ECT in the i

Last week was Mental Health Awareness Week and on Tuesday 8 May 2017 the i newspaper ran an article under a headline about debunking common mental health myths. I thought the headline was a bit misleading as the article was more of an opportunity for six psychiatrists to write about something that interested them, for example the president of the Royal College of Psychiatrists saying that more money should be spent on psychiatric research. But, anyway, the on-line version of the article, published the previous day, had featured an additional “myth” in the form of Raj Persaud writing about electroconvulsive therapy (ECT). I wonder why Raj Persaud’s piece had been left out of the print edition. Perhaps an editor recognised it as a particularly banal and cliche-ridden piece or perhaps there simply wasn’t enough room on the page.

Raj Persaud used to be a media psychiatrist but about ten years ago he ran into trouble with plagiarism and was suspended from the medical register for three months. Persaud’s piece starts, as so many newspaper pieces about ECT do, by saying that it is not like its portrayal in the film One Flew Over The Cuckoo’s Nest. Why should it be? That was a film, made about forty years ago, based on a book written in the 1960s. Even for that era the use of ECT (without anaesthetic, to control behaviour) shown in the film was unusual, though not unheard of.

Then there is a bit about a “mild electric charge” that leaves people feeling “a bit groggy” but with “minimal” side effects. At first sight Persaud appears to have turned to the Royal College of Psychiatrists’ information leaflet on ECT for inspiration. The Royal College leaflet for example talks about patients feeling “muzzy-headed” after ECT, and mentions a 1 in 10 figure in connection with memory loss. The Royal College leaflet says: “Memory problems can be a longer-term side effect. Surveys conducted by doctors and clinical staff usually find a low level of severe side-effects, maybe around 1 in 10.” Persaud though has changed the “severe” to “mild”: “There is risk of mild memory loss, which can happen in around one in 10 people.” If the risk-benefit balance begins to look precarious, just throw a few “milds” onto the risk side and “severes” (as in symptoms to be treated) onto the benefits side. True to this approach, as if he didn’t quite believe his own claims about the mildness of the electric charge and of the memory loss, Persaud launches into a stigmatizing description of an ECT patient:

“Patients for whom ECT is recommended can be catatonic. They are in grave danger of dying as a result of not being able to eat or drink. They might be experiencing crippling hallucinations and could be actively suicidal”.

Well, yes, they might be. But they might also be someone with moderate depression that has not gone away with drug treatment.

Persaud concludes by saying that ECT is used as “a last resort treatment” (although in fact it is used as a second-line treatment) and then, without apparent irony, says that there is a stigma attached to it.

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Geoffrey Knight and psychosurgery

The April 2016 edition of the Journal of Neurosurgery (official journal of the American Association of Neurological Surgeons since 1944) has published an article about British neurosurgeon Geoffrey Knight, who was one of the pioneers of psychosurgery in Britain. I was bemused. Why now? Psychosurgery has been largely abandoned in this country, although a few operations are still carried out every year. I don’t think any of them are of the type devised by Knight although I may be wrong (the Care Quality Commission, unlike its predecessor the Mental Health Act Commission publishes numbers but not details of operations). But a little searching reveals recent attempts to claim Knight as the patron saint of deep brain stimulation for psychiatric diagnoses because, presumably, with his particular operation, called a subcaudate tractotomy, he was destroying the same bits of brain as some deep brain stimulation (DBS) surgeons target.

The article is written by a team of five from the Department of Neurosurgery, Kings College Hospital, London. It starts off with a little about the history of psychosurgery, taken largely from an article published five years ago in the journal World Neurosurgery. A few lines about the Ministry of Health survey of psychosurgery in England and Wales 1942-1954 are copied almost word for word, including at least eight errors made by the previous authors, from the World Neurosurgery article.

There follow some biographical details of Knight, including a mention of his work on injuries during World War II, and then the authors relate how he set up a neurosurgical unit at the Brook Hospital, London, in 1950. Why no mention of his leucotomies at Runwell Hospital, Essex? During the war Knight had found time to experiment with psychosurgery on patients at Runwell Hospital, using the Freeman-Watts technique of frontal leucotomy. It was only in 1949 he adopted William Beecher Scoville’s technique of orbital undercutting.

Most of the article is about how Knight developed his technique of stereotactic subcaudate tractotomy at the Brook Hospital. As for his character, that is summed up by a quote from Paul Bridges, from his 1994 obituary of Knight: “greatly talented, innovative, confident, commanding, reassuring and quite unable to tolerate fools in any form.”  Bridges was for many years the psychiatrist at the Brook psychosurgery unit, although he overlapped only briefly, if at all, with Knight. After his retirement Bridges was struck off the medical register by the General Medical Council following his conviction for sexually assaulting two teenage boys.

The article, which had previously been published on-line, prompted a response from Erlick Pereira, rather inappropriately titled: “Stereotactic subcaudate tractotomy: Knight stood on 3 giants’ shoulders.” In fact, Knight and the three surgeons mentioned by Pereira, Hugh Cairns at Oxford who developed the cingulotomy, F. John Gillingham in Edinburgh, and Wylie McKissock in England, were, as Pereira points out, contemporaries with Knight. Pereira refers to McKissock as a “great man” and refers to the fact that he carried out thousands of leucotomies, but does not consider the impact he had on the lives of the people he operated on.

McKissock was not interested in developing techniques that would spare patients the worst effects of leucotomy. Even into the late 1950s he was still using the standard Freeman-Watts frontal leucotomy or his own variation of it, the rostral leucotomy. He used to drive round England, mostly the south but as far north as Northampton, and Wales, carrying out operations in mental hospitals and in institutions for people described in those days as mentally defective. It took him as little as 15 minutes to operate. According to the Ministry of Health survey, in the 1940s and early 1950s leucotomy had a four per cent mortality rate, and, according to a later survey by Maurice Partridge, 15 per cent of McKissock’s patients were left with epilepsy. To use McKissock’s own words, a few of his first fifty patients “subsided into a harmless vegetable existence” after surgery.

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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.”

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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.

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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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