Hanafy Youssef, D.M., D.P.M., F.R.C.Psych.
Ross Thomson Unit
Route Hospital
Ballymoney, County Antrim
Northern Ireland

Fatma Youssef, D.N.Sc., M.P.H., R.N.
Professor of Nursing Science
School of Health Professions
Marymount University
Arlington, Virginia, USA

Abstract

In Italy, where it began more than 62 years ago, ECT has almost been abolished. In some countries, however, ECT is still used inappropriately, particularly in elderly patients. There is no medical, moral, or legal justification for ECT, and the new requirements of modern psychiatric practice can all be achieved without it. Like prefrontal lobotomy and all previous shock treatments, ECT is non-viable. The death of ECT will help promote mental health and put the treatment where it belongs - in the archaeology of science.

Introduction

The introduction of electroconvulsive therapy (ECT) into psychiatry and the enthusiasm with which it was adopted coincided temporally with the lack of other therapies for mental illness. Indeed, evidence that ECT has a beneficial effect is sparse. In contrast, there are many indications of its ineffectiveness and association with various forms of harm. The role of ECT in modern psychiatry needs re-evaluation, and the time may have come to abandon this unscientific treatment.(1)

By directive of the Minister of Health, use of ECT has been nearly abolished in Italy, where it began 62 years ago.(2) Curiously enough, the Minister's instruction stirred no protest by that country's medical profession, and many psychiatrists welcomed the pronouncement. It is encouraging to know that ECT is nearly obsolete in Germany and Holland.

In Italy, the commission convened to evaluate ECT stated that the procedure was out of line with recent trends and was distinguished by improper use and abuse. Moreover, despite considerable research in recent decades, its mode of action had not been clarified. One commission member described ECT as belonging to the archaeology of science, adding that it should be acknowledged only for what it meant in the 1940s.

Notions that ECT could become more humane by legislation and the intervention of professional societies and colleges are an illusion. As a 1998 report stated, "Two thirds of ECT clinics fall short of the most recent college standards, particularly in relation to the frequency of Consultant attendance and training of junior doctors. These problems have not been fully resolved by 20 years of audit and college activity. There should be a continuing debate as to what future intervention might be considered."(3)

Is ECT Still Abused?

In the past, inappropriate uses of ECT were brought to light by patients and pressure groups. The history of ECT, its abuse, and resultant unfavorable publicity are responsible for its increasingly reduced use.(1) We have been told that various bills introduced by legislators in the United States, professional societies, and the UK Royal College of Psychiatrists would make abuse a thing of the past.(4,5) But it still exists, as this case report indicates. A 30-year-old patient committed suicide while undergoing ECT at Gartnaval Hospital in Scotland.(6) Hospital records stated that he had refused ECT again and again. Health officials were accused of negligence leading to his death, and his family was awarded £50,000. This case exposed the UK's system of a required second opinion before use of ECT as a farce.

In spite of the Mental Health Act and various guidelines to safeguard against coercive treatments, an estimated 20,000 patients a year receive ECT in the United Kingdom, where many foreign doctors receive their psychiatric training. It is therefore not surprising that ECT is big business in private clinics and private hospitals in developing countries.

As the case report showed, ECT is not a suicide preventive.7 In fact, the mortality risk after ECT is higher than in patients who do not receive ECT.(8) Death due to ECT may be rare, but the procedure can sometimes be fatal. A survey of all ECT treatments given with anesthesia in Denmark found a death rate of 1 in 22,000 treatments, ie, 4 to 5 unnecessary deaths per 100,000 treatments.(9) In the past, when ECT was delivered without anesthesia, crush fractures of the vertebrae, among other fractures, occurred. Modified ECT with anesthesia and muscle relaxants is said to be safe; however, when death occurs, it is ascribed to the risk of anesthesia. Yet a significant proportion of anesthetists prefer not to become involved in ECT practice and research.(10)

Abuse of ECT in the young has surfaced in the past, but abuse in the elderly may go unnoticed.