Psychosurgery news

Last year I wrote a post about an article that had appeared in the Journal of Neurosurgery (official journal of the American Association of Neurological Surgeons since 1944). The article, whose five co-authors were based at the Department of Neurosurgery, King’s College Hospital, London, was a tribute to Geoffrey Knight, who developed a technique called subcaudate tractotomy – a form of psychosurgery that has not been used in the United Kingdom for many years (alternative techniques such as capsulotomy or cingulotomy being preferred). Or at least, so I thought.

But in fact, subcaudate tractotomy has been revived. The Care Quality Commission’s annual report on monitoring the Mental Health Act 2016/17 states that one psychosurgical operation was carried out in England in that year, and it was a subcaudate tractotomy.

I have been a bit slow on the uptake in more ways than one, having, until recently remained ignorant of developments in Scotland. For a decade, between 1999 and 2009, there were no psychosurgical operations carried out in England (except for deep brain stimulation) and some English patients travelled to Scotland, where Ninewells Hospital in Dundee performed a few operations. For example, in 2004 they performed two anterior cingulotomies. The neurosurgeon who performed psychosurgery at Dundee was M.S. Eljamel and he has been the subject of recent scandal, which is presumably why that latest report (2016/17) from the Mental Welfare Commission in Scotland says:

“There has been no neurosurgery for mental disorder undertaken in Scotland in the last two years. Patients from Scotland requiring these procedures are now treated at the National Hospital for Neurology and Neurosurgery in London…”

A BBC report found that there had been concerns about Professor Eljamel’s practice and that in June 2013 he had been put under investigation and supervision. He was suspended in December 2013. His psychosurgery practise was not mentioned in the report. It may be because it is less obvious if a psychosurgical operation goes wrong because there is no diseased bit of the brain to be removed. BBC reporters also uncovered discrepancies on his CV, with institutions in the United States (Hartford Hospital and the Universities of Connecticut and San Diego) where he claimed to have held positions saying they had no record of his having done so. Rather than face an investigation by the General Medical Council, Professor Eljamel decided to remove his name from the Medical Register and move to the United States.

Professor Eljamel’s name has appeared as author or co-author of articles in the psychosurgical literature. For example in 2012 he wrote an article for the journal Surgical Neurology International on “the resurgence of behavorial surgery”, which he abbreviates to BS, a rather unfortunate abbreviation. He seems confused about the history of psychosurgery, writing that it “rose and spread in 1960 like wildfire” whereas in fact psychosurgery expanded in the 1940s and was already declining in the 1950s. But then Surgical Neurology International is not a particularly reputable journal. His name however appears as a co-author (one of 34) of an article in the Journal of Neurology, Neurosurgery and Psychiatry, a more reputable journal. When the article was published in September 2014, Eljamel had already been under investigation and supervision at Dundee for more than a year and suspended for eight months.

It is the custom nowadays for journals to include a statement about authors’ financial conflicts of interest, for example an author’s payments from pharmaceutical companies. I am wondering if there should also be a way of flagging up if an author has been removed from the Medical Register or has removed their name from the Register rather than face investigation.

PS Since I wrote this post I have discovered that Professor Eljamel is on the Royal Society of Medicine’s “wall of honour“.

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ECT in Ireland 2016/17

On 12 July 2018 the Mental Health Commission in the Republic of Ireland published, somewhat belatedly, a report on the use of electroconvulsive therapy (ECT) in 2017. There has been little change in numbers from previous years: in 2017 in the Republic of Ireland (population about 4.8 million) 2,558 individual treatments were given to 263 people. 

ECT was given to people aged from 18 to 93 years, with a mean age of 59.  Women accounted for 63 per cent of ECT patients. Fourteen per cent of people did not consent to treatment. In February 2016 a new law came into force which prevented the use of ECT against a capable person’s wishes but this doesn’t seem to have made much difference to the numbers being given ECT without consent. The change in law brought the Republic of Ireland into line with Wales, England and Scotland regarding consent to ECT. In the Republic of Ireland ECT without consent has to have the approval of a second psychiatrist but, unlike in Wales, England and Scotland, this does not need to be a psychiatrist on an official panel. Presumably the second psychiatrist can be someone chosen by the first psychiatrist. In spite of this difference, the percentage of ECT patients being treated without their consent is lower in the Republic of Ireland than it is in Wales, England and Scotland.

As in previous years, ECT use is not evenly distributed:

“In 2016, 65% of approved centres did not provide an ECT service, 23% approved centres provided an ECT service and 8% referred residents to other approved centres for ECT treatment. The remaining 4% of approved centres either normally administer ECT or refer to another approved centre for ECT, but did not do so in 2016.

Three approved centres in the independent sector accounted for half of all programmes. They were St Patrick’s University Hospital, St Edmundsbury Hospital and St John of God Hospital. St Patrick’s University Hospital, a large 241-bed service reported the highest number of programmes. St Patrick’s University Hospital has an arrangement with the HSE for the admission of residents for ECT treatment. As part of this arrangement, residents are admitted to St Patrick’s University Hospital and therefore all such programmes are reported under this service’s figures for 2014-2016 [13 out of 121 in 2016]. The national forensic service, national intellectual disability service and CAMHS services did not report any programmes of ECT. Eight approved centres reported less than five programmes of ECT.” (page 12)

The report does not comment on the number of hospitals (43 out of 66) who do not use ECT or refer patients elsewhere for ECT.

The change in law in the Republic of Ireland leaves Northern Ireland as the only country in the British Isles that still has the “old law” where capable people can be given ECT against their wishes. This is not made clear in the annual report on the use of ECT by The Regulation and Quality Improvement Authority (RQIA). The report refers to “patients who are not capable of giving informed consent”, while the RQIA guidelines refer on page 241 to “detained patients unwilling or unable to give consent to treatment”. 

In the year 2016/17 in Northern Ireland (population about 1.8 million), 123 people (68 per cent of them women) underwent ECT.  Nearly half were treated without their consent. Over 95 per cent had bilateral ECT.

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Would Alex Riley have been institutionalised at the turn of the 20th century?

In a recent post I discussed an article about electroconvulsive therapy (ECT) written by Alex Riley for the BBC.

In the BBC article the author described his own treatment for depression, and speculated what might have happened to him in a previous era.

“Every morning at 09:00, the alarm on my phone reminds me to take my antidepressants. Unlike my previous prescription, these pills seem to be working…

I often wonder what treatment I would receive for my depression if I had been born into a different generation. At the turn of the 20th Century, I might have been institutionalised in one of the many mental hospitals that dotted the British countryside. In the 1930s, I would have been prescribed amphetamines, the class of drugs that includes ecstasy and were marketed as the first antidepressants. And in the 1940s – the decade when my grandparents would have been my age, in their late 20s or early 30s – I would have received electroconvulsive therapy.”

At the turn of the 20th century the chances of Alex having been institutionalised would have been very slim. Alex is one of about 5 million people a year in England who take antidepressants, while in England in 1900 there were probably about 7,000 people admitted to an asylum with a diagnosis of depression. I have not been able to find a figure for England, so have extrapolated from figures for the Norfolk asylum. It is therefore only a very rough figure, but, even so, and allowing for an increase in population, the chances of someone who takes antidepressants today being admitted to an institution in 1900 were in the order of a fraction of one per cent. And once admitted to an institution, what were someone’s chances of being stuck there? Again, they were small. People in those days were discharged from asylums (as cured, relieved or, in fewer cases, not relieved). And a young man with depression would have stood a greater than average chance of discharge, compared to those, say, with general paresis of the insane (neurosyphilis). Asylum doctors in those days were optimistic about the chances of successfully treating their depressed patients.

Outside of an institution, someone who was depressed would still have been able to take pills in 1900. The term anti-depressant was not coined until the 1950s but previously there were plenty of pills which claimed to alleviate nervous disorders – Dr Cassell’s tablets, Beecham’s or Holloway’s pills, for example. There were also various electrotherapy devices such as electric belts that were advertised as beneficial in cases of nervous debility.

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ECT, Mental Health Today and NHS Digital

Mental Health Today (MHT) has been trying to get some statistics about electroconvulsive (ECT) use from NHS Digital. Although MHT asks for donations on their website, it is not a charity but rather a publishing company, Pavilion Publishing and Media Ltd. MHT has taken their case to the Information Commissioner’s Office: “an investigation involving Mental Health Today and the Information Commission enters its eighth month”.

NHS Digital (the new name of the Health and Social Care Information Centre) apparently wanted £21,000 to provide MHT with statistics. They are quoted as saying:

“ECT is within [our] scope. However, we do not have statistics available for use of ECT and this is not currently a priority agreed with NHS England and the Department of Health and Social Care for development. In theory, if ECT is used by providers it should be being submitted to [NHS Digital] by providers. However we cannot confirm the quality of any data held without first undertaking a large piece of work. The work involved would lead to the cost of [Freedom of Information] compliance exceeding the appropriate limit.”

Until 1991 the Department of Health collected and published reasonably accurate statistics on the use of ECT. In 1991 there were about 16,000 courses of ECT in England. But then there was a switch to a new system, which only picked up a fraction of the ECT used. Why? There are several reasons: some psychiatric hospitals decided to simply opt out of the system, or didn’t realise they were meant to be part of it; some didn’t understand the coding system. There may be other reasons. The Department of Health have been aware of the problem for over years but have failed to do anything about it. (I have written about it here.)

MHT identified a rise in the statistics published by NHS Digital between 2013 and 2014 and assume this represents an increase in ECT use, although in fact most of the increase was due to a “data quality issue” with the data submitted by the Northamptonshire Healthcare NHS Foundation Trust, featured here.

Apparently, according to MHT, NHS Digital has not been publishing statistics on ECT use since 2014. (I haven’t looked at their website recently so cannot verify this). Perhaps no statistics are better than very inaccurate ones.

As well as labouring under the misapprehension that ECT use is rising dramatically, MHT has also miscalculated the numbers of people undergoing ECT while detained under the Mental Health Act. “It represents about one in twelve of those detained in hospital” they say. In fact, the figure is nearer to one in thirty. MHT seem to have overlooked the fact that a little over half of the people undergoing ECT are not detained and consent to treatment. Neither do they seem to be aware of the fact that the Care Quality Commission publish annual statistics on people being treated with ECT under the Mental Health Act.

In 2005 Parliament was told that no repeats of the 1999 and 2002 surveys of ECT use would be carried out as “In future, information on the use of electroconvulsive therapy will be available from the mental health minimum dataset” (Hansard, 12 September 2005, column 2712W). But reasonably accurate statistics on ECT use from the mental health minimum dataset never materialised.

I will be interested to see what the Information Commissioner’s Office makes of all this when they conclude their investigation.

Posted in ECT in the UK | 2 Comments

ECT in the Herald

When an article about electroconvulsive therapy (ECT) begins with a reference to the film One Flew Over the Cuckoo’s Nest then it is unlikely that an intelligent discussion on the topic will follow. And this article from the Newcastle Herald in New South Wales, Australia, is no exception.

We are told, inevitably, that ECT is safe, effective and under-utilised (a pretty bizarre claim given that Australia has a very high use of ECT compared to other Western countries). And, it says in the first paragraph, “an invasive form of ECT” is given to people with Parkinson’s disease. Presumably it means deep brain stimulation, which is an entirely different treatment because, unlike ECT, it is not intended to produce seizures and in any case it uses electric currents of just a few milliamps, while ECT uses currents of, typically, 800 milliamps. But the author (psychiatrist Alan Weiss) is just trying to position ECT as a non-invasive treatment, as the next paragraph makes clear:

“For mental illness, ECT is a non-invasive procedure, delivered under anesthesia, using small, controlled pulses of electricity to trigger a brief seizure. The brain is stimulated, the person is not “shocked”.”

People who have ECT are still given powerful electric shocks. If it were possible to rig up a machine to deliver a shock identical to that used in ECT but with the power turned down fifty or a hundredfold or whatever is necessary to deliver an “ouch” shock but nothing dangerous, I would challenge the author or any other psychiatrist to put the electrodes on their hand and describe what they felt when the switch was turned on. It would be an electric shock, not a stimulation or small pulses or anything else. And then perhaps they could try and imagine increasing the power 50 or 100 times or whatever to bring it up to the level used in ECT.

The article continues in like vein as the author plugs his book, The electroconvulsive therapy workbook. Weiss has already featured on this blog, when I discussed an article about giving very large numbers of electroconvulsive treatments to three elderly women in Newcastle, New South Wales, Australia. Weiss was lead author. Two of the women were being given ECT with the machine on a very high setting, delivering 706 millicoulombs of electricity – far in excess of what they might have received in the olden days. Yet in his article, Weiss talks about “beneficial changes in technology” and “lower pulses of energy”.

One thing is inescapable with ECT: if you want someone to have a seizure you have to give them a powerful electric shock. In fact, the power is usually increased to well beyond that needed to cause a seizure (about one-and-a-half times for bilateral electrode placement and about six times for unilateral) because anything less is considered ineffective.

Posted in ECT in the media, ECT machines, ECT worldwide, Electrical parameters | 1 Comment

The BBC celebrates 80 years of ECT

The BBC decided to celebrate the 80th anniversary of the first use of electroconvulsive therapy (ECT) with an article: The surprising benefits of electroconvulsive therapy.

The author, science graduate Alex L. Riley, is fairly new to writing and is working on a book about the treatment of depression world-wide. As he tells us in the article, he takes anti-depressants and also has counselling and has undergone cognitive behavioural therapy, and describes himself as being “in remission”.

The title immediately draws attention to the problem with the article: we are talking about a treatment that has been in use for 80 years, that has in the UK alone been given to over half a million people, and that has been lauded in the psychiatric journals as “safe and effective” for decades, so why should we be surprised to hear of its benefits?

The article follows a familiar formula (anaesthesia solves everything, spectacular success rates, unfairly stigmatised by One Flew over the Cuckoos Nest and Scientologists, etc….). For a long article, approaching 3000 words, it is remarkably lacking in discussion. There are plenty of quotes from psychiatrists, mostly American, and all men, extolling the virtues of ECT but not one word from anyone about the limitations of the treatment. Not a single quote, for example, from a psychologist. And, apart from a brief extract from Sylvia Plath’s book The Bell Jar, not a single word from anyone who has experienced ECT. In places even research along the lines of a quick google would have perhaps made the author think more carefully about the validity of his arguments.

For example:

“At this time [the 1940s], shock therapy was so popular that it was often performed on an out-patient basis.”

ECT was indeed performed on an out-patient as well as an in-patient basis in the early days. But so too was it in subsequent decades right down to the present. A glance at a recent survey of ECT practice in Northern Ireland shows that 13 per cent of ECT patients received outpatient treatment.

And:

“It can’t cure a patient, for example, and has to be performed every few months in order to prevent the original symptoms from returning.”

Perhaps here the author is trying to acknowledge that the benefits of ECT are usually short-term, but the claim about ECT having to be performed “every few months” is bizarre.  Again, a quick glance at a recent survey (this time by the Royal College of Psychiatrists) shows only about 8 per cent of ECT patients undergoing more than one course in a year. In addition, there were a similar percentage on maintenance or continuation ECT, but in this case treatments were nearly all given on a weekly to monthly basis.

The author’s arguments are at times irrelevant. For example, he acknowledges, with a rather strange choice of words and syntax, that benefits have to be weighed against risks: “Like treating any other disease or operation, the possibility of health has to be weighed against that of harm.” The harmful effects of ECT though are dismissed by saying that treatment for cancer has side effects and then suggesting that for many people “ECT could be a life-saver”. This is followed by some statistics to about suicide rates and a mention of “depression is the number one cause of disability globally”, with no evidence to connect the statistics to ECT.

More generally, Riley’s choice of words sometimes jars. For example, he asks whether “these side effects [memory loss, headache and jaw pain] warrant the continuing stigma attached to this treatment?” Wouldn’t “concerns” rather than “stigma” be more appropriate here, quite apart from the fact that headache and jaw pain, if confined to the immediate aftermath of treatment, are not going to contribute to either stigma or concern about the treatment?

At one point he writes that ECT “remains the most effective treatment for a small subset of mental illnesses.” A small subset? ECT, as another quick glance at the ECTAS survey would show, is used in the treatment of depression and, less often, schizophrenia, as well as on small numbers of people with a wide variety of diagnoses. Depression and schizophrenia, far from being a “small subset of mental illnesses” account for the majority of people who receive psychiatric treatment. It is not the indications for ECT that have changed over recent decades, rather it is the number of people prescribed the treatment that has been reduced (by over 80 per cent in the past four decades).

Another example: “It has even shown great promise for pregnant women and the elderly, two populations that are at high risk of depression but often can’t take antidepressants.” A treatment that has been in use for 80 years can hardly be said to be showing promise.  And, again, the language jars, with talk of “the elderly” as a “population”. As for people who “can’t take antidepressants” I  would challenge the author to find me one single published case of an older person who has received ECT in the United Kingdom in recent years who hasn’t taken antidepressants as well.

This article was published as part of the BBC Future strand, which is promoted in the following terms:

“BBC Future was born because you told us you wanted more in-depth coverage of science, health and technology – so we aim to provide expert analysis and features about the big ideas shaping the world, and the new insights challenging what we think we know about ourselves.”

But in this case the article was rather short on both “expert analysis” and “new insights”. In a previous post I wrote about another recent BBC item on ECT, in which a psychiatrist had given, entirely unchallenged, a promotional talk about ECT. Does the BBC have no guidelines on dealing with controversial subjects? Well, yes they do. According to the BBC editorial guidelines:

“When dealing with ‘controversial subjects’, we must ensure a wide range of significant views and perspectives are given due weight and prominence, particularly when the controversy is active.  Opinion should be clearly distinguished from fact…

Due impartiality normally allows for programmes and other output to explore or report on a specific aspect of an issue or provide an opportunity for a single view to be expressed.  When dealing with ‘controversial subjects’ this should be clearly signposted, should acknowledge that a range of views exists and the weight of those views, and should not misrepresent them.”

Where were the signposts?

Posted in ECT in the media, ECT in the UK | 2 Comments

ECT on BBC Radio 4: the wrong numbers

Today’s edition of Start the Week was subtitled “Altered Minds” and included a rather incongruous piece about electroconvulsive therapy (ECT). The programme makers had tried to tie it in with a piece about psychedelic drugs, which according to the programme were used in psychiatry from the 1940s to the 1960s, then banned, and now the subject of a resurgence of interest in research circles.

“While some psychiatrist were getting their patients to experiment with psychedelics in the 1950s, far more were administering electroconvulsive therapy – both have a controversial history. ECT involves sending an electric current through the brain to trigger an epileptic seizure. It gained a reputation as a barbaric treatment, after the film One Flew Over The Cuckoo’s Nest. But the psychiatrist Dr Tammy Burmeister believes that it’s time people understood the therapeutic potential from this procedure.”

This comparison doesn’t quite work, as ECT actually has a very different history. Far from having a newly rediscovered “therapeutic potential” it has been determinedly, doggedly, relentlessly promoted as a “safe and effective” treatment over the decades. But there has always been disagreement between psychiatrists and people who have undergone ECT about the extent of the memory loss caused by the treatment. The influence of One Flew Over The Cuckoo’s Nest on prescribing practice in the United Kingdom is probably exaggerated, but it is much easier for psychiatrists to blame Hollywood rather than take a critical look at their own profession. ECT use may have declined significantly during the 1970s (the film came out in 1975) but it is hard to see how the film can be responsible for the continuing decline of ECT in the United Kingdom.

Dr Burmeister qualified as a doctor in South Africa in 1994 and now works as a psychiatrist in Scotland. The hospital where she works, the Argyll and Bute Hospital, has a low use of ECT and I have been unable to find her name on any published research on ECT. She started off with the misleading statement that ECT involves a “small current”, when in fact the current is in the region of 800 milliamps, a powerful current that would knock you out immediately if the anaesthetic hadn’t already done so. Then we were told that it is different from the 1950s; nowadays there is anaesthetic and EEG monitoring, although no mention was made of the fact that the electric shock lasts much longer nowadays than in the 1950s – several seconds rather than a fraction of a second. She acknowledged that the mechanism of action of ECT is unknown, although, she said, it alters chemicals, hormones and “brain flow” and pointed out that people don’t ask how penicillin works. There was a mention of memory loss being considered by patients as a “small price to pay” and it was at this stage Kirsty Wark, who had been asking a few polite prompting questions, pointed out that her guest had rather elided over memory loss. Dr Burmeister’s reply was decisive – about how depression causes memory loss and patients return to baseline or better on tests after ECT.

Kirsty Wark then claimed that there was no “mass usage” of the treatment as it was only given to about 100 people in Scotland (at this point Dr Burmeister corrected her and said “a few hundred” – in fact about 350 people a year undergo ECT in Scotland) and that there were a “few hundred more” in England, while in fact over 3,000 people undergo ECT in England every year.

There was no mention of the fact that over 30 per cent of people in Scotland, and over 40 per cent in England, are being treated without their consent. No mention either of the fact that women and older people are over-represented in the ECT statistics.

It was disappointing that the programme, having referred in a brief introduction to ECT as controversial, then did nothing to explore the controversy but simply gave a psychiatrist the chance to give a promotional presentation on ECT, and then claimed it is used much less than in fact it is.

Posted in ECT in the media, ECT in the UK, Uncategorized | 3 Comments