ECT in the Republic of Ireland 2015

Last month the Mental Health Commission in the Republic of Ireland published a report on the use of electroconvulsive therapy (ECT) in 2014 and 2015. In February this year the law changed to allow capable people to say no to ECT, so 2015 is the last year that the statistics include people who have been given ECT against their (capable) wishes. In spite of the fact that, in 2015, Irish psychiatrists were able to prescribe ECT without a person’s consent more easily than psychiatrists in England, Wales and Scotland, the percentage of non-consenting ECT patients in Ireland was lower than that in England and Scotland (I don’t have figures for Wales).

In 2015 there were 64 approved centres (psychiatric hospitals) in Ireland: 15 had an ECT service; 2 had an ECT service but didn’t give any ECT; 6 referred patients to another hospital for ECT; 41 had no ECT service. I am curious about those 41 centres that simply have no involvement with ECT. Are they specialist centres, for example, for addiction, that might be expected not to use ECT? Or do they provide a full psychiatric service without recourse to ECT? The report does not say.

308 people received 243 programmes of ECT. A programme is defined as a course of not more than 12 treatments. Does no-one ever receive longer courses? Or, if someone receives, say, 16 treatments, are they counted as two programmes? If so, this could account for the fact that the average number of treatments per programme in Ireland – seven – is less than in England. One person in 2015 in Ireland received six programmes of ECT.

People aged 19 to 85 were treated with ECT. The median age was 60. Two-thirds were women. Depression was the most common diagnosis, accounting for 73 per cent of programmes, followed by schizophrenia and mania.

As in previous years, St Patrick’s Hospital in Dublin was the heaviest user of ECT. St Patrick’s is currently recruiting participants for a clinical study involving ketamine and ECT. Ketamine has been around for a while, and I am puzzled by why ECT psychiatrists have recently begun to take such an interest in it. This particular study will look at whether ketamine can help prevent people who have had ECT becoming depressed again.

The researchers have published a research protocol. They say  that their trial is the first of its kind, although “Ketamine has been used for ECT anaesthesia and is associated with earlier improvement and possibly fewer cognitive side effects but no overall better response [16, 20, 22, 28]. I found this sentence rather confusing. Wouldn’t fewer side effects and earlier improvement constitute an “overall better response”. Or perhaps it means that the different studies cited in footnotes 16, 20, 22, 28 had different findings. So let’s look at the footnotes.

The article referenced in footnote 16 was “A systematic review and meta-analysis of randomized, double-blind, placebo-controlled trials of ketamine in the rapid treatment of major depressive episodes” and had nothing about ECT in it. Neither did the article referenced in footnote 20, “Meta-analysis of short-and mid-term efficacy of ketamine in unipolar and bipolar depression.” Footnote 22 referred to a Cochrane study: “Ketamine and other glutamate receptor modulators for depression in bipolar disorder in adults”. Again, it included nothing about ketamine used in anaesthesia for ECT, but did include one study of ketamine as an alternative to ECT: “Findings from one study also greater symptom reduction for ketamine compared to ECT up to 72 hours after treatment, but not after one or two weeks. This was based on very low quality evidence”.

Finally, in the last footnote, number 28, we get to something relevant: “A controlled systematic review and meta-analysis of randomized controlled trials of adjuctive ketamine in electroconvulsive therapy: efficacy an tolerability.” The authors of this paper looked at five studies where ketamine was used as in anaesthesia for ECT, either alone or in addition to another anaesthetic. Their conclusions: “Our meta-analysis of randomized controlled trials of ketamine augmentation in the ECT setting suggests a lack of clinical efficacy, and an increased likelihood of confusion.”

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