Towards International Standards: East Meets West

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It is well established that electroconvulsive therapy (ECT) practice, like many aspects of medicine, differs between and within countries. In particular, a pattern of distinct patient populations and ECT administration practices has been shown between high-income industrialized countries, predominantly in Europe and North America, on one hand and middle- and lower-income countries in the rest of the world on the other hand. Leiknes et al1 examined 70 studies of ECT practice worldwide and found that Western countries primarily used ECT for depression, with older populations overall, whereas Asian countries used more ECT for schizophrenia in younger people. Similar patterns have also been shown in studies directly comparing practice between Western and Asian countries.2 Even within individual small countries like Ireland, wide regional variability in ECT use and practice can be seen.3
To illustrate this further, we compared 1 year of ECT practice between 2 academic centers in opposite poles of Europe: Dublin in Ireland (n = 125) and Sanliurfa in Turkey (n = 78), which stands at the interface between traditional notions of “East” and “West.” We found similar patterns. The Dublin sample was older, with a mean age of 64 years compared with 35 in the Sanliurfa sample, and had more treatment resistance and physical comorbidities. The younger Sanliurfa sample included significantly more people with diagnoses of schizophrenia (0 in Dublin versus 5% in Sanliurfa) and mania (8.8% in Dublin versus 16.7% in Sanliurfa) and was more likely to be referred for ECT because of the need for a rapid response. The acute ECT utilization rate was high in the Sanliurfa center at 54% compared with only 3.2% in Dublin, because of availability of inpatient care only for emergencies or for ECT in Sanliurfa. When comparing courses of ECT for depression only, clinician-rated illness severity was similar in both centers. Mean charge, motor seizure duration, and EEG seizure duration were all higher in the Dublin sample than the Sanliurfa sample. Those having ECT for depression in the Dublin group were significantly less likely to be the subject of an involuntary admission (13.5% of this group versus 47.4% of the Sanliurfa group). The most common clinician-documented outcome at the end of ECT was recovery from depression, in 90% of those in Dublin and 52.6% in Sanliurfa, but nonrecovery and withdrawal of consent were more common in the Sanliurfa sample. Although the proportion of those referred for ECT for treatment of schizophrenia in Sanliurfa (5%) was lower than the proportion of people with schizophrenia in previously reported ECT cohorts in Turkey (eg, 52% in the study by Canbek et al),4 the overall pattern of differences in ECT practice between the countries was as expected.
It is unclear why such patterns of difference exist between countries around the world. It is likely to be a combination of factors related to the need for ECT, availability of ECT, and uptake of the treatment. We can speculate on some of these factors. Need for ECT may depend not only on the prevalence of disorders but also on the structure and resources of mental health provision in each region. For example, emphasis on community-based treatment and early intervention may result in fewer people requiring emergency ECT and more people with treatment-resistant depression being identified and ultimately referred for ECT. A region in which resources are not available for intervention early in the illness course may report more use of emergency ECT for severe untreated illness. Similarly, where significant stigma and lack of understanding of mental illness persist, only those with severe illness may be able to access psychiatry services.
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