ORIGINAL STUDY
A 10-Year Descriptive Study of Electroconvulsive Therapy at the Neuropsychiatric Hospital, Aro, Abeokuta Edward Babatunde Somoye, MB, BS, FWACP(Psych), Peter Olutunde Onifade, MB, BS, FMCP(Psych), Adedunmola Oluwaseun Oluwaranti, MB, CHB, and Adetayo Adeyinka Adeniji, MB, CHB Objectives: Evidence supports the use of electroconvulsive therapy (ECT) in current practice, and good quality of care is related to adherence to evidence-based guidelines. However, there are no guidelines for the practice of ECT in Nigeria and there is no regulatory body for its standards. The objective of this study therefore was to examine the practice of ECT between 2001 and 2010 at the Neuropsychiatric Hospital, Aro, Abeokuta, regarding consent procedures, staffing, training, indications, and administration with the goal of informing the development of guidelines locally. Methods: Data were extracted from 154 complete ECT treatment records in the register and from the patients’ case files. The data were qualitatively analyzed and described. Results: The mean age of patients who received ECT was 35.5 years and the majority were female. Bilateral electrode placement was invariable for all treatments. The major diagnosis of the patients receiving ECT was schizophrenia, whereas poor response to medication and psychomotor retardation were commonly stated indications. Treatments were largely unmodified during the first 3 years of the review, with a gradual reversal of this pattern in the latter years. The mean number of treatments per patient was 6.6, and only 1 patient received continuation ECT. Conclusions: Although the procedure of ECT in this center is generally similar to what is obtained in many other countries in Asia and Africa, aspects such as that of informed consent require attention. Regular audits of the practice are desirable. Key Words: electroconvulsive therapy, practice, Nigeria (J ECT 2014;30: 315–319)
A
fter its discovery 75 years ago, electroconvulsive therapy (ECT) has become useful in psychiatric practice. Evidence from research supports the effectiveness of ECT in contemporary practice.1 Despite the relative safety of the procedure, the controversies that surround it continue and its role in current psychiatric practice is continually called into question.2 Its practice varies significantly within countries and even within individual centers.3 Electroconvulsive therapy–related good quality of care depends on adherence to evidence-based guidelines.4 Therefore, treatment standards and guidelines have been produced by the Royal College of Psychiatrists and the American Psychiatric Association.1 In Nigeria, however, there are no guidelines for the practice of ECT and there is no regulatory body for its standards.2 An examination of current practice is an important first step in the development of such guidelines. Therefore, the aim of this study was to examine the practice of ECT between 2001 and 2010 regarding consent, staffing, training, indications, and administration. This will inform the development of From the Neuropsychiatric Hospital, Aro, Abeokuta, Ogun State, Nigeria. Received for publication May 31, 2013; accepted October 30, 2013. Reprints: Edward Babatunde Somoye, MB, BS, FWACP(Psych), Neuropsychiatric Hospital, Aro, Abeokuta, Ogun State, Nigeria (e‐mail: [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/YCT.0000000000000095
Journal of ECT • Volume 30, Number 4, December 2014
guidelines for the improvement and standardization of the procedure in this center and nationally.
MATERIALS AND METHODS Practice Setting This retrospective descriptive study was conducted at the Federal Neuropsychiatric Hospital Aro, Ogun State, Southwest Nigeria. The hospital is a tertiary specialist health institution that started at its annex in 1944 as an asylum for soldiers with mentally illness who were repatriated home after the Second World War. This annex was originally an administrative prison established by the colonialists. The need later arose to establish a modern psychiatric hospital; hence, Neuropsychiatric Hospital, Aro, was established in 1954. The hospital has a nationwide catchment area and also provides psychiatric services to some neighboring West African countries. It has a total bed capacity of 526 and provides inpatient, outpatient, 24-hour emergency services, and primary health care to neighboring communities. It offers undergraduate and postgraduate training in mental health and allied disciplines. It also offers post–basic training in psychiatric nursing. It collaborates in research with other bodies especially in the areas related to primary health care delivery, community-based mental health, substance abuse, epilepsy, epidemiology, as well as evaluation of services and drug trials. The hospital adopts the multidisciplinary approach in the management of patients with mental disorders so that the patients are managed by a team of physicians, nurses, occupational therapists, clinical psychologists, and social welfare officers. The practice of ECT commenced in the hospital in 1954. A variety of Ectron ECT machines have been used over time. More recently, these have included the Ectron constant current ECT series 3 and the Ectron Duopulse ECT series C, which remained in use until 2008.
Data Collection and Analysis Historical and administrative data about the deployment and use of ECT in the hospital were obtained from the directorates of clinical and nursing services of the hospital. Records of ECT treatments between January 2001 and December 2010 were obtained from the ECT register. The case notes of the patients were retrieved and comprehensively reviewed with a 26-item checklist, which included sociodemographic data, clinical variables, indications for ECT, consent, and ECT techniques. The study was approved by the research and ethics committee of the hospital. Data analysis was done using Statistical Package for Social Sciences (SPSS v16).
RESULTS Equipment From 2001 to 2008, a constant current sine wave device was used (Duopulse ECT Series C; Ectron Ltd). The timing of www.ectjournal.com
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seizures was done manually. This was replaced in 2008 with a Thymatron brief pulse device (Thymatron System IV; Somatics LLC) with electroencephalographic/electromyographic/ECT capabilities and timer. The Thymatron System IV in use between 2008 and 2010 delivered a maximum dose of 504 millicoulomb (mC) with a pulse width of 0.25 to 1.5 milliseconds. The treatment dose was usually initiated at 20% of this maximal dose (100 mC) with increments of 5% in cases of nonresponse but rarely exceeding 40% (200 mC). Pulse frequency was between 10 and 70 Hz in 10-Hz increments (to 140 Hz for 0.25-millisecond pulse). Current was 0.9 A and its duration was 8.0 seconds. Information on the settings for the earlier sine wave device used (Duopulse ECT Series C) was unavailable. Resuscitative equipment (anesthetic machine, ambu bag, oxygen, suction apparatus) were available. Equipment for endotracheal intubation was also available. However, a defibrillator was not available at the suite.
Medication The anesthetic used was thiopentone, with atropine and succinylcholine also given routinely for all patients undergoing modified ECT. Oxygen was given before and after ECT application. Emergency medications (adrenaline, hydrocortisone) were also available.
Staffing A qualified psychiatrist was in charge to oversee the administrative, logistic, and clinical activities in the ECT suite. In almost all cases, ECT was administered by a junior registrar (psychiatrist in training), whereas an experienced senior registrar was detailed to be at hand in case of complications requiring emergency interventions. Anesthesia was provided by an experienced anesthetic nurse, and each procedure was attended by at least 3 nurses, one of whom was a nurse from the ward where the patient was admitted.
Teaching and Supervision Registrars received instruction in the administration of ECT as part of orientation at the commencement of residency training. Didactic lectures were not received until much later in residency training. The nursing staff received specialized training in the administration of ECT as part of their post–basic psychiatric nursing training.
Documentation As depicted in Figure 1, a total of 191 patients received ECT in the period under review of which 154 (80.6%) complete records were available for analysis. Eleven patients had ECT in 2 different years and 26 case records could not be retrieved or had incomplete records. For treatment spillover into a new year, the starting year was taken as the index year.
Sociodemographic Variables
FIGURE 1. Flow Chart of ECT treatments.
The 2 most commonly stated indications for ECT were poor response to treatment (24%) and psychomotor retardation (16.2%). Indication was not documented in 65 (42.2%) cases. The decision to administer ECT was taken by a psychiatrist in most cases (85.7%), followed by a senior registrar in 9.1% of cases. A registrar took the decision in 5 cases (3.2%), and in 2 (1.3%) cases, the decision maker was not stated.
Special Population Four of the patients belonged to special groups: 3 (1.9%) were elderly patients (>65 years), whereas 1 (0.7%) was an adolescent. No pregnant patient was treated with ECT during the period of the study. Comorbid medical conditions were noted for 6 (3.9%) patients: 4 patients (2.6%) for hypertension and 1 each for benign prostatic hypertrophy and for HIV infection (0.7%).
Consent for the Procedure Proxy consent was obtained from relatives on behalf of all the patients usually at the point of admission to the hospital. It was not documented in 138 (89.6%) cases if, in addition to the proxy consent, direct consent was sought. Fifteen (9.7%) patients did not give direct consent, whereas only 1 (0.6%) did so. An explanation of the risks and benefits of the procedure to the patient was documented in only 3 (1.9%) cases.
Procedure The ECT was administered by a registrar/senior registrar in all cases. All treatments were given on an inpatient basis except one that was given on an outpatient basis (due to lack of finance for admission). Electrode placement was bilateral in all cases.
As shown in Table 1, most (57.8%) of the 154 patients were females. The mean age was 35.5 years (range, 15–66 years) and not statistically different between sexes. They were mostly Christians (83.1%), single (53.9%), and unemployed (69.5%), and 92.2% of them had at least completed primary education.
Frequency of administration was twice weekly in 143 cases (92.9%), weekly in 6 cases (3.9%), thrice weekly in 4 cases (2.6%), and monthly in 1 case (0.6%).
Diagnoses and Indications for ECT
Previous ECT History
Tables 2 and 3 show the diagnosis and the indications for the patients. The most common diagnosis for people receiving ECT was schizophrenia (60.4%), followed by depression (20%).
Fourteen (9.1%) patients had received ECT previously: 11 (7.1%) had 1 (0.7%) course previously, whereas 3 (1.9%) had multiple.
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Treatment Schedule
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Journal of ECT • Volume 30, Number 4, December 2014
Ten-Year ECT Study in Neuropsychiatric Hospital
TABLE 1. Sociodemographic Characteristics of Patients
TABLE 3. Indications for ECT
Characteristic
Indication
n (%)
Sex Male Female Age Male Female Total Completed education No formal Primary Secondary University Marital status Single Married Divorced Separated Widowed Employment Status Unemployed Employed Retired Religion Christian Islam
65 (42.2) 89 (57.8) 34.63 (12.25) 36.19 (10.16) 35.53 (11.08) 12 (7.8) 44 (28.5) 87 (56.6) 11 (7.1) 83 (53.9) 60 (39.0) 3 (1.9) 6 (3.9) 2 (1.3) 107 (69.5) 46 (29.9) 1 (0.6) 128 (83.1) 26 (16.9)
n (%)
Affective symptoms Augmentation of drug treatment Imminent neuroleptic malignant syndrome Not stated Physical distress Poor response to medication Previous response to ECT Psychotic symptoms Psychomotor retardation Refusal of food Refusal of medication Suicidal ideation Inability to take medication
3 (1.9) 1 (0.6) 1 (0.6) 65 (42.2) 1 (0.6) 37 (24.0) 3 (1.9) 6 (3.9) 25 (16.2) 1 (0.6) 5 (3.2) 5 (3.2) 1 (0.6)
examinations were documented by the registrar for only 138 (89.6%) and 3 (1.9%) of the patients, respectively.
Course Completion One hundred forty-one (96.6%) patients completed their courses of ECT, whereas the courses were terminated for 13 (3.4%) patients: 9 (5.8%) because of unstated reasons, 2 (1.3%) because of complications of ECT, and 1 (0.7%) each for uncontrolled hypertension and financial constraints.
Continuation ECT Electroconvulsive Therapy Treatments The mean number of treatments per patient was 6.6 with a range of 1 to 23 treatments (Table 4). The highest number of treatments per year was recorded in 2005, whereas the lowest was recorded in 2003. This pattern was also reflected in the number patients treated per year. Whereas treatments were largely unmodified in the first 3 years (2001–2003), a reversal of this pattern was observed in the last 3 years (2008–2010).
Physical Examination Details and schedule of examinations for the patients are shown in Table 5. The nurses documented pre- and post-ECT vital signs for all the patients, but pre-and post-ECT physical TABLE 2. Clinical Diagnoses of Patients Diagnosis
n (%)
Acute psychotic disorder Bipolar affective disorder (manic episode) Depression Schizophrenia Catatonic Hebephrenic Paranoid Simple Undifferentiated Schizoaffective disorder
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2 (1.3) 18 (11.7) 31 (20.1) 27 (17.5) 5 (3.2) 20 (13.0) 1 (0.6) 40 (26.0) 10 (6.5)
Continuation ECT (C-ECT) was given to 1 patient who received a total of 23 treatments. This patient was a 27-year-old woman managed for schizophrenia with a history of psychoactive substance use. She had an initial course of 6 ECT treatments and showed significant improvement. The patient, however, relapsed while still on admission. She had another course of 6 treatments, showing signs of improvement after 2 treatments. She, however, began showing signs of relapse approximately 2 weeks after completion of the second course. Thus, she was then commenced on C-ECT on a fortnightly basis. She had 11 C-ECT treatments and was to be commenced on monthly ECT treatments after discharge from admission. She, however, defaulted from follow-up.
Measure of Effectiveness The mental state examination findings of the patients in between ECT treatments and at the end of the course were used as measures of treatment effectiveness for all the patients.
Complications Complications were recorded in 5 (3.2%) patients. Complaints of post-ECT memory problems were documented for only 3 patients who then had formal cognitive assessment; 2 (1.3%) of them were noted to have cognitive impairments. Another 2 (1.3%) patients experienced anesthetic complications (prolonged anesthesia and reaction to anesthesia) and 1 (0.7%) patient developed respiratory distress. No mortality was recorded in the period under review.
Failed ECT Treatments Eleven (7.1%) patients were reported to have had failed treatments (convulsive episodes lasting less than 20 seconds). www.ectjournal.com
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TABLE 4. Details of ECT Treatments 2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Total
19 22 120 5.4 41 79
12 13 72 5.5 07 65
10 12 66 5.5 04 62
16 18 95 5.3 57 38
22 24 135 5.6 54 81
17 21 123 5.9 44 79
14 22 116 5.3 90 26
17 17 95 5.6 94 01
12 13 84 6.5 78 06
15 19 104 5.5 103 01
154 181 1010 5.6 572 438
Patients treated (n) No. of courses No. of treatments Mean treatment per course No. of modified No. of straight
Three (1.9%) patients had 1 failed treatment, whereas 8 (5.1%) had multiple (2–5) failed treatments. Of the 11 patients, 3 were restimulated.
Anticonvulsant Use At the point of receiving ECT, 128 (83.1%) of the patients were not on anticonvulsants. Twenty-two patients (14.3%) on anticonvulsants had the medication stopped before commencing ECT. In 2 (1.3%) patients, the anticonvulsant dosage was reduced, and in another 2 (1.3%) patients, the dosage was not adjusted.
DISCUSSION The transition to the use of a brief pulse device (in 2008) represents a welcome development. The tendency of constant voltage sine-wave devices to produce charges in excess of what is required for the therapeutic effect, which thus produces cognitive adverse effects, are well documented. Just above half (58.4%) of the institutions surveyed in Asia had made the transition to brief pulse devices. The monitoring of electroencephalographic and electrocardiographic parameters should also be encouraged because studies have shown that they are not always monitored, even when facilities are present.3 The use of medication is influenced by a number of factors including cost to the patient and availability of an anesthetist. The survey in Asia included 45.1% of institutions that never administered unmodified ECT and 18.3% that reported the use of no medication. The routine use of atropine as premedication for ECT needs to be examined in light of the recommendations of the American Psychiatric Association, which are aimed toward reducing its effects on cardiac rhythm and cognition.5 Medications that have the potential to affect the production of effective seizures (anticonvulsants, sedatives, etc) and produce undesirable effects should also be reviewed before the application of ECT. The female preponderance of patients receiving ECT has often been explained on the basis of higher rates of depressive disorder among this group. This sex difference was also observed in this study, although depression was not the predominant diagnosis. The practice of
ECT administration by a registrar/senior registrar compares unfavorably with that in Asia, where it is administered by a psychiatrist and an anesthesiologist in two-thirds of centers sampled across the continent. However, this is reflective of the manpower strengths in the country as a whole, where there are estimated to be 0.09 psychiatrists and 4 psychiatric nurses per 100,000 population.6 The training of personnel (physicians and nurses) involved in the administration of ECT is one area that has received immediate attention; training is now organized for registrar s before administration of ECT. Furthermore, the institution is equipped with the manpower to adequately train personnel. A major limitation may be the absence of formal training programs outside the hospital. This seems to be a near-global problem because none of the 334 institutions in 29 countries that were surveyed recently possessed a formal ECT training program.3 Formal training programs involving many institutions help approximate ideal practices, aid in eliminating idiosyncratic practices, and are also necessary in generating national guidelines for the practice. A number of studies in Nigeria2 and Hong Kong7 also revealed deficiencies in the process of obtaining consent. In the survey of Asian practice, written informed consent was obtained from the patient in just 23.3% of institutions, but from the relatives in two-thirds of cases, whereas some practitioners admitted to have no informed consent procedure.3 This contrasts with the practice in the United Kingdom and Scotland where well-established consent procedures exist; most patients give consent and the remainder receive treatment under the safeguards of the Mental Health Act.1 The mean number of ECT treatments per course was 5.6, much smaller compared with 6.9 treatments per course obtained in a similar audit in Saudi Arabia.8 The consistent teaching has been to give at least 2 more treatments after treatment response is obtained, as opposed to discontinuing earlier,2 which may be associated with a higher rate of relapse. The American Psychiatric Association recommends that treatment should be continued until remission is obtained; hence, this finding may indicate that treatment response is obtained earlier. Another plausible explanation for this finding may be that other considerations including financial constraints may limit the extensive use of the procedure. The invariability of bilateral electrode placement can
TABLE 5. Pre-/Post-ECT Physical Examination Yes (%) Pre-ECT physical examination Intra-ECT physical examination Post-ECT physical examination Pre-ECT vital signs Post-ECT vital signs Cognitive assessment
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138 0 3 154 154 3
(89.6) (0) (1.9) (100) (100) (1.9)
n (%)
Not Stated (%)
5 (3.3) 2 (1.3) 1 (0.7) 0 (0) 0 (0) 66 (42.9)
11 (7.1) 152 (98.7) 150 (97.4) 0 (0) 0 (0) 85 (55.2)
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Journal of ECT • Volume 30, Number 4, December 2014
be understood as being indicative of the need to obtain rapid symptom attenuation and shorten admission time for these patients, for whom cost of treatment is an important variable. In addition, complaints of cognitive impairment after ECT were relatively infrequent, hence the continued preference of bilateral over unilateral ECT. Just above half of the ECT treatments given during the period under review were modified. This compares favorably against the findings of a survey of 29 Asian countries, in which as many as 55% of patients received unmodified ECT. Several reasons exist for the continued practice of ECT in its unmodified form, of which the most notable is the significantly increased cost to the patient. The dearth of anesthetic personnel is also a noteworthy limitation. Although a survey of ECT in this environment reported that unmodified ECT was fairly well accepted among patients,2 modified ECT is considered the standard in many countries and is recommended by the World Health Organization.9 The trend of modified versus unmodified ECT shows that ECT treatments in more recent years have been modified, which is a step in the right direction. Most patients who received ECT were being managed for schizophrenia, of which most were of the catatonic subtype. This is similar to the finding in Asia3 but different from the finding in European countries, including Scotland1 and Belgium,10 where depression is the most common diagnosis. The Royal College does not encourage the use of ECT for schizophrenia.11 The use of C-ECT in just 1 patient highlights the rarity of the practice in this part of the world compared with Asia, where almost half of the institutions surveyed offered C-ECT. It is also rarely used in Belgium.10 Psychiatrists are still divided over its use in current practice. The Royal College of Psychiatrists discourages its use, and the American Psychiatric Association considers it an option in patients with severe refraction.5 Despite the lack of evidence-based guidelines for use, studies have demonstrated support for the use of C-ECT in combination with antipsychotics in preventing relapse in patients with schizophrenia.12 The default from treatment by the patient receiving C-ECT gives an inkling into the logistic problems that may mar its use in this environment. Although no deaths were reported during the period of the review, mortality rates of ECT have been reported to be similar to that for general anesthesia.13 The low incidence of adverse effects reported by patients, although a positive observation, may be caused by a low index of suspicion by staff involved in administration and by nonimplementation of checklist to routinely assess for adverse effects of ECT.
CONCLUSIONS This review reveals that the practice at the Neuropsychiatric Hospital is generally similar to what is obtained in many other countries in Asia and Africa; it also calls attention to important areas of concern, such as that of informed consent. Regarding the indications for the procedure, the findings are dissimilar to that of several European studies but bear some semblance to that of several Asian studies. It can be argued that, similar to the practice of ECT in Asia, the findings may reflect the standard of health care as a whole as well as the realities and demands of the nation rather than a misuse of ECT.3 It has been noted that implementing guidelines for ECT (where they exist) requires considerable effort and follow-up to ensure
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Ten-Year ECT Study in Neuropsychiatric Hospital
they are implemented in such a manner as to provide the desired improvement in practice.14
Recommendations In light of the findings of this review, some recommendations are deemed necessary. Importantly, protocols for obtaining consent should be developed. Electroconvulsive therapy order sheets that must contain basic information such as indication for ECT should also be introduced and signed by the psychiatrist before the administration of ECT. The reporting of adverse events can be improved with the use of checklists. There is also the need to introduce an objective rating instrument to measure treatment outcome. Documentation of failed treatments and restimulation should also be improved. More research, especially in this environment, is required to better inform the practice of C-ECT. All centers offering ECT in the country should have the practice audited. REFERENCES 1. Fergusson GM, Cullen LA, Freeman CPL, et al. Electroconvulsive therapy in Scottish clinical practice: a national audit of demographics, standards, and outcome. J ECT. 2004;20:166–173. 2. James BO, Morakinyo O, Lawani AO, et al. Unmodified electroconvulsive therapy: the perspective of patients from a developing country. J ECT. 2010;26:218–222. 3. Chanpattana W, Kramer BA, Kunigiri G, et al. A survey of the practice of electroconvulsive therapy in Asia. J ECT. 2010;26:5–10. 4. Prudic J, Olfson M, Sackeim HA. Electro-convulsive therapy practices in the community. Psychol Med. 2001;31:929–934. 5. The Practice of ECT: Recommendations for Treatment, Training and Privileging. 2nd ed. Washington, DC: American Psychiatric Press; 2001. 6. WHO. Country Profile of Nigeria. Mental Health Atlas of the WHO. Geneva, Switzerland: World Health Organization; 2005:348–351. 7. Tang W, Ungvari G, Chan G. Patients’ and their relatives’ knowledge of, experience with, attitude toward, and satisfaction with electroconvulsive therapy in Hong Kong, China. J ECT. 2002; 18:207–212. 8. Alhamad AM, al-Haidar F. A retrospective audit of electroconvulsive therapy at King Khalid University Hospital, Saudi Arabia. East Mediterr Health J. 1999;5:255–261. 9. WHO. WHO Resource Book on Mental Health, Human Rights and Legislation. Geneva, Switzerland: World Health Organization; 2005. 10. Sienaert P, Dierick M, Degraeve G, et al. Electroconvulsive therapy in Belgium: a nationwide survey on the practice of electroconvulsive therapy. J Affect Disord. 2006;90:67–71. 11. Royal College of Psychiatrists. The ECT Handbook. Glasgow, Scotland: Royal College of Psychiatrists; 2005. 12. Trevino K, McClintock SM, Husain MM. A review of continuation electroconvulsive therapy: application, safety, and efficacy. J ECT. 2010;26:186–195. 13. National Institute for Clinical Excellence. Guidance on the Use of Electroconvulsive Therapy (NICE Technology Appraisal Guidance 59). National Institute for Clinical Excellence; 2003. 14. Brookes G, Rigby J, Barnes R. Implementing the Royal College of Psychiatrists’ guidelines for the practice of electroconvulsive therapy. Psychiatr Bull. 2000;24:329–330.
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A 10-Year Descriptive Study of Electroconvulsive Therapy at the Neuropsychiatric Hospital, Aro, Abeokuta Edward Babatunde Somoye, MB, BS, FWACP(Psych), Peter Olutunde Onifade, MB, BS, FMCP(Psych), Adedunmola Oluwaseun Oluwaranti, MB, CHB, and Adetayo Adeyinka Adeniji, MB, CHB Objectives: Evidence supports the use of electroconvulsive therapy (ECT) in current practice, and good quality of care is related to adherence to evidence-based guidelines. However, there are no guidelines for the practice of ECT in Nigeria and there is no regulatory body for its standards. The objective of this study therefore was to examine the practice of ECT between 2001 and 2010 at the Neuropsychiatric Hospital, Aro, Abeokuta, regarding consent procedures, staffing, training, indications, and administration with the goal of informing the development of guidelines locally. Methods: Data were extracted from 154 complete ECT treatment records in the register and from the patients’ case files. The data were qualitatively analyzed and described. Results: The mean age of patients who received ECT was 35.5 years and the majority were female. Bilateral electrode placement was invariable for all treatments. The major diagnosis of the patients receiving ECT was schizophrenia, whereas poor response to medication and psychomotor retardation were commonly stated indications. Treatments were largely unmodified during the first 3 years of the review, with a gradual reversal of this pattern in the latter years. The mean number of treatments per patient was 6.6, and only 1 patient received continuation ECT. Conclusions: Although the procedure of ECT in this center is generally similar to what is obtained in many other countries in Asia and Africa, aspects such as that of informed consent require attention. Regular audits of the practice are desirable. Key Words: electroconvulsive therapy, practice, Nigeria (J ECT 2014;30: 315–319)
A
fter its discovery 75 years ago, electroconvulsive therapy (ECT) has become useful in psychiatric practice. Evidence from research supports the effectiveness of ECT in contemporary practice.1 Despite the relative safety of the procedure, the controversies that surround it continue and its role in current psychiatric practice is continually called into question.2 Its practice varies significantly within countries and even within individual centers.3 Electroconvulsive therapy–related good quality of care depends on adherence to evidence-based guidelines.4 Therefore, treatment standards and guidelines have been produced by the Royal College of Psychiatrists and the American Psychiatric Association.1 In Nigeria, however, there are no guidelines for the practice of ECT and there is no regulatory body for its standards.2 An examination of current practice is an important first step in the development of such guidelines. Therefore, the aim of this study was to examine the practice of ECT between 2001 and 2010 regarding consent, staffing, training, indications, and administration. This will inform the development of From the Neuropsychiatric Hospital, Aro, Abeokuta, Ogun State, Nigeria. Received for publication May 31, 2013; accepted October 30, 2013. Reprints: Edward Babatunde Somoye, MB, BS, FWACP(Psych), Neuropsychiatric Hospital, Aro, Abeokuta, Ogun State, Nigeria (e‐mail: [email protected]). The authors have no conflicts of interest or financial disclosures to report. Copyright © 2014 by Lippincott Williams & Wilkins DOI: 10.1097/YCT.0000000000000095
Journal of ECT • Volume 30, Number 4, December 2014
guidelines for the improvement and standardization of the procedure in this center and nationally.
MATERIALS AND METHODS Practice Setting This retrospective descriptive study was conducted at the Federal Neuropsychiatric Hospital Aro, Ogun State, Southwest Nigeria. The hospital is a tertiary specialist health institution that started at its annex in 1944 as an asylum for soldiers with mentally illness who were repatriated home after the Second World War. This annex was originally an administrative prison established by the colonialists. The need later arose to establish a modern psychiatric hospital; hence, Neuropsychiatric Hospital, Aro, was established in 1954. The hospital has a nationwide catchment area and also provides psychiatric services to some neighboring West African countries. It has a total bed capacity of 526 and provides inpatient, outpatient, 24-hour emergency services, and primary health care to neighboring communities. It offers undergraduate and postgraduate training in mental health and allied disciplines. It also offers post–basic training in psychiatric nursing. It collaborates in research with other bodies especially in the areas related to primary health care delivery, community-based mental health, substance abuse, epilepsy, epidemiology, as well as evaluation of services and drug trials. The hospital adopts the multidisciplinary approach in the management of patients with mental disorders so that the patients are managed by a team of physicians, nurses, occupational therapists, clinical psychologists, and social welfare officers. The practice of ECT commenced in the hospital in 1954. A variety of Ectron ECT machines have been used over time. More recently, these have included the Ectron constant current ECT series 3 and the Ectron Duopulse ECT series C, which remained in use until 2008.
Data Collection and Analysis Historical and administrative data about the deployment and use of ECT in the hospital were obtained from the directorates of clinical and nursing services of the hospital. Records of ECT treatments between January 2001 and December 2010 were obtained from the ECT register. The case notes of the patients were retrieved and comprehensively reviewed with a 26-item checklist, which included sociodemographic data, clinical variables, indications for ECT, consent, and ECT techniques. The study was approved by the research and ethics committee of the hospital. Data analysis was done using Statistical Package for Social Sciences (SPSS v16).
RESULTS Equipment From 2001 to 2008, a constant current sine wave device was used (Duopulse ECT Series C; Ectron Ltd). The timing of www.ectjournal.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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seizures was done manually. This was replaced in 2008 with a Thymatron brief pulse device (Thymatron System IV; Somatics LLC) with electroencephalographic/electromyographic/ECT capabilities and timer. The Thymatron System IV in use between 2008 and 2010 delivered a maximum dose of 504 millicoulomb (mC) with a pulse width of 0.25 to 1.5 milliseconds. The treatment dose was usually initiated at 20% of this maximal dose (100 mC) with increments of 5% in cases of nonresponse but rarely exceeding 40% (200 mC). Pulse frequency was between 10 and 70 Hz in 10-Hz increments (to 140 Hz for 0.25-millisecond pulse). Current was 0.9 A and its duration was 8.0 seconds. Information on the settings for the earlier sine wave device used (Duopulse ECT Series C) was unavailable. Resuscitative equipment (anesthetic machine, ambu bag, oxygen, suction apparatus) were available. Equipment for endotracheal intubation was also available. However, a defibrillator was not available at the suite.
Medication The anesthetic used was thiopentone, with atropine and succinylcholine also given routinely for all patients undergoing modified ECT. Oxygen was given before and after ECT application. Emergency medications (adrenaline, hydrocortisone) were also available.
Staffing A qualified psychiatrist was in charge to oversee the administrative, logistic, and clinical activities in the ECT suite. In almost all cases, ECT was administered by a junior registrar (psychiatrist in training), whereas an experienced senior registrar was detailed to be at hand in case of complications requiring emergency interventions. Anesthesia was provided by an experienced anesthetic nurse, and each procedure was attended by at least 3 nurses, one of whom was a nurse from the ward where the patient was admitted.
Teaching and Supervision Registrars received instruction in the administration of ECT as part of orientation at the commencement of residency training. Didactic lectures were not received until much later in residency training. The nursing staff received specialized training in the administration of ECT as part of their post–basic psychiatric nursing training.
Documentation As depicted in Figure 1, a total of 191 patients received ECT in the period under review of which 154 (80.6%) complete records were available for analysis. Eleven patients had ECT in 2 different years and 26 case records could not be retrieved or had incomplete records. For treatment spillover into a new year, the starting year was taken as the index year.
Sociodemographic Variables
FIGURE 1. Flow Chart of ECT treatments.
The 2 most commonly stated indications for ECT were poor response to treatment (24%) and psychomotor retardation (16.2%). Indication was not documented in 65 (42.2%) cases. The decision to administer ECT was taken by a psychiatrist in most cases (85.7%), followed by a senior registrar in 9.1% of cases. A registrar took the decision in 5 cases (3.2%), and in 2 (1.3%) cases, the decision maker was not stated.
Special Population Four of the patients belonged to special groups: 3 (1.9%) were elderly patients (>65 years), whereas 1 (0.7%) was an adolescent. No pregnant patient was treated with ECT during the period of the study. Comorbid medical conditions were noted for 6 (3.9%) patients: 4 patients (2.6%) for hypertension and 1 each for benign prostatic hypertrophy and for HIV infection (0.7%).
Consent for the Procedure Proxy consent was obtained from relatives on behalf of all the patients usually at the point of admission to the hospital. It was not documented in 138 (89.6%) cases if, in addition to the proxy consent, direct consent was sought. Fifteen (9.7%) patients did not give direct consent, whereas only 1 (0.6%) did so. An explanation of the risks and benefits of the procedure to the patient was documented in only 3 (1.9%) cases.
Procedure The ECT was administered by a registrar/senior registrar in all cases. All treatments were given on an inpatient basis except one that was given on an outpatient basis (due to lack of finance for admission). Electrode placement was bilateral in all cases.
As shown in Table 1, most (57.8%) of the 154 patients were females. The mean age was 35.5 years (range, 15–66 years) and not statistically different between sexes. They were mostly Christians (83.1%), single (53.9%), and unemployed (69.5%), and 92.2% of them had at least completed primary education.
Frequency of administration was twice weekly in 143 cases (92.9%), weekly in 6 cases (3.9%), thrice weekly in 4 cases (2.6%), and monthly in 1 case (0.6%).
Diagnoses and Indications for ECT
Previous ECT History
Tables 2 and 3 show the diagnosis and the indications for the patients. The most common diagnosis for people receiving ECT was schizophrenia (60.4%), followed by depression (20%).
Fourteen (9.1%) patients had received ECT previously: 11 (7.1%) had 1 (0.7%) course previously, whereas 3 (1.9%) had multiple.
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Treatment Schedule
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Ten-Year ECT Study in Neuropsychiatric Hospital
TABLE 1. Sociodemographic Characteristics of Patients
TABLE 3. Indications for ECT
Characteristic
Indication
n (%)
Sex Male Female Age Male Female Total Completed education No formal Primary Secondary University Marital status Single Married Divorced Separated Widowed Employment Status Unemployed Employed Retired Religion Christian Islam
65 (42.2) 89 (57.8) 34.63 (12.25) 36.19 (10.16) 35.53 (11.08) 12 (7.8) 44 (28.5) 87 (56.6) 11 (7.1) 83 (53.9) 60 (39.0) 3 (1.9) 6 (3.9) 2 (1.3) 107 (69.5) 46 (29.9) 1 (0.6) 128 (83.1) 26 (16.9)
n (%)
Affective symptoms Augmentation of drug treatment Imminent neuroleptic malignant syndrome Not stated Physical distress Poor response to medication Previous response to ECT Psychotic symptoms Psychomotor retardation Refusal of food Refusal of medication Suicidal ideation Inability to take medication
3 (1.9) 1 (0.6) 1 (0.6) 65 (42.2) 1 (0.6) 37 (24.0) 3 (1.9) 6 (3.9) 25 (16.2) 1 (0.6) 5 (3.2) 5 (3.2) 1 (0.6)
examinations were documented by the registrar for only 138 (89.6%) and 3 (1.9%) of the patients, respectively.
Course Completion One hundred forty-one (96.6%) patients completed their courses of ECT, whereas the courses were terminated for 13 (3.4%) patients: 9 (5.8%) because of unstated reasons, 2 (1.3%) because of complications of ECT, and 1 (0.7%) each for uncontrolled hypertension and financial constraints.
Continuation ECT Electroconvulsive Therapy Treatments The mean number of treatments per patient was 6.6 with a range of 1 to 23 treatments (Table 4). The highest number of treatments per year was recorded in 2005, whereas the lowest was recorded in 2003. This pattern was also reflected in the number patients treated per year. Whereas treatments were largely unmodified in the first 3 years (2001–2003), a reversal of this pattern was observed in the last 3 years (2008–2010).
Physical Examination Details and schedule of examinations for the patients are shown in Table 5. The nurses documented pre- and post-ECT vital signs for all the patients, but pre-and post-ECT physical TABLE 2. Clinical Diagnoses of Patients Diagnosis
n (%)
Acute psychotic disorder Bipolar affective disorder (manic episode) Depression Schizophrenia Catatonic Hebephrenic Paranoid Simple Undifferentiated Schizoaffective disorder
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2 (1.3) 18 (11.7) 31 (20.1) 27 (17.5) 5 (3.2) 20 (13.0) 1 (0.6) 40 (26.0) 10 (6.5)
Continuation ECT (C-ECT) was given to 1 patient who received a total of 23 treatments. This patient was a 27-year-old woman managed for schizophrenia with a history of psychoactive substance use. She had an initial course of 6 ECT treatments and showed significant improvement. The patient, however, relapsed while still on admission. She had another course of 6 treatments, showing signs of improvement after 2 treatments. She, however, began showing signs of relapse approximately 2 weeks after completion of the second course. Thus, she was then commenced on C-ECT on a fortnightly basis. She had 11 C-ECT treatments and was to be commenced on monthly ECT treatments after discharge from admission. She, however, defaulted from follow-up.
Measure of Effectiveness The mental state examination findings of the patients in between ECT treatments and at the end of the course were used as measures of treatment effectiveness for all the patients.
Complications Complications were recorded in 5 (3.2%) patients. Complaints of post-ECT memory problems were documented for only 3 patients who then had formal cognitive assessment; 2 (1.3%) of them were noted to have cognitive impairments. Another 2 (1.3%) patients experienced anesthetic complications (prolonged anesthesia and reaction to anesthesia) and 1 (0.7%) patient developed respiratory distress. No mortality was recorded in the period under review.
Failed ECT Treatments Eleven (7.1%) patients were reported to have had failed treatments (convulsive episodes lasting less than 20 seconds). www.ectjournal.com
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Somoye et al
TABLE 4. Details of ECT Treatments 2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Total
19 22 120 5.4 41 79
12 13 72 5.5 07 65
10 12 66 5.5 04 62
16 18 95 5.3 57 38
22 24 135 5.6 54 81
17 21 123 5.9 44 79
14 22 116 5.3 90 26
17 17 95 5.6 94 01
12 13 84 6.5 78 06
15 19 104 5.5 103 01
154 181 1010 5.6 572 438
Patients treated (n) No. of courses No. of treatments Mean treatment per course No. of modified No. of straight
Three (1.9%) patients had 1 failed treatment, whereas 8 (5.1%) had multiple (2–5) failed treatments. Of the 11 patients, 3 were restimulated.
Anticonvulsant Use At the point of receiving ECT, 128 (83.1%) of the patients were not on anticonvulsants. Twenty-two patients (14.3%) on anticonvulsants had the medication stopped before commencing ECT. In 2 (1.3%) patients, the anticonvulsant dosage was reduced, and in another 2 (1.3%) patients, the dosage was not adjusted.
DISCUSSION The transition to the use of a brief pulse device (in 2008) represents a welcome development. The tendency of constant voltage sine-wave devices to produce charges in excess of what is required for the therapeutic effect, which thus produces cognitive adverse effects, are well documented. Just above half (58.4%) of the institutions surveyed in Asia had made the transition to brief pulse devices. The monitoring of electroencephalographic and electrocardiographic parameters should also be encouraged because studies have shown that they are not always monitored, even when facilities are present.3 The use of medication is influenced by a number of factors including cost to the patient and availability of an anesthetist. The survey in Asia included 45.1% of institutions that never administered unmodified ECT and 18.3% that reported the use of no medication. The routine use of atropine as premedication for ECT needs to be examined in light of the recommendations of the American Psychiatric Association, which are aimed toward reducing its effects on cardiac rhythm and cognition.5 Medications that have the potential to affect the production of effective seizures (anticonvulsants, sedatives, etc) and produce undesirable effects should also be reviewed before the application of ECT. The female preponderance of patients receiving ECT has often been explained on the basis of higher rates of depressive disorder among this group. This sex difference was also observed in this study, although depression was not the predominant diagnosis. The practice of
ECT administration by a registrar/senior registrar compares unfavorably with that in Asia, where it is administered by a psychiatrist and an anesthesiologist in two-thirds of centers sampled across the continent. However, this is reflective of the manpower strengths in the country as a whole, where there are estimated to be 0.09 psychiatrists and 4 psychiatric nurses per 100,000 population.6 The training of personnel (physicians and nurses) involved in the administration of ECT is one area that has received immediate attention; training is now organized for registrar s before administration of ECT. Furthermore, the institution is equipped with the manpower to adequately train personnel. A major limitation may be the absence of formal training programs outside the hospital. This seems to be a near-global problem because none of the 334 institutions in 29 countries that were surveyed recently possessed a formal ECT training program.3 Formal training programs involving many institutions help approximate ideal practices, aid in eliminating idiosyncratic practices, and are also necessary in generating national guidelines for the practice. A number of studies in Nigeria2 and Hong Kong7 also revealed deficiencies in the process of obtaining consent. In the survey of Asian practice, written informed consent was obtained from the patient in just 23.3% of institutions, but from the relatives in two-thirds of cases, whereas some practitioners admitted to have no informed consent procedure.3 This contrasts with the practice in the United Kingdom and Scotland where well-established consent procedures exist; most patients give consent and the remainder receive treatment under the safeguards of the Mental Health Act.1 The mean number of ECT treatments per course was 5.6, much smaller compared with 6.9 treatments per course obtained in a similar audit in Saudi Arabia.8 The consistent teaching has been to give at least 2 more treatments after treatment response is obtained, as opposed to discontinuing earlier,2 which may be associated with a higher rate of relapse. The American Psychiatric Association recommends that treatment should be continued until remission is obtained; hence, this finding may indicate that treatment response is obtained earlier. Another plausible explanation for this finding may be that other considerations including financial constraints may limit the extensive use of the procedure. The invariability of bilateral electrode placement can
TABLE 5. Pre-/Post-ECT Physical Examination Yes (%) Pre-ECT physical examination Intra-ECT physical examination Post-ECT physical examination Pre-ECT vital signs Post-ECT vital signs Cognitive assessment
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138 0 3 154 154 3
(89.6) (0) (1.9) (100) (100) (1.9)
n (%)
Not Stated (%)
5 (3.3) 2 (1.3) 1 (0.7) 0 (0) 0 (0) 66 (42.9)
11 (7.1) 152 (98.7) 150 (97.4) 0 (0) 0 (0) 85 (55.2)
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be understood as being indicative of the need to obtain rapid symptom attenuation and shorten admission time for these patients, for whom cost of treatment is an important variable. In addition, complaints of cognitive impairment after ECT were relatively infrequent, hence the continued preference of bilateral over unilateral ECT. Just above half of the ECT treatments given during the period under review were modified. This compares favorably against the findings of a survey of 29 Asian countries, in which as many as 55% of patients received unmodified ECT. Several reasons exist for the continued practice of ECT in its unmodified form, of which the most notable is the significantly increased cost to the patient. The dearth of anesthetic personnel is also a noteworthy limitation. Although a survey of ECT in this environment reported that unmodified ECT was fairly well accepted among patients,2 modified ECT is considered the standard in many countries and is recommended by the World Health Organization.9 The trend of modified versus unmodified ECT shows that ECT treatments in more recent years have been modified, which is a step in the right direction. Most patients who received ECT were being managed for schizophrenia, of which most were of the catatonic subtype. This is similar to the finding in Asia3 but different from the finding in European countries, including Scotland1 and Belgium,10 where depression is the most common diagnosis. The Royal College does not encourage the use of ECT for schizophrenia.11 The use of C-ECT in just 1 patient highlights the rarity of the practice in this part of the world compared with Asia, where almost half of the institutions surveyed offered C-ECT. It is also rarely used in Belgium.10 Psychiatrists are still divided over its use in current practice. The Royal College of Psychiatrists discourages its use, and the American Psychiatric Association considers it an option in patients with severe refraction.5 Despite the lack of evidence-based guidelines for use, studies have demonstrated support for the use of C-ECT in combination with antipsychotics in preventing relapse in patients with schizophrenia.12 The default from treatment by the patient receiving C-ECT gives an inkling into the logistic problems that may mar its use in this environment. Although no deaths were reported during the period of the review, mortality rates of ECT have been reported to be similar to that for general anesthesia.13 The low incidence of adverse effects reported by patients, although a positive observation, may be caused by a low index of suspicion by staff involved in administration and by nonimplementation of checklist to routinely assess for adverse effects of ECT.
CONCLUSIONS This review reveals that the practice at the Neuropsychiatric Hospital is generally similar to what is obtained in many other countries in Asia and Africa; it also calls attention to important areas of concern, such as that of informed consent. Regarding the indications for the procedure, the findings are dissimilar to that of several European studies but bear some semblance to that of several Asian studies. It can be argued that, similar to the practice of ECT in Asia, the findings may reflect the standard of health care as a whole as well as the realities and demands of the nation rather than a misuse of ECT.3 It has been noted that implementing guidelines for ECT (where they exist) requires considerable effort and follow-up to ensure
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Ten-Year ECT Study in Neuropsychiatric Hospital
they are implemented in such a manner as to provide the desired improvement in practice.14
Recommendations In light of the findings of this review, some recommendations are deemed necessary. Importantly, protocols for obtaining consent should be developed. Electroconvulsive therapy order sheets that must contain basic information such as indication for ECT should also be introduced and signed by the psychiatrist before the administration of ECT. The reporting of adverse events can be improved with the use of checklists. There is also the need to introduce an objective rating instrument to measure treatment outcome. Documentation of failed treatments and restimulation should also be improved. More research, especially in this environment, is required to better inform the practice of C-ECT. All centers offering ECT in the country should have the practice audited. REFERENCES 1. Fergusson GM, Cullen LA, Freeman CPL, et al. Electroconvulsive therapy in Scottish clinical practice: a national audit of demographics, standards, and outcome. J ECT. 2004;20:166–173. 2. James BO, Morakinyo O, Lawani AO, et al. Unmodified electroconvulsive therapy: the perspective of patients from a developing country. J ECT. 2010;26:218–222. 3. Chanpattana W, Kramer BA, Kunigiri G, et al. A survey of the practice of electroconvulsive therapy in Asia. J ECT. 2010;26:5–10. 4. Prudic J, Olfson M, Sackeim HA. Electro-convulsive therapy practices in the community. Psychol Med. 2001;31:929–934. 5. The Practice of ECT: Recommendations for Treatment, Training and Privileging. 2nd ed. Washington, DC: American Psychiatric Press; 2001. 6. WHO. Country Profile of Nigeria. Mental Health Atlas of the WHO. Geneva, Switzerland: World Health Organization; 2005:348–351. 7. Tang W, Ungvari G, Chan G. Patients’ and their relatives’ knowledge of, experience with, attitude toward, and satisfaction with electroconvulsive therapy in Hong Kong, China. J ECT. 2002; 18:207–212. 8. Alhamad AM, al-Haidar F. A retrospective audit of electroconvulsive therapy at King Khalid University Hospital, Saudi Arabia. East Mediterr Health J. 1999;5:255–261. 9. WHO. WHO Resource Book on Mental Health, Human Rights and Legislation. Geneva, Switzerland: World Health Organization; 2005. 10. Sienaert P, Dierick M, Degraeve G, et al. Electroconvulsive therapy in Belgium: a nationwide survey on the practice of electroconvulsive therapy. J Affect Disord. 2006;90:67–71. 11. Royal College of Psychiatrists. The ECT Handbook. Glasgow, Scotland: Royal College of Psychiatrists; 2005. 12. Trevino K, McClintock SM, Husain MM. A review of continuation electroconvulsive therapy: application, safety, and efficacy. J ECT. 2010;26:186–195. 13. National Institute for Clinical Excellence. Guidance on the Use of Electroconvulsive Therapy (NICE Technology Appraisal Guidance 59). National Institute for Clinical Excellence; 2003. 14. Brookes G, Rigby J, Barnes R. Implementing the Royal College of Psychiatrists’ guidelines for the practice of electroconvulsive therapy. Psychiatr Bull. 2000;24:329–330.
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