Shock Treatment

One of the more enjoyable aspects of blogging is that sometimes even a throwaway comment can trigger an idea for a new post and, given my personal tastes, a new line of inquiry.

And that’s pretty much what happened after I threw this comment into my remarks about the BBC using a quack shrink to comment on Gordon Brown’s state of mind in the middle of major banking crisis…

FFS, her website states that she works, at least some of the time at the private Priory Hospital in Roehampton, which still operates a fucking ECT facility, a practice that most psychologists wouldn’t touch with a barge pole.

… and got several comments to the effect of ‘Hey, but ECT (Electroconvulsive ‘Therapy’) works…’

To which my considered response is ‘I don’t give a toss!’ because I will happily admit to having very profound ethical objections to the use of ECT and the sooner we stop strapping people to a gurney and shoving an electrical current through their brain the happier I will be.

So let’s explain the problem I have, and to illustrate my primary objection to its use we’ll turn to the guidance on the use of ECT in the NHS issued by the National Institute for Clinical Excellence, which states that:

NICE has looked carefully at the evidence and has recommended that ECT should only be used for the treatment of severe depressive illness, a prolonged or severe episode of mania, or catatonia if the conditions described in the following paragraphs are applied.

ECT should be used to gain fast and short-term improvement of severe symptoms after all other treatment options have failed, or when the situation is thought to be life-threatening.

Do you know why ECT is only to be used as a last resort?

Because no one really knows what effect it has on the brain or how, in those cases where is does it appear to work, quite how it works.

Call me picky if you like, but if you’re going to administer a course of ‘treatment’ to someone then you might at least have some idea of how that treatment works, especially when the treatment involves attaching electrodes to someone’s head but the bottom line here is that its impossible to isolate its supposedly therapeutic impact from everything else that goes on when you shove an 800 mA current through someone’s brain for between 1 and 6 seconds.

The only serviceable theory that explains exactly what ECT does to the brain that doesn’t rely on voodoo bullshit and woo is that it causes brain damage. although the both American Psychological Association and NICE have ruled this out on the back of studies that have shown that ECT doesn’t cause gross structural damage despite the fact that its more common side-effects, retrograde amnesia and induced cognitive deficits affecting intelligence are just the kind of things you expect to see from someone whose suffered a brain injury. This almost entirely ignores that fact that as our understanding of the brain develops so we are finding that its gross physical structure is but a very small part of the overall picture and that matters more is the complexity of interconnections between its structural elements, disruption to which cannot be adequately assessed by studying tissue samples collected during autopsy by by using brain imaging. Animal studies, which have also been used to assess the effects of ECT are, similarly, unilluminating due both the differences between the brains of humans and other animal and an absence of satisfactory comparators, the are no satisfactory models of mental illness in animals against which to assess the results of animal studies.

So we don’t know how ECT works and, because of that, there’s no way to adequate assess whether it is likely to prove effective for any given individual patient – basically, the treatement regime is that you run out of options so you wire them up and hope for the best.

What we do know is that whatever positive effects some patients experience, those effects are short-lived and the relapse rate is very high, with one recent (and very rare) follow-up study in New York showing that remission rates for ECT were only of the order of 30-47% while the relapse rate within six months of treatment came in at 64%. Despite this a survey of New York-based psychiatrists showed that they thought that 85% of their patients benefitted from ECT.

This takes us into another major problem with ECT – much of the existing guidance, although relatively recent in origin (the APA’s guidance was issued in 2000, while NICE issue their guidance in 2003) is based on relatively poor quality data much of which has been superceded in the last 3-5 years by more up to date studies based on improved data collection methodologies.

For example, the APA estimates in its guidance on ECT that around 1 patient in 200 will experience significant, prolonged, side-effect (i.e. memory loss and/or cognitive deficits). However, data from the state of California, which has one of the better data recording regimes, suggests that this figure may be out be anything up to 40 times and that the incidence of memory loss and/or cognitive deficits following etc ma be as high as 1 in 5. There have been several published studies since 2000 which show much higher rates of cognitive impairment than those admitted to in the official guidance including a 2007 study by Sackheim et al which indicates that certain forms of bilateral ECT result in patients experiencing cognitive deficits as a matter of routine.

Sackheim’s results take us towards yet another issue that many, myself included, have serious problems with. Here’s what the abstract of the study has to say about its findings…

The seven sites differed significantly in cognitive outcomes both immediately and 6 months following ECT, even when controlling for patient characteristics. Electrical waveform and electrode placement had marked cognitive effects. Sine wave stimulation resulted in pronounced slowing of reaction time, both immediately and 6 months following ECT. Bilateral (BL) ECT resulted in more severe and persisting retrograde amnesia than right unilateral ECT. Advancing age, lower premorbid intellectual function, and female gender were associated with greater cognitive deficits. Thus, adverse cognitive effects were detected 6 months following the acute treatment course. Cognitive outcomes varied across treatment facilities and differences in ECT technique largely accounted for these differences. Sine wave stimulation and BL electrode placement resulted in more severe and persistent deficits.

Setting aside the technical issues relating to ECT technique, the greatest cognitive deficits were to be found in women, older patients and those patients with ‘lower premorbid intellectual function’, i.e. below average intelligence.

Now, let’s look at a couple of graphs showing recent trends in ECT use in the UK, complied from data collected by the NHS, and we’ll start with data on the use of ECT by gender…

Okay, so let’s relate the good news – the use of ECT is in decline with the biggest fall coinciding with the introduction of NICE’s guidelines in 2003, which ruled out both the repeated use of ECT to simply manage serious psychiatric disorders (against which the Royal College of Psychiatry appealed unsuccessfully) and its use as ‘treatment’ for schizophrenia.

But the bad news is that even with the falling numbers just over twice as many women are ‘treated’ with ECT each year than are men – on the most recent data ECT was administered to 592 men during 2006/7 against 1392 women, a 30:70 split.

Now let’s look at the age data…

Again, we see an overall decline in use but what we also see is that more than half of the patients receiving ECT annually are over the age of 60 and just over 20% are over the age of 75!

There’s no data on ECT and intellectual capacity but otherwise what we find is that two of the three groups that are most likely to suffer significant cognitive impairments as a consequence of undergoing ECT account for a majority of those treated with ECT, and in the case of women, a very clear majority.

Now…

Under NICE’s 2003 guidelines, ECT is to be used only a last resort/emergency measure and only then for a limited range of psychiatric conditions, specifically:

a) severe clinical depression where there is a evident risk of suicide,

b) catatonia, and

c) manic disorders.

So, given that women are twice as likely to have ECT administered as a treatment for one of these three conditions, it must be the case that the incidence of these conditions in women is significcantly higher than it in men, right?

Wrong!

Taking each in order…

In the case of clincial depression it is true, overall, that women show a higher incidence of depressive illness than men. In women the incidence is around 11-12% of the population and men its around 7 % but there’s a couple of wrinkles here just on the overall population data. First, the gap between men and women is closing – women are still more likely to be diagnosed with depression than men but increasingly the difference is disappearing, largely, its thought, because more and more men are admitting to feelng depressed and seeking help as opposed to self-medicating with alcohol and/drugs. So, given time and changing attitudes, its seem likely that the apparent gender differences here will largely evaporate.

But we’re not dealing with depression generally, here, what we need to look at is the incidence of several depression of the kind that may result in, at least, a suicide if not a ‘successful’ suicide, and when you look at this data, a very different picture emerges.

For one thing, the overall suicide rates for men are between three and four times higher than they are for women – its actually just over four times higher in the under 25s and three times higher in all other age groups.

That said, we’re not looking at the general population, what we’re actually interested in is the 3.6% of those who’ve been diagnosed with clinical depression whose symptoms are so severe that they attempt to take their own life, and within that group men are seven times more likely to attempt suicide than women.

Something doesn’t add up does it?

And the same is true for the other two conditions for which ECT can be used. But for a very particular form of catatonia that is gender-linked (to men) there is no difference between genders in the incidence of catatonia, while the incidence of manic disorders breaks slightly toward women, even though men tend to show earlier onset, but the differences are not statistically significant.

For two of the three conditions for which ECT is used as a last resort, there is no significant difference in incidence between men and women while in the case of the third, severe clinical depression leading to risk of suicide, women are significantly less likely to become suicidal than men, and yet when it comes to the use of ECT women outnumber men as patients by more than two to one…

…and yes, the explanation given for this is simply that more women are diagnosed with depression than men despite the incidence data saying that the opposite should be the case if the last resort and evident risk of suicide criteria are applied correctly.

Thus far we’ve not distinguished between voluntary and involuntary treatments but this also merits consideration because, on average, a little over a quarter of those to whom ECT administered each year are patients detained (sectioned) under the Mental Health Act and, of these, around 60% are administered ECT without their consent.

Now, of course, NICE’s guidelines make it absolutely clear that ECT is not to be used for managing psychiatric conditions let alone for managing psychiatric patients but the fact of the matter is that ECT has a histroy of misuse attached to it both in relation to it use of inappropriate purposes – there were instance even until the 1980’s of ECT being administered to voluntary patients as a ‘treatment’ for homosexuality and it has certainly, in the past, been used (and abused) as a mean of controlling patients in psychiatirc institutions, as was most famously depicted by Ken Kesey in ‘One Flew Over the Cuckoo’s Nest’, so when you discover that in 60% of cases involving patients detained under the Mental Health Act, ECT is being administered without their consent, then you natuarally start to feel just a little bit queasy.

And even where consent is obtained there are doubts as to whether what is being given is actually informed consent – a 2005 paper in the British Journal of Psychiatry by Rose et al, concluded that…

“About half (45-55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not.”

Before adding that:

“Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form.”

And that:

“The proportion who feel they did not freely choose the treatment has actually increased over time. The same themes arise whether the patient had received treatment a year ago or 30 years ago.”

Before reaching a final conclusion that ”

Neither current nor proposed safeguards for patients are sufficient to ensure informed consent with respect to ECT, at least in England and Wales.”

So, to sum up…

ECT is nothing like as effective as many psychiatrists appear to think.

The assertion that it doesn’t cause brain damage is looking increasing over-optimistic are out understanding of the complexity of the brain increases.

The incidence of significant side effects, particularly memory loss and cognitive deficits is considerably higher than the estimates on which the current guidance is based.

It is disproportionately used on women even though the epidemiological data relating to conditions for which it used as a treatment in the UK suggests that this should not be the case and also more likely to be used on older, and much more vulnerable individuals – more than 20% of those undergoing ECT each year are over the age of 75.

It is also frequently used on patients detained under the Mental Health Act without their consent and the efficacy of the safeguards that are supposed to ensure that informed consent is secured before treatment is given have been identified as being inadequate.

Oh, and despite the Royal College of Psychiatry having launched its own voluntary accreditation scheme for ECT clinics in 2004, a significant number of clinics in the UK and Irish Republic have yet to join the scheme, let alone obtain an accreditation.

As of the RCoP’s most recent figures, of 184 clinic providing ECT services, 84 are accredited, seven have closed or ceased to provide ECT services, eight are currently under review, five have deferred, two have withdrawn and one is just not accredited, while the remaining 76, which include 56 NHS units, aren’t even members of RCoPs scheme.

Amusingly, RCoP’d scheme provides all its members with the usual bullshit including ‘detailed advice and support about areas in need of improvement’ and encourages its members to ‘continuously develop and revise current standards focusing on best practice’…

…and never one to pass up an expressed need, I;ve got an idea as to how we can improve ECT services and ensure best practice –

– we can stop strapping people to gurneys and shoving electric currently through their brain when we really don’t know what the fuck we’re actually doing.

That seems to me to make a lot of good sense.

Let’s be clear about one thing here. ECT exists today only because it originated at a time where ethical standards in the Mental Health sector were nothing like as stringent or enlightened as they are today, a time when no one really cared if psychiatrists treated the inmates of their institutions like lab rats and conducted speculative experiments on them. Today, you wouldn’t have a hope in hell’s chance of getting something like ECT past a reputable ethics committee because there is no way of testing the procedure, other than in crude safety terms, other than by testing it on human subjects.

It persists today on the back of assumptions about its efficacy and safety that are increasingly looking shaky in the light of latest research and, sadly one suspects, because many of those to whom its administered are amongst the most vulnerable members of society and are least able to defend themselves – if the mental picture of a doctor strapping an 80 year old woman to a bed and using an electric shock to brain to create an induced seizure doesn’t disturb you then i guess you taste in films runs to stuff like ‘SS Experiment Camp‘ and the latest trends in torture porn.

Personally, the day when the last ECT clinic in the UK closes its doors forever can’t come soon enough.

  • I do agree with your approach of getting into the data to see if ECT works and to see if its side effects are acceptable. I don’t agree with your assertion that it can’t be used because there is no theory of why it works. Lots of modern treatments are used even though no-one knows how or why they work; anaesthetics, for example.

    Cheers,
    Marksany

  • Unity : I respect you and I’m a big fan of your blog, so please don’t take the following the wrong. It really distresses me to see ECT so misunderstood especially when it’s someone as smart as you doing the misunderstanding.

    Now without further ado –

    Firstly, you’re right that no-one knows how ECT works. (I’d give a Nobel Prize to whoever figures it out, because once we know how ECT works, we will understand mental illness. No exaggeration.) However, this isn’t why ECT is used a last resort, it can’t be because the same applies to every other treatment in psychiatry.

    No-one knows why antidepressants work: we know that Prozac blocks the reuptake of serotonin in the brain, but we don’t know how that makes people feel better. There are a number of theories. Lithium is very effective at treating mania, but no-one knows why. There are a number of theories. I could go on but it would be quite boring.

    More interestingly, no-one knows how psychotherapy works either – therapists will tell you otherwise, naturally, but a Freudian would say it works one way, a CBT therapist would disagree, and a lot of people would say that they’re all just talking psychobabble and therapy works because it’s just nice having someone to talk to about your problems.

    Doctors have never cared unduly about why something works if it works. Doctors are pragmatic. All the evidence says that ECT does work, so no-one spends too much time worrying about how. This is exactly as it should be, I suspect you don’t much care about how your mechanic fixes your car, so long as he fixes it.

    So when you say that “The only serviceable theory that explains exactly what ECT does to the brain that doesn

  • David Bennett

    I’m glad Woobegone posted otherwise I would have been forced to write something very similar.

    ECT, although distasteful to some, is a valid therapy for severe depression.

    I too will be glad when the last ECT clinic closes, along as it’s a result of better treatments becoming available.
    Not before.

  • Personally, the day when the last ECT clinic in the UK closes its doors forever can

  • Because no one really knows what effect it has on the brain or how, in those cases where is does it appear to work, quite how it works.

    That doesn’t seem to stop General Anaesthesia being used every day.

  • David Bennett : Thanks. I think I’ll post something more about ECT on my blog in the near future.

    Louise : “Psychotropic medication has some pretty nasty side effects too and it only takes one consultant psychiatrist to authorise the use of those.

    Sometimes the

  • You’re wrong, I’m afraid – there’s at least one psychiatrist who knows how ECT works.

    One of my students didn’t believe me when I said that no one knows how it works, so he phoned his father who is the director of a mental hospital in the Middle East.

    Apparently, “some people don’t have enough electricity in their brains, so we put some in”.

  • Helen

    Fascinating debate – I’ve learnt a huge amount and I’ve got lots to think about from the comments so thank you everyone. As to my views, I think it’s probably worth investigating whether there are uncalled for biases in treatment rates between, say, men and women, but in general I support the view in the comments that if ECT helps deal with severe depression when nothing else works, then it’s worth it.

  • Thanks Unity. Another interesting thing about Ms Quack and the Priory at Roehampton is of course that she has been purged – possibly with low voltage electricity – from their website. Doesn’t seem to work there …

  • Unity

    Hope I haven’t missed it, but I don’t think you have taken account of varying gender mixes by age in your graphs.

    That will normalise your gender differences somewhat – everything else being equal. You probably need a crosstab analysis grid of the data for 1 sample year (ideally each period), or at least to note the caveat.

    According to the 2001 census, gender population ratios are 1.11:1 women to men for 60-75 age group, and 1.73:1 for 75+. (3.46:1 for 90+).

    Data Source:
    http://www.statistics.gov.uk/census2001/pop2001/united_kingdom.asp

    Matt W

  • >That will normalise your gender differences somewhat – everything else being equal.

    Let me rephrase. If you normalise the gender ratios of ECT treatment by age the larger proportion of women receiving the treatment will reduce slightly on a per-pop basis.

    Taking a gut feel without spreadsheeting your data, your 70:30 split is likely to look more like something between 60:40 and 65:35 after normalisation.

    Matt

  • Good point Matt.

    Also, I’m fairly sure that more women are hospitalised for depression than are men. Which fits with the fact that they are more likely to be diagnosed. However I can’t actually find any figures on this. Can anyone dig any out?

    If more women are hospitalised for depression, then it is no surprise at all that more get ECT, what would be notable would be if a given hospitalised woman had more chance of getting ECT than a hospitalised man. (Although that wouldn’t be evidence of foul play, there might be a real clinical reason for it. But it would be interesting.)

  • Matt:

    If you age-adjust the figures for ECT by population then you get only a projected 6% differential (53% female, 47% male) on an even incidence of depression across both genders.

    The female-male ratio in diagnosis rates is around 61:39, which reflects the greater propensity for women to seek psychiatric help, but that differential narrowing over time, and yet the ratio for ECT use is 70:30 or so.

    Adjusting for gender ratios by age and recorded incidence rates still leaves a 14% or so total differential that can’t be accounted for statistically.

    To account for that, two things come to mind that bear closer examination.

    One is differences in gender attitudes towards treatment – men are generally more averse to seeking clinical help and that may carry through into attitude towards accepting ECT treatment voluntarily.

    The other is attitudes within psychiatry, or more specifically the prevalence of particular perspectives amongst psychiatrists. Certain ‘schools’ of psychiatry are much more averse to the use of ECT and drug interventions than others and this may well influence treatment patterns. You wouldn’t, for example, expect to see too many Rogerians or others of the existential humanist school favouring such drastic interventions, but the same is certainly not true of Freudians or Skinnerians.

    It’s not simply a case of ‘sexist doctors’ but, I suspect, a rather more complex set of questions relating to the prevalence of particular perspectives within the psychiatric profession.

  • Pingback: Britblog Roundup #192 « Amused Cynicism()

  • Sometimes it is, but always bear in mind that severe mental illness is horrible, really, really horrible. Many psychiatric drugs are not much fun either, and are probably over-prescribed (but also underprescribed – many people who should be on drugs aren