A survey of mental health trusts across England has found that Bristol doctors use electroshock therapy – a century-old technique in which brain seizures are induced in mental health patients – more often than anywhere else in England. UK ECT Improving Standards Campaign Group commissioned the audit of NHS trusts, using freedom of information (FOI) requests to obtain data on how often medics applied controversial electroconvulsive therapy (ECT) for depression, mania or schizophrenia.
This named Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) as the most frequent user of ECT, employing it 47 times more often than the least frequent user, Liverpool-based Mersey Care. Medics at AWP treated 169 people using ECT in 2019, or 94 people per million residents within its catchment area. For Mersey Care the figure was just two people per million – a 47-fold difference.
Two ECT teams cover the AWP service area: Linden Unit at Callington Road Hospital in Bristol and Green Lane Hospital in Devizes, Wiltshire. These include doctors and nurses trained in ECT, plus several anaesthetists. In use since the 1930s, ECT involves placing electrodes on the head of a patient and passing an electric current through one or both hemispheres of the brain.
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Graphically depicted in One Flew Over the Cuckoo’s Nest , the treatment was originally given while patients were fully conscious. Doctors now administer general anaesthetic and muscle relaxants before applying the electrodes, meaning the seizure happens only in the patient’s brain and not their whole body. But it remains controversial due to a lack of agreement on how, why or whether it works.
Mental health charity Mind reports that “some people find ECT helpful while others don’t,” adding that “it’s very difficult to know how ECT works, or how effective it is. Many different theories have been suggested, but research hasn’t shown exactly what effects it has or how these might help with mental health problems,” the charity’s website adds, reflecting guidance from the National Institute for Health and Care Excellence (NICE).
Moreover, NICE advice for doctors acknowledges that ECT can have side effects including “short-term or long-term memory loss, which can be very distressing”. One person has approached Bristol Live claiming such long-lasting effects, but did not wish to be identified.
Dr Lucy Johnstone is a consultant clinical psychologist and former AWP mental health worker. She now offers independent training services and has long been an outspoken critic of ECT, amongst other modern psychiatric techniques.
“It’s essentially a head injury, a random blow to the brain,” she said. “There’s never been a strong scientific rationale to inducing epileptic fits – most neurologists will tell you fits aren’t good for the brain and there is a lot of evidence of brain damage caused by ECT.
“In the longer term people lose memories permanently,” she added. “They can’t remember their weddings, do their jobs, recognise their friends, or learn new skills. It can affect any area of their body and cause increased risk of all forms of illness.”
Existing codes of best ECT practice are written and reviewed by the Royal College of Psychiatrists, something Dr Johnstone describes as “doctors marking their own homework”. The process is voluntary and doctors can administer ECT without subscribing to the RCP.
Dr Johnstone sees no reason why the administration of ECT should be so high within areas covered by AWP, compared with elsewhere. “On the face of it, something is going very badly wrong,” she said.
“If it was an operation of any other sort, you would suggest that it was not being used according to the guidelines – either a lot of people here are getting it when they shouldn’t, or people elsewhere are missing out. I believe it’s the former.”
The audit also revealed that up to one-third of people receiving ECT do so against their will, despite NICE and RCP guidance that full and informed consent should be given in all but very limited circumstances.
Of those receiving ECT against their will, elderly women were represented disproportionately highly. “Some cannot give consent because they are severely depressed, but some will be clearly and articulately saying they don’t want it,” said Dr Johnstone.
“We’ve been in contact with a woman locally who has been locked up in a hospital for over a year and has been given over a hundred ECTs. She’s now barely able to recognise anyone or even talk.
“We’ve put in complaints, but doctors can do whatever they like. This case falls well outside the NICE guidelines, but those aren’t legally binding. It’s an absolutely horrendous case.”
Dr Johnstone called the disparity between ECT rates around Bristol and elsewhere “intuitively odd”. She added: “You would expect high ECT use in areas of high deprivation, because depression is a result of life circumstances.
“Bristol is relatively wealthy, so it doesn’t make sense. We think there are just areas where ECT is doctors’ favourite thing – some will use it several hundred times more than others. Clearly in AWP you have one outlier who has given it to a single person a hundred times.”
Bristol Live approached Avon and Wiltshire Mental Health Partnership NHS Trust about the figures, asking them to explain the disparity with other regions and to confirm or deny that patients in their care had received up to a hundred treatments of ECT.
The AWP website claims that ECT “can provide rapid, significant improvements in severe symptoms of mental health conditions” like severe depression, severe mania and catatonia.
It explains that treatment can be received voluntarily or involuntarily – the latter through sectioning under the Mental Health Act or a Community Treatment Order.
Examples of when the trust administers ECT include when other medications might harm an unborn baby, when the side effects of medication are severe, when ECT has been successful treatment in the past and when other forms of therapy have not worked.
AWP medical director Sarah Constantine said: “ECT can be a highly effective procedure, particularly for people with treatment-resistant depression and severe bipolar disorder, as recommended by NICE.
"In some cases it can be lifesaving. ECT is often used when all other treatments and therapy have been explored and utilised, and a patient is not responding to medication.
"Our first priority is to ensure that our patients have access to effective treatments and in AWP we have a good provision of accredited clinics. This may mean we provide more ECT sessions than other mental health trusts."
She added: “Like any medical procedure, ECT has some risks. But these are carefully balanced with the consequences of not providing the treatment for severe psychiatric disorders.”
Dr Johnstone maintains that ECT is “psychiatry’s dirty little secret”, suggesting that most people would be “shocked” to know that it was still being used at all.
“I think ECT really helps doctors feel better, when nothing else has worked,” she said. “They convince themselves it works, and they have a lot to confess to if it turns out it doesn’t.
“It also threatens to take the lid off a much bigger issue in psychiatry which is the question of to what extent any of their practices are evidence based.”
She added: “We think it just shouldn’t be happening, but the best way to campaign seems to be it should be done with appropriate safety measures, so we’ve been campaigning for a long time to say at the least we need proper standards.”
An RCP spokesperson said: "“In line with NICE guidance, ECT is mainly used for patients with severe depression when their condition is life threatening, or when their depression has not responded to other approaches.
“If someone has the capacity to decide whether or not to have ECT, it cannot be given without their fully informed consent. Patients can withdraw consent at any point, even just before the first treatment. They should be given information explaining their rights about consenting to treatment."
They added that while the RCP wrote best practice guidance for ECT providers, the regulation of service quality was the remit of the Care Quality Commission, which grades medical and care facilities across England.
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