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Electroconvulsive Therapy Annual Statistics For the period 1 July 2003 to 30 June 2005

Citation: Ministry of Health. 2006. Electroconvulsive Therapy Annual Statistics: For the period 1 July 2003 to 30 June 2005. Wellington: Ministry of Health.

Published in August 2006 by the Ministry of Health

PO Box 5013, Wellington, New Zealand

ISBN 0-478-30048-4 (Website) HP 4297

This document is available on the Ministry of Health’s website: http://www.moh.govt.nz

Electroconvulsive Therapy Annual Statistics iii

Contents

1 Introduction 1 How effective is ECT? 1 Possible risks 2 Side-effects 2 Does ECT cause brain damage? 2 Is ECT safe for pregnant women? 3 Alternative treatments to ECT 3 Is ECT given only as a last resort? 3 Further information 3

2 Scope of this Report 4 ECT treatments per patient 4 ECT delivered under compulsion 4

3 Number of Patients Treated with ECT 5 Regional variations in the number of ECT treatments given 8

4 ECT Treatments per Acute Course 9

5 ECT and Consent to Treatment 11 The consent process 11 Defining consent to treatment 11 ECT treatments and the Mental Health Act 11

6 Age and Sex of Patients Treated with ECT 14

7 Ethnicity of Patients Treated with ECT 17

iv Electroconvulsive Therapy Annual Statistics

List of Tables Table 1: Total number of patients treated with ECT, by DHB, 1 July 2003–30 June 2005 5 Table 2: ECT treatments per acute course, by DHB, 1 July 2004–30 June 2005 10 Table 3: ECT treatments not consented to during the period 1 July 2003–30 June 2005 12 Table 4: Age and sex of patients treated with ECT, 1 July 2003–30 June 2005 14 Table 5: Ethnicity of people treated with ECT, 1 July 2003–30 June 2005 17

List of Figures Figure 1a: Number of patients treated with ECT per 100,000 population, 1 July 2004–30 June

2005 6 Figure 1b: Number of patients treated with ECT per 100,000 population, 1 July 2003–30 June

2004 6 Figure 1c: Percentage of patients (aged 20+ years) seen at a mental health service treated with

ECT, 1 July 2004–30 June 2005 7 Figure 1d: Percentage of patients (aged 20+ years) seen at a mental health service treated with

ECT, 1 July 2003–30 June 2004 7 Figure 2: ECT treatments per acute course, by DHB, 1 July 2004–30 June 2005 10 Figure 3: Population-adjusted figures for the number of ECT treatments consented to per

100,000 population, 1 July 2004–30 June 2005 13 Figure 4a: Age and sex of patients treated with ECT, 1 July 2004–30 June 2005 15 Figure 4b: Age and sex of patients treated with ECT, 1 July 2003–30 June 2004 15

Electroconvulsive Therapy Annual Statistics 1

1 Introduction Electroconvulsive therapy (ECT) is a therapeutic procedure in which a brief electric charge is delivered to a patient’s brain in order to produce a seizure. ECT is an effective treatment for various types of mental illness including depressive illness, mania and catatonia. Although ECT has been used since the 1930s, how it works is still not fully understood. The most likely way in which ECT has its effect is that, like antidepressants, it affects neurotransmitters (chemical messengers) in the brain responsible for mental illness. ECT is administered under anaesthesia and with muscle relaxants to prevent injury to the patient as a result of the induced seizure. The end result is that the patient drifts off to sleep and wakes up a short time later unable to recall the details of the procedure. ECT is a valuable and sometimes life-saving treatment despite the often negative depictions of it in popular culture and the media. It is mainly used to treat severe depression, particularly if complicated by psychosis. It is also used in cases of severe depression where: • antidepressant medication, psychotherapy, or both, have been ineffective • medication cannot be taken • other treatments would be too slow (for example, in a person with delusional

depression and intense, unremitting suicidal tendencies). ECT is considered the safest treatment option in some cases where depression is accompanied by a physical illness or pregnancy, which renders the use of the usually preferred antidepressants dangerous to the patient or to a developing foetus. When a course of ECT is prescribed, it is usually administered twice a week for 3–6 weeks (ie, a course of 6–12 treatments).

How effective is ECT? Seventy to 80 percent of patients who receive ECT respond well to it. In fact, ECT is the most effective short-term treatment for severe depression. Most patients recover their ability to work and lead a productive life after their depression has been treated with a course of ECT. Because the effects are typically short term, medication is usually required to maintain the beneficial effects of ECT. ECT has also been shown to be effective in depressed patients who do not respond to other forms of treatment. Medication is usually the treatment of choice for mania, but here too certain patients do not respond. Many of these patients have been successfully treated with ECT.

2 Electroconvulsive Therapy Annual Statistics

Possible risks ECT is no more dangerous than minor surgery under general anaesthesia, and may at times be less dangerous than treatment with antidepressant medications. A small number of other medical disorders increase the risk associated with ECT, and patients are carefully screened for these conditions before a psychiatrist will recommend them for ECT. In New Zealand ECT services, the anaesthetic for ECT is given by a consultant (or specialist) anaesthetist, in properly equipped facilities.

Side-effects Some people will experience headaches, muscle ache or soreness, nausea and confusion, usually during the first few hours after the procedure. Over the course of ECT it may be more difficult for patients to remember newly learned information, though this difficulty disappears over the days and weeks following completion of the ECT course. Some patients also report a partial loss of memory for events that occurred during the days, weeks and months preceding ECT. While most of these memories typically return over a period of days to months following ECT, some patients have reported longer-lasting problems with recalling these memories. However, other individuals actually report improved memory ability following ECT, because of its ability to remove the amnesia that is sometimes associated with severe depression. It has sometimes been questioned why ECT continues to be used in New Zealand despite the fact that many patients experience these disturbances in memory following ECT, and some experience severe and prolonged confusion after treatment. Most medical treatments involve some risk to the patient. Decisions about treatment involve a careful balancing of the risks and benefits of different treatment options, including the option of having no treatment. Whenever possible, the patient and/or their family/ whānau should participate in the informed consent process, taking into account any prior wishes or advance directives the patient may have expressed. Although there have been many advances in the treatment of mental disorders in recent years, ECT remains the most appropriate and effective treatment for some people suffering with serious mental illness.

Does ECT cause brain damage? There is no evidence that ECT causes any structural cerebral damage. However, as noted, short-term memory impairment following ECT is common. It is not clear how much of the longer-term memory impairment is caused by ECT and how much by severe depression.


Is ECT safe for pregnant women? ECT does not produce abnormal uterine contractions and it appears to be safe even in complicated pregnancies. Foetal monitoring during ECT has not revealed any untoward effects on the foetus. However, the decision whether to treat pregnant women with ECT needs to take into account the risks associated with alternative treatments, the risks to the mother and foetus of withholding ECT, and any complications of the pregnancy that may increase the risks of ECT or the anaesthetic. ECT may be used with confidence during the second and third trimesters. Little information is available for its use in the first trimester, so until further data is available caution is advisable during this stage.

Alternative treatments to ECT Antidepressant drugs may be appropriate and it is possible that some of them may work as well as ECT. The advantages and disadvantages of other treatments should be discussed with the patient during the informed consent process referred to above.

Is ECT given only as a last resort? When a patient presents with a severe mental illness such as major depression, the various treatment options will be considered as well as their risks, benefits and alternatives. It is not true that the risks associated with ECT are always greater than the risks associated with other treatments, such as antidepressant medication. Some patients may be non-responsive to, or intolerant of, antidepressant medication, and other patients may require a treatment which has a rapid onset of action. For these reasons, ECT is not always a treatment of last resort, and in certain life-threatening situations it may be the first choice treatment option.

Further information The December 2004 publication Use of ECT in New Zealand: A review of efficacy, safety, and regulatory controls is available on the Ministry of Health website. The Royal Australian and New Zealand College of Psychiatrists is the professional body most closely involved in ECT.


2 Scope of this Report This Ministry of Health annual report on ECT covers the two reporting periods from 1 July 2003 to 30 June 2005. In accordance with the Health Select Committee’s recommendations, it shows statistics for the total number of people who received ECT, plus breakdowns by a number of socio-demographic variables. The report also presents statistics on the number of patients who were treated with ECT under compulsion. Where possible this report includes data gathered by the Ministry of Health for the previous reporting period from 1 July 2003 to 30 June 2004. Data from the previous year is included for the total number of patients treated with ECT, the percentage of patients (aged 20+ years) seen at a mental health service treated with ECT and demographic information such as age, sex and gender. Data from the previous 2003/04 reporting period needs to be interpreted with caution for the following reasons:

ECT treatments per patient A series of acute ECT treatments is required to produce a lasting therapeutic effect. This is known as an acute course of ECT. The data collected for the 2003/04 period showed information on the number of ECT treatments given per patient but did not accurately define whether treatment administered was part of an acute course of treatment, or whether it was an additional treatment given to maintain the patient’s mental state (maintenance treatment). Data collected for the 2004/05 reporting period on the type of ECT treatment has lead to improvements in this aspect of ECT reporting.

ECT delivered under compulsion A patient who is subject to compulsion under the Mental Health (Compulsory Assessment and Treatment) Act 1992 (the Act) may nevertheless be capable of consenting to treatment. During the 2003/04 reporting period, there were various interpretations of the word compulsion. Some DHBs mistakenly interpreted compulsion as referring to people subject to the Act, regardless of whether consent was given for ECT. Hence the figures reported on the number of ECT administrations not consented to were over-reported. This aspect of the ECT reporting continues to be refined.


3 Number of Patients Treated with ECT Table 1 shows the annualised total number of patients who received ECT from 1 July 2003 to 30 June 2005, broken down by DHB. A total of 307 people received ECT during the 2004/05 reporting period, equivalent to 7.5 per 100,000 population. This compares with 305 or 7.5 people per 100,000 from 1 July 2003 to 30 June 2004. The average number of treatments per acute course of ECT was 7 treatments. Figure 1a and 1b illustrate the population-adjusted figures for the number of patients who received ECT per 100,000 population during the both reporting periods. They also show the national average number of patients treated with ECT per 100,000 population for each reporting period. Figure 1c and 1d presents the same data, adjusted to relate the use of ECT to the population of mental health service users over the age of 20 in each DHB. Table 1: Total number of patients treated with ECT, by DHB, 1 July 2003–30 June 2005

District Health Board Number of patients treated with ECT 2004/05

Number of patients treated with ECT 2003/04

Auckland 13 7 Bay of Plenty 17 33 Canterbury 79 52 Capital and Coast 15 27 Counties Manukau 24 29 Hawke’s Bay*+ <5 <5 Hutt 9 5 Lakes 22 7 Midcentral 6 10 Nelson Marlborough 11 11 Northland 6 7 Otago 33 39 South Canterbury+ 0 0 Southland 6 10 Tairawhiti <5 5 Taranaki+ 0 <5 Waikato 38 28 Wairarapa+ 0 0 Waitemata 23 30 West Coast <5 <5 Whanganui*+ <5 <5

Total number of individual patients 307 305

NB: In 2004/05 there were four patients treated at two DHBs: • one patient at Canterbury and Otago • one patient at Capital & Coast and Waikato • one patient at Auckland and Waitemata • one patient at Auckland and Canterbury. In 2003/04 there were two patients treated at two DHBs: • one patient at Bay of Plenty and Counties Manukau • one patient at Southland and Otago. Notes: * ECT performed at MidCentral DHB. + DHB does not have an ECT machine. <5 Some DHBs reported very few ECT treatments. A notation of less than 5 was used to ensure that patients remain anonymous.


Figure 1a: Number of patients treated with ECT per 100,000 population, 1 July 2004–30 June 2005

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National average: 7.5

Figure 1b: Number of patients treated with ECT per 100,000 population, 1 July 2003–30 June

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National average: 7.5

* ECT performed at MidCentral DHB. + DHB does not have an ECT machine.


Figure 1c: Percentage of patients (aged 20+ years) seen at a mental health service treated with ECT, 1 July 2004–30 June 2005

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National average: 0.43%

Figure 1d: Percentage of patients (aged 20+ years) seen at a mental health service treated

with ECT, 1 July 2003–30 June 2004

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National average: 0.42%



Regional variations in the number of ECT treatments given No attempt has been made to explain regional variations in the use of ECT. However, the following factors will be relevant: • Regions with smaller populations will be more vulnerable to year-by-year variations

(according to the needs of the population at any time). • Patients receiving continuous or maintenance treatment will typically receive more

treatments in a year than those patients who are treated with an acute course. • ECT is indicated in older people more often than in younger adults because older

people are more likely to have associated medical problems contraindicating medication.

• Some DHBs have better access to ECT services than others, and this factor is likely to influence the rates of use.


4 ECT Treatments per Acute Course A series of ECT treatments is required to produce a lasting therapeutic effect. This is known as an acute course of ECT. Although an acute course may bring an episode of serious mental illness to an end, it will not in itself prevent another episode from occurring weeks, months or years later. Sometimes further ECT treatments will be prescribed at a much less frequent rate to maintain remission, usually on an outpatient basis. Such treatments are known as maintenance treatments. More detailed data from DHBs about the context in which each ECT treatment occurred has allowed for reporting on the number of treatments per course of ECT. The method used to refine the data to show course information involves: • removing those ECT treatments that are not part of an acute course of treatment • excluding acute courses of treatment that occur within five days of the end of one

reporting period and five days into a new reporting period, to ensure only full courses are included in the analysis.

Several factors can influence the number of individual treatments that a patient may need: • the severity of the patient’s illness and the degree of treatment resistance • any complicating medical factors • age (older people may need longer courses, thus if ECT is done mostly in older

people the courses may be longer) • the timeliness of maintenance medication being started during the course • technical factors in how the treatment is given (eg, bilateral versus right unilateral

treatment). Table 2 shows the average number and the range of ECT treatments per course, by DHB. This data is represented graphically in Figure 2, with the national average being seven ECT treatments per acute course of ECT during the 2004/05 reporting period.


Table 2: ECT treatments per acute course, by DHB, 1 July 2004–30 June 2005

DHB No. of courses No. of treatments No. of treatments per acute course:mean (range)

Auckland 11 124 11 (4–18) Waitemata 17 183 11 (2–19) Southland 3 30 10 (5–19) MidCentral 10 80 8 (4–12) Canterbury 63 492 8 (2–18) Waikato 31 237 8 (3–14) Hutt Valley 7 53 8 (4–14) CMDHB 23 172 7 (3–13) Northland 6 44 7 (3–11) BOP 16 109 7 (2–15) Tairawhiti 3 19 6 (4–10) NMDHB 12 74 6 (3–12) Otago 38 228 6 (2–14) CCDHB 9 52 6 (4–8) Lakes 21 113 5 (3–8)

Figure 2: ECT treatments per acute course, by DHB, 1 July 2004–30 June 2005

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National average: 7


5 ECT and Consent to Treatment

The consent process If the patient is competent to consent, the potential benefits and risks of ECT and available alternative interventions should be carefully reviewed and discussed with the patient and, where appropriate, their family/whānau or friends, so that the patient is able to make an informed decision. If the patient is not competent to consent, or is not willing to consent, ECT can not be given without legal authorisation. The most common legal framework for administering ECT to patients who have not given their consent is provided by the Mental Health (Compulsory Assessment and Treatment) Act 1992. Committed patients can be given ECT without their consent only if a psychiatrist appointed by the Mental Health Review Tribunal has given a second opinion stating that the course of treatment is in their interests. Clinicians will generally make the decision about whether ECT is in the interests of the patient after discussing the options with family/whānau and considering any advance statements of the patient that may be relevant.

Defining consent to treatment In the year 1 July 2003 to 30 June 2004, DHBs reported whether or not patients having ECT were subject to the Mental Health Act or were a voluntary patient. Most DHBs did not report whether the patient had consented, and assumed that all patients detained under the Mental Health Act did not consent. It is likely therefore that the reported figures during the 2003/2004 period overestimated the number of treatments not consented to. This aspect of the data was clarified for the 2004/2005 reporting period, and continues to be refined. The important issue is ‘consent to treatment’, because patients may be subject the Mental Health Act but still retain capacity to consent to treatment. During the 2004–2005 reporting period, no patient was treated with ECT if they retained decision making capacity, and refused to consent.

ECT treatments and the Mental Health Act There were 84 patients treated with ECT during the 2004–2005 reporting period who were subject to the Mental Health (Compulsory Assessment and Treatment) Act 1992, which represents 23% of all patients treated with ECT.


Table 3: ECT treatments not consented to during the period 1 July 2003–30 June 2005

Number of administrations not consented to District Health Board

2004/05 2003/04

Auckland 77 (51%) 49 (63%) BOPDHB 2 (1%) 70 (24%) Canterbury 54 (8%) 55 (12%) CCDHB 72 (59%) 42 (15%) CMDHB 73 (36%) 160 (58%) Hawkes Bay*+ 0 (0%) 0 (0%) Hutt Valley 0 (0%) 15 (17%) Lakes 6 (5%) 16 (37%) Midcentral 0 (0%) 15 (16%) NMDHB 15 (19%) 0 (0%) Northland 8 (18%) 0 (0%) Otago 46 (17%) 70 (17%) South Canterbury+ 0 (0%) 0 (0%) Southland 19 (22%) 16 (14%) Tairawhiti 15 (68%) 0 (0%) Taranaki+ 0 (0%) 0 (0%) Waikato 93 (30%) 16 (7%) Wairarapa+ 0 (0%) 0 (0%) Waitemata 113 (39%) 222 (40%) West Coast 0 (0%) 0 (0%) Whanganui*+ 0 (0%) 0 (0%)

Total 593 (22%) 746 (24%)

* ECT performed at MidCentral DHB. + DHB does not have an ECT machine. Note: During the 2004/05 reporting period, all patients not consenting lacked decision making capacity.


Figure 3: Population-adjusted figures for the number of ECT treatments consented to per 100,000 population, 1 July 2004–30 June 2005

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No consentConsent given



6 Age and Sex of Patients Treated with ECT Table 4 shows the age and sex of people who were treated with ECT during the period 1 July 2004–30 June 2005. This information is depicted graphically in Figure 4. Age group was determined by the individual’s age at the beginning of their treatment. Table 4: Age and sex of patients treated with ECT, 1 July 2003–30 June 2005

Number of patients 2004/05 Number of patients 2003/04 Age of patients

Female Male Female Male

15–19 2 0 5 0 20–24 4 5 8 1 25–29 9 3 7 4 30–34 16 7 16 3 35–39 10 8 12 6 40–44 27 7 23 4 45–49 20 6 14 10 50–54 17 7 15 12 55–59 12 6 19 10 60–64 11 8 16 5 65–69 11 8 17 2 70–74 20 8 23 11 75–79 25 10 17 8 80–84 22 9 11 13 85–89 7 1 8 4 90–94 1 2 2 0

Totals 214 95 211 93


Figure 4a: Age and sex of patients treated with ECT, 1 July 2004–30 June 2005

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Figure 4b: Age and sex of patients treated with ECT, 1 July 2003–30 June 2004

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The results show that of the 307 people who were treated with ECT during 2004/05, 212 (69%) were women and 93 (31%) were men. The majority of the difference is attributable to the fact that more women present to our services with depressive disorders. This ratio is similar to that in other countries.


7 Ethnicity of Patients Treated with ECT Table 5 represents the ethnicity breakdown of people who were treated with ECT during the period 1 July 2003–30 June 2005. Table 5: Ethnicity of people treated with ECT, 1 July 2003–30 June 2005

Ethnicity Number of patients 2004/05 Number of patients 2003/04

Asian 5 (2%) 2 (1%) European 260 (85%) 258 (84%) Māori 18 (6%) 15 (5%) Pacific people 7 (7%) 6 (2%) Other 17 (17%) 24 (8%)

The ethnic spread suggests Asian people, Māori and Pacific Islanders are underrepresented for their population demography. However, the numbers are so small it would be unhelpful to show how the percentages relate to the proportion of each ethnic group in the total population.

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