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ECT, Forty Years OnWHY were four decades allowed to elapse

between the introduction of electroconvulsive ther-

apy (ECT) and its proper testing? Until lately thesubject was almost completely neglected byresearch-workers: in 1974 the U.S. National Insti-tute of Mental Health reported that, of almost tenmillion dollars granted for somatic-therapyresearch in 1972-73, less than five thousand wenttowards ECT research. Reports published in thepast fifteen years reflect this lack of serious inter-

est-plenty of testimonies to the value of ECT inall manner of psychological and behavioural

troubles, but a dearth of scientific inquiries intoefficacy. A more critical approach in the early daysof ECT might have spared psychiatry much hos-tility and abuse. Now the position is changing fast;and last month the department of psychiatry atLeicester University ran a conference to examinethe status of this controversial treatment.

In several recent trials ECT has been compared with"simulated ECT" consisting of muscle paralysis andgeneral anaathesia but no actual shock. The most cele-brated account of the efficacy of simulated ECT hasnever been authenticated. According to a story in WorldMedicine2an ECT machine was used for over two yearsin the Midlands without anyone noticing that the ma-chine was defective and not actually producing a shock.All attempts to trace the author of this tale have failed,but it surfaces continually in hostile accounts of ECT.’,’Most of the psychiatrists at Leicester were satisfied ofthe usefulness of ECT in severe depressive illness, but byno means all. One reason for doubts is that the few ade-

quate trials performed so far have not given comparableresults. In the Wessex trials ECT was superior to thesimulated variety only in terms of its effects on anxiety,whereas the Edinburgh group6 declared unequivocallythat ECT is "significantly superior to simulated ECT inthe treatment of depressive illness." A third study, byE. D. WEST, also finds in favour of ECT as a treatment ofdepression but has yet to be published, while a fourth,at Northwick Park, which because of the extreme rigourof its design is regarded by some as likely to settle theissue, is still under way. The differences in the resultsobtained so far may well be a function of differences in

design, in the type of ECT used (the argument overunilateral and bilateral ECT rages on), the frequency ofadministration, the number of treatments given in acourse, and the positioning of the electrodes. On each ofthese matters, further research is needed. Is ECT usefulin the treatment of schizophrenia? PAMELA TAYLOR(Institute of Psychiatry, London) had preliminaryresults suggesting that in acute schizophrenia it may in-

1. Research in the Service of Mental Health: Report of Research Task Forceof National Institute of Mental Health. DHEW Publication (ADM)75-236, 1975, Chap. 12.

2. Easton-Jones J. Non-ECT. World Med Sept. 11, 1974.3. Frank LR. The history of shock treatment. London: Wildwood House, 1979.4. Friedberg J. Shock treatment, brain damage and memory loss: a neurological

perspective. Am J Psychiatry 1977; 134: 1010-14.5. Lambourn J, Gill D. A controlled comparison of simulated and real ECT.

Br J Psychiatry 1978; 133: 520-23.6. Freeman CPL, Basson JV, Crighton A. Double-blind controlled trial of electro-

convulsive therapy (E.C.T.) and simulated E.C.T in depressiveillness. Lancet 1978; i: 738-40.

deed be effective. This question has formerly been bede-villed by arguments about the precise boundary betweenschizophrenia and affective disorders, but with morerefined diagnosis definitive evidence should emerge, oneway or the other.

If ECT does work in depression and we can findout how it works, then we may’ know what is theunderlying biological disturbance in that condition.This approach has been tried at the M.R.C. Clini-cal Pharmacology Unit in Oxford. At LeicesterA. R. GREEN told how, in rats, repeated electro-shock produced behavioural alterations consistentwith the enhancement of postsynaptic sensitivity ofdopaminergic, noradrenergic, and serotoninergicneurones. Such effects were seen only after multi-ple convulsions administered over a time scale anal-ogous to that used in clinical ECT. But the mech-anisms whereby such biological changes might beproduced remain far from clear. More is known ofhow ECT does not work. Since simulated ECT haslittle effect, ECT does not work through provokingnon-specific stress or anticipatory fear. UnmodifiedECT, which is much more stressful, is no moreeffective than modified ECT. In addition, ECTdoes not produce its effects through non-specificevents such as anoxia or hypercapnia since theresults are no less good when the patient has extraoxygen. Nor does ECT seem to produce its effectsthrough memory disturbance since unilateral treatyment is not notably inferior to bilateral treatment,with its greater effect on memory. Physical convul-sion is certainly not an essential element. 8Given the controversial nature of the topic (the

first day of the Leicester conference was picketedby the Citizens Coinmission on Human Rights, afront for the scientologists), it was inevitable and

fitting that the assembled psychiatrists should turntheir attentions to the main areas of disquiet. Asurvey by C. P. L. FREEMAN, in Edinburgh,revealed that most patients found ECT less fright-ening than going to the dentist. The results rein-forced the earlier findings of SPENCER9 that pa-tients are more likely to be distressed by having towait around for treatment, by hearing other pa-tients being treated, or by having treatment badlyapplied (e.g., insufficient muscle relaxant or anæs-

thetic agent) than by the more publicised side-effects such as memory impairment. Yet it is thedisturbance of memory which provokes the mostconcern and criticism. The Leicester conferenceheard evidence that most of the memory impair-ment is transient and inconsequential. Such a con-clusion is in line with the elaborate and imaginativeattempts by SQUIRE and his colleagues in the

7. Grahame-Smith DG, Green AR, Costain DW. Lancet 1978; i: 254-56.8. American Psychiatric Association. Electroconvulsive Therapy Task Force

Report 14. Chap VI: 122-31. Washington, D.C.: American PsychiatricAssociation, 1978.

9. Spencer DJ. Some obsérvations on ECT. Med World 1968; 105:26-29.

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United StateslO-12 to clarify the question of ECT-induced memory impairment, particularly loss ofmemories laid down before treatment. But the

existing tests for remote memory are crude, and de-spite these reassuring findings the Leicester confer-ence called for further research.Regarding other serious side-effects, such as car-

diac arrest and fractures, the psychiatrists werevery happy about the safety of ECT. They reactedbadly, therefore, when LARRY GosTIN, legal adviserto the National Association for Mental Health

(MIND), repeated his view13 that the treatment isstill experimental, hazardous, and irreversible andthat it should never be tried in compulsorilydetained patients without the consent of an inde-pendent multidisciplinary review body akin to themental-health review tribunal. GOSTIN was at painsto point out that it is not the psychiatrist’s clinicaldecision to use ECT which would form the subjectof such a review but his assessment of the incompe-tency of the detained patient to refuse to undergothe treatment. It is the issue of competency and therelated notion of informed consent which have

occupied the minds and affected the decisions oflegislators in several American States. In the mostcelebrated ruling, an Alabama State judge ruledthat, henceforth, before ECT can be given to evena consenting patient the indications have to beadjudged by at least four psychiatrists and oneneurologist with at least two attorneys monitoringthe proceedings. This ruling, incidentally, was thedirect result of a "right to treatment" case whichin turn arose from disquiet over the adequacy ofstaffing and the quality of standards in Alabama’sState psychiatric facilities. Other States and pro-vinces-in the U.S.A. California, Florida, Oregon,Illinois and Connecticut; in Canada Ontario; andin Germany Lower Saxony-have introduced

legislation to curtail the use of ECT. In Britain Prof.R. KENDELL14 is quoted as saying that there is notthe slightest risk of ECT being banned, but the anti-ECT campaign is well-organised and not withoutinfluence. Earlier this year, seven MPs, largely in-fluenced by the hostile criticism, raised the questionof a ban on account of the lack of evidence as toits efficacy and its "alarming side-effects".

It was as a result of the commision of inquiryinto the allegations of ECT abuse at St. Augus-tine’s Hospital that the Royal College of Psychia-trists produced its memorandum on the use ofECT.15 This memorandum strongly endorses the10. Squire LR, Chace PM, Slater PC. Retrograde amnesia: temporal judgements

about remote events following electroconvulsive therapy. Nature 1976;260:775-77.

11. Squire LR, Slater PC, Chace PM. Retrograde amnesia: temporal gradient invery long-term memory following electroconvulsive therapy. Science

1975, 187: 77-79.12. Squire LR, Chace PM. Memory functions six to nine months after electro-

convulsive therapy. Arch Gen Psychiatry 1975; 32: 1557-64.13. Gostin LO. A human condition: the Mental Health Act from 1959-1975

1975). 1 Mental Disability Law Reporter, 1976,55.14. Kendell R. Quoted in Daily Express Sept. 21, 1979.

policy of obtaining a second and independent psy-chiatric opinion in all cases where ECT is beingconsidered as a treatment of a compulsorilydetained patient. But can such a second opinion begenuinely "independent"? GOSTIN thought not andthe assembled psychiatrists at Leicester were

shocked at this challenge to their professional in-tegrity. Ironically, the case for rebuttal of GOSTIN’Sargument was put by the newly appointed medicaladviser to MIND, ANTHONY CLARE, who pointedout that the evidence on ECT reviewed at the con-ference showed clearly that ECT is no more experi-mental, hazardous, or irreversible than certainforms of behavioural modification and psychotro-pic drugs. Why should the call for a multidisciplin-ary panel to review the treatment of the compul-sorily detained patient stop at ECT? What aboutlong-acting phenothiazines? What about potentantidepressants? What, as someone rather point-edly inquired, about psychotherapy; has it not beenshown to be experimental, potentially hazardous,and irreversible? Yet CLARE was on record as

believing, reluctantly, that some form of multidis-ciplinary review would prove unavoidable indetained patients.16 What seems to have changedhis mind is the great complexity of the procedure,which might well persuade psychiatrists to aban-don the treatment. Indeed, some of those who callfor greater restrictions may be hoping for such anoutcome. In the U.S.A. they may well be succeed-ing. A survey in New York Statel7 revealed a 49%reduction in the use of ECT from 1972 to 1977.The largest decline was seen in State psychiatrichospitals. Private mental hospitals remain the

prime users-an observation which conflicts withthe often repeated assertion that ECT is a methodof punitive and social control particularly favouredby those active in the intimidation and oppressionof radical and minority groups.

SELENIUM IN THE HEART OF CHINA

THERE is new evidence that the element named afterthe moon, selenium, may be essential for the function ofthe heart.1.2 Marco Polo gave the first account ofselenium toxicity,3 observed during his travels in China;

15. Royal College of Psychiatrists. Memorandum on the use of electroconvulsivetherapy. Br J Psychiatry 1977; 131:261-72.

16. Clare AW. Therapeutic and ethical aspects of electro-convulsive therapy: aBritish perspective. Int J Law Psychiatry 1978; 1: 237-853.

17. Morrissey JP, Burton NM, Steadman HJ Developing an empirical base forpsycho-legal policy analyses of ECT: a New York State survey. Int J LawPsychiatry 1979; 2: 99-111.

1. Keshan Disease Research Group of the Chinese Academy of MedicalSciences, Beijing, Antiepidemic Stations of Sichuan Province, Chengdu,Xichang District, Sichuan and Mianning County, Sichuan. Observationson effect of sodium selenite in prevention of Keshan disease. Chinese MedJ 1979; 92: 471-6.

2. Keshan Disease Research Group of the Chinese Academy of MedicalSciences, Beijing. Epidemiologic studies on the etiologic relationship ofselenium and Keshan disease. Chinese Med J 1979; 92:477-82.

3. Schroeder HA, Frost DV, Balassa JJ. Essential trace .etals in man: selenium.J Chron Dis 1970; 23: 227-43.