Our interest in this topic was re-awakened when, in 2003, the then National Institute for Clinical Excellence (NICE) published clinical guidelines that intended to restrict the circumstances for the use of electroconvulsive therapy (ECT). ¹ The guidance was controversial, and the Royal College of Psychiatrists subsequently published its own guidance that argued that NICE was too restrictive about the place of ECT in the treatment of major depression, the most common contemporary indication for ECT. ² It was therefore unclear whether NICE would achieve its aim of reducing the use of ECT. We have already reported that there was no early effect of the NICE guidance in that the rates of usage of ECT in Edinburgh were virtually identical in the individual years 2003–2005. ^{Reference Okagbue, McIntosh, Gardiner and Scott3}

We now report the most dramatic fall in the rate of usage of ECT that we have ever observed between consecutive years. In the years 2006 and 2007 the rates of usage were only 0.82 and 0.88 patients per 10 000 total population. This is approximately a third less than the rate in 2005, and three-quarters less than the rate in 1993. ^{Reference Okagbue, McIntosh, Gardiner and Scott3}

The clinical significance of the decrease has never been systematically assessed. Observers have suggested that there is less need for ECT as the number of effective alternative options increases, and as psychiatrists become more experienced with these options. One only hopes that those people who are severely ill who were formally treated with ECT are now offered equally effective alternatives, but this is open to doubt. Electroconvulsive therapy is still the most efficacious treatment for major depression, particularly when the symptoms are severe. ^{Reference Ebmeier, Donaghey and Steele4} The results of the recent STAR^*D trial were salutary: the cumulative remission rate from major depression was only 67% after four sequential and carefully supervised acute treatment schedules. ^{Reference Rush, Trivedi, Wisniewski, Nierenberg, Stewart, Warden, Niederehe, Thase, Lavori, Lebowitz, McGrath, Rosenbaum, Sackeim, Kupfer, Luther and Fava5}

The research implications are clearer. Edinburgh has a long history of ECT research, but the latest fall in usage has meant that we have not been able to complete a controlled comparison of magnetic seizure therapy and orthodox ECT. If the Edinburgh experience is replicated elsewhere, the only options for future clinical research would be to support collaborations among several ECT clinics or the establishment of a regional or national affective disorders research centre, plus a research programme that includes ECT.