The open access journal Brain and Behavior has published an article by a team of Norwegian researchers about the use of electroconvulsive therapy (ECT) worldwide (Kari Ann Leiknes, Lindy Schweder, Bjørg Høie “Contemporary use and practice of electroconvulsive therapy worldwide”). The abstract can be read here and the full article here.
The abstract sums it up nicely:
“Worldwide preferred electrode placement was bilateral, except unilateral at some places (Europe and Australia/New Zealand). Although mainstream was brief-pulse wave, sine-wave devices were still used. Majority ECT treated were older women with depression in Western countries, versus younger men with schizophrenia in Asian countries. ECT under involuntary conditions (admissions), use of ambulatory-ECT, acute first line of treatment, as well as administered by other professions (geriatricians, nurses) were noted by some sites. General trends were only some institutions within the same country providing ECT, training inadequate, and guidelines not followed. Mandatory reporting and overall country ECT register data were sparse. Many patients are still treated with unmodified ECT today. Large global variation in ECT utilization, administration, and practice advocates a need for worldwide sharing of knowledge about ECT, reflection, and learning from each other’s experiences.”
A lot of people undergoing ECT in the world still get unmodifed ECT (that is, without muscle relaxants or anaesthetic). Most people get bilateral treatment, sine-wave machines are still used in some places, and there is large variation not just in the numbers of people undergoing ECT but also their diagnoses, with a lot of countries using ECT mainly for the treatment of schizophrenia, rather than depression. None of this is news, but it is something that is seldom emphasised in psychiatric journals which, when it comes to ECT, tend to reflect the interests of mainly academic ECT-using psychiatrists in English-speaking Western countries.
Contemporary in this case means anything since 1990. ECT practice can change significantly in 20 years, but at least it gave the authors a sporting chance of finding enough published studies to fill an article. With the exception of Sweden, England, and New Zealand, the authors haven’t made use of statistics published by government departments (although they say they looked for them). In some cases these statistics might have filled in notable gaps, for example, Canada, or provided a more recent, or accurate, picture of contemporary practice in a country than the one-site studies found by the authors.
There are coloured diagrams showing the balance between ECT use for the treatment of schizophrenia (brown) and ECT for the use of depression (blue), with most countries having a small number of other diagnoses as well. As you would expect the brown (schizophrenia) areas are larger in Africa, Asia and Latin America than in the United States, Australia and New Zealand, and most European countries. But, perhaps surprisingly, the extremes fall in Europe: Sweden has no brown area, although it is possible that “other” may have included schizophrenia, and the Chuvash Republic of the Russian Federation appears to use ECT only in the treatment of schizophrenia.
The other charts, showing use of ECT in different countries both as the numbers of courses of treatment per 10,000 population and as a percentage of inpatients, need to be viewed with some caution as some of the countries are represented by small-area studies which may not reflect ECT use over the country as a whole. As the authors later say:
“The overall diversity in practice data reporting unclear representativeness of region or land as a whole and large heterogeneity in reported ECT utilization rates did no lend the data to meta-analyses.”
The United Kingdom appears as a very low user on both charts, which is not actually the case. For the courses of treatment per 10,000 population per year the authors have taken a three-month figure and not converted it to an annual figure, and the statistic for the percentage of inpatients comes from just one hospital (or perhaps a group of hospitals). Statistics for a whole country – Scotland (from the Scottish ECT Accreditation Network) – are more than double the figure used. The United States comes out as the highest user of ECT which is unfair as the study concerned looked at use per 10,000 per Medicare population (that is, older people and disabled people) rather than the population as a whole. On the percentage of admissions chart meanwhile they seem to have a very low use, due to using two studies from state hospitals (which have a lower use of ECT than other psychiatric hospitals), as well as one covering the state of California.
The authors conclude their paper with the words:
“Large global variation in ECT utilization, administration, and practice advocates a need for a worldwide sharing of knowledge about ECT, reflection and learning from each other’s experience”.