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The treatment of mania
Journal of Affective Elsevier Biomedical
Duorders, Press
85
4 (1982) 85-92
The Treatment of Mania A Retrospective
Evaluation
of the Effects of ECT, Chlorpromazine, Lithium
J. Thomas
and
‘,* and B. Reddy2
’ Department of Psychological Medicine, St. Bartholomew’s Hospital, London, and 2 Darenth Park Hospttal, Dartford, Kent (Great Britain) (Received 2 June, 1980) (Revised, received 22 September, 1981) (Accepted 5 October, 1981)
Summary
The effects of ECT, chlorpromazine and lithium were evaluated retrospectively in 3 matched groups of manic patients. No statistically significant difference was found either in respect of duration of stay in hospital or length of time from discharge to readmission within 5 years, but patients in the ECT group tended to show longer remissions.
Introduction
Mania is now most often treated either by antipsychotic drugs such as chlorpromazine and haloperidol or lithium. Goodwin and Zis (1979) reviewed the relevant published studies comparing lithium to chlorpromazine and came to the conclusion that lithium was associated with marked improvement or remission in at least 70% of patients and in all but one study (Prien et al. 1972) lithium was reported to be superior to chlorpromazine in the treatment of acute mania as judged by the overall percentage of patients showing marked improvement or remission. However in those severe cases were psychomotor overactivity was seriously interfering with management, chlorpromazine was found to be superior to lithium at least in the initial stages.
* Reprint requests to: J. Thomas, BSc, MB BS, MRCPsych., DPM, Medicine, St. Bartholomew’s Hospital, London, EC I. Great Britain.
Ol65-0327/82/0000-0000/$02.75
% 1982 Elsevier Biomedical
Press
Department
of Psychological
86
Over 30 years ago intensive electroconvulsive therapy (multiple ECTs daily followed by gradually decreasing frequency of treatment) was claimed to be an effective and safe method of control of mania (Thorpe 1947). In a retrospective study of manic patients McCabe (1976) found that ECT when compared to an untreated matched control group markedly improved the outcome as measured by condition at discharge, duration of stay in hospital and social recovery. In McCabe’s study the treatment group consisted of patients admitted between 1945-1949 while the controls were an untreated group from an earlier period (193551941) and the difference shown could have been at least partly due to the differing clinical practices in the two periods surveyed. Langley et al. (1959) compared chlorpromazine and ECT in the treatment of acute manic and acute schizophrenic reactions in 106 women and concluded that the treatments were comparable in effect. Yet the relative efficacy of ECT in mania remains uncertain and the memorandum on the use of ECT published by the Royal College of Psychiatrists (1977) concluded that no satisfactory evaluation of ECT in the treatment of mania had been carried out. In order to obtain more information on the relative value of ECT in the treatment of mania we have compared retrospectively the effectiveness of ECT, chlorpromazine and lithium in terms of duration of stay in hospital and lengths of time from discharge to readmission in 3 groups of matched manic patients (10 each group) treated with a single method of treatment throughout the admission period.
Method The study was conducted at Runwell Hospital using the hospital’s diagnostic and treatment card index in which all admissions are recorded. All cards with a diagnosis of hypomania, mania, and manic depressive psychosis concerning admissions between 1950-1965 were extracted and the appropriate case-notes were examined. The following criteria were used for selection of the cases for the purpose of the study: (1) The diagnosis of mania had been made by the senior psychiatrist (pre-1948) or by the appropriate consultant psychiatrist (post-1948). (2) The case-notes at the time of admission included in the clinical description of the mental state at least 3 of the following 4 symptoms or signs: (a) elated mood; (b) flight of ideas; (c) increased psychomotor activity, and (d) irritability. (3) During the index admission apart from night sedation with hypnotics, only 1 type of physical treatment was administered, viz. ECT, chlorpromazine, or lithium salts. (4) During index admission no secondary diagnosis was offered, e.g. brain damage, drug- or alcohol-dependence. These criteria, particularly the strict adherence to a single line of treatment during the index admission, greatly reduced the number of patients available to the study. There were 723 admissions with a diagnosis of mania, out of which 424 cases had to be excluded for reasons stated in Table 1. Table 2 lists the main physical methods of
87
TABLE
I
TOTAL
NUMBER
Reasons
for non-inclusion
Treatments
against
Diagnosis
in doubt
(a) (b) (c) (d) (e) (f) (g) (h) (i)
medical
723
of 424 patients
not well established
Discharge
Presence
OF PATIENTS=
in the study
from available
advice/transfer
Number
information
of cases
270
to other hospitals
10 15
of seconder?; dicrgnosis
25 16 16 12 13 17 9 6
Senility/non-specific organic states CVS disorders: hypertension/CCF/arteriosclerosis Endocrine disorders: mainly disorder of thyroid function Respiratory disease including pulmonary tuberculosis Alcoholism/drug addiction/psychopathy Death in hospital including I suicide Epilepsy/leucotomy/mental subnormality Neoplasm Others including disseminated sclerosis/anaemia/puerperal fractures
psychosis - I5 4.?4
T0td
treatment used in the remaining 299 patients initially included in the study. The other important exclusion clause, i.e. the administration of only 1 type of physical treatment during the index admission reduced the number of patients available for inclusion in this study still further. In those patients receiving neuroleptics the majority of cases had treatment with chlorpromazine, butyrophenones and other drugs in various combinations. The other drugs commonly used in combination with chlorpromazine and necessitating exclusion were chlorprothixene (Taractan), thiopropazate (Dartlan), promazine (Sparine), thioridazine (Melleril),
TABLE
2
MAIN PHYSICAL METHODS CLUDED IN THE STUDY
OF
Treatment
TREATMENT
Number
Antipsychotic drugs/neuroleptics Electroconvulsive therapy Leptazol convulsive therapy Lithium salts Conservative treatment B *Insulin coma/continuous narcosis Totul
a Conservative treatment meant:sedation with occupational therapy and bedrest.
USED
of patients
99 83 42 30 30 - 15 799 with repeated
IN
299 PATIENTS
INITIALLY
IN-
Percentage 33 28 14 IO IO - 5 100
use of paraldehyde
or barbiturates
combined
88
TABLE
3
COMPARISON
OF THE 3 TREATMENT
GROUPS Lithium
Year of admission Median Range
1957 1955-l
Age at admission Mean Range Number of previous Median Range
962
53.5 yr 20-77 yr
Chlorpromazine
ECT
1960 I 95%
I952 19433
I 962
52.6 yr 27-76 yr
I 95x
48.2 yr 26-70 yr
admissions
Sex Male Female Marital status Married Single Divorced Widow
2.5 O-18”
1 o-5
1.5 O-5
4 6
4 6
4 6
7 2 _
6 3 1
6 3
Social class (Registrar General) 2 4
Type of admission Informal Compulsory Mode of discharge Care husband/wife/children Care parents/siblings Convalescent nursing home Hostel/bed & breakfast accommodation
4 6
4 6
7
’ One patient had I8 admissions. If one excludes that patient, the range for previous lithium group was O-5, i.e. similar to the ECT and chlorpromazine groups.
admissions
for the
pericyazine (Neulactil) reserpine and barbiturates. Similarly the majority of cases treated with ECT received other treatments as well. These included phenothiazine compounds, lithium, leptazol convulsions, insulin coma and prolonged narcosis. In the lithium-treated group additional treatments included a number of antipsychotic drugs as well as ECT in the same instances. The patients in each group were matched for sex and, as nearly as possible, for age at admission and actual year of admission (see Table 3).
89
The duration of stay in hospital for each patient and the length of time from discharge to readmission (up to 5 years) were calculated in days. The scores for each treatment group were ranked separately and, as the sample size was small, a non-parametric statistical technique, the Friedman 2-way analysis of variance (Siegel 1956) was used for analysis.
Results In most cases ECT was given biweekly, the mean number being 6, (range 3-11). The mean dose of chlorpromazine used was 300 mg/day in divided doses (range 150-600 mg/day). All patients in the lithium group received 3 g or more of lithium citrate per day (equivalent to 1 g of lithium carbonate). As far as the mean length of stay in hospital was concerned there was a trend for chlorpromazine to give the best result (52 days) followed by ECT (60 days) and lithium (67 days) respectively. The differences between the 3 treatment groups were, however, not statistically significant (see Table 4). As far as the length of time from discharge to readmission (i.e. duration of remission) was concerned, ECT tended to give the best results followed by chlorpromazine and lithium, but again the differences between treatments were not significant. Fewer patients treated with ECT were readmitted (See Tables 5A and B). Five out of 10 (50%) patients discharged after treatment with either lithium or chlorpromazine were readmitted within 1 year, while only 1 patient treated with ECT was readmitted within this time. By the end of 5 years, 8 out of 10 (80%) patients from both the lithium and chlorpromazine treated groups had been readmitted while only 5 out of the 10 (50%) ECT-treated patients had been readmitted.
TABLE
4
DURATION Triad I
2 3 4 5 6 7 8 9 IO
OF STAY IN HOSPITAL Lithium
Chlorpromazine
ECT
188 51 53 40 72 12 21 42 36 93
28 28 38 46 12 61 41 19 212 29
39 92 28 12 116 71 137 23 59 25
Mem (rn &vs 66.8 (in duys) 21-188 X’ 2 = I .8, d/= 2. 0.3 -c P GO.5 Range
(in days)
5-7 12-212
90 TABLE
5A
LENGTH
OF TIME
FROM
Triad 1
2 3 4 5 6 7 8 9 IO
DISCHARGE
TIME
(in days within 5 years)
Lithium
Chlorpromazine
ECT
28 15 115 68 350 721 > I 825 478 560 > 1825
53 I035 > I 825 297 20 > I 825 192 346 399 I192
2 I825 > I825 219 > I X25 775 910 1107 > 1X25 > I X25 723
(it7du_vs) Medim Runge (ipl &vs) xr’=3.8, df=2, O.i
TABLE
TO READMISSION
I 4hh -‘I Y-I 82.5
3 73 20-I x2.5
414 IS-I 82.5
5B BETWEEN
DISCHARGE
Factor
Readmission within I year Readmission within l-5 years No readmission within 5 years
AND
READMISSION
(in years)
Lithium patients (n= IO)
Chlorpromazine (n= IO)
5
5
I
3
3
4
2
2
5
patients
ECT patients (n= IO)
Discussion and conclusion The outcome measures we used in comparing the 3 treatment groups have obvious drawbacks. Duration of stay in hospital has been shown to be influenced by administrative circumstances that matched likely
to have
as well as therapeutic practice (Copas et al. 1974) and by the social of the patients undergoing treatment. On the other hand, to the extent patients were treated contemporaneously, administrative practice is been
constant.
Case
notes
do not
symptom remission so that the date of discharge an acceptable degree of improvement.
always
give the exact
was the best available
date
of
indicator
of
The other outcome measure, the length of time from discharge to readmission, can also be criticised as patients might have moved from the area and been admitted to other hospitals. The case-notes were scrutinised thoroughly for requests from
91
other hospitals for clinical information, but none were found. Of the 9 patients in our study who were not readmitted within 5 years (2 each in the chlorpromazine and the lithium groups and 5 in the ECT group), the majority did have a readmission some time later. One patient in the ECT group had no further admission recorded while of the remaining 4, 1 was readmitted after 7 years, another after 10 years, another after 13 years and the last after 17 years. Neither patient in the lithium group had a further admission whereas 1 of the 2 chlorpromazine patients not readmitted within 5 years was readmitted after 7 years and the other had no further admission recorded. The information available regarding medication with either lithium or chlorpromazine after discharge was sparse. Premature discontinuance of medication could be one of the factors which affected the readmission rates of the chlorpromazineand lithium-treated groups and is obviously a disadvantage inherent in this method of treatment. No patient was treated with maintenance ECT. Another difficulty with this type of study is that it is not always possible from the case-notes to assess the severity of the manic attack. It could be argued that the severity of the attack might have decided the mode of treatment especially the choice between chlorpromazine and lithium and that the most severely disturbed patients may have been treated with more than one drug and hence excluded from this study. However, if compulsory admission is taken as an indicator of the severity of the illness, then one may argue that the 3 groups were well-matched for the severity of the illness as well (see Table 3, type of admissions). As stated earlier the duration of stay in hospital is however influenced by administrative as well as therapeuticgractices and any such influences would have tended to shorten the stay in the later years of the study as compared with the earlier years. The national figures (Registrar General 1969) for the period in which most of our lithium- and chlorpromazine-treated patients were admitted, show a progressive reduction in the duration of stay in hospital for newly admitted patients. The year of admission of lithium- and chlorpromazine-treated groups is very closely comparable in all cases (see Table 1). The ECT patients however, in contrast to McCabe’s study (1976) were admitted in an earlier era and one might therefore expect these patients to have had a longer duration of stay in hospital. In fact this study shows that their duration of stay in hospital is comparable to the later treated patients in the phenothiazine and lithium group and this may indicate an even greater beneficial effect of ECT in shortening the duration of hospital stay in manic patients. The observed trend towards longer remission after treatment with ECT also seems to highlight the usefulness of ECT in mania. ECT does also have certain clear advantages as a method of treatment: (1) Neurotoxic effects are minimal in comparison with the drugs. (2) Treatment can be seen to be administered and terminated in hospital whereas it is often difficult to determine the end-point of treatment with drugs. As the number of patients in each group of this study was small, the conclusions must be treated with caution. To validate this study with a larger number of patients retrospectively studied may be extremely difficult as a multi-hospital investigation would be necessary using hospitals with both a treatment-diagnostic index and a
92
unit record system at the relevant time, which most British psychiatric hospitals seem not to have had. Another difficulty may be that most of the drug-treated manic patients would have had a combination of neuroleptic and lithium during the admission. In conclusion we consider that our results indicate that ECT may still have a place in the treatment of mania; although the definitive assessment of its relative value as compared to other available treatment must await a more comprehensive prospective clinical trial.
Acknowledgements
We are greatly indebted to Dr. Ashley Robin for his invaluable guidance and help in conducting this study. Our thanks also to Mr. Berk, medical Records Officer, and his colleagues at Runwell Hospital for their help in tracing the vast number of case-notes we screened for this study and to Dr. Trevor Silverstone and Mr. Chris Jennings for their helpful comments on our text.
References Copas, J.B., Fryer, M. and Robin, A., In: A. Robin (Ed.), Treatment Settings in Psychiatry - A Comparative Study, Henry Kimpton Pub]., London, 1974, pp. 81 and 94. Goodwin, F.K. and Zis, A.P., Lithium in the treatment of mania - Comparisons with neuroleptica. Arch. f Gen. Psychiat., 36 (1979) 840-844. Langley, D.G., Enterline, J.D. and Hickerson, Jr., G.X., A comparison of chlorpromazine and EST in treatment of acute schizophrenic and manic reactions, Arch. Neural. Psychiat., 81 (1959) 384-391. McCabe, M.S., ECT in the treatment of mania - A controlled study, Amer. J. Psychiat.. 133 (1976) 688-690. Prien, R.F.. Caffey, Jr., E.M. and Klett, C.J., Comparison of lithium carbonate and chlorpromazine in the treatment of mania, Arch. Gen. Psychiat., 26 (1972) 146- 153. Royal College of Psychiatrists’ Memorandum on the Use of Electra-Convulsive Therapy. Brit. J. Psychiat., 13 I (I 977) 26 I-272. Siegel, S.. Non Parametric Statistics for Behavioural Sciences, McGraw-Hill, London, 1956. The Registrar Generals Statistical Review of England and Wales for the Year 1960 - Supplement on Mental Health, Her Majesty‘s Stationary Office, 1964. Thorpe. F.T., Intensive electrical convulsive therapy in acute mania, J. Ment. Science, 93 (1947) 89-92.
Duorders, Press
85
4 (1982) 85-92
The Treatment of Mania A Retrospective
Evaluation
of the Effects of ECT, Chlorpromazine, Lithium
J. Thomas
and
‘,* and B. Reddy2
’ Department of Psychological Medicine, St. Bartholomew’s Hospital, London, and 2 Darenth Park Hospttal, Dartford, Kent (Great Britain) (Received 2 June, 1980) (Revised, received 22 September, 1981) (Accepted 5 October, 1981)
Summary
The effects of ECT, chlorpromazine and lithium were evaluated retrospectively in 3 matched groups of manic patients. No statistically significant difference was found either in respect of duration of stay in hospital or length of time from discharge to readmission within 5 years, but patients in the ECT group tended to show longer remissions.
Introduction
Mania is now most often treated either by antipsychotic drugs such as chlorpromazine and haloperidol or lithium. Goodwin and Zis (1979) reviewed the relevant published studies comparing lithium to chlorpromazine and came to the conclusion that lithium was associated with marked improvement or remission in at least 70% of patients and in all but one study (Prien et al. 1972) lithium was reported to be superior to chlorpromazine in the treatment of acute mania as judged by the overall percentage of patients showing marked improvement or remission. However in those severe cases were psychomotor overactivity was seriously interfering with management, chlorpromazine was found to be superior to lithium at least in the initial stages.
* Reprint requests to: J. Thomas, BSc, MB BS, MRCPsych., DPM, Medicine, St. Bartholomew’s Hospital, London, EC I. Great Britain.
Ol65-0327/82/0000-0000/$02.75
% 1982 Elsevier Biomedical
Press
Department
of Psychological
86
Over 30 years ago intensive electroconvulsive therapy (multiple ECTs daily followed by gradually decreasing frequency of treatment) was claimed to be an effective and safe method of control of mania (Thorpe 1947). In a retrospective study of manic patients McCabe (1976) found that ECT when compared to an untreated matched control group markedly improved the outcome as measured by condition at discharge, duration of stay in hospital and social recovery. In McCabe’s study the treatment group consisted of patients admitted between 1945-1949 while the controls were an untreated group from an earlier period (193551941) and the difference shown could have been at least partly due to the differing clinical practices in the two periods surveyed. Langley et al. (1959) compared chlorpromazine and ECT in the treatment of acute manic and acute schizophrenic reactions in 106 women and concluded that the treatments were comparable in effect. Yet the relative efficacy of ECT in mania remains uncertain and the memorandum on the use of ECT published by the Royal College of Psychiatrists (1977) concluded that no satisfactory evaluation of ECT in the treatment of mania had been carried out. In order to obtain more information on the relative value of ECT in the treatment of mania we have compared retrospectively the effectiveness of ECT, chlorpromazine and lithium in terms of duration of stay in hospital and lengths of time from discharge to readmission in 3 groups of matched manic patients (10 each group) treated with a single method of treatment throughout the admission period.
Method The study was conducted at Runwell Hospital using the hospital’s diagnostic and treatment card index in which all admissions are recorded. All cards with a diagnosis of hypomania, mania, and manic depressive psychosis concerning admissions between 1950-1965 were extracted and the appropriate case-notes were examined. The following criteria were used for selection of the cases for the purpose of the study: (1) The diagnosis of mania had been made by the senior psychiatrist (pre-1948) or by the appropriate consultant psychiatrist (post-1948). (2) The case-notes at the time of admission included in the clinical description of the mental state at least 3 of the following 4 symptoms or signs: (a) elated mood; (b) flight of ideas; (c) increased psychomotor activity, and (d) irritability. (3) During the index admission apart from night sedation with hypnotics, only 1 type of physical treatment was administered, viz. ECT, chlorpromazine, or lithium salts. (4) During index admission no secondary diagnosis was offered, e.g. brain damage, drug- or alcohol-dependence. These criteria, particularly the strict adherence to a single line of treatment during the index admission, greatly reduced the number of patients available to the study. There were 723 admissions with a diagnosis of mania, out of which 424 cases had to be excluded for reasons stated in Table 1. Table 2 lists the main physical methods of
87
TABLE
I
TOTAL
NUMBER
Reasons
for non-inclusion
Treatments
against
Diagnosis
in doubt
(a) (b) (c) (d) (e) (f) (g) (h) (i)
medical
723
of 424 patients
not well established
Discharge
Presence
OF PATIENTS=
in the study
from available
advice/transfer
Number
information
of cases
270
to other hospitals
10 15
of seconder?; dicrgnosis
25 16 16 12 13 17 9 6
Senility/non-specific organic states CVS disorders: hypertension/CCF/arteriosclerosis Endocrine disorders: mainly disorder of thyroid function Respiratory disease including pulmonary tuberculosis Alcoholism/drug addiction/psychopathy Death in hospital including I suicide Epilepsy/leucotomy/mental subnormality Neoplasm Others including disseminated sclerosis/anaemia/puerperal fractures
psychosis - I5 4.?4
T0td
treatment used in the remaining 299 patients initially included in the study. The other important exclusion clause, i.e. the administration of only 1 type of physical treatment during the index admission reduced the number of patients available for inclusion in this study still further. In those patients receiving neuroleptics the majority of cases had treatment with chlorpromazine, butyrophenones and other drugs in various combinations. The other drugs commonly used in combination with chlorpromazine and necessitating exclusion were chlorprothixene (Taractan), thiopropazate (Dartlan), promazine (Sparine), thioridazine (Melleril),
TABLE
2
MAIN PHYSICAL METHODS CLUDED IN THE STUDY
OF
Treatment
TREATMENT
Number
Antipsychotic drugs/neuroleptics Electroconvulsive therapy Leptazol convulsive therapy Lithium salts Conservative treatment B *Insulin coma/continuous narcosis Totul
a Conservative treatment meant:sedation with occupational therapy and bedrest.
USED
of patients
99 83 42 30 30 - 15 799 with repeated
IN
299 PATIENTS
INITIALLY
IN-
Percentage 33 28 14 IO IO - 5 100
use of paraldehyde
or barbiturates
combined
88
TABLE
3
COMPARISON
OF THE 3 TREATMENT
GROUPS Lithium
Year of admission Median Range
1957 1955-l
Age at admission Mean Range Number of previous Median Range
962
53.5 yr 20-77 yr
Chlorpromazine
ECT
1960 I 95%
I952 19433
I 962
52.6 yr 27-76 yr
I 95x
48.2 yr 26-70 yr
admissions
Sex Male Female Marital status Married Single Divorced Widow
2.5 O-18”
1 o-5
1.5 O-5
4 6
4 6
4 6
7 2 _
6 3 1
6 3
Social class (Registrar General) 2 4
Type of admission Informal Compulsory Mode of discharge Care husband/wife/children Care parents/siblings Convalescent nursing home Hostel/bed & breakfast accommodation
4 6
4 6
7
’ One patient had I8 admissions. If one excludes that patient, the range for previous lithium group was O-5, i.e. similar to the ECT and chlorpromazine groups.
admissions
for the
pericyazine (Neulactil) reserpine and barbiturates. Similarly the majority of cases treated with ECT received other treatments as well. These included phenothiazine compounds, lithium, leptazol convulsions, insulin coma and prolonged narcosis. In the lithium-treated group additional treatments included a number of antipsychotic drugs as well as ECT in the same instances. The patients in each group were matched for sex and, as nearly as possible, for age at admission and actual year of admission (see Table 3).
89
The duration of stay in hospital for each patient and the length of time from discharge to readmission (up to 5 years) were calculated in days. The scores for each treatment group were ranked separately and, as the sample size was small, a non-parametric statistical technique, the Friedman 2-way analysis of variance (Siegel 1956) was used for analysis.
Results In most cases ECT was given biweekly, the mean number being 6, (range 3-11). The mean dose of chlorpromazine used was 300 mg/day in divided doses (range 150-600 mg/day). All patients in the lithium group received 3 g or more of lithium citrate per day (equivalent to 1 g of lithium carbonate). As far as the mean length of stay in hospital was concerned there was a trend for chlorpromazine to give the best result (52 days) followed by ECT (60 days) and lithium (67 days) respectively. The differences between the 3 treatment groups were, however, not statistically significant (see Table 4). As far as the length of time from discharge to readmission (i.e. duration of remission) was concerned, ECT tended to give the best results followed by chlorpromazine and lithium, but again the differences between treatments were not significant. Fewer patients treated with ECT were readmitted (See Tables 5A and B). Five out of 10 (50%) patients discharged after treatment with either lithium or chlorpromazine were readmitted within 1 year, while only 1 patient treated with ECT was readmitted within this time. By the end of 5 years, 8 out of 10 (80%) patients from both the lithium and chlorpromazine treated groups had been readmitted while only 5 out of the 10 (50%) ECT-treated patients had been readmitted.
TABLE
4
DURATION Triad I
2 3 4 5 6 7 8 9 IO
OF STAY IN HOSPITAL Lithium
Chlorpromazine
ECT
188 51 53 40 72 12 21 42 36 93
28 28 38 46 12 61 41 19 212 29
39 92 28 12 116 71 137 23 59 25
Mem (rn &vs 66.8 (in duys) 21-188 X’ 2 = I .8, d/= 2. 0.3 -c P GO.5 Range
(in days)
5-7 12-212
90 TABLE
5A
LENGTH
OF TIME
FROM
Triad 1
2 3 4 5 6 7 8 9 IO
DISCHARGE
TIME
(in days within 5 years)
Lithium
Chlorpromazine
ECT
28 15 115 68 350 721 > I 825 478 560 > 1825
53 I035 > I 825 297 20 > I 825 192 346 399 I192
2 I825 > I825 219 > I X25 775 910 1107 > 1X25 > I X25 723
(it7du_vs) Medim Runge (ipl &vs) xr’=3.8, df=2, O.i
TABLE
TO READMISSION
I 4hh -‘I Y-I 82.5
3 73 20-I x2.5
414 IS-I 82.5
5B BETWEEN
DISCHARGE
Factor
Readmission within I year Readmission within l-5 years No readmission within 5 years
AND
READMISSION
(in years)
Lithium patients (n= IO)
Chlorpromazine (n= IO)
5
5
I
3
3
4
2
2
5
patients
ECT patients (n= IO)
Discussion and conclusion The outcome measures we used in comparing the 3 treatment groups have obvious drawbacks. Duration of stay in hospital has been shown to be influenced by administrative circumstances that matched likely
to have
as well as therapeutic practice (Copas et al. 1974) and by the social of the patients undergoing treatment. On the other hand, to the extent patients were treated contemporaneously, administrative practice is been
constant.
Case
notes
do not
symptom remission so that the date of discharge an acceptable degree of improvement.
always
give the exact
was the best available
date
of
indicator
of
The other outcome measure, the length of time from discharge to readmission, can also be criticised as patients might have moved from the area and been admitted to other hospitals. The case-notes were scrutinised thoroughly for requests from
91
other hospitals for clinical information, but none were found. Of the 9 patients in our study who were not readmitted within 5 years (2 each in the chlorpromazine and the lithium groups and 5 in the ECT group), the majority did have a readmission some time later. One patient in the ECT group had no further admission recorded while of the remaining 4, 1 was readmitted after 7 years, another after 10 years, another after 13 years and the last after 17 years. Neither patient in the lithium group had a further admission whereas 1 of the 2 chlorpromazine patients not readmitted within 5 years was readmitted after 7 years and the other had no further admission recorded. The information available regarding medication with either lithium or chlorpromazine after discharge was sparse. Premature discontinuance of medication could be one of the factors which affected the readmission rates of the chlorpromazineand lithium-treated groups and is obviously a disadvantage inherent in this method of treatment. No patient was treated with maintenance ECT. Another difficulty with this type of study is that it is not always possible from the case-notes to assess the severity of the manic attack. It could be argued that the severity of the attack might have decided the mode of treatment especially the choice between chlorpromazine and lithium and that the most severely disturbed patients may have been treated with more than one drug and hence excluded from this study. However, if compulsory admission is taken as an indicator of the severity of the illness, then one may argue that the 3 groups were well-matched for the severity of the illness as well (see Table 3, type of admissions). As stated earlier the duration of stay in hospital is however influenced by administrative as well as therapeuticgractices and any such influences would have tended to shorten the stay in the later years of the study as compared with the earlier years. The national figures (Registrar General 1969) for the period in which most of our lithium- and chlorpromazine-treated patients were admitted, show a progressive reduction in the duration of stay in hospital for newly admitted patients. The year of admission of lithium- and chlorpromazine-treated groups is very closely comparable in all cases (see Table 1). The ECT patients however, in contrast to McCabe’s study (1976) were admitted in an earlier era and one might therefore expect these patients to have had a longer duration of stay in hospital. In fact this study shows that their duration of stay in hospital is comparable to the later treated patients in the phenothiazine and lithium group and this may indicate an even greater beneficial effect of ECT in shortening the duration of hospital stay in manic patients. The observed trend towards longer remission after treatment with ECT also seems to highlight the usefulness of ECT in mania. ECT does also have certain clear advantages as a method of treatment: (1) Neurotoxic effects are minimal in comparison with the drugs. (2) Treatment can be seen to be administered and terminated in hospital whereas it is often difficult to determine the end-point of treatment with drugs. As the number of patients in each group of this study was small, the conclusions must be treated with caution. To validate this study with a larger number of patients retrospectively studied may be extremely difficult as a multi-hospital investigation would be necessary using hospitals with both a treatment-diagnostic index and a
92
unit record system at the relevant time, which most British psychiatric hospitals seem not to have had. Another difficulty may be that most of the drug-treated manic patients would have had a combination of neuroleptic and lithium during the admission. In conclusion we consider that our results indicate that ECT may still have a place in the treatment of mania; although the definitive assessment of its relative value as compared to other available treatment must await a more comprehensive prospective clinical trial.
Acknowledgements
We are greatly indebted to Dr. Ashley Robin for his invaluable guidance and help in conducting this study. Our thanks also to Mr. Berk, medical Records Officer, and his colleagues at Runwell Hospital for their help in tracing the vast number of case-notes we screened for this study and to Dr. Trevor Silverstone and Mr. Chris Jennings for their helpful comments on our text.
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