This is in reply to David Colquhoun after a twitter discussion. @david_colquhounhas signed a petition calling for ECT to be banned. I think this is a very bad idea.
First off: ECT has been overused and badly used in the past. I don’t think it should be used where a patient doesn’t consent to it, and neither does the RCPsych – see here – “f you have made it very clear that you do not wish to have ECT then you should not receive it”. There are many reasons why people who have been helped by ECT may not wish to disclose that they’ve had it – which is absolutely fine – and this means that, if we go by anecdote, the good outcomes may not be as audible or visible as others.
ECT is not used lightly. There are clear guidelines saying that it should be considered in high-risk or very severe illness. Banning ECT would mean that these groups of patients wouldn’t have it as an option. If ECT works, this would effectively mean prolonging suffering or risk for longer than necessary.
So does it work? One of the very difficult issues with depression research has been the problematic categorisation of low mood. We know that most people have low mood at some point, but we also know that most of this is not depression. David Healy has noted that originally, in the 1950s, pharma were reluctant to do research into antidepressants because depression was uncommon and they were unlikely to recoup their costs. What we term ‘depression’ is likely to be a large mixed bag, with different causes, severities, impacts and best treatments. This problem makes it difficult to tease out what works best for who – we have seem the same problem with SSRIs, for example. I’ve written before about why these medications are effectively overused. I’m also not going to defend poor research, or the lack of useful research into treatments for many mood disorders. The placebo effect is also likely to be strong in many cases, and another frequent problem is the tendency for pharma companies not to include a placebo arm but simply compare one antidepressant to a newer (usually more expensive) one.
So what is the evidence? Cochrane have not found enough evidence to say whether it’s better than antidepressants in older people, and have recommended better research. However, the trials don’t appear to have clearly separated conditions like psychotic depression, or depression where life is at risk eg due to not eating or serious suicide attempts. Cochrane have also published a protocol to assess ECT in adults with depression, and I look forward to reading their conclusions.
ECT has had around 12 trials looking at sham versus ‘real’ ECT. These have been critically assessed here (need Athens login). Interestingly, the review found that there was a similar situation to the SSRI trials, in that the more severe the depression, the greater the distinction between additional response and placebo effect. However, it’s important to note that ‘placebo’ may not be quite accurate: these patients were inpatients, likely to have been receiving support from nursing, psychological and medical staff; they may have been receiving other medication. All we know is that a substantial portion of patients got better over time – whether we can call that ‘placebo’, really, is moot, especially given this Cochrane review. This systematic review in the Lancet grouped ‘depression’ together and found a positive effect in the short term for ECT (it’s well recognised that ECT should be supported by starting other treatment at the same time as it’s instigated.)
I think ECT has a role, though limited. Part of the problem is the poor classification of depression. I think a ban is unfair to people who have found it effective before and would elect to have it in the future. Better research does need to be done. But banning it is unhelpful and disregards the evidence.
Principal CORE Study Reports, 2001-2010.
1. The influence of age on the response of patients with major depression to
electroconvulsive therapy. Am J Geriatr Psychiatry 2001; 9:382-390. [O’Connor MK Knapp R, Husain M, Rummans TA, Petrides G, Smith G, Mueller M, Snyder K,Bernstein H, Rush AJ, Fink M., Kellner C. ]
2. ECT remission rates in psychotic versus non-psychotic depressed patients: A
report from CORE. JECT 2001; 17:244-253. [Petrides G, Fink M, Husain MM,
Knapp R, Rush AJ, Mueller M, Rummans TA, O’Connor KM, Rasmussen KG,
Bernstein HJ, Biggs M, Bailine SH, KellnerCH.].
3. Speed of Response and Remission in Major Depressive Disorder with Acute
ECT: A Consortium for Research in ECT (CORE) Report. J Clin Psychiatry
2004; 65:485-491. [Husain MM, Rush AJ, Fink M, Knapp R, Petrides G, Rummans T, Biggs MM, O’Connor K, Rasmussen K, Litle M, Zhao W, Bernstein HJ, Smith G, Mueller M, McClintock SM, Bailine SH, Kellner CH.]
4. Relief of expressed suicidal intent by ECT: A Consortium for Research in ECT Study.
Am J Psychiatry 2005;162: 977-982. [Kellner CH, Fink M, Knapp R, Petrides G,
Husain MM, Rummans T, Mueller M, Bernstein H, Rasmussen K, O’Connor K,
Smith G, Rush AJ, Biggs M, McClintock S, Bailine SH, Malur C.]
5. Continuation ECT versus pharmacotherapy for relapse prevention in major depression:
a multi-site study from CORE. Archives General Psychiatry . 2006; 63:1337-44.
[Kellner CH, Knapp RG, Petrides G, Rummans TA, Husain MM,
Rasmussen K, Mueller M, Bernstein HJ, O’Connor K, Smith G, Biggs M, Bailine
SH, Malur C, Yim E, Sampson S, Rush AJ, Fink M.]
6. Patterns of Psychotropic Medication Use Among Severely Depressed Patients
Referred for Electroconvulsive Therapy: Data from the Consortium for Research
on ECT. J ECT 2006; 116-123. [Rasmussen KG, Mueller M, Kellner CH, Knapp
RG, Petrides G, Rummans TA, Husain MM, O’Connor K, Black JL, Sampson S,
7. DSM Melancholic Features are Unreliable Predictors of ECT Response.
J ECT, 2007; 23:139-146. [ Fink M, Rush AJ, Knapp R, Rasmussen K, Mueller M, Rummans T, O’Connor K, Husain M, Biggs M, Bailine S, Kellner CH, and CORE group.]
8. Antidepressant Treatment Failure Does Not Predict Lower Remission Rates
with ECT for Major Depressive Disorder. J Clin Psychiatry 2007; 68:1701-1706. [Rasmussen KG, Mueller M, Knapp RG, Husain MM, Rummans TA, Sampson SM, O’Connor MK, Petrides G, Kellner CH, Fink M.]
9. Data management and design issues in an unmasked randomized trial of
electroconvulsive therapy for relapse prevention of severe depression. J ECT
2007; 23:244-250.[Rasmussen KG, Knapp RG, Biggs MM, Smith GE,
Rummans TA, Petrides G, Husain MM, O’Connor MK, Fink M, Kellner CH]
10. Change in seizure threshold during ECT: A CORE study. J ECT 2008; 24:114-
116. [Fink M, Petrides G, Kellner CH, Mueller M, Knapp R, Husain MM,
Rasmussen K, Rummans TA, O’Connor K]
11. Outcome of ECT by race in the CORE multi-site study. J ECT 2008; 24:117-
121. [Williams M, Rummans T, Sampson S, Knapp R, Mueller M, Husain
M, Fink M, Rasmussen K, O’Connor K, Smith G, Petrides G, KellnerCH.]
12a. The efficacy of acute ECT in atypical depression. J Clin Psychiatry 2008;
69:406-411. [Husain MM, McClintock SM, Rush AJ, Knapp RG, Fink
M, Rummans TA, Rasmussen K, Claassen C, Petrides G, Biggs MM,
Mueller M, Sampson S, Bailine SH, KellnerCH.]
12b. ECT not proven for atypical depression. Response to Letter CM Swartz. J Clin
Psychiatry 2008; 69:1662-3. [McClintock SM, Husain MM, Rush AJ,
Claassen C, Biggs MM, Knapp RG, Mueller M, Fink M, Bailine S,
Rummans TA, Sampson S, Petrides G, Kellner CH, Lisanby SH.]
13. Is baseline medication non-response associated with potential for relapse
after successful remission of a depressive episode with ECT? Data from
the Consortium for Research in ECT. J Clin Psychiatry 2009; 70:232-237.
[Rasmussen KG, Mueller M, Rummans TA, Husain MM, Petrides G, Knapp
RG, Fink M, Sampson SM, O’Connor MK, Bailine SH, KellnerCH.]
14. Seizure threshold in a large sample: Implications for stimulus dosing strategies
in bitemporal ECT. A report from CORE. J ECT 2009; 25:232-237. [Petrides
G, Fink M,BragaRJ, Mueller M, Knapp R, Rummans T, Husain M,
Rasmuussen K, Bailine S, Malur C, O’Connor K, Kellner CH]
15. ECT is equally effective in bipolar depression. Acta psychiatr scand 2010:121:431-36
[Bailine S, Fink M, Knapp R, Petrides G, Husain M, Rasmussen K, Sampson S,
Mueller M, McClintock S, Tobias KG, KellnerCH.]
16. Comparing Bifrontal, Bitemporal, and Right Unilateral Electrode Placement in
ECT: A Multisite Study from CORE. Br. J. Psychiatry 2010; 196: 226-
234. [Kellner CH, Knapp R, Husain M, Rasmussen K, Sampson S, Cullum
M, McClintock S, Tobias K, Martino C, Mueller M, Bailine S, Fink M,
Petrides G. ]
17. A randomized controlled trial comparing the memory effects of
continuation ECT versus continuation pharmacotherapy: Results
from the CORE study. J Clin Psychiatry 2010; 71:185-193. [Smith GE,
Rasmussen KG, Cullum M, Felmlee MD, Petrides G, Rummans TA, Husain M,
Mueller M, Bernstein H, Knapp R, O’Connor MK, Fink M, Sampson S, Bailine SH, Kellner CH.]