Editorial for ECT

Abstract

In April 2003, the National Institute for Clinical Excellence (NICE) published its guidance on electroconvulsive therapy (ECT) (report number 59). For those of us involved in work with ECT in the United Kingdom, it produced a mixture of disappointment, relief, and frustration in roughly equal measures. Relief because there were rumors that NICEmight Bban^ECT, frustration because of the nature of theNICEGuidance process, and disappointment because of the limited endorsement that NICE gave to ECT. NICE is a wholly government-funded body set up to provide guidance in England and Wales (not Scotland where I work) on all aspects of evidence-based practice in medicine. NICE produces 3 types of guidance. Clinical guidelines are comprehensive reports often running to several hundred pages based on detailed and systematic reviews and compiled by an expert panel of clinical and research leaders in a particular field along with patients and carers. NICE has produced excellent guidance on depression, posttraumatic stress disorder, eating disorders, and obsessive compulsive disorder and has several other major psychiatric topics in the pipeline (www.nice.org.uk). All reports can be downloaded from their Web site. The second type of guidance is health technology reports. These are on a narrower topic such as drugs, medical devices, diagnostic techniques, or particular surgical procedures. In psychiatry, there have been health technology appraisals on atypical antipsychotics (number 43), the use of the drugs orlistat and sibutramine in the treatment of obesity (numbers 22 and 31), new drugs in the treatment of bipolar disorder (number 66), and computerized cognitive behavior therapy in the treatment of depression and anxiety (number 51). The ECT report which is the subject of this editorial is number 59, its full title, BThe clinical effectiveness and cost-effectiveness of ECT for depressive illness, schizophrenia, catatonia, and mania.^ The third type of guidance covers public health issues. What is most surprising about the ECT appraisal is that no psychiatrist was on the committee; in fact, no mental health professional was part of the group. The group was chaired by a professor of clinical pharmacology. Among its 24 members were 2 general practitioners, 3 professors of pharmacology, 3 consultant physicians, a surgeon, and 2 hospital chief executives. There was no one closely connected with mental health. Unlike the clinical guideline program where a group of specialists is assembled for a particular report, the Health Technology Appraisal Committee is a standing committee with members serving for 3 years and reviewing a wide range of health technologies. The group did, of course, take evidence from clinicians and patient groups, and it is clear that they received very robust evidence from patients and ex-patients about the dangers and harmful effects of ECT. NICE did endorse the use of ECT but only in a limited way and as a treatment of last resort. Their key conclusions were as follows: 1. ECT should only be used for treatment of severe depressive illness, a prolonged or severe episode of mania, or catatonia. 2. ECT should only be used in the above disorder if the conditions below apply. 3. ECT should be used to gain fast and short-term improvement of the severe symptoms after all other treatment options have failed, or when the situation is thought to be lifethreatening. 4. The treatment should be stopped as soon as the person has responded, if there are any adverse effects, or if they withdraw their consent. 5. ECT should not be used as a long-term treatment to prevent recurrence of depressive illness. 6. ECT should not be used in the general management of schizophrenia.