High use of ECT in Sweden 2013

A recent article for the Journal of ECT looks at the use of electroconvulsive therapy (ECT) in Sweden (Electroconvulsive therapy in Sweden 2013: data from the National Quality Register for ECT by Pia Nordanskog et al. )

As the authors of the article point out, there are few countries where the reporting of ECT use is required and in many countries knowledge about use comes only from occasional national surveys. In Sweden there is a mandatory register which gives numbers of people undergoing ECT and also a non-mandatory one which gives more details of patients and treatment and included, for 2013, 85 per cent of the people who underwent ECT.

A total of 3,972 people underwent ECT in Sweden in 2013. The population of Sweden is about 9.64 million and this gives a rate of 41 people per 100,000 population receiving ECT. This, as the authors say, is high compared to other countries. They identify Belgium and Australia as other countries with similarly high rates. They identified Croatia, the Ukraine, Germany and the USA as countries with a low rate of use and Canada, Slovakia and Norway as countries with intermediate use. They didn’t mention Scotland, one of the few countries to publish detailed annual reports of ECT; in fact Scotland uses ECT at about one-sixth the rate of Sweden. What seems very high is the proportion of people hospitalized with severe depression who receive ECT: 40 per cent of women and 38 per cent of men. Most of those receiving ECT had a diagnosis of depression although it was also sometimes used for disorders where it is not recommended in Swedish clinical guidelines.

Detailed information from the non-mandatory register was available for 3,246 patients who received a total of 35,875 treatments (3,746 courses of treatment and 738 continuation series). Their age ranged from 15 to 94 with a median of 55, making them younger than Scottish patients. Six patients were under 18, twenty were over 90 years of age. “Less than 15 per cent” of patients were treated without their consent under the mental health law. Women accounted for 63 per cent of patients which is lower than in some other Western countries or states – for example Scotland and Texas, where about 70 per cent of ECT patients are women. I

Sweden has a high use of unilateral electrode placement, it being used in 86 per cent of courses. This is the highest use of unilateral electrode placement I have found for any country. In Scotland, by contrast, over 90 per cent of ECT patients receive bilateral treatment.

The register also records details of treatment parameters in about 60 per cent of courses. The median stimulus for the first treatment was a current of 800mA for a duration of 7.5 seconds (pulse width 0.5ms, frequency 70Hz) giving a total charge of 358mC. “In 13 per cent of the treatment series, the charge was greater than 576mC.”

The authors expressed concern that ECT was sometimes administered by nursing assistants (unlicensed assistant personnel). Although prescribed by psychiatrists, ECT was often administered by nurses or nursing assistants and psychiatrists only participated in its administration in a minority of hospitals.

The last study of ECT in Sweden was in 1975 (although there was at least one more recent study covering only a part of the country). How have things changed in nearly forty years? Remarkably little in some respects, for example the rate of use is almost exactly the same in 2013 as in 1975. Although it is impossible to make a direct comparison, the number of individual treatments appears to have increased, suggesting longer courses and/or an increased use of maintenance treatment. The stimulus, as it was called in both 1975 and 2013, has increased in duration: in 1975 it was generally between 3 and 6 seconds, and in 2013 it was a median of 7.5 seconds. In 1975 all hospitals used German ECT machines; in 2013 they all used American machines.

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