British Medical Journal
BMJ 1999;319:1092 ( 23 October )
James Ciment
New York

Although still in preliminary draft form and yet to be released officially to the public, the long awaited US surgeon general's report on mental health has already created an uproar, after a consumer health group released excerpts highlighting the efficacy and safety of electroconvulsive therapy (ECT) in the treatment of depression.

According to the draft report, which cites several clinical studies published between 1993 and 1997, electroconvulsive therapy "is regarded as a safe and effective treatment for depression and is recommended for select groups of patients with severe depression, particularly those with associated active suicidal ideation, psychosis or catatonia."

Moreover, the draft report says that the therapy "has the advantage over pharmacotherapy of more rapid resolution of symptoms."

Calling the draft a "blanket endorsement" of electroconvulsive therapy, the National Mental Health Consumers' Self Help Clearinghouse, based in Philadelphia, argues that the surgeon general's office overlooked numerous studies that found electroconvulsive therapy to be more dangerous and less effective than pharmaceuticals for the treatment of severe depression.

In a letter to the surgeon general, David Satcher, the clearinghouse cites numerous studies indicating higher suicide rates for people receiving electroconvulsive therapy compared with those receiving drug treatment, as well as cardiovascular problems, memory loss, and epileptic seizures.

In addition, the letter says that the draft report's underestimation of the risks of electroconvulsive therapy means that there is "no opportunity for truly informed consent" as required by law.

The clearinghouse's executive director, Joseph Rogers, said that his organisation released the report because the draft approves of electroconvulsive therapy in such an unqualified way.

Calling the report premature and unbalanced, Mr Rogers suspected that both politics and bias were factors in the draft report's uncritical assessment of the therapy. "There was a lot of pressure on the National Institute of Mental Health from the vice president's office," he speculated, "to get this report out after the White House conference [on mental health, held in June]."

In addition, Mr Rogers said, the national institute's deputy director, Richard Nakamura, is "very pro-electroconvulsive therapy, and I think he is looking for the surgeon general's report to give better legitimacy to electroconvulsive therapy and a clearer and more definitive statement on electroconvulsive therapy."

The surgeon general's office refused to comment on the released draft except to say that it was not final and that it was still undergoing a "rigorous review and revision process."