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.

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ECT news in Queensland

Queensland, Australia, seems to feature frequently on this blog, considering it is not a very large place (population about 4.7 million). It has a high use of electroconvulsive therapy (ECT), both with and without consent. The latest case to hit the headlines is of a man in who has received a large number of treatments at Prince Charles Hospital, Brisbane.

“No friends, no family and 140 shock treatments since 2015”, said the headline in the Brisbane Times, 21 March 2018. The 37 year old man had been diagnosed as having paranoid schizophrenia and had been continuously hospitalised, as an involuntary patient, since 2011. He had received 140 treatments since November 2015. His guardian has applied for an order to stop the treatment.

Another example of ECT use in Queensland, this time from a few years ago, makes sad reading. The 2013 inquest into the suicide in Townsville Mental Health Unit of a man in his thirties heard how he had been treated with ECT in 2008 and, less than a year later, was dead. In the meantime he had spent time in hospital, been prescribed numerous drugs and had been given various diagnoses. The out-patient ECT had been prescribed by a 78 year old psychiatrist, Basil James, who admitted that it had had only a very slight benefit. Basil James was a British psychiatrist who moved to New Zealand and then to Queensland. In Britain in the 1960s he had been a practitioner of aversion therapy on gay men.

The Queensland government has recently produced an ECT consent form. According to this form, patients should be told that “a modified mild electric current is passed briefly” through the electrodes to their head. The section that deals with memory loss, a common consequence of ECT, is especially misleading and confusing:

“• immediately after ECT most people have a short period of confusion and do not remember the actual treatment; some people may never remember the treatment
• short-term memory may be affected
• existing memory problems, caused by your illness, may also get worse
• memories of events from your past are less likely to be affected than short term memories
• although specific memories may not return, overall memory will usually get better in the weeks to months after treatment”

No wonder people aren’t prepared for the memory loss they experience with ECT. (I featured two views, one of them from Queensland, on this in a previous post.)

On a slightly different topic, Queensland has been having problems with a couple of bogus psychiatrists in recent years. Last month Vincent Berg, a Russian refugee who had posed as a psychiatrist in Queensland hospitals between 1999 and 2002, was found guilty of fraud and forgery. Apparently his supervisor at one hospital found him quite credible, in spite of cultural differences. Vincent Berg’s certificate from a Russian University was found to be a forgery. Meanwhile another fake psychiatrist, Vito Zepinic from the former Yugoslavia, was working as a psychiatrist at Toowoomba hospital from 2000-2002. After his deception was uncovered by Queensland authorities he moved to Sydney and again practised as a psychiatrist. Unmasked again, he moved to London and in 2009 obtained a position as a senior lecturer in psychiatry at Queen Mary, University of London (QMUL). He worked there for five months before his convictions for fraud in Australia were discovered. In 2013 Zepinic was convicted of fraud at Wood Green Crown Court, but oddly the case doesn’t seem to have been reported in any British media, although an article did appear in The Sydney Morning HeraldWhat is Vito Zepinic up to nowadays? Next month (May 2018) he is attending a conference in China. In his biography he describes himself as a “clinician” with thirty years experience, including a post as senior lecturer at QMUL, with no mention of the convictions for fraud. Although his claims to have a medical or psychiatric qualification are false, Zepinic appears to actually have a PhD in psychology from the former Yugoslavia.

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ECT and the machine that wasn’t switched on

On 22 January 2018 the Birmingham Mail published an obituary of Tamworth GP Dr John Weston Smith, who had died aged 95. The obituary mentioned that he had provided anaesthesia for electroconvulsive therapy (ECT) at St. Matthews Hospital in Burntwood. (You can see some historic photographs of St Matthews Hospital here.)

On 15 March an obituary by one of Dr Smith’s children appeared in The Guardian’s “other lives” section, which publishes obituaries of “people less in the public eye”. Jonathan Smith enlarged upon his father’s experience with ECT, identifying him as the author of an anonymous article on ECT that appeared in the journal World Medicine in 1974.

“The needs of a family of six children were considerable. To supplement his income John became a GP anaesthetist, working at a local psychiatric hospital where staff administered electroconvulsive therapy (ECT). By turns of events arising from a replacement machine and a lack of staff training, there was a period of more than two years when the team used a machine they believed was working – but it was not. However, no consultant reported any change in the responses of patients to their treatment.

This unscientific double-blind experiment was the subject of an article in World Medicine in 1974, written by John under a pseudonym. Subsequent research stimulated in part by this article, which cast doubt on the effectiveness of ECT, established its proper place in the treatment of mental illness. The article is still quoted in medical publications.”

The article in question, “Non-ECT”, appeared under the pseudonym of J. Easton Jones in World Medicine 1974, no. 9, p.24. It describes the author’s early experience of ECT in the 1950s, with patients being given muscle-paralysing drugs, but no anaesthetic. At the time, that would have been one of the variants of delivering ECT; some psychiatrists used anaesthesia and muscle-paralysing drugs, some used neither (unmodified ECT) and some used just the muscle-paralysing drugs. The article begins:

“As a general practitioner anaesthetist I was introduced to ECT over eighteen years ago. In those days the object was to give a shot of relaxant before the shock and to press the button at the psychological moment, the idea being to get the maximum relaxation combined with the maximum post-epileptic amnesia of the seconds before the shock. When I mildly suggested that a sleep dose if IV thiopentone might allay the obvious distress of the patients and the high refusal rate, I was brusquely told, “It would interfere with the treatment”. In my innocence I supposed that there was some sort of rational scientific basis for the treatment but the indications seemed vague, ranging from temporal lobe epilepsy, chronic schizophrenia to depression and poking the medical superintendent in the eye.”

The author goes on to relate how he eventually managed to introduce an anaesthetic into ECT practice at the hospital and how, as there was a shortage of psychiatrists, he became responsible for giving the shock as well as the anaesthesia and how a new machine left patients with burns. Then another new machine was ordered:

“It duly arrived and was obviously a great improvement on the previous edition. It had dials and lights and switches for different wave forms. We started treatment, the patient did not twitch, although the red light went on and the needle moved, “Isn’t it working?” I said. “Yes, it is,” said the nurse, “this sort doesn’t give any reaction – it’s in the instructions”. I duly read the instructions and indeed “there should be minimal signs of any seizure with this apparatus.” We used the apparatus for two years with no complaints from the patients and although I did not actually see any consultants, apparently they were satisfied with my work. But on a never-to-be-forgotten day a new charge nurse appeared. After the third treatment, he said, “It’s not working.” “Oh yes it is, this kind of does not cause any twitching”. “Look, I’ve just come from a hospital with one just like this and they twitch all right”. We examined this one closely… he was right. All the patients had been getting for two years was thiopentone and a shot of Scoline – and no one had noticed”.

When the author’s son writes that this article was partly responsible for subsequent research, he is probably referring to a few studies carried out in the late 1970s and early 1980s in which ECT was compared with sham ECT in which the patients, like those of Dr John Weston Smith, received the treatment but without the actual electric shock. In general the studies showed a relatively small advantage for ECT over sham ECT especially in the early stages of treatment, but not enough to settle any debate about the usefulness of the treatment and certainly not enough to establish the “proper place” of ECT in the treatment of mental illness, as the author’s son claims.

Does ECT even have a “proper place”? It depends on where you live. In general ECT is used mostly as a treatment for depression in Western countries while in other countries it is used extensively as a treatment for schizophrenia. Rates of use vary widely between countries, even countries which share a professional body for their psychiatrists (Australia and New Zealand). And similar rates of ECT do not necessarily mean a similar place for the treatment. Texas and Scotland for example have broadly similar rates of ECT use and in both places the treatment is used mostly for depression and about two-thirds or more of patients are women. But in Scotland ECT is used on non-consenting patients at over 25 times the rate in Texas. If ECT has a proper place, it is yet to be found.

Posted in 1970s, ECT in the media, ECT in the UK, ECT machines, Electrical parameters, Techniques | 2 Comments

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.

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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.

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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.

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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.

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