Use of electroconvulsive therapy in psychiatry

Introduction Electroconvulsive therapy (ECT) has been used to treat mental disorders since its introduction in 1938, and it is available in many countries on all continents. However, there are large variations in practice and in rates between countries and regions within those countries, despite internationally accepted guidelines. The ECT intervention is an application of electrical current to the scalp in order to provoke a generalized epileptic seizure, for the purpose of alleviating psychotic and depressive symptoms. Initially ECT was performed without anaesthesia and muscle relaxant (termed unmodified ECT), which among other things, incurred risks of bone fractures and tendon or muscular damage. ECT practices have developed since then; modification of the technique minimizes adverse effects without reducing efficacy. This includes the use of unilateral electrode placement, the adjustment of stimulus intensity to the seizure threshold of each patient, and use of anaesthesia and muscle relaxant (termed modified ECT). ECT still remains controversial, despite well-documented efficacy, especially for major depression, but also for mania and some forms of schizophrenia, and low serious adverse events. Common side effects are transient headaches and memory impairment, whilst long term memory impairment is uncertain and widely debated. Differences in ECT technique may account some for these variances. This thesis explores the topic of electroconvulsive therapy in terms of variations in rates of use, demographics, diagnoses/ indication, outcome, practice, adverse effects as well as attitudes, primarily in Norway but also worldwide. The aims of the present series of studies were to describe: the prescription rate of use of ECT, demographics and diagnoses of the patients at a county hospital in Norway over a period of 11 years (Paper I); the use of ECT, demographics and diagnoses, as well as attitudes among psychiatrists in Norway (Paper II); the practical use of ECT in different psychiatric hospitals in Norway as well as side effects and outcomes (Paper III); the contemporary (1990 to November 2010) worldwide (by continent, country, region, large city hospitals and/or country hospitals) ECT utilization, parameters and practice, in psychiatric establishments, both inpatient and outpatient (Paper IV). Material and methods The thesis consists of four papers. Paper I is based on data from patients admitted to the psychiatric unit of a county hospital between 1993 and 2003, and treated with ECT during their hospitalization. Data were collected retrospectively from specific ECT journals and medical records. The following data were collected: number of patients treated, number of treatments per course, gender, age and diagnoses. Papers II and III are based on answers to a 40-item questionnaire (Appendix I) about the use of ECT in Norway in 2004. Data were collected from psychiatric hospitals, district psychiatric centres (DPC), and child and adolescent psychiatric units. Data included in paper II were number of patients treated, demographics (gender and age), diagnoses and psychiatrists’ attitudes. Data in paper III address the practical uses of ECT, side effects and outcomes. Paper IV is based on information from systematic search of studies published in 1990 through November 2010 in the databases Medline, Embase, PsycINFO, SveMed and EBSCO/Cinahl, in collaboration with the Norwegian Knowledge Centre. Studies reporting original data on ECT utilization and practice in continents, countries, regions, cities or local hospitals were included. Results We found that there were variations in use of ECT between regions of Norway and between countries worldwide. The rate of ECT in Norway was 2.4 / 10,000 inhabitants per year and varied between health regions from 1.83 to 3.44 per 10,000 inhabitants per year (Paper II), whereas worldwide the rate varied from 0.11 to 5.1 per 10,000 inhabitants per year (Paper IV). In Norway, there were twice as many women as men who received ECT, and depressive disorders were the most common diagnostic indication (Papers I and II). Psychiatrists expressed generally positive attitudes towards ECT (Paper II). Unilateral electrode placement was preferred, while antidepressant, lithium and antipsychotic medication during ECT was often continued and continuation/maintenance ECT was used (Paper III). Most patients benefitted from ECT. Side effects such as memory impairment and headache were frequent, but not reported as serious adverse effects (Paper III). In the last study (Paper IV) we found that worldwide practices, indications and use of ECT varied considerably. Unmodified ECT was used in Asia, Africa, Latin America, Russia, Turkey and Spain. In Western countries, the majority of ECT treated patients were older women with depression, versus younger men with schizophrenia in Asian countries. Preferred electrode placement was generally bilateral, excepting some places (Europe and Australia/New Zealand). General trends were often inadequate training, and international guidelines not being followed. Mandatory reporting and overall country ECT register data were sparse. Discussion Methodological challenges and bias influencing the data results are discussed, on the background of use of retrospective data (information depends on the quality of documentation), use of a questionnaire study design, and a systematic review providing a Worldwide picture relying on published data from 1990. We found that many countries have no monitoring or reporting and poor/old data, or data from questionnaire studies. Reasons for differences in rates and practice in Norway and worldwide are discussed. One reason could be economic, another attitude, as well as patient and health personnel knowledge about ECT. Conclusion There are widespread differences in ECT utilization, administration and practice in Norway and worldwide. Most patients who receive ECT in western countries are women and elderly, and depression is the most common disorder. Most patients in Norway are reported to benefit from ECT and adverse effects are reported to be minor problems. Many patients are still treated with unmodified ECT today. Large global variation in ECT utilization, administration, and practice advocates a need for worldwide sharing of knowledge about ECT, reflection, and learning from each other's experiences