On 22 January 2018 the Birmingham Mail published an obituary of Tamworth GP Dr John Weston Smith, who had died aged 95. The obituary mentioned that he had provided anaesthesia for electroconvulsive therapy (ECT) at St. Matthews Hospital in Burntwood. (You can see some historic photographs of St Matthews Hospital here.)
On 15 March an obituary by one of Dr Smith’s children appeared in The Guardian’s “other lives” section, which publishes obituaries of “people less in the public eye”. Jonathan Smith enlarged upon his father’s experience with ECT, identifying him as the author of an anonymous article on ECT that appeared in the journal World Medicine in 1974.
“The needs of a family of six children were considerable. To supplement his income John became a GP anaesthetist, working at a local psychiatric hospital where staff administered electroconvulsive therapy (ECT). By turns of events arising from a replacement machine and a lack of staff training, there was a period of more than two years when the team used a machine they believed was working – but it was not. However, no consultant reported any change in the responses of patients to their treatment.
This unscientific double-blind experiment was the subject of an article in World Medicine in 1974, written by John under a pseudonym. Subsequent research stimulated in part by this article, which cast doubt on the effectiveness of ECT, established its proper place in the treatment of mental illness. The article is still quoted in medical publications.”
The article in question, “Non-ECT”, appeared under the pseudonym of J. Easton Jones in World Medicine 1974, no. 9, p.24. It describes the author’s early experience of ECT in the 1950s, with patients being given muscle-paralysing drugs, but no anaesthetic. At the time, that would have been one of the variants of delivering ECT; some psychiatrists used anaesthesia and muscle-paralysing drugs, some used neither (unmodified ECT) and some used just the muscle-paralysing drugs. The article begins:
“As a general practitioner anaesthetist I was introduced to ECT over eighteen years ago. In those days the object was to give a shot of relaxant before the shock and to press the button at the psychological moment, the idea being to get the maximum relaxation combined with the maximum post-epileptic amnesia of the seconds before the shock. When I mildly suggested that a sleep dose if IV thiopentone might allay the obvious distress of the patients and the high refusal rate, I was brusquely told, “It would interfere with the treatment”. In my innocence I supposed that there was some sort of rational scientific basis for the treatment but the indications seemed vague, ranging from temporal lobe epilepsy, chronic schizophrenia to depression and poking the medical superintendent in the eye.”
The author goes on to relate how he eventually managed to introduce an anaesthetic into ECT practice at the hospital and how, as there was a shortage of psychiatrists, he became responsible for giving the shock as well as the anaesthesia and how a new machine left patients with burns. Then another new machine was ordered:
“It duly arrived and was obviously a great improvement on the previous edition. It had dials and lights and switches for different wave forms. We started treatment, the patient did not twitch, although the red light went on and the needle moved, “Isn’t it working?” I said. “Yes, it is,” said the nurse, “this sort doesn’t give any reaction – it’s in the instructions”. I duly read the instructions and indeed “there should be minimal signs of any seizure with this apparatus.” We used the apparatus for two years with no complaints from the patients and although I did not actually see any consultants, apparently they were satisfied with my work. But on a never-to-be-forgotten day a new charge nurse appeared. After the third treatment, he said, “It’s not working.” “Oh yes it is, this kind of does not cause any twitching”. “Look, I’ve just come from a hospital with one just like this and they twitch all right”. We examined this one closely… he was right. All the patients had been getting for two years was thiopentone and a shot of Scoline – and no one had noticed”.
When the author’s son writes that this article was partly responsible for subsequent research, he is probably referring to a few studies carried out in the late 1970s and early 1980s in which ECT was compared with sham ECT in which the patients, like those of Dr John Weston Smith, received the treatment but without the actual electric shock. In general the studies showed a relatively small advantage for ECT over sham ECT especially in the early stages of treatment, but not enough to settle any debate about the usefulness of the treatment and certainly not enough to establish the “proper place” of ECT in the treatment of mental illness, as the author’s son claims.
Does ECT even have a “proper place”? It depends on where you live. In general ECT is used mostly as a treatment for depression in Western countries while in other countries it is used extensively as a treatment for schizophrenia. Rates of use vary widely between countries, even countries which share a professional body for their psychiatrists (Australia and New Zealand). And similar rates of ECT do not necessarily mean a similar place for the treatment. Texas and Scotland for example have broadly similar rates of ECT use and in both places the treatment is used mostly for depression and about two-thirds or more of patients are women. But in Scotland ECT is used on non-consenting patients at over 25 times the rate in Texas. If ECT has a proper place, it is yet to be found.