When John Read and co-authors were recently researching the use of electroconvulsive therapy (ECT) in England they had to send out requests for information to individual trusts (a hospital or group of hospitals) under the Freedom of Information Act. Some trusts were unable or unwilling to provide information of even the most basic kind. Researchers in Sweden have no such problem as a register is kept of ECT use. The register includes details such as electrode placement and electrical parameters as well as patient demographics. Inclusion on the Swedish National Quality Register for ECT is voluntary, but apparently about 85-90 per cent of patients sign up to it.
Recently four articles based on data from the register have hit the psychiatric press. The September 2017 edition of the journal European Psychiatry contained an article with the title “Self-assessed remission rates after electroconvulsive therapy of depressive disorders”. “Self-assessed remission rates” in this case referred to patients’ scores within one week of finishing treatment on a questionnaire (the MADRS-S) that they fill out themselves, replying to questions about “reported sadness, inner tension, reduced sleep, reduced appetite, concentration difficulties, lassitude, inability to feel, pessimistic thoughts, and suicidal thoughts”. The authors found that, overall, just over 42 per cent of patients reached the cut-off score on the questionnaire for “achieving remission”. The authors were looking for factors that might influence the outcome of treatment and concluded: “Our large-scale study of depressed patients showed that psychotic and an
older age were predictive of higher remission rates after ECT”. They also found that prolonged anti-depressant use, longer courses of ECT, ultra-brief pulse ECT, and personality disorders were associated with lower chances of “remission”. The variable that led to the highest chance of remission was never having taken anti-depressants, while taking lamotrigine (an anti-convulsant) led to the lowest chance of remission.
Although the authors were only interested in patients’ scores on the MADRS-S, the article nevertheless reveals a lot of information about how ECT is used in Sweden, a country which has a relatively high use of the treatment. More men than women are given ECT, but the difference is not so great as in some other Western countries. ECT patients are on average about ten years younger than they are in the United Kingdom. Unilateral electrode placement is used on about 90 per cent of patients, whereas in the United Kingdom bilateral electrode placement is used on over 90 per cent of patients. On the other hand, in Sweden ECT is given three times a week, compared to twice a week in the United Kingdom. All Swedish ECT clinics use American machines. In over 60 per cent of treatments, patients are given an electric shock lasting from 6.9 seconds to 8 seconds, and receive more than 291 millicoulombs of charge. Fewer of 30 per cent of people undergoing ECT in Sweden are classed as “severely ill”, although ECT is almost universally described as a treatment for severe depression or severe illness. Indeed the authors begin their article “Electroconvulsive therapy (ECT) effectively treats severe depression, but not all patients remit”.
There have been another three recently published articles by the same team using data from the Swedish ECT register.
“Subjective memory immediately following electroconvulsive therapy”, published in the June 2017 edition of the Journal of ECT, found that a quarter of ECT patients reported memory worsening shortly (up to one week) after treatment, with reports being more likely amongst younger women.
“Improvement of cycloid psychosis following electroconvulsive therapy”, published in the Nordic Journal of Psychiatry in August 2017, concluded that “ECT is an effective treatment for cycloid psychosis” and that “The high response rate with ECT indicates that cycloid psychosis is a clinically useful diagnosis”.
“Rehospitalization and suicide following electroconvulsive therapy for bipolar depression – A population-based register study”, published in the January 2018 edition of the Journal of Affective Disorders (epublished September 2017), found a “high rate”, in the authors’ words, of suicide or rehospitalization in the year following ECT. The authors looked at 1255 people diagnosed as having bipolar depression who were treated with ECT. Their average (mean) age was 52. In the year following ECT, there were 65 deaths, including 17 suicides. Over half (53 per cent) of those treated with ECT either died by suicide or were rehospitalized within a year. The authors also looked at drug treatment in the three months following ECT; only 2.4 per cent were not prescribed drugs, and 45 per cent were prescribed four or more drugs.