ECT in Illinois: the youngest reported patient?

The February 2019 edition of the Journal of ECT includes a letter from two psychiatrists, Joseph Cooper and Khalid Afzal, at the University of Illinois in Chicago, in which they describe how they gave electroconvulsive therapy (ECT) to two small children with a diagnosis of catatonia secondary to anti-NMDRA encephalitis. The children were aged three and six. The three year old was described as improved following ECT; the six year old was “not functionally improved” but started to improve with immunomodulatory therapy after a further five months.

Both children were given bilateral ECT three times a week with a Thymatron machine on a high setting (up to 504mC).

The authors say that the three-year boy is “the youngest reported recipient of ECT known to the authors”. I know of another reported case of a three-year-old child given ECT: in 1941 psychiatrist R.E. Hemphill and neurophysiologist W. Grey Walter wrote about a three-year-old boy who had been given ECT at the Burden Neurological Institute in Bristol, England, in an attempt to “interrupt a series of minor [epileptic] attacks”. But Cooper and Afzal stressed that their three-year-old patient underwent ECT just after his third birthday, so perhaps they are justified in their claim.

In the state of Illinois it is usually necessary to obtain a court order before giving ECT to a minor. The authors were able to get around this legal requirement because their patients were diagnosed as having “catatonia secondary to aNMDAR encephalitis” while the law refers to minors who are receiving mental health treatment or who have developmental disabilities.

 

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Posted in ECT and young people, ECT worldwide | 2 Comments

ECT in the New Yorker

This month’s edition of The New Yorker features an article about the writer Dan Mallory: “A suspense novelist’s trail of deceptions” by Ian Parker. Mallory, writing under the name of A.J. Finn, is author of best-selling thriller The woman in the window, published in 2018. (I haven’t read it). The article describes how Mallory has invented various stories about his own life, including claims that he had cancer and that he had a PhD from Oxford University. It also describes how on more than one occasion Mallory has spoken about having undergone ECT:

Mallory said that once, in order to alleviate depression, he had undergone electroconvulsive therapy, three times a week, for one or two months. It had “worked,” Mallory noted, adding, “I’m very grateful.” He said that he still had ECT treatments once a year. “You knew he was telling us something that was really true,” Scott recalled. In the room, there was “a huge surge of sympathy.”

Mallory had frequently referred to electroconvulsive therapy before. But, in those instances, he had included it in a list of therapies that he had considered unsatisfactory in the years between 2001, when he graduated from Duke University, and 2015, when he was given a diagnosis of bipolar II disorder, and found relief through medication. In a talk that Mallory gave at a library in Centennial, Colorado, soon after his book’s publication, he said, “I resorted to hypnotherapy, to electroconvulsive therapy, to ketamine therapy, to retail therapy.””

The article does not say if the stories about ECT are true or another fiction, although they certainly appear to be inconsistent as regards whether the treatment was helpful or not. There is something I find unconvincing about it, although it is hard to imagine why anyone would want to claim to have had ECT when they hadn’t.

Nearly forty-five years ago The New Yorker published a long article about ECT by medical writer Berton Roueché (Annals of medicine: as empty as Eve, 9 September 1974). The article described the experience of a government economist who had become depressed following disastrous dental treatment and undergone a course of ECT. The treatment left her with memory loss and she was unable to resume her work. The article lets the woman who had undergone ECT speak for herself, through interviews and extracts from letters she had written while in hospital. The author gives some background about ECT and quotes from the writings of several psychiatrists showing a lack of agreement on the extent of memory following ECT. The article ends with the following words about memory loss: “If I hadn’t been a professional woman – if I hadn’t been a woman with a highly specialized and demanding job – I might never have realized the extent of my amnesia. I would have thought that I was still perfectly whole and complete”.

Posted in 1970s, ECT and memory loss, ECT in the media | 5 Comments

ECT in the Falmouth Packet

While the Science Media Centre was putting out some comments in support of electroconvulsive therapy (ECT), the Falmouth Packet in Cornwall published a sad story about a man who killed himself after having had 33 treatments of ECT. The brief report on the inquest did not say when he had been given ECT, but referred to him as having tried to kill himself on several occasions since the late 1980s. The coroner was quoted as saying he had received “lots of medication and therapeutic input”.

Posted in ECT in the media, ECT in the UK | 1 Comment

ECT in the Science Media Centre

On 31 January 2019 the British Medical Journal published a report on the recent Maudsley debate on electroconvulsive therapy (ECT). I have discussed the debate in a previous post. As soon as the British Medical Journal published the debate, the Science Media Centre sprang into action, with four “experts” weighing in with a quote – all in favour of ECT.

The Science and Media Centre is a charity, which aims to “promote for the benefit of the public accurate, evidence-based information on science and engineering in the media, particularly on controversial news stories”.  The charity’s latest annual accounts (for 2017/18), available on the Charity Commission website, show an annual income of £627,000. The accounts do not tell us where this money comes from. However the charity’s website lists their funders, the major ones being the government and the Wellcome Institute.

The charity has a restricted fund for the employment of someone to deal with mental health and neuroscience matters. The annual report for 2017/18 (available on the Charity Commission website) tells us:

“A restricted fund in the form of grants and donations from several organisations within the mental health and neuroscience research community continues to allow the SMC to employ a full-time member of staff to work specifically on mental health and neuroscience stories in the media.”

The report however does not tell us who those organisations are. From the list of funders the following organisations can be identified as having a specific interest in psychiatry: Mental Health Research UK, Alzheimer’s Research UK, Alzheimer’s Society, MQ transforming mental health, Royal College of Psychiatrists, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), and the Maudsley Charity. There are many more funders – Universities, pharmaceutical companies, Cochrane, NICE, etc. – whose interests will include psychiatry.

I have only been able to positively identify one funder – the Maudsley Charity. On their website they say that they provided a grant to the Science Media Centre towards the cost of “Supporting an independent press office to enable and encourage mental health researchers to engage with the media on key mental health issues. helping secure accurate coverage of controversial, messy and complicated issues”.

Given that psychiatrist Sir Simon Wessely is a trustee of the Science Media Centre, and given the nature of its funders, it is hardly surprising that the charity should, when it comes to matters concerning psychiatry, look like an extension of the Royal College of Psychiatrists’ press office. Hardly surprising too that all four of the “expert comments” produced for the item on ECT come down firmly on the side of ECT.

So who are these commentators and what do they say?

There are three male psychiatrists from England and a female psychologist from Denmark.

Rupert McShane from the University of Oxford says the usual things about effectiveness, stigma, etc., but does acknowledge that ECT has side effects: “Helping patients and their families to balance the benefits against the risks of ECT is an important task.”

Michael Bloomfield from University College London says much the same. Allan Young of the IoPPN says that ECT has side-effects but denies brain damage.

The fourth commentator, psychologist Kamilla Miskowiak from the University of Copenhagen, has an even more positive view of ECT: “highly efficacious and often life-saving treatment”… no evidence of brain damage or long-term cognitive side-effects, etc. She concludes:

“Despite this lack of evidence for ECT-induced brain damage, many people experience cognitive problems, including memory difficulties after ECT.  These cognitive problems are real and should not be disregarded. In fact, we know that long-term memory and concentration difficulties are a core feature of neuropsychiatric disorders themselves and thus exist before ECT is commenced. This highlights the need for novel treatments that can improve cognitive function in people who have suffered from neuropsychiatric conditions like depression.”

I have not been able to make head nor tail of this. First, she seems to be acknowledging that ECT causes cognitive and memory “difficulties” although she wouldn’t class these as evidence of brain damage. But then she appears to backtrack and say that these “difficulties” are in fact caused by depresssion. As for the last sentence – what on earth does it mean? In an attempt to answer this question I decided to look for other evidence of Miskowiak’s views on ECT.

I didn’t have to look far. Miskowiak is currently carrying out a trial in Denmark: “Erythropoietin as an add-on treatment for cognitive side effects of electroconvulsive therapy: a study protocol for a randomized controlled trial.” The title says it all: “cognitive side effects of electroconvulsive therapy”. But if this isn’t enough there are numerous mentions in the text of ECT-induced cognitive deficits and the cognitive side effects of ECT. So why has she changed her tune for the Science Media Centre, with an attempt to shift the blame for cognitive deficits on to “neuropsychiatric conditions like depression”? Perhaps she thought that this was more in line with the requirements of the Science Media Centre.

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Isn’t there anyone in Scotland who can write an ECT leaflet?

In October 2017 the Scottish ECT Accreditation Network (SEAN) published a leaflet about electroconvulsive therapy (ECT). It claims to present “the latest evidence” but in fact it is a reprint of a leaflet published in 2000 with a few numbers changed. But not enough numbers have been changed; for example the leaflet starts off by claiming that “ECT has been used in Scotland for half a century”. That might have been more or less true in 2000 but by 2017 ECT has been used in Scotland for over 70 years – hardly “half a century”. The leaflet continues:

“It is viewed in the medical profession as safe, effective and painless, with a low risk of unacceptable side effects. Furthermore, psychiatrists believe it can save lives.
However, this view has not always been shared by the public; which is perfectly
understandable. Much of what people believe about ECT comes from the way it is portrayed in films, television drama and documentary, where the purpose is often to entertain or to be controversial.”

There is no change in the words there since 2000, perhaps unsurprisingly, since psychiatrists still claim that ECT is safe, effective and life-saving and blame the media for the fact that not everyone believes them.

There then follows quite a bit about a survey in the 1990s with some new text about the “evolvement of the audit”, and some data from the latest SEAN annual survey:

“In 2016 there were 344 patients who received ECT, relating to 408 episodes of
treatment.”

In the original booklet, probably referring to 1999, this figure was “approximately 1,000 people a year”, but the authors of the reprint do not explain that there has been a significant decrease in the use of ECT (more than  60 per cent) over the last 18 years or suggest reasons for this decrease.

Then comes a brief but rather bizarre “history of ECT”, unchanged since 2000, which makes the claim “a great deal is known about how it works”. A section on “When is ECT used?” remains largely unchanged, in spite of the significant decline in its use, while a section on “What safeguards are there?” has added a mention of guidelines on the use of ECT by the National Institute for Clinical Excellence.

The next sections, dealing with the law and ECT, you might think would be very different as, between the 2000 and 2017 versions, the law was changed to give patients deemed to have capacity the right to refuse ECT. But in fact the earlier version of the leaflet blurred the issues around consent, so the addition of “Capable people cannot be given ECT against their will” does not appear to make much difference.

The section on “what actually happens during an ECT treatment” contains another example of how carelessly the leaflet has been updated as it retains the text ” The
photographs and plan of the ECT suite show a typical layout and examples of equipment” although there is now only one photo and the plan, complete with fish tank, has disappeared altogether.

A section on anaesthesia has been added to the the leaflet, so too has a section on “reasons for discontinuing ECT” (22 per cent of courses in 2016).

The rest of the leaflet is more or less unchanged and attempts to convince readers that ECT doesn’t cause brain damage and to dismiss controversy over ECT as down to “misinformation”, with, ironically, a warning about not believing everything you read on the internet. Exactly! A booklet claiming to be “designed to give an impartial presentation of the current evidence and advice on ECT” may in fact be a rehashed version of a leaflet that is more than fifteen years old. There is nothing, by the way, to alert readers to the fact that this leaflet was first published in about 2000, neither is it clear who the author is. The previous version listed a the SEAN management team and thanked Ian Kellagher for “his work in the drafting of this booklet” while the more recent version simply lists the current SEAN management team.

SEAN, meanwhile, appears to have given up on reporting annual statistics on the use of ECT in Scotland – either that or the latest report is very late. Usually their annual reports appear in November, reporting on the previous year, but nothing to date has appeared reporting on 2017.

Posted in ECT and memory loss, ECT in the UK, ECT without consent | 2 Comments

ECT in the Sunday Mirror and on Sky News

The Sunday Mirror on 13 January 2019 ran a feature about the use of electroconvulsive therapy (ECT) in England: “Teenagers with mental health issues given brain electric shock therapy on NHS.”

The article came up with some statistics:

“Figures obtained under the Freedom of Information Act show that from 2016 to 2018, 5,165 patients were given shocks to the brain as high as 460 volts.

The patients were aged 16 to 98. The total number of teens treated is not identified but a separate report seen by the Mirror shows one in six NHS Trusts administered ECT to under-18s.”

The figures are an underestimate as the report says that 37 trusts provided them with information. (There are over 50 mental health trusts in England and nearly all of them use ECT.)

The article interviewed professor of psychology John Read, psychiatrist Tim Oakley and two doctors who had undergone the treatment, Sue Cunliffe and Frances Coleman Williams.

John Read was quoted as saying that there could be no justification for giving the treatment to teenagers.

Tim Oakley was quoted as saying: “There are some patients who would respond very well to ECT who perhaps don’t get it as quickly as they should – or they don’t get it at all – for various reasons. In terms of getting people better, particularly for depression where everything else fails, it is still the best treatment.”

Sue Cunliffe talked about memory loss while Frances Coleman Williams described ECT as being part of a journey out of a dark patch.

The article concluded by saying that “NHS England and the Royal College of Psychiatry were unwilling to give a statement about the role of ECT in memory loss.” (I decided to see what the Royal College says about memory loss in their leaflet about ECT, only to find that it has been removed from their website.)

By the time Sky News ran the story that evening the Royal College had issued a statement saying, predictably, that ECT was “safe and effective”. Sue Cunliffe talked about the brain damage she had sustained when treated with ECT, and John Read was joined by psychiatrist Joanna Moncrieff of University College London, who said:

“If ECT works at all it jolts people out of a state of depression temporarily, but there’s no evidence that it has long-term benefit and there is evidence it causes long-term memory problems and lasting damage.

I think it’s not worthwhile in the vast majority of cases, if at all. We just don’t have enough research on what ECT does to the brain and the developing brain in younger people.

We know it can cause permanent memory loss, so it suggests it may do permanent damage. We know younger brains are more vulnerable to drugs, for example, so they are likely to be more damaged by ECT. Giving it to younger people is a worry.”

Posted in ECT and memory loss, ECT and young people, ECT in the media, ECT in the UK, Uncategorized | 4 Comments

ECT news from the USA, January 2019

Three recent pieces news from the United States have highlighted the controversy surrounding electroconvulsive therapy (ECT). While the Food and Drug Administration (FDA) has downgraded ECT machines from class III to class II risk in certain circumstances, and the National Institute on Aging (NIA) has awarded researchers a $11.8 million grant to experiment with ECT to control behaviour in people with dementia, the Maine Legislature is considering a bill to restrict the use of ECT.

I have written before about the history of the FDA and ECT machines (for example here). In December 2018 the FDA announced that it was reclassifying ECT machines “for the treatment of catatonia or a severe major depressive episode associated with major depressive disorder or bipolar disorder from Class III (higher risk) to Class II (moderate risk) with special controls”.

The NIA grant to study the use of ECT in the control of agitation and aggression in dementia is being divided between  McLean Hospital, Emory University, Mayo Clinic, Pine Rest Christian Mental Health Services and Northwell Health. I have written before (here) about the use of ECT to control behaviour in people with dementia at McLean Hospital, Pine Rest Christian Mental Health Services, and at Emory University Wesley Woods Geriatric Hospital.

In Maine, Representative Reckitt has presented a bill (LD21) to prohibit the use of ECT “on a child under 18 years of age or a person over 65 years of age or a person who is pregnant.”

Posted in ECT worldwide | 2 Comments