© 2008 The Royal College of Psychiatrists
Correspondence |
Decreased usage of electroconvulsive therapy: implications
Royal Edinburgh Hospital, Morningside Park, Edinburgh EH10 5HF, UK. Email: Fiona.Morrison{at}lpct.scot.nhs.uk
Royal Edinburgh Hospital, Edinburgh, UK
Edited by Kiriakos Xenitidis and Colin Campbell
Our interest in this topic was re-awakened when, in 2003, the then National Institute for Clinical Excellence (NICE) published clinical guidelines that intended to restrict the circumstances for the use of electroconvulsive therapy (ECT).1 The guidance was controversial, and the Royal College of Psychiatrists subsequently published its own guidance that argued that NICE was too restrictive about the place of ECT in the treatment of major depression, the most common contemporary indication for ECT.2 It was therefore unclear whether NICE would achieve its aim of reducing the use of ECT. We have already reported that there was no early effect of the NICE guidance in that the rates of usage of ECT in Edinburgh were virtually identical in the individual years 2003–2005.3
We now report the most dramatic fall in the rate of usage of ECT that we have ever observed between consecutive years. In the years 2006 and 2007 the rates of usage were only 0.82 and 0.88 patients per 10 000 total population. This is approximately a third less than the rate in 2005, and three-quarters less than the rate in 1993.3
The clinical significance of the decrease has never been systematically assessed. Observers have suggested that there is less need for ECT as the number of effective alternative options increases, and as psychiatrists become more experienced with these options. One only hopes that those people who are severely ill who were formally treated with ECT are now offered equally effective alternatives, but this is open to doubt. Electroconvulsive therapy is still the most efficacious treatment for major depression, particularly when the symptoms are severe.4 The results of the recent STAR*D trial were salutary: the cumulative remission rate from major depression was only 67% after four sequential and carefully supervised acute treatment schedules.5
The research implications are clearer. Edinburgh has a long history of ECT research, but the latest fall in usage has meant that we have not been able to complete a controlled comparison of magnetic seizure therapy and orthodox ECT. If the Edinburgh experience is replicated elsewhere, the only options for future clinical research would be to support collaborations among several ECT clinics or the establishment of a regional or national affective disorders research centre, plus a research programme that includes ECT.
REFERENCES
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1
- National Institute for Clinical Excellence. Guidance on the Use of Electroconvulsive Therapy. NICE, 2003 . 2
- Royal College of Psychiatrists. The ECT Handbook (2nd edn). Council Report CR128. Royal College of Psychiatrists, 2005 . 3
- Okagbue N, McIntosh A, Gardiner M, Scott A. The rate of usage of electroconvulsive therapy in the City of Edinburgh, 1993–2005. J ECT, in press. 4
- Ebmeier KP, Donaghey C, Steele JD. Recent developments and current controversies in depression. Lancet 2006; 367: 153 -67.[CrossRef][Medline] 5
- Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW,
Warden D, Niederehe G, Thase ME, Lavori PW, Lebowitz BD, McGrath PJ, Rosenbaum
JF, Sackeim HA, Kupfer DJ, Luther J, Fava M. Acute and longer-term outcomes in
depressed outpatients requiring one or several treatment steps: a
STAR*D report. Am J Psychiatry 2006; 163: 1905
-17.
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