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Underused treatments in psychiatry: electroconvulsive therapy, clozapine and lithium

Published online by Cambridge University Press:  16 June 2025

Neil Mayfield Open the ORCID record for Neil Mayfield [Opens in a new window] ,
Suzy Ker  and
Nicola Taylor
Neil Mayfield*
Affiliation:
A consultant in working age adult psychiatry. He has been a principal investigator in several National Institute for Health and Care Research treatment studies involving people with severe mental illness (SMI).
Suzy Ker
Affiliation:
A consultant in working age adult psychiatry. Her research interests focus on inequalities experienced by people with SMI and the role of physical activity in helping people with SMI.
Nicola Taylor
Affiliation:
A consultant in working age adult psychiatry. Her interests are in neurodevelopment and in medical education. She is Deputy Director for Assessment (clinical) at Hull York Medical School, UK, and works at the Mental Health Network North, RAF Leeming, Northallerton, UK.
*
Correspondence Neil Mayfield. Email: neil.mayfield@nhs.net
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Summary

Although fundamental advances in the life sciences raise the exciting possibility of novel translational therapies, optimal evidence-based usage of established treatments should be the bedrock of current clinical care. The authors argue that there are instances where well-established treatments are ‘underused’ in psychiatry; electroconvulsive therapy, clozapine and lithium are exemplars of this. This article explores possible reasons for, and strategies to address, this underuse.

Keywords

Antipsychoticselectroconvulsive therapyevidence-based mental healthmood stabiliserspsychopharmacology

Information

Type
Article
Information
BJPsych Advances , Volume 31 , Issue 5 , September 2025 , pp. 280 - 289
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Copyright
© The Author(s), 2025. Published by Cambridge University Press on behalf of Royal College of Psychiatrists

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References

Andrade, C, Thyagarajan, S (2007) The influence of name on the acceptability of ECT: the importance of political correctness. Journal of Electroconvulsive Therapy, 23: 75–7.Google ScholarPubMed
Barnes, T, Drake, R, Paton, C, et al (2020) Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 34: 3–78.10.1177/0269881119889296CrossRefGoogle ScholarPubMed
Barnes, TE, Haddad, PM, Ferrier, IN (2019) Evidence-Based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 1–76.Google ScholarPubMed
Bickerton, D, Worrall, A, Chaplin, R (2009) Trends in the administration of electroconvulsive therapy in England. Psychiatric Bulletin, 33: 61–3.10.1192/pb.bp.107.019273CrossRefGoogle Scholar
Bramness, JG, Weitoft, GR, Hallas, J (2009) Use of lithium in the adult populations of Denmark, Norway and Sweden. Journal of Affective Disorders, 118: 224–8.10.1016/j.jad.2009.01.024CrossRefGoogle ScholarPubMed
Brodeur, S, Courteau, J, Vanasse, A, et al (2022) Association between previous and future antipsychotic adherence in patients initiating clozapine: real-world observational study. British Journal of Psychiatry, 220: 347–54.10.1192/bjp.2022.1CrossRefGoogle ScholarPubMed
Cleare, A, Pariante, CM, Young, AH, et al (2015) Evidence-Based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. Journal of Psychopharmacology, 29: 459–525.10.1177/0269881115581093CrossRefGoogle ScholarPubMed
Conley, R, Tammiga, C, Kelly, D, et al (1999) Treatment-resistant schizophrenic patients respond to clozapine after olanzapine non-response. Biological Psychiatry, 46: 73–7.10.1016/S0006-3223(99)00029-3CrossRefGoogle ScholarPubMed
Djulbegovic, B, Kumar, A, Glasziou, PP, et al (2012) New treatments compared to established treatments in randomized trials. Cochrane Database of Systematic Reviews, 10: MR000024.Google ScholarPubMed
Electroconvulsive Therapy Accreditation Service (2023) ECTAS Dataset Report: 01 January 2021 – 31 December 2021. Royal College of Psychiatrists.Google Scholar
Fernandes, V, Al-Sukhni, M, Lawson A, et al (2020) Lithium prescribing and therapeutic drug monitoring in bipolar disorder: a survey of current practices and perspectives. Journal of Psychiatric Practice, 26: 360–6.10.1097/PRA.0000000000000493CrossRefGoogle Scholar
Fiorillo, A, Sampogna, G, Albert, U, et al (2023) Facts and myths about the use of lithium for bipolar disorder in routine clinical practice: an expert consensus paper. Annals of General Psychiatry, 22(1): 50.10.1186/s12991-023-00481-yCrossRefGoogle ScholarPubMed
Goodwin, G, Haddad, P, Ferrier, I, et al (2016) Evidence-based guidelines for treating bipolar disorder: revised third edition recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 30: 495–553.10.1177/0269881116636545CrossRefGoogle ScholarPubMed
Govind, R, Fonseca de Freitas, D, Pritchard, M, et al (2021) Clozapine treatment and risk of COVID-19 infection: retrospective cohort study. British Journal of Psychiatry 219: 368–74.10.1192/bjp.2020.151CrossRefGoogle ScholarPubMed
Howes, OD, McCutcheon, R, Agid, O, et al (2017) Treatment-resistant schizophrenia: Treatment Response and Resistance in Psychosis (TRRIP) working group consensus guidelines on diagnosis and terminology. American Journal of Psychiatry 174: 216–29.10.1176/appi.ajp.2016.16050503CrossRefGoogle Scholar
Kane, J, Honigfeld, G, Singer, J, et al (1988) Clozapine for the treatment-resistant schizophrenic: a double-blind comparison with chlorpromazine. Archives of General Psychiatry, 45: 789–96.10.1001/archpsyc.1988.01800330013001CrossRefGoogle ScholarPubMed
Kaster, TS, Vigod, SN, Gomes, T, et al (2021) Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score-matched, retrospective cohort study. Lancet Psychiatry, 8: 686–95.10.1016/S2215-0366(21)00168-1CrossRefGoogle ScholarPubMed
Kessing, LV (2024) Why is lithium [not] the drug of choice for bipolar disorder? A controversy between science and clinical practice. International Journal of Bipolar Disorders, 12(1): 3.10.1186/s40345-023-00322-7CrossRefGoogle ScholarPubMed
Kessing, LV, Vradi, E, Andersen, PK (2016) Nationwide and population-based prescription patterns in bipolar disorder. Bipolar Disorder, 18: 174–82.10.1111/bdi.12371CrossRefGoogle ScholarPubMed
Lambe, S, Mask, J, Trimikas, KA, et al (2014) Trends in use of electroconvulsive therapy in south London from 1949 to 2006. Journal of Electroconvulsive Therapy, 30: 309–14.Google ScholarPubMed
Lambrichts, S, Detraux, J, Vansteelandt, K, et al (2021) Does lithium prevent relapse following successful electroconvulsive therapy for major depression? A systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 143: 294–306.10.1111/acps.13277CrossRefGoogle ScholarPubMed
Leucht, S, Hierl, S, Kissling, W, Dold, M, Davis, JM (2012) Putting the efficacy of psychiatric and general medicine medication into perspective: a review of meta-analyses. British Journal of Psychiatry, 200: 97–106.CrossRefGoogle ScholarPubMed
Li, X-H, Zhong, X-M, Lu, L, et al (2020) The prevalence of agranulocytosis and related death in clozapine-treated patients: a comprehensive meta-analysis of observational studies. Psychological Medicine, 50: 583–94.10.1017/S0033291719000369CrossRefGoogle ScholarPubMed
Lyall, LM, Penades, N, Smith, DJ (2019) Changes in prescribing for bipolar disorder between 2009 and 2016: national-level data linkage study in Scotland. British Journal of Psychiatry, 215: 415–21.10.1192/bjp.2019.16CrossRefGoogle ScholarPubMed
Malhi, GS, Bell, E, Jadidi, M, et al (2023) Countering the declining use of lithium therapy: a call to arms. International Journal of Bipolar Disorders, 11: 30.10.1186/s40345-023-00310-xCrossRefGoogle ScholarPubMed
Maughan, D, Molodynski, A (2016) An international perspective on the acceptability and sustainability of electroconvulsive therapy. BJPsych International, 13: 10–2.10.1192/S2056474000000891CrossRefGoogle ScholarPubMed
Mayfield, N, Ker, S, Steele, R, et al (2024) Transformative technologies in medicine: a primer for psychiatrists. BJPsych Advances, 30: 311–21.10.1192/bja.2023.55CrossRefGoogle Scholar
McAllister-Williams, RH, Baldwin, DS, Fricchione, G, et al (2017) British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017. Journal of Psychopharmacology, 31: 519–52.10.1177/0269881117699361CrossRefGoogle ScholarPubMed
Morlet, E, Costemale-Lacoste, JF, Poulet, E, et al (2019) Psychiatric and physical outcomes of long-term use of lithium in older adults with bipolar disorder and major depressive disorder: a cross-sectional multicenter study. Journal of Affective Disorders, 259: 210–7.10.1016/j.jad.2019.08.056CrossRefGoogle ScholarPubMed
National Institute for Health and Care Excellence (2003) Guidance on the Use of Electroconvulsive Therapy (Technology Appraisal Guidance TA59). NICE.Google Scholar
National Institute for Health and Care Excellence (2014) Psychosis and Schizophrenia in Adults: Prevention and Management (NICE Clinical Guideline CG178). NICE.Google Scholar
National Institute for Health and Care Excellence (2022) Depression in Adults: Treatment and Management (NICE Guideline NG222). NICE.Google Scholar
National Institute for Health and Care Excellence (2023) Bipolar Disorder: Assessment and Management (NICE Clinical Guideline CG185). NICE.Google Scholar
National Institute for Health and Care Excellence (2024) Bipolar Disorder: How Common Is It? NICE (https://cks.nice.org.uk/topics/bipolar-disorder/background-information/incidence-prevalence/).Google Scholar
Ng, VWS, Man, KKC, Gao, L, et al (2021) Bipolar disorder prevalence and psychotropic medication utilisation in Hong Kong and the United Kingdom. Pharmacoepidemiology and Drug Safety, 30: 1588–600.10.1002/pds.5318CrossRefGoogle Scholar
Northwood, K, Myles, N, Clark, S, et al (2024) Evaluating the epidemiology of clozapine-associated neutropenia among people on clozapine across Australia and Aotearoa New Zealand: a retrospective cohort study. Lancet Psychiatry, 11: 27–35.10.1016/S2215-0366(23)00343-7CrossRefGoogle ScholarPubMed
Oloyede, E, Whiskey, E, Casetta, C, et al (2022) Relaxation of the criteria for entry to the UK Clozapine Central Non-Rechallenge Database: a modelling study. Lancet Psychiatry, 9: 636–44.10.1016/S2215-0366(22)00188-2CrossRefGoogle Scholar
Oppenheim, M (2022) Thousands of Women Given ‘Dangerous’ Electric Shocks as Mental Health Treatment in England. Independent, 19 Jun (https://www.independent.co.uk/news/health/electroconvulsive-therapy-brain-mental-health-b2095155.html).Google Scholar
Paton, C, Barnes, TR, Shingleton-Smith, A, et al (2010) Lithium in bipolar and other affective disorders: prescribing practice in the UK. Journal of Psychopharmacology, 24: 1739–46.10.1177/0269881110367728CrossRefGoogle ScholarPubMed
Pérez de Mendiola, X, Hidalgo-Mazzei, D, Vieta, E, et al (2021) Overview of lithium’s use: a nationwide survey. International Journal of Bipolar Disorders, 9: 10.10.1186/s40345-020-00215-zCrossRefGoogle ScholarPubMed
Pippard, J, Ellam, L (1981) Electroconvulsive treatment in Great Britain. British Journal of Psychiatry, 139: 563–8.10.1192/bjp.139.6.563CrossRefGoogle ScholarPubMed
Rawlins (1999) In pursuit of quality: the National Institute for Clinical Excellence. Lancet, 353: 1079–82.10.1016/S0140-6736(99)02381-8CrossRefGoogle Scholar
Rej, S, Herrmann, N, Shulman K, et al (2017) Current psychotropic medication prescribing patterns in late-life bipolar disorder. International Journal of Geriatric Psychiatric. 32: 1459–65.10.1002/gps.4635CrossRefGoogle ScholarPubMed
Rogers, JP, Oldham, MA, Fricchione, G, et al (2023) Evidence-based consensus guidelines for the management of catatonia: recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 37: 327–69.10.1177/02698811231158232CrossRefGoogle ScholarPubMed
Rubio, J, Kane, J, Tanskanen, A, et al (2024) Long-term persistence of the risk of agranulocytosis with clozapine compared with other antipsychotics: a nationwide cohort and case–control study in Finland. Lancet Psychiatry, 11: 443–50.10.1016/S2215-0366(24)00097-XCrossRefGoogle ScholarPubMed
Rybakowski, J (2023) Lithium in mood disorders – an update. Farmakoterapia w Psychiatrii i Neurologii/Pharmacotherapy in Psychiatry and Neurology, 39: 103–13.10.5114/fpn.2023.131702CrossRefGoogle Scholar
Sackheim, HA (2017) Modern electroconvulsive therapy: vastly improved yet greatly underused. JAMA Psychiatry, 74: 779–80.10.1001/jamapsychiatry.2017.1670CrossRefGoogle Scholar
Scottish Intercollegiate Guidelines Network (2013) Management of Schizophrenia (SIGN Publication No. 131). SIGN.Google Scholar
Shorter, E (2009) The history of lithium therapy. Bipolar Disorder, 11 (suppl 2): 4–9.10.1111/j.1399-5618.2009.00706.xCrossRefGoogle ScholarPubMed
Taylor, D, Shapland, L, Laverick, G, et al (2000) Clozapine – a survey of patient perceptions. Psychiatric Bulletin, 24: 450–52.10.1192/pb.24.12.450CrossRefGoogle Scholar
Tihonan, J, Mittendorfer-Rutz, E, Majak, M, et al (2017) Real-world effectiveness of antipsychotic treatments in a nationwide cohort of 29823 patients with schizophrenia. JAMA Psychiatry, 74: 686–93.10.1001/jamapsychiatry.2017.1322CrossRefGoogle Scholar
Tungaraza, T, Farooq, S (2015) Clozapine prescribing in the UK: views and experience of consultant psychiatrists. Therapeutic Advances in Psychopharmacology, 5: 88–96.10.1177/2045125314566808CrossRefGoogle ScholarPubMed
Whiskey, E, Barnard, A, Oloyede, E, et al (2021) An evaluation of the variation and underuse of clozapine in the United Kingdom. Acta Psychiatrica Scandinavica, 143: 339–47.10.1111/acps.13280CrossRefGoogle ScholarPubMed
Yoshimura, B, Yada, Y, So, R, et al (2017) The critical treatment window of clozapine in treatment-resistant schizophrenia: Secondary analysis of an observational study. Psychiatry Research 250: 65–70.10.1016/j.psychres.2017.01.064CrossRefGoogle ScholarPubMed
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