ECT and narcosis on Buzzfeed

On March 17 2018 Buzzfeed published a story by news reporter Hannah Al-Othman about a woman who in 1972 had undergone narcosis and electroconvulsive therapy (ECT) at St Thomas’ Hospital in London. Eleanor (not her real name) had been 22 when she had the treatment, which had been devised by psychiatrist William Sargant. The same year Eleanor was admitted to ward 5 of the Royal Waterloo Hospital for Women and Children (which was given over to Sargant’s use after the amalgamation of the Royal Waterloo Hospital with St Thomas’ Hospital) Sargant had written an article about his experiments “Modified narcosis, ECT and antidepressant drugs: a review of technique and immediate outcome”. The co-authors were C.J.S. Walter and N. Mitchell-Heggs (one of the few women to be a major name in psychosurgery and ECT) and the article appeared in the British Journal of Psychiatry, published by the Royal College of Psychiatrists.

Sargant and his co-authors described the technique for keeping patients asleep for about twenty hours a day over a period of weeks to months, using a variety of drugs which included chlorpromazine, barbiturates, chloral hydrate, Mandrax, diazapam, etc. The patients were also given ECT two or three times a week, antidepressant drugs, which in those days meant tricyclics and monoamine oxidase inhibitors, and sometimes insulin treatment. What was the rationale for keeping patients asleep during a course of ECT? This was not made entirely clear – there was vague talk about it alleviating anxiety or perhaps increasing the effects of ECT. It was also dangerous – four of the 484 people treated between 1962 and 1968 died because of complications from the treatment. Sargant and co-authors found the results “encouraging” and talked about a future longer-term follow up of patients, which does seem to have materialised. In fact the treatment was quietly abandoned.

When Eleanor was treated in ward 5 in 1972 William Sargant had already retired, and it was his successor, John Pollitt, who was responsible for her treatment. John Pollitt died in 2005, but the Buzzfeed reporter tracked down two junior doctors who had been involved in Eleanor’s treatment. Neither agreed to be interviewed. St Thomas’ Hospital refused to answer questions, the Department of Health said they had no records and the Royal College of Psychiatrists told Buzzfeed: “There are no reports or position statements on this form of treatment, so nothing to suggest that the College supported it or opposed it.” As Eleanor says: “They seem to have forgotten that we’re still alive. They talk about it as if we just dropped dead the next day and there is no one left with this.”

The Royal College of Psychiatrists may not have published a report or position statement on narcosis and ECT, but they did publish at least one article about the treatment in their journal. And they accepted money from William Sargant on his death to inaugurate an annual lecture in his name. “Dr William Sargant was recognised as an outstanding psychiatrist, who made an extremely valuable contribution to psychiatry, and the lecture is funded by his bequest” says the Royal College website.

While I was searching for a position statement on the use of narcosis and ECT I came across one from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) on deep sleep therapy (as narcosis is called in Australia): “The Royal Australian and New Zealand College of Psychiatrists (RANZCP) presents this position statement to avow its strong and continuing opposition to the practice of deep sleep therapy. The RANZCP recognises that psychiatrists have a critical role to play in acknowledging historical harmful practices and committing to learn from them.”

Perhaps the Royal College of Psychiatrists in Britain could consider devoting the annual William Sargant lecture in future to the acknowledgement of historical harmful practices, starting with Sargant’s own practice of narcosis and ECT.

Posted in 1970s, ECT in the media, ECT in the UK, Uncategorized | Leave a comment

Two views on ECT, memory loss and consent

The open-access journal Life Sciences, Society and Policy has recently published an article about electroconvulsive therapy (ECT) by Patrick Seniuk, a doctoral student at Södertörn University, Stockholm, Sweden (“I’m shocked: informed consent in ECT and the phenomenological-self”).

The author sets out his aims: “using phenomenological philosophy as an analytical framework, my intention is to investigate the risks and harms associated with ECT, and the way patients are informed about the potential side effects.” He argues that informed consent fails to “prepare patients for the possibility that treatment side effects have implications for future lived experiences” and that it is “crucial to recognize that patients, while able to rationally ‘understand’ memory loss is a potential harm, might fail to appreciate memory loss might interfere with everyday life.”

I think these statements are very pertinent to current discussion and controversy about ECT. You don’t have to look far to encounter people who were misled about the damaging effects of the treatment. But weren’t they warned? didn’t they sign something? is a reasonable reaction. Seniuk’s argument is that, yes, they were warned, but not in a very useful way.  

“I argue that the common experience of post-procedure retrograde amnesia will necessarily affect a patient’s sense of self. For depression patients who retain the capacity for autonomous decision-making, current bioethical attitudes about ECT and informed consent fail to adequately appreciate how ‘loss of memory’ is interwoven with, and inextricable from, the patient’s experience of self.”

Using the American Psychiatric Association’s template for a consent form, Seniuk points out that, even with its warning that people may be left with permanent gaps in their memory, especially for events close to ECT, it fails to address the fact that memory loss “can disrupt both one’s sense of self and life projects”.

No reflection on the author, but the bits about phenomenological philosophy rather went over the top of my head, and I found a few typos distracting (a reflection perhaps on the lack of proofreading by the editors of the journal).

Seniuk’s article contained only a few brief quotes, taken from the literature, from people who had undergone ECT and experienced memory loss. More of their experience, however, is revealed in the other piece of writing referred to in the title of this post. In November 2017 the International Journal of Mental Health Nursing published an article by Australian nurses Karen-Ann Clarke and Margaret Barnes and social worker Dyan Ross  (“I had no other option: women, electroconvulsive therapy, and informed consent.”) I don’t have access to the article, but, via researchgate I obtained a copy of Karen-Anne Clarke’s thesis, “Women diagnosed with depression: making meaning and decisions about electroconvulsive therapy. A feminist analysis”.

Clarke has had a nearly 30 year career as a mental health nurse in Australia and has been involved not only in the administration of ECT but also in educating other practitioners on the subject. This perhaps explains why she describes ECT as involving “the passing of a small charge of electricity across the brain” (compared to Seniuk’s “electrical shocks”), as being “highly refined”, and why she quotes uncritically claims that ninety per cent of depressed people who undergo ECT “obtain significant remission of symptoms within nine treatments”. For her thesis, Clarke interviewed seven women who had had ECT, recruited via advertisements. All of the women had been given ECT with their consent in private hospitals since the year 2000, although one woman had previously been treated without her consent and two women had previously had ECT in public hospitals. The women had had between four and 47 treatments. None of the women had received psychological treatment before having ECT, but all of them had been treated with a drugs: “The decision to receive ECT began in the same place for all seven women in the research – with the introduction of the first pharmaceutical agent, usually an antidepressant drug.” One woman had sought treatment with ECT after researching it on-line, the other six were persuaded to have ECT on account of their “failure to respond” to drugs. Clarke argues “that women may be left disempowered and isolated in vulnerable states of decision-making by powerful and privileged medical experts” and recommends changes to clinical practice, including “the need to challenge the biomedical understanding and medicalisation of women’s distress, the need for an ongoing critique of the power that lies behind the dominant medical discourse…”

Although Clarke was not specifically investigating the effects of ECT on memory, it emerged as a common experience in the interviews, “and the impact on personal identities and associated social roles was one that the women did not feel well informed about or prepared for.” For example:

“Helen’s memory loss following ECT was significant. Her son had two separate engagement parties – one at the family home, and was married in 2009. Helen has absolutely no recall of either party, and only minimal recall of the wedding. She feels that this part of her life was stolen. Although ECT stopped her from the intrusive suicidal thoughts, it stripped her of other powerful memories. Although her husband and children are supportive of her memory loss, it has become a family joke. Helen chuckles at this point – frequently her family will laugh and remind her that she has lost a particular memory. She thinks it is ironic; they could fill in the gap in her memory with anything, and she would have no choice but to believe them. She describes losing self-confidence along with her memory.”

Pauline described not just amnesia for events in the past but also difficulties with learning new skills:

“She is convinced that ECT interfered with the way that she processes information and the way in which she is able to problem solve at both a concrete and abstract level. She still has enormous difficulty in organising her home and housework, and cooking basic meals for herself. She attributes this to the effects of ECT. At the time of our research conversation, Pauline had recently begun working for very short periods of time each week and found the challenges of learning new skills enormously stressful, requiring vast amounts of repetitive practice.”

Kate only had four treatments but experienced problems:

“After ECT, Kate could not recall the faces or names of anybody at church, regardless of how long she had known them. Even today, years after ECT the effect is still pronounced.”

Australia has a high use of ECT, and Queensland, the state where Clarke is based, has the highest rate of use of any state, at least according to the 2014-15 statistics she quotes with the caveat that they may not be accurate and in any case only include Medicare (publically funded) treatments. She also gives a table showing that over 70 per cent of (Medicare) ECT is given to women. In the 25 to 34 age group, treatments given to women outnumber those given to men by more than five to one. Clarke says that the reasons for this remain obscure and are outside the scope of her thesis, although she does say that she has noticed in the hospitals where she worked that men with similar symptoms to women were less likely to be prescribed ECT. Indeed, it was this observation that inspired her to choose the subject of women and consent to ECT for her thesis.

Posted in ECT and memory loss, Gender ECT | 1 Comment

ECT without consent in England 2016/17

Somewhat belatedly (such reports usually come out in November) the Care Quality Commission (CQC) yesterday, 27 February 2018, published its annual report on the monitoring of the Mental Health Act in England. The report covers the period April 2015 to April 2016.

There is minimal information about the use of electroconvulsive therapy (ECT) without consent under the Mental Health Act in the latest report. It simply says: “The number
of visits to inpatients to consider ECT (1,637) remained similar to the previous two years
(1,627 and 1,631 visits respectively)”. The “visits” are those made by psychiatrists on the CQC panel who approve the treatment. Of the 1,617 visits for which there is data the “plan changed” in 348 according to the report, but it doesn’t say in how many cases approval for ECT was not given – usually it is a very small number. The report contains no information on, for example, the age and gender of patients; neither does it give the numbers of times ECT was commenced before the visit from the CQC psychiatrist.

There was one case of neurosurgery for mental disorder (NMD or psychosurgery) in England during 2016/17. This was a subcaudate tractotomy carried out on someone who had previously undergone deep brain stimulation (DBS). Subcaudate tractotomy is a form of psychosurgery that was developed in England by Geoffrey Knight in the 1960s but has not until now been used since the 1990s, with capsulotomies and cingulotomies nowadays the preferred operations. Last year I published a post about an article in praise of Geoffrey Knight in the Journal of Neurosurgery. I was at the time puzzled as to why a group from the department of neurosurgery at Kings College Hospital, London, should be taking such an appreciative interest in Geoffrey Knight. If his subcaudate tractotomy is being revived however, that would go some way to explaining their interest.

The CQC report calls again for regulation of deep brain stimulation:

In previous reports, we have called for DBS to be regulated when used as a treatment for mental disorder. However, there is still no specific regulation of DBS in England, in contrast to the statutory safeguards for other forms of NMD. This is also in contrast with the situation in Scotland, where the government took clinical advice and consequently brought DBS into the scope of its equivalent statutory safeguard to MHA section 57. This regulatory gap in England will form part of the discussions and evidence gathering with the MHA review. We will work together to seek solutions that recognise the need for safeguards over the use of DBS equivalent to those for other, older types of NMD.

The CQC’s predecessor, the Mental Health Act Commission, was calling for such regulation in 2007, over a decade ago, and nothing has been done, so I don’t know if this latest call will make any difference.

The report shows a record number of detentions under the Mental Health Act – 63,622 – in 2016/17.

Posted in ECT in the UK, ECT without consent | 1 Comment

ECT in the United States – how often is it used (more recent information)?

I have written before about the lack of information on the rate of use of electroconvulsive therapy (ECT) in the United States (ECT in the US – how often is it used). An estimate of 100,000 people a year dating from the 1980s is still used as if it is a recent figure.

A recently published article (Identifying recipients of electroconvulsive therapy: data from privately insured Americans, by Samuel T. Wilkinson et al., published in Psychiatric Services) would suggest a much lower figure. I have only been able to read the abstract. The authors looked at the rate of ECT use amongst privately-insured Americans in 2014 and came up with a figure of 5.56 ECT patients per 100,000 in the population. That would be, very roughly, about 18,000 people. That figure only includes privately-insured people. In Texas, where annual statistics on the use of ECT are collected and published, just over half of ECT patients are privately-insured. If this pattern holds true over the rest of the country, it would mean that about 35,000 people receive ECT every year – a far cry from the commonly quoted figure of 100,000. The authors identified a lower use of ECT in the West than in other parts of the country.

Posted in ECT worldwide, Uncategorized | Leave a comment

ECT in Worcestershire: over 90 per cent of patients are women

When I wrote about electroconvulsive therapy (ECT) in Worcester, United Kingdom, two years ago I was unable to find any publications on the treatment from psychiatrists, etc., working in Worcester. However, an article about ECT in Worcester has now been published. The articlePatients’ experiences of and attitudes to ECT, by Latha Guruvaiah, Karthikeyan Veerasamy, Muhammad Naveed, Swami Kudur, Farah Chaudary and Ann Paraiso appeared in the April – June edition of Progress in Neurology and Psychiatry. As the title suggests, people who had undergone ECT were asked to fill in a questionnaire about their experience. The people who were asked to fill in the questionnaire had all been treated by the Worcestershire Health and Care NHS Trust in 2013 and 2014. The lead author is a psychiatrist at the 2together NHS Foundation Trust in Gloucestershire, the others are psychiatrists at Worcestershire Health and Care NHS Trust.

The questionnaire was based on one used by Scottish psychiatrists for a similar study in the 1970s. The authors say: “Since its publication in 1980, we could not find any similar published literature in the UK highlighting the experience and attitudes of patients and carers towards ECT” which is surprising as several such studies have been published. People who had undergone ECT were asked questions about their experience and, based on their answers, the authors concluded that “It is clear from this study that the overall experience and attitude of patients and carers were positive”. For example:

  • 15 out of 27 consenting patients said they had signed a consent form (the others could not remember);
  • 4 out of 27 consenting patients felt forced or pressurised to have ECT (19 did not and four could not remember);
  • 22 out of 30 patients said a member of staff accompanied them to the ECT clinic (2 said no and six could not remember);
  • 28 out of 30 said the clinic was clean and comfortable (2 could not remember);
  • 17 out of 30 rated the recovery period for a few hours after ECT as “pleasant”, 5 as “neutral”, 4 as “unpleasant” and 4 as “do not know”.

Of 29 patients, 24 said they experienced memory loss after treatment, and 13 said they experienced confusion. The authors suggested that the high incidence of memory loss might be explained by the fact that all the patients had been given bilateral treatment. (The survey did not ask participants if they had been given a choice of bilateral or unilateral treatment.)

The researchers found 30 people who were willing to take part in the survey, out of 60 people who had completed a course ECT during 2013 and 2014. The trust came up with a slightly different figure when I put in a Freedom of Information request – 69. Perhaps the difference is explained by people who did not complete a course of treatment. The interviews were conducted in early 2015, that is from immediately to just over two years after treatment (I am going to say on average one year). Six people could not be traced, five people could not take part due to significant cognitive impairment, 11 refused to take part and eight had died. The authors made no comment about those with cognitive impairment or whether it was caused by ECT, and they said that the deaths were “not related to ECT” but due to either “old age or physical ailments”.

But should eight people, out of 60, have died within, on average, a year of ECT? The average age of the people in the final sample of 30 was 62 years (ranging from 20 to 81). The trust told me that the average age of all people who received ECT in 2012 and 2013 was about 63 (64 in 2013 and 62 in 2014). A woman (and nearly all those who received ECT were women) in her early sixties in England can expect to live over twenty years more, so that appears to be a high death rate. It is something that at least deserves more explanation than a vague comment about old age.

Almost all – 28 out of 30 – the people taking part in this study were women. When I read the study I assumed that that must be because women were more willing to participate in the study. But the trust told me that, astonishingly, 63 of the 69 people who underwent ECT in 2013-2014 were women. Over 90 per cent of their ECT patients were women. Again, the authors are unconcerned, saying that depression is more common in women than men. Possibly – but certainly not in the ratio of 9 to 1.

Posted in Uncategorized | 3 Comments

ECT in the Scottish Daily Mail

Today (8 January 2018) the Scottish Daily Mail ran a feature about electroconvulsive therapy, which can be seen hereThe author, home affairs editor Graham Grant, talks about an investigation and it looks as if he has sent off some freedom of information requests to health boards, as well as having spoken to the chairman of the Scottish ECT Accreditation Network (SEAN), Dr Alistair. The article identifies the youngest and oldest patients in Scotland: in Greater Glasgow a 16-year-old was given ECT, while in Forth Valley a 93-year-old was treated.

The average age of patients is around 65 years, because, the article says “older people tend to suffer very few side effects”. I wonder where the author got that idea from.

The article recognizes that ECT can cause memory loss, but goes on to say: “Experts believe administering voltage to only one side of the brain may limit this side-effect”.  Experts (if by experts you mean psychiatrists) have believed this for over 60 years, but they persist in using the more damaging electrode placement, bilateral. If the author had read the latest annual report from SEAN, he would have seen that 98 per cent of ECT courses in Scotland in 2016 involved bilateral ECT.

The newspaper did a brief interview with a woman who had had ECT in 2014, but had stopped after two or three treatments as it left her feeling more traumatised than before. Stopping treatment before the end of a course is not a rare occurrence: the SEAN report for 2014 showed 19 per cent of courses were not completed as planned.

Posted in ECT in the media, ECT in the UK, Uncategorized | Leave a comment

ECT at Cypress Creek Hospital, Houston, Texas

In a recent post about the use of electroconvulsive therapy (ECT) in Texas, United States, I mentioned the fact that Cypress Creek Hospital in Houston is the heaviest user of ECT in the state. In 2016, for example, Cypress Creek was responsible for nearly one-fifth of all treatments given in Texas, although they are just one of 22 hospitals using ECT. And they were responsible for nearly one-third of all reports in Texas for ECT given to people under the age of 25 years.

In spite of the fact that they use so much ECT, there seem to be no psychiatrists at the hospital with a particular academic interest in ECT. I have never come across a published article where one of the authors is affiliated to Cypress Creek Hospital. On their website the hospital has only a brief  section on ECT, which contains several misleading statements. It talks about a “small amount of electrical current” although in fact ECT involves a current of about 800 milliamps flowing for, usually, several seconds – a very powerful electric shock which would knock you out immediately if the anaesthetic hadn’t done it already. “It is often safer than no treatment at all” we are told. What does that mean? It may be an “appropriate treatment option” for patients who are 18 years of age or older, the hospital says, although, in 2016, they submitted 9 reports of ECT use on people aged under 18 years (out of a total 15 for the whole of Texas).

In Texas, psychiatrists are supposed to report any deaths that occur within two weeks of ECT. In the March-May quarter 2006, Cypress Creek reported one death occurring within two weeks of treatment. That, presumably, was the death of 22 year old Jayme Rachelle Cox, whose mother later sued the hospital. The case is reported on the FindLaw website:

“On April 26, 2007 [sic], Jayme Cox voluntarily admitted herself to Cypress Creek. She had been diagnosed with bipolar disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder, and she was determined to be a suicide risk. At the time of her admission, Cox’s medications included Effexor XR, Eskalith, Adderall, Campral, Zyprexa, Provera, Topamax, and Xanax. After admission, her medications were changed slightly and Ambien CR was added to her regimen. Cox was also treated with electroconvulsive therapy (“ECT”). During her admission, Cox injured her left knee and, on May 2, she was prescribed hydrocodone for the pain. On May 3, she was also prescribed Oxycontin for one night, in addition to her routine medications.”

Jayme Cox died the following morning. “An autopsy was later performed, and the toxicology results showed that Cox died as a result of Zyprexa toxicity.”

The case brought against Cypress Creek Hospital by Jayme’s mother was thrown out  of court because the author of her expert-report was not a physician. It is not clear exactly why a report by someone who wasn’t a physician was submitted, but I am left wondering if she could not find a physician who would write a report critical of Jayme’s treatment. Is the amount of drugs Jayme was prescribed, with, in addition, ECT,  considered normal or acceptable practice in the United States?

Posted in ECT and young people, ECT worldwide, Legal cases | 6 Comments