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Experts weigh in on alarming rise in use of electroconvulsive therapy

In the new year, the professional body of psychiatrists in the United Kingdom will release its third set of comprehensive guidelines for clinicians who administer one of the field’s most controversial treatmentselectroconvulsive therapy.

It will be a 244-page handbook that outlines clinical directives on prescribing and practising ECT and highlights the latest research on the adverse cognitive effects that could arise from shocking the brain with electricity to treat severe depression.

“We have several chapters about various anesthetic techniques,” says Dr. Ian Reid, chair of the Royal College of Psychiatrists’ special committee on ECT, which produced the handbook. “People having a seizure makes their jaw muscles contract and that can injure teeth so we have a dental expert writing about the issues with tooth care. We’ve even got a bit from folks who have experienced ECT.”

Canada, meanwhile, has an eight-page position papered on the practice of ECT. It’s what Ontario Health Minister Deb Matthews referred to when asked if she would press for an audit after a Toronto Star investigation revealed a startling increase in the number of treatments administered in the province.

In June 2009, the Canadian Psychiatric Association produced the position paper, the first update of its kind in 17 years. It devotes one page to contraindications.

“I have a friend who … had been institutionalized, unable to cope with life and she received ECT and now lives a very full, rich and happy life,” Matthews told the Star, noting that ECT is a “valuable tool” that has been stigmatized by the media.

She also referred reporters to the Canadian Network for Mood and Anxiety Treatment’s “clinical guidelines” for the management of major depressive disorders in adults — a text that addresses ECT in two pages and says nothing about the issues of consent, training or prohibition against outdated equipment.

Health ministry staff could not explain the 350-per-cent increase in the number of treatments administered across the province in the past seven years. A breakdown by age and gender reveals alarming subsets — a 1,300-per-cent treatment increase for patients in the 55-59 cohort, while women outnumber men nearly two to one in the 60-64 age bracket.

Reid, an advocate who has worked as an ECT clinician and researcher in the United Kingdom for 25 years, says he is astonished at the lack of oversight and transparency surrounding the treatment in Canada.

There is a hint from these statistics that there is something not right,” Reid says. “We need to find out what that is. If you don’t check, how do you know things are OK?”

In England and Scotland, the treatment is scrutinized through regular inspections and an accreditation system.

“Not only do we have that accreditation but that document is published in the public domain. Any citizen can look and see not only where ECT is done but who gets it, how many people get it, what its outcome is, what adverse effects there are and so on,” Reid says.

Such scrutiny does not occur in Ontario for ECT, which is a cornerstone of what many psychiatrists around the world call a “life-saving” treatment for very severe depression and other mental disorders.

Despite a government inquiry into ECT that called for provincial training and clinical practice standards nearly 30 years ago, no such guidelines exist.

Psychiatrists who administer the treatment often disagree about the most effective and least damaging way to deliver the treatment. Protocols can vary dramatically from hospital to hospital and sometimes within a hospital.

“There’s still a lot of heterogeneity in how ECT is done, unfortunately,” says Dr. Kiran Rabheru, adding that the delivery of ECT requires “a lot of sophistication.” Rabheru is past president of the Canadian Academy of Geriatric Psychiatry and a professor of psychiatry at the University of Ottawa.

British Columbia introduced guidelines for the practice 10 years ago “to standardize the delivery of electroconvulsive therapy” across the province.

Since the handbook was published in 2000, there have been refinements in both the application of the treatment and in the use of anesthesia.

“The B.C. ones are dated now” Rabheru says.

A recent clinician-driven survey of 175 Canadian centres that identify ECT as part of their practice estimates that 75,000 ECT treatments are administered across the country annually. Of the 107 sites that responded to the survey, 89 reported the existence of written ECT policies and procedures, less than 40 per cent reported electrode placement policies, only 30 per cent have electrical dosing policies, and less than 30 per cent have ECT-specific anesthesia policies. Just 27 per cent reported written policies for managing concurrent medications during ECT.

In Canada, outdated ECT machines known to cause severe cognitive impairment are still being used by at least three health facilities, a fact unearthed by the national survey. Dr. Nicholas Delva, head of the department of psychiatry at Dalhousie University and chair of the survey group, says confidentiality agreements prevent him from naming the institutions.

The Canadian Psychiatric Association’s eight-page position paper, which the health minister described as a set of “national guidelines” — a claim that even the CPA does not make — notes that sine wave stimuli “have been associated with more marked memory-related adverse effects.” It takes no position on the continued use of the technology.

Through late summer and early fall of 2012, Windsor, Ont., resident Matt Damphouse travelled to another city several times a week for ECT. He describes the early sessions as “hell.” On three occasions, medical staff improperly administered a muscle relaxant before injecting the anesthetic — the reverse protocol of what is required to keep the patient both out and slack during treatment.

He now receives ECT at Windsor Regional Hospital, which opened a neurobehavioural institute in late October. Though he says his treatments there have been “smooth as silk,” Damphouse wants to see the adoption of uniform standards. – News