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.

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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.

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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?

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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

Ewen Cameron: more legal cases

News came a few months ago that a woman in Canada had received compensation from the Canadian government for the damaging treatment her mother had been given by psychiatrist Ewen Cameron at the Allan Memorial Institute at McGill University in Montreal, Quebec, in 1957. It is now more than 50 years since the Cameron retired and thirty years since the first compensation payments to his patients were paid out but the story rumbles on. How is it that someone who was given an award for his “outstanding contribution to the mental health of the Canadian people”  could leave such a legacy of suffering and legal wrangling behind him?

Donald Ewen Cameron, always known as Ewen, was a Scottish-American psychiatrist who had a glittering career. Having qualified in Scotland, he spent some time in Switzerland and Canada before moving to the United States and working at Worcester State Hospital and then becoming a professor at Albany Medical School. In 1943 he was invited to become the founding director of the Allan Memorial Institute and chairman of the department of psychiatry at McGill University in Montreal, Quebec, Canada. It was here, that over the next 21 years until his retirement in 1964, his career was to flourish. There were books and articles, and he was successively elected president of the American Psychiatric Association (1952-53), Canadian Psychiatric Association (1958-9) and World Psychiatric Association (1961).

Cameron developed techniques which he called “depatterning” and “psychic driving”. The idea was to wipe a patient’s mind clean by using drug-induced prolonged narcosis and intensive electroconvulsive therapy (ECT), and then refill the mind with healthier thoughts by playing taped messages, the tape recorder being at the time cutting-edge technology. He described the technique of depatterning at the annual Maudsley Lecture in London in February 1962 (later written up with J.G. Lohrenz and K.A. Handcock for the April 1962 issue of Comprehensive Psychiatry). Firstly he gave credit to doctors in Britain and the United States who had pioneered the use of intensive ECT (multiple treatments a day instead of the usual three times a week) as a way to deliberately produce an organic brain syndrome in patients “with acute confusion, disorientation and interference with learned habits of eating and bladder and bowel control”; then he explained how seven years previously they had “decided to explore the potentialities of this procedure”. They had, he said, already had extensive experience with deep sleep treatment (where people are kept continuously – or nearly continuously – asleep with drugs for prolonged periods) and maintenance ECT (where patients were given monthly ECTs after their initial treatment). So the three techniques were combined in order to produce a person who had lost all feeling and was often unable to walk, feed themselves or go to the toilet, or remember things, but would also be free from “all emotional disturbance save for a customary mild euphoria”. The idea was that they would recover from the organic brain syndrome and the psychiatric symptoms would not return. Cameron and colleagues claimed good results with most of their patients “improved” and the permanent amnesia caused by the treatment was not seen as a serious drawback, merely as a “source of trouble or annoyance” for patients for six months or so, after which they could get by with what they had “been told of events which happened during the amnestic period”.

I have written in a previous post about how the technique of intensive ECT was developed by British psychiatrists Drs Russell and Page from the Three Counties Asylum at Arlesey, Bedfordshire. It was given to thousands of patients there (and at other hospitals). Robert Russell set up his own company making ECT machines, Ectron Ltd, which still exists but I think has passed out of ownership of the Russell family.

Two years after delivering the Maudsley lecture, Cameron retired from the Allan Memorial Institute and returned to a professorship at Albany, where he was still in place when he died in 1967. Obituaries in the medical press paid tribute to him. In one journal it said:

“As a diligent seeker after new knowledge, a gifted author, a renowned administrator and inspiring teacher he brought, not only to his professional colleagues but also to the community at large, a wider and deeper understanding of the importance and significance of the emotional life of man.”

And “W.S.” (probably William Sargant), writing in the British Medical Journal said:

“Ewen Cameron, by his work and example, helped not only many psychiatrists to become much better doctors but directly and indirectly helped hundreds and hundreds of patients…”

Obituaries of course have a tendency to glow, but even the FBI (Federal Bureau of Investigation) file that was opened on Cameron in 1948 when he was being considered for “employment in Canada on duties which will require access to secret data” contains similar sentiments. One former colleague considered Cameron “a man of excellent character and morals” and another “recognized him as one of the top psychiatrists in this country and stated that he unquestionably was regarded as the best man in his field in Canada.” Someone who had lived next door to the Cameron’s for a couple of years said that “she and her husband regarded them as about the finest individuals they had ever met.”

So how did it all go wrong for Cameron’s posthumous reputation? Three letters: C I A.

In the post World War II years the Central Intelligence Agency (CIA) was interested in psychological research that might be of of relevance to mind control. Through a front agency, they channelled funds to academic institutions and researchers whose research sounded promising to them. Although the CIA destroyed most of the records of the programme, known as MK-ULTRA, a few financial records survived and it is known thatthere were 80 institutions involved and over 185 researchers, some aware of where their funding was coming from, some not. A legal attempt to have the names of institutions and researchers made public was unsuccessful. Cameron’s work at the Allan Memorial Institute received about $60,000 funding between 1957 and 1960. There has always been debate about whether Cameron knew where the money came from. Whatever the truth of the matter, his FBI records show that he applied for security clearance from the Canadian Defence Research Board.

In 1980, after details of the CIA funding of Ewen Cameron had emerged, nine of his former patients sued the CIA. The case was settled in 1988 for a total of $750,000. That was just the beginning. If those people who had been left damaged by depatterning funded by the CIA deserved compensation, what about those whose treatment had been funded by the Canadian government? In 1992 the Canadian government decided, after an initial refusal, to compensate a further 77 former patients, who received $80,000 dollars each. But many more were turned down, because they didn’t meet the government’s arbitrary definition of sufficiently damaged. There were appeals: one woman, for example, who was treated for depression aged 19 in 1953 finally obtained compensation in 2004. And in October last year, CBC announced that Alison Steel had been awarded compensation for the treatment her mother underwent at the Allan Memorial Institute some sixty years earlier:

CBC News has learned that the federal government quietly reached an out-of-court settlement with Steel earlier this year, paying her $100,000 in exchange for dropping the legal action she launched in September 2015.

While a non-disclosure agreement prohibits Steel from talking about the settlement itself, the existence of the settlement and the amount was included in the most recent public accounts tabled by the government earlier this month.

Montreal lawyer Alan Stein, who negotiated the deal, said the government’s decision to compensate Steel could provide hope for the families of other patients who were subjects of Cameron’s “de-patterning” experiments but were initially denied compensation.

“They still have a possibility if their medical reports clearly establishes that they were substantially de-patterned.”

Although the official compensation program closed more than 20 years ago, Stein said the federal government has quietly settled claims from a handful of patients in recent years. He said Steel’s settlement is the second case of the government compensating the estate of a former patient.

What emerges from this saga is that it is not about the victims of a secret CIA experiment but about the victims of state-of-the-art psychiatry. Their stories of damaged lives are now told in the media while once, as “clinical material”,  they featured in a Maudsley lecture, and there they would have remained if it wasn’t for a quirk of funding. (After all, the thousands of people who underwent intensive ECT in Britain never received compensation nor escaped from the pages of psychiatric journals.) Cameron’s patients are no longer “schizophrenics” whose treatment left them “improved” with just a little, manageable, memory loss. A media story on Alison Steel’s legal victory says:

“Alison couldn’t ask her mother for advice; she had nothing to give. She was present — she would make grilled cheese sandwiches for her daughter and her friends — but never fully there.”

It is easy to see how Jean Steel’s ability to make grilled cheese sandwiches might have put her into the “social recovery” category in Cameron’s assessment.

And an article in the Washington Post in 1985 about the first claimants quoted a member of parliament talking about his wife who had been treated by Cameron:

“I’d say Velma operates at about 20 percent of capacity,” David Orlikow says. “It’s horrific.”

As the “clinical material” of Cameron’s lecture becomes human, the glittering career and honours and tributes start to tarnish. 

Deep sleep treatment and intensive ECT was ended at the Allan Memorial Institute in 1965, a year of so after Cameron’s departure. But there are aspects to the saga of Cameron and his depatterning that are still relevant today:

  • Psychiatrists may decide that perhaps something wasn’t a good idea and abandon it, but patients still have to live with the consequences;
  • The balancing of risks against benefits can be distorted if damage caused by treatment is dismissed as of minor importance and improvements exaggerated;
  • Just because something uses cutting edge technology, whether it is tape-recorders or computers, it doesn’t mean it is necessarily good;
  • Just because a psychiatrist is eminent and delivers lectures at the Maudsley or other prestigious institutions, it doesn’t mean their ideas are valid;
  • The search for a cure for mental illness can be dangerous.
Posted in 1950s, 1960s, ECT and memory loss, ECT in the media, ECT in the UK, ECT worldwide, Legal cases, Uncategorized | Leave a comment

Electroconvulsive therapy in Texas 2017

The Texas Department of State Health Services have recently published their annual statistics on the use of electroconvulsive therapy (ECT). Texas is one of the few places worldwide that collect and publish statistics on ECT use. Texas counts “reports” rather than people and, as the reports are collected quarterly and people may have ECT in more than one quarter, the number of people undergoing ECT will be smaller than the number of reports. In the fiscal year September 2016 to August 2017, there were 2,773 reports of ECT and a total of 17,631 individual treatments. According to the annual statistics, that represents a rise of 1.04 per cent on the 17,006 treatments in 2016. I make it more like 4 per cent but, no matter, both values count as a small increase. There has been a similar rise in the number of reports, up from 2,675 in 2016.

The rise in the number of reports is entirely accounted for by an increase in men receiving ECT, although women still make up 64 per cent of reports. And the rise, although spread across all age groups, was greatest in the 25-44 age group. People over the age of 65 accounted for fewer than 20 per cent of reports. Seventeen reports were for young people aged 16-17 (ECT in Texas is not permitted on anyone under the age of sixteen). There was a rise in the number of reports for people being given ECT without their consent, up from 25 in 2016 to 48 in 2017. Maintenance treatments accounted for 5,496 of the 17,631 individual treatments.

There has been a change in the way the statistics are published. They are now in more of a glossy brochure format with colourful bar charts but importantly are missing a breakdown of ECT at the level of individual facilities in Texas, something that was always included in previous years.

Posted in ECT without consent, ECT worldwide, Gender ECT | Leave a comment