Electroconvulsive therapy in the UK: not discontinued yet

In my last post I queried the claim made by the Food and Drug Administration (FDA) that electroconvulsive therapy (ECT) use in the United States has undergone a resurgence in recent years. In fact they have no idea how many people are having this form of treatment and whether its use is increasing or decreasing. No sooner had I written that, than I came across an example of a British author going to the other extreme and using ECT as an example of a medical treatment that has all but disappeared.

And in medicine too, many treatments invented in the twentieth century were discontinued, lobotomy and ECT being prominent examples, though the last is still occasionally used“, writes David Edgerton in his book The shock of the old: technology and global history since 1900 (Profile Books, London, 2006).

The book is chock-a-block with interesting statistics, often used to demonstrate the point that old technologies are not always entirely replaced by new. For example, Hitler marched into the Soviet Union with more horses than Napoleon did over a century earlier. So it is a pity that the author didn’t find some statistics about ECT use, especially as when the book was written there were some recent and reasonably accurate statistics available from a Department of Health survey of ECT use in England in 2002. This survey showed that about 9,000 courses of ECT were given in England in 2002. Occasionally is a vague term, but can it really be applied to something that happens to about 9,000 people a year? And when it is still used on this scale is it really a good example of a treatment that has been (almost) discontinued? Its use, however, is certainly declining. Department of Health figures for England show a more or less steady decline in ECT use between 1979 and 2002, from approximately 25,000 courses to approximately 9,000. And estimates suggest that its use had halved during the 1970s. I have been unable to find any reasonably accurate figures for ECT use in England in the 1940s, fifties and sixties. Without figures from these decades, it is impossible to say when the decline began. Was it in the fifties when new classes of drugs for the treatment of schizophrenia and depression were introduced? Or was it later? The fact that about 50,000 courses of treatment were being given every year in the early 1970s suggests that new drugs did not displace ECT to the extent to which they are sometimes assumed to have done.

Writing in the British Medical Journal in 1954, Hugh F. Jarvie suggested that at least one third of the 60,000 people admitted annually to mental hospitals in England and Wales underwent ECT. He pointed out that this estimate did not include people treated as out-patients or in private practice. It also didn’t include patients on long-stay wards. The Journal of Mental Science published the results of a survey into ECT use in 1956-7 by J.C. Barker and A.A. Baker. They came up with a figure of 259,000 individual treatments over a 2-year period, representing about 20,000 courses a year. Their survey included out-patients, but was limited to 13 teaching hospitals in London and 42 mental hospitals (about one third of the total). The hospitals were chosen because they were known to use a lot of ECT, making it difficult to extrapolate from that figure to the country as a whole. But even if you did so, it wouldn’t look as if ECT use was very much greater in the 1950s than it was in the 1970s.

As for the claim that lobotomy has been discontinued: this is an even trickier one as the word lobotomy can be used to mean different things. Lobotomy is an in any case an American word; leucotomy was the word used in the United Kingdom. Usually the word lobotomy is used to refer to a particular type of psychosurgical operation (that is, a brain operation to treat a mental illness). It was coined by the American neurologist Walter Freeman, to describe his form of psychosurgery where an instrument was inserted through burr holes in the skull and swept through the brain to cut the pathways between the frontal lobes and deeper structures. In the United Kingdom these operations were called standard or pre-frontal leucotomies, and were the most commonly used type of psychosurgical operations in the 1940s and 1950s. Freeman later developed an operation where the instrument was inserted through the eye socket. This operation was called a transorbital lobotomy in the US and a transorbital leucotomy in the UK. Meanwhile, in the 1940s and 1950s other psychiatrists and surgeons were developing what they called modified leucotomies, such as the cingulotomy, which although they formed only a minority of the psychosurgical operations performed in the 1950s are still, in some cases such as the cingulotomy, in use today. So, used in the sense of a specific type of psychosurgical operation, it is correct to say that lobotomy has been discontinued. They have not been used since the 1970s in the UK. But sometimes lobotomy is used in a more general sense to mean any kind of psychosurgical operation – and in that sense it has not been discontinued.

Thanks to some surveys that were carried out in the between the 1940s and the 1970s, and the fact that all operations have nowadays to be approved by the authorities, it is possible to trace the extent of psychosurgical operations from the time they were introduced into British hospitals in the early 1940s to the present day. They peaked in the late 1940s with over 1,200 operations annually in England and Wales. By the end of the 1950s that figure had more than halved, although some psychiatrists still used it with unabated enthusiasm and some people who underwent the operation had never previously been admitted to a mental hospital. By the mid 1970s it had declined to some 100-200 operations a year, with only about 3 per cent of them being standard leucotomies. The introduction of the Mental Health Act 1983, which only allowed psychosurgery to be carried out on consenting patients and required the approval of the Mental Health Commission for each operation, led to a further drop in the number of operations – in 1990 for example 28 operations were carried out in the UK. During the 2000s the only centres performing operations (capsulotomies and cingulotomies) in the UK were in Dundee and Cardiff, but last year doctors in Bristol performed a cingulotomy for the treatment of depression (as mentioned in a previous post).

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