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Head To Head Maudsley Debate

Should we stop using electroconvulsive therapy?

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.k5233 (Published 30 January 2019) Cite this as: BMJ 2019;364:k5233

Rapid Response:

Re: Should we stop using electroconvulsive therapy?

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On the other hand, I saw many severely depressed patients who, despite intensive, prolonged drug treatment, became withdrawn and unresponsive and suffered progressive profound weight loss.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.

Competing interests: No competing interests

04 February 2019
Keith E Dudleston
Retired Psychiatrist
Devon, England