A new benchmark for ECT in Canada

By the early 1980s, ECT was a widely recognized, well-established and highly effective treatment for several serious forms of mental illness, but little was known about how it was administered, where it was being delivered and what kind of patients were being treated.

ECT had survived the backlash of the 1970s, but more work still had to be done – in Canada and around the world – to ensure that the procedure was being conducted according to the highest standards of care.

ECT in the UK

Between the 1960s and 1980s, ECT was a commonly used psychiatric treatment in the United Kingdom.  But this period was also characterized by public and professional unrest over some aspects of its use.

There was concern that ECT was provided to people who were unhappy, distressed or sad, rather than genuinely mentally ill, and there was also evidence to show that ECT was forcibly delivered to patients without their consent.

In response to the growing discontent, the Royal College of Psychiatrists in the U.K. created a set of guidelines for ECT, which were published in the British Journal of Psychiatry.  Among other things, the guidelines recommended anesthesia for all patients, and a second opinion for those who were unable or unwilling to provide consent for the treatment.

In order to learn more about the procedure, the United Kingdom was among the first countries in the world to carry out a national survey of ECT.  While the 1981 survey provided a lot of useful information about the treatment, its results were disconcerting.  It revealed that only a handful of psychiatrists and less than half the number of clinics in the country abided by the guidelines, and that psychiatric residents regularly administered ECT unsupervised.

Follow-up surveys were conducted in 1989 and 1995.  Although both showed significant improvements, many institutions still didn’t meet the recommended standards.

Psychiatrists realized that the only effective way to ensure ECT was delivered optimally was to regularly inspect the sites where ECT was administered.  In the U.K., this led to the creation of the Royal College of Psychiatrists-supported ECT accreditation service in 2003, in which hospitals, clinics and doctors’ offices could voluntary request regular ECT audits or inspections.  A similar system was developed in Scotland.

Over time, these audits led to the creation of an updated set of national guidelines, covering everything from consent, electrode placement, dosing, training, supervision, anesthesia, equipment and facilities.

Today in the U.K., standards are updated annually to reflect best practices and are currently in their 12th iteration.  Evidence shows these standards have significantly improved the quality of ECT.  More than 78 per cent of ECT clinics in England and Wales currently participate in the accreditation program.

Canada’s first national survey on ECT

In the early 2000s, little was known about ECT in Canada.  While the Canadian Psychiatric Association had published broad-based position papers supporting ECT in 1980 and 1992, no comprehensive survey of ECT practice had ever been undertaken.

At the time, Dr. Nicholas Delva, now head of psychiatry at Dalhousie University, was living in Kingston, where he was working as an academic psychiatrist.  In the 1980s and 1990s, he was a part of a small group of researchers who participated in a 20-year study, which examined the efficacy of various ECT electrode placements on patients in Eastern Ontario suffering from major depression.

Immersed in the world of ECT research and aware of the efforts being made in the United Kingdom to do surveys and improve the standards for ECT, Delva felt that more needed to be done in Canada to learn about how and where ECT was being delivered.  While the trial he undertook in the ’80s and ’90s was confined to a single centre in Kingston, he knew he wanted his next project to span multiple facilities and provinces.

In an effort to move things forward, Delva and a few of his colleagues, with whom he’d worked on the randomized controlled trial some years earlier, began meeting regularly to discuss how best to proceed.  They thought a national survey, similar to the ones conducted in the U.K., might be a good idea.

In 2004, Dr. Caroline Gosselin, a geriatric psychiatrist from Vancouver, visited Kingston in order to observe bifrontal ECT.  She was connected with Delva, and they quickly became good friends.  Gosselin was interested in being part of the survey, and upon her return to Vancouver, she was able to secure the funds needed to proceed from the Vancouver Coastal Health Authority.  Gosselin, Delva, and the other members of the group began recruiting other ECT practitioners in their field from all over the country to join the efforts.

The Canadian Electroconvulsive Therapy Survey, or CANECTS, was born.  The original team consisted of eight psychiatrists, two psychologists, an anesthesiologist, a nurse and an administrator.  The survey was a bilingual initiative and was endorsed by the Canadian Psychiatric Association.  Its goal was to determine where ECT was available, as well as how and to whom this treatment was provided.

CANECTS members were not compensated for their time.  Delva said they participated in the survey because they felt that it was their duty to raise the bar and ensure state-of-the-art ECT for all Canadians.

Dr. Delva said that 1,273 registered health care centres across Canada were contacted by mail and later by follow-up telephone call to identify the centres providing ECT.

In 2006, a bilingual questionnaire on ECT was developed and later tested at over a dozen centres.  In 2007, the revised questionnaire was mailed to each of the 175 ECT centres previously identified.

“We did quite a lot of preparatory work to motivate people to complete the questionnaire and we had an excellent return rate,” said Delva.  “Sixty-one per cent of the questionnaires were fully completed and another 10 per cent were partially completed, so we had a lot of data to work with.”

According to Delva, because of the enormous undertaking of the survey and because the CANECTS team was doing this voluntarily and weren’t compensated for their time, the results weren’t published in their entirety until 2013.

Results

With 107 ECT centres responding to the survey, the CANECTS team was able to determine rates of ECT utilization between 2006 and 2007.

“Our survey showed that ECT in Canada is quite well done, and people should be reassured by that,” said Delva.

For example, he said the data showed that there is a routine use of up-to-date equipment and that no psychiatric resident delivers ECT unsupervised in Canada.

However, the data also indicated a large variation in dosing practices between ECT centres.  This means that there were vast differences in electrode placement and intensity of the electrical stimulus, making it hard for researchers to determine best practices.

“Variation in medicine is generally not a good idea,” said Delva.  “If there’s a way to do things right then it should be more consistently done.”

Delva used caesarian sections in the United States as an example.  When first measured in 1965, the national C-section birth rate was 4.5 per cent.  By 2009, it had increased sevenfold, to 32.9 per cent.  The spike in C-section rates occurred despite leading professionals in obstetric societies around the world concluding that C- sections can increase the likelihood of adverse effects in both mothers and babies.  Significant regional variations in this practice, Delva said, points to inconsistent utilization of this important, but high risk treatment, demonstrating the risk of variation in medicine.

Furthermore, many ECT treatment centres reported that they didn’t have backup devices or equipment loan arrangements with other institutions.  The CANECTS team found this to be particularly worrisome, because when equipment breaks, it usually takes a long time to repair.  With no backup devices or loan arrangements, doctors have to send their patients to neighbouring communities.

Access to ECT was also identified as an area of concern in the survey.  The results revealed that 12.5 per cent of those living in Newfoundland and Labrador would have to drive more than 5 hours away to reach an ECT clinic.  What’s more, no ECT is delivered in Canada’s three northern territories – Yukon, Northwest Territories and Nunavut.

There were also a number of non-geographic barriers to ECT.

What was most concerning for members of the CANECTS team was that the data showed a huge variation in levels of ECT training.  While some hospitals required residents to attend lectures and observe a minimum number of ECT treatments, others required no training whatsoever.  The data showed that most of the training residents receive is in the classroom rather than hands-on.

Guidelines

The completion of the Canadian ECT Survey and accompanying analysis of the findings marked the end of the first phase of the CANECTS groups’ initiative.

But the work is far from over.

CANECTS II, Canadian ECT Standards, is currently underway and is close to completion as of March 2016.  Delva explained that the standards will be based on both the findings of the survey and the collective clinical experience of the CANECTS team.  It will culminate in one document, which will include a preamble and 17 chapters, each one listing a set of guidelines about an area of ECT practice.

The guidelines will cover everything from consent and confidentiality, to policies, protocols and documentation, patient preparation, equipment, treatment technique, follow-up care and maintenance ECT, said Delva.

The guidelines dealing with training and facilities/environment are expanded on in detail in subsequent sections of this website.

In addition, the standards document will also address more controversial topics, such as the decision to prescribe ECT in the first place. For example, Delva explained that a clinician would be unlikely to suggest ECT for someone who has a case of mild depression, which could be treated using alternative therapies.

“The Canadian ECT Standards will provide a new kind of benchmark for all centres,” said Delva.

While Delva was the chair of the ECT survey, he handed over the reins for this next phase to two of his CANECTS colleagues, Dr. Caroline Gosselin, a clinical professor of psychiatry at the University of British Columbia, and Dr. Murray Enns, head of the Department of Psychiatry at the University of Manitoba.

Gosselin said now that the guidelines have been penned from the point of view of the CANECTS team, the next step is to seek feedback from external stakeholders.

In late February 2016, the document was distributed to a wide array of clinicians, hospital administrators and ECT educators.

“The more eyes that see a document from different perspectives, the richer and more accurate the document becomes,” said Gosselin.

Gosselin said she expects the review process to take about six months.

Following the feedback process, the CANECTS team will review the stakeholder comments, and will then decide whether or not to make changes to the standards document.

Once finalized, it will then be sent to the Canadian Psychiatric Association for review.

“It was important for us to attach our document to a recognized and well respected body in psychiatry, like the CPA,” said Gosselin.

The CPA had expressed interest in endorsing and eventually publishing the guidelines and Gosselin believes that its seal of approval will go a long way in encouraging ECT centres to voluntary comply.

Gosselin said the CANECTS team looks forward to receiving feedback, especially because some of the standards outlined in the document weren’t fully agreed upon by members of the group.

“That was something we were very transparent about when we sent the document out to stakeholders for comment,” said Gosselin.

One of the sources of contention stemmed from the 24-hour period following ECT, in which the patient is discharged into the care of a responsible adult.  Canadian anesthesia guidelines stipulate that patients must be monitored for 24 hours following the administration of a general anesthetic.  But some psychiatrists feel that people are generally able to conduct themselves normally within a few hours of the procedure, and that stringent and inconvenient monitoring requirements may lead people to abandon the treatment altogether.

Another thing the CANECTS team made sure to clarify with stakeholders is that the standards document is in no way set in stone.

“This is something that will change and grow overtime because the field is changing and how medicine is delivered in Canada is changing,” said Gosselin.  “This is just the first crack to get us going and hopefully people will carry the torch and move this forward in the coming years.”

Gosselin said that she and the CANECTS team want the standards document to be completely transparent and accessible to everyone.  Following the peer-review process, her hope is that the document will be placed online, included as an attachment to relevant medical journals and made available to all ECT practitioners to consult while in the ECT suite performing the procedure on patients.

Then what?

In the coming years, Gosselin and Delva envision adopting the U.K. approach to ECT by conducting regular audits of centres throughout the country.

“The whole idea is to just provide better patient care, so instead of us coming to the centres with the stick, it would be us coming to support and guide,” said Gosselin.

Over the past 10 years, Gosselin’s had the opportunity to teach ECT to a wide array of practitioners throughout the country and said that there are a lot of ECT clinicians who already deliver state-of-the-art care and who are very proud of the work they do.

“I think that needs to be endorsed and validated through some kind of certification or accreditation,” she said.

Furthermore, Gosselin explained, there are also ECT centres that are very motivated to do better, and she feels that the standards and audits will help them reach their full potential.

On the other hand, she said some smaller centres have expressed concern that their limited resources might not allow them to comply with the standards and may result in them being shut down.  This is particularly worrisome for facilities in rural areas, which struggle to attract enough psychiatrists to their community to provide ECT in the first place.

Delva acknowledged that the guidelines may have to be somewhat more malleable for the smaller centres, but Gosselin didn’t rule out the possibility of closures if patient care is at risk.

“It would have to be an extraordinary circumstance for that to happen, but if the audit raised awareness of something that was involved with patient safety, then there would have to be a very fast response,” she said.

While still in the early stages, Gosselin has had some preliminary discussions with Accreditation Canada, the national body that certifies hospitals throughout the country, to see how ECT can be incorporated into the hospital audit process.  She explained that each hospital/facility would be accredited for housing the ECT clinic.  Receiving that certification and having accreditors conduct audits based on the standards document would be paid for by the hospital, so CANECTS wouldn’t have to absorb any of the costs.  Ultimately, the cost would be borne by the taxpayer — like nearly all other health quality and patient safety initiatives in Canadian health environments, Delva explained.

Gosselin said that while some members of the CANECTS team are interested in acting as accreditors, there is ultimately going to be a lot more manpower needed than the team alone can provide.

“I’m very committed to this process and I plan on remaining involved to see it all through,” said Gosselin.