The Scottish ECT accreditation network (SEAN) has just published their annual report for 2011. At first glance the report looks similar to previous years. A bar chart showing the number of courses of electroconvulsive therapy (ECT) given in Scotland over the past five years bobs along the 500 line; this year it was 522 courses given to 418 people (68 per cent of them women). People received on average 8 treatments per course. 94 per cent of courses involved bilateral electrode placement. There is regional variation (Dumfries and Galloway using ECT at more than 4 times the rate of Forth Valley for example) on which the authors comment as follows: “Despite this [cross-board activity] there is an unexplained variation in practice between Health Board areas that we would like to investigate further“.
But on closer inspection there are one or two significant developments. The use of ECT on people aged under 18 has returned to Scotland after several years’ absence. Although the report does not draw attention to the fact (the age ranges the bar chart have even been changed to hide it), the sentence used in previous reports “No-one under the age of 20 years has been recorded as being given ECT since 2005” has been removed. The Mental Welfare Commission annual report for 2009-10 meanwhile referred to a 16 year old patient being given ECT without their consent.
Another significant development is the increase in courses where the patient is being treated without their consent – 35 per cent of the total up from 27 per cent in 2009 and the increase is mostly down to an increase in the numbers of women being treated without their consent. The report says: “Evidence of any change in the relationship between gender and capacity continues to be evaluated and will be investigated further if a sustained trend emerges“.
Looking at the longer-term there has been a considerable increase in the numbers of people in Scotland being given ECT without their consent. In 1998/9 it was about 145 courses, in 2010 it was 184. And this is in spite of the fact that ECT use overall in Scotland has nearly halved since 1999 and legislation has been introduced to give capable patients the right to refuse ECT (about one-third of the patients treated without consent in 1999 were described as refusing rather than incapable).
Courses of ECT (numbers for 1999 are approximate, from National audit of electroconvulsive therapy (ECT) in Scotland published in 2000)
Consenting 790 338
Without consent (incapable) 96 184
Without consent (capable) 50 0
All the patients treated without consent in 2010 were considered to lack capacity to make a decision about treatment, with about 40 per cent of them resisting or objecting to treatment. The latest figures from the Mental Welfare Commission, which cover the period April 2010 to March 2011, show an even higher percentage (64 per cent) objecting or resisting. When the current legislation (the Mental Health (Care and Treatment) (Scotland) Act 2003 was being discussed in the Scottish Parliament there were concerns about the use of ECT on people who objected to it (even if they were considered to lack the capacity to make a decision) but the Minister for Health said that if ECT could not be given to people who objected to it would “deny people in that desperate situation access to the very treatment that might help them to recover their capacity“. According to the 2011 SEAN report, however, only a minority (27 per cent) of patients without capacity had regained it at the end of the course of ECT, even though psychiatrists considered the results of ECT especially good in people who had not consented to the treatment.