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UNMODIFIED ECT
486 UNMODIFIED ECT
SIR,-Your Feb. 16 editorial might have done more to inform us correctly on the subject of unmodified ECT and spared us the emotionalism of the lay Press. You seem confident that every problem with ECT can be solved by the intramuscular injection of a major tranquilliser. Unmodified ECT is not an anachronism: it is the form of treatment offered in many parts of the world today, though rarely in Britain. In my twenty-five years in psychiatry I have given it on several occasions, usually because the patient needed treatment urgently and, for some reason, intravenous injection was impracticable (e.g., where the veins were thrombosed after previous treatments for diabetic coma). I have also known patients who were willing to have ECT only if there were no injections and no anxsthetic. ECT induces an epileptic seizure and, as with any other seizure without an aura, the patient is completely unaware of anything happening until he wakes up afterwards and finds himself on the ground. The incident may seem alarming to the inexperienced observer, but it is not for the patient. We know from experience with epileptics that a convulsion carries little risk, apart from tongue biting or injury when falling. In unmodified ECT the patient is held by nurses and the tongue is protected, so, for the physically healthy and the not too old, it is not a hazardous treatment (look at the older textbooks or ask overseas colleagues). The advantage of giving a muscle relaxant, which modifies the muscular violence without preventing the seizure, is that it then becomes safe to give ECT to a wider selection of patients-the elderly, those with a history of coronary thrombosis, and those with hypertension, for example. The sole purpose of the anaesthetic is to prevent the patient experiencing the onset of’the muscle relaxant. The ECT itself will render him briefly unconscious and provide amnesia for the moments before the shock. Suggestions that unmodified ECT is malpractice or is barbarous are puzzling in the light of forty years’ successful use of this treatment, and those who make them should provide some facts to support their allegations. I think that those who raise scares about ECT overestimate its potency and are terrified that it will be applied by policeman, terrorists, brainwashers, and torturers to change people’s minds and personalities. If it does not even require the presence of a doctor (anaesthetist) and can be given without the recipient being aware that he has had it, who, the argument runs, will be safe from thought control? Better to hush up the facts and condemn the treatment as painful, dangerous, and ineffective-or only for the superspecialist. What is the evidence that ECT can be used effectively as torture or punishment? As ordinarily applied, ECT is painless and only seems to do something to certain kinds of psychotic, people in whom it is now beginning to be possible to demonstrate specific brain abnormalities before treatment. People with other kinds of mental illness, or no illness, are not changed by ECT. ECT is like penicillin or morphine: it has saved lives, relieved anguish, and helped tens of thousands of people, but we must be careful to prevent its abuse, to use it on medical indications only, and to give it compulsorily only with due safeguards and only for the patient’s benefit (is there any evidence that this was not done at Broadmoor?). The Lancet’s job should be to match fears with facts instead of simply hinting, from a platform of ignorance, at improprieties and malpractice. ’
,
Maudsley Hospital, London SE5
JOHN CRAMMER
HEALTH INSURANCE: LESSONS FROM AMERICAN EXPERIENCE
SIR,-Professor Torrens (Jan. 5, p. 27) argues that health insurance tends to encourage high-cost, high-technology ser-. vices, and that a move towards more private health insurance
in Britain might actually worsen the health economic situation. Surely, he misses the key point of control. No patient in this country gets consultant care without referral by a general practitioner, unless admitted from a casualty department as an emergency. Without the signature of the referring general practitioner no private medical insurance plan will pay the accounts arising-a sanction that does not exist in the U.S.A. Dewlands
Gate, Rotherfield,
D.
East Sussex
J.
D. TORRENS
VANCOUVER WOES
SiR,—Iam writing, against time, a chapter for a new edition of a book. I have just noticed, among the lengthy instructions to contributors (from the publishers, not the editors) that in this edition we must supply reference lists with the names of journals written out in full. A very minor imposition, you may say, but I begin to wonder if too much detail is not being asked of us poor authors, and too much space wasted in journals by these elaborate lists. Soon, if the process continues, we will have to supply abstracts of all the articles cited. Time was when all we were asked for was authors’ names (and there were rarely more than three), journal, year, volume, and page number. Titles in full and last page have been added almost universally, and with what profit? Neither is any use in finding the article cited, which is what the reference is there for. And why need all the authors be included-unless for their own vainglory? Some jourrials draw the line at six and allow "et al." or, for very long lists, "et mult. al."-but three is more than enough. Who does not quail at having to cite one of those papers that come in series, with a long main title and a longer subtitle for the individual paper, usually with ten authors variously permutated : "Studies in the tumorigenic potentialities of Miyawaganella paraphlogistons in hippogriffs. I Preliminary multicentric study of phraseological subexactitudes in pseudoparaphlogiston micro-classification by etc... It all has to be copied, typed, and checked, set in type, and proof-checked. Life is too short. I know there is a new international agreement (Vancouver), but international bodies always opt for longwindedness. Could we not go back to the minimum reference needed to find an article-or, at the very least, not allow things to get worse? My secretary adds a hearty agreement on behalf of all who have to type these lists. "
Department of Pathology, Infirmary, Glasgow G11 6NT
Western
BERNARD LENNOX
CLINICAL TRIAL OR PROMOTIONAL EXERCISE?
StR,—I have been approached by of in
a
medical
representative
company with a view to my taking part a clinical trial. When I examined the protocol of the study, I was most surprised at its design. The study purported to be an investigation of the efficacy of transferring patients with angina pectoris from multiple doses of beta-blocking drugs to a proprietary drug requiring once daily dosage. It was to be a multicentre trial, each centre providing four patients. Only patients who had already been established for three months on beta-blockers were to be included. On the first visit the doctor would be asked to give each patient a diary card to record frequency of anginal attacks and the consumption of glyceryl trinitrate tablets. At this visit the investigator was to measure heart rate and blood pressure, assess the severity of the angina, report any adverse events, and assess whether these were due to
a
pharmaceutical
drug therapy.
After a month the patient would make a second visit to the doctor and have his treatment changed to the once-daily drug.
SIR,-Your Feb. 16 editorial might have done more to inform us correctly on the subject of unmodified ECT and spared us the emotionalism of the lay Press. You seem confident that every problem with ECT can be solved by the intramuscular injection of a major tranquilliser. Unmodified ECT is not an anachronism: it is the form of treatment offered in many parts of the world today, though rarely in Britain. In my twenty-five years in psychiatry I have given it on several occasions, usually because the patient needed treatment urgently and, for some reason, intravenous injection was impracticable (e.g., where the veins were thrombosed after previous treatments for diabetic coma). I have also known patients who were willing to have ECT only if there were no injections and no anxsthetic. ECT induces an epileptic seizure and, as with any other seizure without an aura, the patient is completely unaware of anything happening until he wakes up afterwards and finds himself on the ground. The incident may seem alarming to the inexperienced observer, but it is not for the patient. We know from experience with epileptics that a convulsion carries little risk, apart from tongue biting or injury when falling. In unmodified ECT the patient is held by nurses and the tongue is protected, so, for the physically healthy and the not too old, it is not a hazardous treatment (look at the older textbooks or ask overseas colleagues). The advantage of giving a muscle relaxant, which modifies the muscular violence without preventing the seizure, is that it then becomes safe to give ECT to a wider selection of patients-the elderly, those with a history of coronary thrombosis, and those with hypertension, for example. The sole purpose of the anaesthetic is to prevent the patient experiencing the onset of’the muscle relaxant. The ECT itself will render him briefly unconscious and provide amnesia for the moments before the shock. Suggestions that unmodified ECT is malpractice or is barbarous are puzzling in the light of forty years’ successful use of this treatment, and those who make them should provide some facts to support their allegations. I think that those who raise scares about ECT overestimate its potency and are terrified that it will be applied by policeman, terrorists, brainwashers, and torturers to change people’s minds and personalities. If it does not even require the presence of a doctor (anaesthetist) and can be given without the recipient being aware that he has had it, who, the argument runs, will be safe from thought control? Better to hush up the facts and condemn the treatment as painful, dangerous, and ineffective-or only for the superspecialist. What is the evidence that ECT can be used effectively as torture or punishment? As ordinarily applied, ECT is painless and only seems to do something to certain kinds of psychotic, people in whom it is now beginning to be possible to demonstrate specific brain abnormalities before treatment. People with other kinds of mental illness, or no illness, are not changed by ECT. ECT is like penicillin or morphine: it has saved lives, relieved anguish, and helped tens of thousands of people, but we must be careful to prevent its abuse, to use it on medical indications only, and to give it compulsorily only with due safeguards and only for the patient’s benefit (is there any evidence that this was not done at Broadmoor?). The Lancet’s job should be to match fears with facts instead of simply hinting, from a platform of ignorance, at improprieties and malpractice. ’
,
Maudsley Hospital, London SE5
JOHN CRAMMER
HEALTH INSURANCE: LESSONS FROM AMERICAN EXPERIENCE
SIR,-Professor Torrens (Jan. 5, p. 27) argues that health insurance tends to encourage high-cost, high-technology ser-. vices, and that a move towards more private health insurance
in Britain might actually worsen the health economic situation. Surely, he misses the key point of control. No patient in this country gets consultant care without referral by a general practitioner, unless admitted from a casualty department as an emergency. Without the signature of the referring general practitioner no private medical insurance plan will pay the accounts arising-a sanction that does not exist in the U.S.A. Dewlands
Gate, Rotherfield,
D.
East Sussex
J.
D. TORRENS
VANCOUVER WOES
SiR,—Iam writing, against time, a chapter for a new edition of a book. I have just noticed, among the lengthy instructions to contributors (from the publishers, not the editors) that in this edition we must supply reference lists with the names of journals written out in full. A very minor imposition, you may say, but I begin to wonder if too much detail is not being asked of us poor authors, and too much space wasted in journals by these elaborate lists. Soon, if the process continues, we will have to supply abstracts of all the articles cited. Time was when all we were asked for was authors’ names (and there were rarely more than three), journal, year, volume, and page number. Titles in full and last page have been added almost universally, and with what profit? Neither is any use in finding the article cited, which is what the reference is there for. And why need all the authors be included-unless for their own vainglory? Some jourrials draw the line at six and allow "et al." or, for very long lists, "et mult. al."-but three is more than enough. Who does not quail at having to cite one of those papers that come in series, with a long main title and a longer subtitle for the individual paper, usually with ten authors variously permutated : "Studies in the tumorigenic potentialities of Miyawaganella paraphlogistons in hippogriffs. I Preliminary multicentric study of phraseological subexactitudes in pseudoparaphlogiston micro-classification by etc... It all has to be copied, typed, and checked, set in type, and proof-checked. Life is too short. I know there is a new international agreement (Vancouver), but international bodies always opt for longwindedness. Could we not go back to the minimum reference needed to find an article-or, at the very least, not allow things to get worse? My secretary adds a hearty agreement on behalf of all who have to type these lists. "
Department of Pathology, Infirmary, Glasgow G11 6NT
Western
BERNARD LENNOX
CLINICAL TRIAL OR PROMOTIONAL EXERCISE?
StR,—I have been approached by of in
a
medical
representative
company with a view to my taking part a clinical trial. When I examined the protocol of the study, I was most surprised at its design. The study purported to be an investigation of the efficacy of transferring patients with angina pectoris from multiple doses of beta-blocking drugs to a proprietary drug requiring once daily dosage. It was to be a multicentre trial, each centre providing four patients. Only patients who had already been established for three months on beta-blockers were to be included. On the first visit the doctor would be asked to give each patient a diary card to record frequency of anginal attacks and the consumption of glyceryl trinitrate tablets. At this visit the investigator was to measure heart rate and blood pressure, assess the severity of the angina, report any adverse events, and assess whether these were due to
a
pharmaceutical
drug therapy.
After a month the patient would make a second visit to the doctor and have his treatment changed to the once-daily drug.