Madam,

You have recently published the views of a number of eminent psychiatrists advocating the continued use of ECT including, in certain cases, its involuntary use. These psychiatrists relied on a number of points:

-    that ECT is highly effective;

-    that the side effects of ECT are minimal;

-    that, in Ireland, the use of ECT is now tightly regulated both by law and by the professional bodies. 

In relation to its supposed effectiveness, the contention is best encapsulated in a statement by Dr. Brophy, President of the College of Psychiatry of Ireland, who “cites recent Scottish evidence which indicated that 86% of people who received ECT in circumstances where consent was not given recorded an improvement in their condition.” [IT, 7th Dec.]. 

The report referred to appears to be SEAN (2009) which analysed the 278 courses of ECT completed in Scotland in 2008; of these, 71 were involuntary and 86% of these involuntary patients were reported as having shown “a definite improvement” based on MADRS depression scores taken before and after the course of ECT.  However, 15% of those administered ECT had no such score taken and it appears that the scores of over 21% of involuntary patients were “missing”; furthermore 58 courses (21%) had been stopped prematurely because of side effects or lack of improvement.  The MADRS depression measure is a test administered by doctors and there is evidence of poor concordance between patient's and the clinician's assessment of depression, moreover Rose (2003) has reported that “patient’s views have never been systematically reviewed”.  Thus the claim that ECT should be regarded as highly effective, is suspect.

In relation to the supposed lack of side effects, SEAN (2009) – which only discussed side effects occurring during the course of treatment (only 73% of which were recorded) – found that side effects such as ‘anaesthetic complication’, ‘acute confusion’, ‘confusion’, ‘cognitive problems’ and ‘memory problems’ occurred in over 48% of cases; 13 of which were deemed to be “critical incidents (e.g. deterioration in vital signs)”. 

In relation to long term side effects, Rose (2003) examined studies estimating memory loss, these ranged between 29% and 79%; some studies, however, ignored patient accounts of memory loss with one particular study not reporting a finding (contained in the original data) that a third of those who had received ECT believed that it “permanently wipes out large parts of memory”. 

The Royal College of Psychiatry’s fact sheet on ECT acknowledges that user-led surveys have found long term memory problems occurring in 50% of patients; it continues “Some people have complained of more distressing experiences, such as feeling that their personalities have changed, that they have lost skills or that they are no longer the person they were before ECT.  They say that they have never got over the experience and feel permanently harmed.”  These facts are difficult to reconcile with the Dermot Walsh’s statement  [IT, 28th Dec.] that “ the only side-effect of any consequence was slight memory impairment for some hours subsequent to treatment.  In a few cases memory impairment was more prolonged, but reversible.”

In relation to the statutory regulation of ECT (which numerous psychiatrists have described as being closely regulated) it is of interest to note the comments of the Mental Health Commission Report (2009) that the non-compliance by the Mater Hospital, with statuary provisions on the use ECT: “ was of concern and was in breach of the rights afforded to residents as part of the Mental Health Act, 2001.”

Fink (2007) described the professional regulation of ECT in the US as “haphazard” and he noted that the lack of adequate standards was not restricted to the US but “is found worldwide”.  Scotland – which according to Fink was “shamed by the continuing poor assessments of ECT practice” - inaugurated the ECT Accreditation Service (ECTAS) resulting in reports such as SEAN (2009) mentioned above; Fink is of the opinion that ECTAS has revolutionised the practice of ECT.  A 2007 listing by ECTAS mentions 27 ECT clinics in the Republic of Ireland, of which only 4 are accredited and only 1 has a rating of ‘excellent’.  Unless Dr. Brophy can convince us that the clinical standard of ECT clinics in the Republic is of a standard equal to or surpassing those of Scotland then the results of the SEAN (2009) are of scant relevance to the debate. 

For reasons of space, I have made no mention of the most serious consequence of forcible administration of ECT and that is the grievous insult to the autonomy of the individual.

Might I finish by quoting a reviewer’s comment on a textbook on ECT [Lisanby & Morales (2003) reviewing Abrams (2002)]:  “Does ECT cause any degree of permanent memory loss? … Abrams answers … with an unequivocal ‘No!’ … We must not be so enamoured with our treatment that we lose sight of the patient receiving it.” 

Could it be that Irish psychiatry has also lost sight of its patients?

Yours Sincerely,

Gerry Roche, MSc., MPhil, BCL, BL.

Gleninagh Quay,

Ballyvaughan,

Co. Clare.

20th January