brain are, presumably, based on scientific facts.

ECT figures for 2021 from the Royal College of Psychiatrists

The Royal College of Psychiatrists has just (December 2023) published their latest figures (for 2021) on the use of electroconvulsive therapy (ECT) in clinics that belong to the Royal College Electroconvulsive Therapy Accreditation Service (ECTAS) in England, Wales, Northern Ireland and the Republic of Ireland.

The press release headline says: “New data shows more than a thousand people benefit from life-saving electroconvulsive therapy, majority of which are women“. Quite apart from the doubtful claim that people “benefit from life-saving” treatment, the headline is misleading in saying “more than a thousand” as in fact the report looks at ECT given to nearly 2,000 people. I suppose that nearly 2,000 is, technically, “more than a thousand”. This in any case is not the total amount of ECT used in England, Wales, Northern Ireland and the Republic of Ireland as some ECT clinics do not submit data to ECTAS.

As in Scotland, more than half of patients did not consent to treatment. Nearly half (463) of those courses where the patients had not consented were started “under urgent authorisation”, which I think means before a psychiatrist from the Care Quality Commission has authorised treatment.

Women accounted for 67 per cent of ECT patients. The average age of patients receiving ECT was 62 years, covering a range from 17 to 93 years. The mean age for patients receiving maintenance ECT was slightly older at 67 years with the same range of 17 to 93 years.

The mean number of treatments in a course was 10, and the mode, accounting for over a quarter of courses, was 12. For the first time, information was given on electrode placement and it was overwhelmingly bilateral, with fewer than 5 per cent of courses started with unilateral electrode placement (and some of those may have switched to bilateral during the course).

ECT: joules and millicoulombs

In my last post I wrote about how psychiatrists have switched from joules to millicoulombs to measure the strength of the electric shock in electroconvulsive therapy (ECT). A recently published article (M Marcille et al. Durable response to electroconvulsive therapy with atypical electrode placement in a post-middle cerebral artery stroke patient, Psychiatric Research Case Reports, vol 2 issue 2, December 2023) explains in more detail:

“Given that ECT devices are constant current, we used charge (mC) as the primary parameter to measure the electrical stimulus, rather than energy (J), because charge is more reliable, consistent, and clinically relevant. The charge does not depend on the resistance of the circuit, which can vary widely, and it correlates well with the seizure threshold and the clinical response of the patient. Charge also allows for a standardized comparison and replication of different ECT devices, electrodes, and techniques across studies and settings. Energy, on the other hand, depends on the resistance, which can introduce error and variability, and it does not correlate well with the efficacy or adverse effects of ECT. Energy also does not allow for a valid comparison, as it depends on factors that are not controlled or reported in most studies.”

The article, by a team of psychiatrists in Florida, describes how they gave ECT to a 43 year old woman who had had a stroke at birth and lost a large proportion of her right cerebral hemisphere. The article did not describe the extent of any disabilities, but did mention that she had completed high school. She had been diagnosed as having a schizoaffective disorder in her early twenties and had, over the years, taken 15 different psychotropic drugs and undergone previous ECT. When admitted to hospital she was taking fluoxetine, lithium, carbamazepine, thiothixene, trazodone and topiramate, as well as five non-psychotropic drugs. and was described as having “mild, persistent auditory hallucinations” with “sad mood, amotivation, anergy, anhedonia, and diminished ability to achieve meaningfulness in life“.

The authors announced: “ECT improved the patient’s mood and interpersonal functioning, reduced her psychotic symptoms, and did not cause any serious adverse effects or complications” and her family reported that “she was now sitting through an entire meal with the family, chatting, and pleasant.” The article did not say who the family was – partner and children, or parents and siblings.

Is this a success story? Should we be thankful that psychiatry has the answer in the shape of ECT for people with illnesses that have not been cured by drugs? Or should we see it as a cautionary tale of what can happen when you get involved with psychiatry? The authors acknowledge the limitation of not having a control group, by which I expect they mean people taking six psychotropic drugs but not being given ECT. The really useful control group however would be the ones who got away and, by definition, are never going to find their way into psychiatric journals; those people who, by chance or design, never became psychiatric patients even if they faced similar difficulties in life. Although we are told that the patient had been diagnosed as having a schizoaffective disorder twenty years previously, no details are given about the circumstances of the diagnosis.

ECT and joules

Psychiatrists in Belgium recently (November 2023) published a case report about a woman who was given electroconvulsive therapy (ECT) while she had a deep brain stimulator in place for the treatment of Parkinson’s disease.

The 79 year old woman was admitted to hospital, diagnosed with major depressive disorder with psychotic features, and treated with quietapine, sertraline and clozapine. She then underwent 17 bilateral ECT treatments.

“The stimulus dose was established by means of the half-age estimation method. The stimulus was given with a Thymatron System IV ECT device at a frequency of 30 Hz, pulse width 0.5 ms, stimulus duration 7.47 s, and charge of 201.6mC (39.9 Joules). During the ECT procedure, vital parameters were monitored, and a mouth guard was placed before stimulating.”

It is rare for modern descriptions of ECT to include joules in the technical parameters, which makes comparison with older techniques, where joules were the standard measurement, difficult. And therefore it is difficult to test claims that ECT “uses far milder electrical impulses than decades ago” (from the Institute for Healthcare Policy & Innovation).

In fact, a comparison between the amount of electrical energy used in early ECT and modern ECT shows that modern ECT uses more electrical energy. Typically, machines used in the 1940s delivered 18 joules, less than half the amount of electrical energy used, for example, on the patient in Belgium recently.