SURVEY OF THE PROVISION OF ELECTRO-CONVULSIVE THERAPY (ECT)
AT NEW YORK STATE PSYCHIATRIC CENTERS
BY THE COMMISSION ON QUALITY OF CARE
AUGUST 7, 2001

I. Introduction
At the request of Assemblyman Martin Luster, Chair of the Assembly Committee
on Mental Health, the Commission agreed to conduct a survey of the provision
of Electro-convulsive Therapy (ECT) at state psychiatric centers. The
purpose of this survey was to obtain information about the frequency of
administration of this treatment; facilities’ management of such, and the
patients who undergo this treatment, but not to evaluate its efficacy. As a
result, the Commission obtained information about facility-specific
procedures governing the use of ECT; protocols for privileging physicians to
administer the procedure; and demographic information regarding the age,
gender, diagnosis, and capacity to consent for those persons receiving ECT in
state psychiatric centers between June 1, 1999 and May 31, 2001. In
addition, a review of individual clinical records was conducted according to
a specific protocol for approximately one in three individuals identified as
receiving ECT during the survey period, to develop an understanding of the
patients who receive it.
ECT is currently administered in Manhattan Psychiatric Center, Creedmoor
Psychiatric Center, Pilgrim Psychiatric Center, The Psychiatric Institute
(PI), and Rockland Psychiatric Center.

II. Executive Summary
The Commission’s survey revealed that during the two-year period of the
review, 164 of the more than 10,000 inpatients received ECT is state operated
facilities. At The Psychiatric Institute, almost all of the individuals
receiving ECT were diagnosed with mood disorders–either Bipolar Disorder or
Major Depression. Three out of four individuals at the other four facilities
were diagnosed as psychotic; either having schizophrenia or schizoaffective
disorder. Our record review revealed that the clinical presentation of these
individuals justified the use of ECT as a treatment modality.

Further, excluding PI, where all ECT patients are voluntary participants in a
research protocol, approximately two out of five individuals in state
facilities receiving ECT are doing so pursuant to a court order.

Our review of the policies and procedures for administration of ECT revealed
that protocols varied in detail regarding the procedure itself, as well as in
issues such as physician privileging and determining capacity to consent.

III. Overview of ECT
ECT was first introduced in 1938, and consists of the application of an
electric shock to the brain, which causes a convulsive seizure.
Controversial from the start, ECT was used in the 1940's and 50's to treat a
variety of mental illnesses. Its popularity diminished in the 1960's with
the introduction of pharmacological treatments, but again became a popular
treatment for certain types of symptoms in the 1970's.

A course of treatment with ECT usually consists of six to twelve treatments
given up to three times a week. ECT is generally administered in designated
suites in which there is a specially equipped treatment room as well as a
recovery room. The patient is given general anesthesia (without intubation)
and a muscle relaxant. When these have taken full effect, a course of
electricity is applied to the patient’s brain through electrodes, which
produces a seizure lasting approximately one minute. Due to the use of
muscle relaxants and anesthesia, the patient does not convulse nor does he or
she feel any pain.

Although the exact reason why ECT works in not known, it is generally
believed that the biochemical events that accompany or result from the
electrically induced seizure alter impaired electrochemical processes in the
brain. One common theory is that ECT stimulates the long-term production of
neurotransmitters. The accompanying muscle convulsions, memory loss or other
neurologic effects do not contribute to the therapeutic effect. Thus, modern
improvements in the technique of ECT such as sedation, anesthesia, muscle
relaxation, selective electrode placements and current, have all contributed
to the improved safety of the process while maintaining the beneficial
aspects of the seizure itself. In essence, if properly administered, the
patient experiences a brain seizure without sustaining the classic muscle
convulsions typical of a seizure.

Professional literature[1] indicates that ECT has been proven effective in
the treatment of major depressive disorder, bipolar disorder, schizophrenia,
schizoaffective disorder, and schizophreniform disorder. The major side
effect, short-term memory loss, is of great concern to many individuals.
Bilateral ECT (i.e. electric current introduced at both sides of the head) is
associated with greater memory loss than unilateral ECT, but with greater
efficacy.

ECT is an effective treatment where the illness is characterized by behavior
which is a threat to the safety and well-being of the patient or others, and
which cannot be controlled by drugs or other means, or, for which drugs
cannot be employed because of adverse reactions or because of the risks which
their use entails.

IV. The Patients Who Received ECT
In the two year period reviewed, our survey identified 164 patients who
received ETC. According to the New York State Office of Mental Health (OMH),
during calender year 2000, approximately 1.3% of the 10,000 adult inpatients
in OMH operated psychiatric centers, received ETC. Of the approximately 60
cases reviewed in depth during our survey, the Commission found that all met
criteria for use of ETC. Additionally, it was found that when ECT did not
result in desired outcomes, it was promptly terminated.

A. Gender/Age: As can be seen below, at New York State facilities, ECT is
administered to women more often than men.
Table 1.

Gender	Manhattan	Creedmoor	Pilgrim	PI	Rockland	Total
Total	23	19	45	66	11	164
Males	12 (52%)	4 (21%)	17 (38%)	21 (32%)	8 (73%)	62 (38%)
Females	11 (48%)	15 (79%)	28 (62%)	45 (68%)	3 (27%)	102 (62%)

ECT was most commonly given to those individuals between 18 and 64, and is
not administered to children.

Table 2.

Age	Manhattan	Creedmoor	Pilgrim	PI	Rockland	Total
<18	0	0	0	0	0	0
18-64	22 (96%)	17 (89%)	34 (76%)	58 (88%)	11 (100%)	142 (86%)
>64	1 (04%)	2 (11%)	11 (24%)	8 (12%)	0	22 (14%)

B. Diagnosis: The diagnosis of individuals receiving ECT at PI reflects
what one would expect at a typical voluntary hospital. Most people (88%) are
diagnosed with either major depression or bipolar disorder. The record
reviews reveal that these individuals are all being treated with ECT after
traditional pharmacological therapy has failed to lift their depressions.

However, at the other state facilities, the vast majority of individuals are
diagnosed with schizophrenia or schizoaffective disorder. Most often, their
ECT is designed to treat severe psychoses with much different
symptomatology–severe self injury such as biting off pieces of one’s tongue
or drinking household chemicals; significant assaultive behavior toward staff
and peers; or severe psychosis. Typically, these individuals are either not
able to tolerate pharmacological interventions, or such interventions have
proven ineffective.

Table 3.

Diagnosis	Manhattan	Creedmoor	Pilgrim	PI	Rockland	Total
Major Depression	1 (04%)	4 (21%)	0	45 (68%)	1 (09%)	51 (31%)
Bipolar Disorder	2 (09%)	1 (05%)	10 (22%)	13 (20%)	1 (09%)	27 (16%)
Schizophrenia	8 (35%)	2 (11%)	10 (22%)	1 (01%)	5 (46%)	26 (16%)
Schizo-affective Disorder	10 (43%)	12 (63%)	24 (53%)	0	3 (27%)	49 (30%)
Other	2 (09%)	0	1 (03%)	7 (11%)	1 (09%)	11 (07%)

The record review at Manhattan revealed that the typical person receiving ECT
is similar to Mr. MJ, a 51 year old man diagnosed with schizoaffective
disorder. He has a history of more than ten hospitalizations with paranoid
delusions and homicidal threats. His psychiatrist justified the use of ECT,
stating that his symptoms of mental illness have persisted, despite receiving
both traditional and new antipsychotic medications. He received a total of
56 treatments over a seven month period. They were eventually stopped due to
a lack of response.

Mr. SS is a man diagnosed with chronic undifferentiated schizophrenia,
polysubstance abuse, and antisocial personality disorder, who was noted to be
paranoid and suicidal. A course of 26 ECT treatments along with high doses
of Effexor, Seroquel, and Gabapentin brought his clinical picture under
control.

A third individual, Mr. EC, is noted to be sensitive to certain types of
medication, which caused severe extrapyramidal symptoms. Diagnosed with
schizoaffective disorder and obsessive compulsive disorder, ECT was justified
due to his non-response to the medication he was taking.

Similarly, Ms. BN, with a history of several past suicide attempts, was given
ECT after sustaining several serious complications to medications she was
taking and not responding to medications she did tolerate. ECT was justified
based upon her continued significant psychosis and assaultive behavior.

At Creedmoor, 63% of individuals receiving ECT had a diagnosis of
schizoaffective disorder. Ms. RP hears voices telling her she is going to
die and has been in Creedmoor since 1991. She is sensitive to all
neuroleptics which cause severe EPS, mimicking catatonia. The record states
that she is responsive only to ETC.

Ms. YN lives in a state operated community residence and comes into Creedmoor
for maintenance ECT every two weeks. Diagnosed with schizoaffective
disorder, she has a long history of suicide attempts and assaultive behavior.
A combination of maintenance ECT and medication have been successful in the
past two years.

Ms. XL is described as withdrawn, depressed, and hallucinating. ECT was
administered to treat her suicidal ideation and hopelessness. After 15
sessions, the treatment was stopped due to a lack of response. She has been
placed on a different anti-depressant and anti-psychotic medication.

Nearly one-quarter of the people receiving ECT at Creedmoor have
schizophrenia diagnoses. Ms. EP has had multiple hospitalizations, is
noncompliant with medications, and rapidly decompensates. She is paranoid,
religiously preoccupied, and delusional. She is so aggressive and assaultive
that she requires secure care. She has been receiving ECT for a number of
years, and the treatment decreases her preoccupation, delusions about devils,
and aggressive and assaultive episodes. However, she remains floridly
delusional and psychotic.

Patients receiving ECT at Pilgrim are particularly ill. For example, Ms. PS
has been treatment refractory since 1986, in spite of various trials of
psychotropics. She is assaultive, delusional, and has a history of past
suicide attempts.

Ms. GL is paranoid, believes her food is poisoned, and will not eat. She has
received naso-gastric tube feeding in the past after losing 20% of her body
weight. The record indicates that ECT is the only option for this woman, as
neuroleptics have not helped.

Mr. JS has a psychiatric history going back to 1948. He has received insulin
shock, pre-frontal lobotomy and ETC. The record noted that Mr. JS was
showing severe refractory mania, not responsive to conventional mood
stabilizers. The mania is debilitating with fatigue. ECT was prescribed to
prevent dangerous levels of exhaustion.

Mr. WP also has an extensive history of ECT going back to 1953. He gets
severe extrapyramidal symptoms with standard neuroleptics and has had four
episodes of Neuroleptic Malignant Syndrome (NMS)[2] in the past five years.
Most recently, ECT was justified to try to control his abusive, agitated,
paranoid behavior. “Due to patient’s inability to tolerate antipsychotic
mediations, history of NMS, positive and favorable responses to ECT, ECT is
considered the safest and the only mode of treatment to prevent further
deterioration...”

Mr. JM, twenty years old, has a history of multiple psychiatric admissions,
and multiple suicide attempts including: cutting his wrist, jumping off a
bridge, and overdosing on insulin. At moderate risk for suicide, the record
noted he was almost mute, refusing to eat or take insulin. He has a past
history of successful ECT treatment.

Ms. PJ has a twenty-year history of psychiatric hospitalization, and exhibits
very difficult behaviors including head banging, throwing self to the floor,
and drinking household chemicals. The record notes that despite intensive
pharmacological interventions, there has been no sustained improvement in her
psychiatric symptomatology, and ECT is the only treatment modality left that
may produce a desired outcome.

Ms. CD also has a twenty-year history of psychiatric hospitalization. She
has a history of NMS and violent self injury that shows dramatic improvement
after treatment with ETC.

Mr. RB, who has a twenty-plus-year history of mental illness, was most
recently admitted to Pilgrim after assaulting seven staff members at
Southside Hospital. On continuous one-to-one supervision since his
admission, he has been restrained numerous times to prevent self injury. He
bites off pieces of his tongue in response to command hallucinations, and is
now missing two-thirds of his tongue. ECT was ordered after he lost 35
pounds in a month and developed stage II ulcers on his buttocks.

At Rockland, Ms. SK is being treated for a history of self-injurious
behavior, severe psychosis, homicidal and suicidal ideation. She currently
receives once weekly maintenance ETC. Mr. AA, with a history of 17 previous
suicide attempts, was prescribed ECT after a poor response to treatment with
medication.

V. Governance of ECT in State Psychiatric Centers
While all facilities have policies and procedures in place governing the use
of ECT,[3] policies regarding the credentialing of physicians and addressing
informed consent varied widely.

A. Policies and Procedures: Each facility visited during the survey has a
readily available written procedure for administering ETC. The procedures
varied from the very basic to the exceptionally detailed. All, however, were
current, and contained sections detailing clinical indications for ECT,
referral process, capacity to consent determinations, pre-ECT medical
clearance, pre-treatment considerations, anesthesia, the actual
administration of ECT, post-ECT care, and documentation requirements.

Rockland Psychiatric Center’s protocol was last revised on January 20, 2000.
It is a very basic, nine-page protocol. Manhattan Psychiatric Center’s
protocol was last revised on March 17, 1999. It runs ten pages, with over
two of the ten pages devoted to special considerations and precautions.
Creedmoor’s protocol was issued in December, 1998 and runs fourteen pages.
Although the protocol describes at some length the indications for usage, it
does not define contraindications for use as do some other facilities’
policies.

The Pilgrim policy is a very detailed 58 pages, last revised on February 20,
2001. While the protocol states that there are no “absolute”
contraindications to ECT, it recognizes that there are situations in which
ECT is associated with an appreciable likelihood of serious morbidity or
mortality. “Those situations associated with substantial risk are not
treated at PPC and would require transfer to a general medical facility for
treatment.” PI’s policy was revised on January 22, 2001 and is a very
detailed thirty pages, plus a number of appendices.

B. Physician Privileging: Each facility devotes a portion of its protocol
to defining the manner in which physicians are privileged to conduct ETC. At
Rockland, to be credentialed to perform ECT, a psychiatrist must
successfully complete a five-day ECT fellowship program or a preceptorship;
perform a minimum of five supervised ECT treatments; be Intermediate Response
EMS trained every six months; and be approved by the Privileging Committee
and the Clinical Director.

At Manhattan Psychiatric Center, to be ECT certified, a psychiatrist must
pass a written examination on ECT, observe five administrations of ECT, and
perform five supervised ECT treatments.

At Pilgrim, a psychiatrist must have completed an accredited ECT training
course and/or performed at least 20 supervised ECT treatments. Additionally,
re-privileging requires “relevant CME credits related to ECT.”

At Creedmoor, a psychiatrist must have completed 50 hours of theoretical and
practical training in ECT, which meets with the approval of the head of the
ECT program.

At PI, the medical director of ECT recommends psychiatrists for privileging.
The recommendation is reviewed in turn by the Medical Staff Credentialing and
Privileging Committee, the Medical Staff Executive Committee and the
Governing Body. Privileging is based upon an assessment of the general
competency of the psychiatrist and specific experience with and knowledge of
ETC. Supervised administration at PI of at least 20 ECT treatments is
required before a physician will be considered for privileging.

C. Informed Consent: Obtaining a patient’s informed consent for ECT, among
other specified treatments which require informed consent, is the subject
matter of 14 NYCRR §27.9. This provision is part of the body of regulations
promulgated before the Department of Mental Hygiene was reorganized in 1978
into three autonomous offices: OMH, OMRDD, and OASAS. Since that
reorganization, these offices, including OMH, have promulgated regulations
specific to their own functions which have superceded in part the earlier
provisions. Section 27.9 is one of those earlier regulations which has been
superceded, though only in part.

Section 27.9 provides as follows (in non-emergency situations):

If an adult patient has the requisite capacity to consent to ECT treatment
and does so, the treatment may proceed;

If the patient has the requisite capacity to consent to ECT treatment but
objects, the treatment may not proceed;

If it is not clear whether the patient has the requisite capacity to consent
to ECT treatment, an independent opinion about the patient’s capacity must be
obtained from a qualified consultant who is not an employee of the facility;
and,

If the patient does not have the requisite capacity to consent to ECT
treatment but does not object, the treatment may only proceed if substituted
consent is obtained from a surrogate decision-maker such as the spouse, a
parent, an adult child, or a court of competent jurisdiction.

Section 27.9 also provides that if the patient does not have the requisite
capacity to consent to ECT treatment but does object, the objection may be
overridden administratively by the hospital. However, this provision of
Section 27.9 has been superceded as a result of the Court of Appeals’ 1986
decision in Rivers v. Katz. OMH promulgated Section 527.8 to supercede this
provision in order to clarify that an incapacitated patient may be treated
over objection only by court order.

Only Pilgrim’s policy operationally defines capacity to consent. It is
defined as being able to comprehend the nature and seriousness of the illness
for which treatment is offered, to understand the information provided
concerning the treatment modality, and to form a rational response based upon
this information. PI indicates that, in their view, patients are considered
to have the capacity to consent for ECT unless the evidence to the contrary
is “compelling.”

For a patient who has sufficient mental capacity to give informed consent to
ECT, according to policy at PI, Pilgrim and Creedmoor, only the patient can
give consent, and if the patient refuses to give consent, ECT will not be
administered and the hospital will not go to court. If ECT treatment is
deemed necessary for a competent patient who refuses ECT, Rockland and
Manhattan policy allows them to go to court to obtain an order for treatment
over objection.

Policies generally define the length of time a consent is valid. At PI,
informed consent is good for up to 25 treatments of a single course of ETC.
For maintenance ECT, consent is good for 25 treatments or six months,
whichever comes first. At Pilgrim, consent is good for 25 treatments or
three months, whichever comes first. For maintenance ECT, new consent must
be obtained every six months. Except for patients receiving maintenance ECT,
a gap of more than 14 days requires that a new consent be obtained at both PI
and Pilgrim. Creedmoor requires a new consent every three months. Rockland
requires that consent be updated every six months. Manhattan has no written
requirement for the renewing informed consent, but does require that MHLS be
notified before anyone, consenting or not, receives ETC.

Policies at PI, Pilgrim, Creedmoor indicate that legally designated
surrogates or a court of competent jurisdiction can give consent to ECT if
the patient lacks capacity to give informed consent, but does not object.
Creedmoor mandates that two psychiatrists, neither associated with the ECT
unit, must certify that a patient lacks the capacity to give informed consent
because of impaired mental ability to comprehend the nature of the need for
ECT, and they must further certify that the patient does not object. At
Manhattan and Rockland, court orders are required before ECT can be given to
anyone who is determined to lack the capacity to give consent.

In cases where a patient lacks capacity to give informed consent, and does
object to ECT, all five facilities require that ECT be administered pursuant
to court order.

Table 4. Consent Status
Manhattan Creedmoor Pilgrim PI
Rockland Total
Has Capacity 6 (26%) 13 (68%) 31 (68%) 66 (100%) 10
(91%) 126 (77%)
Lacks Capacity 1 (4%) 0 1 (02%) 0
0 1 (1%)
Court Ordered 16 (70%) 6 (32%) 14 (30%) 0
1 (09%) 37 (22%)

Because in most cases the provision of ECT at PI is part of a research
protocol, all patients receiving ECT there are considered to have the
capacity to consent. If PI is thus excluded from this discussion,
approximately two in five patients at the remaining four facilities are
receiving ECT as a result of a court order.

Table 5. Consent Status (Excluding PI Patients)
Manhattan Creedmoor Pilgrim Rockland
Total
Has Capacity 6 13 31 10
60 (61%)
Surrogate Consent 1 0 0 0
1 (01%)
Court Order 16 6 14
1 37 (38%)

At Rockland Psychiatric Center, Ms. SK did not object to treatment, but
because she was determined to lack capacity, the hospital successfully sought
a court order. At Pilgrim, doctors wrote that Ms. LB had “no factual
understanding” of the treatment. The ECT procedure was explained to Ms. PS,
, but she “did not seem to understand.” “The proposed treatment benefits
and risks have been explained,” to Ms. GL, but, “she does not have the
capacity to give or withhold consent.” Mr. JS was declared to not have
capacity because, “he is unable to concentrate due to acute mania, racing
thoughts and is unable to process information given to him.” For Manhattan
patient PC, “...the patient’s ability to make a reasoned decision relative
to the proposed treatment, its risks, benefits and alternatives, is
considered to be poor.”

Family gave consent for ECT for Mr. RB. “I have tried several times to
explain to the patient about ECT and its benefits and complications...(he)
does not have capacity to sign permits...”

Notes justifying an individual’s ability to give consent were similar to
this: “ECT was discussed with (Pilgrim patient CD) and she is aware of ECT
need, side effects. Is capable of signing consent. Feels ECT will help
her.” At Creedmoor, Ms. YN signed consent as she “has capacity and
understands risks/benefits.”

VIII. Summary and Recommendation
The Commission’s survey revealed that during the two-year period of the
review, 164 individuals received ECT in state-operated facilities. Our
record review revealed that the clinical presentation of these individuals
justified the use of ECT as a treatment modality.

With respect to consent, excluding patients at PI, approximately two out of
five individuals in state facilities are receiving ECT pursuant to court
order.

Our review of the policies and procedures revealed differing protocols. Not
only were they varied in detail regarding the procedure itself, they varied
regarding physician privileging and discerning consent issues.

Accordingly, the Commission recommends that the Office of Mental Health
establish a blue ribbon task force charged with the responsibility of
developing ECT protocols that can be applied consistently in state facilities
administering ECT and which promote the application of best practices while
ensuring strict adherence to statutory and regulatory standards for
safeguarding patient rights. The Commission would welcome the opportunity to
assist OMH in this regard.

VIII. Addendum
In his response to this survey, OMH Commissioner James Stone indicated that
his agency has been at work since last January developing a set of guidelines
based upon the recently revised American Psychiatric Association’s ECT
standards. These guidelines will soon be forwarded to groups such as the APA
and HANYS for comment.

[1] See for example, Hermann et al, “Diagnoses of Patients With ECT: A
Comparison of Evidence-Based Standards With Reported Use.” Psychiatric
Services: 1059-1065, August 1999; or National Institute of Mental Health:
Consensus conference on electroconvulsive therapy. JAMA: 254:103-108, 1985.

[2] Hyperthermia with extrapyramidal and autonomic disturbances which may
result in death, following the use of neuroleptic medication.

[3] Manhattan Psychiatric Center routinely performs ECT on patients from
Kirby Forensic Psychiatric Center and Bronx Psychiatric Center. For purposes
of this survey, we did not include protocols from these two facilities.

Source: http://www.cqc.state.ny.us/ectsurvey.htm