Audit of Electroconvulsive Therapy Reveals Poor Administration and Monitoring

The report concludes that institutional practices are insufficient to guarantee the safety of patients who undergo electroconvulsive therapy.

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Electroconvulsive Therapy (ECT) passes electricity through the brain to cause a seizure in patients. In light of current debates about this controversial treatment, an audit examined thousands of cases where ECT was used in England. The audit found multiple failures in the monitoring and accreditation of ECT clinics.

The authors, led by psychologist John Read, report that many patients are receiving ECT against their will, clinics are not complying with the law regarding compulsory treatment, and the use of treatment efficacy assessments by clinics has decreased to 30% or lower. In response to the findings, Read added:

“ECT is a potentially very dangerous procedure which, if it is to be used at all, requires the most stringent scrutiny. Relying on the Royal College of Psychiatry to monitor ECT clinics is not working because of their obvious conflict of interest. It is hard for them to acknowledge that a treatment used by some of their members causes high rates of memory loss and is largely ineffective, so their monitoring is half-hearted and tokenistic.”  

Electroconvulsive therapy, also known as electroshock therapy or ECT, is often a topic of impassioned disagreement among advocates and detractors. It has become a polarizing issue among mental health professionals.

In recent years, U.S. lawsuits against ECT device manufacturers have brought many issues to the fore. Reports have raised issues with the insufficient warning of risks to patients, violation of federal regulations, permanent brain damage, memory loss, and impairment.

Moreover, reviews comparing ECT with placebo treatments for depression have led researchers to call for a halt to ECT administration due to insufficient evidence of its effectiveness. Such research has resulted in other efforts to raise awareness about ECT’s harms, for example, by demanding transparency from the FDA.

In England, a Freedom of Information Act request was sent to 56 NHS Trusts. 37 of these responded with data that was then analyzed against previous audits’ results to determine whether any improvement in the administration and monitoring of ECT had occurred since the last independent audit covering 2011-2015.

Oversight of ECT in England is the responsibility of the Royal College of Psychiatrists’ ‘ECT Accreditation Service’ (ECTAS). Independent audits undergone over the last two decades have been more comprehensive than ECTAS’ monitoring standards, including questions about the use of proper assessment measures, complicity with the Mental Health Act’s mandates regarding forced treatment, and guidelines that ECT should be a “last resort” treatment after psychological therapy has been tried.

Worryingly, the Accreditation Service cannot sanction ECT clinics that fail to meet their already rather low standards, and 20% of ECT clinics do not participate in the ECTAS process.

The new, independent audit found no improvement from previous audits. The authors write:

“A return to comprehensive national annual audits seems urgently needed. These should include attention to compliance with N.I.C.E. guidelines and mental health legislation. In the meantime, all mental health service providers must take responsibility for monitoring their own adherence to government guidelines and the law and should familiarize themselves with the research literature on the long-term benefits and adverse effects of this controversial treatment. A multidisciplinary investigation into the ongoing excessive use of ECT on women and older people seems long overdue.”

While the response rate (66.1%) was slightly higher than previous audits, there were oddities like the same sentence being written verbatim across 12 trusts, leading the auditors to suspect the sites may be sharing information in unknown ways.

There was a 47-fold difference between the two Trusts with the highest and the lowest rates per capita, raising concern that the probability of receiving ECT is based on little more than local psychiatrists’ opinion. The number of people given ECT in 2019 in the responding Trusts was 1,964, ranging from 14 and 16 to 143 and 169, with a mean of 53.1.

11% of Trusts had given ECT to a child under 18, and 66.7% of ECT recipients overall are women. 20 Trusts administered ECT to women twice as often as men.

Only 3 of 87 Trusts gave responses about how many people had ECT without receiving recommended psychological therapy. These were vague or claimed that people were too unwell to engage in psychotherapy. On the question of consent, 28 Trusts revealed that 36% of patients receive ECT without giving consent.

A similarly small number of Trusts (16.2%) provided data on efficacy, all of which used invalidated ‘impression’ scales that had been collapsed into measuring if the patients were “improved,” “no change,” or “worse” at the endpoint of treatment but at no time afterward:

“Combining the 169 patients from the six Trusts, 88.2% were ‘improved,’ 10.1% showed ‘no change’ and 1.8% were ‘worse.’ However, the 79 patients in the three Trusts that used all seven points of the scale, reveal a more nuanced picture: 15.2% ‘very much improved,’ 27.8% ‘much improved,’ 44.3% ‘minimally improved’ and 12.7% ‘no change.’ Thus, the majority (57%) showed either no change or only minimal improvement.”

Only 7 Trusts provided data on adverse effects, most of which reported that they were unaware of any cases, with only four gesturing toward memory loss or cognitive impairment. Therefore, the majority of Trusts could not provide any data for positive outcomes or adverse effects during the three-week treatment period. None provided data on efficacy or adverse effects beyond the end of treatment.

These audit findings relay a long-term failure in ensuring appropriate standards of care are enforced in the administration and monitoring of ECT. Best practice recommendations, like valid cognitive follow-up tests, informed consent, and exploration of non-ECT treatments, are still being ignored.

The audit concluded:

“Given the apparent failure of current monitoring and accrediting ECT clinics in England, by the Royal College of Psychiatrists ECT Accreditation Service (ECTAS), an independent government-sponsored review is urgently needed.”

 

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Read, J., Harrop, C., Geekie, J., Renton, Cunliffe, S. (2021). A second independent audit of ECT in England, 2019: Usage, demographics, consent, and adherence to guidelines and legislation. Psychology and Psychotherapy: Theory, Research, and Practice, in press. DOI: 10.1111/papt.12335

13 COMMENTS

  1. To imply that the genocidal crime of electroshock could ever be ameliorated by better bureaucratic procedures is offensive in itself, and reminds me of Eichmann and the phrase “the banalty of evil.” The APA keynote speaker in its 1941 Convention (I believe) discussed the pros & cons of euthanizing “mental patients” in a similarly academic manner.

    • I think you’re talking about the pro-‘euthanasia’ editorial in the APA’s in house journal. Peter Breggin talks about it here. Hitler was an avowed fan of the eugenics policies of American psychiatry.

      In fact shrinks were consistently ahead of the Nazis in advocating and implementing the Holocaust. I touch on the history of it here.

          • Of course.
            Psychiatry appeals to certain personalities. I mean to sit in a cushy office and bestow people with “you are sick in the head”.
            That is ALL the DSM is.
            The labels all say “YOU ARE SICK IN THE HEAD”.

          • It was more a case of the Nazis being foursquare behind the psychiatrists.

            When Dr Alfred Hoche laid down the utilitarian principles of ‘life unworthy of life’ in 1920 the newly named NDSAP (Nazi Party) had less than 200 members and was almost unknown outside Munich.

            When Germany invaded Poland the shrinks took it upon themselves to start exterminating the institutionalised ‘mentally deficient’ to free up hospital space for wounded soldiers. Hitler only found out later and signed backdated orders authorising it.

            When Hitler was forced to close down the official program exterminating the ‘mentally ill’, psychiatrists took it underground and increased the rate of killings.

            When the ‘Final Solution’ was implemented the Nazis turned to psychiatrists to bring their expertise in mass extermination to the death camps, with Dr Irmfried Eberl designing Treblinka and becoming its first commandant. He was soon dismissed for the casual way he left piles of rotting corpses around the railway lines, making it impossible for ‘good Germans’ to pretend they didn’t know what was going on there.

            And after the Germans surrendered and the camps were liberated psychiatrists continued to kill hospital and asylum inmates for weeks until occupying authorities found out what was going on and put a stop to it.

            So when it came to genocide the shrinks were both ahead of the Nazis and still kept going after the Nazis had been stopped.

          • Thanks for the ongoing education! Difficult reading, but it says so very much about why this “profession” has roots in very dark and destructive places, and why trying to “reform” the profession is destined to complete and utter failure.

          • And basically all the psychiatric industry has done, since the Nazi days, is find mind altering drug classes that can make people sick. And change the word ‘eugenic,’ to the word ‘genetic.’

            When, in reality, the word that should be used to describe the psychiatrists’ DSM disorders, is iatrogenic. Given the fact that the ADHD drugs and antidepressants can create the “bipolar” symptoms.

            https://www.google.com/amp/s/www.alternet.org/amp/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america-2647214860

            And the antipsychotics (aka neuroleptics) can create both the negative and positive symptoms of “schizophrenia,” via NIDS and anticholinergic toxidrome.

            https://en.m.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

            https://en.m.wikipedia.org/wiki/Toxidrome

            The systemic crimes of the psychiatric profession continue, and they are not as “complex,” as the psychiatrists’ would like the world to believe.

            What is more difficult to come to grips with, is the pure evil, of what the psychiatric system is doing. Their modern day psychiatric holocaust is killing “8 million” innocent people worldwide, every year.

            https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2015/mortality-and-mental-disorders.shtml

          • and why trying to “reform” the profession is destined to complete and utter failure.

            Yeah. There are decent psychiatrists out there trying to put the profession onto a humane and scientific basis but there’s too much cultural baggage to overcome in my opinion. The guilds crucify criticalists and reformists and there’s too many external vested interests who like the illegitimate authority of psychiatry just the way it is (drug companies, courts, authoritarian governments, oppressive families, etc).

            Reformers think that if psychiatry can legitimise its own authority with treatments and professional ethics that actually help people it won’t have to maintain symbiosis with external authorities who need a pliant pseudo-scientific priesthood to leverage their own power. But I can’t see how to overcome the inertia of all those dysfunctional interlocking institutions.

            Better to start from scratch with a new caring profession that salvages what it can from benevolent psychiatric initiatives like Soteria and Open Dialogue without climbing into bed with those who prefer a white-coated political police force. Then, hopefully, psychiatry will lose its mystique to the real carers, become useless to its totalitarian sponsors and just wither on the vine.

            Problem is it’s been tried before. We call it psychology. And the US version of that has a long and sordid history of torture and brainwashing for the military and CIA. Is it wishful thinking to believe we might learn from those mistakes and try again?

      • Nope, I’m talking about the APA convention somewhere around 1941. I’m aware of those articles as well.

        Breggin did a comprehensive study of psychiatry’s role in the holocaust as well — including the note that shrinks were found still independently “euthanizing” inmates after the camps had been liberated.

        I have these links but I’m feeling lazy, sorry…

        • This I believe is the publication you are mentioning.

          http://breggin.com/wp-content/uploads/2008/01/psychiatrysrole.pbreggin.1993.pdf

          Some interesting analysis has emerged from broader historical research and analysis that I came across in the American film archives catalogue of videos. It is documentable beyond any reasonable doubt that german psychiatrists were in Breggins words the “entering wedge” the broader refusal to acknowledge this historical legacy of nefarious characters pursuing scientifically justified murder only adds to the murky waters of unscrupulous minds and beliefs that remain preeminent to every inch of the domains resultant knowledge and scientific validity. Rotten to the core is the story of how eugenics remains vibrant and booming in its country of origin to this day.

          I feel like I am going to spend the rest of my life crafting ways to directly and inadvertantly circle all discussion and debate to the eugenics heart of darkness the fact that they continue to funnel billions towards genetic biological research baffles the mind for so many reasons the most salient of which being the fact that they have literally forcible sterilized, and actively prevented our capacity to reproduce with each and at all whether due to chemical or physical castration or outright murder and incarcerations’ during “breeding years” yet there was no benefit to prevalence to the fact that despite their literally life ending operational tactics for nearly a century there now stands a pattern that suggests incidence and prevalence is growing rapidly. I’m trying to not loose my fucking shit over the totality of the cancer because that is no way to keep myself safe let alone sustain to any degree of disruption. There have got to be more fruitful ways in which this information can be shared widely or at least culpability might be pursued formally and to the record of law

          • Thanks for that. I thought I was well across the history of psychiatry’s role in the Holocaust, but it taught me a few things.

            And yeah, oldhead was essentially right about the 1941 APA convention.

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