The Food and Drug Administration (FDA), in a briefing for the advisory panel that was looking at electroconvulsive therapy (ECT) machines last month, had this to say about ECT use in the US:
“However, in recent years, interest in, and use of, ECT has experienced a resurgence; ECT use in the US has been estimates [sic] at 100,000 individuals receiving this treatment annually (Hermann et al. 1995)”.
The immediate problem with this statement is that the reference is fifteen years old. No-one knows how many people receive ECT in the US today, or even in the recent past. No-one knows whether its use is going up or down, let alone going up by enough to talk about a resurgence. Only a few states have a system for reporting ECT use, and of these I have only been able to find statistics for one – Texas. And in Texas there seems to have been little change in the numbers of people undergoing ECT between 1993 and 2008 – 2,583 reports of ECT over a 19-month period 1993-1995, and 1,760 reports over a 12-month period 2007-8. So, no sign of a resurgence in recent years of ECT in Texas at least. The population of Texas is about 25 million. If the whole of the US (population approximately 312 million) used ECT at the same rate as Texas the numbers of people undergoing ECT annually would be nearer 20,000 than 100,000. But Texas isn’t necessarily typical and it is very possible that it is indeed using ECT at one-fifth the national average rate – ECT is known for being subject to wide variation in use.
What about the Hermann et al 1995 article? Where did they get the figure of 100,000 from? In fact the 100,000 figure was an estimate based on information from the 1988-89 professional activities survey of the American Psychiatric Association (APA), making it more than 20 years old. Not only is the figure not very recent, it is also of questionable accuracy, being based on psychiatrists’ recollection of how much ECT they used. Surveys by the National Institute of Mental Health (NIMH) based on sampling hospital records produced much lower figures, although their accuracy has also been questioned. In 1986, for example, the NIMH survey came up with a figure of 36,558 people receiving ECT. For 1976 the NIMH figure was 58,667; that of the APA was 88,604.
What emerges from these figures is that it would be fairly reasonable to suggest that a decline of ECT use in the 1970s was reversed in the 1980s. But there is no statistical evidence to justify talk about a resurgence in recent years. The idea of a “comeback” for ECT (and a figure of 100,000) have been around for over thirty years. In 1979 Time Magazine ran a story with the title Comeback for shock therapy, which said “Despite years of experience and large numbers of patients (an estimated 100,000 people undergo treatment in the U.S. each year), no one is exactly sure how ECT works”. Over thirty years later the New York Times is still talking about a resurgence and uses the same figure as Time Magazine did: “The procedure has had a resurgence in recent years. And an estimated 100,000 Americans — two-thirds of them women — undergo the treatment for major depression and other illnesses each year”.
It is disappointing that the FDA briefing, instead of looking at statistics from the few states where they are available and acknowledging the difficulties of estimating the numbers of people who undergo ECT every year, simply repeated an estimate based on a survey done over 20 years ago.