The Canberra Times today has an article entitled “ACT patients turn to shock therapy”. You might expect, with a title like that, that the article would be about an increasing use of electroconvulsive (ECT) in the Australian Capital Territory (ACT). And that indeed is how it starts off:
“ONCE DERIDED as a form of medical cruelty forced upon the mentally ill, electro-convulsive therapy is now being increasingly accepted among Canberrans with severe depression, says the ACT chief psychiatrist.
Peter Norrie says changes to the way the electric shock is delivered have significantly lowered the risk of the patient suffering memory loss, the most well-known side effect of the treatment”.
But where is the evidence for this increasing acceptance? According to the article, 28 people have undergone ECT in ACT over the past 10 months. For a nearly 11 month period July 2010 – 26 May 2011 the number was 24. For the year 2009/10 it was 23, and for the year 2008/09 it was 32. So, yes, an increase, but not a very dramatic one. These figures are for treatment in the public health sector only. Over the 3 year period 2008-2011, nearly half of the 79 ECT patients – 36 – were being treated without their consent under s55E of the Mental Health (treatment and care) Act 1994, and that doesn’t include anyone treated under emergency orders. Those figures were given in an parliamentary answer last year.
Dr Peter Norrie, Director of Clinical Services and ACT Chief Psychiatrist, is quoted as saying that many patients had returned for further courses after their initial treatment. That may go some way to explaining why there is a high mean number of treatments per person (in 2010/11 it was about ten).
”Almost always people who have had ECT, and who have had a sustained benefit from it, will actually come back to us if they are unwell again and ask us if they can have another course of ECT,” Dr Norrie said.
”I think that’s testament to the proof that it works very well.”
It is also testament to the fact that, when ECT works, it may not be for long. One patient, according to the parliamentary answer last year, had had a total of 145 treatments between 2006 and 2011.
The article continues:
Dr Norrie said the shock itself had changed about two years ago and now a much shorter pulse was used.
”Rather than delivering a fairly strong electric shock it actually targets a particular area of the brain and we can monitor that,” he said.
What Dr Norrie is apparently referring to here is the use of an ultra-brief pulse rather than a brief pulse waveform when administering ECT. Presumably, if Dr Norrie is to be believed, the psychiatrists in Canberra switched their machine to the ultra-brief pulse waveform setting two years ago. There is nothing new about ultra-brief pulse; it was first used in the 1940s. There has however been some renewed interest in it recently and some psychiatrists are conducting experiments comparing brief-pulse and ultra-brief pulse waveforms in ECT though it is too early to come to any definite conclusions about whether it really reduces the damaging effects on memory. The ultra-brief pulse refers to the electrical waveform, and not to the electric shock itself which is even longer than that used in brief-pulse. For example, using the specification of a commonly used model of ECT machine, to deliver a typical charge of about 170-190 millicoulombs with ultra-brief pulse (0.3 millisecond pulses at a frequency of 60 per second) the current would flow for 6 seconds, whereas with brief-pulse (1 millisecond at 60 per second) the current flows for 2 seconds. So it is still a powerful electric shock.
And the electrodes are only applied to the right side of the head, away from the left where memory function lies.
”[That] allows us to know that we’re delivering a smaller pulse of electricity and that the risk of memory loss will be much significantly lowered,” Dr Norrie said.
But in some cases where treatments were not having an effect on the depression, a bilateral shock could still be recommended, he said.
There is nothing new about unilateral electrode placement. It was first used in the 1950s, but did not prove popular with psychiatrists. Australia is one of the few countries where it is used on a significant proportion of ECT patients – more than half according to some surveys. But that still leaves a significant number getting bilateral.