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Controversial Treatments in Psychiatry ARTICLE Jason Luty BJPsych Advances (2017), vol. 23, 169–178 doi: 10.1192/apt.bp.115.014803 Controversial treatments in psychiatry ARTICLE Jason Luty basis of the incorrect theory that epilepsy and Jason Luty is a consultant in SUMMARY schizophrenia could not exist together. Electri- addictions psychiatry at Borders Health. He has published in the Psychiatry uses some of the most controver­ cally induced seizures were developed by Italian sial treatments in medicine. This may be partly addictions field, trained at the psychiatrists Ugo Cerletti and Lucio Bini in 1938. Maudsley Hospital, London, because several are administered under coercion This followed Cerletti observing seizures in pigs who and spent 8 years as consultant and opposed to the patient’s expressed will, under were given an electric shock as an anaesthetic before in addictions at the South the protection of the relevant mental health Essex Partnership NHS Trust. legislation. Electroconvulsive therapy (ECT) is being slaughtered. ECT was effective in depression Correspondence Dr Jason Luty, perhaps the archetypal controversial treatment; and catatonic schizophrenia. In the 1940s, ECT Borders Addiction Service, The although it is considered to be effective, the was usually given in ‘unmodified’ form, without Range, Tweed Road, Galashiels research supporting it is much less impressive than muscle relaxants. Muscle relaxants (curare and TD1 3EB, UK. Email: jason.luty@ yahoo.co.uk one would expect. The prescription of stimulant suxamethonium) were introduced later, along with drugs for childhood attention­deficit hyperactivity general anaesthesia to reduce the risk of fractures Copyright and usage disorder (ADHD) and substitution therapy (such as © The Royal College of Psychiatrists during seizures. ECT became less popular with the 2017. methadone maintenance) in addic tions treatment arrival of modern antidepressants in the 1950s. In remain topical and appear to be subject to political the UK, an estimated 12 000 people received ECT interference. ‘Treatment’ for homosexuality and in 1980 (Department of Health 2003), although psychosurgery were common in the past but are now rare. These issues are discussed to give the prevalence had fallen to around 400 patients insight into how once common controversial by 2013 (Reed 2013). ECT is typically given twice treatments can decline and become obsolete. a week for 6–12 weeks. In the past, women were at However, seclusion and covert medication remain least twice as likely to receive ECT as men. This has in practice and are highly scrutinised. raised concerns about gender bias as, until recently, psychiatrists were usually men. LEARNING OBJECTIVES ECT is now used to treat very severe psychiatric • Recognise that many controversial treatments, disorders which are often life threatening, where such as psychosurgery, have been superseded by psychotropic drugs used since the 1950s a rapid response is required. These include severe depression, resistant mania or catatonia (National • Be aware of the limitations of evidence supporting Institute for Health and Care Excellence (NICE) controversial treatments, such as stimulants for childhood ADHD and ECT for depression in adults 2003). To give an illustration of the risk and benefits, it is estimated that 15% of people with • Be aware that controversial treatments are severe depression will die by suicide. highly emotive and may be viewed negatively by the public or politicians, despite evidence for NICE (2003) refers to a report containing 90 their safety and effectiveness randomised controlled trials of ECT in depression and 25 trials in schizophrenia. Many of the trials DECLARATION OF INTEREST were performed prior to the 1980s, when ECT None was not used in the same manner or for the same indications as in current practice. For example, one study from 1959 involved patients who did not Electroconvulsive therapy know they were being included in a trial. Many of There are few treatments as controversial as the older studies had fewer than 10 participants. electroconvulsive therapy (ECT). The US author Overall, the trials suggest that ECT has the Ernest Hemingway died by suicide shortly after advantage of rapid response but is no more effective undergoing ECT at the Mayo Clinic in 1961, than antipsychotics in schizophrenia. reportedly saying about ECT ‘What is the sense of Several studies have compared the effect of ruining my head and erasing my memory?’. ECT ECT with placebo – that is, using a brief general was graphically described by Ken Kesey, who had anaesthetic without inducing a seizure using an worked as an orderly at a mental health facility in electric current (‘sham ECT’). The UK ECT Review California, in One Flew Over the Cuckoo’s Nest. Group (2003) and NICE (2009) analysed results Seizures have been used to treat mental health from 31 randomised trials including over 1600 problems (‘hysteria’) since the mid-1700s. In 1934, participants. They reported an effect size of 0.230– the Hungarian psychiatrist Ladislas Meduna used 0.322 (by convention, this is considered a small-to- camphor-induced seizures as a treatment, on the medium effect size). This provides some evidence 169 Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 00:40:11, subject to the Cambridge Core terms of use. Luty that ECT is superior to sham ECT (anaesthesia patients report that up to half of those who have alone), although the placebo response is remarkably had ECT complain of significant memory problems high (Rasmussen 2009). (Rose 2003). NICE (2003) concluded that ‘There Perhaps the best known trial is the Northwick is clear evidence that cognitive impairment occurs Park study of ECT (Clinical Research Centre 1984) both immediately after administration of ECT involving 70 patients. The results were presented and following a course of therapy’, although it is graphically. There was a reduction from baseline uncertain whether memory loss exceeds 6 months. scores of 50–55 on the Hamilton Rating Scale for Short-term amnesia occurs in many mental health Depression to an average score of around 15 in the problems, particularly following acute episodes ECT group and 25 in the sham ECT group. The (Ingram 2008). Hence, it is difficult to determine proportion of patients showing clinically significant whether amnesia is due to ECT or to the severe improvement (halving of the Hamilton score) was mental illness that ECT was being used to treat. probably very close between the ECT and sham A particular issue for patients is the report that ECT groups. By contrast, the Nottingham ECT ECT may cause more profound memory problems, study (Gregory 1985) involved 3 groups of 26 specifically amnesia for autobiographical events patients (total 78) receiving bilateral, unilateral such as memories of childhood (Lisanby 2000; Rose and sham ECT. There was a baseline mean 2003; Ingram 2008). This is rather challenging to Montgomery–Åsberg Depression Rating Scale neuroscientists, as most other physical traumas, score of approximately 34, falling to 10 in both the such as serious head injuries, do not cause specific ECT treatment groups but 24 in the sham group. autobiographical amnesia, at least not without This was a highly significant outcome. obvious damage to global brain functions like speech The effect size of 0.2–0.3 reported by the and movement. Although many expert groups are meta-analysis of sham ECT is surprisingly small. probably reluctant to enunciate this, some patient Similarly, the large and often quoted Northwick accounts raise the possibility of suggestibility and Park study found a significant improvement in the dissociative disorders that could explain some response of the control group, with the proportion of reported autobiographical memory problems. of participants reporting clinically (rather than In other words, these are subconscious memory statistically) significant difference being probably problems rather than a result of neurological very close (the results are portrayed graphically, damage. This is a particular possibility for patients which hampers further scrutiny). Consequently, with emotionally unstable personality disorders – a much of the scientific support for ECT is based group who are also highly vocal and particularly on the Nottingham trial. Considering the highly prone to dissociative disorders. Rose et al (2003) controversial nature of ECT, this paucity of evidence summarised the results of 7 studies reporting on is surprising. Moreover, there is far more evidence perceived memory loss and found that between 29 to support other controversial treatments such as and 55% of respondents believed they experienced stimulant use in children (possibly because this long-lasting or permanent memory changes. This research was funded by pharmaceutical companies). issue remains unresolved. Some researchers have analysed the work that The Royal College of Psychiatrists’ ECT Accredi- has been done on patients’ experiences of ECT. tation Service (ECTAS) provides independent They reported that the proportion of people who assessment of the quality of ECT services. ECTAS had had ECT and found it helpful ranged from 30% sets very high standards and visits all the units to 80%. However, the researchers noted that studies registered with it – currently over 78% of ECT clinics reporting lower satisfaction tended to have been in England and Wales, plus a number in Northern conducted by patients, and those reporting higher Ireland and the Republic of Ireland (www.rcpsych. satisfaction were carried out by
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