The National Audit of ECT in Scotland: Executive Summary

The National Audit of ECT in Scotland was ambitious in its aims, seeking to answer questions about clinical practice, facilities and staffing, training and clinical efficacy. Yet it tried to remain practical by attempting to introduce incremental changes into normal clinical activity. Through involving all the clinical team at ECT (doctors, anaesthetists and nurses) and encouraging local site ownership of results the audit sought to produce improvements in practice which will be maintained in the long term.

The audit was divided into three phases and provided a detailed examination of the practice of ECT in Scotland. Against pre-set national standards (with reference to the Royal College of Psychiatrists Handbook and the CRAG Good Practice Statement on ECT) two audit loops measured the standard of facilities, equipment, staffing, training and supervision; two audit loops measured clinical outcome; and one measured nursing levels. At the end of Phase 3 a further six months funding was secured in order to establish a mechanism for ongoing data collection.

The views of a wide group of people including users and representatives were sought at an early stage and input from them was very valuable in planning the project. No one member of this Reference Group has signed up to all the statements made and the report itself may not reflect the views of every member.

The audit was designed to gather basic facts about facilities, staffing, use of ECT and outcome. Some of the more controversial questions raised, for example: the validity of the consent process, long term relapse rates and measurement of side effects have been outwith the scope of this project and will only be answered by further research work. We hope that the interest generated by this audit will result in such research being undertaken.

Main results

• Between 1st August 1997 and 30th April 1998, 872 courses of ECT were given to 794 patients. The average number of ECT treatments per course was 6.8.
• Between 1st August 1998 and 30th April 1999, 752 courses of ECT were given to 717 patients. The average number of ECT treatments per course was 6.6.
• During the survey period treatment was given at the rate of 21.2 courses of ECT to 19.7 patients per 100,000 population per year.
• This represents an annual rate of ECT in Scotland of 142 ECT treatments per 100,000 population. (155 in 1997/98; 130 in 1998/99).
• ECT was given mainly to white adult in-patients suffering from depressive illness.
• The ratio of female to male patients was approximately two to one.
• 76% of patients in the audit were informal (voluntary) patients and 81.8% of all patients gave informed consent to the course of treatment.
• There was a definite clinical improvement with treatment in 71.2% of those treated for a depressive illness and 65% of those treated for other (psychotic) illnesses.

Key Findings and Conclusions

• The national audit has involved all ECT centres in Scotland. Meetings involving ECT co-ordinators and user groups have been well attended and general awareness remains high. The audit was on the whole well received and its methodology has now begun to be integrated into clinical practice.
• The standard of ECT treatment in Scotland has been found to be high. This compares with results from a smaller audit of ECT in England and Wales which revealed disturbing deficiencies in the quality of treatment.
• Facilities and equipment at ECT centres are up to date and of a generally high standard.
• The rate of use of ECT in Scotland is comparable with the lowest figures from previous British audits.
• The higher figure for use of ECT in females reflects the higher incidence of female admissions for depressive disorder (F:M = 1.6: 1 in Scottish Health Statistics 1998).
• There was no evidence that male psychiatrists prescribed ECT preferentially to female patients.
• ECT was not given disproportionately to the elderly.
• The ethnic minorities make up 1.25% of the Scottish population and therefore the figure of 0.7% receiving ECT is well below the population norm.
• The audit standards set for clinical improvement following ECT were met.
• ECT is not effective for everyone but the number of patients whose symptoms became worse during the audit was less than would be expected without any intervention.
• The quality of audit data received was significantly higher from those centres employing an ECT nurse specialist.
• Issues of consent have been highlighted and clarified. The audit has proved to be a useful sounding board for The Mental Welfare Commission in their development of new guidelines on consent issues related to ECT.
• The areas highlighted for improvement are mainly related to the ongoing supervision of trainee doctors which correlates with the lack of co-ordinator sessional time.