News of the World on ECT

News of the World (although there's rarely much world news, so it's clearly an ironic title) recently published a feature on the Coronation Street actress Bev Callard's experience of a severe depressive episode during which she received ECT. It was titled: "Frankenstein op saved me from suicide".

It's relatively rare for someone in the public spotlight to talk about their experiences of mental illness; less frequent for them to touch on treatments such as ECT. So, this is to be commended. It's a shame that the paper didn't really take much of an opportunity to provide the information that the average reader might have found helpful. Such as:

1. ECT is not always a "last-resort". Indeed, in this case, it seems as though it was suggested relatively early in a course of treatment.
2. For many people, ECT is offerred for a variety of reasons which include: a) a quick response is needed. This is the case when someone is at high risk of suicide, or they are not eating/ drinking; b) ECT has worked in the past and the person wishes to have it again because they know it works. For some people, ECT can be more effective than drugs, and in most cases will work more quickly. The most common reasons for giving ECT in Scotland are 'Previous Good response' and 'Resistance [to antidepressants]' (Scottish ECT Accreditation Network (SEAN) Annual Report, 2009).
3. Effects on memory are not uncommon, with approximately two-thirds of people experiencing some effect on autobiographical memory for the period in which they're receiving ECT. The vast majority of studies have found that memory returns to normal 2-3 months after a course of ECT, but memories from the period of treatment may always be hazy. However, the majority of people in hospital for severe depression do not report unbroken and clear autobiographical memory anyway.
4. Twelve treatments is the typical maximum number of treatments in a course, although some people might choose to stop after fewer, and other people (those with delayed response and chronic depression) might have more. Like most things, it's a discussion about risk versus benefit. Someone who has had 10 treatments with no benefit and memory problems might choose to stop. Another with partial improvement and few memory problems might choose to continue. In Scotland, the mean number of treatments per course is 7.6 (Scottish ECT Accreditation Network Annual Report, 2009).

The article does reflect some realities about ECT:

1. Most people will experience some sense of improvement after 3-4 treatments.
2. ECT can be very effective. Indeed, it is probably one of the most effective treatments in modern psychiatry. The SEAN Report 2009 indicates that 50% of people experienced a 75-100% improvement in depressive symptoms from baseline to end of treatment. A further 26% experienced a 50-74% improvement. In psychiatry, a 50% improvement in symptoms is usually classified as 'response' (not remission), so in Scotland approximately 75% of people respond to ECT.

Suicides at the FoxConn plant at Longhua in China

There has been much written about the recent suicides at the FoxConn manufacturing plant in Longhua in China. FoxConn is one of the largest electronics companies in the world, making everything from iPods, iPads, iPhones, the Nintendo Wii, Microsoft Xbox 360s, and the Playstation 3.

Conditions on the complex sound far from ideal (see this article from the Shenzen Post).

Apparently, the Longhua site houses 300,000 - 400,000 people and there have been 16 suicide attempts (12 deaths), and 20 people have been stopped before they could attempt suicide. If we round up the timescale to six months, that means there will be 20-30 deaths in one year due to suicide at the plant.

The company have, in the last few weeks, increased wages and attempted to improve conditions on the site. However, what would be the expected number of suicides in such a population?

It's difficult to know what the suicide rate for a similar population in China is, so we will have to extrapolate from UK figures.

1. The age-standardised suicide rate (male and female) is approximately 15 per 100,000 people per year. More details can be found on the ONS website.
2. This means that 15 people will die by suicide for every 100,000 people each year.
3. In a population of 300,000, there will be 15x3=45 suicides.
4. In a six-month period, you would expect there to be 20-25 suicides in 300,000 people.

This means that even though any suicides are troubling and tragic, the number seen at the Longhua plant is slightly less than what one would expect to see by chance alone. Given that the Longhua employees are younger, the expected rate would be even higher than the population rate.

This fact has been explained by Steve Jobs in the last week. If the concern generated improves conditions for workers producing expensive technology then this can only be a good thing, but chance alone would have produced the same rate.

BBC website reports that, "'Green' exercise quickly 'boosts mental health'"

The BBC (and other sites) are reporting a study that apparently claims that "'Green' exercise quickly 'boosts mental health'". The study has been picked up by the US National post, and the UK Daily Mail.

The authors were Jo Barton and Jules Pretty (personal page at University of Essex here) and the study was published in the Environmental Science and Technology journal.

There are some bold claims, such as:

1. "The biggest effect was seen within just five minutes."
2. "A bigger effect was seen with exercise in an area that also contained water - such as a lake or river."

The paper can be found here (Abstract only | subscription required for full paper).

The authors state: "The research used meta-analysis methodology to analyze 10 UK studies involving 1252 participants." It doesn't say that it was a meta-analysis, only that it used the methodology (sic) of meta-analysis. Of course, you can only really meta-analyse studies with a degree of homogeneity and the conclusions one can draw from such reviews depend greatly on the quality of the underlying studies. Poorly-controlled and heterogenous studies with wild estimates of effect sizes don't lend themselves to robust systematic review.

Another alarm bell starts ringing when one reads, "Outcomes were identified through a priori subgroup analyses". Okay, the sub-groups were determined a priori, but subgroup analysis is often used as a way of mining the data for some significant finding. The BMJ has a recent article on the credibility of subgroup analyses.


It's surprising that the study also reported, "Dose responses for both intensity and duration showed large benefits from short engagements in green exercise, and then diminishing but still positive returns." This is counter-intuitive. If exercise is so good, why does it get less effective the more you do of it? I doubt the included studies were looking at elite athletes who may have been overtraining - the authors are reporting that more exercise is less beneficial for most of the reported outcomes (e.g. self-esteem).

It's clear that Jules Pretty is favourably disposed to exercise in green environments (who wouldn't be?), but previous 'reviews' would indicate that reported benefits in different studies are taken at face value, and not critically appraised in the way that they should be. For example, many studies in exercise for depression look at those with mild depressive illness which is, for many people, a self-limiting condition. The fact that someone feels better after a six-week course of exercise may have little to do with the exercise per se, and more to do with the natural course of the illness.

The 2009 Cochrane Review of Exercise for Depression concluded: "Exercise seems to improve depressive symptoms in people with a diagnosis of depression, but when only methodologically robust trials are included, the effect sizes are only moderate and not statistically significant." Essentially, when you exclude poorly-conducted trials, the effects of exercise are not statistically different from those that you would see with chance alone.