Annex G

Report on the National Conference held at Paisley

on 12th November 1999

Programme:

Content and Discussion:

Sir David Carter welcomed the audit and the publication of the ECT in Scotland booklet.

1. Demographics:

The audit data on the type of patient receiving ECT was presented and for the first time on a national basis evidence was produced to show that ECT is not being overused or given preferentially to the disadvantaged. The following points were raised during discussion:

• The fall in ECT use has been national and there is now some concern that ECT is underused in some areas.
• The need to ensure that very elderly patients who may respond very well to ECT are not deprived of the treatment.
• The safeguards surrounding ECT for adolescents.

2. Fabric and Process:

The results showed an improvement in facilities, equipment and treatment schedules over the three year period. There were no concerns over the initial training of junior staff but still some definite problems with continued supervision. One unit which failed to reach adequate teaching standards had been closed. The demand for allocated consultant time was supported. The points discussed were:

• The need to train junior doctors to be the consultants of tomorrow.
• The need to ensure there is a continuing high quality supervision of junior staff
• Whether ECT should be delivered by junior doctors under supervision or only by more senior psychiatrists.
• The lack of evidence for complicated treatment protocols.

3. The role of the Nurse:

There has been a huge change in the role of the nurse in ECT clinics over the past ten years. The nurse is now an important team member who influences decision making and has clear responsibilities often including pre-ECT workup and aftercare. The audit data was completed most efficiently at those centres employing a specially designated ECT nurse. The points raised in discussion included:

• The formalisation of nurse training and accreditation in ECT.
• The role of the nurse in seeking consent for treatment.
• The role of the nurse in the development of safety standards.

4. Clinical Effectiveness:

The presentation covered the indications for ECT and the outcome of treatment. The audit found that ECT is used principally in depression and over 70% of patients gain significant benefit. Data on adverse effects showed that 38 out of 1314 patients experienced medical problems which led to the treatment being discontinued. Two elderly patients died during a course of treatment. The following points were raised:

• The discrepancy between the figure for adverse events quoted in the ECT in Scotland booklet (1:50,000) and the findings of the audit
• The failure to use a self rating scale
• Preliminary results were reported on longer term benefits of treatment. Five per cent of patients followed up at one centre had experienced a relapse within six months of finishing a course of ECT.

5. The law and ECT:

The role of the MWC was explained and includes the overseeing of safeguards in place and the appointment of second opinion doctors. Recent guidelines for consent to ECT have been produced. The capacity to give consent was explained and examples were given of the reasons for detention. Data was presented on the return of Consent to Treatment forms and it was thought there was good agreement on treatment options between local consultants and second opinion doctors. The debate centred around:

• Difficulties in the present system of recording informed consent.
• Reference was made to the Adults with Incapacity Bill and plans for the new Mental Health Act.
• The value of advance statements was debated but no conclusions drawn.

6. SAMH position:

There would not be an anti-ECT lobby if all patients were happy with the treatment process. There is concern that some patients feel pressurised into giving consent and more should be done to assess outcome from the patients perspective. There should be independent advocacy available for all patients and ECT should not be given without consent except in an emergency. SAMH are not an anti-ECT organisation but they do support the call for more work to be done on long term follow up and measurement of side-effects. A policy statement on ECT is available. The discussion included:

• An outline of some of the neurobiological processes which explain the mechanism of ECT were described in response to a question from SAMH on how ECT actually works.
• The observation that ECT booklet painted too optimistic a picture of the audit data.
• A call for careful research into the indications for ECT.

7. Status and Consent at ECT:

Over 75% of the patients were informal and over 80% gave informed consent to treatment. This left around 20% of patients who were given ECT either because of an inability to give consent or refusal to accept treatment (2:1). These patients are usually the most severely ill and would be denied treatment if there was no provision under the Mental Health Act to proceed. Many questions were raised in discussion:

• How can consent be rated as freely given if assessment relies on the opinion of clinicians.
• In the situation of treatment refusal should a patient be allowed to continue to suffer and even die rather than be detained and given the treatment without fully informed consent?
• Should advance statements refusing ECT be over-ridden in an emergency situation?

8. IT and the future of the audit:

The prototype of a CD-ROM method of continued data collection was demonstrated. This could allow ECT suites to collect data locally and anonymously feed into a national database for two way information sharing. The system would be password protected and user friendly and could be designed to collect specific information on adverse events as well as acting as a failsafe reminder of the statutory documentation required.

9. Final Remarks:

Professor Cheetham congratulated all participants, thanked the audience and closed the meeting.

Conference organisation: The SEAN committee would like to thank Kate McKie at the Convention Management Service, Scottish Health Service Centre, Edinburgh, EH4 2LF for organising the conference.

Note

• CMO - Chief Medical Officer.
• SEAN - Scottish ECT Audit Network.
• SENF - Scottish ECT Nurses Forum.
• MWC - Mental Welfare Commission.
• SAMH - Scottish Association for Mental Health.
• CALAIB - a software production company.