Electroconvulsive therapy on the rise again in England

The use of electroconvulsive therapy to treat serious mental health problems, a procedure long thought to be in steep decline, is on the rise again in England, a Guardian analysis indicates.

Exclusive data covering four-fifths of NHS mental health trusts in England shows that more than 22,600 individual ECT treatments were carried out in 2015-16, a rise of 11% from four years ago, when about 20,400 were carried out.

The number of patients treated also rose, albeit more modestly, to more than 2,200, suggesting that on average individuals undergo more ECT procedures than before.

The figures, obtained through freedom of information requests, show that despite being a crude, controversial treatment, which fell sharply out of favour around the turn of the millennium, ECT is enjoying a revival.

The procedure involves anaesthetising the patient and passing electricity through the brain to induce seizure. Despite ghoulish depictions in popular culture and a marked lack of science explaining how and why it works, treatments can prove effective. Patient stories range from life-changing benefits to tales of lives being ruined.

The data collected by the Guardian covers 44 NHS trusts that provided comparable data. Figures for private clinics are not included.

After considerable fluctuation over the last four years, a comparison of figures from 2012-13 and 2015-16 reveals an 11% rise when it comes to the number of ECT treatments. Almost two-thirds of NHS trusts reported a rise in the number of ECT treatments carried out over the four-year period. The average number of ECT treatments per patient also rose, from 9.6 in 2012-13 to 10.1 four years later.

The changes in ECT were more striking in some parts of the country than others. While the number of treatments carried out by Mersey Care NHS trust, for example, has remained fairly constant over the last four years, the figures for Lincolnshire Partnership NHS foundation trust show a 75% increase in treatments.

Experts and practitioners say a slew of factors could be responsible for the revival. Some say it is down to improved patient access, lack of credible alternatives for serious cases of mental illness and the fact that in many cases ECT does seem to make a difference.

“I think [ECT] should be on the increase because it has been underused for a number of years,” said Tim Oakley, chair of the ECT Accreditation Service (ECTAS) accreditation committee and a clinical director at the Northumberland, Tyne and Wear NHS foundation trust.

“There are some patients who would respond very well to ECT who perhaps don’t get it as quickly as they should or don’t get it at all for various reasons,” he said. “In terms of getting people better, particularly for depression where everything else fails, it is still the best treatment.”

Others point to the patchwork nature of provision – popular in some parts of the country, not in others – as a sign that it is down to local medical preferences.

“The decision about whether ECT is to be used or not is based on the quirks of the local psychiatrist,” said Richard Bentall, professor of clinical psychology at Liverpool University. “There are some places where psychiatrists think it works, and they just do it lots of times, and there are some places where people think: ‘Bloody hell, I don’t think the evidence for this is very good,’ so will only do it in absolutely desperate circumstances.”

He added: “My view is that ECT is a classic failure of evidence-based medicine. I don’t believe that there are adequate clinical trials of ECT to establish its effectiveness.”

While some, including Oakley, have argued that historical ECT trials do show a benefit from the treatment, Bentall believes their design was not up to scratch, and said the data obtained by the Guardian highlighted the need for large randomised placebo-controlled clinical trials – a proposal some proponents of ECT have argued would be unethical.

But Bentall said: “It is clearly unethical to pass electric shocks across people’s brains unless it is effective [and] helpful to do so and therefore there is an ethical requirement to show that treatment is effective.”

Others have suggested the increase in number of ECT treatments could be down to a change from bilateral to unilateral therapy, where the electrodes are applied to one side of the head, rather than at both temples.

“That has slightly fewer side-effects and is less likely to cause memory impairment,” said Andrew Molodynski, consultant psychiatrist at Oxford Health NHS foundation trust and national mental health lead of the British Medical Association’s consultant committee. “It is also slightly less powerful, so it might be that if more people are having that then they are needing slightly more treatments.”

“It is by far the most powerful treatment for depression,” he added. “As a treatment it is certainly not bad as long as it is done properly and for the right people, which is people with genuinely treatment-resistant depression.” While Molodynski added that he did not believe it would be ethical to carry out new clinical trials of the effectiveness of ECT, he thought studies into outcomes over prolonged periods would be valuable.

But Molodynski pointed out that the Guardian figures suggested either that the procedure was being used more freely, or that more people appeared to be falling into the category of those with treatment-resistant depression.

He said the increase should be viewed negatively if it was a result of people with less severe forms of depression not getting the care they needed. “Equally, if people are resorting to ECT for inpatients more quickly, because it works more quickly than antidepressants, in order to get them out of hospital because of our perpetual bed crisis, that would be a major concern.”

One ECT service manager from a London-based mental health trust, who asked not to be named, said the Guardian findings tallied with his own experience of a recent rise in ECT use, adding that the trend was likely to be linked to changes in practice and better regulations, with people becoming more accepting of the procedure. “Our trust treated more patients last year than they have ever treated before,” he said.

A 2014-15 survey which included clinical outcomes for 2,148 people, published by ECTAS and covering England, Wales, Northern Ireland and the Republic of Ireland, reported that 91.5% of patients had improved after the treatment, compared with 1.7% who had become worse.

The mental health charity Mind, however, warned of side-effects, pointing to a 2003 survey it carried out with patients who had undergone ECT who reported memory loss, difficulty concentrating and dizziness.

While the idea of inducing a seizure for therapeutic reasons was first recorded in 1785, ECT was not developed until the 1930s. It was subsequently introduced to England and was commonly used well into the 1960s and 1970s.

But its use waned towards the end of the 20th century. According to the Royal College of Psychiatrists: “Between 1985 and 2002, its use in England more than halved, possibly because of better psychological and drug treatments for depression.”

Dr Rob Chaplin, from the Royal College of Psychiatrists, said: “Previous data collection has shown a decline in ECT, but this appears to have plateaued, perhaps suggesting a change in attitude towards a therapy that has historically been poorly administered and badly misunderstood.

“Since the launch of our accreditation service for ECT in 2003, safety standards have doubled, making ECT in the UK one of the best in the world.

“There is unmistakable evidence that electroconvulsive therapy is an effective treatment for many depressive illnesses, and can act much faster than drugs.”

At present, the National Institute for Health and Care Excellence (Nice) advises that ECT be used only as a last resort for those with prolonged or severe manic episodes, who are in a catatonic state, or who have severe depression or moderate depression when other treatments have not worked.

The data

There is a dearth of information on how widely ECT is used, so the Guardian requested data from every English NHS mental health trust, as listed by the Care Quality Commission, under the Freedom of Information Act for a 10-year period between 2005-06 and 2015-16.

It quickly became clear that many trusts either did not hold or could not access relevant data for the decade covered by the request.

The vast majority could not provide data for the full 10-year period requested. The data presented here begins in 2012 for that reason: a number of trusts were unable to provide figures prior to that year.

Three trusts refused the request outright, saying the staff time required to comply with the request was too great, while seven trusts could not even provide consistent data from 2012-13 onwards. Some trusts admitted they were missing data over periods of months in certain years.

Two trusts provided data that turned out to be completely incorrect, only providing accurate figures after multiple contacts.

The majority of the trusts provided financial year data. However, in those cases where calendar year data was provided, the data was grouped with the closest financial year.

This project may have revealed an increase in ECT use in England but it has also uncovered a lack of properly collected data relating to the procedure.

Electroconvulsive therapy on the rise again in England