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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 07-July-2006, Vol 119 No 1237

Electroconvulsive therapy in New Zealand: terrifying or electrifying?
Pamela Melding
Abstract
Electroconvulsive therapy (ECT) is viewed by many patients as a ‘terrifying’ treatment. A petition to ban ECT presented to the House of Representatives in 1999 resulted in the commissioning of a comprehensive review of efficacy and safety of the treatment in New Zealand as well as a requirement for the Ministry of Health (MOH) to collect annual statistics on ECT use.
Although the systematic review found that ECT was a safe and effective treatment for depression and some other serious mental illnesses, it still attracted adverse comments from opponents. Almost immediately following its publication, another petition was presented to Parliament, this time requesting that ECT be banned for young people, pregnant women, and older people.
Compared to similar countries, New Zealand has a low rate of use for ECT overall, with wide regional variance. There are many misconceptions about ECT in New Zealand that are not in keeping with current standards of practice and may be limiting its use in some areas. However, access to resources for the treatment of depression may be a major limiting factor. ‘Electrifying’ new research emanating from neurobiological and magnetic resonance imaging (MRI) studies is challenging traditional notions of depression, and is providing more explanations on how ECT and other antidepressant treatments might work. These new findings demonstrate that cognitive deficits and structural brain changes play important roles in serious depression and suggest that early and adequate treatment of major depression should be paramount.

Background

In 1999, a petition presented to Parliament requested that the House of Representatives ban electroconvulsive therapy (ECT)—a treatment option for severe depression—stating that the treatment is “degrading and inhumane” and “the scientific fact is that ECT always causes brain damage including memory loss.”1
The Health Select Committee, after hearing many submissions on both sides of the argument, made several recommendations. Amongst them was the commissioning of an independent review of the efficacy, safety, and legal aspects of ECT in New Zealand, and a request to the Ministry of Health (MOH) to collect and publish annual statistics on ECT use in New Zealand.
Previous meta-analytic systematic reviews of properly conducted current controlled trials had concluded that ECT was an effective and safe treatment2–6 but a New Zealand–specific review was sought by the Health Select Committee. The reviewers were Professor Craig Anderson (a neurologist and expert in evidence-based medicine), Professor Peter Skegg (a lawyer), and Ms Ranui Wilson (a consumer consultant). To ensure impartiality, neither a psychiatrist nor a member of the anti-ECT lobby were included as reviewers. An expert reference group of stakeholders advised the Review Group on the practice of ECT together with cultural and social issues directly relevant to New Zealand.
The Review Group evaluated over 400 scientific papers using the guidelines methodology of the New Zealand Guidelines Group (NZGG) and the Scottish Intercollegiate Guidelines Network (SIGN). They also appraised the various Acts of Parliament and regulatory documents concerning ECT in New Zealand and similar nations, and they undertook focus groups meetings to incorporate the views of consumers.7
The Review Group concluded that ECT is an effective treatment for depression and some other serious mental illnesses and stated that the treatment should not be banned. However, they stated that there was a lack of randomised evidence that could inform definitive statements about the efficacy and safety of ECT given to the special population groups of young people, pregnant women, and older people. They were also concerned about the adequacy of legal provisions regarding informed consent.
Despite the comprehensiveness of the review, the petitioners and opponents of ECT described the review as “flawed,” and they questioned the impartiality and integrity of the reviewers by suggesting their independence could have been “compromised” because they were “hand-picked” by the MOH.8 A few weeks later, a new petition was presented to Parliament requesting that ECT be banned for those special groups of patients highlighted by the Review as lacking randomised evidence.9 Simultaneously with the review’s publication in March 2005, the first year’s raw statistics were prematurely posted on the MOH website. The data collection was very basic and showed that there was wide variation in its use across the country. They indicated that a considerable number of patients were being treated under the provisions of the Mental Health Act, people over 60 years received 45% of treatments and that two-thirds of ECT was given to women. Despite the statistics being removed within hours of posting, an immediate media reaction ensued (with articles, radio interviews, and press releases).8,10,11
The raw statistics were described as “appalling” and “shocking” in the press release of one prominent member of Parliament.10 Precipitate and ill-informed interpretations in the media of the unpublished data gave the impression that district health boards (DHBs) had been exposed in a nefarious use of a terrifying treatment. This reaction was a very good example of how simplistic data can be easily over-interpreted. The 2003–4 statistics, together with those for the latest year of 2004–5, will be officially published shortly. We can expect a similar media response on their release.

Rates of use

The new petition9 is currently before the Health Select Committee and once again puts ECT into the spotlight. The use of the treatment in New Zealand needs to be put into perspective with use in similar nations. ECT is not a major treatment option in New Zealand, and currently we have a mean rate of 8 courses per 100,000 adult population (MOH statistics).
In contrast, Scotland recently reported a rate of 19.7/100,000,12 Wales a rate of 22 patients per 100,000,13 and the Australian state of Victoria an adult rate of 44/100,000 in the public sector.14 Rates of ECT use in Australian psychiatry private practice averages 22/100, 000, with a range across the states from 34/100,000 in Queensland to 14/100,000 in Western Australia. Furthermore, ECT use in Australian private practice has been steadily increasing each year since 1991.15
The number of individual ECT courses done also needs to be seen in the context of the prevalence of severe depression in our communities. The Christchurch epidemiology study found the 2-week prevalence of major depressive episodes was 3.7%.16 This suggests that in any 100,000 population, 3700 individuals could, theoretically, have the most severe forms of depression needing clinical management. Of these individuals, clinical trials indicate that 70% could be expected to respond to each class of antidepressants, thus controlling symptoms for about 90%.
In New Zealand, ECT is only considered as a last resort treatment for people who have usually failed at least two (sometimes more) trials of different classes of antidepressants, each trial taking several weeks to months. Thus, the 10% (theoretically 370 people) who don’t respond to two antidepressants are the patient population for whom ECT might be indicated. Consequently, even the highest rate of 22 patients per 100,000 given ECT in some DHBs indicates that only 0.6% of potentially seriously depressed patients in their catchments are actually treated with ECT.
The large range in the rates of use of ECT across the nation, from 22–1/100,000, is intriguing and there could be many factors contributing. However, an important contributor could be access to treatment for serious depression. As individuals having ECT are at the very severe end of the depressive spectrum, they are often unable to look after themselves or maybe acutely suicidal, and they usually require hospitalisation for their course of ECT. Access to inpatient bed resources also vary markedly throughout the country and it is interesting to note that the DHBs with more inpatient beds per unit of population also do more ECTs than those with proportionally fewer beds.
The decline of ECT as a treatment in New Zealand has probably less to do with its efficacy as a treatment (or negative public opinion) and more to do with lack of access to treatment facilities for adequate treatment of depression.
The unpublished Ministry data indicates that a higher number of women are receiving ECT. Whilst this seemed sinister to some critics, there are reasonable explanations. There is a female preponderance in the epidemiology of depression,16 and women more commonly present to mental health services and are admitted to inpatient facilities.
Critics of ECT argue that the treatment is more commonly given to older people. However, the MOH data shows that there are slightly more people under 60 years having ECT (55% in 2003/4 and 53% in 2004/5) than over 60 years. This is despite the fact that older people have more co-morbidities, which makes the prescribing of all classes of antidepressants problematic in terms of side effects, and they have fewer options for the treatment of depression.
There is also increasing good evidence (from meta-analyses of random controlled trials [RCTs]3,5,17 and good quality non-RCT research)18 that ECT is an effective treatment for late-life depression and its severest form melancholia.19 This latter condition is not only more common in older people but can be life-threatening due to poor nutrition and hydration.

Consent

The ECT Review7 was quite justifiably concerned with issues of consent for ECT, as this is a major issue for some critics. As one report put it, Treatment without patient consent is interpreted by some as the arrogance of the medical profession versus the powerlessness of the patient.20
When the MOH data indicated that a considerable number of patients having ECT were also under the Mental Health Act (24% in 2003/4), opponents to ECT in New Zealand quickly assumed that, our regulatory controls are insufficient to prevent excesses. 8
Most patients are capable of informed consent,21 but for some, the most important issue is not their willingness to consent but their ability or competency to make decisions concerning their treatment. As ECT is usually indicated only late in a patient’s illness (at its most severe after failure of conventional treatments), they are often extremely mentally unwell, depressive thinking rendering them incapable of weighing up relevant information or making decisions about ECT or any other treatment.
Use of the regulatory controls for patients who are incapable of giving informed consent (because of severe illness) indicates that the Mental Health Act is working and that patients having a controversial procedure are being protected by a defined legal process that requires two consultant psychiatrists to approve the treatment. The provisions of the Mental Health Act make sure that if individuals are incapable of, or passively consenting without understanding, there is an oversight process set in motion. Furthermore, a treatment order under the Mental Health Act does not necessarily mean the patient did not voluntarily consent to the procedure.

Misconceptions about ECT

There are many misconceptions held by the general public about ECT. The stories of former patients appear frequently in the media, with the implication that their experiences would be as true today as they were half a century ago. These influences, despite the patients lacking knowledge of modern day practice, are pervasive on politicians and even health professionals.22
Kerr et al23 identified four sources from which the public form their impressions about ECT. These were (in order of frequency) a friend; films and television; a doctor; and newspapers and magazines. In the twenty-first century we should add the Internet as a primary source, which has many websites perpetuating terrifying myths about ECT.
Kerr found that subjects whose information had come from a doctor had significantly fewer misbeliefs but those who identified films and television or a friend as a source of information held significantly more erroneous views and were more afraid of ECT.
Recent research from two Scottish universities, on the views of patients following ECT, found that the patients considered ECT helpful for 73% having the treatment voluntarily, and also helpful for 81% of the patients who had not consented.24 Other studies25,26 showed similar results. People exposed to the treatment for themselves, family, or friends have far fewer misconceptions and more positive attitudes.27 But, for others, the misconceptions continue. Whilst the technology, techniques, and practice of ECT have progressed in keeping with other medical practice, the public perception is still rooted in the 1950s and 1960s with ideas kept alive by sensationalist media and Internet articles, more interested in perpetuating the misbeliefs than reporting clinical evidence.
The original petition cited the misconception that ECT is “degrading and inhumane”. Current practice is no more degrading or inhumane than is any other procedure requiring anaesthesia. Is it the epileptic seizure, which occurs during treatment that is perceived as inhumane, despite it being barely noticeable in today’s clinical practice, or is it the notion that having severe depression that fails to respond to treatment is degrading?

The interesting issue of ‘brain damage’

The over-riding concern of ECT opponents is the scientific fact that ECT always causes brain damage including memory loss.1 However, this assertion is simply not true and completely ignores the evidence-based medical approach. Indeed, much of the ‘scientific’ evidence cited to support the ‘fact’ is anecdotal, outdated, and some of it discredited.28
A popular misconception is that all memory loss, transient or prolonged, during or following ECT, is a result of the treatment. Certainly, patients can and may experience declarative and episodic memory loss during their course of ECT.29, 30 For the majority, this is transitory, improving within a few weeks, sometimes to a much better level than it was before the treatment began. These temporary memory disturbances are thought to be caused by the various neurochemical changes that occur with the ECT induced seizure.31,32 In animal experiments, these changes reverse after about 40 days, with return of memory functions.32

Depression and cognitive deficits

Significantly, depression itself causes memory loss. Porter et al assessed depressed drug-free adults, not having ECT, on a range of neuropsychological instruments and found the patients had impairments across a range of cognitive domains, including attention/executive function and visiospatial learning and memory.33 Other workers have found similar results with elderly depressed people.34–36
Importantly, for some adult and older patients, cognitive impairments, including memory losses, can persist despite clinical recovery.36, 37 The advent of the MRI scanner has started to clarify this phenomenon.
We now know that treatment-resistant depression and chronic psychological stress can cause structural loss of neurons in the limbic system, hippocampus, and frontostriatal regions of the brain (areas important for memory function), and that these changes increase with age.38,39 These findings are overturning traditional theories of the aetiology of depression, casting doubt on the notion that the cognitive impairment of depression is solely due to mood disturbance and/or neurotransmitter imbalance. Instead, this new research is pointing to structural brain changes playing an important role.40

Seizures and ‘brain damage’

Opponents argue that inducing seizures causes brain damage. Several studies have shown that seizures can cause brain damage if they are prolonged or under conditions of hypoxia. Such conditions possibly did apply to some people in the days of unmodified ECT and, together with the now outdated use of sine wave delivery machines, they may explain many of the memory complaints patients from that time suffered.
In modern ECT, the brief-pulse seizures are highly controlled, lower in dose, and given under oxygenation and anaesthesia. Under these conditions, structural damage has not been shown despite several prospective MRI studies of the brain, or cerebrospinal fluid (CSF) and blood marker studies for products of neuronal breakdown.41, 42
In contrast, ‘cutting edge’ neurobiological research is revealing that both antidepressants and ECT cause an increase not only in neurotransmitters important in maintaining mood but also brain-derived neurotrophic factor (BDNF), and other neurobiological factors that actually enhance new neuronal growth.38,39,43–46 Furthermore, of all the antidepressant treatments, ECT seems to be the most effective method of inducing neurogenesis, at least in animal models.47 This rapidly-growing, exciting field of research is promising to identify the neurobiological changes underpinning observed clinical improvement,45 which in turn will lead to newer and better treatments for depression, including increasingly sophisticated brain stimulation techniques.48

Conclusion

It was naïve to think that the Review Group’s comprehensive review would resolve the controversies about ECT for New Zealand. The people, who believe that they have suffered as a result of ECT in the past, and their supporters, are committed to seeing the treatment banned.
The latest petition9 will no doubt be followed by another, if the current one also fails to secure the opponent’s main objective. In the past, misuse and inappropriate use of ECT certainly occurred in New Zealand and overseas. However, the correct response to misuse is not to ban use but to make sure there is correct use. Current practice guidelines and high-level training requirements for ECT are designed to do just that.
Unfortunately the new petition on ECT is likely to focus attention onto this very small area of psychiatric practice, diverting (once again) from the much bigger issue of access to treatment for depression in New Zealand.
Inpatient facilities are at capacity treating major psychoses leaving few beds for treating depression. Furthermore, not enough people with depressive disorders can access treatment from primary care through to tertiary services. The struggle needs to be directed towards making sure there are sufficient resources to treat depression early and adequately.
For the few who do require ECT, the clinical evidence from controlled trials has clearly demonstrated its efficacy for treatment resistant depression and some other serious mental disorders. New research is giving us major insights into the neurobiology of depression and its treatments and is signalling the importance of treating depression early and comprehensively.
ECT in New Zealand is well beyond its history, perceived as ‘terrifying’ by many, and ‘electrifying’ new research is confirming ECT’s place as an important option for the treatment of serious depression.
Author information: Pamela Melding, Consultant (responsible for the ECT Service at Waitemata DHB), Mental Health Services, Waitemata District Health Board, Takapuna, Auckland—and Senior Lecturer, Department of Psychological Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland
Correspondence: Dr Pamela Melding, Mental Health Services, Waitemata District Health Board, Takapuna, Auckland 1309. Fax: (09) 486 1722; email: p.melding@auckland.ac.nz
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