Brief Report Decline in the Use ofECT The York Study

A national survey in 1980 drew attention to the wide variation in frequency with which electro-convulsive treat ment was being used. Yorkshire Region was at the top of the league with three times the level of the Oxford Region which had the lowest rate. Since then a good deal more research has been published on the effectiveness and limi tations of ECT. ' "3 Other factors which might have influenced clinicians in their prescribing of this treatment include much stricter conditions in the 1983Mental Health Act for giving ECT compulsorily, plenty of media comment which may have reduced its acceptability, the increasing confidence of general practitioners in prescribing anti-depressant drug therapies, and the greater emphasis on community care. We report a substantial reduction of ECT in York District during the period from 1980to 1984,and some of the reasons for it, with parallel information obtained from the Department of Health on ECT trends in the Yorkshire Region and England as a whole. Methods and results Using ECT diaries kept in two mental hospital treatment units in York District (Bootham Park and Naburn Hospi tals), a progressive decline in the use of ECT was plotted over the fiveyear period 1980-84; 45% fewer persons were treated in 1984. Those who were treated had more and somewhat longer courses of treatment, rising from 1.3 courses per patient in 1980with an average 6-2 treatments per course, to 1.6courses/person and 7.5 treatments/course 1984.The overall numbers of ECT given in 1984was 17% fewerthan of of their the proportion of first-timers 43% 35% the proportion treated as out-patients doubled from 9% to 18%. No differences found in sex and age the

A national survey in 1980 drew attention to the wide variation in frequency with which electro-convulsive treat ment was being used. Yorkshire Region was at the top of the league with three times the level of the Oxford Region which had the lowest rate. Since then a good deal more research has been published on the effectiveness and limi tations of ECT. ' "3 Other factors which might have influenced clinicians in their prescribing of this treatment include much stricter conditions in the 1983Mental Health Act for giving ECT compulsorily, plenty of media comment which may have reduced its acceptability, the increasing confidence of general practitioners in prescribing antidepressant drug therapies, and the greater emphasis on community care.
We report a substantial reduction of ECT in York District during the period from 1980 to 1984, and some of the reasons for it, with parallel information obtained from the Department of Health on ECT trends in the Yorkshire Region and England as a whole.

Methods and results
Using ECT diaries kept in two mental hospital treatment units in York District (Bootham Park and Naburn Hospi tals), a progressive decline in the use of ECT was plotted over the five year period 1980-84; 45% fewer persons were treated in 1984. Those who were treated had more and somewhat longer courses of treatment, rising from 1.3 courses per patient in 1980 with an average 6-2 treatments per course, to 1.6courses/person and 7.5 treatments/course in 1984. The overall numbers of ECT treatments given in 1984was 17% fewer than in 1980.
Using case notes of all 241 patients treated in 1980and in 1984, comparison of their characteristics showed that the proportion of first-timers fell from 43% to 35% and the proportion treated as out-patients doubled from 9% to 18%. No significant differences were found in sex and age distribution, the proportion of patients on compulsory orders, the time between referral and receiving the first ECT, or the diagnostic grouping. The majority of patients had a diagnosis of depression, but the proportion of patients in 1984 with a diagnosis of schizophrenia (11%) and 'other diagnosis' (12%) was very similar to 1980.
1985 ECT figures, however, showed only a small decline ( â€"¿ 2-5%) in York while there was a 15% rise in Yorkshire and 10% rise in England figures.
DHSS data on numbers of courses and treatments given depend on returns of SBH 112. (See Table I). Numbers of persons treated were unavailable from this source. There are bound to be differing errors in these data compared with the York study, but the trends are large and in the same direction. York seems to have been outstripped by other Districts in the Yorkshire Region in reducing the numbers of treatments though not the number of courses of treat ment. Though the decline is greater, Yorkshire remains above the national average. TABLEI ECT use in York, Yorkshire and England During 1980and 198419X0 1984 i Change A structured interview was carried out with each of the York Consultants to assess their reasons for any perceived change in their own practice. All underestimated their use of ECT, but each correctly surmised some decline in rate of prescription. The main perceived reasons for the decline were better community care and lithium prophylaxis. Some Consultants agreed that the new Mental Health Act was having a limited effect and that recent research on indications for ECT had reduced their prescribing a little. The attitudes of other professional colleagues in the multi-disciplinary team were acknowledged to be having a more significant inhibiting effect on offering this treatment to patients.

Comments
The conclusions of the last ten years' research on ECT con firm that it is a very effectivetreatment for selected severe or chronic mental illnesseswhen antidepressant drug therapies have failed or are deemed less safe. The benefit conveyed by a standard course of four to eight treatments is measurable up to about four months compared with controls. For many psychiatrists this knowledge about its reasonable place in therapy has not changed much over the period of this study. However, the Royal College of Psychiatrists' survey of ECT practice in the late 1970sdid raise concern about over-use and poor technique of application in some hospitals. The decline in its use in high rate areas like the Yorkshire Region may mean improving standards or at least approximation to more generally held views on indications. However, a similar rate of decline in use across England suggests an overall greater reluctance to prescribe. The finding in York of a decreasing proportion of first-timers among patients receiving ECT and anecdotal accounts from Consultants of persuasion against by non-medical members of the multidisciplinary team suggests that non-clinical considerations are important in explaining the reduction in use. The figures for 1985suggest, however, that the trend is not continuing in a downward direction in Yorkshire and England.
Fears have been expressed that ECT is under-used in some services and that one of the consequences might be a rise in the suicide rate. The numbers of suicides in York have increased over the last fiveyears but only in males and most particularly among the 25-45 age group. This is typical of the rest of the country. The decline in the use of ECT in York has not been relatively greater in men in this age group.

DISCLAIMER
The study findings represent the viewof authors alone, who wish to thank the DHSS, Research and Statistics Division at Norcross, Blackpool, for providing Yorkshire and England figures.

The Child Psychotherapy Trust
The It has been estimated that about one in ten children suffers some kind of abuse and disturbance. There are many kinds of emotional distress severe enough to need specialist attention. While some children survive a personal crisis, many do not and they need the expert help child psycho therapists can provide. Without it, difficulties can persist into adult life, hindering emotional maturity, causing personality and relationship problems, and in extreme cases, severe mental illness.
There is a great shortage of trained child psycho therapists to treat those children who need their help; in five Health Regions there are no NHS child psychotherapists at all. The Child Psychotherapy Trust will raise funds to support the training of more child psychotherapists, par ticularly in those areas where there are none. The Trust will also seek, through public education and in co-operation with other professionals entrusted with the care of children, to increase understanding of the emotional factors in child development.

Dance and Movement Therapy
In the USA, dance and movement therapy is established within mental health provision but it isa comparatively new field in the UK.
The Laban Centre for Movement and Dance at the University of London Goldsmiths' College accepted its first students for an MA in Dance and Movement Therapy in September 1985. The degree is validated by Hahnemann University, Philadelphia, USA and the programme places equal emphasis on the art and science of dance therapy.
The full-time course extends over two academic years (part-time three or four years) and covers child develop ment, descriptive psychiatry, defence mechanisms, abnor mal psychology, Piaget's theories of cognitive development and research methodology. Enquiries: Course Information, Laban Centre for Move ment and Dance at University of London Goldsmiths' College, New Cross, London SE14 6NW (telephone 01 692 4070).