ECT in Scotland 2016

This week (14 November 2017) the Scottish ECT Accreditation Network (SEAN) published their annual report on the use of electroconvulsive therapy (ECT) in Scotland.

In 2016 in Scotland 344 people received 408 courses of ECT, compared to 367 and 448 the previous year (a decrease of about 8 per cent in the number of people and 9 per cent in the number of courses). The proportion of people who consented to treatment rose slightly, to 67 per cent. The third of patients who didn’t consent were considered to lack the capacity to make a decision.

As usual, the majority of patients (69 per cent) were women and “the trend for relative use of ECT to increase with age persists”, with more than 70 per cent of patients aged over 50. The report says that the proportion of women receiving ECT is “in keeping with the rates of depressive disorder in the general population”. But it is not that simple. In the general population in Scotland men and women report equal rates of the symptoms of depression. Women however accounted for 67 per cent of people prescribed antidepressants in 2012/13. When it comes to hospital treatment of depression, the ratio is nearer 60/40.

On the subject of women and men, it is predominantly male psychiatrists who are involved with the SEAN reports. On the steering group there are six male psychiatrists and no female psychiatrists. On the report writing group there are three male psychiatrists and one female psychiatrist.

ECT was given with bilateral electrode placement in 98 per cent of courses. A survey published in 2009 found that 18 per cent of the psychiatrists in Scotland who responded preferred unilateral electrode placement. What happened to them I wonder? Or perhaps it is a case of what they say and what they do are different things.

Just over one fifth of courses were not completed as planned. This, says the report, is evidence that ECT is “well-tolerated” (although it could equally be seen as evidence for the opposite).

Once again, chair of Healthcare Improvement Scotland Dame Denise Coia has cut-and-pasted her annual foreword to the report. “I am delighted to be asked, once again to provide the foreword for the Scottish ECT Accreditation Network’s (SEAN) ninth annual report” it begins. A few words have been changed or shuffled around and a comma added but apart from that it is identical to previous ones.

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ECT in the Swedish National Quality Register

When John Read and co-authors were recently researching the use of electroconvulsive therapy (ECT) in England they had to send out requests for information to individual trusts (a hospital or group of hospitals) under the Freedom of Information Act. Some trusts were unable or unwilling to provide information of even the most basic kind. Researchers in Sweden have no such problem as a register is kept of ECT use. The register includes details such as electrode placement and electrical parameters as well as patient demographics. Inclusion on the Swedish National Quality Register for ECT is voluntary, but apparently about 85-90 per cent of patients sign up to it.

Recently four articles based on data from the register have hit the psychiatric press.  The September 2017 edition  of the journal European Psychiatry contained an article with the title “Self-assessed remission rates after electroconvulsive therapy of depressive disorders”.  “Self-assessed remission rates” in this case referred to patients’ scores within one week of finishing treatment on a questionnaire (the MADRS-S) that they fill out themselves, replying to questions about “reported sadness, inner tension, reduced sleep, reduced appetite, concentration difficulties, lassitude, inability to feel, pessimistic thoughts, and suicidal thoughts”. The authors found that, overall, just over 42 per cent of patients reached the cut-off score on the questionnaire for “achieving remission”. The authors were looking for factors that might influence the outcome of treatment and concluded: “Our large-scale study of depressed patients showed that psychotic and an
older age were predictive of higher remission rates after ECT”. They also found that prolonged anti-depressant use, longer courses of ECT, ultra-brief pulse ECT, and personality disorders were associated with lower chances of “remission”. The variable that led to the highest chance of remission was never having taken anti-depressants, while taking lamotrigine (an anti-convulsant) led to the lowest chance of remission.

Although the authors were only interested in patients’ scores on the MADRS-S, the article nevertheless reveals a lot of information about how ECT is used in Sweden, a country which has a relatively high use of the treatment. More men than women are given ECT, but the difference is not so great as in some other Western countries. ECT patients are on average about ten years younger than they are in the United Kingdom. Unilateral electrode placement is used on about 90 per cent of patients, whereas in the United Kingdom bilateral electrode placement is used on over 90 per cent of patients. On the other hand, in Sweden ECT is given three times a week, compared to twice a week in the United Kingdom. All Swedish ECT clinics use American machines. In over 60 per cent of treatments, patients are given an electric shock lasting from 6.9 seconds to 8 seconds, and receive more than 291 millicoulombs of charge. Fewer of 30 per cent of people undergoing ECT in Sweden are classed as “severely ill”, although ECT is almost universally described as a treatment for severe depression or severe illness. Indeed the authors begin their article “Electroconvulsive therapy (ECT) effectively treats severe depression, but not all patients remit”.

There have been another three recently published articles by the same team using data from the Swedish ECT register.

Subjective memory immediately following electroconvulsive therapy”, published in the June 2017 edition of the Journal of ECT, found that a quarter of ECT patients reported memory worsening shortly (up to one week) after treatment, with reports being more likely amongst younger women.

Improvement of cycloid psychosis following electroconvulsive therapy”, published in the Nordic Journal of Psychiatry in August 2017, concluded that “ECT is an effective treatment for cycloid psychosis” and that “The high response rate with ECT indicates that cycloid psychosis is a clinically useful diagnosis”.

Rehospitalization and suicide following electroconvulsive therapy for bipolar depression – A population-based register study”, published in the January 2018 edition of the Journal of Affective Disorders (epublished September 2017), found a “high rate”, in the authors’ words, of suicide or rehospitalization in the year following ECT. The authors looked at 1255 people diagnosed as having bipolar depression who were treated with ECT. Their average (mean) age was 52. In the year following ECT, there were 65 deaths, including 17 suicides. Over half (53 per cent) of those treated with ECT either died by suicide or were rehospitalized within a year. The authors also looked at drug treatment in the three months following ECT; only 2.4 per cent were not prescribed drugs, and 45 per cent were prescribed four or more drugs.

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The Sacklers

I recently listened to an entertaining talk by economist Ha-Joon Chang. He was quite critical about economists and at the end of his talk he lamented the fact that they could get things spectacularly wrong without it damaging their reputation. He gave the example of 1995 Nobel prize winner Robert Lucas who announced that the problem of depression-prevention had been solved – a few years before the recession. Dr Chang invited the audience to imagine how improbable a similar scenario would be in other disciplines, for example, in medicine. Supposing someone made some pills and the pills ended up killing thousands of people? They would, he said, be hung, drawn and quartered.

Except they wouldn’t. Instead they would make lots of money, give some of it to museums, galleries, universities, etc., and become respected members of the philanthropic community.

As if on cue, the BBC ran a story about opioid use in the US and how the drugs killed about 33,000 people in 2015. Purdue Pharma was mentioned as the manufacturer of  “popular opioid painkiller” OxyContin but the article did not say how many deaths they were responsible for. It must however be thousands every year. The 30 October 2017 edition of the New Yorker magazine has an article about how the Sackler family, owners of Purdue Pharma, made a fortune from OxyContin and distributed some of that fortune to institutions around the world. At Ha-Joon Chang’s own university, Cambridge, there are Sackler fellowships and scholarships, a Sackler lecture theatre, a Sackler prize and a Sackler distinguished lecture.

In 1956, a few years after they had acquired Purdue Pharma, the three psychiatrist Sackler brothers, Arthur, Mortimer and Raymond, together with another psychiatrist Felix Marti-Ibanez, edited a book with the title Great physiodynamic therapies in psychiatry: an historial appraisal. The book includes contributions by Ugo Cerletti (electroshock), Egas Moniz (leucotomy), Laszlo Joseph Meduna (convulsive treatment and carbon dioxide treatment), Manfred J. Sakel (the classical Sakel shock treatment), and Roy G. Hoskins (hormone therapy). Jakob Klaesi was supposed to contribute a chapter on deep sleep treatment but was prevented, the editors said, by ill health.

The grandiose language of the title of the book is continued in the editors’ foreword, where centuries of care and treatment of those deemed insane are dismissed in a couple of paragraphs about how mental disorders  were often considered to be due to possession by devils or divine punishment and how therapeutic nihilism prevailed, until, that is, the invention of the “great physiodynamic” therapies. (In fact, the history of the insane is far more complicated. Yes there were cases of horrific abuse and neglect – just as there are now – but in other cases people were treated decently and often recovered. Medical and legal authorities in those days, as in these, attempted to understand why people became insane and to what extent they were responsible for their actions.) The authors predict that the physiodynamic therapies, together with the more recent “narcobiotic” (tranquillising) drugs, will lead to the “advance from empiric therapeutic benefit to a clearer understanding of the metabolic processes that mediate them and to the ultimate biochemical deviations out of which the disease process arises”. (They were wrong about that one; sixty years on and still no sign of the “ultimate biochemical deviations”.)  Neither are they modest about their own achievement in editing a book, describing their volume as “unprecedented in the annals of medicine”. As for the contributors, they are described as having a “fame whose green laurels are represented by the gratitude of the mentally sick to the men who devote their lives and genius to their treatment”.

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The best laid schemes…

“… one participant (ECT) fell asleep during the fMRI scan”

The scans were being conducted by Kamilla Miskowiak and colleagues in Copenhagen, Denmark (Neural response after a single ECT session during retrieval of emotional self-referent words in depression: a randomized, sham-controlled fMRI study, International Journal of Neuropsychopharmacology).

People who had been prescribed electroconvulsive therapy (ECT) were randomised, for their first treatment only, to either ECT or sham ECT (the anaesthetic, etc., without the actual electric shock). The next day the researchers carried out fMRI scans on them. The researchers found that:

“A single ECT session had no effect on hippocampal activity during retrieval of emotional words. However, ECT reduced the retrieval-specific neural response for positive words in the left frontopolar cortex. This effect occurred in the absence of differences between groups in behavioral performance or mood symptoms.”

They concluded that ECT may facilitate memory for positive self-referent information and thus increase feelings of self-worth.

The researchers also got another article out of the same experiment, this time in the Journal of Psychopharmacology, September 2017 (Does a single session of electroconvulsive therapy alter the neural response to emotional faces in depression? A randomised sham-controlled functional magnetic resonance imaging study.) They concluded:

“Despite no statistically significant shift in neural response to faces after a single electroconvulsive therapy session, the observed trend changes after a single electroconvulsive therapy session point to an early shift in emotional processing that may contribute to antidepressant effects of electroconvulsive therapy.”

This time the researchers suggested the antidepressant effect was mediated by a “lower fear vigilance”. All the ECT group managed to stay awake for this part of the experiment.

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ECT in England 2011-2015

The journal of the British Psychological Society, Psychology and Psychotherapy: theory, research and practice, has published an article about the use of electroconvulsive therapy (ECT) in England (An audit of ECT in England 2011-2015: Usage, demographics, and adherence to guidelines and legislation by John Read, Christopher Harrop, Jim Geekie and Julia Renton).

The authors sent freedom of information requests about ECT use to 56 National Health Service (NHS) trusts and received “usable data” from 32. (A trust is a hospital or group of hospitals; most ECT in England is given within the NHS, although there are some private hospitals, for example the Priory Group, using ECT.) Why do researchers have to resort to the Freedom of Information Act to obtain information about ECT use, when it should be readily available from NHS Digital? The answer is simply because some trusts do not report their use of ECT and the NHS lacks the will to remedy the situation.

The authors looked at the rate of ECT use in different trusts, taking into account the size of populations covered, and found a fifteen-fold difference for 2015. Surrey and Borders was the highest user; Black Country the lowest. It may be that the difference in rates of use is even higher if you take into account those trusts who didn’t provide data. For example two trusts, Avon and Wiltshire and Southern Health, that made the highest number of requests to the Care Quality Commission to use ECT on non-consenting patients (2016/17) were amongst those that didn’t provide data to the researchers.

Trusts were also asked for information on the sex of ECT patients, how many were under 18 or over 60, and how many were being treated without their consent. Two-thirds of people given ECT were women, and over half of people given ECT were aged over 60 years. Nearly 40 per cent were being treated without their consent, probably rather lower than the actual proportion, due to the absence of high users of ECT without consent. Some trusts (six out of the twenty that provided information) did not use the right combination of professionals for consultation with the Care Quality Commission psychiatrists who authorise ECT without consent.

The researchers asked for information about the use of psychological therapies prior to ECT, and information about how the effect of ECT on patients was monitored, but few trusts provided useful information.

The authors conclude with recommendations:

“A return to comprehensive national annual audits seems urgently needed. These should include attention to compliance with N.I.C.E. guidelines and mental health legislation. In the meantime, all mental health service providers must take responsibility for monitoring their own adherence to government guidelines and the law, and should familiarize themselves with the research literature on the long-term benefits and adverse effects of this controversial treatment. A multidisciplinary investigation into the ongoing excessive use of ECT on women and older people seems long overdue.”

And what do we get from the Royal College of Psychiatrists in response? A commitment to the long overdue investigation? No. Just the same old excuses. The Guardian newspaper ran an article about the report and invited a comment from the Royal College. Retired professor Nicol Ferrier, who is now chair of the Royal College ECT Committee was quoted as saying that the higher rates of ECT use among women and older people was “neither surprising nor a cause for concern”.

““Depression is more common in females than males,” he said, noting that the ratios were particularly high for treatment-resistant forms of the condition.”

 

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Bismarck, wet leaves, cheap wine, and a nun

Last month (September 2017) the National Health Service in England issued official guidance for general practitioners (GPs) on older people and mental health (Mental Health in Older People: A Practice Primer).

The guidance is written by four psychiatrists and a GP: Alistair Burns, professor of old age psychiatry at the University of Manchester and national clinical director for mental health in older people and dementia, NHS England; Amanda Thompsell, Christoph Mueller and Daniel Harwood, all old age psychiatrists at South London and Maudsley NHS Foundation Trust; and Peter Bagshaw, GP.
There is a brief paragraph about ECT, which is described in the following terms:

“Electroconvulsive Therapy (ECT) is a treatment used in a small number of people with depression, which involves passing a small electrical current through the brain under a general anaesthetic, to induce an epileptic seizure.”

The current used in ECT is in fact a powerful one, usually 800 milliamps, enough to cause immediate unconsciousness if the anaesthetic hadn’t already done so, and about one hundred times the current that would produce a painful electric shock. There is no mention of risks or adverse effects of ECT, or of maintenance ECT.

Reading the rest of guidance I felt at times that I had stepped into an episode of Dr Finlay’s casebook (a TV series from the 1960s that was set in the 1920s). GPs are told, in a section that reminds them not to overlook physical conditions, that a “patient’s breath smelling of wet leaves may indicate tuberculosis”.  There are about a thousand new cases of tuberculosis a year in older people in England, meaning that on average each GP may see one such case during their career, although in practice, since tuberculosis is not evenly distributed over the country, some will see none and some more than one. When I googled the sentence “A patient’s breath smelling of wet leaves…” the only example that came up was in a detective novel by Patricia Cornwell. Perhaps one of the authors of the official NHS guidance is a Patricia Cornwell fan or perhaps the wet leaves are just a piece of medical folklore, like “red sky at night…”

In general the guidance is confusing when it comes to distinguishing between physical and mental conditions. For example, it tells GPs that older people with depression may report physical symptoms, for example, constipation, instead of emotional symptoms, while it goes on to say that “simple constipation may present as either confusion or low mood”.

When it comes to diagnostic tests for depression, GPs are spoilt for choice, with the guidance listing five different tests, from the 15-item Geriatric Depression Scale, via the 4-item version, the two questions recommended by the National Institute for Health and Care Excellence, the one question recommended by the authors (whether someone enjoys visits from their grandchildren), to gut instinct (“A person who consistently annoys you could well be depressed or have a personality disorder, and a person who perplexes you might be psychotic.”) One of the questions on the 15-item Geriatric Depression Scale asks “Do you think that most people are better off than you are?” Surely, for a proportion of the population, it is a simple truth, not a symptom of mental illness, that most people are better off?

The guidance contains some case histories, for example a nun who is getting forgetful and is prescribed mirtazapine and a bereaved man who drinks “cheap wine”. Does it matter how much the wine costs? The nun’s case is used to illustrate the difficulty in distinguishing between dementia and depression. The guidance given to GP’s is that “a pragmatic approach would be carrying out a dementia blood screen and a 6-week trial of antidepressants”, in spite of the fact that one of the authors, Christoph Mueller, recently co-authored a paper that concluded that the “prescription of antidepressants around the time of dementia diagnosis may be a risk factor for mortality”.

Old age apparently starts at 65. That, the guidance explains, is because it was the qualifying age for an old-age pension when German chancellor Otto von Bismarck introduced social security in the 1880s. Actually, it isn’t; Bismarck set the age for pensions at 70 (it was reduced to 65 in 1916). But anyway, why does psychiatry have to follow what a German chancellor did a hundred years ago?

Posted in ECT in the UK, Electrical parameters, Miscellaneous | 2 Comments

Electroconvulsive therapy in the Huffington Post

The Huffington Post yesterday (4th October 2017) ran an advertisement for electroconvulsive therapy (ECT) at the McLean Hospital, Belmont, Massachussetts, USA, psychiatric affiliate of Harvard Medical School and “ranked #1 by U.S. News and World Report”.

“The truth about electroconvulsive therapy” was written by McLean psychiatrist Stephen J. Steiner and took a well-worn path: stigmatized by misleading portrayals in Hollywood – anaesthesia – mild discomforts (little pinprick and mild headaches) – doesn’t damage the brain – neurogenesis – improves cognition and anterograde memory – trivial amount of retrograde amnesia (forgetting details of a play) – only rarely administered involuntarily and only when there is a court order and even then the majority of involuntary patients are “very grateful afterward”, etc. etc.

At the end of the there is a link to the McLean ECT service where there is more of the same: “mild electrical currents”, and “minor problems with memory”.

“The great majority of patients will have only minor problems with memory, though some will experience no difficulties at all. While these problems usually subside, there is no way to predict their extent. The psychiatrist will discuss this potential side effect in greater detail during consultation.”

You don’t have to look far though to find McLean Hospital talking about ECT-induced memory loss in a rather more brutal fashion: “ECT treatment can lead to several known side effects including confusion and memory loss”. This is a typical example of how psychiatrists forget about the minor and transient (usually) nature of memory loss when they are trying to sell an alternative to ECT.  In this case it is intracranial electrical seizure therapy (ICEST) for which McClean filed for a patent in 2011. The technique is similar to ECT but involves planting electrodes into the brain rather than putting them on a person’s head. Memory loss would have to be pretty bad before invasive brain surgery becomes a better alternative.

You also don’t have to look very far to find Stephen Seiner and colleagues experimenting with ECT as a treatment to control agitated and aggressive behaviour in people with dementia. The results were published in the International Journal of Geriatric Psychiatry in 2015. The authors made it clear that they were treating behaviour rather than depression: “The treating psychiatrist, in consultation with the ECT service, made a clinical decision regarding the use of ECT treatment for agitation or aggression associated with dementia, irrespective of mood symptoms”.  Twenty-three patients from McLean Hospital and Pine Rest Christian Mental Health Services were given ECT. One person died a month after ECT (due the authors said to dementia and not ECT) and several people experienced delirium and other adverse events; scores improved on Cohen-Mansfield Agitation Inventory (CMAI)-short form. The authors found the results “encouraging” and concluded that ECT was a safe and effective treatment. Fifteen of the patients were recommended for continuation ECT.

Posted in ECT in the media, ECT worldwide | 7 Comments