Changing use of ECT

S. Kemsley

Address supplied; correspondence c/o the British Journal of Psychiatry, 17 Belgrave Square, London SW1X 8PG, UK

I would like to point out a couple of facts about the decline in electroconvulsive therapy (ECT) use not mentioned by Eranti & McLoughlin (2003) in their recent editorial.

The use of ECT without consent has not declined at all since 1985. There were 3362 people given ECT without their consent under section 58 of the Mental Health Act 1983 in England and Wales in the 2-year period 1985–87, 4454 in 1987–89 and 4463 in 1999–2001, with little change in the years between (Mental Health Act Commission, 1988–2002).

It was the 1970s that saw the greatest decline in ECT use, from an estimated 60 000 courses in Great Britain in 1972 to 30 000 in 1979 (Pippard & Ellam, 1981).

The decline in ECT use over the past 20 years or so has been marked by regional variations. While in England ECT use fell fairly steadily during the 1980s, in Scotland it remained fairly constant during the 1980s and early 1990s and then fell by about a half in the mid-1990s (Freeman et al, 2000). In the East Anglian region ECT use actually increased during the 1980s (Pippard, 1992).

I think it is hard to reconcile these facts with the authors' suggestion that new drugs, improvements in patient care and better appreciation of the indications for ECT are responsible for the decline in ECT; although this would be the most respectable explanation for the decline in use of a treatment which is still described as safe, effective and life-saving — especially since the textbook indications for its use have changed little over the past two or three decades. Is it really the case that fewer people need ECT nowadays — or was it given needlessly to large numbers of people in the recent past? Since no research into the reasons for the decline in the use of ECT has been done, it remains impossible to answer this question with any certainty.

EDITED BY STANLEY ZAMMIT

Author: Col. 1: written permission for Sanofi-Synthelabo needed

REFERENCES

Eranti, S. V. & McLoughlin, D. M. (2003) Electroconvulsive therapy — state of the art. British Journal of Psychiatry, 182, 8–9.[Free Full Text]

Freeman, C. P. L., Hendry, J. & Fergusson, G. (2000) National Audit of Electroconvulsive Therapy in Scotland. Edinburgh: Scottish Office.

Mental Health Act Commission (1988–2002) Biennial Reports (2nd to 9th). London: Stationery Office.

Pippard, J. (1992) Audit of electroconvulsive treatment in two National Health Service regions. British Journal of Psychiatry, 160, 621–637.[Abstract]

Pippard, J. & Ellam, L. (1981) Electroconvulsive Treatment in Great Britain 1980. London: Gaskell.


 

Authors'reply

S. V. Eranti and D. M. McLoughlin

Institute of Psychiatry, Section of Old Age Psychiatry, Box PO70, De Crespigny Park, Denmark Hill, London SE5 8AF, UK

EDITED BY STANLEY ZAMMIT

Sue Kemsley has raised some important issues regarding ECT. The use of ECT without consent has not declined in absolute numbers since 1985 but, as discussed in our editorial (Eranti & McLoughlin, 2003), the total number of patients receiving ECT has substantially fallen during this period. Little research has been directed at understanding this change in the pattern of ECT use. One possibility is that there exists a core group of patients with severe depressive illness and possible psychosis that requires treatment with ECT, while the decline in use predominantly occurs in people with less severe illness. So why has the use of ECT declined in this latter group?

As we have already suggested, we believe that this is due to historical changes in general psychiatry, especially psychopharmacology. One has to bear in mind that, following its introduction in 1938, ECT was one of the first truly effective treatments for severe debilitating psychiatric disorders and thus its use rapidly became widespread (Fink, 2001). We are currently investigating trends in ECT practice over the past 50 years in the Maudsley and Bethlem Royal Hospitals in south London. Its use peaked in 1956 when 34% of admissions were treated with ECT. This rate fell steadily thereafter to 30% in 1959, 21% in 1968 and 5% in 1987. It is interesting to note here that imipramine was introduced in 1958, coinciding with the beginning of this decline in use of ECT. Similarly, ECT use further declined after the introduction of fluoxetine, the first of the selective serotonin reuptake inhibitors, in 1988, such that by 1991 2% of admissions received ECT. Currently, less than 1% of admissions are treated with ECT and nearly 90% of these have a diagnosis of major depressive disorder, which is well-established as being the main indication for contemporary ECT (Carney et al, 2003).

REFERENCES

Carney, S., Cowen, P., Geddes, J., et al (2003) Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet, 361, 799–808.[Medline]

Eranti, S. V. & McLoughlin, D. M. (2003) Electroconvulsive therapy — state of the art. British Journal of Psychiatry, 182, 8–9.[Free Full Text]

Fink, M. (2001) Convulsive therapy: a review of the first 55 years. Journal of Affective Disorders, 63, 1–15.[CrossRef][Medline]





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