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Rapid Responses: Rapid Responses published:
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Conflicting Advice on ECT Confuses Prescribers
- Rob Evans, Dr. P. C. Naik, Dr. S Alikhan (20 June 2003)
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Cerletti &Bini, their treatment survives after other treatments ...etc
- A.K Al-Sheikhli MRCPsych DPM (20 June 2003)
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The Issue of Consent
- David F Locke, LL.M (21 June 2003)
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Groping about in the dark
- Gurli Bagnall (21 June 2003)
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ECT-the Indian scenario
- srivatsa gopal vyasarayani (22 June 2003)
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ect
- gordon o dubourg (23 June 2003)
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NICE guidance on ECT
- Robert Ian Tobiansky, Catherine Cole (27 June 2003)
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N.IC.E. New Guidelines for the use of E.C.T.
- H.Louise Relton (27 June 2003)
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Should we be satisfied with NICE's ECT appraisal?
- Janice Campbell (27 June 2003)
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Rob Evans, Specialist Registrar in Psychiatry Lyndon Resource Centre, Hobs Meadow, Solihull, B92 8PW, Dr. P. C. Naik, Dr. S Alikhan
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We read with much interest the editorial by Carney and Geddes on the recently published NICE guidelines on the use of Electroconvulsive Therapy (ECT) (1). The authors highlight the conflicting advice on the use of ECT by two influential bodies, NICE and the Royal College of Psychiatrists. The NICE guidelines restrict the use of ECT while the Royal College argue for wider inclusion criteria. The NICE guidelines also emphasise that no patient should be coerced into treatment. This would imply that Psychiatrists prescibe ECT prematurely for vulnerable patients. However in clinical situations the reverse may be encountered whereby patients may coerce their doctors to prescibe ECT based on their previous positive experience. We report two such recent cases which illustrate how difficult it was for us to balance between the patient's choice versus the conflicting views from the two bodies. Both patients presented with a moderate depressive episode. Neither had psychotic symptoms nor were they suicidal. Neither patient fell within the NICE criteria for the use of ECT. Both had previously responded well to courses of ECT with no adverse effects. Both patients, along with their partners repeatedly requested ECT stating that they were unwilling to wait for medication to work. They both had full capacity to make informed decisions about their treatment. Both were reluctantly prescribed a course of ECT and showed a good response. Neither suffered any lasting cognitive effects. So what is the reason for the disagreement between the Royal College of Psychiatrists and NICE? It is reported that NICE deliberately wants to curb the use of ECT because of unresoved concerns about side effects, particularly memory loss (2). There is a surprising lack of studies into the long term effects of ECT on cognitive function (3) but in their systematic review Rose et al state that 29 to 55% of patients report persistent memory loss (4). However one could question the validity this figure because of the poor methodological design of the studies included. Faced with such a lack of convincing evidence NICE's approach has been to restrict the use of ECT on the one hand whilst emphasising the need for fully informed consent on the other. How is the latter possible if we are still uncertain of the long term risks involved with ECT? Our two cases illustrate that patient choice will be restricted and doctors will now be placed in a difficult position. Psychiatrists will now have to decide which expert opinion to accept, that of the Royal College or NICE. In the current climate within the NHS the medicolegal implications of operating outside the NICE guidelines are likely to trump other considerations such as patient choice. We would advocate that the Royal College and NICE should meet and resolve their differences and provide unified guidelines for patients and clinicians. 1.) Carney S, Geddes J "Electroconvulsive Therapy - Recent recommendations are likely to improve standards and uniformity of use." BMJ 2003;326:1343-4 2.)White C "New Guidance on ECT looks set to curb its use." BMJ (News) 2003;326:1003 3.) The UK ECT Group and John Geddes "Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis." The Lancet 2003;361;9360:799-808 4.) Service User Research Enterprise, Rose D, Fleischmann P, Wykes T, Leese M, Bindman J "Patients perspectives on electroconvulsive therapy:sytematic review." BMY 2003;326:1363-5 Competing interests: None declared |
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A.K Al-Sheikhli MRCPsych DPM, Loc.Consultant Psychiatrist Medical Centre,Manor Court Avenue,Nuneaton,CV11 5HX,UK
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Dear Editor, It was interesting to read the editorial ,Electroconvulsive therapy, Carney &Geddes (journal 2003). It seems that the treatment survives after more than 60 years, while other types of treatments are not now part of psychiatric treatments, those were introduced in the 1930s, ECT, Insulin coma therapy, Psychosurgery, and metrazol convulsive therapy(1). Electroconvulsive therapy will continue to have a place in psychiatric treatments, although the introduction of new psychotropic drugs like the new generation of antidepressants, atypical antipsychotics, mood stabilisers did improve the treatment of psychiatric disorders, but still we have patients who might need ECT, which include severe depressive illness with threat to life either from starvation or suicide, cases of severe & resistant depressive illness, catatonic schizophrenia, cases of resistant mania that are not responding to treatments. I wonder myself whether we ought to include paranoid schizophrenics who are hearing voices or have got strongly held paranoid delusions againt others who might attack them as a response to their psychotic symptoms and who are not responding to antipsychotic medications. I quite agree with NICE guidlines about the use of ECT (2), but whatever we do to restrict the use of ECT, Cerletti & Bini will survive. Yours sincerely A.K.Al-Sheikhli Reference, 1.Endler NS,The origin of ECT,Convuls ther,1988,4(1),5-23. 2.Guidance of the use of Electroconvulsive therapy,decision of the appeal panel,London,NICE 2003,WWW.nice.org.UK,pdf/ECT Competing interests: None declared |
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David F Locke, LL.M, Lawyer Tunbridge Wells, TN1 1EG
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It is noted with interest that the real clinical benefits of ECT are still the point of much contention and research and the effects of such treatment in the long-term are still largely uncharted. Notwithstanding this, ECT is still administered to patients without their [informed] consent. It seems that we are, rather, working backwards - forcing the treatment upon those who are amongst the most vunerable in our society whilst we still debate its basic value. The short term clinical benefits of ECT on acute depression may be largely agreed but the long-term effects of the treatment on the individual are not. The oft used argument in respect of tobacco smoking is equally applicable here - were the use of ECT in psychiatry to be proposed for the first time tomorrow, is there any real prospect of its use being sanctioned? I would suggest not. If that point is agreed friends, then were does that leave the continued use of ECT in this country? Competing interests: None declared |
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Gurli Bagnall, Patients' Rights Campaigner Independent, Marlborough Sounds, 7273, New Zealand
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Whether it be ECT for depression or drugs for physical diseases or mental disorders, when it comes to adverse reactions, there is only one expert and that is the person on the receiving end - the patient. Once again it is a case of what the patients say versus what the main body of the medical profession preach. The arguments used by the medical group in favour of ECT, indicate one of two things: the patient who complains of long term or permanent memory loss and other adverse effects, is at best an idiot and at worst a liar. (Well, he must be since his testimony is generally ignored.) However, like everything else in psychiatry, such conclusions are not scientific. They aren’t even logical. The situation is similar to the nonsense we heard for 30 plus years about the benzodiazepines. In the mid 1990s, a programme regarding the dangers of these drugs was shown on Australian television. The studio audience was made up of victims, carers and physicians. Many harrowing stories of ruined health and lives were heard, and they were countered by, “But these drugs help many people.” It was an argument that was relied upon heavily by the medical profession just as it is now with ECT. The message from this respected member of the medical profession was not lost on the studio audience - as long as the drugs helped a few patients, the rest were unimportant and completely expendable. In common with many treatments of other diseases, ECT represents a game of Russian Roulette. The doctor points the pistol at the patient and pulls the trigger without any idea of the outcome. Will the response will be favourable or will another life will be destroyed if not taken? The controversy currently surrounding ECT highlights how little progress medical science has made in the field of disease. And then there is of course the question about what will happen to medical mystique if this final resort to the treatment of depression is banned. It would be a fairly clear indication that the definition of “medical mystique” is “groping about in the dark”! Competing interests: None declared |
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srivatsa gopal vyasarayani, P.G Registrar in Psychiatry, Christian Medical College,Vellore
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Sir, The views held by NICE are fine,excellent and in the patient's interest.In the west, where there are lots of state funded economic schemes,we can wait for the drug response.In India,where 80% of the population is below the poverty line,ECT becomes the first line treatment to control the acute problem.The country is slowly shifting from unmodified to modified ECT in many rural/small centers.Hence,the western guidelines may be difficult to apply in a country like India. The other important factor in India is the rapid turnover of patients in the general wards of most of India's psychiatric centers. Competing interests: None declared |
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gordon o dubourg, soad, mhac 23 misterton crescent, ravenshead, ng15 9ax
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Electroconvulsive therapy (ECT) is a heavily stigmatised form of treatment.The general public, and a number of professionals, forget that psychotic depression is a potentially lethal condition which has claimed thousands of lives over the years, and when not lethal is a living hell for patients whose illness does not respond to other forms of treatment. I draw an analogy: a patient suffering from a potentially fatal condition who submits to surgery may suffer pain, disfigurement, the loss of parts of his/her body and secondary disability, but may still thank the surgeon for being enabled to stay alive, knowing full well that there can be a price to pay for the privilege of continued life. In the course of my duties as a Mental Health Act Commission doctor, when visiting a non-competent patient suffering from severe recurrent depression, the nursing staff have told me that the relatives are angry because ECT has not been started immediately, saying "Why are you leaving him/her to suffer when you know the treatment has worked before?" I would like to know if the studies quoted broke down the patient groups by severity of illness and by response to previous courses of treatment; also, were the relatives interviewed? Finally, I refer to the trailer on page 326; where did the editor get that photograph from? In over 40 years of practice in a variety of units i have never seen a patient's face covered, or a patient surrounded by white coats - is it from a B feature movie? Competing interests: None declared |
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Robert Ian Tobiansky, Consultant Old Age Psychiatrist Colindale Hospital, London. NW9 5HG, Catherine Cole
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Editor, In their editorial, Carney and Geddes predict that most parties will be reasonably satisfied with the National Institute for Clinical Excellence’s (NICE’s) appraisal of electroconvulsive therapy (ECT) (1,2). We are less sanguine than Carney and Geddes on this matter. Whilst we share the authors’ view that the appraisal is a welcome document addressing a neglected area of psychiatry, our clinical experience is that many patients who may benefit from ECT will be denied it under these guidelines. For example, the NICE guidelines state that ECT should not be used as a maintenance therapy in depressive illness (2). In clinical practice, we do see a small number of patients, for whom maintenance ECT (MECT) has proved to be the only effective treatment, allowing them to remain symptom-free for long periods when all other treatment options have failed. In our opinion, it would be wrong to deny this group of patients an effective treatment, albeit at the possible expense of some potential memory disruption, when the alternative is the intractable torment of severe depression. Apparently, the NICE appraisal panel did not include a single psychiatrist and this may partly explain why clinical experience of the potential benefits of MECT, as described in many reports (eg 4), appears to have been discounted. The recommendations from NICE have also to have failed to acknowledge the different potential for memory disruption and cognitive side effects arising from bilateral as opposed to unilateral ECT, which is extensively described in the literature (5). Given the concerns about memory disturbance as a side effect of bilateral ECT, this is a surprising omission. NICE recommends that the use of ECT in depressive illness should be restricted to patients with severe depressive illness or catatonia, in whom an adequate trial of other treatment options has proven ineffective and / or when the condition is considered to be potentially life- threatening. (2). We would argue that, in severely depressed patients who have shown a good response to ECT in the past, it may be appropriate to consider ECT as a first-line treatment. The NICE guidelines do not recommend ECT as a treatment for moderate depressive episodes. As discussed in the response to the appraisal from the Royal College of Psychiatrists’ Special Committee on ECT and the Scottish ECT Audit Network (SEAN)(3), the randomised controlled trials which form the evidence base for ECT were carried out mainly on moderately or moderately severely depressed patients, excluding those with severe depressive episodes who were unable to give informed consent. We consider the NICE guidelines to be unduly restrictive and limiting, encouraging clinicians to deny patients potentially beneficial treatment. Catherine Cole, Specialist Registrar in Psychiatry
Barnet, Enfield and Haringey Mental Health NHS Trust. Colindale Hospital, London NW9 5HG 1. Carney S, Geddes J. Electroconvulsive therapy. Recent recommendations are likely to improve standards and uniformity of use. BMJ 2003; 326: 1343-4. 2. National institute for Clinical Excellence. Guidelines on the use of electroconvulsive therapy. London: NICE, April 2003. www.nice.org.uk/pdf/59ectfullguidance.pdf 3. Royal College of Psychiatrists’ Special committee on ECT and Scottish ECT Audit Network (SEAN). Statement on ECT Practice. 25 May 2003. www.sean.org.uk/appraisal.php 4. Gagne G, Furman M, Carpenter L et al. Efficacy of continuation ECT and Antidepressant Drugs compared to long-term Antidepressants alone. Am J. Psychiatry 2000;157:1960-1965. 5. Abrams R. Electroconvulsive Therapy. Third Edition. 2002. Oxford University Press. Competing interests: None declared |
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H.Louise Relton, Co Chair &E.C.T Special Interest Rep U.K.Advocacy Network Volserve House 14-18 West Bar Green Sheffield S1 2DA
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I would like to add my comments with regard to the debate around the new guidelines. I was a member of the review group which produced the guidelines, have personal experience of E.C.T.and have spent a very significant amount of my own time researching(qualitatively) the patient experience of E.C.T. Over many years and with a range of groups I have listened to observed and 'lived' with recipients of E.C.T. over long periods and do feel that the views and experiences of thousands of people should not be discounted or dismissed on the basis that the evidence was not gathered 'scientifically' or in 'medical trials'. As service users we have historically had no hope or prospect of attracting research monies(who would want to fund research into a dissenting view of the efficacy of E.C.T. from 'the ground floor'). With the recognition and acknowledgement of recent years that patients do hold valid expertise in relation to their lived experience the climate for partnership and inclusive working has improved,hopefully to the benefit of patients and practitioners(and one may of course be either at different times in life). The new guidelines were produced after a full and thorough assessment of ALL available data both clinical and experiential,and representation on the group included all key stakeholders. All committee members worked very hard to see things from every perspective and everyone including the R.C.P. felt that the new guidelines were appropriate and workable and were a great step forward. The bottom line is all patients and practitioners want the same things. The committee was a fine example of collaborative working and no group reps. found themselves at loggerheads with each other. Fact:Much patient/carer information(which is scant) denies the possibility of long term cognitive impairment. Fact:There is no long term follow up of live individuals in terms of cognitive abilities.Therefore there cannot be reliable evidence of long term effect. Fact:It is openly acknowledged by the R.C.P. that practice within any previous guidelines has not been to standards that the R.C.P set for themselves,in terms of safety,consistency,environments and expertise of professionals who carry out treatments. Fact:Individuals(myself included)have sought help to live with the consequences of treatment as opposed to the consequences of 'illness'. I have undergone,at my instigation neuropsychological testing and measurement,the final report states unequivocally that I have 'acquired cognitive deficits' which in some areas of functioning take me from 'well above average' to the lowest recordable level that acknowledges that 'functioning' in these areas continues at all. I and many others would agree that whilst E.C.T. remains an accepted and useful treatment for some people those people should be able to have the greatest possible confidence that they are receiving it in only where there is compelling evidence of likely efficacy based on best available data/experience. The N.I.C.E guidelines desire to achieve only this. Competing interests: None declared |
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Janice Campbell, Survivor Researcher None
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Re. the final paragraph by Carney and Geddes (1), NICE’s stated intention is “to make sure that all the evidence on a topic has been identified....” (2) Presumably, therefore, the important consideration is that the facts are being got right. I am in communication with NICE about evidence which didn’t inform their prescriptive guidance on electroconvulsive therapy (ECT). I have drawn attention to Dubovksy’s understanding that ECT is neurotoxic by virtue of the excitotoxins “released during seizures” (3) – in which connection Dubovsky mentions the likely role of aspartate and his Figure 32.29-3 reveals that ECT causes release of glutamate. I happen to read medical research “because it’s a satisfying intellectual experience” (4), so naturally I consulted a principal neurological source and learnt that “in contrast to ischaemia, where glutamate is released in large quantities, hypoglycaemia releases more aspartate than glutamate.” (5) The implication is that ECT induces brain damage of the hypoglycaemic and/or ischaemic kind. Given Dubovsky refers to “a period of electrical silence (postictal suppression) lasting up to 90 seconds” (3) after ECT, of particular relevance is that “it is the presence or absence of cerebral EEG isolectricity (the ‘flat’ EEG) which determines the presence or absence of brain damage. ... Without EEG silence..., brain damage in the form of neuronal necrosis is absent.” (5) According to Nobler et al., “bioelectric suppression immediately after seizure termination...[has] been associated with superior ECT outcome....” (6) Carney and Geddes remark "improved consent procedures" (1), yet I doubt recipients will be told they are agreeing to benefit through harm, to include the risk of neuronal necrosis. When there is suppression and distortion of the knowledge what, indeed, “is the current status of our knowledge about electroconvulsive therapy?” (1) Because psychiatrists claim benefit in circumstances where neurologists claim pathology, I suggest consumer (sic) ECT researchers should be wary of “genuinely collaborative...research” (1) and would be well advised to stick to whistle-blowing. 1 Carney S, Geddes J. Electroconvulsive Therapy. Editorial, BMJ, 21 June 2003 2 National Institute for Clinical Excellence 2003. Technology appraisal guidance on ECT London NICE 2003, Media Briefing 3 Dubovsky S L. in Comprehensive Textbook of Psychiatry V1, Kaplan and Sadock (eds.), Baltimore Williams & Wilkins, 1995, 2129-2140 4 Smith R. Do patients need to read research? BMJ, 14 June 2003 5 Ischaemic brain damage / Hypoglycaemic brain damage. in Greenfield’s Neuropathology, 6th edition, 1997, Graham and Lantos (eds.) Arnold, 238- 241: 284-289 6 Nobler, M S, Oquendo, M A, Kegeles, L S, Malone, K M, Campbell, C, Sackeim, H A, Mann, J J. Decreased Regional Brain Metabolism After ECT. Am. J. Psychiatry 158:2, 2001, 305-308 Competing interests: None declared |
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