Friday, December 14, 2012

No one can explain the spike in ECT's in Ontario...why?

Introduced in Ontario during the 1940s, electroconvulsive therapy has never been subject to provincial standards.
Health ministry staff cannot explain the explosion of the practice and said no one in government could speak to the issue. The ministry deferred comment to individual hospitals and local health integration networks. (from  "Electroshock therapy more prevalent in Ontario, but guidelines are minimal"
By Jennifer Wells and Diana Zlomislic, Toronto Star December 14, 2012, below)
Memo to the psychiatric profession:
This is not only dangerous, and requires strict, enforced and transparent guidelines, but the use of electric shock therapy would be better eliminated than continued. There is a line in the hippocratic oath about "doing no harm" and the oath is a requirement for all doctors practicing in Ontario, or was when we last checked. Where are the clinical trials of this form of treatment, or is the public expected to believe the anecdotal reporting of those in the medical profession about the positive impact of its use? And how recently were clinical trials even conducted, or even required on equipment for which clinical trials are simply not available because they have never been conducted.
A patient's depression, while severe, and also while not adapting to medications might be telling the medical profession that this "patient's story" does not fit the medical diagnosis or treatment histories currently known and available to the profession. A simple layperson question arises, as I write this: When last did the attending physician and/or psychiatrist conduct a full biographical history of the patient, share that history with a team of both clinicians and lay people including nurses, chaplains and family members, and together design a treatment plan that is guaranteed to 'do no harm'? And while no drug can be guaranteed to 'do no harm' increasing evidence about the side effects of new drugs points to an elevated need and hopefully a requirement that the profession, including those providing both drugs and invasive equipment, that their "prescriptions" (in the widest sense of that word) will do much less harm than healing.
How is anyone to measure "less harm than healing"?...
Very carefully, and even more rigidly than ever before.
We have things like traditions, for the medical profession, that were established long before some of the current treatments were even experiments in the researchers laboratories. And if those traditions, including the omnipotent and all-knowing character of those traditions, are no longer approrpriate and relevant to the treatment modalities now available and in extensive and alarmingly high use, then we need new traditions, new cautions, new protocols and new enforceable guidelines for the profession.
Governments and their laws clearly are playing catch-up with the new technologies in the private and national security fields. Perhaps this is also the case in professions that rely heavily on invasive technologies like medicine.
Public protection, in a general way, seems to be left to individual families, and garners public attention only after devastating results of treatments that went horrible wrong. The families in turn file law suits and several years later the courts award penalties, if required. In the meantime, however, hundreds, if not thousands of other patients and their families may be subject to a similar, malignant treatment, with no caution or legal sanction having been put in place to protect the public from serious harm.
This is one voice that joins with those seeking to abolish ECT from the treatment arrows in the psychiatrist's quivver. Certainly, there must be a public inquiry into the use of ECT, and not done only by those whose confidence in its use exceeds any reasonable level of confidence among an engaged if untrained public, any of whom could be subject to such treatment, either voluntarily or "involuntarily"...another of those antiseptic words that really means, "we are going to force you to undergo this treatment whether you like it or not"....
Hippocrates would be appalled by such a situation, and it exists in every psychiatric ward in Ontario, if not far beyond.

Electroshock therapy more prevalent in Ontario, but guidelines are minimal

By Jennifer Wells and Diana Zlomislic, Toronto Star December 14, 2012
Electroshock — a brute force assault on the brain deemed the most controversial treatment in psychiatry — is being administered across Ontario in record numbers and with scant oversight.
Nearly three decades after a government inquiry called for provincial training and clinical practice standards — an inquiry launched after a Hamilton housewife was prescribed shock therapy against her will — no such guidelines exist.
Data released to the Toronto Star by the Ministry of Health show an almost incomprehensible spike in what is conventionally referred to as electroconvulsive therapy, or ECT.
Considered a “last-resort” therapy to lift severe depression, ECT is being increasingly relied upon to treat patients for whom antidepressants have proved ineffective.
In the fiscal year 2010-2011, the most recent year for which statistics are available, 16,259 ECT treatments were administered throughout Ontario, an increase of more than 350 per cent in seven years. A breakdown by age and gender reveals startling subsets, especially a 1,300-per-cent treatment increase for patients in the 55-59 age cohort. The statistics also reveal that women outnumber men nearly two to one in the 60-to-64 age bracket.
ECT patients across Ontario interviewed by the Star described numerous cognitive side effects as a result of the treatment. Though some credit ECT for breaking their extreme anguish, they say the practice must be regulated.
Some want it abolished.
Annette VanEs was a single mother in her 40s when she underwent a series of 40 treatments that, she says, resulted in catastrophic memory loss. “My brain goes into this scramble mode,” she says of her frame of mind now, 12 years later. “Scrambling, scrambling . . . You know that you lived. You went places. You made friends. You talked to people. You went to parties. You had values. You had ideas. You had beliefs. And now they’re not there.”
VanEs shared her story for the first time as part of an in-depth investigation published Friday at StarDispatches.com.
VanEs’s children say the shock treatments left her “infantile.” Daughter Erica recalls that she spent her high school years trying to teach her mother basic skills: how to pay bills again, how to shop for groceries. She worried that her mother’s frustration over her lost memory would drive her to suicide.
“Her increasing suicide ideation in the moments of her freedom from hospital had me lugging all the kitchen knives in my backpack to school and at times searching for her on the piers,” Erica told the Star.
In Toronto, a 36-year-old woman received six treatments at one hospital before doctors advised she would be better served by improved technology at another facility, where she was given an additional 16 treatments. She now attends daily cognitive therapy sessions.
“My memories of the past 10 years, sometimes more, are spotty, and a lot of it has to be filled in by my husband,” she says. She asked to not be identified. She worries the stigma of ECT could hurt her re-entry into the work force.
Through late summer and early fall, Windsor resident Matt Damphouse travelled to another city several times a week for ECT. He describes the early sessions as “hell.” On three occasions, medical staff improperly administered a muscle relaxant before injecting the anesthetic — the reverse protocol of what is required to keep the patient both out and slack during treatment.
Damphouse was left temporarily paralyzed, awake and unable to breathe. “I used to be so full of terror,” he says. “To do the things that they did to me as often as they did shows that there’s something wrong there.”
He now receives ECT at Windsor Regional Hospital, which opened a neurobehavioural institute in late October. Though he says his treatments there have been “smooth as silk,” Damphouse wants to see the adoption of uniform standards.
Introduced in Ontario during the 1940s, electroconvulsive therapy has never been subject to provincial standards.
Health ministry staff cannot explain the explosion of the practice and said no one in government could speak to the issue. The ministry deferred comment to individual hospitals and local health integration networks.
As it stands, many physicians disagree about the most effective and least-damaging way to deliver the treatment. Protocols vary dramatically from hospital to hospital and sometimes within a hospital.
“There’s still a lot of heterogeneity in how ECT is done, unfortunately,” says Dr. Kiran Rabheru, an Ottawa psychiatrist, adding that the delivery of ECT requires “a lot of sophistication.” Dr. Caroline Gosselin, a geriatric psychiatrist in Vancouver, calls it an “art.”
Critics have likened ECT, which channels electricity into the brain to “shock” the body into seizure, to an electrical lobotomy.
Attempts to refine the treatment have included experimenting with the placement of electrodes on the skull and modulating the form of the current to try to target the frontal lobe, where depression is believed to reside. Cerebral spinal fluid “basically takes that electrical field and moves it everywhere in the brain,” says Dr. Jeffrey Daskalakis, who runs the ECT program at the Centre for Addiction and Mental Health in Toronto.
“The only way it can work is by damaging the brain,” says Dr. Peter Breggin, a New York psychiatrist who has been a thorn in the side of the ECT advocates since the 1960s. “It works by temporarily obliterating mental functions.”
Advocates, however, insist the treatment is the best alternative for patients for whom antidepressants offer no relief.
Rabheru, past president of the Canadian Academy of Geriatric Psychiatry and a professor of psychiatry at the University of Ottawa, believes that ECT is the best ticket to returning quality of life to older people with acute depression. This group, he says, “responds almost 100 per cent of the time to ECT.”
Rabheru is working toward establishing an out-patient ECT program.
“We know that ECT works well, but I don’t think we’ll have the supply to meet demand, the resources to meet demand.”
He’s in the process of putting together a proposal to the Ministry of Health for extra support.
Windsor Regional executives have been so firm in their belief of a desperately underserved community that the hospital’s ECT suite was opened in the absence of provincial funding.
“We’re hoping that through the number of cases we’ll be able to show within the first couple of months that this is a needed service,” says David Musyj, Windsor Regional’s CEO.
Musyj has put $250,000 of Windsor Regional funds on the line — enough to cover six months of operations to the end of March.
Windsor administrators set a forecast of 750 treatments annually.
Dr. Leonardo Cortese, the hospital’s chief of psychiatry, believes that’s an underestimate.
Increasing awareness of treatment availability will, he predicts, be a spur to a “very high increase” in treatment delivery — as much as 25 per cent within the year. “It’s like anything else,” he says. “You build it, they will come.”
The demand is there. But what, precisely, is being supplied?
Asking that question leads straight into a bog of outdated guidelines at best, absent guidelines at worst, confused protocols, non-existent standards and catastrophically outdated equipment.
A recent survey of 175 Canadian centres that identify ECT as part of their practice estimates that 75,000 ECT treatments are administered across the country annually. Of the 107 sites that responded to the survey, 89 reported the existence of written ECT policies and procedures, less than 40 per cent reported electrode placement policies, only 30 per cent have electrical dosing policies, and less than 30 per cent have ECT-specific anesthesia policies. Just 27 per cent reported written policies for managing concurrent medications during ECT.
Contrast that with Australia, where the state of Victoria sets licensing requirements, equipment standards and clinical guidelines. Under the state’s Mental Health Act, a course of ECT is defined as up to six treatments, after which the patient is asked to sign a new consent form.
In Canada, outdated ECT machines known to cause severe cognitive impairment are still being used by at least three health facilities, a fact unearthed by the national survey. Dr. Nicholas Delva, head of the department of psychiatry at Dalhousie University and lead author of the survey dgroup’s study on access to treatment, says confidentiality agreements prevent him from naming the institutions.
The study also revealed that 14 per cent of responding ECT sites reported they did not have funds to purchase up-to-date ECT or related anesthesiology equipment.
Dr. Barry Martin, the former head of CAMH’s ECT service, says the lack of data is troublesome, presenting what he calls the “invited question as to whether or not they are documenting their treatment dosages even within those sites . . . If they’re not providing it to us on request by a group of professional peers, and are not required to present it in some form to government — what have they got?”



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