ECT practitioners and users welcome review

Advocates and detractors of the controversial treatment unite in hope that the Nice appraisal will raise the bar in standards of practice, but areas of contention still loom

David Batty
Guardian (UK)
Wednesday August 29, 2001

News that the national institute for clinical excellence (Nice) has been asked to deliver a definitive verdict on the use of electroconvulsive therapy (ECT) has led to rare agreement between psychiatrists and service users on the controversial practice.

Few medical treatments have so divided health professionals and service users as ECT. While regarded as a lifesaver by most psychiatrists, many former patients believe that it is barbaric and has ruined their lives. However, both the pro and anti lobby have welcomed the Nice review, believing its appraisal guidance will raise standards of practice.

This has come as a relief to the Department of Health, which hopes that the institute can help to establish a consensus on the appropriate use of the treatment for depression, schizophrenia and other mental health problems. A statement issued by Nice last month said: "We need to see if ECT still has a valuable role among the options for modern treatment."

The treatment has been administered in the UK for more than 60 years. While the procedure is now far less commonly administered than previously, approximately 22,000 still receive it every year.

ECT involves delivering an electric shock to the brain. Patients first receive a general anaesthetic and a muscle relaxant before a current is administered via electrodes for about three to four seconds. This provokes an epileptic seizure, which appears to have a beneficial impact on depression in about 70% of cases, according to the Royal College of Psychiatrists.

Although it is still not clear exactly how and why it works, the RCPsych insists that it is a highly effective treatment for those patients who fail to respond to medication or talking therapies.

Dr Susan Benbow, a member of the college's committee on ECT, said the practice must remain an option in "a humane and sensible society".

"Whether people like it or not ECT has saved lives," she argues. "How can it be humane to withhold a treatment that can help patients who cannot sleep or eat. Should we just leave them to die?"

The banning of ECT by several countries and the emergence of the mental health user movement in the 1980s forced the RCPsych on the defensive, with former patients complaining of devastating after effects and mental health charities calling for it to be banned in Britain.

For example, a report by Mind in March claimed to show that ECT was used indiscriminately, without proper consent and often led to psychological trauma and long-term memory loss.

The survey of 418 Mind supporters found that 40% reported permanent memory loss and 36% had difficulty concentrating. More than half were unaware that they could refuse consent to the procedure, while three-quarters said they were given no information about possible side effects.

One man, who had received more than 10 courses of ECT, described the treatment as humiliating. "I was sexually abused as a boy, and suffered severe depression ever since. I think I should have been given counselling. Instead I just feel as if I'm being punished all the time," he said.

The RCPsych dismissed the Mind survey as biased and unscientific but its own audits - and those by the DoH - have also identified poor standards of practice at many ECT clinics.

Its most recent report in 1999 rated only a third of clinics in England and Wales as good. It also found that junior doctors were often left unsupervised and many ECT machines were outdated.

Dr Benbow admitted that ECT practice had not always been found to meet RCPsych guidelines.

"At present you should have a consultant in charge of the ECT clinic overseeing the technicians and junior doctors administering the treatment to ensure it is up to scratch," she said, adding: "However, audits have found that some consultants spend very little time in these units, so if you accredit them that might not have much impact upon standards."

The college had considered adopting the US regulatory system of accrediting ECT practitioners, revealed Dr Benbow, but its preferred option was accrediting the clinics instead. This would bring poorly performing units under its scrutiny and make them liable to face sanctions up to and including closure.

While Mind and anti-ECT user groups such as ECT Anonymous welcome any moves to improve inspection, the sticking point of the Nice review is likely to be the issue of consent.

Mind believes that anyone who is capable of informed consent should not be given ECT against their will and believes stringent safeguards should be in place where it is administered to patients who lack capacity.

Margaret Pedler, head of policy development at the charity, wants all patients to have access to an independent legal advocate.

However, the RCPsych believes that the procedures governing consent are already strict enough.

"It's the nature of severe depression that some people cannot give consent for themselves," said Dr Benbow. "It would be unreasonable to expect someone who is not eating or sleeping to be able to make such a decision."

Ultimately, both ECT's advocates and detractors admit it may take further legislation to satisfy their concerns. And charities and user groups have already given notice they will be lobbying for the issue to be addressed in the still expected reform of the Mental Health Act.