email: Alexdoherty@btinternet.com
27 January 2002
Richard Norris
SAMH
GLASGOW

Dear Richard
SCOTTISH ECT AUDIT
We wrote to you recently about the above audit. As you know, we decided to look further into the facts and figures published by Freeman & Company. We now wish to comment in detail to their publication, ECT In Scotland.

The articles quoted. Table 21 on page 20
Reid 98.) Reid gives the figure of 0.31% for deaths within two weeks. We think Freeman has taken out the 2 suicides and I accident to reach his figure of 0.2%.

Murphy 88. ) Murphy looked at 4 year ( not 1 week ) mortality in elderly people, and he found an increased mortality in depressed people, even when physical health was controlled ( but the increased mortality was not necessarily caused by depression and some of Murphy's patients may have had ECT. The Audit authors seem to be confusing percentage points with percentages, but that works against the point they are trying to make.

Prudic 99. ) Sackeim & Prudic did not claim that ECT reduces the suicide rate. "The comparisons of long-term outcome in patients hospitalised in pre-ECT & ECT eras found that the introduction of ECT had little impact on suicide rates.....The findings from the quasi-controlled studies, particularly the more recent investigations, show little uniform evidence for a positive effect on long term suicide rates"....

Lee 96. ) Lee is referring to 0.3 - 0.4 medical complications not specifically anaesthetic. (He was quoting earlier studies so we don't know if the complications were enough to stop the course.

Peet 94. ) Should be Śless than 1% - 11%' not 1% (0.52% of unipolar patients on tricyclics to 11.2% of bipolar on tricyclics). Again, the authors don't say if the mania was enough to stop the course.

Page 19
Inskip.) 6% not 7%.

Thorogood.) The 17X figure is for psychotropic drugs (major and minor tranquillisers, tricyclics, thioxanthene, barbiturates) not specifically tricyclics.

To conclude this section of our observations, We think it would be a reasonable assumption to say and make. That most patients undergoing ECT are also taking psychotropic medication. We find it difficult to discern however Dr. Freeman's use of comparisons regarding drugs and ECT. Which begs the questions. Were none of the patients treated with ECT in the audit taking medication ? And if so. Why was no information given on drugs within the audit? This study comparing the safety of ECT against tricyclic medication is therefore flawed.

Moving on to the adverse events quoted in the audit. We think this section of the findings are the main reason why no press release accompanied its publication. To say that ECT is a safe and effective treatment based on these figures, is disgraceful and misleading.

Phase 2 735 courses analysed. 1 in 24.5 courses not completed.
Patient unwilling ...............................15 = 1 in 49
Medical related/unrelated/manic ........... 14= 1 in 53
Suicide.............................................1= 1 in 735
Phase 3 579 courses
1 in 10 not completed
Unwilling.........................................18 = 1 in 32
Medical..........................................37 = 1 in 16
Death.............................................2 = 2 in 579
Crime (murder).................................1= 1 in 579
Phase 2+3 combined 735 + 579 = 1314 courses
Unwilling ........................................33 = 2.5% = 1 in 40
Medical..........................................51 = 3.9% = 1 in 26
Death (inc. suicide)............................3 = 0.2% = 1 in 438
Crime 1

Total 88 = 6.7% = 1 in 15 not completed

We would welcome any comments SAMH may have on our analysis of the audit findings. Thanks for pointing me in the right direction to obtain the Milan report. There's a lot of good stuff in there, although I'm unhappy with some of their recommendations. E.g.: Psychosurgery and certain aspects of ECT. I am delighted that ECT, if Milan's recommendations are taken up, will not be given to anyone capable of refusing it. In theory this would have prevented Joseph getting it. In theory..... Speak with you soon

Alex Doherty
cc Sue Kemsley