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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

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Re: 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.

Competing interests: No competing interests

25 February 2019
Per Bergsholm
Psychiatrist, M. D.
Slåttebøen 22, 6810 Førde, Norway