Maintenance ECT in Victoria, Australia

In my last post I looked at the high use of electroconvulsive therapy (ECT) in Victoria, Australia, and in particular its high use on people without their consent. Last year an article published in the journal Epilepsia provided a glimpse of the use of ECT in Victoria. The article, “Temporal lobe epilepsy following maintenance electroconvulsive therapy – electrical kindling in the human brain“, by A. Bryson et al., looked at five people who developed temporal lobe epilepsy while they were undergoing maintenance ECT.

All five patients were described as having been referred for neurological assessment after experiencing “unusual events”: patient 1 had blank spells lasting up to 20 seconds; patient 2 had cognitive and memory problems; patient 3 lost awareness for 2 or 3 minutes; patient 4 had confusion and psychomotor slowing; patient 5 had a deterioration in cognition. I am actually quite surprised that such events would be picked up and be of enough concern to warrant a referral to a neurologist (after all, a lot of people experience cognitive and memory problems with ECT and they are generally not taken very seriously) and I am left wondering if perhaps the neurologists who wrote the article were actively recruiting ECT patients for their research.

Three of the four authors are affiliated to Austin Hospital, Melbourne, Victoria; the fourth to a Queensland Hospital. It is not clear whether all five patients were having ECT in Victoria, and no information is given about the time scale over which the referrals took place.

The patients (three men and two women) ranged in age from 31 to 81 and had had 873 electroconvulsive treatments between them. Four were having bilateral ECT, one had had a combination of bilateral and unilateral. All the patients were also taking drugs and were described as having a treatment-resistant disorder (schizophrenia, depression or schizo-affective disorder) but no information was given about how treatment resistance was defined.

Patient 1 for example was a 39-year-old woman with a diagnosis of schizophrenia who had been given 106 bilateral treatments over the past year. Now, in the UK, where treatment is usually given twice a week, that would represent a continuous course of ECT lasting over a year, rather than maintenance ECT. Even if, as the article says, she was sometimes having ECT three times a week, it still means that the maintenance treatments must have been very closely spaced. After neurological assessment revealed epileptiform abnormalities her treatments were reduced to once a week. The other four patients had their ECT stopped after neurological assessment. It was patient 5, a 59-year-old man who who had had the most ECT, 348 treatments over 7 years. His ECT was stopped after he had a generalised convulsion.

The authors of the article conclude: “These patients suggest that maintenance ECT is potentially hazardous”. The article did not look at how these people had come to have such large numbers of treatments, or how they fared (apart from their EEGs) after their treatment was stopped.

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ECT without consent in Victoria, Australia

The Supreme Court of Victoria, Australia, has today (14 August 2017) been hearing a case involving electroconvulsive therapy (ECT) brought by Victoria Legal Aid.  Two people who did not want ECT had the treatment ordered by the Mental Health Tribunal, and their appeals were rejected by the Victorian Civil and Administrative Tribunal. One of them has already had ECT and the other has not yet started treatment. Both have been given a diagnosis of schizophrenia. The case is explained by Victoria Legal Aid here.
The 2014 Mental Health Act established a system whereby Mental Health Tribunals consisting of a legal member, a psychiatrist and a community member, authorise the use of ECT on non-consenting patients as long as they are considered to lack capacity to make a decision and ECT is considered the least restrictive treatment available. In some ways it is similar to the system in England, Wales and Scotland, with a three-person tribunal replacing the one person (a psychiatrist) who authorises treatment. In most cases in Victoria the tribunal does indeed authorise treatment, although the proportion drops considerably when the patient has legal representation. According to Victoria Legal Aid: “In 2015-16, the tribunal conducted 707 ECT hearings. It made orders for ECT in 620 cases (88 per cent) and refused applications in 86 cases (12 per cent).”

The population of Victoria is about 5.8 million and 620 courses of ECT were given without consent. Scotland has a fairly similar sized population (about 5.3 million) and yet in 2015 there were 170 courses of ECT given without consent. And in Texas (population 28 million) 25 people were given ECT without their consent. In New Zealand (population 4.7 million) 71 people received ECT without their consent.  So why is Victoria using ECT without consent on so many more people than other places? 

ECT involves giving someone a powerful electric shock, using a current of about 800 milliamps. The Victoria state government tries to disguise this fact:

“ECT is a medical procedure in which a person’s brain is stimulated with a brief, controlled series of electrical pulses using electrodes placed at precise locations on the person’s head. This stimulus causes a seizure within the brain. ECT is always performed under general anaesthetic and with a muscle relaxant, which prevents the person from feeling any pain and prevents the person’s body from convulsing.”

Would, I wondered, Victoria Legal Aid be more accurate? Actually they manage to avoid mentioning the electric shock at all:

Electroconvulsive treatment is a medical procedure to induce a seizure within the brain, aimed at reducing some of the symptoms of mental illness. It is performed under general anaesthetic.”

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ECTAS survey 2016/17

Earlier this month (July 2017) the Royal College of Psychiatrists published the results of a survey of electroconvulsive therapy (ECT) use in 71 clinics in England, Wales, Northern Ireland and the Irish Republic.

They found that two thirds of the people undergoing a course of ECT were women. That proportion rose to almost three-quarters for people having maintenance ECT. The mean age of ECT patients was 61 for those having a course of treatment and 66 for those having maintenance treatment.

Over 40 per cent of those having a course of ECT were treated without their consent, after their psychiatrist had decided they lacked the capacity to make a decision. Nearly one in five of those having maintenance ECT were not consenting.

Nearly ninety per cent of people having a course of ECT had a diagnosis of depression, split fairly equally between severe and moderate. The mean number of treatments per course was 9.8, with 12 treatments being by far the most common number in a course. In about 100 courses, out of the 1821 in the survey, the patient had fewer than four treatments, whilst at the other end of the scale about 50 courses consisted of twenty or more treatments. Courses of even numbers were far more common than courses of odd numbers, presumably something to do with the way ECT clinics are run.

The 71 clinics in the survey were clinics who belong to ECTAS (ECT Accreditation Service) and chose to take part in the survey. By extrapolating from the participating English clinics the authors of the survey came up with a figure of 2135 courses for England in 2016/17, a decline from previous years.

These estimates of the total number of ECT courses for England do not tally however with figures from the Care Quality Commission on requests to use ECT on detained patients without their consent. For example, in 2014/15 the Care Quality Commission authorised the use of ECT without consent on 1554 occasions. Yet for that year the estimate of the Royal College for the total number of courses was 2302, of which about 40 per cent or 900 would have been detained, non-consenting patients who required Care Quality Commission authorisation. There is a big difference between 900 and 1554.

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ECT: back to the fifties

A recent episode of the popular TV series, Call the Midwife, set in the late 1950s to early 1960s, included a story-line about Sister Cynthia, a young midwife and nun, who became depressed after being attacked when out at night, and was given ECT (electroconvulsive therapy) in a mental hospital. I have never actually watched Call the Midwife so I don’t know if the programme showed Cynthia having ECT and, if so, whether or not it was an realistic portrayal. Showing ECT being used either modified (with anaesthesia and muscle paralysing drugs) or unmodified would have been accurate as both forms were in use in British mental hospitals in the 1950s.

Call the Midwife is created by screenwriter Heidi Thomas, and her husband, Stephen McGann (one of the four acting McGann brothers), plays the role of Dr Turner. Stephen McGann’s autobiography has recently been serialised in the Daily Mail.  Mcgann described how his mother, less than a year after her marriage, gave birth to premature twins, one stillborn and the other surviving only minutes. Afterwards she became depressed.

“By that September, my mother could take no more. She went to see her doctor for a routine visit and burst into tears. Once started, the tears wouldn’t stop. Referred to a psychiatrist, Mum was told that she was severely depressed and would need to have electric shock therapy if she didn’t improve within three months.”

But before the three months were up, Clare was pregnant again, so did not undergo ECT. This was in 1957 and Clare McGann’s experience was not unusual. The novelist Catherine Cookson for example wrote about undergoing ECT in a hospital near Hereford in the 1940s after she had had a miscarriage. And TV presenter Bill Oddie’s mother Lilian, who lost two babies before Bill’s birth in 1941, spent nine years in a mental hospital and was treated with ECT. Featuring in an episode of Who do you think you are, Oddie recalled how his mother didn’t recognise him when he visited her as a child.

Clare McGann went on to have four sons and a daughter, but her marriage was not a happy one and the couple divorced, although they would later live together again. Her husband had been wounded in the D-Day landings and had been diagnosed as having an “anxiety neurosis”, something he was deeply ashamed of. Joe McGann was not alone: during World War II the largest single category of discharge from the UK and the US Armies on medical grounds was “psychiatric”. In the UK Army it was 30.5 per cent of medical discharges, ahead of musculo-skeletal, which included the majority of battle casualties, on 23 per cent.* And there were others, who although not discharged on medical grounds, were diagnosed with anxiety neurosis after the war. One such was the writer and broadcaster Ludovic Kennedy, who was a naval officer during the war. In his autobiography On my way to the club (1989) he wrote about how he made hundreds of visits to psychiatrists over a twenty-five year period before he finally became free from his symptoms and was left wondering if the time and money he had spent on psychiatrists were worth it or if he would have simply “outlived the neurosis anyway”. At one time he underwent ECT, which left him feeling “refreshed and invigorated” for about a week or ten days before his symptoms returned.

* R.H. Ahrenfeldt, 1958, Psychiatry in the British Army in the Second World War, page 279.

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ECT without consent in England: the highest users

Non-consenting patients make up an increasing proportion of people treated with electroconvulsive therapy (ECT) in England. Most, though not all, of the people given ECT without their consent are treated under section 58A of the Mental Health Act. The patient has to be assessed as lacking capacity to make a decision about treatment, and the treatment approved by a psychiatrist from the Care Quality Commission panel.

Last year (April 2016/March 2017) the Care Quality Commission received 2,261 requests for a visit from one of their psychiatrists to approve the use of ECT on a patient who was not consenting to treatment. The number of requests does not equate to the number of people treated without their consent: some requests may be cancelled, sometimes (very rarely) the psychiatrist does not authorise ECT, and more than one request may be made for the same person during the year; on the other hand there are other ways to treat people without their consent, for example, under section 62 of the Mental Health Act or under the provisions of common law.

In 2016/17 two NHS trusts in England made more than 100 requests for a visit from a Care Quality Commission psychiatrist to approve the use of ECT without consent under section 58. They were Avon and Wiltshire Mental Health Partnership NHS Trust (116 requests) and Southern Health NHS Foundation Trust (106 requests).

Avon and Wiltshire Mental Health Partnership NHS Trust treated 143 people with ECT in 2016/17, of whom nearly half (68) lacked capacity to consent. Southern Health NHS Foundation Trust meanwhile treated 176 people with ECT and were not able to say how many had not consented to treatment.

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The Royal College ECT lecture: don’t mention its history!

The Royal College of Psychiatrists has created a template for a lecture on ECT. The lecture is designed to be given to a target audience which would include “Trust Boards, Clinical Commissioners, medical psychiatric trainees and associated health professionals new to psychiatry, general hospital staff, general practitioners, medical students, patients and interested public groups.” Its stated aim is to both educate and promote ECT. (Are education and promotion necessarily compatible?) Lecturers are told not to mention the history the ECT as it might engender “a negative mind-set in the audience”.

Turning to the template, the lecture starts off with lists of symptoms of depression (evidently, as well as ignoring history it is also going to ignore the use of ECT in conditions other than depression, or, indeed, its use as a treatment for moderate as well as severe depression) and with an attempt, with the help of lots of bright colours, to convince the audience that it is all down to malfunctioning circuits in the brain. Having set the scene and hopefully engendered a positive mind-set in the audience, ECT itself is introduced and lecturers are told to play a few minutes from a BBC video. Then there are a couple of diagrams which show lines going in the direction of improved following ECT. One of the diagrams, confusingly, is from an American study comparing right unilateral, bitemporal and bifrontal electrode placement. In the UK nearly all ECT is given with bitemporal (that is, bilateral, electrode placement). A little further on there is a discussion of this article, although it is of little relevance to British practice. Perhaps the idea is to convey the impression that interesting research is being done. Meanwhile the audience has been given a list of mechanisms of action of ECT (normalisation of ventro-lateral PFC, reduction of CBF and CMR in PFC, etc.) all very scientific sounding.

There follows, under ECT procedure, another list: diagnosis, consent, etc., work up, anaesthetic, treatment, recovery and review. Is the lecturer given free rein here? Are they supposed to mention the fact that about forty per cent of ECT patients in England are treated under the Mental Health Act without their consent because they are deemed to lack capacity? Or is that, along with history, another unmentionable? After a picture of an ECT machine and an EEG recording, comes a section on risks/adverse effects of ECT. When it comes to long-term risks, lecturers are prompted with: “Long term, ?Auto-Biographical ?? None. Other causes (depr, meds, organic brain dis.)” The lecture ends with a plug for TMS (transcranial magnetic stimulation).

I find it slightly worrying that psychiatrists can’t be trusted to compose their own lectures. Hopefully when they deliver their lecture they will at least tell their audience that it is based on a template by the Royal College ECT Committee. And what is that quote about those who ignore history…?

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ECT given to young child(ren) in England

In England the NHS publishes statistics on the use of electroconvulsive therapy (ECT). Unfortunately, because many hospitals do not report their use of ECT, the statistics only pick up a fraction of ECT used, probably about a fifth to a quarter.

The statistics for April 2015 to March 2016 show that ECT was given to at least one child in the age range 5 to 9 years. This is unusual for England, where recently published accounts of the use of ECT on young people have revealed small numbers of children over the age of 12 receiving treatment, but not children as young as 5 to 9. The NHS statistics for the two previous years show ECT was used on at least one child aged 10 to 14 each year.

Next Saturday BBC World  News is broadcasting a programme about the use of ECT in the United States on children diagnosed as autistic.

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