John Read: No benefits from damaging brains

John Read

Electro-convulsive therapy, or ECT, involves administering electricity to the brain to cause a seizure, in the hope of alleviating mental-health problems such as depression and schizophrenia.

As in the rest of the world, about two-thirds of New Zealand's ECT recipients are 50 or older, and about a third 70 or older. Twice as many women as men receive ECT.

Last week, the Ministry of Health released the final report of the ECT Review Committee, the culmination of much hard work by many New Zealanders.

In 1999 the Patient Rights Advocacy Group presented to Parliament a petition stating that "ECT is degrading, inhumane and causes brain damage and memory loss". The health select committee met this petition with impressive open-mindedness.

Three senior Maori mental health colleagues and I, for instance, were allowed a fair amount of time to present information to the committee. I summarised the international research literature showing that ECT had few short-term benefits and none at all after four weeks.

There is no evidence to substantiate the claim, made by ECT supporters - including Ministry of Health officials - that ECT saves lives by preventing suicide. It also causes permanent memory dysfunction in a minority of recipients and involves a small but significant mortality risk.

My Maori colleagues were allowed to explain to the select committee why the head is tapu, making the idea of electrocuting the brain alien to many Maori.

The committee recommended to Parliament that there should be an independent review of the safety and efficacy of ECT, and the adequacy of regulatory controls. This was welcomed by the Mental Health Commission, the Human Rights Commission and the Health and Disability Commission. Parliament gave the go-ahead.

The review's independence, however, may have been compromised by the ministry handpicking the chair, attending initial committee meetings and controlling who had the right to see and respond to the draft report.

It should come as no surprise that the review rejected the recommendation that ECT be banned, and concurred instead with the ministry's stated presumption that ECT was safe and effective.

A request to have my analysis of the research literature appended to the report, so that Parliament had more than one view to consider, was ignored.

The review committee's gathering of research data was commendably extensive, but the analysis was flawed.

For example, the report rightly concluded: "There is no definitive randomised evidence that ECT prevents suicide." So it seems illogical that it went on to recommend that ECT should be used when patients are "at a high risk of suicide".

The report's claim that "ECT is an effective treatment" is not supported by research evidence. There are no studies showing any benefits beyond a few weeks. Only one properly designed study has ever followed patients for six months. It found no difference between those who received ECT and those who did not.

The report acknowledged that "ECT may permanently affect memory" and may cause "changes to structure, and presumed function, of the brain. This could explain both the beneficial effects and the adverse effects on the brain".

This is consistent with the fact that when ECT was invented it was argued, in medical journals, that it worked precisely because it caused brain damage. It was thought that some people were better off with fewer memories and lower intelligence.

If subsequent studies have, indeed, found permanent brain damage, how can the report recommend continued use of ECT, especially when there are no proven lasting benefits?

In deciding how to respond to the report, Parliament may be tempted to bow to pressure from vocal professional ECT advocates, relying on the adage that "doctor knows best". Surely no doctor would recommend something that has no long-term benefit and carries significant risk of permanent memory impairment.

But the history of medicine includes many treatments later found to be ineffective and dangerous. In the mental-health field, these include surprise baths, rotating chairs and, more recently, lobotomies.

At the time, the doctors genuinely believed they were helping people. So, no doubt, do the dwindling number of psychiatrists still using ECT.

Perhaps, regardless of the outcome in Parliament, the democratic process has already served a valuable function. When I discussed ECT on this page more than three years ago, I did so partly because Ministry of Health figures had shown an increase from 209 treatments in 1995 to 713 in 1999. The public debate stimulated by the Patient Rights Advocacy group and the select committee's positive response to its petition has been followed by a decline in use to 414 in 2001-02 and 307 in 2003-04.

At this rate of attrition ECT will have gone the same way as lobotomies before 2010. Use has been declining in most countries, except the United States, for some time.

While no doubt disappointed with the report, those ECT recipients who have worked so hard to draw this issue to our attention should be pleased at, and take some credit for, the fact that New Zealand is now in line again with this international slide to obsolescence.

In the meantime, some important questions need to be addressed by some of our district health boards. Why, for example, does Otago have an ECT rate of 22 per 100,000, three times the national average and 20 times higher than Auckland? Why does the Bay of Plenty have a rate of 17 per 100,000?

Why does our national average for the number of treatments given to each person, 10.4, exceed international guidelines of six to 10? Why does the Waitemata District Health Board use an average of 18 treatments per person?

And why are so many New Zealanders given ECT against their will? Clearly our regulatory controls are insufficient to prevent excesses.

I hope the Government will be bold enough to make New Zealand the first country to render ECT illegal. It is already hardly used at all in many countries.

Parliament should at least consider ensuring that all New Zealanders have the right to accurate, comprehensive information about the limited benefits and the serious harmful effects of ECT. This is far from the case at the moment.

Parliament should certainly insist that we all, not just those deemed competent to know what is best for us - as recommended by the report - have an absolute right to refuse ECT if we wish.

* Dr John Read teaches psychology at Auckland University.