Sue Kemsley has raised some important issues regarding ECT. The use of ECT without consent has not declined in absolute numbers since 1985 but, as discussed in our editorial (Reference Eranti and McLoughlinEranti & McLoughlin, 2003), the total number of patients receiving ECT has substantially fallen during this period. Little research has been directed at understanding this change in the pattern of ECT use. One possibility is that there exists a core group of patients with severe depressive illness and possible psychosis that requires treatment with ECT, while the decline in use predominantly occurs in people with less severe illness. So why has the use of ECT declined in this latter group?

As we have already suggested, we believe that this is due to historical changes in general psychiatry, especially psychopharmacology. One has to bear in mind that, following its introduction in 1938, ECT was one of the first truly effective treatments for severe debilitating psychiatric disorders and thus its use rapidly became widespread (Reference FinkFink, 2001). We are currently investigating trends in ECT practice over the past 50 years in the Maudsley and Bethlem Royal Hospitals in south London. Its use peaked in 1956 when 34% of admissions were treated with ECT. This rate fell steadily thereafter to 30% in 1959, 21% in 1968 and 5% in 1987. It is interesting to note here that imipramine was introduced in 1958, coinciding with the beginning of this decline in use of ECT. Similarly, ECT use further declined after the introduction of fluoxetine, the first of the selective serotonin reuptake inhibitors, in 1988, such that by 1991 2% of admissions received ECT. Currently, less than 1% of admissions are treated with ECT and nearly 90% of these have a diagnosis of major depressive disorder, which is well-established as being the main indication for contemporary ECT (Reference Carney, Cowen and GeddesCarney et al, 2003).