Recent articles by John Menadue on health costs in Australia have emphasised the high fees charged by private procedural medical specialists. In a paper to be published next month (McLaren, N., “ECT in Context,” Ethical Human Psychology and Psychiatry, April 2018), I examine costs associated with the use of ECT (electroconvulsive treatment) in psychiatry. This is a short version of that paper.
In a variety of submissions and statements, the Royal Australian and New Zealand College of Psychiatrists (RANZCP), the main professional body for psychiatrists, says ECT is “useful,” “essential,” “irreplaceable,” “effective,” “valuable,” “clinically-indicated,” “important and necessary,” and harmless, while opposition to it is “irrational,” out-dated and unscientific. These are very strong claims; a brief survey of readily available figures casts major doubt on them.
Internationally and within nations, there is enormous variation in the use of ECT. Australia ranks very near the top and, most unusually, private use of ECT is rapidly increasing. In the UK from 1985-2015, ECT use dropped about 90% but in Australia from 2005-15, rebatable (private) ECT usage jumped 85%. In Queensland, it rose 90% while West Australia showed a remarkable 190% increase over the decade. In 2010, NSW men under 24 were given ECT at three times the rate of their counterparts across the River Murray while Victoria as a whole uses ECT 600% more than New Zealand.
In 2015, Queensland, with a population of 4.8m, practitioners gave almost as much ECT (19,500) as the England-Wales division of the UK NHS (22,500 for 53m people) – i.e. at a rate 1000% more. Italy hardly uses ECT: in 2014, 91 centres were licensed to give it but only 14 did, meaning some 53m Italians did not have access to this “life-saving and indispensable” form of treatment. Queensland uses ECT 132,500% more than the northern Italian province of Pavia. The suggestion that these discrepancies arise from some undefined “clinical indication” cannot be taken seriously.
ECT is most emphatically not “essential, irreplaceable and indispensable” but the major problem comes in its allocation. In the US, the median ECT patient is an older, white woman paying private rates for her treatment. The same is true of Australia: 25yrs ago, Dr Carolyn Quadrio showed that the great bulk of ECT is given to distressed middle-aged women. 93% of ECT is given by male psychiatrists, and 80% of patients are female. Yet figures from Beyond Blue show that the risk of suicide among depressed women is barely 15% of that among men. That is, the patients who are most at risk of suicide don’t get the treatment which psychiatry touts as essential for saving lives in emergencies. At the same time, it would be absurd to suggest that all depressed people (at least 1.5m a year in Australia) should be admitted to hospital for ECT.
How effective is ECT? Two of its most fanatical supporters, Harold Sackeim of Columbia University, NY, and Charles Kellner, of Mt Sinai Hospital, NY, claim it is about 55-65% effective. That is, ECT is only marginally better than placebo. However, Sackeim says:
Our study indicates that without active treatment, virtually all remitted patients relapse within 6 months of stopping ECT.
The RANZCP agrees:
5.6: The use of evidence based pharmacotherapy and other strategies to prevent relapse after improvement from ECT is essential for obtaining a lasting improvement.
The current Medicare rebate for ECT, MBS Item 14224, is $70.35. In 1974-6, while I was in training in Perth, and assisted by an anaesthetist, I routinely gave four to six modified ECT per hour (55 minutes of which was spent standing around watching). That seems to be very good money, but practically no private psychiatrists bulk-bill ECT. The going rate in Brisbane today is $200+, for about two minutes “work” (the total cost of each treatment, including anaesthetic and hospital fees, is about $620). A 5-week admission to hospital for 12 ECT treatments will cost something like $56,000, whereas six months of bulk-billed psychotherapy will give much the same results for about $1500. There are, however, numerous perverse incentives built into the Medicare schedule encouraging over-use of ECT, and private psychiatry, including the prodigiously expensive private hospitals, respond accordingly.
How did this come about? Psychiatry is able to dictate terms to governments and funders through its claimed “science of mental disorder.” Just by virtue of having a unique model, psychiatry is granted the exorbitant privilege having its form of treatment funded as applied science. However, as a scientific model, it must be subject to the most stringent criticism. However, psychiatry doesn’t like criticism, not least because it doesn’t actually have a model of mental disorder (McLaren, N., 2013. “Psychiatry as Ideology,” Ethical Hum Psychol. Psychiat., 15: 7-18). Thus exposed, psychiatry heads off potential critics by claiming that criticism damages their business model, and can therefore be suppressed by civil laws such as trades practices, defamation, etc.
It doesn’t stop with ECT. The bulk-billed rate for an initial consultation (Item 296) is $221.30. Private psychiatrists can charge what they like, and generally do. One enterprising soul demands $735.00 for the hour, helpfully pointing out that the rebate is $385. That, however, is the rebate for Item 291, which is restricted to one consultation only. Another charges $720 for Item 296, meaning the patient has to find about $500 for the pleasure. Reviews range from $450-550 per hr, for which the rebate is $156.15.
However, the most brutal psychiatric costs are seen in relation to legal reports. Medicare values a psychiatrist’s clinical work at $156.15 per hour, which must fund the entire business. Of course, the psychiatrist must give full care and attention to the patient. However, when a person is ordered by, say, a court, to obtain a psychiatric report, suddenly, the worth of a psychiatrist jumps 300-400%. Just by changing hats, psychiatrists decide they are worth up to $5500 for perhaps a few hours work. There is, however, no extra skill involved. It is not the case that psychiatrists give public patients $156 worth of skill an hour, reserving their turbo-charged version for the wealthy who can cough up $660 an hour.
This is rapacious, there is no other word for it. The unfortunate patients have no choice as it may mean the difference between seeing one’s children or not seeing them, but the institution of psychiatry doesn’t show the slightest concern for this sort of conduct. While this is not strictly a medical cost, it is yet another example of how “the system” sets up restrictive practices which specialists then exploit. By such means, psychiatry’s exorbitant privilege is converted into an extortionate privilege, hostile to all criticism.
In brief, people with a very low risk of suicide are admitted to private hospitals for an expensive form of treatment they don’t need. This constitutes a gross misallocation of resources, draining the limited mental health budget and private insurers, to no measurable advantage. Radical change is needed, but there is little reason to expect it will come from psychiatry itself.
Niall McLaren is a Brisbane-based psychiatrist. His books include Humanizing Madness; The Biocognitive Model for Psychiatry, and the forthcoming Anxiety: The Inside Story.