Electroconvulsive therapy practice in Western Australia

Electroconvulsive therapy in a tertiary Australian mental health facility between 2009 and 2020

BACKGROUND

Despite electroconvulsive therapy being one of the most effective treatments in psychiatry, few studies report trends in the provision of electroconvulsive therapy over time. This study aims to investigate the use of electroconvulsive therapy between 2009 and 2020 in an Australian public tertiary mental health facility, and to describe the electroconvulsive therapy patient population and change in courses of treatment.

METHODS

Routinely collected data for 677 patients who received 1669 electroconvulsive therapy courses of treatment at an Australian public tertiary mental health facility between 2009 and 2020 were examined.

RESULTS

The provision of acute electroconvulsive therapy was stable across the study period; however, the number of maintenance electroconvulsive therapy courses commenced declined over the study. Schizophrenia was the most common indication for index treatment (37.4%). The majority of patients (85.7%) received acute electroconvulsive therapy only. Voluntary provision of electroconvulsive therapy declined over the study period, reducing from 44.9% in 2009 to 16.3% in 2020.

CONCLUSION

Over the study period, there was a significant reduction in the number of maintenance electroconvulsive therapy courses commenced, and a large increase in involuntary treatment. The provision of electroconvulsive therapy was more likely to occur in males with a diagnosis of schizophrenia. Further studies are needed to generate a greater understanding of the factors influencing the provision of electroconvulsive therapy within differing geographical, social and healthcare landscapes.

Factors associated with electroconvulsive therapy treatment for adults with serious psychiatric conditions in Australia

OBJECTIVE

To identify factors associated with receiving electroconvulsive therapy (ECT) for serious psychiatric conditions.

METHODS

Retrospective observational study using hospital administrative data linked with death registrations and outpatient mental health data in New South Wales (NSW), Australia. The cohort included patients admitted with a primary psychiatric diagnosis between 2013 and 2022. The outcome measure was receipt of ECT.

RESULTS

Of 94,950 patients, 3465 (3.6%) received ECT. The likelihood of receiving ECT was higher in older (hazard ratio [HR] = 1.03), female (HR = 1.24) patients. Compared to depression, patients with schizophrenia/schizoaffective disorder (HR = 0.79), schizophrenia-related disorders (HR = 0.37), mania (HR = 0.64) and other mood disorders (HR = 0.45) had lower odds of receiving ECT. Patients with depression and one other serious psychiatric condition had higher odds of receiving ECT than depression alone. Bipolar disorder likelihood of ECT did not differ from depression. A higher number of mental health outpatient visits in the prior year and an involuntary index admission with depression were also associated with receiving ECT. Likelihood of receiving ECT increased with year of admission (HR = 1.32), private patient status (HR = 2.06), higher socioeconomic status (HR = 1.09) and being married (HR = 1.25).

CONCLUSIONS

ECT use for depression and bipolar disorder in NSW aligns with clinical national guidelines. Patients with schizophrenia/schizoaffective, schizophrenia-related disorders, mania and other mood disorders had lower likelihood of ECT than depression, despite ECT being recommended by clinical guidelines for these diagnoses. Variations in ECT were strongly associated with healthcare access, with private patients twice as likely to receive ECT than their public counterparts, suggesting a need to explore ECT accessibility.

Electroconvulsive Therapy Use in Psychiatric Hospitalizations in Portugal: A Nationwide Descriptive Study

OBJECTIVES

The primary aim of this study was to describe a Portuguese nationwide epidemiological perspective on the use of electroconvulsive therapy (ECT) in hospitalized psychiatric patients. The secondary aims of the study were to characterize clinical and sociodemographic trends of hospitalized patients treated with ECT.

METHODS

A retrospective-observational study was conducted using an administrative database gathering every registered Portuguese public hospital hospitalizations from 2008 to 2015. We selected all hospitalizations with a procedure code 94.27 (Other electroshock therapy) defined by the International Classification of Diseases version 9, Clinical Modification. Variables included birth date, sex, address, primary and secondary diagnoses, admission/discharge date, length of stay, and discharge status from each single hospitalization episode. We also calculated Portugal's inpatient ECT prevalence rate (iP%).

RESULTS

There were a total of 879 registered hospitalizations with ECT within the 8-year period of this study. Most occurred in female patients (53.4%), belonging to the age group of 51 to 70 years old, with a mean age of 50.5 years. The median length of stay was 43.0 days with an interquartile range of 27.0 to 68.0. The most frequent primary diagnosis was major depressive disorder, recurrent episode, representing 19.6% of all hospitalizations. The iP% for the study period was 0.71%.

CONCLUSIONS

In Portugal, most of the patients who received ECT were women above middle age, and depressive disorders were the most common indication. Portugal's iP% represents a low rate when compared with other European countries, which might indicate an underutilization of ECT in Portuguese psychiatric hospitals.

A Descriptive Study of Data Collection Systems Used in Electroconvulsive Therapy Units in the Province of Quebec, Canada

OBJECTIVES

This study aimed to describe the data collection systems routinely used by electroconvulsive therapy (ECT) units across the province of Quebec, Canada.

METHODS

We conducted a descriptive, cross-sectional study. Using an online survey, 31 ECT units delivering inpatient or outpatient ECT treatments in the province of Quebec provided information on the data collection systems used, data recorded, data collection strategies, indicators of satisfaction, limitations of the current data collection systems, and expectations toward the improvement of ECT data collection.

RESULTS

Most units routinely collected information on individuals receiving ECT treatments, mainly on the medical chart (80%) and in paper format (71%). Most units (88.9%) collected ECT data manually. Electroconvulsive therapy parameters are collected by 66% to 80% of units, but only 16% of them have computerized records. The main limitations of the current systems are as follows: (a) the low frequency of computerization, (b) the underutilization of data, and (c) difficulties in the integration of information from different ECT units. Although 83.3% were satisfied with the current data collection strategies, 80% had a very positive opinion about the development and implementation of an innovative ECT provincial data collection registry.

CONCLUSIONS

An integrated ECT provincial data collection system could overcome the variability documented in existing strategies and respond to the current provincial needs and expectations. Also, an integrated ECT provincial data collection system could support both clinical research and quality assurance necessary to inform standards of ECT practice in Quebec.

Electroconvulsive practice in Singapore: a cross-sectional national survey

INTRODUCTION

The use of electroconvulsive therapy (ECT) in Singapore dates back to 1947. However, there is little local information on the clinical practice of ECT and its standards. We aimed to conduct a comprehensive national survey of ECT practice in Singapore.

METHODS

A cross-sectional structured questionnaire assessing the types of ECT (e.g. electrode placement, stimulus parameters), indications, anaesthetic technique, dosing methods, monitoring of outcomes and credentialing was sent in 2015 to all ECT centres in Singapore via email to collect qualitative and quantitative data regarding ECT.

RESULTS

Data was obtained from all ECT centres (n = 6), which represented that ECT was available in 23.1% of all hospitals and 50.0% of all psychiatric specialist centres. The rate of ECT was 5.89 treatments per 10,000 residents per year, and each patient received an average of 5.4 ECT per course. Only 7.0% of ECT was administered for continuation/maintenance ECT. The most common indication for ECT was depression in 5 (83.3%) out of six centres, with schizophrenia being the second most common. In 5 (83.3%) out of six centres, ECT was brief (0.5 ms) bitemporal ECT with age-based dosing, and 93.0% of the sessions were conducted in an inpatient setting. All ECT was conducted under general anaesthesia, with propofol (66.7%) being the most common type of anaesthetic used.

CONCLUSION

The practice of ECT in Singapore was highly uniform. The rates and indications for ECT were consistent with those of other developed countries, with greater use of ECT for schizophrenia. Future advances for ECT in Singapore include the use of individualised dosing based on empirical seizure threshold titration, expanded electrode placements and increased utilisation of continuation/maintenance ECT.

Low-charge electrotherapy for patients with schizophrenia: A double-blind, randomised controlled pilot clinical trial

A double-blind, randomised controlled pilot clinical trial was conducted to assess the potential effectiveness and safety of low-charge electrotherapy (LCE) for patients with schizophrenia. Bitemporal LCE (approximately 2.8 Joules) was administered three times a week. The Positive and Negative Syndrome Scale score was set as the outcome measure. Any adverse event (AE) was recorded. Three visits occurred at baseline, post-treatment, and after one month of follow-up. Twelve patients were randomised to the electroconvulsive therapy (ECT) group or LCE group (6 patients in each group). No patient withdrew during the study. The LCE group did not experience seizures during the trial. Patients in both groups showed significant improvements in clinical measures after treatment, and the reduction of all scale scores between the two groups was nonsignificant. The LCE group experienced significantly fewer AEs than the ECT group. Compared with ECT, LCE exerts similar antipsychotic effects while causing fewer AEs. Thus, LCE has the potential to be a safe and effective treatment for patients with schizophrenia, but further research is needed.

Hip Hip Hooray, ECT turns 80!

OBJECTIVE:

This paper reviews the history of electroconvulsive therapy (ECT) with an emphasis on the Australian context over the past 30 years. The review includes data collection, the contribution of the RANZCP, and changes in legislation.

CONCLUSION:

ECT remains the most effective treatment for severe depression. Since the 1950s efforts have been made to make it more effective, tolerable and acceptable. Over the same period, significant social and political forces have acted to have the practice of ECT restricted or banned. Psychiatrists, through the RANZCP and other bodies, have the responsibility to promote quality ECT practice, advocate for patients, carers, and clinicians, counter inaccurate negative portrayals, and lobby for balanced legislation for ECT and other neurostimulation.

Effectiveness of Electroconvulsive Therapy and Associated Cognitive Change in Schizophrenia: A Naturalistic, Comparative Study of Treating Schizophrenia With Electroconvulsive Therapy

OBJECTIVE

There is limited evidence regarding the relative treatment effectiveness and cognitive effects of different types of electroconvulsive therapy (ECT) in schizophrenia. In this study, we sought to determine the overall effectiveness and compare the symptomatic and cognitive outcomes of patients with schizophrenia who received different modalities of ECT treatment.

METHODS

Patients received 1 of 4 of the following ECT modalities: bitemporal ECT with age-based dosing, right unilateral ECT with seizure threshold-based dosing, bitemporal ECT with seizure threshold-based dosing, and bifrontal ECT with seizure threshold-based dosing ECT. The Brief Psychiatric Rating Scale (BPRS) and Montreal Cognitive Assessment (MoCA) were administered to 62 patients before and after the ECT course.

RESULTS

There was a significant improvement in both the total and psychotic subscales of BPRS and MoCA scores across the patients after the course of ECT. The global improvements in both BPRS and MoCA scores after ECT were not influenced by the type of ECT administered. Age-based dosing, however, was associated with poorer memory outcomes posttreatment. The overall symptomatic response rate, defined as 40% or more reduction in the psychotic subscale of BPRS, was 64.5%. The response rates did not significantly differ between the 4 types of ECT.

CONCLUSIONS

Our present findings suggest that an acute course of ECT is effective in schizophrenia and may have cognitive benefits for some patients.

Electroconvulsive Therapy in Schizophrenia in China: A National Survey

OBJECTIVE

Little is known about electroconvulsive therapy (ECT) use in the treatment of schizophrenia in China. This study examined the frequency of ECT use, its trend between 2006 and 2012, and its independent demographic and clinical correlates in a nationwide survey in China.

METHODS

A total of 5162 inpatients in 45 Chinese psychiatric hospitals/centers were interviewed (2696 in 2006 and 2466 in 2012). Patients' sociodemographic and clinical characteristics were recorded using a standardized protocol and data collection procedure.

RESULTS

Electroconvulsive therapy was used in 6.1% of the whole sample; 4.7% in 2006 and 7.7% in 2012 (P < 0.001) with wide interprovince variations. Multiple logistic regression analyses of the whole sample revealed that patients receiving ECT were more likely to be women, receive second-generation antipsychotics, treated in tertiary referral centers (level III hospitals), had a shorter illness duration, and more positive and depressive symptoms (R = 0.181; P < 0.001).

CONCLUSIONS

Electroconvulsive therapy for schizophrenia has increased between 2006 and 2012 in China. Its percentage was higher than the figures reported in most other countries. Reasons for the substantial variations in the frequency of ECT across different provinces in China require further investigations.

Electroconvulsive Therapy in Women: A Retrospective Study from a Mental Health Hospital in Turkey

The aim was to evaluate the clinical profile and effectiveness of ECT in women. A retrospective chart review was carried out to identify female patients who had received ECT during the period September 2013-February 2015. Details regarding their sociodemographic, clinical, and treatment data were extracted from these records for the present study. The total number of patients, admitted to our psychiatry inpatient clinic during the survey period, was 802. During this period, 26 (3.24 %) female patients received ECT. Patients who received ECT were mostly in age group of 25-44 years (76.9 %). Twenty percent of patients were in the postpartum period. Psychotic disorders (46.1 %) was the most common diagnosis for which ECT was used, followed by bipolar affective disorder, current episode manic (19.2 %). At the end of ECT courses, 70 % of the patients showed good response with a CGI-I of 1 or 2, and 30 % showed minimal response with a CGI-I score of 3. The most common side effects were post-ECT confusion (15.4 %) and prolonged seizure (11.5 %). This rate of prolonged seizure was higher the rates reported in the literature. The bronchospasm related with remifentanil, post-ECT bradycardia, hypertensive crisis and oligohydramnios were also reported in one case each. ECT is a safe and effective treatment option in women with severe psychiatric disorders and disorders in the perinatal/postpartum period are a major area of ECT use. The female gender may be a contributing factor for the higher rates of prolonged seizure.

The Prevalence of Electroconvulsive Therapy Use Since 1973: A Meta-analysis

OBJECTIVES

A formal meta-analysis of the use of electroconvulsive therapy (ECT) has never been conducted before in literature reviews or syntheses. Such a study would be hampered by heterogeneity and potential reporting biases. However, it would provide a single comparable measure to allow an analysis of statistical key dimensions such as trends across time and psychiatric resources available. It would also help planners and decision makers to set standards and benchmarks for national and regional guidelines for quality assurance and research in health services.

METHODS

We surveyed different databases for relevant studies, limited from 1973 to October 2013. Data were extracted independently by 4 reviewers. The articles retrieved were peerreviewed studies (data-based studies or surveys) presenting ECT population rates (annual patient rates calculated from the general population) or number of patients receiving ECT during or after 1973 and attending a psychiatric establishment (either hospitals or approved ECT delivery centers for inpatients and outpatients in well-defined geographic areas).

RESULTS

This meta-analysis includes a total of 18 studies from 12 countries. A composite event rate of 16.9/100,000 inhabitants emerged, characterized by high heterogeneity. Across the countries assessed, the prevalence of ECT was higher in older studies.

CONCLUSIONS

By its prevalence, ECT remains rare to exceptional as a specialist treatment for mental disorders. Heterogeneity across regions or countries could best be explained by insufficient standardization of ECT procedures and practices. Linked health databases and audits could help strengthen the effectiveness of ECT in relation to primary outcomes such as suicide and help determine the gap in ECT provision, if any.

A retrospective chart audit of electroconvulsive therapy at a regional Australian hospital

OBJECTIVES

The objective of the current study was to provide a contemporary review of electroconvulsive therapy (ECT) practice in Far North Queensland, Australia.

METHOD

Demographic, diagnostic and treatment characteristics were extracted from the hospital files of people who received ECT between 2011 and 2013. Data were quantitatively analysed and described.

RESULTS

Depressive illnesses were the most common indicator for treatment. However, psychotic illnesses also made up a large proportion of treated cases. The technical aspects of treatment were commensurate with previous Australian findings except for the higher incidence of bifrontal ECT and maintenance treatment.

CONCLUSIONS

Further research is needed across Australia to determine whether the findings of the current study represent changes in Australian ECT practice.

Twice versus thrice weekly ECT in a clinical population: an evaluation of patient outcomes

Increasing demand on electroconvulsive therapy (ECT) services led to a recommendation that low risk patients be considered for twice weekly ECT rather than the usual thrice weekly. We evaluated whether practice changed and compared patient clinical outcomes for twice and thrice weekly ECT. Medical records for all patients receiving ECT in the 2-year study period (1/9/08 to 30/8/10) were reviewed to determine ECT protocol, diagnosis, admission duration and readmission rates. During the study period, 119 patients received 150 treatment courses. Patient outcomes were compared for twice weekly ECT and thrice weekly ECT protocols, as well as for 1 year before and after the recommendation (1/9/09). Twice weekly ECT courses increased (8-20) after the recommendation while thrice weekly ECT courses decreased (64-30). The recommendation had no significant effect on patient outcomes. Comparing twice and thrice weekly ECT, patient clinical outcomes were similar between the two groups, though non-affective twice weekly patients waited longer before starting ECT. In the context of resource constraints, psychiatrists can be influenced to examine and change their ECT prescribing practice. This bodes well for the implementation of evidence-based treatment into mental health services. Secondly, for adults, there appear to be no significant differences in clinical outcomes for twice versus thrice weekly ECT.

Has electroconvulsive therapy use remained stable over time? A decade of electroconvulsive therapy service provision in Victoria, Australia

OBJECTIVE

Despite the long history of electroconvulsive therapy (ECT) as a psychiatric treatment modality in Australia, existing literature regarding ECT use and practices in Australia is limited. In this unique study, we report ECT provision in Victoria to adults aged 25 years and over from 1998 to 2007, based on complete data from all public and private treatment settings within the State; compare our results to previous literature in the field; and offer possible explanations for these findings as a basis for future research.

METHOD

Analysis of statutory ECT service provision data collected by the Office of the Chief Psychiatrist of Victoria.

RESULTS

ECT use declined overall from 2001 onward, followed by a small increase in use in 2007. Eighty per cent of patients received ECT for depression and 14% for psychosis. Sixty-two per cent of ECT recipients were women. Although patients aged 65 years and over were small in number, age adjustment of data was indicative of a higher utilisation rate in this group. With increasing age, the percentage of ECT recipients treated for depression increased, whereas the percentage treated for psychosis decreased. Sixty per cent of patients were treated in the public sector. Public-private sector ECT use did not differ greatly for depression, but more patients were treated in the public sector for psychosis. The majority of patients with depression received treatment voluntarily, but the converse was true for patients with psychosis. Unilateral electrode placement predominated.

CONCLUSIONS

While utilisation rates gradually declined over the decade studied, patients continued receiving ECT in significant numbers, suggesting its role in treating severe mental illness is far from superceded. The present, population-level research cannot explain the causative factors underlying the patterns observed, but raises interesting questions for further investigation. Ongoing collection of statutory ECT data in a manner making it amenable to research applications is recommended.

Contemporary use and practice of electroconvulsive therapy worldwide

To explore contemporary (from 1990) utilization and practice of electroconvulsive therapy (ECT) worldwide. Systematic search (limited to studies published 1990 and after) was undertaken in the databases Medline, Embase, PsycINFO, SveMed, and EBSCO/Cinahl. Primary data-based studies/surveys with reported ECT utilization and practice in psychiatric institutions internationally, nationally, and regionally; city were included. Two reviewers independently checked study titles and abstracts according to inclusion criteria, and extracted ECT utilization and practice data from those retrieved in full text. Seventy studies were included, seven from Australia and New Zealand, three Africa, 12 North and Latin America, 33 Europe, and 15 Asia. Worldwide ECT differences and trends were evident, average number ECTs administered per patient were eight; unmodified (without anesthesia) was used in Asia (over 90%), Africa, Latin America, Russia, Turkey, Spain. Worldwide preferred electrode placement was bilateral, except unilateral at some places (Europe and Australia/New Zealand). Although mainstream was brief-pulse wave, sine-wave devices were still used. Majority ECT treated were older women with depression in Western countries, versus younger men with schizophrenia in Asian countries. ECT under involuntary conditions (admissions), use of ambulatory-ECT, acute first line of treatment, as well as administered by other professions (geriatricians, nurses) were noted by some sites. General trends were only some institutions within the same country providing ECT, training inadequate, and guidelines not followed. Mandatory reporting and overall country ECT register data were sparse. 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.

Practice of electroconvulsive therapy at the research and training hospital in Turkey

OBJECTIVE

We sought to obtain an overview of electroconvulsive therapy (ECT) practice in Bakirkoy Research and Training Hospital for Psychiatric and Neurological Diseases, which is the biggest hospital for psychiatry in Turkey.

METHOD

From 1st January 2006 to 30th June 2007, a form enquiring about evaluation of ECT was filled retrospectively.

RESULTS

The total number of patients, admitted for psychiatry during the survey period was 265,283. A total of 1,531 patients (12.4% among inpatients and 0.58% in all psychiatric admissions) received 13,618 sessions (including multiple hospitalizations) of ECT from 12,341 psychiatric inpatients during the survey period. Ninety-eight patients had multiple hospitalizations. The male-to-female ratio was 1.26-1. Patients with bipolar affective disorder, current episode manic with or without psychotic symptoms received ECT most frequently (30.3%), followed by patients with schizophrenia (29.5%), severe depressive episode with or without psychotic symptoms (include bipolar affective disorder current episode severe depression) (15.2%), other non-organic psychotic disorders (14.4%), schizoaffective disorders (6.3%), mental and behavioral disorders due to psychoactive substance abuse with psychotic disorders (3.5%) and catatonic schizophrenia (0.7%). Patients who received ECT were in age group of 25-44 years (64.7%), followed by 45-64 years (17.7%), 18-24 years (15.4%), 65 years and older (1.4%), and younger than 18 years (0.8%). All patients received modified ECT. There were no ECT-related deaths during the survey.

CONCLUSION

The rate of ECT among all psychiatric inpatients during the survey period was 12.4%. The majority of patients who received ECT were diagnosed with bipolar affective disorder-current episode manic and schizophrenia. ECT training programs for psychiatry residents and specialists should be planned, and conducted systematically.

A questionnaire survey of ECT practice in Australia

OBJECTIVE

To determine the characteristics of electroconvulsive therapy (ECT) practice in Australia.

METHOD

From October 1, 2002 to February 29, 2004, a 29-item questionnaire was sent to 136 hospitals in Australia.

RESULTS AND CONCLUSIONS

One hundred thirteen hospitals (83%) completed the questionnaire. Electroconvulsive therapy was available in 90 hospitals. A total of 7469 patients received 58,499 ECTs from 356 psychiatrists, which gives an average course length of 8.5 treatments. Electroconvulsive therapy use as assessed by the crude treated-person rate was 37.85 persons per 100,000 population per annum. Of the number of patients, 63.4% were women. Brief-pulse devices were used in all hospitals. Electroencephalogram monitoring was used routinely in 80 hospitals. Of the total number of ECT treatments, 82.3% were given to patients with major depression, 9.6% to patients with schizophrenia, 4.9% to patients with mania, and 1.7% to patients with catatonia. Patients who received ECT were in an age group older than 65 years (38.4%), followed by 45 to 64 years (28.3%), 25 to 44 years (26.3%), 18 to 24 years (6.9%), and less than 18 years (0.2%). Unmodified ECT was not used in any hospital. One thousand one hundred ninety-six patients received continuation ECT in 83 hospitals, and 1044 received maintenance ECT in 77 hospitals. There was no case of ECT-related death during a survey period. Only 31 hospitals rated their teaching program for medical students as acceptable to excellent, and for psychiatry residents, it was 58.