The decline in use of ECT

Dr Dermot J Ward

“There is little risk in this country (UK) , except in the aftermath of some unforeseen tragedy, of legislation restricting the use of ECT being enacted as it had been in California.

“The evidence for its efficacy and safety is too strong and parliament has always been commendably reluctant to restrict the right of physicians to treat patients as they think best.”

So stated Edinburgh University Professor of Psychiatry RE (Bob) Kendall in 1978. He was an outstanding, widely regarded psychiatrist at that time (JRSM. 71, 319). But within a few short years Dr John R Hamilton (The Mental Health Act Commission, BMJ 292, 849) reported “The Mental Health Act 1983 (England and Wales) requires a consultant psychiatrist to seek a concurring consultant second opinion from a doctor appointed by the Mental Health Act Commission when he/she proposes to administer electroconvulsive therapy or medication beyond three months to a patient who is incapable of, or refuses consent”.

So much for the commendable reluctance of parliament to restrict the right of physicians to treat their patients as they think best. For the present let us leave medication aside. Perhaps, you may say, there had been “some unforeseen tragedy” which precipitated the profound change in legislation. You would be wrong. There was not.

A news item on ECT in May 7, 2014 Irish Medical Times (IMT) surrounding a Southern Ireland national survey of ECT headlined a finding of a decline in its usage . Remarkably, 30 years ago an IMT leader on ECT (24/9/1984) sounded a similar note on a then recent survey. ‘‘ In general  reassuring.......but there is a major caveat, we must not be complacent’’, and a bit further on....The fact that it has been received with such little public discussion suggests complacency’’. I am reminded of Mark Twain’s quip “Rumours of my death have been greatly exaggerated”. It appears there is a strong ill-informed group in society well represented within  the general media (not in IMT) who will only be satisfied by the total abolition of ECT. That group never considers the possibility that their goal would result in the prolongation of psychologically tortured inadequately treated severely mentally ill patients encountered in psychiatric practise. Rather than their promoting compassion for suffering they are unwittingly peddling cruelty by inhibiting ECT’s use. The plain fact is that the treatment only survives because the vast majority of clinical psychiatrists support its judicious use; and as justice delayed is justice denied, so sadly, ECT withheld for a needy patient is suffering prolonged. 

It is only an eccentric few, amongst the corpus of psychiatrists, that do not support the responsible use of ECT in carefully selected patients. Their mindset may have been supported by the 1975 Hollywood film  One Flew Over the Cuckoo’s Nest. The Jack Nicholson central character, as Randie McMurphy, and his portrayal of a fictitious patient in a US mental hospital. It was based on Ken Kesey’s novel of the same name. Kesey was a countercultural figure who considered himself to be a link between the Beat generation of the 1950s and the hippies of the 1960s. I recall a colleague suggesting the film had set back the cause of mental illness and its treatment by ten years. That may  have been an understatement. It was a hugely successful film because it was hugely entertaining.

Back in the real world in 1982 Dr R H Latey and Prof T J Fahy published ‘Electroconvulsive therapy in the Republic of Ireland, 1982, a Report to the Irish Division of the Royal College of Psychiatrists. It represented not only an admirable extension of a similar study conducted throughout the USA, but yet another example of our profession’s willingness to look at its performance in an open and constructive way. Let me mention a recent study “Scottish psychiatrist’s attitudes to electroconvulsive therapy:survey analysis.” (The Psychiatrist, 2013, 37, 261-266.) 91 psychiatrists participated. “ Almost all surveyed psychiatrists (97%) agreed that ECT has a place in current psychiatric practice”. Yet, there is need for analytical research beyond bean counting regarding the observed decline in ECT usage. Can it be reliably shown to be the result of more effective psychoactive drugs? Or can it be shown to be merely the result of forceful but ill-informed anti-ECT media pressure inhibiting its use and thereby increasing otherwise avoidable suffering? 

The absurd legal consequences if the ECT nay sayers had their way would be that all those doctors in psychological medicine are guilty of gratuitously inflicting a wholly unnecessary medical procedure, which like most effective medical and surgical interventions carries some risk, on recipient patients. If such were the case the police would rightly have been fingering their collars long ago. The case rests.

Epilogue. On June 13, 2014 Dr Arthur Dolan of Mohill,Co. Leitrim wrote (to the Editor, IMT)  with great and appropriate regard for the late Dr Henry Rollin, consultant psychiatrist, widely respected in these islands who died earlier this year aged 102. I knew Henry since 1962 in my first England  psychiatric job and never lost touch with him. I mention him here because one day some years back as we (not unusually!) chatted shop he declared firmly that he had inserted a clause in his will that should he become seriously depressed later in life that he would strongly support having ECT if such were recommended by his doctor.