Standards of Electroconvulsive Therapy (ECT) Services at Zomba Mental Hospital (ZMH)

Standards of Electroconvulsive Therapy (ECT) Services at Zomba Mental Hospital (ZMH) Michael M. M. Udedi

Introduction • The hospital acquired a donation of 2 ECT machines (Mecta SR models) from Scotland and anaesthetic equipment through the Ministry of Health in 2007. • Modified ECT was introduced at Zomba Mental Hospital in the first week of September in 2007 . • Selis, Kauye & Leentjens, (2008:140) suggested that modification of ECT approaching western standards was possible with clear ECT guidelines, consent procedures, and adequate monitoring of effect and side effects. • It is against this background that there was need to conduct ECT audit at ZMH in order to assess the provision of care

Objective • To identify the quality of care in terms of ECT provision to patients at Zomba Mental Hospital

ZMH - SET STANDARDS FOR ECT • The ECT should be done under anaesthesia (90% of cases) • Files for the patients undergoing ECT should include ECT forms (95% of cases) • The indication of ECT should be written down (95% of cases) • The consent form should completed appropriately (90% of cases) • Physical examination should be done and recorded within a week before ECT (95% of cases)

ZMH - SET STANDARDS FOR ECT • Vital signs should be checked before and after the ECT and recorded (95% of cases) • Each ECT, dose, seizure length and anaesthetic given should be recorded (90% of cases) • Every patient receiving ECT should be reviewed and review recorded after every two ECT sessions before further ECT session is conducted (Clinical condition, side effects and consent status) [90% of cases]

Design • This was a retrospective case file audit study • It looked at previous patients records who underwent ECT and also the administration of ECT itself in an attempt to determine the quality of care in terms of patients.

Sampling & sample size • Patients’ records for this study were randomly selected using a systematic sampling technique • A sample size of 30 case files belonging to the patients who were previously admitted at the hospital between August 2008 and December 2008 who underwent ECT • 60 patients underwent ECT during the study period thus in this case every 2nd case file of the population was selected

Inclusion Criteria • Cases included in the audit were all the case files for psychiatric patients registered with ZMH from August 2008 to December 2008. • The patients selected were based on the fact that they underwent ECT.

Data Collection • Data was collected using specially designed form which included the following: • Demographics, • Diagnosis • Indication for ECT • Consent • Physical Examination and Vital signs check • Procedure • Reviews after ECT

General Results • During the study period, 60 patients under-went ECT but 30 were sampled - 6 men and 24 women. • Their ages ranged from 16 to 54 years. • 10 patients were diagnosed with a bipolar disorder (33%), 5 with a depression (17%), 4 with a mania (13%), 2 with a postpartum psychosis (7%), 3 with a schizophrenia (10%) and 6 with a schizoaffective disorder (20%). • The total number of sessions varied from 4 to 6. • The length of the clinically observed convulsions varied from 11 to 160 seconds and the dose ranged from 225 to 400mc.

Criteria Results

DISCUSSION • All patients underwent modified ECT • Almost all files had consent forms although most of the consent forms were not completed appropriately • ECT form did not cater properly for all pre ECT vital signs and post ECT vital signs • Consent form was in English language • ECT information sheet was in English language and was not available in all patient files • 37% of patients did not undergo physical examination prior to ECT • Most of the indications written on the ECT form were also the diagnoses

RECOMMENDATIONS FOR CHANGE • Consent forms to be completed appropriately • ECT form to be reviewed to cater properly for all pre ECT vitals and post ECT vitals • Consent form to be translated into vernacular language • ECT information sheet to be translated into vernacular language and be put in patient files • ECT protocol to be pasted in all wards and also to be placed in procedure manuals

Cont’d • The indication written on the ECT form should be specific i.e. Emergency life saving, too distressed to await response to medication, severe psychomotor retardation/agitation, suicidal ideation, patient preference, medication resistance , previous good response

RECOMMENDATIONS FOR FURTHER AUDIT • Re-audit of the ECT standards • Dosing and seizures • Number of sessions per week • Average effective ECT sessions • Side effects of modified ECT

Conclusion • The results revealed the gaps in the provision of ECT services in relation to the required standards. • The results also indicated commitment to satisfy the introduced standards • Efforts to improve other treatment standards should be undertaken i.e. consent & indication.

Acknowledgements • Dr Kauye for the support • Dr Stewart for the guidance and support • Records Clerks for their assistance in locating the files • Colleagues in Clinical Psychiatry Department for moral support during the data collection

Standards of Electroconvulsive Therapy (ECT) Services at Zomba Mental Hospital (ZMH)