Intended for healthcare professionals

CCBYNC Open access

Rapid response to:

Research

Comparative efficacy and acceptability of non-surgical brain stimulation for the acute treatment of major depressive episodes in adults: systematic review and network meta-analysis

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1079 (Published 27 March 2019) Cite this as: BMJ 2019;364:l1079

Rapid Response:

Re: Comparative efficacy and acceptability of non-surgical brain stimulation for the acute treatment of major depressive episodes in adults: systematic review and network meta-analysis

ECT (Electroconvulsive Therapy) is Not Like the Others: It is the Proven Standard

Mutz et al. present an elegant and scientific review of brain stimulation treatments for depression. However, I would like to bring to readers’ attention two points about the article that could potentially be misconstrued. First, the title, “Comparative efficacy and acceptability of non-surgical brain stimulation for the acute treatment of major depressive episodes in adults: systematic review and network meta-analysis,” while technically accurate, implies that there are surgical treatments for acute depression. There are not. Vagus nerve stimulation is not indicated for acute depression; deep brain stimulation for depression is experimental only (1), and (even mentioning this is a stretch) psychosurgery is not considered for depression.

Second, their statement, “Given that tDCS tends to be a less expensive treatment than transcranial magnetic stimulation, ECT, or psychotherapy, this finding is particularly relevant for policy makers who might consider tDCS as a clinical therapy outside the research setting.” Such a conclusion conflates treatments that are so different in clinical practice that is inappropriate to consider them together. Clinically, ECT is often indicated for patients who are urgently ill, with severe, sometimes life-threatening, mood (2) and psychotic disorders or catatonia. Such patients should never be offered tDCS as a primary treatment, and probably not any of the others mentioned, either.

A compilation and comparison of research studies that happen to involve patients with the same diagnostic label of “major depression” (a broad and heterogeneous mix of conditions with a very wide range of severity), no matter how sophisticated the statistical techniques used, should not be misused to give a false appearance of clinical equivalence (3,4). That bilateral ECT was again found to be the most effective treatment modality (5) is no surprise, but ECT is so different from the other techniques studied, with a vast evidence base and decades-long track record of worldwide safety and efficacy, that none of the other brain stimulation techniques should be considered adequate substitutes in real world practice for seriously ill psychiatric patients.

References

1. Coenen VA, Bewernick BH, Kayser S et al. Superolateral medial forebrain bundle deep brain stimulation in major depression: a gateway trial.
Neuropsychopharmacology. 2019 Mar 13. doi: 10.1038/s41386-019-0369-9. [Epub ahead of print]

2. Kellner CH, Goldberg JF, Briggs MC, Liebman LS, Ahle GM. Somatic treatments for severe bipolar disorder. Lancet. 2013 Aug 10;382(9891):505-6.

3. Cole C, Tobiansky R. Electroconvulsive therapy: NICE guidance may deny many patients treatment that they might benefit from.
BMJ. 2003 Sep 13;327(7415):621.

4. Kellner CH, Kaicher DC, Banerjee H et al. Depression severity in electroconvulsive therapy (ECT) versus pharmacotherapy trials.
J ECT. 2015 Mar;31(1):31-3.

5. Fink M. What was learned: studies by the consortium for research in ECT (CORE) 1997-2011. Acta Psychiatr Scand. 2014 Jun;129(6):417-26.

Competing interests: No competing interests

31 March 2019
Charles H. Kellner
Psychiatrist
1) New York Community Hospital; 2) Icahn School of Medicine at Mount Sinai
2525 Kings Highway, Brooklyn, NY, 11229 USA