Thursday, 7 February 2008

ECT

On talking of ECT treatment, Mandy asked about use of ECT in the elderly, specifically with regards to side effects.

I'm not particularly pro or anti ECT, any more than I'm pro or anti tablets or pro or anti psychological therapies. Any intervention has potential benefits, risks and side effects. The issue is simply one of offering a choice of the right therapies for the right problem at the right time.

If you had free choice of treatment, rather than the NHS where you can only choose from what's offered to you, what do informed patients choose? The USA shows us this. In America, where patients have informed consent (i.e. are told all the risks and benefits of all options) and through private health care can pay for the treatment of their choice (or go see another shrink who'll take their cash and do it for them), how much ECT is used? Answer : twice as much as in the UK.
The latest DoH data suggests we're undertaking about 4266 sessions of ECT a month in the UK, about 140 a day. From their stats, most (84%) is undertaken with consent.

Why do Americans prefer ECT when given a free choice? Because in a few situations it's a safer and better treatment than alternatives. Bottom line : people can get better much quicker, with fewer side effects than other treatments.

That sounds great, so why's it not used more? Because it's only a few situations where it's the treatment of choice. Severe mood disorders, rare subtypes of schizophrenia and post natal depression are pretty much the only good reasons. Most people with depression don't benefit from ECT, it's only severe depression and depression with marked physical symptoms (the "somatic syndrome" bit) that responds well to ECT.

How is ECT given? You lie down, you have an anaesthetic injection, you go to sleep for about 2 minutes. In that time two handles are put on your head, a charge is delivered and you have a fit. Fit is over stating things. The anaesthetic stops you having a fit, in modern ECT. 5 years ago I timed ECT by watching how long someone fitted for. Nowadays I see nothing as we don't physically move, being anaesthetised and relaxed. Now we look at EEG (brain wave monitoring) to monitor the seizure since the person's relaxed, but typically it lasts 25 seconds or so. A minute later you come round, have a cup of tea and a biscuit and all's done.

Risks? It's been shown to half the incidence of death, compared to tablet/talking therapy treatment. So tablets/talk is twice as risky as ECT for severely depressed folk. Safer than other alternatives, then.

What of long term risks to mind and memory? Some people have no change at all, so have their ECT, are right as rain and go home (having out-patient ECT). Most people are more confused after ECT, for a short while. Some papers show no change to memory over the long term (i.e. after 12 months, memory's the same as before ECT). This paper also confirmed that older patients regained their memory better than younger patients, ECT is often better tolerated and more useful in older adults. Imporantly, everyday memory isn't changed.

This all sounds rather positive. Doesn't ECT cause permanent memory change? Tricky. Maybe yes, maybe no, if it does so it's a rare event (which trials haven't been able to tease out). The problem is that being severely depressed affects our memory, long term. So you can see memory and cognitive changes in folk with severe depression whether they do or don't have ECT. Because depression causes memory change, this makes it really tricky to work out how much ECT adds to the chance of this happening.

What of people in the know, would I want ECT? The Royal College of Psychiatrists surveyed us all, asking us that. If severely depressed, almost every psychiatrist said they'd want ECT. Those who didn't were Child & Adolescent psychiatrists and Psychotherapy psychiatrists who never saw ECT so hadn't formed the opinion on it.

So, if cautiously used for the right folk, I see ECT as a useful thing that may have risks (but the evidence base and clinical experience happily both confirm it's much safer than medication and safer than doing nothing). Serious long term risks (like memory loss) are rare.

Of the thousands of unwell patients in my corner each year, how many do I feel should be offered ECT as the best treatment? Not many. Last year it was just two folk in my whole sector who had ECT.

10 comments:

Xavier Emmanuelle said...

Too bad it is so negatively portrayed in the media (at least it is here) given that it could do some good for severely depressed patients.

P.S. Want an invite? xavier_emmanuelle@hotmail.com

mandy lifeboats appeal said...

thanks for posting this.

It is very difficult to get 'objective' evidence and I am in a state where objectivity is fleeting. There are too many emotions involved as well as my own mental illness.

My own view, and having spoken to Dad about this, is that it is his decision and I don't want to prevent him (be it with authority or through the power of my own feelings/thoughts) from having any treatment that will benefit him.

His history is one of mostly non response to medication or maybe a little bit. In fact the side effects he is getting from medication at the moment are most probably aggrevating his fears as well as inflicting on his speech and eating. he is finding food difficult to swallow but that could be as psychological as it is side effect of meds.

I wouldn't say he is 'morbidly depressed' although there is depression there. Either underlying the psychosis or running parallel to it (most probably heavily entwined). My laymen's view is that the psychosis is worse than the depression right now. Not sure I feel comfortable that the psychiatrist seems to be focussing on the depression more. Again, purely my view from being an outsider (and the one meeting I have been party to).

the problem is being a family member and close to him, whilst not being able to see him day to day, is that I am being driven by worry rather than anything else here. Anyway, that aside for now. If I thought ECT would benefit him and without serious damage I would be feeling/thinking that it is the best option. As medication is really hit and miss and it could take months for a level to be found..and then it becomes a battle of personal stamina doesn't it? It does for me, anyway and right now I am trying to find enough stamina in myself (and often losing any battles I won previously).

All I hope is that if Dad gets ECT, it does some good and no harm.

Elaine said...

I last thought aboout ECT when I was a Studemt Nurse in the late 1970s. I witnessed a few and found theconvulsions rather horrifying. I also found that many patients claimed to feel worse afterwards. A neighbour with long standing depression told me that it did not help her at all, and would not countenance having it again.

Your post opened my mind to the other side to the argument.

Thank you.

Dr. Shock said...

This is probably the shortest but most accurate and readable account of what ECT is.
There is no hard evidence yet but "soft" evidence suggests that ECT is probably even more effective in the elderly than in younger patients thanks and regards,
Dr Shock

Zarathustra said...

I've nursed a few people through ECT, though I don't expect to do any more since I've made child and adolescent mental health my speciality.

When I was a student nurse I was given the job of placing my hands on the patient's feet and letting them know when the convulsions started and stopped. The "convulsions" were actually little more than a bit of quivering for a few seconds (hence why I had to have my hands on her feet to detect them). I saw some very dramatic improvements over the next few days in what had been extremely ill people.

I'm not saying ECT doesn't have risks or side effects, but I'm convinced there is an appropriate use for it.

ditzydoctor said...

i had privilege of watching an ECT session as a medical session - seems pretty safe and nothing like what i imagined!

i'm not too sure about the results but a few of patients i've spoken to seem to think that it's pretty beneficial and don't mind going :)

Am Ang Zhang said...

We can continue to knock the U.S. at our own peril. There is indeed much that is good. My colleagues in different specialties used to confide in me that they preferred U.S. conferences, knowing that I attended APA (American Psychiatric Association) meetings instead of U.K. ones. (With limited funding, I had to choose one or the other.) I found that ECT was preferred twelve years ago when I first attended an APA conference. The U.S. is also able to support such seemingly useless research as quorum sensing. This will be the next “black” in medicine.

Also most U.S. working couples I know pay less in Health Care Insurance than we do in National Insurance. Given that so many in the UK are permanently on benefits, are you surprised?

The Cockroach Catcher

Polly said...

Thanks for explaining that Shrink! Very interesting.

the A&E Charge Nurse said...

I have read that ECT produces effects identical to a head injury (moderate cerebral contusion) - Dr Samant described it as a controlled type of brain damage produced by electrical means (Clinical Psychiatric News, 1983).

Some authorities have argued that there is little evidence to support the life saving claims made for ECT (Buchan, et al 1992 - Who benefits from ECT, British Jounal of Psychiatry).

The Royal College of Psychiatrists have said 'clearly, no one is certain' when it comes to severe side effects. These include, personality changes, loss of skills, feeling permanently harmed.
http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/electroconvulsivetherapy,ect.aspx

Isn't ECT a classic, 'the end justifies the means' sort of issue ?

I don't dispute the rapid, and marked changes that occur following a little bit of electricity (in fact, I have witnessed them for myself after delivering depressed patients to the ECT suite) but is there any evidence to suggest that they can be sustained 6 months down the line, say ?

The Shrink said...

"is there any evidence to suggest that they can be sustained 6 months down the line, say ?"

A&E CN, the evidence is better for ECT, yes. The point is that swift resolution of the depressive episode doesn't address existing predisposing, precipitating or perpetuating factors for that episode, in the first place. As such you can get folk well with ECT but if the cause for the depressive episode aren't considered then it is likely to happen again.

Psychoeducation, CBT, antidepressants, mood stabilisers and social change all have been shown to have utility in relapse prevention. Thinking ECT alone is a long term cure is, usually, unrealistic.

For one of my two patients that's the case - she has ECT and is well for ages (years) with no other intervention. For my other, she had ECT and relapses after 8 to 10 weeks unless she's also on medication, then she stays well for well over a year too.

She's pragmatic about it. Her husband has heart problems (IHD, MIs) so is admitted to hospital at least once a year and is on 3 daily cardiac drugs. She reckons she also has a long term medical problem but, unlike him, she takes just 1 tablet a day and is admitted episodically to then keep her asymptomatic and well for over 12 months. She rightly sees this as very positive!