Abstract
An analysis of changes in private sector electroconvulsive treatment (ECT) in Australia [1] showed considerable regional and temporal variation in usage. In all areas, its use was declining at the outset of the study period (1984), then rose again in most areas. There was also about 600% difference between the highest and lowest rates of utilization. As the authors indicated, statistical treatment may blur important local variations. I report one such variation from my own practice which raises a question they did not consider.
Since 1977, I have practiced psychiatry in both private and public sectors, in the North and the South of Australia. In Perth, I was head of the Department of Psychiatry at the Repatriation Hospital when it serviced about 87 000 elderly people. In 1987–1993, I spent 6 years as regional psychiatrist, Kimberley Health Region in WA, establishing a genuinely isolated psychiatric practice with no staff and practically no utilization of outside services [2].
Since then, I have spent 3 years as senior psychiatrist for the Top End, NT Mental Health Services, with an eligible population of about 180 000, and 10 years in solo, bulk-billing private practice in Darwin, part of that time as the only private psychiatrist in NT (total population about 250 000). During my years with Darwin MHS, there were some 650 admissions per year, most of whom I saw personally. In addition, I saw hundreds of outpatients, directly managing about 200 per year myself.
At present, I see approximately 550 new patients per year, most of them for treatment. Based on the annual Medicare Statistical Feedback Sheet, my treatment costs are extremely low, something like 50% of the national averages, but these figures do not take into account hospital admission costs, which are paid by the state services. Using these figures, my costs shrink even further as very few (around 1%) of my patients are admitted to hospital each year [3]. As a psychiatrist, I have personally assessed and managed something like 12 000 patients. For 19 years, I have practiced psychiatry in one of the rougher areas of the country, most of it with no support services whatsoever.
I do not use ECT and have not done so since June, 1977. At both hospitals where I worked, ECT was used before and after my appointments, but not during. There is no evidence that my patients have a substandard outcome. For example, in the past 10 years, only two patients are known to have committed suicide during treatment. Neither would have been considered for ECT elsewhere.
Their paper provides no evidence to suggest that any psychiatrist need to use ECT. It appears to be little more than façon de utilizer, having more in common with, say, circumcision rather than medical necessity. It would be ironic indeed if ECT actually led to an increase in costs.