A Pan-African Survey of ECT
and establishing a
Practitioners’ Network
Dr Johan Leuvennink
Consultant Psychiatrist
SMMHEP
2nd Malawi Mental Health Research and Practice
Development Conference
Blantyre, Malawi
March 2012
Declaration of interest
• The speaker has no pecuniary interest in
promoting the use of ECT
• The speaker has received funding for teaching
in ECT in an African setting from the Scottish
Government under SMMHEP
• The speaker has received research, advisory
boards membership and speaker funding from
pharmaceutical companies not in relation to
ECT.
• The speaker has not received funding for this
survey.
ECT: it's place in modern
psychiatric practice
• ECT trend in UK
• Severe / Rx resistant major depressive
episodes
ECT: it's place in modern African
psychiatric practice
• Severe / Rx resistant major depressive episodes
• Difference from UK practice:
– Indications
• Mania, acute schizophrenia, NMS
– Treatment thresholds
• in resource constrained areas (bed occupancy, available
antipsychotic preparations IM, Oral, staff constraints)
– Severity of psychopathology at time of presentation
• Limited community psychiatry and early intervention
opportunities
Challenges in providing a modern, safe,
evidence based ECT Service
• Human resources: psychiatrists/ clinical officers/
specialist nurses/ anaesthetic staff
• Equipment:
– Availability, familiarity, maintenance
– ECT machine, anaesthetic equipment, including
machine,oxygen/O2 saturator, suction machines, emergency
medicines & equipment, monitoring equipment.
•
•
•
•
Isolation and deskilling
Locality appropriate treatment and safety protocols
Training opportunities
Opportunities for collaborative research and audit
Experience of ECT Clinical Networks
elsewhere:
•
•
•
•
SEAN
ECTAS
European ECT Network
Setting up a Southern African Network for
ECT (SANECT)
SANECT February 2011 to date:
•
•
•
•
First annual meeting (inaugural)
Membership
Links with other Networks
Discussion forum
– HIV and ECT
– Serum glucose and ECT
– Metal plate in skull
• Pan-African Survey of ECT
Purpose of Study
•
•
•
•
Commonly prescribed treatment
Similarities in challenges throughout Africa
Scoping survey
Baseline for further collaboration
What this is not….
• Comprehensive survey of services
• Ranking of service excellence
Subjects and settings
• Psychiatrists throughout Africa
• Private Practice, District General Hospital
and Teaching Hospitals
Methodology
•
•
•
•
•
Subject identification
Questionnaire sent as email attachment
Questionnaire resent after 2 months
Data analysed
Anonymity protected in
presentation/publication as regards
Country of practice, Practitioners’ names
and contact details.
• Total
questionnaires
sent: 54
• Total respondents:
19
• Geographical
spread: 12
countries
• Practice type
distribution: wide
Survey Questionnaire
Your name:
……………………………………………………………………………………………………………
Your country of practice:
……………………………………………………………………………………………………………
Is this a Private Practice?
Yes / No
Is this a teaching/academic hospital practice?
Yes / No
Is this a non-teaching hospital practice?
Yes / No
Your contact email address: ………………………………………………..
Please use this Word document to complete the questionnaire. Merely delete the wrong
answer “Yes” or “No”. Then save the document (e.g. on your desktop) and send it back by
attaching it to the return email to this address: JLeuvennink@nhs.net
General:
Do you practice or prescribe ECT in your service?
Yes / No
(If above answer is “No”, please still return the questionnaire and only answer the following 2
questions.)
Do you consider ECT to be a controversial treatment in psychiatry?
Yes / No
Do you consider ECT an essential treatment in psychiatry?
Yes / No
Prescription:
How many patients are on average given ECT per week in your service?
What are the indications for your prescription of ECT?
Severe depression
Mild to moderate, but treatment resistant depression
Mania
Acute schizophrenia
OCD
Yes / No
Yes / No
Yes / No
Yes / No
Other (Please specify) ……………………………………………………………………….
Is maintenance ECT given in your service?
Yes / No
Practice:
Are patients given ECT in a dedicated ECT suite/treatment room/theatre?
Yes / No
Do you use modified ECT? (with anaesthetic and muscle relaxant)
Yes / No
Do you monitor seizure activity with EEG monitoring?
Yes / No
Do you use bilateral and unilateral ECT application?
Yes / No
Do you titrate the dose of electricity given or are patients given a fixed dose?
Dose titrated according to seizure threshold ………………..Yes / No
Fixed dose given according to certain guidelines ………….Yes / No
Is the dose of electricity altered according to seizure length/side effects/clinical response?
According to seizure length
Yes / No
According to side effects
Yes / No
According to clinical response/non-response
Yes / No
Is a suction machine available in the treatment room?
Yes / No
Are patients monitored by a. ECG?
Yes / No
b. pulse oxymetry?
Yes / No
c. BP?
Yes / No
d. end-tidal CO2?
Yes / No
Is an emergency drug trolley/box available in the treatment room?
Yes / No
Is resuscitation equipment available in the treatment room?
Yes / No
Monitoring:
Are patients routinely assessed for treatment emergent physical side effects?
Yes / No
Are patients routinely assessed for treatment emergent cognitive impairment?
Yes / No
If above answer “Yes”, how is this done?
……………………………………………
……………………………………………………………………………………………………………………
………….
……………………………………………………………………………………………………………………
………….
How long is treatment continued for?
………………………………………………………………………..
……………………………………………………………………………………………………………………
………….
Staff training and experience:
Do you consider staff prescribing and delivering ECT in your service to be adequately trained and
updated in this treatment?
Yes / No
Results
Responders' Practice Settings
100%
90%
80%
9
9
10
70%
60%
Series2
Series1
50%
40%
30%
10
10
9
20%
10%
0%
Private Practice
Teaching
Non-teaching
General attitude to ECT
100%
1
2
90%
80%
9
70%
60%
50%
18
17
Series2
Series1
40%
30%
6
20%
10%
0%
Prescribe
Controversial
Essential
• 2 non-prescribers are in teaching hospitals, of whom one
believes ECT is essential, though controversial; the other
believes ECT to be both controversial and non-essential
• All Private practitioners are ECT prescribers, though 4 of
5 who believe ECT to be controversial are private
practitioners.
Number of patients per week
• Range in this sample from estimated 2 to 80 patients per
week
• Higher prescription levels were found in all settings.
• Levels of prescription did not correlate with the
practitioners’ view on whether ECT is a controversial
treatment.
• Furthermore, low prescription levels were also found in
cases where practitioners viewed ECT as an essential
treatment.
• Therefore, levels of ECT may well be related to other
factors, e.g. practice isolation and deskilling, equipment
or human resource constraints, logistics, alternative
treatments preferred by patients, etc.
Indications for ECT
100%
0
0
90%
80%
10
70%
60%
15
17
50%
16
17
16
Series2
40%
Series1
12
30%
7
20%
10%
2
1
1
1
1
0%
Severe
Mania
OCD
Catatonia
Acute Schizophrenia,
Depression
Postpartum Psychosis
Mild-Moderate Depression but
Treatment resistant
NMS
Epileptic
Fugue
Agression
Maintenance
41%
1
2
59%
• No differentiation in Maintenance ECT
prescription according to treatment setting was
found.
Modified ECT
0
1
2
17
ECT Suite/Theatre
Resuscitation equipment, 0
Emergency drugs, 0
Suite, 4
1
2
Suite, 13
Emergency drugs, 17
Resuscitation equipment, 17
Monitoring during ECT
0
100%
3
90%
5
80%
8
9
10
70%
11
11
11
12
60%
17
50%
Series2
14
Series1
40%
12
30%
9
8
7
20%
6
6
6
5
10%
0%
EEG
B/L & U/L
Titration
Dose Seizure Dose S/E's Dose Clinical
length
response
Parameter
ECG
Oxymetry
BP
end-tidal CO2
Side effect Monitoring
17
18
16
13
14
11
12
10
Series1
n
8
6
4
2
0
Total
Physical S/E's
Cognitive S/E's
• Cognitive Side-effects were reported to be
mainly clinically monitored by usual interview.
• 3 practitioners use the MMSE routinely for this
purpose.
Staff training Perception
4
1
2
12
• Of those practitioners who perceived that their staff were
insufficiently trained, 2
(50%) were based at teaching hospitals and 2 (50%)
were based in non-teaching, non-private practice
hospitals. One practitioner abstained from answering this
question.
Conclusion
• Wide variety in ECT prescription and
practice
• Not apparently related to practice setting
• Opportunity is clear for collaboration in
setting standards, training, protocol
development, audit and research