ECT in The Guardian

On Monday 17th April 2017 The Guardian newspaper ran an article about electroconvulsive therapy (ECT) under the heading: “Electroconvulsive therapy on the rise again in England: ECT stages comeback after years of decline, with thousands treated on NHS despite lack of scientific explanation for effects”. The text of the article contained the claim that ECT “is enjoying a revival”. But do the facts support these comeback and revival claims?

The authors of the article, Nicola Davis and Pamela Duncan, had sent a freedom of information request to mental health trusts asking about their use of ECT over the past few years and received a usable reply from 44 trusts

“Exclusive data covering four-fifths of NHS mental health trusts in England shows that more than 22,600 individual ECT treatments were carried out in 2015-16, a rise of 11% from four years ago, when about 20,400 were carried out. The number of patients treated also rose, albeit more modestly, to more than 2,200, suggesting that on average individuals undergo more ECT procedures than before. The figures, obtained through freedom of information requests, show that despite being a crude, controversial treatment, which fell sharply out of favour around the turn of the millennium, ECT is enjoying a revival…  After considerable fluctuation over the last four years, a comparison of figures from 2012-13 and 2015-16 reveals an 11% rise when it comes to the number of ECT treatments. Almost two-thirds of NHS trusts reported a rise in the number of ECT treatments carried out over the four-year period. The average number of ECT treatments per patient also rose, from 9.6 in 2012-13 to 10.1 four years later.”

The article did not contain any information about the use of ECT in the past, although information is readily available. Until 1991 the Department of Health collected and published reasonably accurate statistics on the use of electroconvulsive therapy in England. That year, there were about 16,000 courses of ECT, down from about 25,000 ten years earlier, but still more than five times higher than The Guardian’s figure, even allowing for missing fifth of trusts. The Department of Health later carried out two surveys of ECT use, in 1999 and 2002, by which time ECT use had further fallen to about 9,200 patients in 2002. And in 2009 the Royal College of Psychiatrists conducted a survey and concluded that between 5,100 and 6,720 people received ECT, still about twice as high as The Guardian’s figures. So, if ECT is making a comeback, it has quite a way to go, even to reach its level of eight years ago. It would have been more realistic to suggest that, after decades of declining use, ECT use may have levelled off.

A five per cent increase in the number of patients receiving ECT over four years probably is not large enough to be certain that ECT is making a comeback. (The other five per cent increase was accounted for by lengthening of courses by on average about half a treatment.) But are the figures provided by the trusts even accurate? The authors of the article say that two trusts “provided data that turned out to be completely incorrect, only providing accurate figures after multiple contacts”. Would they have recognised less startling errors? The authors don’t mention the fact that the Care Quality Commission keeps reasonably accurate track of the number of people being given ECT without their consent under the Mental Health Act. Comparison of the two sets of figures is a rough and ready way of seeing if the trusts’ figures are likely to be reasonable.

The authors comment on the difficulties of obtaining information:

“Three trusts refused the request outright, saying the staff time required to comply with the request was too great, while seven trusts could not even provide consistent data from 2012-13 onwards. Some trusts admitted they were missing data over periods of months in certain years.”

All trusts are supposed to record ECT use (code 83.8 for the first treatment and 83.9 for subsequent treatments in a course) and submit the data to the Health and Social Care Information Centre (HSCIC), so the information should be available at the click of a mouse, but it seems that some trusts don’t bother to submit data to HSCIC or do it incorrectly. The information the authors were looking for should have been available from the HSCIC website without the need to put in Freedom of Information requests, but, as long as trusts don’t submit accurate codes (or any at all) the HSCIC figures are not useful. As the authors conclude:

“This project may have revealed an increase in ECT use in England but it has also uncovered a lack of properly collected data relating to the procedure.”

Posted in ECT in the media, ECT in the UK | 3 Comments

ECT and ketamine: the published results

Two groups of psychiatrists in the United Kingdom have been carrying out studies on the use of ketamine during ECT, one group in Scotland and the other in England. I have featured the studies here, herehere, here and here.

Both teams have now published their results in psychiatric journals, the Scottish team in the British Journal of Psychiatry and the English team in Lancet Psychiatry.

The teams were investigating whether the use of ketamine as anaesthetic (Scotland) or added to anaesthetic (England) might make ECT work quicker and/or cause less cognitive damage. Both teams got the same results: no significant difference. The English team concluded: “The main finding of the Ketamine-ECT study is that there was no evidence of benefit in terms of cognitive and efficacy outcomes from using low-dose ketamine as an adjunctive anaesthetic agent for ECT, as currently administered in the UK.” And the Scottish team reached a similar conclusion.

The Scottish team recruited 40 ECT patients for their experiment. They were on average younger and more male than ECT patients in general in Scotland. All had bilateral ECT, as is the custom in Scotland. The team had a problem with “patient attrition”: only 26 patients were still there at the last follow-up one month after ECT. Reasons for withdrawal included having another course of ECT, having maintenance ECT, having fewer than four treatments, having a complication, taking a unprescribed drug or just deciding not to continue in the trial.

The English team, who were funded to the tune of over a million pounds, had a particular problem with recruitment. According to their original press release they were looking to recruit 160 ECT patients over a large area of the north of England. But, out of a total of 628 patients who were given ECT, they ended up with just 70 starting the trial and 37 still there for the final assessment four months after ECT. And to get even that 70 they had to change their protocol so that patients were only excluded if they had had previous ECT in the past three, rather than six, months.

“In total, 628 patients received ECT at 11 ECT suites based in seven NHS trusts in the north of England, of whom 31% were potentially eligible for the study (47% were ineligible because of detention under the MHA).”

A few detained patients consent to ECT. However most of those 47 per cent would have been treated without their consent, having been deemed incapable of making a decision. In England, ECT without consent is becoming nearly as common as ECT with consent.

“The remission rate at the end of treatment was 35% on saline and 39% on ketamine…” There were seven “serious adverse events”: two suicide attempts, two overdoses requiring hospital treatment, one case of “clinical deterioration” requiring admission to hospital, one case of chest pain requiring admission to hospital, and one case of a spontaneous seizure and status epilepticus between treatments. The authors show some reluctance to implicate ECT in any of these events. The suicide attempts “were deemed likely to be related to the underlying clinical illness, although a triggering effect of ECT cannot be excluded” and the spontaneous seizure “may be a rare adverse effect of ECT,157 but concomitant treatment of the patient with quetiapine is also likely to be a cause.”

Nearly 90 per cent ECT patients had bilateral treatment. The mean amount of electrical charge was 306 mC for the ketamine group and 276.5 mC for the control group.

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ECT and young people in China

China accounts for over one sixth of the world’s population, but it generally does not receive much attention in discussions on the use of electroconvulsive therapy (ECT). Such discussions generally centre on its use in Western countries, especially English-speaking ones, with only the occasional survey of its use in other places. These surveys generally show that in Asian countries ECT patients are more male, younger, and more likely to have a diagnosis of schizophrenia than ECT patients in Western countries.

An article published recently in the Journal of ECT (Qing-E Zhang et al. Common use of electroconvulsive therapy for Chinese adolescent psychiatric patients, Journal of ECT 2016 December; 32(4): 251-255) looked at the use of ECT on young patients (aged 13-17 years) at a Beijing hospital with 800 beds and a catchment area of 20 million. It can be read here

The retrospective study found that 406 young people under the age of 18 had been given ECT between 2007 and 2013. In 2013, 46 per cent of adolescents admitted to the hospital were treated with ECT. During the same period, a total of 12,608 patients at the hospital (54 per cent) were given ECT, suggesting that psychiatrists were slightly more cautious in their use of ECT on adolescents than on adults.

The most common diagnosis of the young people undergoing ECT was schizophrenia-spectrum disorders (over one third), followed by major depression, bipolar disorder and “others”. Almost all the ECT patients were prescribed anti-psychotic drugs, 70 per cent were prescribed benzodiazipines, 60 per cent mood stabilizers and 35 per cent antidepressants. Over 70 per cent were considered to be at “high risk” for aggression.

The hospital uses an American ECT machine and treatment is given in modified form, that is, with an anaesthetic (propofol) and a muscle-paralysing drug (succinylcholine). Unlike in Western countries, where ECT is usually given two or three times a week, the hospital give patients ECT five times in the first week and then three times a week. The authors say that adolescents are “usually receive fewer sessions than adult patients” but don’t give details.

The authors included, as well as Chinese psychiatrists, a psychiatrist working in Australia and two American psychiatrists, and the language of ECT is familiar – “safe”, “effective”, “treatment-resistant”, “therapeutic armamentarium”, etc. But, unusually, the use of ECT on adolescents at this particular hospital is described as “alarmingly” and “exceedingly” high. Reasons for this high use, the authors say, “should warrant urgent investigations”. The authors mentioned a survey in Australia which found that only 0.2 per cent of ECT patients were under the age of 18, whereas at the Beijing hospital under 18 year olds accounted for 3.2 per cent of ECT patients. Which is right and which is wrong? Can the differences be accounted for by the concept of “socioculturally distinct regions” mentioned by the authors?


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ECT without consent in England 2015/16

In November 2016 the Care Quality Commission (CQC) published their annual report on the monitoring of the Mental Health Act (MHA) in England. At the time of publication statistics on the use of the MHA were not yet available, but they were finally published at the end of November:

“The total number of detentions under The Act continued to rise, increasing by 9 per cent to 63,622 compared to 58,399 detentions in 2014/15”.

On page 18 of the CQC there is a diagram showing the increasing use of detention under the MHA from 2008/2009 to 2014/2015. In the first year detained patients accounted for fewer than 30 per cent of admissions (I think they are referring to admissions, although it is not absolutely clear). By 2014/15 they account for over half. And presumably that proportion has increased further with the latest statistics.

As far as ECT is concerned, patients treated without consent under the MHA continue to make up an increasing proportion of all ECT patients. The use of ECT on consenting patients is declining but its use on non-consenting patients (under current legislation that is restricted to patients who are deemed incapable of making decisions over treatment) is not showing a similar decline. In their previous annual report the CQC noted that the numbers of people being treated with ECT without their consent were actually rising.

“To explore possible reasons for this change, we will be looking more closely at our national data on ECT second opinions, for example to see whether there are regional differences and will discuss our findings with the Department of Health.”

Whatever the outcome of the discussion, they have not mentioned it in the 2015/2016 report.

The number of requests for authorisation of ECT on a non-consenting patients is almost exactly the same as last year – 1627 requests this year compared to 1631 last year. The report does not say in how many cases authorisation was not given; in 2014/2015 it was withheld in just under 5 per cent of requests.

The CQC also approved four psychosurgical operations, the same number as last year. (Psychosurgery can only be carried out with the consent of the patient and the approval of the CQC). Two of the operations were on people who had had a previous operation.

Posted in DBS and psychosurgery, ECT in the UK, ECT without consent | 2 Comments

ECT in Scotland, Texas and Queensland

There are few places in the world that collect and publish reasonably accurate statistics on the use of electroconvulsive therapy. Scotland and Texas, USA, publish annual reports on the use of ECT; Queensland, Australia, recently published some statistics in response to a freedom of information request.

In Scotland (population approximately 5.3 million), the latest annual report from the Scottish ECT Accreditation Network shows that, in 2015, 367 patients received 448 courses of ECT (a total of 4,166 treatments). This is a very small increase from 2014, but slightly below the 2013 figure. There has been an increase in the number of patients treated without their consent – 38 per cent, up from 35 in 2014. The number of people given ECT without their consent who were objecting or resisting but deemed to lack capacity rose from 53 in 2014 to 67 in 2015.

The gender gap for ECT patients in Scotland has narrowed slightly. In 2015, 62 per cent of patients were women, compared to 68 per cent in 2014. Only about ten per cent of ECT patients were under 40 years of age; the report refers to “adults” of all ages receiving ECT, so presumably no-one under the age of 18 received ECT.

In Texas (population approximately 27 million) the Department of State Health Services publishes annual statistics on the use of ECT although for 2015 I could only find the summary. The summary shows an increase of 7.5 per cent in reports from 2014. Almost all patients consent to treatment, with only 0.6 per cent treated without their consent.

About 70 per cent of patients are women. Nearly 45 per cent of patients are aged under 44, with four patients aged under 18.

Psychiatrists in Texas, are using ECT at a slightly higher rate than psychiatrists in Scotland, but the difference is not enormous. In Texas almost all patients consent to treatment; in Scotland over one-third are deemed to lack capacity and treated without their consent. ECT patients in Texas are, on average, younger than patients in Scotland.

In Queensland (population approximately 4.7 million) the Mental Health Commission recently published figures for ECT use in 2015 in response to a freedom of information request from a newspaper. These show that, in the year July 2014-June 2015, ECT was given to 1,543 “distinct patients”, including nine under the age of 18, who received 7,698 “episodes of care” totalling 19,365 treatments. Nearly one third of patients had an “involuntary legal status”. I am not sure exactly what an “episode of care” is, but it appears that Queensland, with a slightly smaller population than Scotland, is using over four times as much ECT.

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ECT in the Republic of Ireland: women, men, and misquoted statistics

In my last post I discussed the latest statistics on electroconvulsive (ECT) use in the Republic of Ireland, which can be found in a report by the Mental Health Commission. The report showed that two-thirds of those give ECT in the Republic of Ireland are women. There is nothing unusual, for most Western countries, about this statistic. But why? Why are women in these countries twice as likely to be given ECT than men are? It is not a question that bothers psychiatrists who use ECT; they tend to shrug it off with something about women being more likely to be depressed than men. For example, the annual reports on ECT use in Scotland say: “This reflects the relative higher prevalence of depressive illness in women compared with men”.

In the Irish report (in the summary and key findings) the authors say: “More females than males received treatment approximately two-third to one-third reflective of the relative incidence of depressive illness in women compared to men”. Unusually, the authors elaborate (in a footnote on page 17): “The percentage of females is reflective of a greater proportion of women (68%) admitted to approved centres with a primary diagnosis of depressive disorders in 2014 (HRB, 2015) and as highlighted in section 1.4 of this report, Depressive disorders are the most common diagnosis of those who are administered ECT.” (Most ECT patients are being treated for depression: 82% in 2014 and 73% in 2015. But a minority are being treated for other diagnoses, for example schizophrenia, where admissions for men outnumber those for women. The ECT report however did not include statistics on gender and diagnosis.) Let’s turn then to section 1.4:

“The Health Research Board reported that in 2014, depressive disorders were the most common diagnoses recorded, accounting for 27% of all admissions and the highest rates of all admissions (105.3). Schizophrenia accounted for 20% of all admissions and had the second-highest rate of all admissions (77.2). There was an equal proportion of male and female admissions, with rates being almost equal, at 388.7 per 100,000 for males and 387.1 for females. Females had a higher rate of admission for depressive disorders than males, at 9.1 per 100,000 for females and 6.3 for males (Daly and Walsh, 2015).”

Now, I can’t immediately see how these rates of admission for depressive disorders for men and women (6.3 and 9.1 per 100,000) become the 68 per cent women claimed by the report. (I make it nearer 59% women.) But at least the report tells us where the figures come from – Daly A, Walsh D (2015), HRB Statistics Series 26 Activities of Irish Psychiatric Units and Hospitals 2014. Health Research Board (Dublin).
So let’s turn to the original statistics.

Looking at the Daly and Walsh statistics, it becomes apparent what the authors of the ECT report have done. The earlier part of the above-quoted paragraph is correctly taken from Daly and Walsh’s statistics for admissions to psychiatric hospitals in Ireland in 2014. But the final sentence, referring to comparative rates of admission of men and women for depression is taken from a different section of Daly and Walsh’s report and refers to the inpatient census, that is, only to people in hospital on 31 December 2014. What they should have quoted is the total number of admissions for depression in 2014. That can be found in table 2.6a and shows that the rates, per 100,000 population, are 96 for men and 115 for women. There were, according to the same table, 2,176 admissions for men and 2,656 admissions for women. Women, therefore, accounted for about 55% of admissions for depression. Where then does the 68% claimed by the authors of the Mental Health Commission ECT report come from?

I searched the Daly and Walsh document for 68% and found (on pages 27 and 199) this sentence: “Females accounted for 68% of all admissions with a primary diagnosis of depressive disorders…”. But it is in the section of “Child and adolescent admissions” and refers only to patients aged under 18 and is therefore not relevant to ECT.

So, by misquoting statistics, the authors of the ECT report have tried to make it look as if ECT is not being given disproportionately to women. In fact, the figures show that, in Ireland, a woman who is admitted to hospital with a diagnosis of depression is more likely to be given ECT than a man. Psychiatrists should be asking themselves why.

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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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