Martin Ba

The Clarke Institute experience with completed suicide: 1966 to 1997.

Objectives: To describe the caseload of completed suicides at a single psychiatric facility and to review the perceived deficiencies in the care of those patients. Method Demographic and diagnostic data, clinical circumstances, and the deficiencies in care and documentation or both were extracted from medical records and post-suicide audit reports. Results There were 276 completed suicides over the period reviewed, yielding suicide rates of 206 per 100 000 registered patients and 123.5 per 100 000 inpatient discharges. The male to female ratio was 2:1, and patients with schizophrenia or depression accounted for 63.7% of the caseload. Only 18% of inpatients were involuntary, and only 10% were under individual observation at the time of suicide. Individual psychiatrists had up to 15 suicides in their caseloads. Deficiencies and recommendations pursuant to case audits are summarized. Conclusion This is the first report of the entire cumulative experience with completed suicide, including audited deficiencies in the care and documentation of that caseload, at a single Canadian psychiatric facility.

Propofol anesthesia, seizure duration, and ECT: a case report and literature review.

Propofol is a nonbarbiturate anesthetic induction agent known to have anti-convulsant properties. When used as an anesthetic for electroconvulsive therapy (ECT), it can reduce seizure duration to a significant degree, which may not be fully appreciated. A case is presented in which propofol caused a 63.1% reduction in mean seizure duration compared with preceding and subsequent treatments with thiopental anesthesia. The literature on the use of propofol for ECT was reviewed with specific reference to its effect on seizure duration and any evidence of superiority to the barbiturate induction agents. It is concluded that propofol may have only very circumscribed indications as an anesthetic for ECT. If used, psychiatrists and anesthetists must be aware of its potency as an anticonvulsant.

Access to electroconvulsive therapy services in Canada.

Objectives We sought to determine factors governing access to electroconvulsive therapy (ECT) in Canada. Methods We contacted all 1273 registered health care institutions in Canada and invited the 175 centers identified as providing ECT to complete a comprehensive questionnaire. To determine geographic access to ECT, we used a geographic information system, population density data, and road network data. Responses to 5 questions from the questionnaire were used to identify local barriers to access. Results Approximately 84% of the population in the 10 Canadian provinces live within a 1-hour drive of an ECT center, but 5% live more than 5 hours’ drive away. There was significant province-to-province variation, with all of the citizens of Prince Edward Island living within 2 hours of an ECT center but 12.5% of those in Newfoundland and Labrador living more than 5 hours’ distance away. There are no ECT services at all in the 3 territories, which contain 3% of the Canadian population. Nongeographic barriers to access included inadequate human resources, particularly, a lack of anesthesiologists, in 59% of the centers; logistical impedances (52%); space limitations (45%); strictures on the hiring of adequate staff (29%); imposed limits to number of treatments or to operating or postanesthetic room time (28%); and a lack of funds to purchase up-to-date ECT or related anesthesiology equipment (14%). Conclusions Electroconvulsive therapy is geographically accessible for most Canadians. Even when geography is not a factor, however, there are significant barriers to access resulting from inadequate availability of qualified professional staff, treatment areas, and funding.

The clinical investigation of dementia.

The clinical investigation of 63 patients with a hospital discharge diagnosis of dementia was reviewed. The review focused on the completeness of ancillary investigations to detect treatable causes of dementia, and on the follow-up examination to confirm the diagnosis. Patients admitted to specialized geriatric psychiatry beds were compared to those admitted to other hospital services. The clinical investigation of the groups did not differ significantly with the respect to the search for treatable dementias, and in this series no treatable cases were detected. The non-selective use of a battery of ancillary diagnostic tests is questioned. The most notable finding was the almost uniform absence of follow-up examinations to document progressive deterioration of cognitive function. The indication for such follow-up is discussed in the context of previously reported diagnostic inaccuracy in this syndrome.The clinical investigation of 63 patients with a hospital discharge diagnosis of dementia was reviewed. The review focused on the completeness of ancillary investigations to detect treatable causes of dementia, and on the follow-up examination to confirm the diagnosis. Patients admitted to specialized geriatric psychiatry beds were compared to those admitted to other hospital services. The clinical investigation of the groups did not differ significantly with the respect to the search for treatable dementias, and in this series no treatable cases were detected. The non-selective use of a battery of ancillary diagnostic tests is questioned. The most notable finding was the almost uniform absence of follow-up examinations to document progressive deterioration of cognitive function. The indication for such follow-up is discussed in the context of previously reported diagnostic inaccuracy in this syndrome.

The Clarke Institute experience with electroconvulsive therapy: II. Treatment evaluation and standards of practice.

Contemporary standards of practice of electroconvulsive therapy with respect to the treatment procedure, clinical indications, and dosage (number of treatments per course) are summarized. The actual clinical practice at one psychiatric hospital over a 16-year period, comprising 22,647 treatments, was compared to those standards. The most significant findings in this series were the over-representation of patients with a diagnosis of schizophrenia and the absence of any clinically significant difference in the treatment dosage for schizophrenia and affective disorders. The significance of these findings is discussed with respect to their identification of patient subgroups that warrant case auditing. In addition, the results are used as a basis for a critical examination of the rationale for the presently recommended maximum treatment dosages.

Delivery of electroconvulsive therapy in Canada: a first national survey report on usage, treatment practice, and facilities.

Objectives The aims of this study were to document electroconvulsive therapy use in Canada with respect to treatment facilities and caseloads based on a survey of practice (Canadian Electroconvulsive Therapy Survey/Enquete Canadienne Sur Les Electrochocs-CANECTS/ECANEC) and to consider these findings in the context of guideline recommendations. Method All 1273 registered hospitals in Canada were contacted, and 175 sites were identified as providing electroconvulsive therapy; these sites were invited to complete a comprehensive questionnaire. The survey period was calendar year 2006 or fiscal year 2006/2007. National usage rates were estimated from the responses. Results Sixty-one percent of the sites completed the questionnaire; a further 10% provided caseload data. Seventy were identified as general; 31, as university teaching; and 21, as provincial psychiatric/other single specialty (psychiatric) hospitals. Caseload volumes ranged from a mean of fewer than 2 to greater than 30 treatments per week. Estimated national usage during the 1-year survey period was 7340 to 8083 patients (2.32–2.56 per 10,000 population) and 66,791 to 67,424 treatments (2.11–2.13 per 1000 population). The diagnostic indications, admission status, and protocols for course end points are described. Conclusions The usage rates are in keeping with earlier Canadian data and with those from other jurisdictions. The difficulty obtaining caseload data from individual hospitals is indicative of the need for standardized data collection to support both clinical research and quality assurance. The wide variation in protocols for number of treatments per course indicates a need for better informed clinical guidelines. The broad range of caseload volumes suggests the need to review the economies of scale in the field.

Canadian survey of perianesthetic care for patients receiving electroconvulsive therapy.

Objectives We report on the anesthesia subsection of a comprehensive nationwide survey (Canadian Electroconvulsive Therapy Survey/Enquête canadienne sur les electrochocs) on the practice of electroconvulsive therapy (ECT) in Canada. Methods This comprehensive survey was sent to the 175 Canadian institutions identified as providers of ECT in 2007. Among other topics, 9 anesthesia-related questions were administered regarding anesthesiology consultation; high-risk patients; credentials of the anesthesia provider; monitoring, airway, and resuscitation equipment; anesthetic induction, muscle relaxant, vasoactive, and other perianesthetic drugs and practices; and postanesthetic discharge. Results Sixty-one percent (107/175) of the institutions returned completed survey questionnaires. More than 70% of the sites reported pre-ECT anesthesiology consultation for all (61%) or most (11%) patients. In more than 90%, a Canadian Royal College–certified anesthesiologist, or equivalent, provided anesthetic care. Routine use of oximetry, electrocardiography, and blood pressure monitoring were reported by all but 2 sites; use of bite block was reported by all but 4 sites; and preoxygenation was reported by all but 7 sites. Dantrolene and capnography were not reported as readily available by 35% and 40%, respectively, with comparatively less frequent availability at non–operating room and lower-volume sites. Conclusions These results suggest safe practices of anesthesia for ECT in Canada. Further attention needs to be paid to ready availability of dantrolene and capnography, particularly at non–operating room ECT sites. Improvements in anesthetic care of patients undergoing ECT may be realized through continued knowledge translation efforts and by expanding access to currently unavailable anesthetic induction agents and, in some settings, limited clinical anesthesiology resources.

Civil commitment trends in Ontario: the effect of legislation on clinical practice

The rationale for and history of civil commitment legislation in Ontario are reviewed. The civil commitment rate in Ontario from 1926 to 1980 for provincial psychiatric hospitals, and from 1974 to 1980 for all psychiatric inpatient facilities was analyzed to detect variation in the rate over time and with relevant legislation. The findings indicate that mental health legislation has had little effect on commitment practices in Ontario. In addition, the variation in the commitment rate over the period reviewed cannot be ascribed to inconsistent application by physicians. The other variables affecting the rate are discussed in this context. The need for more descriptive studies of the major determinants of the commitment rate is emphasized.The rationale for and history of civil commitment legislation in Ontario are reviewed. The civil commitment rate in Ontario from 1926 to 1980 for provincial psychiatric hospitals, and from 1974 to 1980 for all psychiatric inpatient facilities was analyzed to detect variation in the rate over time and with relevant legislation. The findings indicate that mental health legislation has had little effect on commitment practices in Ontario. In addition, the variation in the commitment rate over the period reviewed cannot be ascribed to inconsistent application by physicians. The other variables affecting the rate are discussed in this context. The need for more descriptive studies of the major determinants of the commitment rate is emphasized.

Electroconvulsive therapy and the seizure threshold

The use of a pulsatile square wave stimulus for a large series of electroconvulsive treatments under conditions of routine clinical practice is compared to the equivalent experience with a sine wave stimulus. The literature indicates that both waveforms are equally effective convulsants. However, in this series, the induction of a convulsion was found to be much more difficult with the pulsatile square wave such that the rate of failure to convulse was four times that compared to sine wave stimulation. A number of variables that may affect the seizure threshold during ECT were examined. It is concluded that the benefit obtained by reducing the electrical energy transmitted to the patient with the pulsatile stimulus offsets the difficulty encountered in reaching the seizure threshold.

Electroconvulsive therapy and the stimulus waveform.

The amount of electrical energy transmitted to the patient while inducing a seizure during electroconvulsive therapy (ECT) may vary considerably depending on the waveform of the electrical stimulus. The majority of ECT equipment used in the past employed a sinusoidal waveform for the stimulus. Advances in waveform technology have led to the development of pulsatile waveforms which are effective convulsants requiring a fraction of the electrical energy transmitted by the sinusoidal waveform. This paper summarizes the clinically relevant advances in waveform technology. The therapeutic principle of using the minimum effective dosage is emphasized.The amount of electrical energy transmitted to the patient while inducing a seizure during electroconvulsive therapy (ECT) may vary considerably depending on the waveform of the electrical stimulus. The majority of ECT equipment used in the past employed a sinusoidal waveform for the stimulus. Advances in waveform technology have led to the development of pulsatile waveforms which are effective convulsants requiring a fraction of the electrical energy transmitted by the sinusoidal waveform. This paper summarizes the clinically relevant advances in waveform technology. The therapeutic principle of using the minimum effective dosage is emphasized.