A. E.C.T. and Its Use in England and Wales.

5.1 E.C.T. and its use.

1. E.C.T. is perhaps the most controversial treatment currently used by the medical profession. Many patients, survivors, relatives, professionals and others have serious concerns about the use of electro-convulsive therapy. While some survivors report it as helpful or lifesaving to them, many others see it as a damaging and threatening tool of psychiatric oppression.

2. E.C.T. is used mainly to treat depressive disorders, but also mania, schizophrenia and neuropsychiatric conditions. It is also reported as having been used for a variety of other conditions for which its use is not generally clinically indicated.

3. E.C.T. has cardiovascular, cerebral, intraocular and intragastric effects in patients.

4. There are a range of theories about how E.C.T. works. There is no firm evidence to demonstrate how the process operates.

5. Most patients receive E.C.T. two or three times per week as part of a course of treatments which usually number between two and 12. There is some evidence that E.C.T. given twice per week is as effective as E.C.T. three times per week and has less severe cognitive effects. A significant number of patients receive several courses of treatment over time.

6. About 22 000 people are given E.C.T. in England each year. This is a rate considerably higher than other countries in Europe, some parts of North America and the Far East.

7. Women are far more likely to be given E.C.T. than men, at a ratio of about 2:1.

8. Older people (especially those over 65) are more likely than younger people to get E.C.T., the average age of patients being somewhere in their fifties.

9. E.C.T. is rarely given to people under 18 years, with no evidence of its use for children under 12.

10. There is no reliable information about the use of E.C.T. in regard to the ethnicity of patients.

5.2 Effectiveness of E.C.T.

1. Clinical studies tend to concentrate on (short-term) symptom reduction rather than on the quality of life, physical health or social functioning of survivors.

2. There is very little good research on the long-term effectiveness or side-effects of E.C.T.

3. E.C.T. is demonstrably effective for a narrow range of severe psychiatric disorders in a limited number of diagnostic categories: delusional and severe endogenous depression and manic and certain schizophrenic syndromes.

4. Most clinical research concludes that E.C.T. is effective for the treatment of depressive illness and is preferable to drugs for some patients.

5. Clinicians generally hold that E.C.T. is particularly effective for patients with a higher number of typical features of depressive illness, especially where these include psychotic features. It is also reported that two particular symptoms - retardation and depressive delusions - respond well to E.C.T. and that patients without these symptoms do not benefit significantly from E.C.T.

6. E.C.T. is not effective in treating Type II (chronic) schizophrenia and has only a limited use in treating Type I (acute) schizophrenia in patients with specific indicators.

7. E.C.T. is effective in treating people with affective and catatonic disorders, but only where there is account taken of specific medical risks and appropriate modifications made.

8. There is little evidence for the use of E.C.T. in treating either Parkinson's Disease or epilepsy.

9. There are no symptoms or clinical features proven as criteria to determine who will benefit from E.C.T., although most recent work indicates that psychotic features and psychomotor disturbance (rather than the severity of depression) are best correlated with a good response for E.C.T.

10. E.C.T. can prevent death when a person is severely depressed and is in a critical state through no longer eating or drinking.

11. There is no good evidence to prove that E.C.T. prevents suicide or affects the suicide rate.

12. E.C.T. is not effective for violent or offending behaviour, diabetes, obsessive-compulsive disorders, anxiety, post-traumatic stress disorder, stroke, dementing illnesses or cardiovascular disease.

13. There has been relatively little work done to establish survivors' views on E.C.T. Some of the research that has been undertaken is of poor quality.

14. From the limited surveys undertaken, between 30% and 43% of survivors report E.C.T. as being helpful or life-saving to them. Between 37% and 51% of survivors found E.C.T. unhelpful or damaging. Factors which appear to increase the proportion of patients finding E.C.T. helpful are:

-being treated voluntarily rather than compulsorily

-being treated with one's consent rather than without consent

-E.C.T. not being used as a threat

-being given a full explanation before E.C.T.

-diagnosis: more people diagnosed with depression report positive outcomes than people diagnosed with schizophrenia, more of whom in turn report positive outcomes than people diagnosed with manic conditions.

15. The beneficial effects of E.C.T. are rapid and only short-term (at most eight weeks).

16. There is a high relapse rate within the first four months after E.C.T., and an even higher rate in the longer term.

17. There is no high quality research to support the use of "continuation" or "maintenance" E.C.T.

18. E.C.T. has no positive long-term effect and does not positively influence long-term survival. Indeed, it has been argued that index E.C.T. treatment predicts high long-term mortality and readmission risks.

19. When effective, E.C.T. relieves only the symptoms of depression and is ineffective in treating depressive illness itself. There is no evidence that it helps patients to deal with their underlying problems more effectively.

20.There is very little good research on the effects of different medications on the efficacy and safety of E.C.T. for patients, although at least some drugs may reduce the effect of E.C.T.