The Mental Health Commission in the Republic of Ireland have just published their report on the use of electroconvulsive therapy (ECT) during 2010. This is the third such report, following on from 2008 and 2009. Since 2009 there has been a small reduction in the number of ECT programmes administered in approved centres – from 373 to 347 (thirty years ago there were about 3,000). A programme of ECT is I think what would be called a course of treatment in some places (the report specifies that a programme refers to a maximum of 12 treatments – it doesn’t say how people who had more than 12 treatments in a course were counted). About one in eight people received more than one programme during the year, so that figure of 347 represents slighter fewer people.
An approved centre is, if I have understood correctly, a psychiatric unit that is registered with the Mental Health Commission to admit patients under the Mental Health Act 2001. What I am not clear about is whether all psychiatric units in the Republic of Ireland are approved centres and therefore whether the survey covers all the possible places in Ireland where someone might be treated with ECT. What the survey does not seem to cover is the use of outpatient ECT, so the total number of programmes will in any case be higher than the 347 in the survey. Also, it would appear that, since the survey counted programmes when they ended, someone on maintenance ECT would not necessarily be counted.
Of the 67 approved centres in the survey, 23 centres administered ECT during 2010, with a further 7 referring patients for ECT to one of these centres. This means that more than half of the centres in Ireland did not prescribe or administer ECT in 2010. That number will include centres that might not be expected to use ECT, for example because they only have very small numbers of patients or because they only treat children, but it would be interesting to know if there are centres providing a full psychiatric service to a reasonably-sized population that do not see the need to use ECT.
Just over two-thirds of the patients were women. Patients ranged in age from 20 to 90, with a mean age of 57. Over a quarter of the total patients were women over 65 years of age. The report concluded:
“Most programmes of ECT were administered to females and the most frequent diagnosis indicated was Depressive disorders. This is reflective of a greater proportion of women (57.8%) admitted to approved centres with a primary diagnosis of depressive disorders in 2010.”
But the percentage of women undergoing ECT is 68.4, which shows that the difference is not entirely accounted for by women being more likely to be admitted to hospital with a diagnosis of depression.
Most (84.3%) of the programmes of ECT were for the treatment of depression. Schizophrenia (8.2%) was the next most common reason for treatment. 32 people underwent 35 programmes of ECT without their consent. In Ireland ECT can be given to non-consenting patients whether or not they are capable of making a decision, if a form is signed by a second psychiatrist (who, unlike in England, Scotland and Wales, is chosen by the treating psychiatrist and not supplied by the Mental Health Commission). In 23 cases both psychiatrists agreed the patient was unable to consent, in 5 cases they agreed the patient was unwilling to consent, in 1 case both psychiatrists ticked both boxes and in the other 6 cases they ticked different boxes.
The Irish Times ran a story on the report under the headline “Psychiatric patients given ECT without consent”. The Irish Medical Journal published a brief article, “ECT use is in steady decline”, and also a letter from a doctor, “ECT gave patient her life back”. The letter describes how the writer’s sister, a widow in her 80s, became depressed following a fall in which she broke her clavicle and wrist.
“Her response to ECT was miraculous. Eight months have passed and she is now wonderfully well…. The purpose of this letter is to highlight the benefit that ECT has in the treatment of psychiatric illness… In view of the present controversy in its use, I have been requested by colleagues to highlight its vital role in the treatment of this case.”
But there seems to be a problem with the time-line. Eight months takes us back to the beginning of July last year. Allow another 6-7 weeks for the 13 ECTs the writer’s sister underwent and we are back to May. And yet we are told she had her fall “on February 15 [last year],” spent a week in hospital and six weeks convalescing in a nursing home. Which leaves just a month or two for “some months at home”, a holiday with family in England, a spell in a psychiatric unit in Ireland, another spell in a general hospital, another trip to Bristol, where sheltered accommodation didn’t work out, and five months in a psychiatric unit in Western-super-Mare before having ECT. Never mind, perhaps there were some typos with the dates. A bigger problem is the description of ECT:
” 10 treatments, each lasting seven seconds at intervals of twice a week. I concurred with this treatment in spite of some reservations, as there was no alternative. Her medicines at this time were all continued, Sertraline, Nitrazepam, Aripiprazole (Nitrazepam, Losartan and Furosemide). The new treatment made no difference to her mood or level of psychosis, when treatment was upped to 20 seconds. She was like a new person for a day, then seemed to return to previous form. Two further treatments were given and then her mood stayed up and all psychotic behaviour disappeared.”
Are there really ECT machines that deliver an electric shock lasting 20 seconds? I thought 7-8 seconds was about the maximum duration of the shock. Or is there some confusion here between the duration of the electric shock and the duration of the seizure?