1. A Pan-African Survey of ECT and establishing a Practitioners’ Network Dr Johan Leuvennink Consultant Psychiatrist SMMHEP 2 nd Malawi Mental Health Research and Practice Development Conference Blantyre, Malawi March 2012

2. 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.

3. ECT: it's place in modern psychiatric practice ECT trend in UK Severe / Rx resistant major depressive episodes

4. 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

5. 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

6. Experience of ECT Clinical Networks elsewhere: SEAN ECTAS European ECT Network Setting up a Southern African Network for ECT (SANECT)

7. 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

8. Purpose of Study Commonly prescribed treatment Similarities in challenges throughout Africa Scoping survey Baseline for further collaboration

9. What this is not…. Comprehensive survey of services Ranking of service excellence

10. Subjects and settings Psychiatrists throughout Africa Private Practice, District General Hospital and Teaching Hospitals

11. 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.

12. Total questionnaires sent: 54 Total respondents: 19 Geographical spread: 12 countries Practice type distribution: wide

13. 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 Survey Questionnaire

14. 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 depressionYes / No Mild to moderate, but treatment resistant depressionYes / No ManiaYes / No Acute schizophreniaYes / No OCD Other (Please specify) ………………………………………………………………………. Is maintenance ECT given in your service?Yes / No

15. 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 lengthYes / No According to side effectsYes / No According to clinical response/non-responseYes / 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

16. 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

17. Results

19. 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.

20. 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.

22. No differentiation in Maintenance ECT prescription according to treatment setting was found.

26. Cognitive Side-effects were reported to be mainly clinically monitored by usual interview. 3 practitioners use the MMSE routinely for this purpose.

27. 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.

28. 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