The use of electroconvulsive therapy in Quebec - INESSS

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The level of use of ECT in Québec, expressed as a percentage of the population, falls within the limits observed in other countries. The large geographic variations observed in other countries are also found in the hospitals of Québec. The quality of the data available does not permit a comparison of current ECT use for recognized indications. The efficacy and safety of ECT use depend on the technical parameters of such use, which must be monitored through quality assurance programs. Because of geographical variations in ECT use and the absence of uniform, effective institutional and professional regulation, the existing regulations must be strengthened to provide a medically and ethically appropriate practice, including compliance with recognized indications, the use of a state-of-the-art technique maximizing efficacy and minimizing adverse effects, and the respect of patient autonomy. Are these regulatory, informational and organizational actions worth the effort required in view of the technological changes that could render ECT obsolete? The history of depression treatment has taught us to be cautious. The prediction that advances in pharmacotherapy would render ECT pointless has proven to be false. This prediction may have had something to do with the fact that in several countries ECT use has not received the attention it deserves. In Ontario, the work of the Electro-Convulsive Therapy Review Committee, published in 1985, has not been followed up. The recommendations of the National Institutes of Health 1985 Consensus Development Conference on ECT pertaining to research on treatment risks and patient experiences have not been followed up either [Center for Mental Health Services Administration, 1998]. According to the analysis we have presented in this report, ECT is an important therapeutic mode for a number of patients suffering from mental-health problems. We therefore consider it essential that the health system make the effort necessary to ensure a high level of quality of ECT practice in Québec. In conclusion, we would like to present this exceptional testimony of a patient who was able to associate her personal ECT treatments experience with a scientific-literature analysis on the subject: “Occasionally, I feel bitter. More often it is sadness, a sense of a deep loss that may not even had to happen. It is a grief that keeps deepening over time, because there is hardly a week that goes by that I do not discover yet another part of my life that is lost somewhere in my memory cells. Despite that, I remain unflagging in my belief that the electroconvulsive therapy I received in the fall of 1995 and then the spring of 1996 – 33 treatments, initially unilateral and then bilateral – may have saved not just my mental health, but my life. If I had the same decision to make over again, I would choose ECT over a life condemned to psychic agony, and even suicide.[…] My long-term memory deficits far exceeded anything my doctors anticipated, I was advised about, or that are validated by research. To the contrary, either I am one in a thousand, a complete anomaly, to be able to document memory loss still remaining after 3 years and extending as far back as incidences eight or nine years ago, or the profession in general, after all these years of treatment with ECT, has still failed to identify and come to grips with the true potential risks. While the more distant events may be random events, they are hardly insignificant ones: hosting and driving Mother Teresa for a full day visit to Los Angeles in 1989; the dinner reception for C ONCLUSION 67
68 my National Jefferson Award in Washington, D.C., in 1990, where I met and sat beside my co-honoree, General Colin Powell; my brother’s wedding in 1991 – the list goes on, and keeps growing as people bring up references to the past in casual conversations. Human memory seems to me to be one of the most precious aspects of our personality, since our memories are so critical to who we are and how we see ourselves and others. The memories of our past give us an understanding of where we fit in the world. I have experienced more than a ‘cognitive deficit’. I have lost a part of myself.” [Donahue, 2000, p. 134] This quotation is taken from an article published in the year 2000 in the Journal of ECT, the leading professional publication devoted to this treatment. The person describing the impact of her permanent retrograde amnesia due to ECT does not challenge the necessity of the 33 electroconvulsivetherapy treatments, which she admits probably saved her life. However, she questions the lack of research on the subject, the lack of communication between physicians and their patients and the discrepancy between the official recommendations and the actual practice of ECT: “Without these advances – more comprehensive research regarding causes and rates of the most severe instances of memory loss, better transmission of new clinical information to practitioners, and more comprehensive, accurate information and follow-up for patients – a vital tool [electroshock] in the battle against lifethreatening affective disorder will remain underutilized. It is a major social loss that should not have to be that way. If sharing my own experience of successful treatment but deeply troublesome side effects can help in that cause – if my voice is heard, and heard to speak for others like me – then my THE USE OF ELECTROCONVULSIVE THERAPY IN QUÉBEC own sense of damage and abandonment will be assuaged. It will give my experience a value in the lives of others. It will not help my memory to return, but it will ease the pain of the feeling that the damage may have been unnecessary to achieve the results.” [Donahue, 2000, p. 134] The patient therefore suffers not only from the effects of her amnesia but also because she is aware that the existing discrepancy between the official recommendations and the ECT treatments she received may be responsible for the loss of part of her life. This disturbing testimony reflects the central message of this document: ECT is necessary for some patients – for whom it may relieve suffering – but research and rigorous quality control programs are essential in order to optimize the benefits and mimimize the adverse effects of ECT for these patients.
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The use of electroconvulsive therap
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II This report was translated from
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THE USE OF ELECTROCONVULSIVE THERAP
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From the time it was introduced int
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the physician’s judgment and the
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GLOSSARY Anterograde amnesia: learn
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XIV 4 5 6 SAFETY . . . . . . . . .
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XVI 12 RECOMMENDATIONS . . . . . .
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Electroconvulsive therapy (ECT) is
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Table 1 Synoptic table of historic
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“The invention of electroconvulsi
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The use of ECT to control patient b
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400 millicoulombs, which still corr
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2.7 Community-group perspectives Th
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However, despite the use of high el
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According to the 1985 Consensus Dev
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Page 52 and 53: characterized by significant hypert
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Page 88 and 89: AETMIS recommends that: 1) the Fond
Page 90 and 91: Treated-patient-rate data (per 10,0
Page 92 and 93: ECT-treatment session-rate data (pe
Page 94 and 95: Ancelin ML, De Roquefeuil G, Ritchi
Page 96 and 97: Burr ML, Davies BH, Hoare A, Jones
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Page 100 and 101: Finch JM, Sobin PB, Carmody TJ, DeW
Page 102 and 103: Guscott R, Grof P. The clinical mea
Page 104 and 105: Kellner CH. Health care reform and
Page 106 and 107: Martin BA, Glancy GD. Consent to el
Page 108 and 109: Odejide AO, Ohaeri JU, Ikuesan BA.
Page 110 and 111: Roose SP, Nobler M. ECT and onset o
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The use of electroconvulsive therapy in Quebec - INESSS

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