ECT and post-ictal confusion

Confusion following electroconvulsive therapy (ECT) is recognised as a common side effect, but one that passes off quickly and is of little consequence. The Royal College of Pyschiatrists patient information leaflet for example says only: “Immediately after ECT, you may experience… confusion, particularly if you are elderly (this usually wears off after 30 minutes)”. Meanwhile, patients in Birmingham and Solihull Mental Health NHS Foundation Trust are given a leaflet which tells them:

“Some people wake up with no side effects at all and simply feel very relaxed. Others may feel somewhat confused or have a headache. There will be a nurse with you when you wake up after the treatment to offer you reassurance and make you feel as comfortable as possible…. A nurse will be there when you wake up in the recovery area and will offer you a cup of tea or a drink of your choice.”

A rather different post-ECT experience emerges from an article published in the March 2023 edition of the Journal of ECT (G Shuur et al. Severe Postictal Confusion After Electroconvulsive Therapy: A Retrospective Study. Journal of ECT 39(1):34-41). The authors, from the Rijnstate Hospital, Arnhem in the Netherlands, retrospectively studied the charts of 295 ECT patients and found that 25 per cent of them experienced sPIC (severe post-ictal confusion). All those experiencing severe confusion after ECT “needed extra medication”, 7 were subjected to physical restraint and 4 were put in seclusion. According to the abstract (I have not read the article), there was no way to predict the occurence of severe post ictal confusion. Older patients were not identified as being at particular risk.

ECT: a cardiac complication

Controversy about ECT usually revolves around its impact on the brain. A recently published case report however serves as a reminder that the risks of ECT, where a powerful electric shock is used to induce a generalised seizure, are not confined to the brain.

Writing in Cureus, three emergency medicine physicians from Texas describe the case of a healthy young man who experienced atrial fibrillation following ECT. He underwent cardioversion and recovered. (Olsen B, Trent J S, Inman B L (November 28, 2022) Electroconvulsive Therapy-Induced Paroxysmal Atrial Fibrillation in Healthy Young Male. Cureus 14(11))

Zholia Alemi: another conviction

I have written before (here, here and here) about Zholia Alemi, who worked for over 20 years as a psychiatrist in the UK without a medical qualification. She forged a certificate from a New Zealand University in order to register with the General Medical Council (GMC) in 1995 and then embarked on training as a psychiatrist, eventually passing the Royal College of Psychiatrists exams.

In 2018 she was convicted of forging a patient’s will and sentenced to five years in prison. During her career, in spite of several run-ins with the GMC, no-one had thought to check her credentials. Neither apparently did the police when investigating the forged will. It was a journalist on a local newspaper (Phil Coleman at the News and Star in Cumbria) who took the simple step of contacting the University, who confirmed that she had not completed a medical degree.

On 15 February 2023, after a five-week trial at Manchester Crown Court, Alemi was convicted of “13 counts of fraud, two counts of forgery, three counts of deception and two counts of using material to falsify medical qualifications”. The Crown Prosecution Service (CPS) says they will now try to recover some of the more than £1million proceeds of crime, that is, the money she earned by using her false qualification.

Judge Hilary Manley adjourned sentencing unti 28 February 2023, remanding Alemi into custody and telling her to expect a substantial jail sentence. She said that before sentencing she wanted to find out “how it was this defendant was able to practise as long as she was, in so many positions.” I expect she just means why did no-one who registered her or employed her check her credentials, but it would be nice to think that the case might start a wider debate about how an unqualified doctor can practise as a psychiatrist for so long without arousing any suspicion. Would this have happened in any other medical specialty?

ECT in Scotland 2021 without consent

Scotland (population about 5.5 million) is one of the few countries that collects and publishes statistics on the use of electroconvulsive therapy (ECT). The latest figures were published by the Scottish ECT Accreditation Network (SEAN) in November 2022 and cover the year 2021.

In 2021, 284 patients underwent 321 courses of ECT. They received a total of 3128 individual treatments. 68 per cent of patients were women. 49 per cent of patients were aged over 60. Almost half of the patients did not consent to treatment.

The SEAN report includes a section on “patient engagement”:

“SEAN is aware that speaking about the experience of receiving ECT treatment, either as a patient or as someone caring for a family member, may be difficult and uncomfortable. We have made a commitment through the development of our new quality improvement standards that every patient, and their carers/families, will be offered opportunities to communicate their experiences of treatment in a way that suits them best.”

Meanwhile, one of the people given ECT without their consent in Scotland in 2021 has communicated his experience by writing an article for the Mad in the UK website, and it makes for very disturbing reading. In “My experience of being subjected to ECT illegally without consent”, Jon (the author writes under his first name) describes how he became depressed after being diagnosed with Stage IV prostate cancer and was detained in the Royal Cornhill Hospital, Aberdeen. While there he was given sertraline, mirtazapine, olanzapine and diazepam (two antidepressants, an antipsychotic and a tranquilliser). After three weeks, a psychiatrist from the Mental Welfare Commission (MWC) panel authorised ECT without consent and he was given four treatments. He writes that three of these treatments were not carried out legally, as the hospital had failed to obtain an extension to his detention order, which expired between the first and second treatments. At this stage I am getting a bit confused and have to remind myself of the law regarding ECT without consent in Scotland.

Under Scottish law, patients who are “capable and refusing”, whether informal (voluntary) or detained, cannot be given ECT even in an emergency. Informal patients who are deemed to lack capacity may be treated without their consent under the 2000 Act if authorised by a psychiatrist from the Mental Welfare Commission (MWC) panel of designated medical practitioners, but only if they are not resisting or objecting. Detained patients who are deemed to lack capacity may be given ECT without their consent with the authorisation of the MWC psychiatrist under the 2003 Act on a form T3A. If they are resisting or objecting they can be treated without their consent in “situations of necessity” on a form T3B. In “urgent” situations patients may be treated with ECT in advance of the MWC psychiatrist’s authorisation. (The information in this paragraph is taken from the MWC good practice guide 2021, page 35.)

Were those three treatments therefore carried out illegally? Or is a T3B form still valid in spite of a change from detained to informal status? The good practice guide says on page 38: “If there is a gap in detention, a fresh authorisation is needed”. This would suggest that the T3B loses its validity when a detention order is no longer, for whatever reason, in place.

The article includes a link to Jon’s website, where he has posted copies of his medical records, including his ECT treatment form. If I have understood the form correctly, the first treatment consisted of “dose titration”, that is, he was given three electric shocks of increasing strength in an attempt to establish his seizure threshold but none elicited a seizure. At this stage it was decided to abandon the attempt and continue at the next session, which is standard practice. As a seizure is considered necessary for a therapeutic effect, it would mean that, if the other treatments were not legal, the only legal treatment was the one without any therapeutic value.

An ECT patient’s experience of memory loss

Prospect magazine has just (25 January 2023) published an article by a woman undergoing electroconvulsive therapy (ECT).

In the article psychiatrist Rebecca Lawrence describes how ECT has caused her memory loss.

 My long-term diagnosis is of psychotic depression and bipolar disorder, and when I had multiple ECT courses before, the main side effect was memory loss. I thought to myself that surely I would be able to retain my memory on this occasion; surely I could make the effort. Needless to say, I was wrong. My husband tells me that my memory loss was not immediate, but that within about four treatments it was apparent. The whole experience was bizarre and disorientating, although all the staff I encountered were very kind to me….. After the treatment, I did get slowly better, I think, although my memory got incrementally worse. It was quite peculiar—I couldn’t remember who the prime minister was, or even had been, but given the revolving door at Number 10 last year, who can blame me? More problematically, trying to remember the right Christmas presents for my family was a shocker! I had been working on a novel over the past year—I had no recollection of it. Another feature of my experience was overspending. My husband was rendered slightly exasperated by the arrival in the post of lots of brightly coloured clothing. We managed to work out, by a process of elimination, that I had bought it all for myself. Fortunately it’s very pretty, but I would never have purchased it normally. The memory loss has been particularly confusing in that it’s hard to know what I’ve forgotten, especially in relation to work, or to understand why I made certain decisions. 

There is of course nothing unusual about this description of ECT and memory loss. Search the internet and you will find many people writing about similar experiences. It even reminds me of an article in The New Yorker from nearly fifty years ago in which a woman described the memory loss caused by ECT (Berton Roueché, 1974, As Empty as Eve, The New Yorker).

What is more unusual however about the article in Prospect is that the writer is someone who has co-authored articles with ECT proponents Robert Howard and Stephen Lawrie and has recently been held up by another ECT proponent Sameer Jauhar as an example of “patients who have described how they have benefited from ECT and are still able to function and work”, according to a report of his talk at Birmingham Medical Institute on the Mad in the UK website.

ECT in the Republic of Ireland 2021: mainly for older people

The Mental Health Commission has recently (November 2022) published a report on the use of electroconvulsive therapy (ECT) in the Republic of Ireland (population 5.028 million) in 2021.

A total of 2281 treatments were given in 293 programmes to 219 patients in 2021. A programme is a course of up to 12 treatments. Presumably anything over 12 treatments counts as a second programme. In any case the most common number of treatments in a programme was 12, accounting for over 20 per cent of programmes.

ECT was given to patients aged from 25 to 93 years. Only 17 per cent were aged under 50. Women accounted for 59 per cent of ECT patients. Looking at a break down of age range by gender shows that the largest groups to be given ECT were women in their sixties and seventies.

Of the 67 psychiatric units in the Republic of Ireland, 29 either provided ECT or referred patients to another unit for ECT. One hospital, St Patrick’s University Hospital in Dublin, was responsible for over half of all programmes of ECT. It was Professor Declan MacLoughlin at St Patrick’s University Hospital who famously, and erroneously, claimed that ECT uses less energy than a banana.

Compared to the United Kingdom patients are more likely to consent to treatment, with 14 per cent of programmes including one or more treatments without consent, and are more likely to be treated with unilateral electrode placement, with nearly half of programmes being given with exclusively unilateral electrode placement.

The report concludes that, given in particular the lack of data on where ECT patients live and on long-term outcome of treatment “… it is neither useful nor practicable to offer recommendations based on the results of the data collected, nor to make either a positive or negative statement about the impact and usefulness of ECT treatment.”

ECT: a strange version of neutrality

Last month I wrote about a Swedish woman who had experienced memory loss after electroconvulsive therapy (ECT) and talked about the injustice of not being believed. Now I find an example of this professional scepticism about memory loss in an article published in February 2022 on the BMC Psychiatry website (Recipients’ experience with information provision for electroconvulsive therapy by A Coman).

The author, Alina Coman, is affiliated to the Centre for Medical Ethics at the University of Oslo, Norway. In the article, Coman states that she has a “neutral stance”.

The “neutral stance” is certainly not apparent from a quick glance at the references. Nine of the 44 references come from the Journal of ECT, where practitioners of ECT can publish anything they like as long as it is supportive of the treatment. Looking just at the first paragraph, several big names in ECT are cited – Kellner, Petrides, Sienaert, Anderson. There is also a reference to a book by Jonathan Sadowsky (Electroconvulsive therapy in America: the anatomy of a medical controversy) and a reference to a small review of the literature on the use of ECT for catatonia.

The second paragraph deals with the subject of memory loss and here the author sets out their “neutral stance”. We are told that “substantial data” shows that neurocognitive functions return to baseline after a few days or weeks or are even boosted. There is then an aknowledgement that some patients experience long term memory loss, only for it to be explained away: “Subjective memory complaints have often been opposed by objective neuropsychological studies, or explained by low mood, prior poor cognitive functioning, older age or negative expectations”. The paragraph ends with a call for further research into “subjective memory complaints”. Note the contrast between “substantial data”, “objective neuropsychological studies” and “subjective memory complaints”.

What of Coman’s own research? She recruited 21 people, aged from 21 to 65, from two websites and a psychiatric department. Six of the participants were descibed as holding “strongly critical views towards ECT given the costs to memory”. One described severe memory loss that made her feel as if she had not existed before, while others described losing work-related knowledge. The author is dismissive of these “subjective complaints”, suggesting that they might be due to negative expectations of ECT.

The author concludes: “Further research should monitor how enhanced patient education influences consent processes, satisfaction with information and treatment.”

£118 billion

According to an article in the Daily Mail (28 November 2022) British prime minister Rishi Sunak has declared war on mental health.

“Rishi Sunak has declared war on cancer, obesity, mental health and addiction with a blueprint inspired by the Covid vaccine rollout.”

Does that mean that we can expect his policies to drive people deeper into despair? It’s a thought, but I expect the Daily Mail writers are simply using the term “mental health” as an euphemism for “mental illness”. Other reports on the same theme use terms such as “mental ill-health”, “mental health problems” and “poor mental health”.

The story came from a government press release:

“The government has today announced over £113 million to fund research into 4 healthcare missions – cancer, obesity, mental health and addiction – to unlock the next generation of medicines and diagnostics to save lives, transform patient care and ensure UK patients are the first to benefit from medical breakthroughs…. In addition, tackling these healthcare challenges could save the NHS and the economy billions of pounds – it is estimated obesity costs the NHS £6.1 billion a year and poor mental health costs the economy £118 billion a year.”

Poor mental health costs the economy £118 billion a year! That is an awful lot of money. In fact it is about £4,000 for every household in the United Kingdom. Where does the figure come from? How is it calculated?

The Government press release does not give us the source of this figure, but it is not difficult to track down. A quick search comes up with a news item from the London School of Economics (LSE): “Mental health problems cost UK economy at least £118 billion a year – new research”. The research, published in March 2022, was a collaboration between the LSE and the Mental Health Foundation (MHF).

“Almost three quarters of the cost (72%) is due to the lost productivity of people living with mental health conditions and costs incurred by unpaid informal carers who take on a great deal of responsibility in providing mental health support in our communities.”

Now it is beginning to make sense. The £118 billion is not what the government actually spends on mental health, but consists largely of an estimate of what the government loses in lost productivity and also an estimate of the costs incurred by unpaid carers. But I was still intrigued by how these figures are calculated. So let’s turn to the LSE/MHF report.

The report is called “The economic case for investing in the prevention of mental health conditions in the UK”. Note the word prevention. The new government initiative is about spending £40.2 million for “research into mental health to develop and introduce digital technologies to support patients”, rather than anything to do with prevention. But as the report is only being used as the source of the £118 billion figure, that does not really matter. We already have the treatment with, for example, nearly one in five adults being prescribed anti-depressants in a year and millions getting cognitive behavioural therapy (CBT) via the increased access to psychological therapies (IAPT). And yet “poor mental health” is still costing £118 billion.

On page 11 the report gives a breakdown of that figure of £118 billion:

£36.4 billion – informal care costs

£36.2 billion – costs of economic inactivity

£26.1 billion – lost quality of life

£13 billion – specialist mental health services

£2.5 billion – educational services

£2.3 billion – GP services

£1.2 billion – social care services

The largest cost is informal care. This is not an actual cost; informal carers are defined as unpaid and any loss of productivity they experience as a result of their caring responsibilities does not appear to have been included in these costs. So how is that figure arrived at? The authors explain:

We have drawn on literature, plus a recent survey we conducted for the European Federation of Associations of Families of People with Mental Illness on informal care, to make some estimates of the cost of informal care. In this study values were elicited from carers on their willingness to accept payment to provide one extra hour of care (McDaid D, Park A-L. Understanding the value and impacts of informal care for people living with poor mental health. London: Care Policy and Evaluation Centre, London School of Economics and Political Science; 2020). We have used these values to value each hour of informal care.

And then, in the absence of data, there is an estimate of how many people with mental health problems receive informal care. As for the hours each person receives – I could find no mention of how this is estimated.

But anyway, how is this £40.2 million for “research into mental health to develop and introduce digital technologies to support patients” going to be spent? According to the government press release: “This could include technology allowing patients to monitor their mental health at home and instantly report to their doctor if in need of help.” Meanwhile the government is paying advertising agency M&C Saatchi up to £28.6 million for a campaign to discourage people from visiting their GP.

To finish on a brighter note – neither the Daily Mail article, the government press release, the LSE news item nor the LSE/MHF report are illustrated with a picture of someone with their head in their hands. The Daily Mail has a picture of Rishi Sunak; the government press release has a picture of someone in a laboratory; the LSE news item has Scrabble letters arranged to spell mental health; the LSE/MHF report has a picture of people in a balloon floating through clouds and giant gold coins.

Two different views of ECT

The British Journal of Psychiatry and the British Journal of Social Work have recently (March and November 2022) published articles by women, both academics, who have undergone electroconvulsive therapy (ECT).

In the British Journal of Psychiatry Tania Gergel has written an article entitled “‘Shock tactics’, ethics and fear: an academic and personal perspective on the case against electroconvulsive therapy” (which can be read here) while in the British Journal of Social Work Jennie Moberg has written an article entitled “‘The Great Oblivion’ – an autoethnographic depiction of social and personal recovery after electro-convulsive therapy (ECT)”.

Gergel became depressed while a student at Bristol University after her best friend was killed in a car accident in the early 1990s. She was diagnosed as bipolar and prescribed antidepressants before undergoing a course of ECT. After 11 years with no further psychiatric treatment, she had another course of ECT following a miscarriage. Gergel recounted this in an interview for the Daily Mail in 2011. Her treatment left her with positive views on ECT. She acknowledged some memory loss but described it as “nothing really substantial”. Six years later she was interviewed again, this time by the BBC as “A mum on having electric shock therapy while pregnant”.

Gergel, whose background is in ancient philosophy, is now a Wellcome Trust senior research fellow at Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, and has recently teamed up with psychiatrists to co-author a couple of articles about ECT. She is however the sole author of her latest article, which revisits the familiar themes of One flew over the cuckoo’s nest, the “anti-ECT lobby”, etc. By now she has had over 150 ECT treatments. Why so many? According to an article in a 2016 ECTAS (the Royal College of Psychiatrists’ ECT Accreditation Service) newsletter, she had short courses of ECT in 1992, 2005, 2011 and 2016. That would amount to about 30 treatments. The 2011 course was followed by monthly maintenance treatments for a year and she was also embarking on maintenance ECT after the 2016 course. So, since 2016, she must have had over 100 treatments. Even monthly treatments since 2016 would not account for that many treatments, so there must have been further courses. She now says that she has been left with “considerable autobiographical memory loss from later treatments”.

Moberg, who is studying for a PhD in social work at Stockholm University, was given 47 ECT treatments during a six-month hospital stay in 2007 and was left with memory loss. Her article explores the themes of “epistolic injustice” (originating from the scepticism of clinicians regarding memory loss and ECT) as a barrier to recovery. Moberg describes her own experience:

[A]ccording to the psychiatric ‘expertise’, my memory disorders were experienced due to the depression itself, sedatives, me being fragile, stress or a number of other phenomena. Since I was suddenly being viewed merely as a psychiatric patient, I was considered unable to decide what type of forgetfulness I was experiencing, namely a profound and personality-changing oblivion rather than having forgotten the car keys or a telephone number. Instead, I spoke in terms of not remembering my family, my home, my immediate surroundings, my earlier education or my closest friends—all significant social parameters for human life. This interpretive precedence made by the care and support system had major consequences on how my life was shaped, which is why this article is formed as an autoethnographic depiction exploring my experiences of ECT.

Daily ECT in Denmark

The Nordic Journal of Psychiatry has recently published an article with the title “The use of electroconvulsive therapy (ECT) en bloc in Denmark: a nationwide register-based study”. The authors define ECT en bloc as “ECT administered on 2–3 consecutive days”. Why not just refer to it as daily ECT?

The study found that 2173 patients received a total of 2734 ECT en bloc treatment courses in Denmark between 2006 and 2019, representing 6 per cent of the total number of courses of ECT. The figures incidentally suggest a high overall use of ECT in Denmark.

The study also found that people who had been given ECT en bloc were more likely to die in the year following treatment than those who had been given standard ECT (“The 1-year mortality rate ratio for ECT en bloc compared to standard regimen ECT was 1.42″). I do not have access to the article and have only read the abstract so I do not know how many people that figure represents.

The authors conclude that this higher mortality rate can be explained by ECT en bloc “being used for severe conditions”.

Four of the five authors are affiliated to Aarhus University Hospital in Denmark. The fifth author is American psychiatrist Charles Kellner. I wonder what his contribution was.