ECT in Worcestershire: over 90 per cent of patients are women

When I wrote about electroconvulsive therapy (ECT) in Worcester, United Kingdom, two years ago I was unable to find any publications on the treatment from psychiatrists, etc., working in Worcester. However, an article about ECT in Worcester has now been published. The articlePatients’ experiences of and attitudes to ECT, by Latha Guruvaiah, Karthikeyan Veerasamy, Muhammad Naveed, Swami Kudur, Farah Chaudary and Ann Paraiso appeared in the April – June edition of Progress in Neurology and Psychiatry. As the title suggests, people who had undergone ECT were asked to fill in a questionnaire about their experience. The people who were asked to fill in the questionnaire had all been treated by the Worcestershire Health and Care NHS Trust in 2013 and 2014. The lead author is a psychiatrist at the 2together NHS Foundation Trust in Gloucestershire, the others are psychiatrists at Worcestershire Health and Care NHS Trust.

The questionnaire was based on one used by Scottish psychiatrists for a similar study in the 1970s. The authors say: “Since its publication in 1980, we could not find any similar published literature in the UK highlighting the experience and attitudes of patients and carers towards ECT” which is surprising as several such studies have been published. People who had undergone ECT were asked questions about their experience and, based on their answers, the authors concluded that “It is clear from this study that the overall experience and attitude of patients and carers were positive”. For example:

  • 15 out of 27 consenting patients said they had signed a consent form (the others could not remember);
  • 4 out of 27 consenting patients felt forced or pressurised to have ECT (19 did not and four could not remember);
  • 22 out of 30 patients said a member of staff accompanied them to the ECT clinic (2 said no and six could not remember);
  • 28 out of 30 said the clinic was clean and comfortable (2 could not remember);
  • 17 out of 30 rated the recovery period for a few hours after ECT as “pleasant”, 5 as “neutral”, 4 as “unpleasant” and 4 as “do not know”.

Of 29 patients, 24 said they experienced memory loss after treatment, and 13 said they experienced confusion. The authors suggested that the high incidence of memory loss might be explained by the fact that all the patients had been given bilateral treatment. (The survey did not ask participants if they had been given a choice of bilateral or unilateral treatment.)

The researchers found 30 people who were willing to take part in the survey, out of 60 people who had completed a course ECT during 2013 and 2014. The trust came up with a slightly different figure when I put in a Freedom of Information request – 69. Perhaps the difference is explained by people who did not complete a course of treatment. The interviews were conducted in early 2015, that is from immediately to just over two years after treatment (I am going to say on average one year). Six people could not be traced, five people could not take part due to significant cognitive impairment, 11 refused to take part and eight had died. The authors made no comment about those with cognitive impairment or whether it was caused by ECT, and they said that the deaths were “not related to ECT” but due to either “old age or physical ailments”.

But should eight people, out of 60, have died within, on average, a year of ECT? The average age of the people in the final sample of 30 was 62 years (ranging from 20 to 81). The trust told me that the average age of all people who received ECT in 2012 and 2013 was about 63 (64 in 2013 and 62 in 2014). A woman (and nearly all those who received ECT were women) in her early sixties in England can expect to live over twenty years more, so that appears to be a high death rate. It is something that at least deserves more explanation than a vague comment about old age.

Almost all – 28 out of 30 – the people taking part in this study were women. When I read the study I assumed that that must be because women were more willing to participate in the study. But the trust told me that, astonishingly, 63 of the 69 people who underwent ECT in 2013-2014 were women. Over 90 per cent of their ECT patients were women. Again, the authors are unconcerned, saying that depression is more common in women than men. Possibly – but certainly not in the ratio of 9 to 1.

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ECT in the Scottish Daily Mail

Today (8 January 2018) the Scottish Daily Mail ran a feature about electroconvulsive therapy, which can be seen hereThe author, home affairs editor Graham Grant, talks about an investigation and it looks as if he has sent off some freedom of information requests to health boards, as well as having spoken to the chairman of the Scottish ECT Accreditation Network (SEAN), Dr Alistair. The article identifies the youngest and oldest patients in Scotland: in Greater Glasgow a 16-year-old was given ECT, while in Forth Valley a 93-year-old was treated.

The average age of patients is around 65 years, because, the article says “older people tend to suffer very few side effects”. I wonder where the author got that idea from.

The article recognizes that ECT can cause memory loss, but goes on to say: “Experts believe administering voltage to only one side of the brain may limit this side-effect”.  Experts (if by experts you mean psychiatrists) have believed this for over 60 years, but they persist in using the more damaging electrode placement, bilateral. If the author had read the latest annual report from SEAN, he would have seen that 98 per cent of ECT courses in Scotland in 2016 involved bilateral ECT.

The newspaper did a brief interview with a woman who had had ECT in 2014, but had stopped after two or three treatments as it left her feeling more traumatised than before. Stopping treatment before the end of a course is not a rare occurrence: the SEAN report for 2014 showed 19 per cent of courses were not completed as planned.

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ECT at Cypress Creek Hospital, Houston, Texas

In a recent post about the use of electroconvulsive therapy (ECT) in Texas, United States, I mentioned the fact that Cypress Creek Hospital in Houston is the heaviest user of ECT in the state. In 2016, for example, Cypress Creek was responsible for nearly one-fifth of all treatments given in Texas, although they are just one of 22 hospitals using ECT. And they were responsible for nearly one-third of all reports in Texas for ECT given to people under the age of 25 years.

In spite of the fact that they use so much ECT, there seem to be no psychiatrists at the hospital with a particular academic interest in ECT. I have never come across a published article where one of the authors is affiliated to Cypress Creek Hospital. On their website the hospital has only a brief  section on ECT, which contains several misleading statements. It talks about a “small amount of electrical current” although in fact ECT involves a current of about 800 milliamps flowing for, usually, several seconds – a very powerful electric shock which would knock you out immediately if the anaesthetic hadn’t done it already. “It is often safer than no treatment at all” we are told. What does that mean? It may be an “appropriate treatment option” for patients who are 18 years of age or older, the hospital says, although, in 2016, they submitted 9 reports of ECT use on people aged under 18 years (out of a total 15 for the whole of Texas).

In Texas, psychiatrists are supposed to report any deaths that occur within two weeks of ECT. In the March-May quarter 2006, Cypress Creek reported one death occurring within two weeks of treatment. That, presumably, was the death of 22 year old Jayme Rachelle Cox, whose mother later sued the hospital. The case is reported on the FindLaw website:

“On April 26, 2007 [sic], Jayme Cox voluntarily admitted herself to Cypress Creek. She had been diagnosed with bipolar disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder, and she was determined to be a suicide risk. At the time of her admission, Cox’s medications included Effexor XR, Eskalith, Adderall, Campral, Zyprexa, Provera, Topamax, and Xanax. After admission, her medications were changed slightly and Ambien CR was added to her regimen. Cox was also treated with electroconvulsive therapy (“ECT”). During her admission, Cox injured her left knee and, on May 2, she was prescribed hydrocodone for the pain. On May 3, she was also prescribed Oxycontin for one night, in addition to her routine medications.”

Jayme Cox died the following morning. “An autopsy was later performed, and the toxicology results showed that Cox died as a result of Zyprexa toxicity.”

The case brought against Cypress Creek Hospital by Jayme’s mother was thrown out  of court because the author of her expert-report was not a physician. It is not clear exactly why a report by someone who wasn’t a physician was submitted, but I am left wondering if she could not find a physician who would write a report critical of Jayme’s treatment. Is the amount of drugs Jayme was prescribed, with, in addition, ECT,  considered normal or acceptable practice in the United States?

Posted in ECT and young people, ECT worldwide, Legal cases | 6 Comments

ECT in New Zealand and Queensland, 2016

Queensland, Australia, and New Zealand have similar-sized populations – about 4.7 million – and their psychiatrists share a professional body, the Royal Australian and New Zealand College of Psychiatrists. But use of electroconvulsive therapy (ECT) is very different in the two countries.

The New Zealand Ministry of Health has just published the annual report (2016) of the office of the director of mental health. In 2016, 251 people in New Zealand underwent a total of 2,746 treatments. There has been little change in the number of people receiving ECT over recent years (in 2012 for example 265 people received 2670 treatments). Women accounted for 62 per cent of ECT patients. Almost one-third of patients were aged over 65. Forty-one per cent of ECT was given to people who had not consented. All ECT in New Zealand is given in public, rather than private, hospitals.

In some ways the use of ECT in New Zealand is similar to that in England, Wales and Scotland: a low use, with women and older people over-represented in the statistics, and a relatively high proportion of patients treated without their consent. But, unlike England, Wales and Scotland, New Zealand retains mental health legislation that allows psychiatrists to give ECT to people who don’t want it, even if they have the capacity to make a decision. In 2016, ten of the 102 people treated without their consent were having their capacitious decision over-ruled.

Meanwhile, in Queensland, Australia, the mental health tribunal approved 506 applications to use ECT on non-consenting patients in the year 2015-16, according to an article in the Brisbane Times. That is five times as many as in New Zealand.

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ECT in Texas 2016

Earlier this year (in February 2017) the Texas Department of State Health Services published their annual statistics on the use of electroconvulsive therapy (ECT) in the state.

In the fiscal year 2016, that is, from September 2015 to August 2016, there were 22 hospitals in Texas that used ECT and they submitted 2,675 reports of ECT, one per cent up on the previous year. That figure represents fewer than 2,675 people receiving ECT, or even the number of courses of ECT, because the reports are submitted quarterly and so a course that begins in one quarter and ends in the next will be counted twice. Someone undergoing maintenance ECT with, say, monthly treatments throughout the year will be counted four times.

Women accounted for 68 per cent of the ECT reports in Texas in 2016. People over the age of 65 accounted for 504 reports; those under the age of  25 for 176 reports, including fifteen reports for 16-17 year olds. People aged 25-64 accounted for 1995 reports. Overall, the age of ECT patients is younger than in, say, England or Scotland (or in Texas some years back). Nearly all ECT patients in Texas consent to treatment. There was one report of death within 14 days of treatment (at Laurel Ridge).

Six of the 22 hospitals in Texas that used ECT in 2016 are responsible for about two-thirds of all reports. They are: Cypress Creek, Texas West Oaks, Laurel Ridge, Zale Lipshy University,  Seton Shoal and Green Oaks hospitals. Cypress Creek is, as in previous years, the heaviest user with 530 reports, almost one-fifth of the total for Texas. Nearly one-third of reports for under 25-year-olds came from Cypress Creek.

When submitting ECT reports, psychiatrists in Texas are supposed to include information on symptom severity and memory impairment before and after treatment. The assessments are made by the treating psychiatrists and include no information on how they are carried out or whether standard tests are used so are of limited use. One hospital, St Joseph Medical Center, submitted 25 reports. All their patients, according to the reports,  had severe – extreme symptoms before ECT and none at all after ECT. And all their patients had moderate to extreme memory impairment before ECT and none at after ECT. In previous years they have submitted similar reports – all patients symptom-free after ECT and with no memory loss, in spite of memory impairment before treatment, something that is difficult to believe.

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ECT in the Independent

On 4 December 2017 the Independent online published an article about electroconvulsive therapy (ECT) by Robyn Wilson: “Electroconvulsive therapy is still being used today”. While the title is true, the subtitle begins to mislead: “One of the most controversial treatments could be making a comeback in England, with the number of people seeking electroconvulsive therapy on the rise. But is it really worth the risk?”

The idea that ECT use is increasing comes from an article in the Guardian earlier this year. The Guardian journalists had used the Freedom of Information Act to ask a number of hospitals about their ECT use over the past few years and decided that there had been a slight increase in use, though hardly enough to start talking about a comeback. What is more, their findings are not in agreement with those of the Royal College of Psychiatrists or the Scottish ECT Accreditation Network. In any case, an increase in the use of ECT is not the same as “the number of people seeking electroconvulsive therapy on the rise” as about 40 per cent of people are treated without their consent, and even consenting patients may not have sought the treatment but merely accepted a psychiatrist’s prescription.

Unusually for an article about ECT, the author does not include quotes from psychiatrists or psychologists, which is not necessarily a bad thing. The “long read” consists of a various snippets about the history of ECT together with interviews with two young women who have had the treatment recently in the United Kingdom. If the author is trying to find a thread that ties it together, it is revealed in this sentence: “Previously an unmodified and gruelling procedure, ECT today is a far cry from the treatment it once was.” But this is a simplistic view: there are advantages and disadvantages to both forms of treatment, witness the famous legal case in 1957, or the length of time (decades) the two forms of treatment co-existed in the United Kingdom. It is easy to find, as the author has, an example of someone who died whilst undergoing unmodified treatment, that is, ECT without anaesthesia and muscle-paralysing drugs. But there is no mention of people who have died whilst undergoing modified treatment. Anaesthesia introduced a new set of risks: in his book The Story of a Mental Hospital: Fulbourn 1858-1983, psychiatrist David Clark wrote about how a woman died when undergoing modified ECT soon after it was introduced at the hospital. 

The article starts with some jaunty paragraphs about the invention of ECT in Italy (“The team braced themselves as the electrical current coursed through the man’s head.” and then jumps to the Fitzsimons Army Hospital outside Denver, United States, in 1959. Taken from Alan Stone’s 2010 memoir in Psychiatric Times the article relates how patients were give 20 to 25 treatments and describes this as taking misuse of ECT to “unthinkable levels”. But, ironically, one of the women featured in the article as having recently undergone ECT had 20 treatments – a high number but not exceptionally so. And the electric shocks used today are just as powerful, if not more so, as those used fifty or more years ago.

In England around the same time, things weren’t any better” says the article and at this stage I thought for a moment that the author was going to discuss experiments with intensive ECT in British hospitals, for example, those at the Three Counties Hospital in Stotfold, Bedfordshire. But no, instead the author has got confused between ECT and aversion therapy (where people are given much smaller painful shocks that do not cause convulsions) and starts talking about treatment of homosexuality:

“Each unnecessary session lasted around 30 minutes, with some participants even taking home portable electric shock boxes to use by themselves when aroused by members of the same sex, according to a BMJ medical research paper.”

Next comes a mention of Sylvia Plath and, inevitably, Ken Kesey and One Flew Over the Cuckoo’s Nest, as well as an account of a woman who died whilst undergoing unmodified ECT in Beaumont, Texas, United States, in 1967.

The final section of the article takes us to recent times and two young women who have had ECT. As women, they are in a group that is over-represented in ECT statistics; both in their twenties they are however in an age group that is under-represented, as ECT is more commonly given to older people. One woman, who had become depressed after a physical assault, described being given 20 treatments without her consent under the Mental Health Act, which means that she must have been assessed as lacking capacity to make a decision about treatment. She also described how ECT left her with memory loss for the three years preceding the treatment. “I feel detached from my former self, like a new person born again as an adult and thrown into a chaotic world.” The second woman had six treatments with her consent: “It takes me a little longer to process complex things but I wouldn’t say I’ve been robbed of anything.”

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ECT in the Scientific American

The Scientific American website has published (27 November 2017) an article about electroconvulsive therapy (ECT), “Neuroscience: Beyond the Cuckoo’s Nest: The Quest for Why Shock Therapy Can Work”, by R. Douglas Fields. The subtitle says: “Nearly 90 years old, electroconvulsive therapy can rescue some people, but not others, from depression, bipolar and other mental disorders.”

Can anyone at Scientific American do some simple arithmetic? If, as the article (correctly) says, electroconvulsive therapy was first used in April 1938 then it is nearly 80 years old, not 90.

The article that follows brings out all the tropes that characterize articles about ECT in the popular scientific press: One flew over the cuckoo’s nest, pigs and slaughterhouse, kinder and gentler, over 100,000 a year in the US…

Is ECT really used on over 100,000 people a year in the US? The article helpfully gives us a link to support their claim and the link takes us to an article published in the American Journal of Psychiatry in 1994. The title of the article is: “Use of ECT in the United States in 1975, 1980 and 1986.” The abstract to the article says that an estimated 37,000 people were given ECT in 1986 compared to 59,000 people in 1975. I don’t know how the author of the Scientific American article used those figures from thirty to forty years ago to arrive at an estimate of over 100,000 people currently being given ECT every year in the US.

There is mention of a recently published article from the Journal of ECT on state regulation of ECT: “Six states have no regulation at all on ECT, limiting who can administer or receive the treatment, who can provide consent, how it is practiced or administrative requirements on reporting.” Surely it is the other way round, with those states that have regulations putting limits on the practice, while in states without regulation it is a free-for-all.

Most articles of this type would talk about “small currents” but this author has tried something different, describing the electric shock as “pulses of high-voltage electricity”. The wave-form used in American ECT machines is brief-pulse, but coming at a rate of, typically, 70 a second you are not going to feel pulses but a continuous electric shock, just as with sine-wave current you don’t feel waves of electricity. What about high-voltage? ECT machines nowadays in the United States are “constant current”, leaving the voltage to vary automatically according to impedance. Specific voltages are not therefore included in electrical parameters, but the Thymatron machine for example has a maximum voltage of 450. There is, meanwhile, no generally accepted definition for “high-voltage”: Collins Dictionary says anything over 1,000 volts, while Oxford Dictionaries simply says “An electrical potential large enough to cause injury or damage”. So ECT would not qualify as high-voltage using one definition but possibly would using another.

The article focuses on Wendy Ingram, PhD, Psychiatric Epidemiology Postdoctoral Fellow at Johns Hopkins Bloomberg School of Public Health in the Mental Health Department, who, together with Sharon Larson, Stanley Poler and Fatin Nahi, is looking at the effect of using different anaesthetic agents on the outcome of ECT. Dr Ingram is understandably disappointed that the patient records (from Geisinger Health Center) are so poor that it is impossible to draw any useful conclusions from them. She describes how a cousin killed herself following ECT, but this doesn’t seem to have influenced her views of the treatment and its “tremendous therapeutic effects”.

The article predictably finishes with a call for less stigma, less regulation of ECT, the need to acknowledge mental illness as a biological disease, and more funding for research.

Posted in ECT in the media, ECT worldwide, Electrical parameters | 2 Comments