Electroconvulsive Therapy
Annual Statistics
For the period 1 July 2003
to 30 June 2005
Citation: Ministry of Health. 2006. Electroconvulsive Therapy Annual Statistics:
For the period 1 July 2003 to 30 June 2005. Wellington: Ministry of Health.
Published in August 2006 by the
Ministry of Health
PO Box 5013, Wellington, New Zealand
ISBN 0-478-30048-4 (Website)
HP 4297
This document is available on the Ministry of Health’s website:
http://www.moh.govt.nz
Contents
1
Introduction
1
How effective is ECT?
Possible risks
Side-effects
Does ECT cause brain damage?
Is ECT safe for pregnant women?
Alternative treatments to ECT
Is ECT given only as a last resort?
Further information
1
2
2
2
3
3
3
3
Scope of this Report
4
ECT treatments per patient
ECT delivered under compulsion
4
4
Number of Patients Treated with ECT
5
Regional variations in the number of ECT treatments given
8
4
ECT Treatments per Acute Course
9
5
ECT and Consent to Treatment
11
The consent process
Defining consent to treatment
ECT treatments and the Mental Health Act
11
11
11
6
Age and Sex of Patients Treated with ECT
14
7
Ethnicity of Patients Treated with ECT
17
2
3
Electroconvulsive Therapy Annual Statistics
iii
List of Tables
Table 1:
Table 2:
Table 3:
Table 4:
Table 5:
Total number of patients treated with ECT, by DHB, 1 July 2003–30 June 2005
ECT treatments per acute course, by DHB, 1 July 2004–30 June 2005
ECT treatments not consented to during the period 1 July 2003–30 June 2005
Age and sex of patients treated with ECT, 1 July 2003–30 June 2005
Ethnicity of people treated with ECT, 1 July 2003–30 June 2005
5
10
12
14
17
List of Figures
Figure 1a:
Figure 1b:
Figure 1c:
Figure 1d:
Figure 2:
Figure 3:
Figure 4a:
Figure 4b:
iv
Number of patients treated with ECT per 100,000 population, 1 July 2004–30 June
2005
Number of patients treated with ECT per 100,000 population, 1 July 2003–30 June
2004
Percentage of patients (aged 20+ years) seen at a mental health service treated with
ECT, 1 July 2004–30 June 2005
Percentage of patients (aged 20+ years) seen at a mental health service treated with
ECT, 1 July 2003–30 June 2004
ECT treatments per acute course, by DHB, 1 July 2004–30 June 2005
Population-adjusted figures for the number of ECT treatments consented to per
100,000 population, 1 July 2004–30 June 2005
Age and sex of patients treated with ECT, 1 July 2004–30 June 2005
Age and sex of patients treated with ECT, 1 July 2003–30 June 2004
Electroconvulsive Therapy Annual Statistics
6
6
7
7
10
13
15
15
1
Introduction
Electroconvulsive therapy (ECT) is a therapeutic procedure in which a brief electric
charge is delivered to a patient’s brain in order to produce a seizure. ECT is an
effective treatment for various types of mental illness including depressive illness, mania
and catatonia. Although ECT has been used since the 1930s, how it works is still not
fully understood. The most likely way in which ECT has its effect is that, like
antidepressants, it affects neurotransmitters (chemical messengers) in the brain
responsible for mental illness.
ECT is administered under anaesthesia and with muscle relaxants to prevent injury to
the patient as a result of the induced seizure. The end result is that the patient drifts off
to sleep and wakes up a short time later unable to recall the details of the procedure.
ECT is a valuable and sometimes life-saving treatment despite the often negative
depictions of it in popular culture and the media. It is mainly used to treat severe
depression, particularly if complicated by psychosis. It is also used in cases of severe
depression where:
• antidepressant medication, psychotherapy, or both, have been ineffective
• medication cannot be taken
• other treatments would be too slow (for example, in a person with delusional
depression and intense, unremitting suicidal tendencies).
ECT is considered the safest treatment option in some cases where depression is
accompanied by a physical illness or pregnancy, which renders the use of the usually
preferred antidepressants dangerous to the patient or to a developing foetus.
When a course of ECT is prescribed, it is usually administered twice a week for 3–6
weeks (ie, a course of 6–12 treatments).
How effective is ECT?
Seventy to 80 percent of patients who receive ECT respond well to it. In fact, ECT is
the most effective short-term treatment for severe depression. Most patients recover
their ability to work and lead a productive life after their depression has been treated
with a course of ECT. Because the effects are typically short term, medication is
usually required to maintain the beneficial effects of ECT.
ECT has also been shown to be effective in depressed patients who do not respond to
other forms of treatment. Medication is usually the treatment of choice for mania, but
here too certain patients do not respond. Many of these patients have been
successfully treated with ECT.
Electroconvulsive Therapy Annual Statistics
1
Possible risks
ECT is no more dangerous than minor surgery under general anaesthesia, and may at
times be less dangerous than treatment with antidepressant medications. A small
number of other medical disorders increase the risk associated with ECT, and patients
are carefully screened for these conditions before a psychiatrist will recommend them
for ECT. In New Zealand ECT services, the anaesthetic for ECT is given by a
consultant (or specialist) anaesthetist, in properly equipped facilities.
Side-effects
Some people will experience headaches, muscle ache or soreness, nausea and
confusion, usually during the first few hours after the procedure.
Over the course of ECT it may be more difficult for patients to remember newly learned
information, though this difficulty disappears over the days and weeks following
completion of the ECT course. Some patients also report a partial loss of memory for
events that occurred during the days, weeks and months preceding ECT. While most of
these memories typically return over a period of days to months following ECT, some
patients have reported longer-lasting problems with recalling these memories.
However, other individuals actually report improved memory ability following ECT,
because of its ability to remove the amnesia that is sometimes associated with severe
depression.
It has sometimes been questioned why ECT continues to be used in New Zealand
despite the fact that many patients experience these disturbances in memory following
ECT, and some experience severe and prolonged confusion after treatment. Most
medical treatments involve some risk to the patient. Decisions about treatment involve
a careful balancing of the risks and benefits of different treatment options, including the
option of having no treatment. Whenever possible, the patient and/or their family/
whānau should participate in the informed consent process, taking into account any
prior wishes or advance directives the patient may have expressed.
Although there have been many advances in the treatment of mental disorders in recent
years, ECT remains the most appropriate and effective treatment for some people
suffering with serious mental illness.
Does ECT cause brain damage?
There is no evidence that ECT causes any structural cerebral damage. However, as
noted, short-term memory impairment following ECT is common. It is not clear how
much of the longer-term memory impairment is caused by ECT and how much by
severe depression.
2
Electroconvulsive Therapy Annual Statistics
Is ECT safe for pregnant women?
ECT does not produce abnormal uterine contractions and it appears to be safe even in
complicated pregnancies. Foetal monitoring during ECT has not revealed any untoward
effects on the foetus.
However, the decision whether to treat pregnant women with ECT needs to take into
account the risks associated with alternative treatments, the risks to the mother and
foetus of withholding ECT, and any complications of the pregnancy that may increase
the risks of ECT or the anaesthetic. ECT may be used with confidence during the
second and third trimesters. Little information is available for its use in the first
trimester, so until further data is available caution is advisable during this stage.
Alternative treatments to ECT
Antidepressant drugs may be appropriate and it is possible that some of them may work
as well as ECT. The advantages and disadvantages of other treatments should be
discussed with the patient during the informed consent process referred to above.
Is ECT given only as a last resort?
When a patient presents with a severe mental illness such as major depression, the
various treatment options will be considered as well as their risks, benefits and
alternatives. It is not true that the risks associated with ECT are always greater than the
risks associated with other treatments, such as antidepressant medication. Some
patients may be non-responsive to, or intolerant of, antidepressant medication, and
other patients may require a treatment which has a rapid onset of action. For these
reasons, ECT is not always a treatment of last resort, and in certain life-threatening
situations it may be the first choice treatment option.
Further information
The December 2004 publication Use of ECT in New Zealand: A review of efficacy,
safety, and regulatory controls is available on the Ministry of Health website.
The Royal Australian and New Zealand College of Psychiatrists is the professional body
most closely involved in ECT.
Electroconvulsive Therapy Annual Statistics
3
2
Scope of this Report
This Ministry of Health annual report on ECT covers the two reporting periods from
1 July 2003 to 30 June 2005. In accordance with the Health Select Committee’s
recommendations, it shows statistics for the total number of people who received ECT,
plus breakdowns by a number of socio-demographic variables. The report also
presents statistics on the number of patients who were treated with ECT under
compulsion.
Where possible this report includes data gathered by the Ministry of Health for the
previous reporting period from 1 July 2003 to 30 June 2004. Data from the previous
year is included for the total number of patients treated with ECT, the percentage of
patients (aged 20+ years) seen at a mental health service treated with ECT and
demographic information such as age, sex and gender.
Data from the previous 2003/04 reporting period needs to be interpreted with caution for
the following reasons:
ECT treatments per patient
A series of acute ECT treatments is required to produce a lasting therapeutic effect.
This is known as an acute course of ECT. The data collected for the 2003/04 period
showed information on the number of ECT treatments given per patient but did not
accurately define whether treatment administered was part of an acute course of
treatment, or whether it was an additional treatment given to maintain the patient’s
mental state (maintenance treatment). Data collected for the 2004/05 reporting period
on the type of ECT treatment has lead to improvements in this aspect of ECT reporting.
ECT delivered under compulsion
A patient who is subject to compulsion under the Mental Health (Compulsory
Assessment and Treatment) Act 1992 (the Act) may nevertheless be capable of
consenting to treatment. During the 2003/04 reporting period, there were various
interpretations of the word compulsion. Some DHBs mistakenly interpreted compulsion
as referring to people subject to the Act, regardless of whether consent was given for
ECT. Hence the figures reported on the number of ECT administrations not consented
to were over-reported. This aspect of the ECT reporting continues to be refined.
4
Electroconvulsive Therapy Annual Statistics
3
Number of Patients Treated with ECT
Table 1 shows the annualised total number of patients who received ECT from 1 July 2003
to 30 June 2005, broken down by DHB. A total of 307 people received ECT during the
2004/05 reporting period, equivalent to 7.5 per 100,000 population. This compares with
305 or 7.5 people per 100,000 from 1 July 2003 to 30 June 2004. The average number of
treatments per acute course of ECT was 7 treatments.
Figure 1a and 1b illustrate the population-adjusted figures for the number of patients who
received ECT per 100,000 population during the both reporting periods. They also show
the national average number of patients treated with ECT per 100,000 population for each
reporting period. Figure 1c and 1d presents the same data, adjusted to relate the use of
ECT to the population of mental health service users over the age of 20 in each DHB.
Table 1:
Total number of patients treated with ECT, by DHB, 1 July 2003–30 June 2005
District Health Board
Number of patients treated
with ECT 2004/05
Auckland
Bay of Plenty
Canterbury
Capital and Coast
Counties Manukau
Hawke’s Bay*+
Hutt
Lakes
Midcentral
Nelson Marlborough
Northland
Otago
South Canterbury+
Southland
Tairawhiti
Taranaki+
Waikato
Wairarapa+
Waitemata
West Coast
Whanganui*+
Total number of individual patients
Number of patients treated
with ECT 2003/04
13
17
79
15
24
<5
9
22
6
11
6
33
0
6
<5
0
38
0
23
<5
<5
7
33
52
27
29
<5
5
7
10
11
7
39
0
10
5
<5
28
0
30
<5
<5
307
305
NB: In 2004/05 there were four patients treated at two DHBs:
• one patient at Canterbury and Otago
• one patient at Capital & Coast and Waikato
• one patient at Auckland and Waitemata
• one patient at Auckland and Canterbury.
In 2003/04 there were two patients treated at two DHBs:
• one patient at Bay of Plenty and Counties Manukau
• one patient at Southland and Otago.
Notes:
* ECT performed at MidCentral DHB.
+ DHB does not have an ECT machine.
<5 Some DHBs reported very few ECT treatments. A notation of less than 5 was used to ensure that patients remain anonymous.
Electroconvulsive Therapy Annual Statistics
5
6
* ECT performed at MidCentral DHB.
+ DHB does not have an ECT machine.
Electroconvulsive Therapy Annual Statistics
District Health Board
Whanganui*+
West Coast
Waitemata
Wairarapa+
Waikato
Taranaki+
Tairawhiti
Southland
South Canterbury+
Otago
Northland
Nelson Marlborough
Midcentral
Lakes
Hutt
Hawke's Bay*+
Counties Manukau
Capital & Coast
Canterbury
Bay of Plenty
Auckland
Whanganui*+
West Coast
Waitemata
Wairarapa+
Waikato
Taranaki+
Tairawhiti
Southland
South Canterbury+
Otago
Northland
Nelson Marlborough
Midcentral
Lakes
Hutt
Hawke's Bay*+
Counties Manukau
Capital & Coast
Canterbury
Bay of Plenty
Auckland
Figure 1a: Number of patients treated with ECT per 100,000 population, 1 July 2004–30 June
2005
25
20
15
10
National average: 7.5
5
0
District Health Board
Figure 1b: Number of patients treated with ECT per 100,000 population, 1 July 2003–30 June
2004
25
20
15
10
National average: 7.5
5
0
Figure 1c: Percentage of patients (aged 20+ years) seen at a mental health service treated
with ECT, 1 July 2004–30 June 2005
1.2%
1.0%
0.8%
0.6%
National average: 0.43%
0.4%
0.2%
Whanganui*+
West Coast
Waitemata
Wairarapa+
Waikato
Taranaki+
Tairawhiti
Southland
South Canterbury+
Otago
Northland
Nelson Marlborough
Midcentral
Lakes
Hutt
Hawke's Bay*+
Counties Manukau
Capital & Coast
Canterbury
Bay of Plenty
Auckland
0.0%
District Health Board
Figure 1d: Percentage of patients (aged 20+ years) seen at a mental health service treated
with ECT, 1 July 2003–30 June 2004
1.2%
1.0%
0.8%
0.6%
National average: 0.42%
0.4%
0.2%
Whanganui*+
West Coast
Waitemata
Wairarapa+
Waikato
Taranaki+
Tairawhiti
Southland
South Canterbury+
Otago
Northland
Nelson Marlborough
Midcentral
Lakes
Hutt
Hawke's Bay*+
Counties Manukau
Capital & Coast
Canterbury
Bay of Plenty
Auckland
0.0%
District Health Board
* ECT performed at MidCentral DHB.
+ DHB does not have an ECT machine.
Electroconvulsive Therapy Annual Statistics
7
Regional variations in the number of ECT treatments given
No attempt has been made to explain regional variations in the use of ECT. However,
the following factors will be relevant:
•
Regions with smaller populations will be more vulnerable to year-by-year variations
(according to the needs of the population at any time).
•
Patients receiving continuous or maintenance treatment will typically receive more
treatments in a year than those patients who are treated with an acute course.
•
ECT is indicated in older people more often than in younger adults because older
people are more likely to have associated medical problems contraindicating
medication.
•
Some DHBs have better access to ECT services than others, and this factor is likely
to influence the rates of use.
8
Electroconvulsive Therapy Annual Statistics
4
ECT Treatments per Acute Course
A series of ECT treatments is required to produce a lasting therapeutic effect. This is
known as an acute course of ECT. Although an acute course may bring an episode of
serious mental illness to an end, it will not in itself prevent another episode from
occurring weeks, months or years later. Sometimes further ECT treatments will be
prescribed at a much less frequent rate to maintain remission, usually on an outpatient
basis. Such treatments are known as maintenance treatments.
More detailed data from DHBs about the context in which each ECT treatment occurred
has allowed for reporting on the number of treatments per course of ECT. The method
used to refine the data to show course information involves:
•
removing those ECT treatments that are not part of an acute course of treatment
•
excluding acute courses of treatment that occur within five days of the end of one
reporting period and five days into a new reporting period, to ensure only full courses
are included in the analysis.
Several factors can influence the number of individual treatments that a patient may
need:
•
the severity of the patient’s illness and the degree of treatment resistance
•
any complicating medical factors
•
age (older people may need longer courses, thus if ECT is done mostly in older
people the courses may be longer)
•
the timeliness of maintenance medication being started during the course
•
technical factors in how the treatment is given (eg, bilateral versus right unilateral
treatment).
Table 2 shows the average number and the range of ECT treatments per course, by
DHB. This data is represented graphically in Figure 2, with the national average being
seven ECT treatments per acute course of ECT during the 2004/05 reporting period.
Electroconvulsive Therapy Annual Statistics
9
Table 2:
ECT treatments per acute course, by DHB, 1 July 2004–30 June 2005
DHB
No. of courses
No. of treatments
No. of treatments per acute course:
mean (range)
Auckland
11
124
11 (4–18)
Waitemata
17
183
11 (2–19)
Southland
3
30
10 (5–19)
MidCentral
10
80
8 (4–12)
Canterbury
63
492
8 (2–18)
Waikato
31
237
8 (3–14)
7
53
8 (4–14)
23
172
7 (3–13)
6
44
7 (3–11)
16
109
7 (2–15)
3
19
6 (4–10)
NMDHB
12
74
6 (3–12)
Otago
38
228
6 (2–14)
9
52
6 (4–8)
21
113
5 (3–8)
Hutt Valley
CMDHB
Northland
BOP
Tairawhiti
CCDHB
Lakes
Figure 2: ECT treatments per acute course, by DHB, 1 July 2004–30 June 2005
12
10
8
National average: 7
6
4
2
District Health Board
10
Electroconvulsive Therapy Annual Statistics
Lakes
CCDHB
Otago
NMDHB
Tairawhiti
BOP
Northland
CMDHB
Hutt Valley
Waikato
Canterbury
Midcentral
Southland
Waitemata
Auckland
0
5
ECT and Consent to Treatment
The consent process
If the patient is competent to consent, the potential benefits and risks of ECT and
available alternative interventions should be carefully reviewed and discussed with the
patient and, where appropriate, their family/whānau or friends, so that the patient is able
to make an informed decision.
If the patient is not competent to consent, or is not willing to consent, ECT can not be
given without legal authorisation. The most common legal framework for administering
ECT to patients who have not given their consent is provided by the Mental Health
(Compulsory Assessment and Treatment) Act 1992. Committed patients can be given
ECT without their consent only if a psychiatrist appointed by the Mental Health Review
Tribunal has given a second opinion stating that the course of treatment is in their
interests. Clinicians will generally make the decision about whether ECT is in the
interests of the patient after discussing the options with family/whānau and considering
any advance statements of the patient that may be relevant.
Defining consent to treatment
In the year 1 July 2003 to 30 June 2004, DHBs reported whether or not patients having
ECT were subject to the Mental Health Act or were a voluntary patient. Most DHBs did
not report whether the patient had consented, and assumed that all patients detained
under the Mental Health Act did not consent. It is likely therefore that the reported
figures during the 2003/2004 period overestimated the number of treatments not
consented to. This aspect of the data was clarified for the 2004/2005 reporting period,
and continues to be refined.
The important issue is ‘consent to treatment’, because patients may be subject the
Mental Health Act but still retain capacity to consent to treatment.
During the 2004–2005 reporting period, no patient was treated with ECT if they retained
decision making capacity, and refused to consent.
ECT treatments and the Mental Health Act
There were 84 patients treated with ECT during the 2004–2005 reporting period who
were subject to the Mental Health (Compulsory Assessment and Treatment) Act 1992,
which represents 23% of all patients treated with ECT.
Electroconvulsive Therapy Annual Statistics
11
Table 3:
ECT treatments not consented to during the period 1 July 2003–30 June 2005
District Health Board
2004/05
2003/04
Auckland
77 (51%)
49 (63%)
BOPDHB
2 (1%)
70 (24%)
Canterbury
54 (8%)
55 (12%)
CCDHB
72 (59%)
42 (15%)
CMDHB
73 (36%)
160 (58%)
Hawkes Bay*+
0 (0%)
0 (0%)
Hutt Valley
0 (0%)
15 (17%)
Lakes
6 (5%)
16 (37%)
Midcentral
0 (0%)
15 (16%)
15 (19%)
0 (0%)
8 (18%)
0 (0%)
46 (17%)
70 (17%)
0 (0%)
0 (0%)
Southland
19 (22%)
16 (14%)
Tairawhiti
15 (68%)
0 (0%)
Taranaki+
0 (0%)
0 (0%)
Waikato
93 (30%)
16 (7%)
NMDHB
Northland
Otago
South Canterbury+
0 (0%)
0 (0%)
Waitemata
113 (39%)
222 (40%)
West Coast
0 (0%)
0 (0%)
Whanganui*+
0 (0%)
0 (0%)
593 (22%)
746 (24%)
Wairarapa+
Total
*
Number of administrations not consented to
ECT performed at MidCentral DHB.
+ DHB does not have an ECT machine.
Note: During the 2004/05 reporting period, all patients not consenting lacked decision making capacity.
12
Electroconvulsive Therapy Annual Statistics
Figure 3: Population-adjusted figures for the number of ECT treatments consented to per
100,000 population, 1 July 2004–30 June 2005
160
No consent
Consent given
140
120
100
80
60
40
20
Wairarapa+
Taranaki+
South Canterbury+
Whanganui*+
Hawke's Bay*+
Midcentral
West Coast
Northland
Auckland
Hutt
Capital and Coast
Counties Manukau
Tairawhiti
Nelson Marlborough
Waitemata
Southland
Bay of Plenty
Waikato
Lakes
Canterbury
Otago
0
District Health Board
*
ECT performed at MidCentral DHB.
+ DHB does not have an ECT machine.
Electroconvulsive Therapy Annual Statistics
13
6
Age and Sex of Patients Treated with ECT
Table 4 shows the age and sex of people who were treated with ECT during the period
1 July 2004–30 June 2005. This information is depicted graphically in Figure 4. Age
group was determined by the individual’s age at the beginning of their treatment.
Table 4:
Age and sex of patients treated with ECT, 1 July 2003–30 June 2005
Age of patients
Number of patients 2004/05
Female
Male
Number of patients 2003/04
Female
Male
15–19
2
0
5
0
20–24
4
5
8
1
25–29
9
3
7
4
30–34
16
7
16
3
35–39
10
8
12
6
40–44
27
7
23
4
45–49
20
6
14
10
50–54
17
7
15
12
55–59
12
6
19
10
60–64
11
8
16
5
65–69
11
8
17
2
70–74
20
8
23
11
75–79
25
10
17
8
80–84
22
9
11
13
85–89
7
1
8
4
90–94
1
2
2
0
Totals
214
95
211
93
14
Electroconvulsive Therapy Annual Statistics
Figure 4a: Age and sex of patients treated with ECT, 1 July 2004–30 June 2005
40
Male
Female
35
30
25
20
15
10
5
0
15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85–89 90–94
Age group (years)
Figure 4b: Age and sex of patients treated with ECT, 1 July 2003–30 June 2004
40
Male
Female
35
30
25
20
15
10
5
0
15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–74 75–79 80–84 85–89 90–94
Age group (years)
Electroconvulsive Therapy Annual Statistics
15
The results show that of the 307 people who were treated with ECT during 2004/05, 212
(69%) were women and 93 (31%) were men. The majority of the difference is
attributable to the fact that more women present to our services with depressive
disorders. This ratio is similar to that in other countries.
16
Electroconvulsive Therapy Annual Statistics
7
Ethnicity of Patients Treated with ECT
Table 5 represents the ethnicity breakdown of people who were treated with ECT during
the period 1 July 2003–30 June 2005.
Table 5:
Ethnicity of people treated with ECT, 1 July 2003–30 June 2005
Ethnicity
Asian
European
Māori
Pacific people
Other
Number of patients 2004/05
Number of patients 2003/04
5 (2%)
2 (1%)
260 (85%)
258 (84%)
18 (6%)
15 (5%)
7 (7%)
6 (2%)
17 (17%)
24 (8%)
The ethnic spread suggests Asian people, Māori and Pacific Islanders are
underrepresented for their population demography. However, the numbers are so small
it would be unhelpful to show how the percentages relate to the proportion of each
ethnic group in the total population.
Electroconvulsive Therapy Annual Statistics
17