Restrictive ECT use not warranted

[David Baxter PhD]

Restrictive ECT use 'not warranted'

Electroconvulsive therapy (ECT) improves mood, quality of life, and function in people with major depression, say US investigators who suggest that a restrictive attitude towards this therapy is unwarranted.

"Guidance on the use of ECT in the UK issued by the National Institute for Clinical Evidence recommended sharp restrictions on the use of this therapy until more information becomes available about its effects on memory, quality of life, and other pertinent health outcomes," explain W Vaughn McCall and colleagues from Wake Forest University Health Sciences in Winston-Salem, North Carolina.

To address this issue, the researchers measured changes in quality of life, function, mood, and cognition in 77 depressed patients before they received ECT and again 2 weeks and 4 weeks after completing treatment.

Overall, 66% of the patients responded to ECT, with improvement seen in every measure of mood, cognition, quality of life, and function at both the 2-week and 4-week assessments.

Interestingly, improvement in quality of life was related to mood, whereas improved ability to carry out activities of daily living was related to enhanced global cognition.

Comparing test results before and after ECT for patients who responded to treatment showed statistically significant differences on nine of the 10 psychological tests, the researchers note in the British Journal of Psychiatry.

The only decline was seen on the autobiographical memory test, but the researchers stress that this test is designed to show memory loss rather than improvement.

"The results are consistent with the premise that ECT produces a net improvement in health for most patients, and should help fill in the knowledge gap that led to the restrictive guidance on the use of ECT in the UK," say McCall and team.

Br J Psychiatry 2004; 185: 405-409

 

[jubjub]

Regarding this article, this scares me. Very much. Obviously these experts in the field do not have first hand knowledge of the inner turmoil that goes on when one is strapped to a gurney, watching gurney after gurney going into the shock room ahead of you. When it is your turn, being wheeled in, hooked up and zapped into oblivion. Waking up dazed and incoherent and traumatized. Looking around you and seeing a load of other people stretched out, attempting to recover their wits as well. Watching from your gurney as a crash cart comes wheeling into the room while they attempt to resusitate an old guy whose heart has stopped due to the shock. When you are allowed up, walking around like a zombie wondering what the heck just actually happened. I read this article and it brought back a whole slew of unpleasant memories for me.........I am almost crying. I hope no one has to go through this procedure because some experts think in "net" or "overall" terms that this treatment is beneficial.

 

[David Baxter PhD]

Note: jubjub and I discussed this issue via email before she posted her reply. I think the concerns she expresses well represent the other side of the debate referenced in the article and I'm sure echo many people's concerns about the procedure, especially anyone who has seen films like One Flew Over The Cuckoo's Nest, or anyone who, like jubjub underwent the procedure around the time she did (1968).

First, I want to emphasize that modern ECT procedures are not what they were 15-20 years ago or longer. Nontheless, I do understand that a lot of procedures that are beneficial can also be quite frightening, even a simple one like an injection, to certain patients. This is especially true when the patient is involuntary or otherwise being given the treatment without his or her consent.

I also want to emphasize that ECT is a "treatment of LAST choice", not first choice, used in cases of severe or intractable depression where nothing else has worked.

I have seen remarkable results in a couple of patients where honestly nothing else has worked -- for example, a young man who was actively suicidal and whose life was literally turned around with ECT.

It is certainly not without side-effects and it is also true that we still do not fully understand how or why it works (although there are some hypotheses about that). But I would note that severe suicidal depression is of course also not without significant risks.

I dont think articles like the one above are trying to promote casual or more frequent use of ECT in tyreating depression. Rather, I see them as a reaction to a movement which would see the treatment banned outright as an option for treatment. The authors are essentially saying that the option should not be denied to patients who require it, at least not until we have better treatments or a broader range of treatments for patients who are "treatment resistant" by today's standards.

To me, an appropriate analogy is radiation therapy and perhaps even certain types of chemotherapy in the treatment of cancer. Some of the side effects are quite severe but in a lot of cases they do achieve remission of symptoms and without the treatment most patients are facing a significant risk of death. In the future, I have no doubt that treatment for various cancers will become more refined and we will no longer need the broad systemic procedures currently in use. But until something better comes along, doctors should continue to have such procedures in the repertoire of available treatments.

 

[Bo]

I've just got to jump in on this one: I truly believe that rTMS is better. I'm about to post more info on my experiences with it.

I would like to add this, though. There's a lady at the clinic where I'm getting rTMS, and she's getting a double-treatement: left side of the brain for depression, then a half hour break while I'm being treated, and then the right side of the brain for anxiety. She's already had ECT, she's had a rough go of it. Apparantly, she is responding to the rTMS though. I'm hoping that I can sit down with her tomorrow and have an in-depth conversation with her, 'cause I'd love to hear her opinion of this treatment versus ECT.

Of course, I'm biased. Any "treatment" that contains the word "convulse" will always scare the heck out of me.

 

[David Baxter PhD]

Again, I would emphasize that ECT is and always should be "the treatment of last resort". Of course, in 1968, no one had even heard of SSRIs, SNRIs, or rTMS.

 

[ectsurvivor]

ECT use

I think it is unlikely that the NICE guidelines have restricted the use of ECT in the UK. Unfortunately, since the Department of Health doesn't collect reliable annual statistics on ECT use, it is impossible to say if the guidelines have had any effect its use (which has in any case been declining steadily for at least 30 years). They certainly have not led to a significant decrease in the use of ECT on non-consenting patients, for which statistics are available.

The guidelines recommend that ECT should be used as a short-term measure in the treatment of severe depression which hasn't responded to drugs or where it is potentially life-threatening. Terms such as "severe" and "potentially life-saving" are flexible and would probably cover any situation in which most psychiatrists would normally use ECT in the UK today. If fact psychiatrists have been saying for many years that they only use ECT in these circumstances anyway (and they have a long history of ignoring guidelines on ECT) so I don't know why they are complaining about "restrictions".

In spite of the fact that they claim only to use ECT for severe depression, the Royal College of Psychiatrists did appeal against the guidelines on the grounds that they thought theyshould recommend ECT for moderate depression as well. NICE agreed that the evidence base covered moderate as well as severe depression but refused to recommend it for moderate depression as they said there were still concerns about it's long-term effects and a lack of research which takes into account patients' views and quality of life.

Which is why they are waving this piece of research by the president of the American Association for ECT - even though it is short-term research and doesn't address the things which concern people who have had ECT.

 

[David Baxter PhD]

Thanks for your thoughtful comment on ECT, ectsurvivor.

I agree that, from my viewpoint, most of this is hype and scaremongering based on impressions of ECT use (both frequency and procedures) that are outdated. As you point out, use of ECT has been declining steadily since the 50s and 60s and, as I keep saying, it is a treatment of last resort when all else fails. I don't know of a single clinician anywhere who is recommending this be the starting point in the treatment of depression...

 

[Daniel E.]

From what I have read, rTMS may be no more effective than ECT since both rTMS and ECT work by creating seizure activity in the brain. Obviously, ECT is very effective at creating seizure activity, possibly more so than rTMS.

Regarding the earlier versions of ECT, I think the main problem was not using general anesthesia...or anesthesia of any type.

Personally, eight sessions of ECT did nothing for my depression, though I have heard that ECT can be more effective than antidepressants. The experience of having ECT was quite positive for me because the general anesthesia helped me be very calm after each session.

 

[ectsurvivor]

I was talking about the UK, where ECT use decreased from about 60,000 people a year in the early 70s to about 12-15,000 nowadays. I think in Canada the situation may not be the same, for example in Quebec between 1988 and 1995 ECT use nearly doubled.

Even with the decrease in the UK there is still wide variation in use between different psychiatrists, and a small number of people receiving ECT as treatment of first choice (a use which is endorsed by the NICE guidelines).

 

[David Baxter PhD]

It is not in common use in Canada.

 

[ectsurvivor]

It depends what you mean by common, and what part of Canada you live in.
It is certainly more common than it is in the UK. In fact per head of the population Canada is probably using it at about one and a half times the rate of the UK. I think there are probably about 10,000 people a year in Canada getting ECT if I have done the sums right.
As in the UK, there is great variation across the country, with Prince Edward Island using it at more than 10 times the rate of Newfoundland. Quebec is actually quite a low user, despite of increases in the 1990s. Other high users are New Brunswick and the one beginning with S I can't remember how to spell.
The statistics are available on http://www.aetmis.gouv.qc.ca

 

[David Baxter PhD]

Where specifically are those stats on the site?

 

[ectsurvivor]

Type electroconvulsive backgrounder into the search box and it should be the first title that comes up. It is called Electroconvulsive therapy in Quebec. Backgrounder - or something like that.

 

[David Baxter PhD]

Whenever one talks about rate per capita, you need to look at specifics of the region in question and also how the statistics are gathered and defined. What I see in the referenced statistics is wide apparently variations from province to province but also from year to year. The range (minimum to maximum) of these rates from 1994 to 2003 across regions is from 0.02% to 0.14%, which are pretty low. The fact that the rates seem to be a bit higher (though still very low) in less populated regions like Saskatchewan and PEI is explained partly by the following quote:

The figures in this table represent the number of hospitalizations during which ECT was used. For example, a same patient hospitalized on several occasions and having received ECT treatment each time is counted according to the number of his or her hospitalizations. In addition, ECT treatments administered in outpatient clinics (without hospitalization) are not counted. The fact that practices vary from region to region may explain the extremes noted in the less populous provinces, while such extremes are concealed into the average rates in more populous provinces.

 

[ectsurvivor]

Are we looking at the same statistics? I found larger variations, from 0.37% in Prince Edward Island 1995/6 to 0.016 in Newfoundland in 1999/2000.
It is interesting that the extremes are the two smallest provinces in terms of population, and I would agree with the explanation offered by the note. After all, variation comes down to individual hospitals and psychiatrists and presumably there are only a small number of hospitals on Prince Edward Island and in Newfoundland. There might, for example, in British Columbia (a more average user) be hospitals even more extreme but, if there are some of each, they balance each other out. As it says - I don't have a quarrel with that.
But I think the wide variations means that different psychiatrists have very different understandings of "last resort", if indeed they do claim to be using ECT as a treatment of last resort.

 

[David Baxter PhD]

Note the part that each ECT treatment, including multiple treatments for a single patient, are counted as separate instances... that's a bit misleading, it seems to me. If one person from a small province like PEI were to recieve 10 treatments, or 20, or 30, the per capita rate would spike -- the data may therefore be very misleading.

 

[ectsurvivor]

Those are definitely courses of treatment, not individual treatment sessions (there is a fuller explanation of the same statistics at www.aetmis.gouv.qc.ca/fr/publications/scientifiques/aetmis_x/2002_05_en.pdf).

As you say, someone who is admitted to hospital for a course of ECT more than once in the year will get counted more than once, so "courses" isn't exactly the same as "people". But outpatient ECT isn't counted at all which means that these figures may be an underestimate.
As for my calculation for the total number of people receiving ECT in Canada - it was wrong as I had given Ontario a population of 1.7 million rather than 11.7 million. In fact it should be about 14,000. By the way that is a very, very approximate figure (because of the problems with multiple admissions/outpatients etc). I'm just saying its 14,000 rather than 7,000 or 21,000.
Is 14,000 people a year a lot or a little, common or uncommon? It would certainly put Canada quite high in the international ECT use league table, although admittedly statistics aren't available for most countries.
A survey of hospitals in Quebec found that between 2% and 20% of their depressed inpatients were given ECT. I think that it's a good way of putting the figures into perspective - if you are treated for depression in one hospital you have a one if fifty chance of getting ECT (uncommon) whilst at another you have a one in five chance (not quite so uncommon).

My objection to the claim that ECT is only used as a last resort is that, while there is such large variation in use, you cannot describe ECT patients as a homogenous group; it is stigmatizing; it distracts attention from valid questions about ECT's safety; it is discouraging for those people who are not helped by ECT; and in any case simply isn't true (I don't know about Canada, but in the UK we have a resort beyond ECT - psychosurgery)

 

[David Baxter PhD]

Ectsurvivor, I've downloaded and skimmed all three available documents from the site you referenced. I haven't had time to go back and check all the data points you've mentioned but any way you look at it those stats tell me pretty clearly that well under 1% of people suffering from depression will ever receive ECT (and that includes the fact that those stats include multiple reatments for the same individual counted as separate instances -- that alone is a very suspect and rather lazy way of compiling statistics, enough to have it considered for rejection by most peer-reviewed scientific journals).

Is the rate higher for hospitalized patients? Given that today, with advances in treatment including a large variety of medications, the vast majority of depressed patients never see the inside of a hospital ward and are managed as outpatients, I can believe that those who are hospitalized may be more likely to be considered for ECT -- because they are more likely to have been non-responsive to other treatment approaches, which is why they are in hospital.

As for outpatient ECT, I cannot definitively say it doesn't happen. But I can say that in a professional career that is now approaching 30 years I have never seen a single case of this happening.

And finally, the issue of psychosurgery: Again, this may still be on the books, but psychosurgery for depression? I have never heard of a case of this happening. A century or two ago, there were few effective treatments for mental illness and also sorts of things, including 24/7 restraints and clumsy psychosurgery, were common because there were no other choices. But let's not fall into the trap of believing or even speculating that in 2004 anyone is even considering going back to standards and procedures from the 19th century.

 

[ectsurvivor]

I don't know if Canada still uses psychosurgery. But the UK certainly does, although there are fewer than 10 operations a year now (operations can only be done with the permission of the Mental Health Act Commission, so they are well-documented.) Most of the patients are depressed, although some are operated on for OCD or anxiety.
As for outpatient ECT - you may be surprised. In Quebec in 2001 28 per cent of ECT was given on an outpatient basis.

 

[David Baxter PhD]

Perhaps. As I said, those stats are misleading and difficult to interpret. But any way you slice it:

1. As I said above, "those stats tell me pretty clearly that well under 1% of people suffering from depression will ever receive ECT ", even assuming they aren't inaccurate
2. ECT is not, to my knowledge, a treatment of first choice anywhere in the world and hasn't been for many many years
3. ECT when it is used is used as a treatment of last resort for suicidal patients who are not responsive to other treatments
4. My conclusion: ECT is not being abused as a treatment, can be of significant benefit to a certain small percentage of patients who do not respond to other treatments, while not without side-effects is certainly far less dangerous than leaving suicidal patients untreated, and should not be taken away as a potential alternative treatment for the few patients who require it. [/list]