2012 and still no Holy Grail

Allan and colleagues provided a helpful reappraisal on the use of neurostimulatory treatments for depressive illness. ¹ In their words, the Holy Grail of treatment would be one as effective as electroconvulsive therapy (ECT), but better tolerated and ideally without the need for general anaesthesia. They concluded that ECT has not yet been supplanted, but we wonder whether the authors were aware of how pertinent this observation is for the year 2012.

Electroconvulsive therapy may not be in use in England by the fiscal year 2011–12. Practitioners in ECT will have seen the graph to support this suggestion at various educational events in recent years. It is based on an extrapolation of data that used to be collected by the Department of Health in quarterly surveys of the number of ECT treatments administered in England. The last two surveys were in the fourth quarter of 1998–99, and the fourth quarter of 2001–02. ² The estimated annual use fell from about 66 000 to 51 000 treatments; if this decline in ECT use continued at the same rate, then the straight line extrapolated from the last data point would reach zero by the year 2011–12. There has never been another national survey. A partial survey of English ECT clinics in the first quarter of 2006 suggested a further fall, to only about 27 000, which was in line with the extrapolation. ³ The re-appraisal prompted us to review the rate of ECT usage in our clinic since 2006.

The rates of ECT usage in 2006 and 2011 were almost identical, that is, 0.82 and 0.83 individual treated patients per 10 000 population in the City of Edinburgh. Likewise, the rates in the intervening years were also almost identical. We therefore conclude, at least for Edinburgh, that the rate of ECT use has been stable for the past 6 years.

The electronic data collection system in our ECT clinic was updated at the end of 2004, and included a record of the primary psychiatric diagnosis of referred patients. The number of referred patients diagnosed with a severe depressive episode (both with and without psychotic features) varied little in these 6 years, from 23 to 28 patients. This gave a crude referral rate of 25 patients with severe depression per year per total population of 500 000.

If we are treating just as many patients with severe depression as 5 or 6 years ago, then this must continue to be resourced. It is not just ECT practitioners that have heard the suggestion about the demise of ECT. Senior managers locally have expressed surprise to hear that there is still a need for the ECT clinic at the Royal Edinburgh Hospital. This concerned us because when the availability of ECT was reduced in Glasgow, ECT use fell. ⁴ The search for the Holy Grail is laudable, but patients with severe depression still need access to ECT.