Variation in ECT use

Electroconvulsive therapy (ECT) has been identified as one of the highest-variation procedures in medicine. Some psychiatrists don’t use it at all, some use it sparingly, others use a large amount. You won’t though find this lack of consensus reflected in the literature, which tends to be written by a small number of psychiatrists who are enthusiastic about ECT and claim it is a safe, effective and even life-saving treatment.

The variation in rates of ECT use between different countries and regions is often mentioned in academic articles but merely noted as if it were some naturally occurring phenomenon like rainfall, with no attempt to find reasons or discuss implications. One article about ECT use in the United States had a helpful map with areas shaded according to their ECT use. Over a third of the metropolitan statistical areas had no ECT, with one whole state (Wyoming) appearing to be completely ECT-free.

As an article by psychiatrist Pat Bracken points out, if ECT was really a life-saving treatment, the variation in its use and its disappearance from some hospitals would be a scandalous situation.

In most countries, there are hospitals where ECT is used and hospitals were it isn’t. England is unusual because ECT appears to still be used in all hospitals, although rates of use vary between hospitals and there are individual psychiatrists who don’t use it.

A survey of ECT use in Great Britain funded by the Department of Health in 1980 (which remains the most comprehensive survey of its kind) found that “some hospitals providing a full service for a catchment area gave up to 17 times as much [ECT] as others“. The authors could find no reasons for this variation, other than the attitudes of individual psychiatrists towards ECT. Within hospitals it was often just one or two psychiatrists who were responsible for most of the ECT.

“We found a sudden drop in the ECT use in a hospital was often associated with the retirement of a consultant locally know to favour the practice, e.g. in one hospital the number of treatments dropped by 1000 in one year to half its previous level when a consultant retired”.

Since 1980 the use in ECT in GB has fallen by about 80 per cent, and no psychiatrists use ECT as much as some did in those days. But there remain wide variations. A survey of ECT use by different psychiatrists in Edinburgh in the 1990s found a more than 18-fold variation. The authors did not try to find reasons for this variation, but suggested they “merit further study”.

There have in fact been very few attempts to study the differences between psychiatrists who use a lot of ECT and psychiatrists who use little or don’t use it at all, although for many patients their psychiatrist’s attitude towards ECT, rather than their own symptoms or condition , will determine whether or not they receive ECT. In the US a study found that psychiatrists who used ECT in 1988-9 were more likely than non-users to be male, to have trained in the 1960s and 1980s rather than the 1970s, and to have graduated from a medical school outside the US.

Meanwhile in Britain I had to go back to 1973 to find something vaguely similar, a study which examined the relationship between social attitudes and treatment preferences among psychiatrists. They found that conservative attitudes were associated with a preference for physical methods of treatment, such as ECT, as was tough-mindedness. The authors concluded that their findings raised 2 important issues:

“Firstly, psychiatrists should realize that there is an association between the social attitudes they hold and the treatment they recommend for their patients. In a system like the National Health Service, where the patients does not choose his psychiatrist, this may create problems which are rarely discussed. Secondly, statements which are frequently made with some ideological fervour about the value of different treatment methods should perhaps be viewed with more caution. It is likely that if treatment orientation is embedded in general social attitude, discussion about the advantages of the various treatments will not be guided by factual arguments alone”.

These issues remain just as important nearly forty years on. NHS patients still do not choose their psychiatrist, or even hospital (mental health services are excluded from the NHS free choice policy). And the problems are still rarely discussed.

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