Intended for healthcare professionals

Rapid response to:

Head To Head Maudsley Debate

Should we stop using electroconvulsive therapy?

BMJ 2019; 364 doi: (Published 30 January 2019) Cite this as: BMJ 2019;364:k5233

Rapid Response:

Re: Should we stop using electroconvulsive therapy?

The fight over ECT is a prism that highlights how partisan divisions hold back progress in mental health. Rather than it being an intervention to be evaluated on evidence, your attitude to ECT has become a sign of tribal affiliation.

The evidence for ECT is surprisingly poor compared to other treatments. There is evidence for immediate effects but no reliable evidence for long-term benefits. It's not that they definitely don't exist, it's just we can't tell because it's under-researched, despite its wide use. Psychiatrists tend to defend it, saying they see dramatic and life-saving effects beyond what the trials show for people who have shown no response to other treatments or who can't tolerate appropriate medication. But if you think this is the case, you should be banging down doors of research funders demanding well-controlled trials to confirm this. This doesn't happen though, because it would mean admitting the evidence is poor for a treatment you've defended as 'indisputably' beneficial.

On the other hand, critics of ECT won't demand controlled trials because they're committed to saying it's a 'brain damaging treatment,' without reliable evidence, and why would you demand further tests on something you've committed to condemning as 'indisputably' harmful? It's also interesting that critics of ECT are often the same people who claim there is "no evidence that mental health problems are biological illnesses" on the basis that there are no reliable structural changes to the brain or individually diagnostic biological tests. But when it comes to the after-effects of ECT (no reliable structural changes to the brain or anything diagnosable by biological tests) they suddenly claim it indisputably causes 'brain damage'. Double standards are no obstacle when you're trying to win a war.

So the fights continue because neither side will admit the evidence to back up either of their positions is actually quite poor, and everyone has a vested interest in playing to the gallery by accusing the other side of 'harming patients'.

Meanwhile, ECT is one of the least understood treatments in psychiatry, which is plainly bad for everyone. Not least people with severe mental health problems for whom knowing the scope, harms and benefits of treatments is essential.

Competing interests: No competing interests

04 February 2019
Vaughan Bell
Associate Professor / Clinical Psychologist
University College London / South London and Maudsley NHS Foundation Trust
UCL Research Department of Clinical, Educational and Health Psychology