ECT: Effective, but standards vary widely

IN a crowded conference room in Hobart, the banter is reaching boiling point.

Psychiatrists from across the country have convened to discuss developments in electroconvulsive therapy (ECT) and neuropsychology as part of last week's Royal Australian & New Zealand College of Psychiatrists annual congress. And the topic has turned to the tricky balancing act of maximising efficacy while minimising side effects.

One psychiatrist tells of a patient who came to him recently following ECT treatments that successfully lifted her from a deep, debilitating depression.

The treatment was prescribed appropriately and it worked. But before treatment she had a successful sales business, which was effectively lost as she no longer recognised her clients.

"She got well, but her business, career and livelihood was destroyed in the process. That' s an unacceptable outcome," the psychiatrist concludes.

It's also an outcome that can often be avoided, experts say.

During ECT, patients are anaesthetised before a series of brief or ultra-brief electrical pulses are administered, prompting seizures. Why this lifts people out of depression is unclear. What is clear is that it works, even in cases where medication and psychotherapy have failed.

ECT is the most effective treatment available for patients with severe depression, with about 80 per cent experiencing dramatic improvements. For patients who are suicidal, ECT can be life-saving. It's also effective for those with bipolar disorder and psychotic illnesses such as schizophrenia who have severe symptoms or don't respond to other treatments.

ECT these days bears little resemblance to the disturbing images in the 1975 film One Flew Over the Cuckoo's Nest. It's now tailored to individual patients to minimise cognitive impairment. Yet with no national standards or specific training universally required, there's no guarantee a patient will receive the most up-to-date treatment. For instance, a psychiatrist may have trained years ago, and may not be taking advantage of the latest evidence and research available, says the University of NSW's Colleen Loo, a consultant psychiatrist and leading ECT expert.

NSW Health recently released mandatory guidelines to improve quality control and standards of ECT. Other states, including Victoria, Western Australia and Queensland, have also developed guidelines. But there's still a long way to go.

"There has been a recognition that the standard of ECT is variable and in some places (it is) done poorly," Loo told delegates at a special interest meeting at the congress. "I have major concerns about the technique and the knowledge base of some of the people administering ECT."

There's work to be done to ensure all practitioners are trained to a consistent standard, Loo says.

It's a point echoed by other psychiatrists at the conference, such as John Tiller, head of ECT at Melbourne's Albert Road Clinic and co-ordinator of Victoria's ECT training program.

He spoke of the need for stronger credentials for practitioners, noting there are psychiatrists who attend "some of the (training) course, some of the time" and leave with a certificate. But whether they have the appropriate skills is questionable.

"Attending training is not the same as competence, and auditing is absolutely critical," he says.

In Britain, voluntary auditing has been taken up widely by hospitals that administer ECT, resulting in an improvement in overall standards and consistency, according to Loo, who recently returned from a UK visit.

She says ECT is diverse and variables such as where the electrodes are placed and the length of pulse affect patient outcomes. She refers to a study that compared efficacy, side effects and quality of life among patients at seven hospitals in New York. At all seven sites, the ECT was highly effective and the patients got better. At some sites, though, patients experienced almost no cognitive impairment, while at others they experienced significant impairment.

"So the take-home message was it's not hard to make ECT effective, no matter what form you give, but the sophisticated practitioner manages to give ECT effectively and with minimal side effects, whereas the less sophisticated practitioner gives ECT effectively but with more side effects," says Loo, noting that this tallies with what she has observed in Australia.

"When I first started ECT 20 years ago as a trainee, it was very simple. We never touched the machine settings. It was one size fits all. We gave the same stimulus to all patients for all treatments, and that was it," she recalls.

Today in most centres the procedure is monitored and doses are adjusted to the type of treatment matched to patient needs. Still, at some centres all patients receive the same type of ECT regardless of their specific situation.

According to Loo, that's not necessarily a problem if there's a good rationale for it. "But I suspect in some cases people are only prescribing one form of ECT because that's what they know best, and they're not necessarily familiar with some of the other forms, particularly some of the newer forms," she says.

"When we have a new drug, the drug companies go around and market it, and they play a useful role in informing everybody about the drug. But when we have developments in ECT, there is no equivalent body to bring everybody up to speed."

Still, improvements are on the horizon as more states develop guidelines and educational forums become more common.

Salam Hussain, a psychiatrist at Sir Charles Gairdner Hospital in Perth and a clinical lecturer at the University of Western Australia, also attended the Hobart congress. He says national guidelines that promote higher standards and training can only be a good thing, but reducing the stigma surrounding ECT is just as important.

"ECT is an important treatment for people who need it. It's not magic and it's not evil. It's a clinical treatment," says Hussain, adding that ECT isn't the only thing that can impair cognition.

"Depression itself, when it's severe, can affect emotional memory. So when people are severely depressed, their memory becomes distorted too."