What is the state of the clinical practice of electroconvulsive therapy (ECT) in the United States today?
Surveys of ECT use in the United States show disparate applications, with the principal use in academic medical centers. While more than half the treatments are given to outpatients, whole populations are underserved.1 Reports of ECT practices in community settings are disquieting, with out-of-date equipment and nonstandard treatment protocols described, resulting in preventable untoward consequences.2-4 The education of practitioners in ECT is limited, and no standards for certification or requirements in experience are routine.5
Similar circumstances in Great Britain a quarter century ago elicited criticism of the profession that eventually led to a voluntary response by the national psychiatric associations. Training and practice standards have been reset, with increasing numbers of clinical centers meeting practice standards. This experience can be used as a model to ensure effective and safe treatment in the United States.
The British experience
In 1980, Britain's Royal College of Psychiatrists (RCP) commissioned a national survey of the practice of ECT in response to public and professional concerns.6 A questionnaire was sent to psychiatrists, psychiatric facilities, and general practitioners. In addition, two surveyors observed ECT treatments in 100 of 180 treatment facilities. The surveyors reported that obsolete devices, minimal training of personnel, lack of seizure monitoring, and missed seizures were frequent. In 27 clinics, ECT practice was so deficient that surveyors would not hazard the treatments for themselves or their patients.
After the findings were published, the editors of The Lancet chastised the profession. "Every British psychiatrist should read this report and feel ashamed and worried about the state of British psychiatry. If ECT is ever legislated against or falls into disuse it will not be because it is an ineffective or dangerous treatment; it will be because psychiatrists have failed to supervise and monitor its use adequately."7
In 1989 the RCP issued ECT practice guidelines.8 A follow-up 1991 survey of a sample of National Health Service (NHS) hospitals and private clinics in two British NHS regions found much improvement in the physical and anesthetic conditions of ECT practice, but half the units were still using outdated equipment, few consultant arrangements were satisfactory, and the training of registrars was still inadequate. ECT usage varied widely, with a 55% drop in one region and a 20% rise in another since 1979.9
Updated guidelines for effective treatment, facilities, and training of personnel were issued by the RCP in 1995.10 A third survey in 1998 again found deficiencies; a third of the clinics did not meet RCP guideline standards, 41% still used outdated equipment, and only 16% of the responsible consultants attended weekly ECT treatment sessions. After 20 years of activity by the RCP and three audits, there was only modest improvement in clinical practices.11
The training of the junior doctors who administered ECT was of variable quality; more than half asserted that their first treatment was given without the supervision of a qualified consultant. In examination questions, 45% lacked knowledge about one or more basic issues in ECT practice.12
Within one academic Scottish hospital over three years, usage varied 18-fold among 11 general adult consultant teams and 2-fold among three geriatric psychiatric teams.13