Overview

Bethlehem Psychiatric Hospital (BPH), in the city of Bethlehem in the south of the territory, provides the country’s only mental health in-patient service. It also provides the only ECT service, to both in-patients at BPH and out-patients. Obstacles to travel, including poor road infrastructure and checkpoint restrictions, especially from northern districts of the territory, mean that out-patients often miss planned treatments. ECT clinics run on Sundays and Wednesdays, with 8 to 16 patients typically treated per list and 1050 treatments delivered to around 250 individual patients annually. Psychiatric indications and sex data are shown in Table 1.

Table 1 Diagnostic indications for electroconvulsive therapy in the West Bank, Palestine, January to December 2023, stratified by sex

Challenges

The absence of mental health legislation means that consent is taken from relatives in all cases; establishment of decision-making capacity does not feature in Palestinian medical practice. For out-patients, consent is given by families specifically for ECT; for in-patients, however, relatives are asked to consent to admission and any treatment that might be subsequently prescribed; ECT is not always specified when consent is taken.

There is a concern among Palestinian doctors regarding litigation in the event of a medical intervention resulting in an untoward event that outweighs worry about criticism of withholding treatment. This leads to even minor medical cautions, such as mild systemic disease, resulting in denial of treatment.

Unmodified ECT (induction of seizures without muscle relaxation or anaesthesia) was occasionally used if a patient declined anaesthesia or the anaesthetist considered there to be specific cautions to its use. Just as many patients opt against sedation for short procedures like endoscopy, anaesthesia for ECT was often declined for broadly similar reasons: a wish for the procedure to be swift, or an aversion to cannulation or the sensation of being induced. Additionally, mild systemic disease, such as hypertension, could lead the anaesthetist to withhold anaesthesia, in the knowledge that the patient would receive treatment anyway.

There was no formal training for senior psychiatrists or the resident doctors who delivered the treatment. Consequently, there was a lack of updated specialist knowledge of ECT among those responsible for it. The same applied to nursing auxiliaries, reflected in their approach to manually holding patients during treatment.

There was no evidence-based approach to ECT delivery. All treatments were given bilaterally and there was no system for dosing, risking unnecessary exposure to cognitive side-effects. ^{Reference Gill, Hussain, Purushothaman, Sarma, Weiss and Chamoli10} For out-patients, a set number of sessions, typically four or six, was requested in advance by referrers. This is in contrast to evidence-based guidance ^{Reference Kellner11} and represents significant undertreatment in many cases. Limited communication with out-patient referrers precluded discussions around stopping anticonvulsant medication.

Dated ECT machines with non-functioning electroencephalogram (EEG) functions meant that seizures could not be analysed for quality and safety. Conversely, cardiorespiratory monitoring equipment was in working order but not routinely used. Limited anaesthetic cover was vulnerable to absences. The anticonvulsant agent propofol was the only choice of anaesthetic, leading to difficulties in achieving adequate therapeutic seizures in some patients. ^{Reference Bryson, Aloysi, Farber and Kellner5}

Equipment and training

Practical training with RB in Bethlehem in May 2022 was primarily directed at residents. It covered use of the newly procured ECT machines, focusing on EEG monitoring and interpretation. Efforts were made to develop knowledge and skills of anaesthetic and nursing staff during this visit, encouraging the use of monitoring equipment and pre-ventilation, while refraining from administering physical restraint unless ECT was unmodified. Use of unmodified ECT was itself discouraged. This training continued over further ECT sessions during a second mission in July 2022. Subsequently, monthly online supervision sessions were set up between RB and residents. There was an undertaking by MoH to maintain the new equipment.

Protocol revision

Meetings were held, before, during and after both RCPsych missions to Bethlehem, to find a consensus on developing Bethlehem’s written ECT policy and to guide practice in line with international standards. Throughout this process, the importance of local clinicians and stakeholders finalising their own protocol, with guidance from RCPsych experts, was held paramount. To this end, consultations involved local psychiatry residents and specialists, as well as the hospital’s medical director, ECT anaesthetist, lead nurse for ECT and chair of the Mental Health Unit at MoH. The protocol has been adopted as an official MoH policy document.

Regarding minimum staffing, it was agreed that an anaesthetist and a psychiatry resident with adequate competencies must be present at every treatment. There was consensus that unmodified ECT should stop, recognising that (a) resource limitations in the West Bank are not so profound that they necessitate the practice; (b) patients were not likely to be making truly informed choices when they opted for it; and (c) the process by which clinicians were selecting this form of treatment was rarely evidence based.

The revised protocol introduced a more advanced, evidence-based administration of treatment, with stimulus dosing ^{Reference Dunne, O’Neill-Kerr, McLoughlin, Waite, Ferrier and Waite12} and EEG monitoring. ^{Reference Semple, Devlin, Ferrier and Waite13} It incorporated improved anaesthetic procedures, mandating the use of cardiorespiratory monitoring equipment for all patients throughout the peri-ECT period, and pre-oxygenation to allow for adequate seizure monitoring. ^{Reference Kellner11}

Lastly, an improved system for liaison with community referrers was written into the policy. This mandated more extensive, structured clinical information to be submitted with the referral and frequent reviews during the treatment course, to ensure clinically appropriate duration of treatment.