I know that by the time we’re considering ECT, we are barely able to make it through the day, but I think it’s better to ask and know upfront what turns your life could take post-ECT rather than be surprised by something that’s already been documented that it might happen.
If you experience any physical discomfort after ECT, such as a really bad headache or a sore throat/jaw pain, you should let your doctor know. S/he may be able to adjust your mouth guard or give you something for the pain.
Compared to 1999 and 2002 data from a recent survey in 2006 show an overall decline in the number of ECT applications and the number of patients treated in the United Kingdom over the 7-year period between 1999 and 2006. An increasing proportion of patients were treated under the Mental Health Act (1983).
The number of ECT clinics is likely to continue to decrease and psychiatrists may have decreasing experience of treating patients with ECT.
In The Netherlands there is an opposing trend. In the past decades the number of clinics preforming ECT has increased and the number of patients being treated also increased, but than the state of ECT was deplorable in the eighties of the previous century. In 1992 only 30 patients in 1 year were treated with ECT on a population of 13 million people. In 2000 it were around 300 patients a year. The restricted use of ECT in The Netherlands in those day was due to socio-political factors such as unfavourable public perception and professional attitude.
From a recent survey in The Netherlands (Journal of ECT, published ahead of print) (2008) of all Dutch facilities with mental health beds in 2008, all 8 university hospitals (100 %), 16 of 86 (19 %) general hospitals and 11 of 48 (23 %) psychiatric hospitals had an ECT service. The total amount of ECT sessions in the Netherlands was approximately 13,500 a year (8.5 sessions per 10,000 inhabitants). This is low compared with e.g. the 14 treatments per 10,000 in Scotland and the approximately 27 per 10,000 in the USA. However, use of ECT in the Netherlands has increased substantially since 1999, at which time it was only 1.8 per 10,000 inhabitants
For comparison in Belgium a recent nationwide survey among all the psychiatric services providing ECT revealed that in 2003-2004 ECT was performed in 32 psychiatric services (21.5% of all psychiatric services). ECT is available in 13.6% of psychiatric hospitals and 32.8% of general hospitals with a psychiatric department, but two thirds of these ECT facilities treat less than 2 patients per month. The annual rate of ECT use in Belgium is increasing. In 2000, the ECT rate was 4.8/10,000 inhabitants. By 2006 it had increased to 6.6/10,000 inhabitants. For more information from one of the experts of ECT in Belgium please see the blog: Electroconvulsive therapy
According to the University of Munich, the renaissance of ECT in Germany is still ongoing; from 1995 to 2002 the number of treatments in that hospital more than doubled. From personal communications we learned that in Portugal, in the past few years, a total of 6 ECT-units became active, 3 of which are situated in the Lisbon area (Lisbon, Amadora). These units performed a total of 500-1200 treatment sessions in 2007. This corresponds to an ECT-rate of 0.5-1.2/10.000 inhabitants. Data on the use of ECT in France and Spain are scarce or very limited.
EFFECT aims to promote access to safe and effective ECT when appropriate for patients across Europe by promoting research into ECT, combating the stigma associated with ECT, educating and informing both mental health professionals and the general public about ECT and its use.
This seems to benefit the deplorable state of the use of ECT in some European countries. Now back to the UK. The authors of this publication of the survey stated the following reasons for the decline:
The National Institute for Health and Clinical Excellence (NICE) has recommended restricting its use to severe depression, catatonia or severe mania when other treatments have failed
Electroconvulsive therapy is under a process of centralisation and rationalisation, which may reflect the lower numbers of patients treated and a need to concentrate resources and local expertise in driving up standards
Availability of a greater variety of safe alternative antidepressants
A reduction in in-patient bed numbers
Probably the amount of patients treated in the UK and the rest of Europe will meet somewhere in between. In the UK, ECT used to be frequently used, in the rest of Europe ECT was underutilized until recent. What do you think?
D. Bickerton, A. Worrall, R. Chaplin (2009). Trends in the administration of electroconvulsive therapy in England Psychiatric Bulletin, 33 (2), 61-63 DOI: 10.1192/pb.bp.107.019273
T. C. Baghai, A. Marcuse, H.-J. Möller, R. Rupprecht (2005). Elektrokonvulsionstherapie an der Klinik für Psychiatrie und Psychotherapie der Universität München Der Nervenarzt, 76 (5), 597-612 DOI: 10.1007/s00115-004-1813-5
P SIENAERT, M DIERICK, G DEGRAEVE, J PEUSKENS (2006). Electroconvulsive therapy in Belgium: A nationwide survey on the practice of electroconvulsive therapy Journal of Affective Disorders, 90 (1), 67-71 DOI: 10.1016/j.jad.2005.09.016
On psychiatrictimes.com Prof Max Fink discusses the 2 most important articles on continuation therapy after ECT for depression. ECT is very effective in the treatment of depression even if several antidepressants have failed. He discusses a large, government-supported, collaborative study led by the Columbia University Consortium (CUC), patients with unipolar major depression that had failed to respond to multiple trials of medications were treated with ECT to clinical remission and then randomly assigned to one of three continuation treatments: placebo, nortriptyline alone, or the combination of nortriptyline and lithium.
The other important trials is the multi site Consortium for Research in ECT (CORE) collaborative study that used the same populations with the same inclusion and exclusion criteria, evaluations, and time periods as the CUC study. After remission, the patients were randomly assigned to continuation treatment with the same combination of lithium and nortriptyline or with ECT.
Relapse The six-month relapse rates for the two treatments were not statistically different from that of the lithium and nortriptyline combination in the CUC study
His conclusions: 1. Efficacy: ECT was effective in both studies. ECT compared favorably with the STAR*D study of patients with nonpsychotic major depression.
2. Psychotic Depression: 95% of the patients who had psychosis and depression remitted compared with 83% of patients who had nonpsychotic depression.
3. Suicide: In the CORE study, 29.5% of the patients expressed suicidal thoughts or reported suicidal acts at baseline. The HAM-D scores for suicidal intent were reduced to zero in 38% of the patients after one week of treatment, in 61% after two weeks, and in 81% at the end of the course. These findings are supported by comparable CUC data.
4. Prior treatment: In the CORE study, the adequacy of prior treatment bore no relation to treatment efficacy, a finding that is confirmed in other studies.
5. Elderly: older patients with depression exhibit better clinical outcomes than younger patients when treated using ECT
6. Relapse rates after successful ECT are reduced by either the combination of lithium and nortriptyline or by continuation ECT.
7. Continuation therapy: the combination of lithium and nortriptyline, both monitored with serum blood levels, is the preferred medication when continuation ECT is not available or is refused.
8. Electrode placement: bilateral electrode placement and half-age dosing estimates, monitored by EEG adequacy, ensures greater efficacy for the first treatment and overall with fewer treatments
Leon Rosenberg, a former dean of medicine at Yale University, had just attempted suicide by overdose. He was admitted to hospital and prescribed electroconvulsive therapy, or ECT.
This is the start of an excellent article by Michael Evans an associate professor at the University of Toronto and staff physician at Toronto Western Hospital. This article also discusses some other myths, for instance about depression:
Those on the outside still see it as not really a disease but a weakness. Those on the inside see it as a chronic disease like any other, but with a twist.
Or this one about suicide, one of the complications of depression:
“Heart attack victims are consoled (‘Isn’t it a pity?’); suicide victims are cursed (‘How could he?’).”
We discount a therapy that has proven effectiveness because of its image, yet every day embrace unproven therapies that have benefited from a public-relations makeover.
To my opinion the most nuanced view on side-effects of ECT:
Memory loss seems the side effect of most concern to patients. With current ECT, it is usually transient, but any unauthorized withdrawal from the memory bank is a travesty. The medical community has occasionally shown insensitivity to this, but researchers are now attempting to better delineate the cause and effect.
On this site a clear and concise description of indications for electroshock (ECT) are given by NICE. NICE produces guidance in clinical practice. The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health in the United Kingdom. This information on electroconvulsive therapy is provided for use by the public and provides an explanation of the guidance. NICE was asked to look at the available evidence on electroconvulsive therapy and to provide guidance that will help the NHS in England and Wales decide when it should be used. This resulted in a nice pdf file with that information.
This blog about depression and it’s treatment especially with ECT is in the air for a while. I hope a lot of readers benefit from these scribbles. The truth be told, I learn a lot from writing these articles. Mostly I gather a lot of information for my work as a psychiatrist which end somewhere in a drawer or the “round archive” without being read at all. Since writing this blog I actually read them and when appropriate post the information on my blog. Surfing on the net nowadays is always accompanied by the question: Is this information relevant, blogable? Now I take the privilege today to look back on my posts and make a round up of the most important sites with information about ECT relevant for interested readers in this subject, hope you like it.
1. About ECT for bipolar disorder from healthyplace.com, also more general information about ECT, the procedure, side effects.
2. Take it easy on ECT. Opinion of a patient treated with ECT about the side effects and the discussions about this topic in the media.