Electroconvulsive practice in Singapore: a cross-sectional national survey

Abstract

Electroconvulsive therapy (ECT) is a safe and effective treatment for mood disorders (1,2) and schizophrenia. (3) The mechanism of ECT is not completely understood but is likely to involve changes in cerebral noradrenaline, serotonin and dopamine activities, permeability of the blood-brain barrier and neurogenesis. (4) Common side effects include headache, myalgia and transient cognitive impairment, (5) with an estimated mortality rate of 2.4 per 100,000 treatments. (6) Many surveys have been conducted in several countries and regions worldwide, reflecting that ECT practice is highly heterogeneous. (7) For instance, in Europe and Australia, (8)(9)(10)(11) ECT is primarily used for the treatment of depression, while in Asia, it is also frequently used for psychotic disorders (12)(13)(14)(15) and high suicide risk. (16) The United States and most Asian countries use bitemporal ECT, (7,(17)(18)(19)(20) while in Europe and Australia, the most prevalent electrode placement is right unilateral. (7,21) While this information is valuable, specific data on ECT parameters (e.g. pulse width), anaesthetic technique, methods of dosing, monitoring of ECT outcomes and credentialing is still lacking. For this reason, we developed a questionnaire exploring detailed information about ECT practice. This survey was conducted in Singapore to provide insights into current ECT practice and identify areas for future clinical improvement.Singapore is a small nation state at the tip of the Malaysian archipelago. It has a population of approximately 5.5 million people consisting of 74.3% ethnic Chinese, 13.3% Malays and 9.1% Indians. The average per capita gross domestic product in 2015 was USD 53,947.93. (22) The lifetime prevalence of depression in Singapore is 5.8%, with a 12-month prevalence of 2.2% (23) and mean annual cost of treatment of USD 7,638. (24) Treatment of depression is estimated to give a 5.7-to-1 benefit-tocost ratio. (25) While equivalent figures for schizophrenia are not available in Singapore, it is widely accepted that the economic burden of schizophrenia is significant, estimated between 0.02% and 1.65% of gross domestic product. (26) ECT is a highly effective short-term treatment for depression and should be considered for patients who have not responded to standard antidepressant therapy. (27) There are currently 26 general hospitals and specialist centres, of which 12 offer specialist psychiatry services. (28) ECT was introduced in Singapore in 1947; (29) however, ECT practice has been little studied since then. Data on Singapore has been included in general Asian surveys on ECT practice, (18,30,31) and suggests that the usage of ECT for schizophrenia in Singapore decreased in 2000-2009 and that continuation ECT was performed by some centres in Singapore. Another survey published in 1992 examined the

Demographic and Clinical Profile of Patients Receiving Electroconvulsive Therapy at a Tertiary Care Hospital in Oman: A Cluster Analysis

“…In cluster one, > 51% of patients had a depressive disorder (25.7%) and BAD (25.7%), which is similar to a previous study that showed that depressed female patients were more referred to ECT. 21 The average number of ECT sessions delivered to patients in cluster two was 8.7±4.0, similar to previous studies in Asia. The average number of ECT sessions for patients with depressive disorder was 6–9 treatments.…”

“…A study in Singapore shows that patients’ quality of life with depression improves after receiving ECT. 21 In Oman, further research on ECT is recommended, especially regarding its effect on patients’ quality of life in each subgroup.…”

ECT on a world map - a narrative review of the use of electroconvulsive therapy and its frequency in the world

“…Interestingly, in the largest center half of the sessions are performed in the case of schizophrenia, while at other institutions mainly in resistant depression. Other disease entities include mania, schizoaffective disorder, catatonia, and malignant neuroleptic syndrome [45]. In Japan (J) and India (I), adult patients were treated with ECT for schizophrenia (J -48.9%, I -36.5%), followed by major depression (J -37.4%, I -33.5%), catatonia (J -6.8%, I -6.2%), mania (J -4.4%, I -17.9%) and dysthymia (J -0.8%, I -2.8%) [46,47].…”

Electroconvulsive Therapy in a Time of Coronavirus Disease

“…The Singapore Institute of Mental Health (IMH) is the only tertiary psychiatric hospital in Singapore with 1900 inpatient beds and about 40,000 outpatients and treats about 80% of the national load of psychiatric patients. In IMH, ECT is prescribed primarily for schizophrenia (47%) with schizoaffective disorder (20.3%), depression (20.4%) and mania (6.8%) being the other major indications 15 . In 2015 IMH moved from a one-size-fits-all approach (age based dosing with bitemporal electrode placement) to an individualized seizure threshold titration based approach 31,32 with a range of electrode placements (Bitemporal, Bifrontal, Right unilateral) and pulse parameters (Brief or Ultrabrief pulsewidth) using the CARE network system to collect ECT data 33 .…”

“…This tragic vignette underscores the importance of not just having an ECT service but having one that can respond in a timely fashion to patient needs. While 5 of the 7 ECT services 15 in Singapore were still operational at the time of this writing, the other 2 have shut down due to lack of anaesthesia manpower while others now require case by case approval for ECT by the operating theatres.…”