6. PHASE 2

Objectives and method

Data was collected on all ECT treatments in the whole of Scotland during a nine month period. The information collected described the diagnostic groups receiving ECT and provided details of patients legal status and consent. All patients should either give consent or be appropriately detained under The Mental Health (Scotland) Act 1984. Further information about the Act as it applies to ECT is available in the CRAG Good Practice Statement and is summarised in Annex F. The audit described the practice of ECT in terms of frequency, number and type of treatment given. It measured the effectiveness of ECT in a clinical setting using the MADRS and Clinical Global Impression Scales. Based on findings from research (Freeman 1978, Johnstone 1980) clinical benefit was defined as at least a 50% reduction in the MADRS score in 70% of patients or a definite global clinical improvement in the majority if more relevant.

Complementary to phase 1 results, five months into phase 2, all trainee doctors were asked about their knowledge of the audit and to provide their views on the effectiveness of their ECT training.

Results (July 1998)

i. ECT usage

All ECT sites returned data. Quality assurance was undertaken and missing data explained where the process of audit had not been fully integrated into routine practice.

Table 2: ECT usage during Phase 2 of the audit

(ref: SMRO 1991, National Census and ISD)

• Prescription rates of ECT varied throughout the country but no significant trend could be seen between type of hospital (e.g. teaching, district general) or location i.e. whether rural, urban or mixed.
• The rates are directly comparable with the lower rates of usage in England and Wales in 1991 and 1996 (Pippard 1992, Duffet & Lelliot 1996) and are less than half of the estimated use in Scotland over the years 1985-95, (Freeman CPL 1997). See Table 3.

Table 3: Comparison of annual ECT usage between 1981 and 1999

ii. Demographic data

Table 4: Age and sex of patients receiving ECT during Phase 2 of the audit

• All but three of the patients (0.4%) were white. This means that ECT was given to a minority ethnic mix considerably lower than in the Scottish population as a whole (1.25%).
• The higher number of females receiving ECT is a reflection of the higher number of female admissions. (F:M = 1.6:1 in Scottish Health Statistics 1998)
• 91.7% were treated as inpatients and 8.3% as day patients or outpatients.
• ECT was given once weekly to 2.3% and twice weekly to 95% of patients. 2.3% of patients received thrice weekly ECT at the start of their course.
• The bilateral electrode placement was used in over 95% of occasions.
• The prescription of ECT according to age group and a diagnosis of depressive illness is given in table 5.

Table 5: Courses of ECT per 100 depressed inpatients by age group

(ref: Scottish Health Statistics 1998)

iii. Legal status and consent at outset

Further information about the sections of The Mental Health (Scotland) Act 1984 which apply to ECT is given in Annex F.

Table 6: Legal status and consent at outset during Phase 2 of the audit

• In 41 of the 89 patients subject to Form 10 the reason specified was incapable in 27; refused in 14.
  • S 102 is a record of urgent treatment rather than a consent document per se. Ambiguity in the data collection form meant that this information was not always filled in.

At the completion of the ECT course the number of patients detained under the Mental Health Act had fallen by 1%.

Feedback to the units where a Form 9 was missing resulted in the implementation of a system aimed at improving Mental Health Act documentation.

At this stage the audit forms were adapted to record more detail on the reason for treatment under Form 10.

iv. Diagnosis and indication for ECT

By far the majority of patients suffered from a depressive illness (85%). A further 7.8% were diagnosed as having a schizophrenic illness and 2% a manic illness. 1% of patients suffered from a neurotic illness and data was missing for 4.3% of patients.

Table 7: Indications for ECT during Phase 2 of the audit

Indications for ECT (more than one could be selected per patient)

v. Outcome measures

Data was returned for 602 ECT courses representing 82% of the audit forms returned (602/735) and 69% of the total number of ECT courses given (602/872). Results were obtained from all centres.

For MADRS scores the standard set for a good outcome was defined as a 50% reduction in score in at least 70% of patients. Table 8 summarises the results.

Table 8: MADRS score (depressive illness) during Phase 2 of the audit

(n=542 patients)

Therefore, ECT given in a routine clinical setting was effective for the majority of patients. Factor analysis looking for predictors of good outcome was not conclusive at this stage.

For those patients for whom the CGIC was more appropriate the standard set was a definite clinical improvement in the majority of patients. The results are given in table 9.

Table 9: Clinical Global Impression of Change (CGIC) (other than depressive illness) during Phase 2 of the audit

At this time ECT centres were encouraged to record a CGIC rating on all patients so that the next round of data collection would include a CGIC rating for depressive illness.

vi. Untoward events

Of the 735 courses of ECT given 30 (4.1%) were reported as discontinued prior to completion as a result of some untoward event. Reasons given are set out in Table 10.

Table 10: Reasons for discontinuation of ECT during Phase 2 of the audit

(* see Table 21).

See Section 9 for a discussion of adverse events temporally related to ECT.

vii. Questionnaire to doctors administering ECT

66 out of the 145 doctors surveyed (45.5%) returned questionnaires. Of these 56% were SHOs on psychiatry, 14% were GP trainees and 14% were non training grades.

Table 11: Training and supervision of doctors administering ECT (1998)