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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ECT and ketamine: the Manchester study results

The Manchester ECT and ketamine study has featured several times on this blog (just type ketamine into the search box and the posts will appear). The study is funded to the tune of about a million pounds by the National Institute for Health Research (“We invest in excellence. Our funding goes to the best research studies that have been shaped by the leading academics and clinicians of the nation. Funding decisions, assessed on the basis of the importance of the research question, the quality of the science, and value for money, are made by independent, expert panels and committees and include patient and public representatives.”) The lead researcher is Ian Muir Anderson, professor of psychiatry at the University of Manchester. The stated aim of the study is to see if adding ketamine to the anaesthetic during ECT reduces the damaging cognitive effects of ECT and enhances the effects on symptoms of depression. This always seemed like a long shot as generally attempts to reduce the cognitive damage of ECT are accompanied by a reduction in effectiveness. Additionally, patients were to undergo brain scans and give DNA samples, and I have a suspicion that for the researchers this was the most interesting part of the study.
Some results of the study have recently emerged at the 29th Congress of the European College of Neuropsychopharmacology (ECNP). They can be seen here, on the FirstWord Pharma website.

Apparently the addition of ketamine to the anaesthetic did not significantly speed up clinical response or reduce adverse cognitive effects. On one test of cognitive function the patients who had been given ketamine did significantly worse than those who had not.

Posted in ECT in the UK, Techniques | 2 Comments

Lost in a sea of abbreviations

If you go to a doctor and say you feel depressed you might be diagnosed as having MDD (major depressive disorder) and prescribed an SSRI (selective serotonin reuptake inhibitor). If that doesn’t work there is ECT (electroconvulsive therapy), or VNS (vagal nerve stimulation) or DBS (deep brain stimulation), or TMS (transcranial magnetic stimulation), or NMD (neurosurgery for mental disorder). ECT might be UL (unilateral electrode placement) or, more commonly, BL (bilateral electrode placement). American psychologist Harold Sackeim has taken out a patent on something called FEAST (focal electrically-administered seizure therapy) and then in China there is a treatment for depression called FOREST (oops, no, that actually involves sending patients to stay at a site in a forest).

On the psychological front, there is CBT (cognitive behavioural therapy) or IPT (interpersonal therapy). And now there is BAT (behavioural activation therapy). Actually BAT has been around for a while but recently got some publicity when the University of Exeter put out a press release. For example, the i paper ran a headline in their health section on 23 July: “Getting out more ‘as good as therapy’ for depression”.

“A therapy which encourages people with depression to get out more and do something enjoyable is as effective as the much more expensive top-of-the-range treatment provided by doctors, says a new study.”

The article went on to explain that a new study led by Professor David Richards that “the NHS could make huge savings by adopting BA”, on the basis that it was 20 per cent cheaper than CBT. Apparently the study had found that BA therapy was as effective as CBT.

So what does this behavioural activation therapy consist of? The article explains:

“Patients undergoing Behavioural Activation (BA) therapy are encouraged to seek out ‘positive activities’ such as dancing, gardening, rambling, and going to the theatre. Pastimes such as reading or sewing could be equally important, researchers believe, as long as the patients enjoy them.”

All very well, but, I ask myself, who is going to pay for the theatre tickets? Or is there perhaps a poor-doors version of behavioural activation therapy? It doesn’t take long to find it. An article published in Advances in Psychiatric Treatment in 2007 (Behavioural activation for depression by David Veale) reveals a rather different version: “Goals should include a return to normal work and social roles as soon as possible” and the avoidance behaviours that have to be tackled include “watching rubbish on television” and “excessive exercise”. So you can ramble but don’t go too far.

All these abbreviations have made me wonder when electroconvulsive therapy acquired its name and common abbreviation. After all, Ugo Cerletti and Lucio Bini didn’t invent something called ECT. They invented something called elettroshock. Looking through some English-language articles from the 1940s and 1950s there seemed to be a tendency for American authors to talk about electric shock or electroshock treatment while British authors preferred electric convulsive or convulsion therapy or electroplexy. By the 1950s the abbreviation E.C.T. had become common in Britain, although article titles often expanded the abbreviation, for example an article in the Journal of Mental Science in 1958 had the title: “Electroplexy (E.C.T.) techniques in current use”. In the United States the term electroshock therapy, abbreviated to EST, remained popular, at least into the 1960s, although nowadays it is frowned upon by psychiatrists (except when they are talking about animal experiments) and the term electroconvulsive is preferred, even though, with the use of muscle paralysing drugs, patients no longer convulse whereas they are still given an electric shock.

I forgot TRD. If the drugs don’t work you might be diagnosed as having TRD (treatment resistant depression).

 

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The dark side of being a baby boomer

Three stories in the media in recent weeks have looked at how young people in the 1960s, 1970s and early 1980s experienced psychiatry.

On Saturday 30 July the Guardian newspaper featured a story, taken from the ITV series Long Lost Family about a woman who was re-united with her daughter after nearly fifty years. In 1967 Susan Webb gave her baby up for adoption, then became depressed and was given ECT. Susan said the ECT left her with memory loss so she had no recollection of the occasions on which she had been able to see her baby while she was in foster care for six months awaiting adoption.

 “Although a few photographs, taken by her mother, were a crucial solace that proved there had been an early bonding with her daughter, they were also a bitter reminder of how the ECT had robbed her of those memories. ‘I get so frustrated and angry that I can’t even recall feeding and changing her.’”

When Susan Webb had ECT in 1967 or 68 she was on one of probably about 50,000 people in the UK who underwent the treatment that year. That is about ten times the number of people who undergo it every year currently. Also, in those days, young people made up a much greater proportion of ECT patients. It is hard to explain these changes in scientific terms, and indeed psychiatrists don’t try to. Fifty years ago psychiatrists had anti-depressant and other drugs and various psychotherapies so it was not the case that there were no alternatives in those days. Some people claim that nowadays ECT is less likely to cause memory loss than it was in the past, but if that was the case why then have younger people become less and less likely to be given ECT than older people (at least in most Western countries)?

The variety of drugs at the disposal of psychiatrists in that era was highlighted by an item on the news on 13 July about the publication by the Diocese of Rochester of a report into Kendall House children’s home, Gravesend (Report of a review of Kendall House, Gravesend 1967-1986, prepared for the Church of England Dioceses of Rochester and Canterbury, S. Proctor, S. Cohen and R. Galloway, June 2016).

Originally Kendall House had been a mother and baby home for unmarried mothers but in 1967 its purpose was changed to a home for girls aged from 11 to 16 and the principal, Doris Law, was sent off to Birmingham to do a course in social work. The report explains why girls were sent to Kendall House:

“Girls who were placed there were aged between 11 and 16 years and often had serious behavioural or emotional problems. Many had been to a succession of children’s homes and had very troubled and difficult backgrounds…. Why were girls placed at Kendall House? A variety of reasons were identified. For some it was deemed a place of safety; others were on remand after committing offences such as theft, violent acts or for antisocial behaviour. Some had very troubled, fractured or violent family backgrounds; others had psychological or behavioural problems and were felt to be in need of a secure and structured home placement. Placements ranged from a matter of weeks to over four years.”

Some of the girls who were resident at Kendall House were prescribed psychotropic medication (major and minor tranquillisers, anti-depressants, etc.) often in high doses or PRN (‘to be given as needed’) with staff at the home deciding when to administer the drugs. The drugs were prescribed by a child and adolescent psychiatrist from Stone House Hospital, Dartford. Dr Marenthiran Perinpanayagam, who visited the home at weekly intervals, and also worked at a Borstal Institution. In 1977 the British Medical Journal published a letter from M.S. Perinpanayagam and Robin A. Haig, “Use of depot tranquillisers in disturbed adolescent girls”. The authors wrote:

“We have been treating girls in a secure home for disturbed adolescents with the intramuscular depot preparations fluphenazine decanoate [Modecate] and flupenthixol decanoate. Most of the girls admitted to this home have already been in care, all come from broken or severely disrupted homes, and all the girls have been uncontrollable in their previous situations. Many have been in conflict with the law. The environment of the home is extremely caring but with firmly defined limits of what is acceptable and what is not… Over the past year 10 of these girls who were extremely disturbed, violent, and aggressive and who were not influenced by tender, lover care or by psychological strategies were started on depot tranquillisers….The girls on this regimen benefited, their disturbed behavior subsided, they became more approachable in a psychotherapeutic framework, and were alert, co-operative, and psychologically more stable… We would be interested to hear of any other doctors’ experience in this field.”

The use of drugs at Kendall House attracted the attention of those, such as Professor Laurie Taylor, who were concerned about such use of psychotropic medication in children, and in 1980 the regime at Kendall House was criticised in the Daily Mail and in a TV programme. The home however weathered the storm: the Royal College of Psychiatrists issued a supportive statement:

‘Children may be acutely mentally disturbed with a variety of mental illnesses, some associated with brain disease. Their nursing may pose a serious problem, especially if there is violence or repeated running away. For the most part such problems are handled by competent nursing staff in sufficient numbers. However, it is sometimes fully justified to give tranquillisers and/or sedatives and other drugs.'( Quoted in Kendall House report, page 79)

Dr Perinpanayagam, who had qualified in medicine in Sri Lanka, died aged 60 in 1988. An obituary in the Psychiatric Bulletin described “his distinguished career in psychiatry” and how “his charisma gave hope to those in distress”. It mentioned the annual study days at Stone House Hospital for sixth formers from local schools, his interest in the welfare of overseas graduates and his love of music. “He will undoubtedly be remembered for his formidable energy, enthusiasm and compassion” it concluded. (Psychiatric Bulletin, 4 August 1989, page 462).

The recent report came about as a result of campaigning by a former resident who is concerned that women who as girls were given high doses of medication at Kendall House went on to have children with birth defects, but this particular concern was not something that was discussed in the report.

BBC Radio’s File on 4 on 19 July looked at the use of abreaction therapy on children and young people at Aston Hall Hospital, Derbyshire, in the 1960s and 1970s. Dr Kenneth O. Milner would interview child patients after they were given injections of sodium amytal, in the hope of uncovering traumatic incidences. The programme included an interview with Sir Michael Rutter, professor of child psychiatry, who had been practising in those days. He said that he hadn’t been aware of the use of abreaction therapy on children. Would he have done anything had he known, he was asked? To which he diplomatically replied that he would have been concerned. The programme left it at that, but it is difficult to imagine what if anything would have been done if Dr Milner’s work had been more widely known about at the time, even if people were concerned. There was a rule that doctors didn’t criticise other doctors and I can’t off-hand think of a single occasion when a psychiatrist, thanks to the actions of other psychiatrists, has had to abandon even the most outlandish practices. This was highlighted in the Kendall House report, when, following adverse publicity about the drug regime at the home in 1980, the Church of England committee responsible for its oversight gave the staff a vote of confidence. There was just one member of the committee who was not convinced; they wanted to discuss the matter with a psychiatrist of their acquaintance. They were reassured, as the committee minutes document:

(The member) having sought guidance from a local psychiatric doctor has now a clearer picture of the medical requirements of the girls and is confident that their present treatment is in the best interests of the girls”. (Quoted in Kendall House report, page 80)

 

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