An audit of ECT in England 2011-2015: Usage, demographics, and adherence to guidelines and legislation

Geographic Variation in Receipt of Electroconvulsive Therapy Among US Department of Veterans Affairs Patients

OBJECTIVE

The aim of the study is to characterize geographic variation in electroconvulsive therapy (ECT) receipt across the United States (US) Veterans Administration (VA) healthcare system and explore potential explanatory variables.

BACKGROUND

ECT is a highly effective and rapidly acting treatment for multiple mental disorders. However, there may be geographic disparities in access to ECT across the US.

METHODS

We conducted a retrospective, cross-sectional study of all VA patients from 2003 to 2019 to describe rates of ECT within previously defined mental health referral regions (MHRRs). We investigated differences between the population that received ECT and other patients with a mental health condition severe enough to warrant inpatient hospitalization. We analyzed crude as well as age, sex, race, and ethnicity-adjusted ECT rates and explored potential explanatory variables. We compared MHRRs in the highest and lowest tertiles of ECT receipt.

RESULTS

The rate of ECT receipt among VA patients was 1.7 individuals per 10,000 (SD = 1.6) annually. Among 115 MHRRs, the rate ranged from a minimum of 0 (effectively no utilization in some areas) to a maximum of 8.9. Regression analysis revealed few significant explanatory variables.

CONCLUSIONS

There is significant geographic variation in ECT receipt among VA patients that is not well explained by population characteristics and may be indicative of suboptimal treatment for several mental health conditions.

An independent audit of electroconvulsive therapy patient information leaflets in Northern Ireland, Scotland and Wales

OBJECTIVES

To evaluate the accuracy of patient information leaflets about electroconvulsive therapy (ECT) used in Northern Ireland, Scotland and Wales, and their compliance with the principle of informed consent.

DESIGN AND METHODS

To replicate an audit in England, Freedom of Information Act requests were sent to the 26 providers of ECT for their ECT patient information leaflet. These were scored, by two independent raters, on the same 40-item accuracy measure used in the England audit.

RESULTS

The number of accurate statements (out of a possible 29) ranged from seven to 20, with a mean of 16.9. The most frequently omitted statements included: cardiovascular risks (mentioned by five leaflets), that it is not known how ECT works (3), risk of mortality (2), risks from multiple general anaesthetic procedures (2), how to access a legal advocate (2) and that that there is no evidence of long-term benefits (1). The leaflets made between six and nine inaccurate statements (out of 11) with a mean of 7.0. Nineteen minimised memory loss, blamed the memory loss on depression, claimed that ECT is the 'most effective treatment' and asserted it has very high response rates without mentioning similar placebo response rates. All 23 leaflets wrongly told patients that ECT saves lives.

CONCLUSIONS

Electroconvulsive therapy information leaflets in these three nations are barely more accurate than those in England and do not comply with the ethical principle of informed consent. Patients and families across the UK are systematically being misled about the risks they are taking and the limited nature of ECT's benefits.

Understanding healthcare services response to technology - assisted child sexual abuse: A freedom of information study

BACKGROUND

The reported rates of technology-assisted child sexual abuse (TA-CSA) have increased in the last decade. It is unclear how services are currently responding to cases of child sexual abuse that involve an online element.

OBJECTIVE

The aim of this study is to understand the current framework of support offered by National Health Service (NHS) UK Child and Adolescent Mental Health Services (CAMHS) and Sexual Assault Referral Centres (SARC) for cases involving TA-CSA. This includes understanding if a services' current assessment tools refer to TA-CSA, whether interventions address TA-CSA, and assessing what training for TA-CSA is offered to practitioners.

SETTING

Sixty-eight NHS Trusts with either an affiliated CAMHS or SARC.

METHOD

A Freedom of Information Act request was sent to NHS Trusts. Under this Act, the Trust had 20 working days to respond to the request, which included 6 questions.

RESULTS

86 % Trusts (42 CAMHS and 11 SARC) responded to the request. Of the responses, 54 % CAMHS and 55 % SARC offer relevant training to practitioners. 59 % CAMHS and 28 % SARC provide tools for their initial assessment that reference online life. No Trust provided a clear treatment approach for TA-CSA, with 35 % CAMHS and 36 % SARC responding that treatment would address the mental health needs of the young person.

CONCLUSIONS

There is a need for a nationwide understanding of how to clearly define TA-CSA in policies and how to approach TA-CSA during an initial assessment. Further, a consistent approach on how to equip practitioners with tools to support individuals who have experienced TA-CSA is urgently needed.

How Do People Perceive and Adapt to Any Consequences of Electro Convulsive Therapy on Their Daily Lives?

Great controversy surrounds the use of electroconvulsive therapy or ECT. However, it continues to be used internationally. While research on short term effects of ECT abound, there is limited knowledge about long term impacts of ECT on individuals, especially from the lived experience perspective. The aim of this qualitative study was to gain an in-depth understanding of longer-term lived experiences of ECT and how people navigate any impacts on their daily lives. Twenty-three people participated in semi-structured interviews. Data collection and analysis involved an iterative process. Data were coded into four categories: (1) My ECT experience included physical mechanics, decision making, clinic experiences, post ECT support and attitudes and support of others); (2) Direct impacts of ECT on me encompassed both cognitive and emotional impacts; (3) Impacts on my life comprised daily activities, relationships, ongoing health care; and My strategies incorporated fixing or working around the problem, reframing, using support networks, protecting myself and taking control. Insights gleaned through lived experiences have important implications for other service users, direct service providers and those striving for system reforms that embrace more recovery orientated and trauma informed practices.

Depression: why drugs and electricity are not the answer

The dominant view within mental health services and research suggests that feeling depressed is a kind of medical illness, partially caused by various biological deficits which are somehow corrected by physical interventions. This article critically appraises evidence for the effectiveness and value of antidepressant drugs and electroconvulsive therapy (ECT), the two principle physical treatments recommended for depression. It also describes the negative effects of these interventions and raises concerns about how they impact the brain. We propose an alternative understanding that recognises depression as an emotional and meaningful response to unwanted life events and circumstances. This perspective demands that we address the social conditions that make depression likely and suggests that a combination of politics and common sense needs to guide us in providing help for one another when we are suffering in this way. This alternative view is increasingly endorsed around the world, including by the United Nations, the World Health Organization and service users who have suffered negative consequences of physical treatments that modify brain functions in ways that are not well-understood.

What are the ethical dilemmas in the decision-making processes of nursing people given electroconvulsive therapy? A critical realist review of qualitative evidence

WHAT IS KNOWN ON THE SUBJECT?: ECT is a treatment which has a long and complicated history. There is no consensus on its effectiveness and there is a great deal of polarized debate as to whether it should be used. MHNs are asked to work with people who are receiving ECT as part of their duties. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper seeks to move beyond the polarized arguments and to consider how MHNs can work with people where ECT is being considered or administered as part of their treatment in a manner which satisfies their professional obligations. IMPLICATIONS FOR PRACTICE: MHNs may need to broaden their understanding of ethics beyond the traditional biomedical ethics model of beneficence, non-maleficence, justice and autonomy, as well as improving their understanding of social and political factors which may have an unseen effect of the use of ECT as a treatment in order to meet their professional obligations when working with people being administered ECT. ABSTRACT: INTRODUCTION Electroconvulsive therapy (ECT) has a complex and contentious place in psychiatric care. Mental health nurses (MHNs) are of obligated to be part of this practice despite ethical concerns. Aim To consider the ethical dilemmas and decision-making processes facing MHNs involved in the administration of ECT. Method A critical realist review of the literature surrounding ethical considerations and ECT was undertaken using thematic analysis. Findings Four key themes emerged: the MHN as an advocate and conflict in their role, issues surrounding consent, questionable efficacy and unknown method of action, side effects, and legal issues and clinical guidelines. Discussion Using a critical realist framework for understanding, the decision-making process and ethical considerations are viewed as part of the empirical and actual parts of reality, while the potential for other, unseen causal powers to be at play is acknowledged. Implications for practice MHNs need to ensure they have an adequate ethical underpinning to their practice to enable them to navigate contentious areas of practice such as ECT to practice effectively and preserve safety. This may require moving beyond the traditional biomedical model of ethics. Developing an appreciation of unseen causal factors is also an essential part of MHNs' developing professional competency.

A response to yet another defence of ECT in the absence of robust efficacy and safety evidence

It is estimated that electroconvulsive therapy is still administered to approximately a million people a year. It involves passing enough electric current through the human brain, eight to twelve times, to cause convulsions, in the hope of somehow alleviating emotional suffering, primarily depression. There have only ever been 11 placebo-controlled studies (where general anaesthesia is administered but the electric shock is withheld), all of which were pre-1986, had very small sample sizes and were seriously methodologically flawed. Five of these studies found no difference between the two groups at the end of treatment, four found ECT produced better outcomes for some patients, and two produced mixed results, including one where psychiatrists' ratings produced a difference, but the ratings of nurses and patients did not. In the 80 years since the first ECT no studies have found any evidence that ECT is better than placebo beyond the end of treatment. Nevertheless, all five meta-analyses relying on these studies have somehow concluded that ECT is more effective than placebo despite the studies' multiple failings. Meanwhile, evidence of persistent or permanent memory loss in 12% to 55% of patients has accumulated. Attempts to highlight this failure of ECT proponents to provide robust evidence that their treatment is effective and safe are routinely dismissed, diminished, denied and denounced. This paper responds to one such attempt, by Drs Meechan, Laws, Young, McLoughlin and Jauhar, to discredit two systematic reviews of the eleven pre-1986 studies, in 2010 and 2019, the latter of which also reviewed five meta-analyses that had ignored the studies' failings. The criticisms and claims of the recent crtiique of the two systematic reviews are examined in detail, by the first author of both reviews, for accuracy, relevance and logic. The critique is found to include multiple errors, misrepresentations, omissions, inconsistencies and logical flaws. It is concluded that Meechan et al. fail to make a fact-based, coherent argument against suspending ECT pending a series of large, carefully designed placebo-controlled studies to establish whether ECT does have any beneficial effects against which to weigh the significant established adverse effects.

A second independent audit of electroconvulsive therapy in England, 2019: Usage, demographics, consent, and adherence to guidelines and legislation

OBJECTIVES

To assess progress towards improving the administering of electroconvulsive therapy (ECT) in England since an audit covering 2011, 2013, and 2015. The same information was gathered, for 2019, on usage, demographics, consent, and adherence to national guidelines and the Mental Health Act.

DESIGN AND METHODS

Freedom of Information Act requests were sent to 56 National Health Service Trusts.

RESULTS

Thirty-seven trusts (66%) provided data. The gradual decline in the use of ECT in England has levelled off at about 2,500 people per year. There was a 47-fold difference between the Trusts with the highest and lowest rates per capita. Most recipients are still women (67%) and over 60 (58%). Only one Trust could report how many people received psychological therapy prior to ECT, as required by government (NICE) guidelines. More than a third of ECT (37%) is still given without consent, with 18% of Trusts non-compliant with legislation concerning second opinions. There were slight declines, compared to a previous audit, in the use of standardized depression scales, down to 30%, and standardized measures of cognitive dysfunction, down to 24%. Only six Trusts provided any data for positive outcomes and seven for adverse effects. None provided data on efficacy or adverse effects beyond the end of treatment. Twelve Trusts used identical sentences to each other, verbatim, in response to one or more questions.

CONCLUSIONS

Given the apparent failure of current monitoring and accrediting of ECT clinics in England, by the Royal College of Psychiatrists' ECT Accreditation Service (ECTAS), an independent government sponsored review is urgently needed.

PRACTITIONER POINTS

Psychologists and other mental health staff should ensure that people are offered evidence-based psychological treatments before being offered E.C.T. All staff should ensure that patients are fully informed of the high risk of memory loss and the smaller risk of cardiovascular failure and mortality. Individuals receiving ECT should be closely monitored for adverse cognitive effects, and treatment immediately terminated if these become apparent. Because of increased risk of memory loss for women and older people, the use of ECT should be kept to a minimum and avoided where possible, with these two groups.

On this month's Round the Corner: I welcome the argument about ECT

A recent review of research in electroconvulsive therapy (ECT) for depression, for which I was the first author, found that only 11 placebo-controlled studies have even been conducted, all pre-1986. Our review concluded that they were so flawed that the meta-analyses that relied on them were wrong to conclude that ECT is effective. This commentary responds to a critique of the review by Ian Anderson. Some valuable comments are acknowledged and several errors or misunderstandings rectified.

Psychological and Medico-Legal Perspectives on Electroconvulsive Therapy and Patient-Centered Care: A Short Review of Cross-Cutting Issues

Electroconvulsive therapy is a treatment that, since its first administration, has been a major topic for debate within the scientific world. In recent years, the debate has become increasingly focused on the short- and/or long-term efficacy of electroconvulsive therapy, its appropriateness in clinical settings, its mechanism of action, the impact evaluation of transient and/or persistent adverse effects, and the drafting of international guidelines,etc.

From the authors’ point of view, these themes are inevitably crossed by three other fundamental issues of significant psychological, relational, ethical, and medico-legal impact. Still, they are less studied than purely biomedical issues in recent times. Therefore, the aim of this article is to focus on the following cross-cutting issues: the therapist-patient relationship, the patient’s perspective, the attitude on electroconvulsive therapy, and informed consent.

This short review refers to the international literature on ECT published since 2000. Analyses of the three previously listed topics are, in part, made within the context of Italian medical settings.

Electroconvulsive Therapy for Depression: A Review of the Quality of ECT versus Sham ECT Trials and Meta-Analyses

Background

Electroconvulsive therapy (ECT) is still being administered to approximately a million people annually. There have been no ECT versus simulated ECT (SECT) studies since 1985. The five meta-analyses of ECT versus SECT studies all claim that ECT is more effective than SECT for its primary target, severe depression. This review assesses the quality of those meta-analyses and of the 11 studies on which they are based.

Methods

The meta-analyses were evaluated primarily in terms of whether they considered the quality of the studies they included, but also in terms of whether they addressed efficacy beyond end of treatment. The methodological rigor of the 11 studies included by one or more of the meta-analyses was assessed using a 24-point Quality scale developed for this review.

Results

The five meta-analyses include between 1 and 7 of the 11 studies. The meta-analyses pay little or no attention to the multiple limitations of the studies they include. The 11 studies have a mean Quality score of 12.3 out of 24. Eight scored 13 or less. Only four studies describe their processes of randomization and testing the blinding. None convincingly demonstrate that they are double-blind. Five selectively report their findings. Only four report any ratings by patients. None assess Quality of Life. The studies are small, involving an average of 37 people. Four of the 11 found ECT significantly superior to SECT at the end of treatment, five found no significant difference and two found mixed results (including one where the psychiatrists reported a difference but patients did not). Only two higher Quality studies report follow-up data, one produced a near-zero effect size (.065) in the direction of ECT, and the other a small effect size (.299) in favor of SECT.

Conclusions

The quality of most SECT–ECT studies is so poor that the meta-analyses were wrong to conclude anything about efficacy, either during or beyond the treatment period. There is no evidence that ECT is effective for its target demographic—older women, or its target diagnostic group—severely depressed people, or for suicidal people, people who have unsuccessfully tried other treatments first, involuntary patients, or children and adolescents. Given the high risk of permanent memory loss and the small mortality risk, this longstanding failure to determine whether or not ECT works means that its use should be immediately suspended until a series of well designed, randomized, placebo-controlled studies have investigated whether there really are any significant benefits against which the proven significant risks can be weighed.

Decision making and support available to individuals considering and undertaking electroconvulsive therapy (ECT): a qualitative, consumer-led study

BACKGROUND

Electroconvulsive therapy (ECT) is one of the most controversial treatments in psychiatry. This controversy and diverse and often strongly held opinions can make decision making processes around ECT more complex.

METHOD

This consumer-led project explored the experiences of individuals who had received ECT in terms of the information they received, their experience of ECT and suggestions for ways that decision making processes and experiences of ECT can be improved. Interviews were conducted by consumer researchers who had also received ECT and transcripts were analysed using constant comparative techniques.

RESULTS

Seventeen individuals participated. Four overarching categories were identified from participant interviews: Information matters; Preparation and decisions before ECT; Experience of ECT; and Suggestions for improvement. Most participants suggested that more information was required and that this information should be made available more regularly to support decision making. Additional suggestions included greater involvement of family and friends (including having a family member or friend present during the ECT procedure), opportunities to gain information from individuals who had received ECT and more support for managing memory and cognitive side effects.

CONCLUSION

This study provides valuable consumer-provided insights and recommendations for psychiatrists and mental health clinicians working within ECT clinics and with consumers considering or preparing for ECT.