Should we stop using electroconvulsive therapy?

The first study
According to Read and Cunliffe1 “The first study, in 1951, showed that people who had had ECT fared worse than those who hadn’t.” They refer to Karagulla (1950)2, who evaluated 923 patients treated in the Royal Edinburgh Hospital for Mental and Nervous Disorders between the years 1930-48. However, Karagulla concluded more positively: “Although the statistical evidence in this survey does not prove that E.C.T. increases recovery rate, decreases duration and prevent recurrence in depressive states … Convulsion therapy frequently ameliorates symptoms and renders the illness more bearable.” Moreover, her study was re-evaluated by Slater (1951)3, who pointed out that “the proportion of persons who died in the untreated groups is about eight times as great as the proportion of those who died in the treated groups. Secondly, the proportion of recoveries is substantially higher in the treated groups than in the untreated.” Slater summarized as follows: “The statistical data provided by Karagulla … do not justify two of her main conclusions, which were that electric convulsion therapy is without effect either on the recovery rate or on the duration of hospitalization in depressive states … the exact contraries of both propositions are correct.” Karagulla did not publish arguments against this. Consequently, the exact contrary of Read and Cunliffe’s statement, too, are correct, i.e. people who had had ECT fared better than those who hadn’t.

Mortality and ECT
The significant lower mortality rate when ECT is used in depressive patients is further demonstrated by Avery and Winokur (1978)4 in their summary of 15 follow-up studies (including Karagulla 1950) from 1930 to 1975, involving a total of over 4500 patients. This was also confirmed in a recent 8 years follow-up study, including a significant reduction in suicide rate when ECT was used.5 The reduced mortality by ECT is even more impressive in early studies of malignant catatonia.6

ECT versus anaesthesia
Read and Cunliffe1 claim that half of 10 studies found no difference between ECT and general anaesthesia as placebo. In fact, 11 of 12 such studies found a difference in favour of ECT, however, this was often not statistically significant due to very low sampe size.7 The only study without any difference used low dose unilateral ECT,8 which is known to have little or no effect.

Follow-up studies
Read and Cunliffe1 criticize that no placebo-controlled study shows ECT to reduce depression beyond the treatment course. However, such studies are impossible to carry out, because patients in the placebo groups cannot be denied ECT after the end of the trial. Long-term effects have to be documented in other types of follow-up, like the mortality studies above, studies of continuation/maintenance ECT,9 and the recent study of Slade et al,10 documenting that ECT resulted in 46% fewer inpatient readmissions within 30 days of discharge.

Controlled studies since 1985
Read and Cunliffe1 maintain that there is “lack of evidence” for the effect of ECT, and that “no studies to establish efficacy of ECT have been conducted since 1985.” However, four randomized, controlled, double-blind studies were published between 1987 and 2000.11-14 All of them demonstrated bitemporal and high-dose right unilateral (RUL) ECT to be markedly and significantly more effective than low-dose RUL ECT, which can be regarded as a more sophisticated “placebo” than anaesthesia alone.

Patients’ perspectives
Read and Cunliffe1 emphasize the review of Rose et al (2003),15 which reported “persistent or permanent memory loss” in 29% to 55% of patients after ECT. However, This review was re-evaluated by Bergsholm (2012),16 who concluded that “data used by Rose et al are severely flawed, making their results inconclusive and misleading.” For example, they included among studies of persistent/permanent memory loss that of Pettinati et al,17 on the basis of reported memory problems within 48 hours of an ECT series. Rose et al have not published arguments against this re-evaluation. Collaborative, consumer-led research teams with a neutral stance will hopefully bring new answers to controversial questions about ECT. Such a team is the Australian “ECT – Let’s talk about it!!” project, which recently published a valuable report.18

1 Read J, Cunliffe S, Jauhar S, McLoughlin DM. Should we stop using electroconvulsive therapy? BMJ 2019;364:k5233.
2 Karagulla S. Evaluation of electric convulsion therapy as compared with conservative methods of treatment in depressive states. J Ment Sci 1950;96:1060-91.
3 Slater ETO. Evaluation of electric convulsion therapy as compared with conservative methods of treatment in depressive states. J Ment Sci 1951;97:567-9.
4 Avery D, Winokur G. Mortality in depressed patients treated with electroconvulsive therapy and antidepressants. Arch Gen Psychiatry 1976;33:1029-37.
5 Ahmadi N, Moss L, Simon E, Nemeroff CB, Atre-Vaidya N. Efficacy and Long-Term Clinical Outcome of Comorbid Posttraumatic Stress Disorder and Major Depressive Disorder after Electroconvulsive Therapy. Depress Anxiety 2016;33:640-7.
6 Shorter E, Fink M. The madness of fear: a history of catatonia. New York: Oxford University Press; 2018.
7 Rasmussen KG. Sham electroconvulsive therapy studies in depressive illness: a review of the literature and consideration of the placebo phenomenon in electroconvulsive therapy practice. J ECT 2009;25:54-9.
8 Lambourn J, Gill D. A controlled comparison of simulated and real ECT. The British Journal of Psychiatry 1978;133:514-9.
9 Elias A, Phutane VH, Clarke S, Prudic J. Electroconvulsive therapy in the continuation and maintenance treatment of depression: Systematic review and meta-analyses. Aust N Z J Psychiatry 2018;52:415-24.
10 Slade EP, Jahn DR, Regenold WT, Case BG. Association of Electroconvulsive Therapy With Psychiatric Readmissions in US Hospitals. JAMA Psychiatry. 2017;74:798-804.
11 Sackeim HA, Decina P, Kanzler M, Kerr B, Malitz S. Effects of electrode placement on the efficacy of titrated, low-dose ECT. Am J Psychiatry 1987;144:1449-55.
12 Sackeim HA, Prudic J, Devanand DP, et al. Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 1993;328:839-46.
13 Sackeim HA, Prudic J, Devanand DP, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Am J Psychiatry 2000;57:425-34.
14 McCall WV, Reboussin DM, Weiner RD, Sackeim HA. Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy: acute antidepressant and cognitive effects. Arch Gen Psychiatry 2000;57:438-44.
15 Rose D, Fleischmann P, Wykes T, Leese M, Bindman J. Patients' perspectives on electroconvulsive therapy: systematic review. BMJ 2003;326:1363.
16 Bergsholm P. Patients' perspectives on electroconvulsive therapy: a reevaluation of the review by Rose et al on memory loss after electroconvulsive therapy. J ECT 2012;28:27-30.
17 Pettinati HM, Tamburello TA, Ruetsch CR, Kaplan FN. Patient attitudes toward electroconvulsive therapy. Psychopharmacol Bull 1994;30:471-5.
18 Wells K, Scanlan JN, Gomez L, et al. Decision making and support available to individuals considering and undertaking electroconvulsive therapy (ECT): a qualitative, consumer-led study. BMC Psychiatry 2018;18:236.

Yes. A world in which electrical current is used to treat complex mental health conditions is symptomatic of the lack of resources and answers in 2019 to the human brain.
I have met and spoken to several people with brain injuries as a result of ECT treatment. Their therapy was given instead of talking therapy, not as a ‘last resort’ as advised by NICE. They were not fully consented, being unaware they would have lasting memory issues and inability to complete tasks, some as everyday as making a cup of tea.
The continuing denial of the suffering of these former ECT patients is unbelievable. It is a national and indeed worldwide scandal.
I have spoken to some who believe ECT saved their life. They were frantic to kill themselves and believe this was used responsibly and as a last resort. I can not deny their stories. For them, it stopped the suicide attempts. Yet they also live with brain damage from ECT.
Rehabilitation for brain injury from this extreme therapy is urgently required for the hundreds (maybe more) in the UK living with brain damage from ECT.
Brain injury is denied at present from NHS Trusts administering ECT.
ECT is seen as a fast and cost-efficient way to save lives of those suffering from mental health illness. Other therapies are being ignored because of the expense and time required.
What a world we live in. The stigma for those suffering from mental health continues long after ECT as their stories are considered false testimony. To listen to the stories of those who have survived ECT, as I have done, is to witness the effects of removing someone’s spirit. The human spirit cannot be measured, yet we believe it to be present. We can feel it.
We need better research and solutions for mental health care. We need to launch an immediate government and NHS investigation into use of ECT, as called for by Barbara Keeley, Labour MP, in response to FOI requests I did for the Sunday Mirror. I found that teenagers as young as 16 were being given ECT, despite the teenage brain still developing.
Media do not need to sensationalise the treatment of electricity through a human brain. Up to 460 volts in one treatment, randomly hitting parts of the brain to induce a seizure. Many believe this therapy has already been consigned to the history books. They could not fathom a modern medicine allowing ECT.
Let’s make 2019 the year we say enough is enough. No more electric shock therapy. It wastes lives.

I was very struck by the opinion piece you published recently on ECT [BMJ 2019;364:k5233]. As a young doctor, I witnessed the double-blind placebo-controlled trial of the short term efficacy of ECT treatment of depressed inpatients that was conducted at Mapperley Hospital, Nottingham in the very early 1980s. [British Journal of Psychiatry (1985), 146, 520- 24]

After the results came out, showing ECT was clearly more effective than the sham placebo treatment, we were told that repeating such a study would probably be unethical. Perhaps this is why, as Read and Cunliffe report, no such trials have been conducted since 1985.

The authors also correctly report that "none of them [reviews and meta-analyses] identify any placebo-controlled studies showing that ECT reduces depression beyond treatment or prevents suicide". However, the fact that no such evidence exists is not evidence that no such effects exist. How would you design a placebo-controlled trial to find out if ECT treatment changed the suicide rate?

I do not doubt that ECT causes brain damage. The question is how severe is this damage and how long does it usually persist. The finding that, following ECT treatment, there is no increase in the incidence of dementia in elderly patients, reassures me [The Lancet (2018), 5, 4, p348-356].

The only death associated with ECT that I witnessed in nearly 40 years of practice as a psychiatrist occurred when I decided not to give ECT to a severely depressed inpatient who later died by suicide. A decision that haunts me still.

On the other hand, I saw many severely depressed patients who, despite intensive, prolonged drug treatment, became withdrawn and unresponsive and suffered progressive profound weight loss. Their condition would invariably improve following ECT. Sometimes lives were saved.

It seems to me it is a serious decision to deny such patients ECT. If faced with having to care for such a person what would Drs Read and Cunliffe do? I ask this question because it saddens me when those who question the efficacy ECT also question the quality of the values and attitudes of those who prescribe it. The truth is that these doctors are just trying to do their best under challenging circumstances. I'm sorry if it wasn't always enough.

It was difficult to see the middle ground in this article - something quite necessary for ECT given the wide divides in opinion.
However my main reservation about it related to the picture. I have had a number of courses of ECT, the most recent being in autumn 2018. I have found it helpful, despite the persistent holes in my memory, and I would have it again. But I find the image of a brain composed of wires and attached to a switch both upsetting and offensive, and was disappointed to see this in the BMJ.