Recently there was a debate on Twitter about the safety and efficacy of an important treatment, electroconvulsive therapy (ECT). Maybe on Twitter everybody is entitled to their opinion, but I think it is our right and responsibility when medically important information is being discussed, that we challenge opinions been expressed without substantiation. We do it all the time with quack medical advice and self-help gurus, we should do it more often with advice offered to vulnerable persons facing difficult medical decisions.
This is the first of a series of quick digests of the literature concerning electroconvulsive therapy. It’s intended to aid mental health professionals having discussions with seriously depressed persons and their families concerning treatment options.
In the Twitter discussion, we saw far too many clinicians and persons posing as clinicians offering unsubstantiated opinions. Some were simply well-meaning, but ill informed. Some were quacks. Others had an ideological commitment that they wanted to promote, but not expose to debate. We should call them out.
A lot of what I will be offering over coming post about ECT will be current and classic literature. However I will try to include more accessible sources as well. Where possible, I will link the two.
In this blog post I start with an excerpt from an article in The Conversation that is available for reposting and excerpting under its creative Commons license. The article’s author, George Kirov is a Clinical Professor at Cardiff University who supervises the ECT delivery in Cardiff.
The use of electroconvulsive therapy (ECT) to treat psychiatric disorders is on the rise in England, according to a new report in the Guardian. There was an 11% rise in the number of procedures performed on the NHS between 2012-13 and 2015-16.
ECT involves passing an electric current through the head of an anaesthetised patient. The aim is to produce an epileptic fit. It is used mostly to treat severe or treatment-resistant depression, but it can also have beneficial effects in some cases of mania and schizophrenia.
Its therapeutic effect was discovered in 1938. Today, it remains the most effective treatment for severe depression. Yet, for some reason, it is always presented in a negative light. Not least in The Guardian’s latest report where it is described as “a crude, controversial treatment, which fell sharply out of favour around the turn of the millennium”. Cue the inevitable debate about the treatment.
Although presented as “exclusive data” in the Guardian, the authors largely reiterate the data collected by the body that monitors ECT in the UK: the ECT Accreditation Service (ECTAS). The data is freely available on the Royal College of Psychiatrists website and counted 2,148 courses of ECT given during 2014-2015.
A quick glance through the ECTAS document can tell us a lot about the nature of the illnesses treated with ECT and the remarkable outcomes: 51.7% of people were rated as “severely ill” and another 18.7% as “among the most severely ill” prior to ECT. At the end of their treatment, however, 74.4% were “much improved/very much improved”, while only 1.7% had deteriorated. This is a treatment reserved for the most severely depressed patients, and it produces unrivalled improvements. Despite this, it is still a treatment that has its passionate opponents.
What does the evidence show?
Let us consider some of the arguments of the opponents. Speaking to The Guardian, Richard Bentall, a professor of clinical psychology at the University of Liverpool, said he “doesn’t believe that there are adequate clinical trials of ECT to establish its effectiveness” and that the design of trials had not been “up to scratch”. In other words, we are not sure that ECT works.
But there have been plenty of trials. A review in The Lancet listed the various ways ECT had been tested over the years. ECT has been compared with simulated ECT (six trials, all favouring real ECT). ECT has been compared with drugs in 13 trials (11 favoured ECT). Bilateral ECT was more effective than unilateral (that is, treatments given to the whole brain are more effective than those given to half of the brain). And, finally, six trials that compared higher electric charges with lower electric charges found that higher charges produced greater improvements.
Still, every few years the opponents of ECT demand more evidence. In response to such demands, a large study was conducted in the US (the CORE report on 253 patients) and the results were published in 2004. The study set the bar for improvement very high: it required depressed patients to have almost no symptoms on two consecutive measurements at the end of the treatment period. Three-quarters of patients reached those remission criteria. No other treatment in psychiatry has come even close to such effects
I suspect that the opponents of ECT will still reject the evidence from new trials – after all, one can find something “not up to scratch” with anything, if one has already formed a strong belief. Perhaps such people might be persuaded if they go to an ECT clinic and witness one of the miraculous changes that can occur there. I do this with medical students who come to observe one session of ECT, as part of their education.
Every few weeks, we have a patient who enters the treatment room mumbling incoherently, or telling us that they are a sinner deserving to be punished, or complaining that they have no intestines or some other vital body part or function. And, after a single bout of ECT, while still in the recovery room, some of these patients start talking coherently and change the topic away from their tormenting delusions. The students come back, after exchanging a few words with the patients, with their jaws dropped and a sense of disbelief in their eyes. This does not happen every day, and usually takes more than one session, but you only need to see it once to remember forever that ECT does work.
A now classic article cited in The Conversation
The UK. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. The Lancet. 2003 Mar 8;361(9360):799-808.
A free summary of it in Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].
Results of the review
Seventy-three RCTS were included in the review. In addition, fourcohort studies and three observational studies were also identified.
The authors noted that a meta-analysis of the data on short-term efficacy from RCTs was possible. Real ECT was significantly more effective than simulated ECT in reducing depressive symptoms (6 RCTs, n=256); the standardised effect size (SES) was -0.91 (random-effects) (95% confidence interval, CI: -1.27, -0.54). At 6 months, no significant difference was noted. There was no significant difference between the ECT and simulated ECT for premature discontinuation (3 trials). No deaths were reported.
Treatment with ECT was significantly more effective than pharmacotherapy in reducing depressive symptoms (n=1,144; SES -0.80, 95% CI: -1.29, -0.29). Discontinuation was typical in both groups, but significantly lower in the ECT arm (risk difference 0.03, 95% CI: -0.09, -0.03). Four trials in this group had discontinuations in the pharmacotherapy arm only. One trial reported a death in each group.
Bilateral ECT was more effective than unipolar ECT (n=1,408; SES 0.32, 95% CI: -0.46, 0.19). Six trials reported that the times to orientation were longer for patients treated with bilateral ECT than for those treated with unilateral ETC. Four trials reported the results from testing retrograde memory within a week of the end of the course of ETC.
Observational studies: four non-randomised cohort studies were found, of which three reported lower overall mortality in patients treated with ECT and one showed no difference. Funnel plots did not reveal any publication bias.
ECT was shown to be an effective short-term treatment for depression and is probably more effective than drug therapy. Bilateral ECT is moderately more effective than unilateral ECT, while high-dose ECT is more effective than low-dose ETC.
The DARE summary includes evaluation of the quality of the evidence that is reviewed and the quality with which it is reviewed.
A classic article by Max Fink, whose international reputation is grounded in evidence-based appraisals of ECT research, including his own citation classics.
Fink M, Taylor MA. Electroconvulsive therapy: evidence and challenges. JAMA. 2007 Jul 18;298(3):330-2.
Remission Efficacy for Depressive Illness Many studies documenting the efficacy of ECT for depressive illness have been published,3 finding ECT superior to “sham” ECT and to medications in the treatment of patients with severe depressive illness. Two multisite collaborations—the Consortium for Research in ECT (CORE)4 and Columbia University Consortium (CUC)2—studies are illustrative. Both were designed to examine relapse prevention after successful ECT involving patients with major unipolar depression. The 2 patient groups were similar in mean age (55 and 59 years), sex ratio (70% female), and pretreatment severity (mean Hamilton Depression Scale scores, about 34).Index episode duration was 24 to 31weeks (CUC study) and 45 to 49 weeks (CORE study). At remission, themean Hamilton scores were 5 to 6(±3). Remission rates were 55% (159 of 290 patients completing the CUC study) and 86% (341 of 394 patients completing the CORE study). These results compare favorably to the initial 30% remission rate with citalopram and the remission rates of about 23% with bupropion, 21% with sertraline, and 25% with venlafaxine for patients who did not respond to citalopram in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial of outpatients with nonpsychotic major unipolar depression.5
A recent large scale study of inpatient mortality
Liang CS, Chung CH, Tsai CK, Chien WC. In-hospital mortality among electroconvulsive therapy recipients: A 17-year nationwide population-based retrospective study. European Psychiatry. 2017 May 31;42:29-35.
ECT recipients had lower odds of in-hospital mortality than did those who did not receive ECT.
Using data from the Taiwan National Health Insurance Research Database from 1997 to 2013, we identified 828,899 inpatients with psychiatric conditions, among whom 0.19% (n=1571) were treated with ECT.
We found that ECT recipients were more frequently women, were younger and physically healthier, lived in more urbanized areas, were treated in medical centers, and had longer hospital stays. ECT recipients had lower odds of in-hospital mortality than did those who did not receive ECT. Moreover, no factor was identified as being able to predict mortality in patients who underwent ECT. Among all patients, ECT was not associated with in-hospital mortality after controlling for potential confounders.
ECT was indicated to be safe and did not increase the odds of in-hospital mortality. However, ECT appeared to be administered only on physically healthy but psychiatrically compromised patients, a pattern that is in opposition with the scientific evidence supporting its safety. Moreover, our data suggest that ECT is still used as a treatment of last resort in the era of modern psychiatry.
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