5. Guidelines, audits and rating scales

Three decades of quality improvement in electroconvulsive therapy. (2013) Murphy G, Doncaster E, Chaplin R et al. J of ECT;29:312-317.
The authors describe the introduction of the Royal College of Psychiatrists ECT Accreditation Service in 2003. This followed the need for change as evidenced by three earlier audits of ECT practice in England and Wales. Year on year since then there have been improvements against the 10 audit standards. However the system has not been able to equate these improvements to clinical outcome since outcome measures are not gathered like they are in the Scottish ECT Accreditation Network (SEAN).

 

Delivery of electroconvulsive therapy in Canada. A first national survey report on devices and techniques. (2013) Gosselin C, Graf P, Milev R et al. J of ECT; 29:225-230.
A questionnaire to all 175 ECT services produced a 61% response rate. Brief pulse machines with EEG monitoring are now the norm. Bilateral ECT was most often given but the authors report a striking variation in dosing practice and call for a national standard to work towards.

 

The practice of electroconvulsive therapy in Greece. (2013) Kaliora SC, Braga RJ, Petrides G et al. J of ECT; 29:219-224.
Eighty-two per cent of the 67 ECT units in Greece responded to this postal survey. Schizophrenia was the most common patient diagnosis and bilateral ECT was the preferred modality; all treatment was modified. Written consent was required in 78% of services; the rest gave verbal consent. Outpatient treatment was rare. Maintenance ECT was used in 33% of hospitals.

 

Report on 3 years’ experience in electroconvulsive therapy in Bakirkoy research and training hospital for psychiatric and neurological diseases. (2013). Canbek O, Menges O, Atagun M et. al. J of ECT; 29:51-57.
This was a three year survey of 3490 patients receiving ECT in a Turkish tertiary referral service. Psychotic disorders were the most common diagnosis (52%) cf affective disorders (47%). Clinical reasons for ECT were recorded and patient demographics compared to other countries. The average length of course was 8 treatments and the average length of stay in hospital was 33 days. There were no serious adverse events reported.

 

Pharmacological strategies in the prevention of relapse after electroconvulsive therapy. (2013). Prudic J, Haskett RF, McCall WV, et. al., J of ECT; 29:3-12.
Relapse after ECT is high; the authors set out to determine whether starting an antidepressant or mood stabiliser early in the course of ECT made any difference to relapse rates. The conclusion was that starting pharmacological treatments early made no difference to starting them at the end of the course of ECT.

 

Scottish psychiatrists’ attitudes to electroconvulsive therapy: survey analysis. (2013). Martin F & Elworthy T. The Psychiatrist 37, 261-266.
This was a self administered 19 item survey that was returned by 91 psychiatrists. Over 90% felt that ECT was safe and effective but 43% noted that prescription rates had decreased. Reasons for this were thought to relate to better antidepressants, public and patient perception and NICE guidelines. Male psychiatrists were more likely to prescribe ECT compared to females but no other significant factors were found in relation to prescribing rates.

 

Electroconvulsive therapy in the United States: How often is it used? (2013), Weiner R. & Prudic J. Biol Psych. 73; issue 2; 119-126.
There are no national statistics to answer this question. The authors refer to a large database of inpatient treatment given from 1993-2009 but only around 50% of ECT clinics were involved. In addition, there is a growing practice of outpatient ECT. There are concerns that the centralisation of ECT clinics and the possible reclassification of ECT machines will affect access to ECT so now would be a good time assess ECT utilisation as a baseline measure.

 

Electroconvulsive therapy in Brazil after the “psychiatric reform”. (2012), Ribeiro R., Ribeiro D., Rigonatti S. et al. Journal of ECT; 28:170-173.
Availability of ECT in Brazil is limited to a few academic centres and demand for treatment is high. Combined statistics showed that 63% of patients were from the public sector and the authors press for changes in mental health policies and funding to enable access to ECT in order to meet the demand.

 

Declining use of electroconvulsive therapy in US general hospitals. (2012), Case B., Bertollo D., Laska E. et al. Biol Psych. http://dx.doi.org/10.1016/j.biopsych.2012.09.005

This US survey adds to the observation, seen previously in North Glasgow, Scotland, that reduction in rate of use of ECT is related to availability of treatment within the base hospital. There was a one third reduction in use of ECT in services without ECT units over the period from 1993-2009.

 

Electroconvulsive therapy in China. (2012), Tang Y., Jiang W., Ren Y., Journal of ECT;28:206-212 and 213-218.
These two articles report on clinical practice, efficacy, technical aspects and proposed mode of action.
ECT has been used in China since the early 1950s and there are now more than 900 published articles on the topic, most in the Chinese language and so not easily available to the international community. The most common patient diagnosis is schizophrenia and certain populations tend to be excluded, eg elderly and children. Modified treatment has replaced unmodified and outcome for both schizophrenia and mood disorders is reported as good.

 

Appropriateness for electroconvulsive therapy (ECT) can be assessed on a three-item scale.(2012), Kellner C, Popeo D, Pasculli R et al., Med Hypotheses; http://dx.doi.org/10.1016/j.mehy.2012.04.036

The authors attempt to measure appropriateness for ECT using factors of severity, heritability of depression and episodic nature of the illness. There is a clear statement that the scale is not meant to predict outcome at ECT.

Electroconvulsive therapy in Bulgaria. A snapshot of past and present.(2012), Hranov LG, Hranov G, Ungvari GS et al., J of ECT; 28:108-110.

A semi-structured questionnaire was sent to all psychiatric inpatient units in Bulgaria. Only 4 of the 33 units surveyed confirmed the use of ECT and only three of these used a machine capable of EEG monitoring; all were university departments in Sophia. There is understandable concern that many patients in other parts of the country were being denied access to an effective treatment for severe depressive disorders.

Appropriateness for electroconvulsive therapy (ECT) can be assessed on a three-item scale.(2012), Kellner C, Popeo D, Pasculli R et al., Med Hypotheses; http://dx.doi.org/10.1016/j.mehy.2012.04.036

The authors attempt to measure appropriateness for ECT using factors of severity, heritability of depression and episodic nature of the illness. There is a clear statement that the scale is not meant to predict outcome at ECT.

Electroconvulsive therapy in Bulgaria. A snapshot of past and present (2012), Hranov LG, Hranov G, Ungvari GS et al., J of ECT; 28:108-110.

A semi-structured questionnaire was sent to all psychiatric inpatient units in Bulgaria. Only 4 of the 33 units surveyed confirmed the use of ECT and only three of these used a machine capable of EEG monitoring; all were university departments in Sophia. There is understandable concern that many patients in other parts of the country were being denied access to an effective treatment for severe depressive disorders.

Comparison of electroconvulsive therapy practice between London and Bengaluru. (2011), Eranti S, Thirhalli J, Pattan V et al. J of ECT27: 275-280

The rates of ECT referral were 0.9% of total annual admissions at a London teaching hospital and 8.2% at the Indian teaching hospital site. Reasons for ECt differed and the most common diagnosis in the Indian site was schizophrenia. The London site used the half age method for dose estimation and seizure threshold was measured at the Bebgaluru site. The course of ECT was shorter in India. Outcome was assessed as better in Bengaluru with 80% reported as recovered compared to 60% in London.

Electroconvulsive therapy in Norway. (2011), Schweder L, Lydersen S, Wahlund B et al. J of ECT, 27: 292-295.

There was a 54% response to this 42 item questionnaire on the use of ECT in Norway. Rate of use varied from 1.83 to 3.44 per 10,000 inhabitants per year. Demographic details are reported. The most common reason for ECT treatment was depression.

Access to electroconvulsive therapy services in Canada (2011), Delva N, Graf P, Patry S et al. J of ECT, 27: 300 309

Returns from this questionnaire are presented and confirm that there is reasonable availability of ECT centres across the country but that there are concerns about access to this in view of limited finances and availability of properly trained staff.

Electroconvulsive therapy clinical database. A standardised approach in tertiary care psychiatry. (2010), Rai S, KivisaluT, Rabheru K et al. J of ECT 26;304-309.

This is a description of an electronic case record of patient characteristics, treatment characteristics and outcome in a Canadian service giving similar information to that collected throughout Scotland. The authors describe the usefulness of such  information at the various levels from the scheduling of appointments to the analysis of outcome and advise other services to follow suit.

Use of continuation and maintenance electroconvulsive therapy; UK national trends.(2011), Gupta S, Hood C & Chaplin R. J of ECT 27;77-80

Thirty five percent of clinics in England and Wales responded to a national survey; around one quarter of these clinics gave either continuation or maintenance ECT. The number of patients receiving continuation or maintenance ECT appears to have declined since the introduction of National Institute for Clinical Excellence (NICE) guidelines in 2003 though the number reported for 2006-07 (26) is still higher than that estimated for 1996-97 (14).

Trends in the administration of electroconvulsive therapy in England.(2009), Bickerton D, Worrall A, Chaplin R. Psychiatric Bulletin, 33, 61-63.

This group from the Royal College of Psychiatrists research and training unit surveyed the use of ECT over a 3 month period in England in 2006, comparing rates with those published by the Department of Health in 1999 and 2002. Both the number of clinics and the number of patients had declined giving rise to concerns about the availability of training and experience.

Unilateral and bilateral electroconvulsive therapy: what informs Scottish psychiatrists choices? (2009). Kevin Brown. Psychiatric Bulletin, 33, 95-98.

The UK ECT Review Group concluded that on the evidence available in 2003 that bilateral ECT was slightly more efficacious than unilateral but resulted in more cognitive side effects. More recent studies have suggested that unilateral ECT given at doses higher than previously is equally as effective. This survey showed that the majority (79%) of Scottish psychiatrists still prefer bilateral electrode placement but that a significant minority (18%) were now using unilateral ECT to try and minimise cognitive side-effects. The author postulates that data from the Scottish ECT Accreditation Network (SEAN) could be used to gather sufficient information to inform practice based on evidence.

ECT practice and psychiatrists attitudes towards ECT in the Chuvash Republic of the Russian federation. (2009), Golenkov A, Ungvari GS, Gazdag G. JeuroPsych. 2009.02.011.

This survey describes the practice of ECT in the Chuvash Republic since becoming available in 1997. The rate of use has doubled from a very low base line to 8 per 100,000 population and most people treated have a diagnosis of schizophrenia. Many psychiatrists held negative attitudes and more than half of those poled believed that ECT was painful and caused brain damage. Reasons for this could be attributed to out of date educational material at Russian medical schools.

Electroconvulsive therapy practice in Poland. (March 2009). Gazdag et al. J of ECT; 25:34-38.

This article contains a table comparing rates of ECT use and concludes that use in Poland is low compared to others. However ECT is mainly given for affective disorders using the bitemporal electrode position, twice or three times per week. There is little standardisation of treatment protocols but all patients are anaesthetised.

Modified and unmodified electroconvulsive therapy. A comparison of attitudes between psychiatrists in Beijing and Hong Kong. (June 2009). Leung C et al. J of ECT; 25:80-84.

Unmodified ECT is still being used in China where 56% of respondents to a survey questionnaire said that they preferred this form of treatment. Patient choice, financial status and safety considerations were the main factors affecting this decision.

The practice of electroconvulsive therapy in Malawi. June 2008. Selis M, Kauye F, Leentjens A. J of ECT; 24:137-140

This article describes ECT as it was in 2006. 47 patients received unmodified ECT during a two month spell with good clinical outcome in 71 – 90% and tolerable side-effects. There were no serious complications.
A Scottish group are now helping with equipment and training as part of the Malawi project.

The rate of use of electroconvulsive therapy in the city of Edinburgh, 1993-2005. September 2008. Okagbue et al, J of ECT; 24:229-231.

This survey was undertaken to try and detect any effect that the National Institute for Clinical Excellence (NICE) had on the rate of use of ECT in a stable population. The group found a 60% reduction in use of ECT over the study period but no accelerated fall in use since the introduction of the NICE guidelines in May 2003. Rates of ECT are tabulated according to age groups.

Electroconvulsive therapy: the practice and training needs of referring psychiatrists in the United Kingdom and Republic of Ireland. Blaj A, Worrall A, Chaplin R. June 2007. J of ECT;23:78-81.

Questionnaires were sent to 490 prescribing psychiatrists to determine their knowledge about the consent process and practice at ECT. Examples of positive and negative comments are given. The conclusion was that the quality of information could be improved in both content and form paying particular attention to written information and the possibility of long-term cognitive side effects.

A questionnaire survey of ECT practice in Australia. Chanpattana W. June 2007. J of ECT;23:89-92.

There was an 83% response rate to this first national survey of ECT in Australia between 2002 and 2004. Rate of use averaged 38 persons per 100,000 population per annum but with significant regional variation. Average length of course was 8.5 treatments and the major characteristics of ECT practice are reported as similar to those in the United States.

What does Star*D tell us about ECT? McCall WV. March 2007. J of ECT;23:1-2.

This editorial describes the conclusion of a large (n=3671) study, funded by the NIMH, of antidepressant treatment for major depressive disorder. The results indicate that there is no point going on past three failed antidepressant trials, so the suggestion is that ECT should be tried early in any treatment algorithm.

Belling the cat: ECT practice standards in the United States. Fink M & Kellner C March 2007. J of ECT; 23:3-5.

An editorial calling for standardisation of training, fabric and practice in the delivery of ECT in the United States. The authors describe the two successful models operating in the UK.

Monitoring electroconvulsive therapy by electroencephalogram: an update for ECT practitioners. Allan Scott July 2007. Adv in Psych Treatment, vol13,298-304.

This article is a practical guide for practitioners and gives helpful hints on determining seizure end-point. Also discussed is the evidence (or lack of) for the suggestion by machine manufacturers that adequacy of treatment can be assessed by EEG characteristics.

Electroconvulsive therapy in Belgium: A nationwide survey on the practice of electroconvulsive therapy. Sienaert et al. J of Affective Disorders 90(2006) 67-71.

This was a questionnaire survey to all 32 hospitals in Belgium who offer ECT. There was a 100% response rate. The usage of ECT varied five fold; the major indication for ECT was depression (89.7%). One third of clinics still used a sine wave device and 25% of the total used a fixed dose treatment schedule. The choice of treatment modality was between bitemporal(66%) and bifrontal (19%).

College Guidelines on electroconvulsive therapy: an update for prescribers. Scott AIF. Advances in Psychiatric Treatment (2005), vol 11, 150-156.

This comprehensive guideline describes the process by which the Royal College of Psychiatrists arrived at the recommendations made in the recently revised ECT handbook. It also outlines the NICE guidelines on ECT and suggestions for the psychiatrist considering ECT outwith these guidelines. The importance of the role of the patient in decisions about prescription is emphasised and the debate on concomitant drug treatment is outlined.

Editorial for ECT. Freeman C. J of ECT vol 22(1), March 2006.

This editorial by Chris Freeman, ex chair of the Royal College of Psychiatrists ECT committee, explains the National Institute for Clinical Excellence (NICE) process in reaching their guidance on ECT and the subsequent appeal launched by the College in response. He also hopes that the forthcoming NICE update review will take cognisance of recent evidence published in this edition of the journal.

Electroconvulsive therapy in Belgium. A  questionnaire study on the practice of electroconvulsive therapy in Flanders and the Brussels capital region. March 2005. Sienaert P et al. J of ECT; 21:3-6.

This study reports limited use of ECT in Belgium and the authors conclude that the standards of practice generally fall below available guidelines.

Survey of the practice of electroconvulsive therapy in teaching hospitals in India. June 2005. Chanpattana et al. J of ECT, 21(2):100-104.

66 institutions were surveyed. Most treatments were given in base psychiatric hospitals, all with a psychiatrist present. 52% treatments were given unmodified and less than half of the units had a brief pulse ECT machine. 8 units monitored EEG. Bilateral ECT was the norm and main indications for use were: schizophrenia (36%), depression (33%) and mania (18%). A training program for junior doctors existed in 44/61 institutions.

ECT practice in Japan. September 2005. Chanpattana W et al. J of ECT 21(3):139-144.

In order to develop standards for ECT in Japan the authors sent questionnaires to 100 institutions. There was a 40% response rate indicating that ECT use was low but that more than 50% was given unmodified. Main indications for use were schizophrenia (49%) and depression (37%) and the most common age group receiving treatment was in the 45-64 year olds.

Electroconvulsive therapy Practice in Western Australia. September 2005. The S et al. J of ECT 21(3): 145-150.

The authors call for a more information on the use of ECT in Western Australia (WA) so that comparisons could be made between States. Their survey concluded that the use of ECT in WA was lower than previously reported for Victoria and for older people use was noticeably lower than in NSW.

A National Survey of electroconvulsive therapy use in the Russian Federation. September 2005. Alexander Nelson. J of ECT 21(3):151-157.

ECT in Russia is available to 22% of the population. This questionnaire survey concluded that methods and equipment are outdated and less than 20% of treatments were modified. There is no training programme or organisation working to improve standards but most institutions reported they were eager to adopt modern methods.

Use of electroconvulsive therapy at a university hospital in Karachi, Pakistan: a 13 year naturalistic review.September 2005. Naqvi H & Khan M. J of ECT 21(3):158-161

The authors present their experience of this consultant run service, concluding that effective ECT can be given in a developing country if practitioners follow guidelines. Successful outcome was reported in 75% of patients most of whom (76%) had suffered from a depressive illness.

Trends in the administration of electroconvulsive therapy in England' by David Bickerton, Adrian Worrall and Robert Chaplin. Psychiatric Bulletin (2009), 33, 61-63

Electroconvulsive therapy practice in Thailand. Chanpattana W & Kramer A. June 2004. J of ECT;20:94-98.

This questionnaire survey reports on the high usage but generally poor standard of ECT in Thailand. Most ECT is given to male inpatients (72%) with a diagnosis of schizophrenia (74%). The treatment is unmodified on 94% of occasions and is almost exclusively given using a bilateral electrode placement with only a small number of clinics paying attention to dosing schedules. The quality of consent varies and there is no formal training programme for professionals

Electroconvulsive therapy in Scottish clinical practice: a national audit of demographics, standards and outcome. Fergusson G, Cullen L, Freeman C & Hendry J. September 2004. J of ECT 20:166-173.

A full report on the Scottish ECT Audit Network (SEAN) 3-year audit of ECT between 1997 and 1999, the first report to gather national data and measure outcome, including side-effects, in a routine clinical setting.

The electroconvulsive therapy accreditation service. Caird H, Worral A & Lelliot P. July 2004. Psychiatric Bulletin, 28,257-259.

The ECT accreditation service for England and Wales was launched in May 2003 and aims to maintain a database of standards, facilitate and e-mail discussion group and organise an annual members forum. Membership is voluntary and twenty five clinics subscribed to the first wave of accreditation.

Rates of electroconvulsive therapy use in Hungary in 2002. Gazdag G, Kocsis N, Lipcsey A. Journal of ECT March 2004, 20(1):42-44.

The rate of use of ECT is low and in 2002 was given in 34/43 departments. Indications for ECT were schizophrenia (56%) and affective disorder (40%) and treatment was given bilaterally three times per week.

A questionnaire survey of ECT practice in university hospitals and national hospitals in Japan. Motohashi N. Awata S, Higuchi T. Journao of ECT March 2004, 20(1):21-23.

In Japan ECT is given in 84 university hospitals and 37 national hospitals using machines delivering sine wave electricity. There is a wide variation in use and unmodified ECT is still given on occasions in two thirds of hospitals, anaesthetics and muscle relaxants are mainly reserved for operating room ECT. Indications for ECT were as in the UK but unilateral ECT was seldom used.

Knowledge of ECT among Staff of a Mental Health Service. Culas R & Ashaye K. Journal of ECT December 2003. 19:245-246.

75 members of all staff (66% of the total) in a mental unit of a general hospital completed a semi-structured questionnaire on ECT. Only 37% were aware of guidance with respect to informed consent, leading to a revision of the local ECT training programmes.

Has the Practice and Outcome of ECT in Adolescents Changed? Findings from a Whole-Population Study. Walter G & Rey J Journal of ECT June 2003, 19(2):84-87.

The authors compared the practice and outcome at ECT in adolescents over two survey periods: 1990-95 and 1996-99. Numbers were small at 1.53/100,000 14-18 year olds per year. Results showed an increase in the use of dose titration, bilateral ECT and EEG monitoring but no significant difference in outcome or side-effects. Good outcome was associated with a diagnosis of severe mood disorder while co-morbidity with personality disorder or substance abuse predicted a poorer outcome.

ECT in the Asia Pacific Region: What do we Know? John Little. Journal of ECT June 2003, 19(2):93-97.

This review describes the practice of ECT in 12 out of the 34 counties of the region, identified prior to the first Asia Pacific ECT conference held in Melbourne in the year 2000. There was wide-spread use of ECT and all countries used anaesthesia, brief pulse machines and bilateral electrode placement. Reported response rates were >86%, cognitive side-effects were noted and there was a generally negative community attitude. There was a high rate of use in Nepal and in Asia ECT was used more commonly for schizophrenia than depression.

Electroconvulsive Therapy in Hong Kong: Rates of Use, Indications and Outcome. Ka Fai Chung. Journal of ECT June 2003, 19(2):98-102.

This paper combines results from a five-year central database, 1997-2002, and a one year prospective study of 167 patients. Rate of use was low at around 3/100,000 population and an average course was 6-7 treatments. The gender distribution was similar to other studies but ECT was less likely to be used in the elderly. 40% of patients were diagnosed as suffering from depression and 23% schizophrenia. Outcome, according to clinical impression, showed a definite improvement in 83%. Side-effects were not routinely reported but only 6% of courses were discontinued because of adverse events.

Do patients who receive electroconvulsive therapy in Scotland get better? Results of a national audit Fergusson G, Hendry J & Freeman C. Psychiatric Bulletin April 2003; vol 27, no 4, 137-140.

This paper summarises the results of the national audit which took place between 1997 and 2000. A full copy of the report can be downloaded from the professional section of this website.

Australian and US Responses to Electroconvulsive Therapy Dosage Selection. Little J et al. Australian and New Zealand Journal of Psychiatry, Oct 2002, Vol 36 Issue 2, 629-633.

Two hundred and thirty six consultant psychiatrists across Australia and United States were asked to respond to a standardised clinical vignette on dosage selection. Results showed considerable variation and the authors conclude that the use of such vignettes (as at the Royal College of Psychiatrists UK training days) may be a useful training method.

An audit of seizure duration in electroconvulsive therapy. MacEwan T., (September 2002). Psychiatric Bulletin, 26, No 9, 337-339.

The author reports an improvement in adequate seizures following the introduction of a more flexible ECT machine and more emphasis on training and communication between ECT and clinical teams.

Initial seizure threshold of bilateral electroconvulsive therapy in Chinese. Chung KF and Wong SJ. Journal of ECT December 2001. 17(4):254-258.

An examination of the initial seizure threshold of 54 patients using a Mecta SR1 revealed an average threshold for bilateral ECT of 117mC (range 48-403mC). Variance factors were reported as: age = 36%, body mass index = 7%, gender = 6% leaving the authors to conclude that seizure threshold determination dosage for both sexes should commence at level 1 on the ECT machine.

Audit of an electroconvulsive therapy clinicss missed fit rate. Davies RH & Wilson R (2001), Psychiatric Bulletin, vol 25, 6, 215.''

A statewide survey of ECT policies and procedures .Westphal J & Rush J, September 2000, J of ECT 16(3):279-286.

An audit of ECT services in Louisiana where most hospitals have policies on electrical safety, pre-ECT workup, clinical privileging and documentation but where only a minority have policies on clinical aspects eg. stimulus dosing, seizure monitoring, or continuing education for ECT staff.

Running an ECT department. Eve Russell, 2001, Advances in Psychiatric Treatment, vol 7, 57-64.

This excellent overview outlines the responsibilities for clinical managers of an ECT service and concentrates on the first steps to be taken in raising the standards at ECT.

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