Health: The shocking truth

Does ECT do more harm than good? Nobody seems to know. Yet it is still widely used.

Many people in this country could now tell you the precise symptoms of clinical depression and the main properties of antidepressant drugs, helped in part by Psychos, a new drama series on Channel 4 set in a psychiatric ward.

The programme's latest story-line involves an elderly patient who requires electro-convulsive therapy (ECT). Ever since its introduction into Europe in the late Thirties, the use of ECT has been fraught with controversy. To many lay people, its use is barbaric. They associate it with the electric chair or torture, and base their ideas of how it is carried out in the terrifying scene in One Flew Over the Cuckoo's Nest, when Jack Nicholson is forcibly treated by unfeeling and totally unsympathetic staff.

Given the controversy that ECT attracts, it comes as a surprise to discover that the Government does not know how often the treatment is used, and whether its use is waxing or waning. The Department of Health has not collected statistics since 1991 when the then Health Secretary, Kenneth Clarke, decided that such monitoring was unnecessary. At the time, about 20,000 patients were having about 100,000 treatments a year. About 2,000 of these patients were detained in hospital under the Mental Health Act.

Now the Government has decided to update its figures. Every psychiatric unit has recorded its use of ECT during the first three months of this year and the Department of Health intends to publish the results in the summer.

Whatever the figures show, certain groups are bound to protest that it is still being used too often. The most prominent organisations opposed to it are Mind, the National Association for Mental Health, and ECT Anonymous, a Yorkshire-based group, which has been campaigning for three years against the use of the treatment without properly informed consent.

ECT Anonymous has just published the results of its own survey, a questionnaire which it sent out to 500 people who had previously complained about the serious harm they had suffered from ECT. Mrs Pat Butterfield, the organisation's co-founder, said the results were "so horrifying that it is difficult to comprehend the scale of the harm that is occurring. About half our respondents were able to report that ECT initially had some effect... [but] when it came to the long-term result, almost three-quarters reported that it had been completely ineffective. All our respondents found the after- effects widespread and devastating".

Only 7 per cent had been able to return to their original occupation. Eighty-seven per cent felt they had been pressured into having ECT, and 98 per cent felt that the risks had not been fully explained to them.

"At the moment, people cannot give informed consent because they are not being given the full information. Anybody who was fully informed would not agree to it," said Mrs Butterworth.

Mind's attitude is similar. It would also like to see a ban on the use of ECT without informed consent, would like it banned in the treatment of children, and would like to see even its voluntary use scaled down.

Are they right? Is this a treatment that should be virtually abandoned, or does it have a place in 21st-century psychiatry? "For certain people, ECT is a life-saving treatment," said Dr Susan Benbow, consultant psychiatrist for the elderly at Manchester Royal Infirmary and a member of the Royal College of Psychiatry's special committee on ECT.

"In the vast majority of cases, it is given for severe depression," she added. "Usually the patient is so acutely ill that you cannot wait long enough for antidepressant drugs to work. Often the patient is reluctant to eat or drink, or is acutely suicidal. You may feel that if you wait, he or she will die."

Most psychiatrists would agree. "The evidence is that ECT is the most effective treatment we have by miles," said Dr Chris Freeman, consultant psychotherapist at the Royal Edinburgh Hospital and chairman of the Royal College of Psychiatrists special committee on ECT.

"I am not surprised that it has such a bad reputation, because film and television footage of it is always so misleading. If every time they showed an appendix operation on television, they showed a barber surgeon carrying out the operation without an anaesthetic, with staff holding the patient down and blood spurting everywhere, the public would be terrified of having their appendix out. And people would complain that it was inaccurate. Yet every media clip on ECT is seriously out of date, and shows patients having treatment without anaesthesia, without a muscle relaxant, and with staff in white coats holding the patient down. It is a travesty of the truth," he said.

Dr Robert Kendell, president of the Royal College of Psychiatrists, admitted that he was worried by the public's antagonism towards the treatment. "To psychiatrists, it is the most dramatically effective treatment that we possess, so we are puzzled by the sometimes vociferous hostility that it provokes," he pointed out.

But members of the Royal College of Psychiatrists would agree with its critics in admitting that ECT is not always administered in the correct way. Dr Kendell believes that it is often administered by inadequately trained staff, without enough supervision, and sometimes with out-of-date equipment. The last audit that was carried out by the college revealed that only a third of centres met the standards laid down by the Royal College's ECT handbook.

"The Royal College does not have the power to issue orders," said Dr Kendell. "But we do inspect hospitals' training programmes on a three- yearly cycle. Following the results of the last audit, we have started taking a particularly close interest in whether junior staff are properly taught and supervised.

"Where they are not, we tell hospitals that they will lose their training licence if they do not do something about it."

Dr Kendell feels that the Government is not interested in the administration of ECT. The Royal College of Psychiatrists wrote to the chief executives of all the NHS trusts two years ago, drawing their attention to the guidelines on ECT. But when the college recently asked the Department of Health to write to the same chief executives to ask them what action they had taken following the letter, the department did not respond.

What can happen if an inexperienced, poorly trained member of staff gives ECT without supervision? One result is that patients may be given the wrong dose. If the dose is too low, it will not cause a seizure (and it is the seizure which is the therapeutic agent, not the electricity itself), with the result that the patient is exposed to the disadvantages of the treatment, such as the anaesthetic, without any possibility of benefiting from it. If the dose is too high, there is avoidable impairment of memory.

When ECT clinics are run by inexperienced staff, patients may also be given it without their level of depression being monitored. The college recommends that doctors never prescribe more than two treatments without reviewing a patient's level of depression. In older people, doctors also need to monitor the patient's intellectual function, as they are more sensitive to the side-effect of memory loss.

"ECT is becoming more technical," said Dr Freeman. "If you are giving ECT to a 21-year-old woman, for example, the amount of electrical energy required to trigger a seizure is considerably lower than that required for an old, bald man, because men and older people have higher fit thresholds than women and younger people; and bald people have more resistance than people with hair, because the skin is thicker," he added.

"If you give everyone the same dose, you will be overtreating some people and undertreating others," Dr Freeman explained. "It is also important that the length of the seizure is measured because it needs to be about 25-50 seconds to have the right effect."

One woman who thinks she was overdosed when she was treated with ECT is 52-year-old Helen Crane from Ashstead, Surrey. She has been hospitalised three times for severe depression, and in 1997 she was given a course of ECT, which, she is convinced, resulted in her suffering from serious memory loss.

"It was after I came out of hospital that I had problems. I have lived in the same place for years but I kept getting lost. I was also aware that my mother was not around but I did not know why. My husband had to explain that she had died in the autumn of 1995," said Mrs Crane, who is a journalist on a local newspaper.

"I also couldn't add up. It took me over a year before I learnt again how to count out the right change in shops. Even now, if I am going to interview someone for my job, I have to rehearse the interview beforehand, otherwise I cannot remember the right words."

Mrs Crane, who says that her depression improved with ECT, feels that she would never tell anyone not to have ECT, but she would warn anyone to ask plenty of questions beforehand. "The psychiatrists do not tell you that only one-in-three clinics come up to the proper standards," she explained. Dr Kendell admits that many patients suffer temporary memory loss after ECT, but says that research shows that after three months, memory impairment is almost undetectable, and permanent impairment extremely rare. "The problem is that when people are depressed, they cannot concentrate, so they don't take things in. They interpret that as being memory loss."

Undoubtedly, memory loss is just one of the many aspects of ECT over which doctors and some mental health campaigners will never agree. Even the Royal College's campaign to improve training and supervision annoys those who would like to see the practice banned. So when the Department of Health publishes its statistics on how many patients are having the treatment, we can expect to see more sparks fly.