ORIGINAL STUDY
Access to Electroconvulsive Therapy Services in Canada
Nicholas John Delva, MD,* Peter Graf, PhD,Þ Simon Patry, MD,þ Caroline Gosselin, MD,§
Roumen Milev, MD,|| Ian Gilron, MD,¶ Barry Martin, MD,L James Stuart Lawson, PhD,**
Murray Enns, MD,ÞÞ Mark Jewell, BA, RPN,þþ and Peter Chan, MD§
Objectives: We sought to determine factors governing access to electroconvulsive therapy (ECT) in Canada.
Methods: We contacted all 1273 registered health care institutions
in Canada and invited the 175 centers identified as providing ECT
to complete a comprehensive questionnaire. To determine geographic
access to ECT, we used a geographic information system, population
density data, and road network data. Responses to 5 questions from the
questionnaire were used to identify local barriers to access.
Results: Approximately 84% of the population in the 10 Canadian
provinces live within a 1-hour drive of an ECT center, but 5% live more
than 5 hours’ drive away. There was significant province-to-province
variation, with all of the citizens of Prince Edward Island living within
2 hours of an ECT center but 12.5% of those in Newfoundland and
Labrador living more than 5 hours’ distance away. There are no ECT
services at all in the 3 territories, which contain 3% of the Canadian
population. Nongeographic barriers to access included inadequate human resources, particularly, a lack of anesthesiologists, in 59% of the
centers; logistical impedances (52%); space limitations (45%); strictures on the hiring of adequate staff (29%); imposed limits to number
of treatments or to operating or postanesthetic room time (28%); and
a lack of funds to purchase up-to-date ECT or related anesthesiology
equipment (14%).
Conclusions: Electroconvulsive therapy is geographically accessible for most Canadians. Even when geography is not a factor, however,
there are significant barriers to access resulting from inadequate availability of qualified professional staff, treatment areas, and funding.
Key Words: access to ECT, geographic information system analysis,
health human resources, health funding
dalities for depression fail, negative views regarding ECT have
led to legislated limits on its use in many jurisdictions.3Y5 Furthermore, a lack of financial resources, geography, and other
factors may also contribute to the restricted availability of this
treatment.6 Beyond ready availability, it is also important that
ECT be conducted according to the highest standards of care,
and this goal has been the motivation for a number of qualityimprovement initiatives, one of the earliest being a survey of
ECT in the United Kingdom in 1980.7
Although position papers on ECT have been developed
and approved by the Canadian Psychiatric Association,8Y10 to
date, no comprehensive national survey of ECT practice has
been conducted in Canada. In 2004, a multidisciplinary national
committee including physicians and researchers from the fields
of psychiatry, psychology, anesthesiology, and nursing was
formed to determine where ECT is available and precisely how
and to whom this treatment is provided in the various regions of
the country. This bilingual endeavor, the Canadian Electroconvulsive Therapy Survey/Enquête canadienne sur les electrochocs
(CANECTS/ECANEC), received the endorsement of the Canadian Psychiatric Association.
This initial report by the CANECTS/ECANEC Associates provides an analysis of the major factors governing access
to ECT in Canada: these include geographic access to ECT
services, and the other nongeographic aspects of access to
treatment.
MATERIALS AND METHODS
(J ECT 2011;27: 300Y309)
Identification of ECT Centers
E
To identify institutions that provide ECT, an initial mailout to all 1273 registered health care institutions in Canada
was made and then followed by telephone calls to ensure that
no center was missed.
lectroconvulsive therapy (ECT) is a well-established and
highly effective treatment for severe depression and for several other serious psychiatric illnesses.1,2 Despite that ECT may
be lifesaving, and at times effective when other treatment mo-
Development of the Questionnaire
From the *Department of Psychiatry, Dalhousie University, Halifax;
†Department of Psychology, University of British Columbia (UBC), Vancouver, BC; ‡Department of Psychiatry, Laval University, Sillery, Quebec;
§Department of Psychiatry, UBC, Vancouver, BC; ||Departments of Psychiatry and Psychology, and ¶Departments of Anesthesiology, and Pharmacology and Toxicology, Queen’s University, Kingston, Ontario; LDepartment of
Psychiatry, University of Toronto, Toronto, Ontario; **Department of Psychiatry, Queen’s University, Kingston, Ontario; ††Department of Psychiatry,
University of Manitoba, Winnipeg, Manitoba; and ‡‡Addiction and Mental
Health, Alberta Health Services, Edmonton, Alberta, Canada.
Received for publication January 3, 2011; accepted January 26, 2011.
Reprints: Nicholas John Delva, MD, Department of Psychiatry, Dalhousie
University, Room 8210, Abbie J. Lane Building, 5909 Veterans’
Memorial Ln, Halifax NS B3H 2E2, Canada (e-mail: delvan@
cdha.nshealth.ca).
Funding for this study was provided by the Vancouver Coastal Health
Authority, which had no further role in any aspect of the conduct of
the study.
The authors have no conflict of interest to declare.
Copyright * 2011 by Lippincott Williams & Wilkins
DOI: 10.1097/YCT.0b013e318222b1b8
300
www.ectjournal.com
A bilingual questionnaire on ECT was developed; equivalence of the English and French versions was assured by the
use of several procedures, including the consistent involvement
of bilingual members of the CANECTS/ECANEC Associates
in reviewing the translation, back-translation by an independent
bilingual physician, and pilot testing.11,12 The initial Englishlanguage version developed by the Associates was subsequently
translated into French by a bilingual member of the team whose
mother tongue is French. This initial French version was backtranslated to English by a second bilingual medical doctor who
was independent of the team, who had not been involved in the
development of the questionnaire up to that point, and whose
mother tongue is also French. Any inaccuracies in the backtranslation resulted in amendments to the French-language text,
which was further edited for style and clarity at this stage. The
French and English versions of the questionnaire were piloted
at 14 ECT centers in 2006, and further modifications were made
on the basis of comments received on both the English and
Journal of ECT
&
Volume 27, Number 4, December 2011
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT
&
Volume 27, Number 4, December 2011
French versions. The final versions of the questionnaire were
ready for distribution in 2007.
The questionnaire, which is available from the authors,
had 11 sections and a total of 76 questions or items seeking
information on facilities, equipment, number of treatments, patient diagnoses, nursing, clinical and administrative practices
(including anesthesiology, consent, and technical aspects of
treatment), teaching, budget, and access to care.
The questionnaire was sent to each of the 175 identified
ECT providers along with a personalized letter inviting completion of the questionnaire. In the case of nonresponse after the mail-out of the questionnaire, one of the CANECTS/
ECANEC Associates personally contacted each nonresponding center to encourage completion of the questionnaire, with
repeated reminders if necessary.
The section of the questionnaire on access to ECT treatment had 3 questions: one each on human resources, space,
and logistics. The section on budget included 2 questions relating to whether a lack of funds had prevented either the hiring of staff or the purchase of equipment for ECT. There was
also space for written comments on potential barriers to ECT
access, as well as a separate section for general comments not
specifically addressed to any question.
Geographic Information System (GIS) Analysis
The locations of all ECT service providers were entered
into a geographic information system (ArcGIS V 9.2; Esri, Redlands, California) using latitude and longitude coordinates obtained from Google Earth. Population density maps were created
with the use of Statistics Canada 2006 Census tract polygons
using dissemination area identifiers (http://www12.statcan.ca/
english/census06/data/popdwell/Table.cfm?T = 307&S = 3&O =
D&RPP = 699) color-coded by population density. To show main
roads and highways on the maps and for computing all drive time
statistics, we used the 2006 Census road network geometry
(http://geodepot.statcan.ca/Diss2006/DataProducts/BoundaryFiles/
RNGAF_FRRAG_e.jsp). Drive-time isochrons (distances that
are reachable in 1, 2, 3, 4, or 5 hours of driving) were calculated
for each ECT center with the use of the 2006 Census boundary
data (http://www12.statcan.ca/census-recensement/2006/geo/
bound-limit-eng.cfm). Finally, we intersected the population
density data with each isochron, by province, to compute the
percentage of Canada’s population within a 1-, 2-, 3-, 4- or 5-hour
drive time of an ECT center. If the centroid of a census enumeration area was within the isochron, then all people in the area
were considered to have the access afforded by the isochron.
When ECT centers were close geographically, duplicates were
eliminated so that each person was counted only once.
The University of British Columbia Research Ethics Board
provided approval for this investigation.
RESULTS
Questionnaire Completion Rate
Of the 175 ECT centers in Canada, 107 (61%) returned
completed questionnaires, all of them usable, and very few
questions were left unanswered. Eighteen other centers provided
minimal data, limited to the numbers of patients treated and ECT
treatments provided each year; their inclusion brings the total
response rate to 71%.
To evaluate the representativeness of the sample completing the questionnaire, we compared the bed counts of the fully
responding sites with the remaining sites. Bed counts were
available for 92 of the 107 facilities that responded fully to our
survey, and for 62 of the 68 facilities that did not respond
* 2011 Lippincott Williams & Wilkins
Access to ECT Services in Canada
fully. The mean (SD) number of beds was 335 (268) for the
nonresponders and 336 (253) for the responders. With bed
count used as a proxy for institutional size, these data reveal
no size difference between responding and nonresponding sites
(t = 0.51). We also compared the responding and nonresponding sites by their catchment populations, and more specifically,
by the number of people who live within a 1-hour drive of each
site; it will be noted that for this analysis, those living within
a 1-hour reach of multiple sites could be counted more than
once. The average catchment populations were 1,413,656
and 1,564,106 for the responding and nonresponding sites,
respectively. These averages are not significantly different
from each other (t = 0.61), providing additional evidence
that the responding and nonresponding sites were similar to
each other.
Geographic Access to ECT
In 2006, the population of Canada was 31,612,897, including
31,511,587 in the 10 provinces and 101,310 in the 3 territories
(Yukon, Northwest Territories, and Nunavut). Figures 1 to 4 show
both the population density and the centers offering ECT in the
different regions of Canada. The maps highlight the fact that most
of Canada has a very low population density and that the areas
of highest density are found mainly in the southern part of the
country. Not surprisingly, this area of the country is also where
most ECT centers are located.
Of the Canadian population living in the provinces, 84.3%
live within a 1-hour drive of an ECT center and 91.5% live within a
2-hour drive, but 4.7% live more than 5 hours away from a center.
Figure 5 is a cumulative histogram showing the percentage of
people in each province within a 1-, 2-, 3-, 4-, 5- or more than
5-hour drive of an ECT center. In a limited number of cases,
driving times would be shorter than the calculated values if
patients were to cross a provincial border for the purpose of
receiving ECT at the center nearest to them. In recognition of
the small effect of any such cross-border access to health care
services, which, to some extent, is discouraged by provincial
health care plans, and because it was very difficult to quantify its
potential influence, we ignored it in our GIS analysis.
It is evident that the provinces vary widely in geographic
access to ECT. At one extreme, all of the residents of Prince
Edward Island live within the 2-hour isochron, whereas a substantial proportion of the population of some provinces dwell
outside the 5-hour isochron (eg, Ontario, 7.4%; Newfoundland
and Labrador, 12.5%). None of the 3 territories offer ECT services,
and although arrangements may be in place to offer ECT to acutely
ill patients in the territories by admitting them to hospitals in
provinces to the south, it is evident that access to outpatient or
maintenance ECT would be very limited for these patients. A
statistical analysis of the data by means of the Marascuillo procedure revealed significant differences for all possible pairings of
provinces in the percentage of people living within the 1-hour
isochron (even the small difference between British Columbia
[86.1%] and Ontario [86.6%] was significant at P G 0.001), an
outcome which is not surprising in view of the large populations in
each province. When dealing with entire populations, what is
more concerning than statistical significance, which is very easy
to achieve, is the number of people represented by even a small
difference in percentage. Concretely, a 1% advantage, for example, for the province of Ontario represents approximately 120,000
additional individuals who are 1 hour closer to ECT services.
Nongeographic Barriers to Access to ECT
Significant nongeographic barriers to access to ECT
were described in some of the responses. A lack of funds had
www.ectjournal.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
301
Journal of ECT
Delva et al
&
Volume 27, Number 4, December 2011
FIGURE 1. Locations of ECT service providers and population density (number of people per square kilometer) in the Atlantic
provinces and eastern Quebec.
prevented the purchase of up-to-date ECT or related anesthesiology equipment in 14% of the centers offering ECT, and the
hiring of adequate staff to deliver the required services had been
impeded in 29% of the centers. It will be noted from Figure 6
that limited human resources, particularly of anesthesiologists,
reduced the availability of ECT in more than half of the centers; limitations of space were significant in nearly half of the
centers, and logistical barriers constrained the delivery of outpatient ECT in just more than half of the centers.
Fifty-eight of the 107 centers that returned fully completed questionnaires (54%) provided written comments in re-
302
www.ectjournal.com
sponse to the question, ‘‘In your opinion, what, if any, is the
single most important barrier?’’ Thirty of these centers (28%)
provided details of limits to the number of treatments available (as few as one case per day) or to the availability of operating
room or postanesthetic recovery room time (eg, in one center, the
ECT patients were ‘‘evicted [from the postanesthetic recovery
area] by 8:45 A.M. at the latest’’). Lack of availability of anesthesiology services was often given as the reason for a limit
to the number of ECT treatments. Outpatient ECT was not always available. Stigma, which was not specifically addressed in
the questionnaire, was spontaneously identified as the most
* 2011 Lippincott Williams & Wilkins
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT
&
Volume 27, Number 4, December 2011
Access to ECT Services in Canada
FIGURE 2. Locations of ECT service providers and population density (number of people per square kilometer) in western Quebec
and Ontario.
* 2011 Lippincott Williams & Wilkins
www.ectjournal.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
303
Journal of ECT
Delva et al
&
Volume 27, Number 4, December 2011
FIGURE 3. Locations of ECT service providers and population density (number of people per square kilometer) from eastern
Alberta to Ontario.
important single barrier by 6 of the 107 centers: stigma, ignorance, myths, and misinformation were identified as affecting not
only the choice of ECT by patients or families but also as interfering with the cooperation of other health professionals and
affecting the privacy and dignity of patients in the recovery areas.
DISCUSSION
Electroconvulsive therapy is provided from coast to coast,
and approximately 84% of Canadians have good geographic
access to this treatment. Geographic access is variable, however, and some one and a half million people in Canada live
more than 5 hours’drive away from an ECT center. Furthermore,
some 2 and a half million Canadians live more than 2 hours’
drive from an ECT center, making it very difficult to provide
outpatient or maintenance ECT for these patients. In the experience of the authors, even a 2-hour drive usually necessitates
an overnight stay in the ECT center or nearby, thus further
increasing the inconvenience and costs of maintenance ECT
and reducing ease of access for anyone not living within an
hour or so of the center.
The distribution of services is, however, only one of
the variables that determine accessibility of ECT services in
Canada, and our questionnaire revealed other significant barriers to access within most of the centers, especially limits
to qualified professional staff, treatment areas, and financial
resources.
Response rates in published surveys of ECT practice have
been highly variable, ranging from as low as less than 1%13
in voluntary surveys to the 100% rates achieved by compulsory audits (eg, Fergusson et al14). Although ‘‘survey fatigue’’
is prevalent, and the CANECTS/ECANEC questionnaire was
extensive, requiring input from several individuals at each
304
www.ectjournal.com
ECT center, the questionnaire was completed by 61% of the
centers. This response rate compares very favorably with the
average rate in empirical studies conducted within the behavioral and managerial sciences when data were voluntarily gathered from organizations (mean [SD], 35.7% [18.8%]; response
rates are typically higher when data are collected from individual persons: mean [SD], 52.7% [20.4%]).15 With the addition
of those centers providing minimal information, we were able
to obtain data from 71% of Canada’s ECT centers for at least
some of the questionnaire items. This high level of response
can be attributed to several factors, some of them methodological: CANECTS/ECANEC was made known to the centers
from the time of the first mail-out, which sought only to determine whether a health care institution offered ECT services,
and anticipated the request to complete the questionnaire itself
by several years; other efforts were made to publicize our work,
including the development of a Web site and presentations
at professional meetings; sites that initially failed to respond
were personally contacted by members of CANECTS to offer guidance and assistance and to encourage completion of
the questionnaire; and finally, the survey may have been seen
to be helpful in enabling ECT centers in Canada to operate at
the highest standards of care and to secure greater support
from their host institutions. The high response rate and our
finding of the comparability of the responding and nonresponding centers allow us to be confident that the results of
the questionnaire element of our study validly represent the totality of Canada’s ECT centers.
It is recognized that a lack of personnel and other resources
can make it a challenge to deliver health care in rural areas, even
in more densely populated countries like the United Kingdom.16
Rural Canada has approximately 20% of the employed Canadian
workforce, 31% of the population, and more than 99% of
the nation’s territory.17 In addition to psychiatric and nursing
* 2011 Lippincott Williams & Wilkins
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT
&
Volume 27, Number 4, December 2011
Access to ECT Services in Canada
FIGURE 4. Locations of ECT service providers and population density (number of people per square kilometer) in BC and Alberta.
services, access to anesthetic services is crucial for the provision
of safe ECT. Reported evidence of regional disparity in anesthetic services18 and of the impact of access to anesthetic care
providers on ECT provision19 indeed suggest that the geographical distribution of anesthetic services is another important
determinant of ECT access. Furthermore, even when anesthetic
services are available in a particular center, these services may be
limited as far as ECT is concerned, as shown by the questionnaire
element of our survey.
Hermann et al6 found a 200-fold range in ECT use in the
United States, from 0.4 to 81.2 patients treated per year per
* 2011 Lippincott Williams & Wilkins
10,000 people; ECT availability did not depend on population
density alone, and one third of metropolitan areas did not provide
ECT. In the United Kingdom, there are up to 12-fold differences
in ECT usage between health districts.20 In Russia, it has been
estimated that ECT is available to only 22% of the population.21
In many developed countries, ECT has come to be less available
to economically disadvantaged groups, and prejudice against
ECT is particularly evident in the reduced availability of this
treatment for certain groups of patients: the elderly, young
people, those with intellectual disabilities, the chronically mentally ill, and forensic patients.5
www.ectjournal.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
305
Journal of ECT
Delva et al
&
Volume 27, Number 4, December 2011
FIGURE 5. Cumulative histogram of isochrons for drive time to ECT centers in the Canadian provinces.
Four principles guide medical ethics: beneficence (the
treatment is helpful), nonmaleficence (it is not harmful), autonomy (there are proper procedures for consent to treatment, including substitute decision making when the patient’s judgment
is impaired), and justice (all persons have equal access to good
medical care). Although it is acknowledged that ECT can lead
to cognitive adverse effects, these are generally short-lived and
can be minimized by appropriate attention to electrode placement, stimulus waveform, and electrical dose. Ottosson and
Fink5 have demonstrated that ECT can satisfy only the first 3
principles of medical ethics because this treatment may not be
available to all who need it, thus leading to unnecessary suffering
and death. The reasons for this are several, and include stigma,
lack of trained personnel, legislative and bureaucratic barriers,
economic factors, and distance. Electroconvulsive therapy has
been considered the ‘‘most stigmatized treatment in medicine,’’22
and negative attitudes toward this form of treatment seem to
affect its availability in Canada, too, as described explicitly in
some of the comments, and apparently implicitly in the relatively
low ranking of ECTwhen operating room and postoperative care
schedules are prepared, resulting in limits to the numbers of ECT
procedures. The experience of being ‘‘evicted’’ from the recovery area by a cutoff time is something that would be unthinkable
for patients undergoing other procedures, but is unfortunately
not likely to be unique to the center reporting this approach to
ECT scheduling.
The initial 1981 UK audit by Pippard and Ellam,7 referred
to earlier, was followed by follow-up audits in 1991 and 1996,
but only modest improvements were seen in clinical practice.20,23 Nevertheless, the quality improvement cycle must start
with documentation of the status quo, and if the initial efforts to
achieve the desired improvements are not successful, other
approaches will clearly be required. The Scottish ECT Audit
Network (SEAN) stands out as having achieved a large measure
of success in ensuring high standards of care.14
CONCLUSIONS
More than 90% of Canadians in the 10 provinces live within
2 hours’ drive of an ECT center, but some 5% live more than
5 hours’ drive away from these centers, and there are no ECT
306
www.ectjournal.com
services in the territories, which are home to approximately 3%
of the population. Greater distance from an ECT center (ie, more
than an hour or 2) makes outpatient or maintenance ECT particularly challenging. The geographic distribution of services is,
however, only one of the variables that determine accessibility of
ECT services in Canada, and the questionnaire survey revealed
that there are other significant barriers to access within most of
the centers, constituted by limits in qualified professional staff
(nursing, anesthesiology, and psychiatry), treatment areas, and
financial resources. Given the crippling effects of severe depression and the other disorders, which may benefit from ECT,
these findings are of concern. Our study provides some of the
information needed to ensure that access to this important
treatment is both adequate and equitable.
LIMITATIONS
There are several caveats. First, as mentioned above, the
Canadian territories were omitted from our estimates of geographic access to ECT, which examined only the 10 provinces.
Three percent of the Canadian population live in these territories,
and it is clearly a challenge for the inhabitants of the territories to
obtain access to ECT, particularly for outpatient or maintenance
ECT. Second, we were not able to take account of the crossing of
provincial borders to gain easier access to ECT, which would
serve to reduce the distances to ECT centers; again, the percentages of Canadians affected would be small. These first 2
caveats relate to the difficulties in doing research on health care
delivery in a large federated country in which health care is a
provincial responsibility. Third, as we mentioned in the ‘‘Materials and Methods’’ section, if the centroid of a census enumeration area were within an isochron, then all people in the
enumeration areas were considered to have the access afforded
within the isochron, but of course, enumeration areas do not have
uniformly distributed populations. Fourth, our comparison of
responding and nonresponding sites did not take into account
any possible differences in psychiatric focus. Fifth, the barriers
identified in the questionnaire as resulting from limited personnel, space, and equipment are based on the experiences
and opinions of those answering the questions rather than on
any clearly specified minimum standards, and there were no
* 2011 Lippincott Williams & Wilkins
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT
&
Volume 27, Number 4, December 2011
Access to ECT Services in Canada
method can only be fully addressed by a more detailed audit,
which our group plans to implement in the coming years.
ACKNOWLEDGMENTS
The authors thank Ms Lorna Howes, BPN, Director,
Mental Health and Addictions, Vancouver Coastal Health, for
supporting this project from its inception; Mr Jeff Clark,
Geospatial Consultant, Spatial Vision Group, who performed
the GIS analysis and provided guidance and assistance with the
maps; the 14 centers that did the pilot work and the 107 ECT
centers that completed the survey; Dr Pierre L. Delva, who
performed the back-translation from French to English and
provided suggestions on the French translation; Dr Jeanne
Ferguson, CANECTS/ECANEC associate, who promoted the
gathering of the questionnaire data; Mr Gerardo Merlo
Rodriguez, who developed the CANECTS/ECANEC Web site;
Ms Mijke Rhemtulla, MA, who helped perform the statistical
analysis; and assistants Mr Tracey Meintjes, NHD Metallurgy,
Ms Mary Anne Throop, and Ms Patricia Wiggins.
REFERENCES
1. Abrams R. Electroconvulsive Therapy. 4th ed. New York, NY: Oxford
University Press; 2002.
2. Carney S, Cowen P, Dearness K, et al. Efficacy and safety of
electroconvulsive therapy in depressive disorders: a systematic review
and meta-analysis. Lancet. 2003;361:799Y808.
3. Reid WH, Keller S, Leatherman M, et al. ECT in Texas: 19 months
of mandatory reporting. J Clinical Psychiatry. 1998;59:8Y13.
4. Kramer BA. Use of ECT in California, revisited: 1984Y1994. J ECT.
1999;15:245Y251.
5. Ottosson J-O, Fink M. Justice. In: Ethics in Electroconvulsive Therapy.
New York, NY: Brunner-Routledge; 2004:89Y107.
6. Hermann RC, Dorwart RA, Hoover CW, et al. Variation in ECT
use in the United States. Am J Psychiatry. 1995;152:869Y875.
7. Pippard J, Ellam L. Electroconvulsive Treatment in Great Britain, 1980.
London, UK: Gaskell; 1981.
8. Pankratz WJ. Electroconvulsive therapy: the position of the Canadian
Psychiatric Association. Can J Psychiatry. 1980;25:509Y514.
9. Enns MW, Reiss JP. Electroconvulsive therapy (Canadian Psychiatric
Association position paper). Can J Psychiatry. 1992;37:671Y678.
10. Enns MW, Reiss JP, Chan P. Electroconvulsive therapy
(Canadian Psychiatric Association position paper). Can J Psychiatry.
2010;55(6): 1Y12. Available at: http://publications.cpa-apc.org/
media.php?mid=978. Accessed January 3, 2011.
11. Brislin RW. Back-translation for cross-cultural research. Journal
of Cross-Cultural Psychology. 1970;1:185Y216.
12. Chapman DW, Carter JF. Translation procedures for the cross cultural
use of measurement instruments. Educational Evaluation and Policy
Analysis. 1979;1:71Y76.
FIGURE 6. Barriers to access to ECT in Canada: human resources
(A), space (B), and logistics (C).
independent or corroborating sources of information for any
of these assessments. Finally, although responding and nonresponding sites may have been similar in size and catchment
populations, there may have been a tendency for preferential
response by those sites with perceived problems in personnel,
equipment, funds, or other pertinent issues affecting access.
Regarding caveats 5 and 6, any possible biases permitted by our
* 2011 Lippincott Williams & Wilkins
13. Little JD. ECT in the Asia Pacific region: what do we know? J ECT.
2003;19:93Y97.
14. Fergusson GM, Cullen LA, Freeman CPL, et al. Electroconvulsive
therapy in Scottish clinical practice: a national audit of demographics,
standards, and outcome. J ECT. 2004;20:166Y73.
15. Baruch Y, Holtom BC. Survey response rate levels and trends in
organizational research. Human Relations. 2008;61:1139Y1160.
16. Swindlehurst HF, Deaville JS, Wynn-Jones J, et al. Rural proofing
for health: a commentary. Rural and Remote Health. 2005;5:1Y5
(online), 2005. Available at: http://www.rrh.org.au/publishedarticles/
article_print_411.pdf. Accessed January 3, 2011.
www.ectjournal.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
307
Journal of ECT
Delva et al
17. Hutton-Czapski P. The state of rural healthcare. Presentation
to the Standing Senate Committee on Social Affairs, Science
and Technology, May 31, 2001. Available at: http://www.srpc.ca/PDF/
state-rural-healthcare.pdf. Accessed January 3, 2011.
18. Orkin FK. Analysis of the geographical distribution of anesthesia
manpower in the United States. Anesthesiology. 1976;45:592Y603.
19. Dexter F, Macario A, Cowen DS. Staffing and case scheduling for
anesthesia in geographically dispersed locations outside of operating
rooms. Curr Opin Anaesthesiol. 2006;19:453Y458.
20. Pippard J. Audit of electroconvulsive treatment in two National Health
Service regions. Br J Psychiatry. 1992;160:621Y637.
21. Nelson AI. A national survey of electroconvulsive therapy in the
Russian Federation. J ECT. 2005;21:151Y157.
22. Fink M. Is the practice of ECT ethical? World J Biol Psychiatry.
2005;6:38Y43.
23. Duffett R, Lelliot P. Auditing electroconvulsive therapy: the third cycle.
Br J Psychiatry. 1998;172:401Y405.
APPENDIX: Canadian ECT
SurveyVResponding Centers
Alberta Hospital Edmonton (AHE), Edmonton, AB
Alexandra Marine & General Hospital, Goderich, ON
Battlefords Union Hospital, North Battleford, SK
Baycrest Centre for Geriatric Care, Toronto, ON
Brandon Regional Health Centre, Brandon, MB
Brant Community Healthcare SystemYBrant
General Hospital Site, Brantford, ON
Brockville Psychiatric Hospital, Brockville, ON
Burnaby Hospital, Burnaby, BC
C.H.R. de Trois-RivièresYPavillon Ste-Marie,
Trois-Rivières, QC
Cape Breton District Health AuthorityYRegional
Hospital, Sydney, NS
Capital District Health AuthorityYHalifax Infirmary,
Halifax, NS
Centre for Addiction and Mental HealthYCollege
St. Site, Toronto, ON
Centre for Addiction and Mental HealthYQueen
St. Site, Toronto, ON
Centre hospitalier Baie des Chaleurs, Maria, QC
Centre hospitalier de CharlevoixYClinique externe
de sante mentale, Baie-Sainte-Paul, QC
Centre hospitalier de Gaspé, Pavillon
Monseigneur-Ross, Gaspé, QC
Centre hospitalier de l’Archipel, Cap-aux-Meules, QC
Centre hospitalier De St-Mary, Montreal, QC
Centre hospitalier Honoré-Mercier, Sainte-Hyacinthe, QC
Centre hospitalier Pierre-Janet, Gatineau, QC
Centre hospitalier régional de Rimouski, Rimouski, QC
Centre hospitalier régional de Sept-Îles, Sept-Îles, QC
Centre hospitalier Robert-Giffard, Institut universitaire en
santé mentale, Quebec, QC
Centre hospitalier Rouyn-Noranda, Rouyn-Noranda, QC
Chaleur Regional Hospital, Bathurst, NB
Chatham-Kent Health AllianceYMental
Health Service, Chatham-Kent, ON
CHAUYHôpital de l’Enfant-Jésus, Quebec, QC
CHAUYHôpital du Saint-Sacrement, Quebec, QC
Chilliwack General Hospital, Chilliwack, BC
CHUSYHôpital Hôtel-Dieu, Sherbrooke, QC
Credit Valley Hospital, Mississauga, Mississauga, ON
308
www.ectjournal.com
&
Volume 27, Number 4, December 2011
CSSS de Chicoutimi, Pavillon Rolan-Saucier, Chicoutimi, QC
CSSS de l’Energie, Site Ste-Therese, Shawinigan, QC
Dawson Creek and District Hospital, Dawson Creek, BC
Foothills Provincial General Hospital, Calgary, AB
G.R. Baker Memorial Hospital, Quesnel, BC
Grand River Hospital, Kitchener-Waterloo Health
Centre, Kitchener-Waterloo, ON
Halton Healthcare Services CorporationYOakville
Trafalgar Memorial Hospital, Oakville, ON
Health Sciences Centre, Winnipeg, MB
Health Service Association of the South ShoreYSouth
Shore Regional Hospital, Bridgewater, NS
Homewood Health Centre, Guelph, ON
Hôpital Charles LeMoyne, Greenfield Park, Greenfield Park, QC
Hôpital Général de Montréal, Montreal, QC
Hôpital Louis-H. Lafontaine, Montreal, QC
Hôpital Maisonneuve-Rosemont, Montreal, QC
Hôpital Montfort/Montfort Hospital, Ottawa, ON
Hôpital régional Dr-Georges-L.-Dumont, Moncton, NB
Hôtel-Dieu de Lévis, Levis, QC
Hôtel-Dieu de Montmagny, Montmagny, QC
Hôtel-Dieu de Roberval, Roberval, QC
Hôtel-Dieu Grace Hospital, Windsor, Windsor, ON
Humber River Regional Hospital, Toronto, York, ON
Huron Perth Healthcare AllianceYStratford General
Hospital, Stratford, ON
Joseph Brant Memorial Hospital, Burlington, ON
Kelowna General Hospital, Kelowna, BC
Kingston General Hospital, Kingston, ON
Lake of the Woods District Hospital, Kenora, ON
Lakeridge Health CorporationYOshawa Site, Oshawa, ON
Langley Memorial Hospital, Langley, BC
Lethbridge Regional Hospital, Lethbridge, AB
Lions Gate Hospital, North Vancouver, North Vancouver, BC
Medicine Hat Regional Hospital, Medicine Hat, AB
Mental Health CentreYPenetanguishene, Penetanguishene, ON
Mental Health ServicesYProvidence Continuing Care
Centre, Kingston, ON
Misericordia Community Hospital, Edmonton, AB
Moose Jaw Union Hospital, Moose Jaw, SK
Mount Saint Joseph Hospital, Vancouver, BC
Mount Sinai Hospital, Toronto, Toronto, ON
Nanaimo Regional General Hospital, Nanaimo, BC
New Westminster Surgical Centre, New Westminster, BC
North York General Hospital, Toronto, ON
Northeast Mental Health CentreYNorth Bay Campus,
North Bay, ON
Orillia Soldiers’ Memorial Hospital, Orillia, ON
Peace Arch Hospital, White Rock, BC
Peter Lougheed Hospital, Calgary, AB
Prince County Hospital, Summerside, Summerside, PE
Prince George Regional Hospital, Prince George, BC
Queen Elizabeth Hospital, Charlottetown, PE
Queensway Carleton Hospital, Nepean, Ottawa, ON
Red Deer Regional Hospital Centre, Red Deer, AB
Regina General Hospital, Regina, SK
Riverview Hospital, Coquitlam, BC
Rockyview General Hospital, Calgary, AB
Rouge Valley Health SystemYCentenary Site, Toronto, ON
Royal Alexandra Hospital, Edmonton, AB
Royal Columbian Hospital, New Westminster, BC
Royal Inland HospitalYKamloops Mental
Health Centre, Kamloops, BC
Royal Jubilee HospitalYDepartment of Psychiatry, Victoria, BC
Royal Ottawa Hospital, Ottawa, ON
* 2011 Lippincott Williams & Wilkins
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Journal of ECT
&
Volume 27, Number 4, December 2011
Royal University Hospital, Saskatoon, SK
Saint John Regional Hospital, Saint John, NB
Selkirk Mental Health Centre, Selkirk, MB
Seven Oaks General Hospital, Winnipeg, MB
Southlake Regional Health Centre, Newmarket,
Newmarket, ON
St. Boniface General Hospital, Winnipeg, MB
St. Joseph’s General Hospital, Comox, BC
St. Joseph’s Healthcare HamiltonYCentre
for Mountain Health Services, Hamilton, ON
St. Michael’s Hospital, Toronto, ON
St. Paul’s HospitalYProvidence Health Care, Vancouver, BC
St. Therese Health Centre, St. Paul, AB
Sunnybrook Health Sciences Centre, Toronto, ON
Swift Current Regional Hospital, Swift Current, SK
The Nova Scotia Hospital, Dartmouth, NS
The Ottawa HospitalYGeneral Campus, Ottawa, ON
The Ottawa Hospital/L’Hôpital d’OttawaYCivic
Campus, Ottawa, ON
The Salvation Army Grace General Hospital, Winnipeg, MB
The Scarborough HospitalYGrace Division, Scarborough, ON
* 2011 Lippincott Williams & Wilkins
Access to ECT Services in Canada
The Toronto General Hospital, Toronto, ON
Thunder Bay Regional Health Sciences Centre,
Thunder Bay, ON
Timmins and District Hospital, Timmins, ON
Toronto East General Hospital, Toronto, ON
Trillium Health CentreYMississauga Site, Mississauga, ON
UBC Hospital, Mood Disorders Inpatient Unit,
Detwiller Pavillion, Vancouver, BC
University of Alberta Hospital, Edmonton, Edmonton, AB
Valley Regional Hospital, Kentville, NS
Vancouver General Hospital, General Psychiatry,
Vancouver, BC
Victoria General Hospital, Winnipeg, MB
Victoria Hospital, Prince Albert, SK
Waterford HospitalYMental Health Program, St. John’s, NL
Western Memorial Hospital, Corner Brook, NL
Whitby Mental Health Centre, Whitby, ON
William Osler Health Centre, Etobicoke and Brampton, ON
Yarmouth Regional Hospital, Yarmouth, NS
York County Hospital, Richmond Hill, Richmond Hill, ON
Yorkton Mental Health Centre, Yorkton, SK
www.ectjournal.com
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
309