ECT is one of the most effective treatments in medicine but has adverse effects

 

It is World ECT protest day on Sat 16th May 2015 and no doubt the usual hoary old myths about ECT being ineffective and causing brain damage will abound. Electro-convulsive treatment, or therapy, is abbreviated to ECT either way. Even though some call it Electro-Shock Treatment, they still call it ECT. ECT is often described as the most controversial treatment in medicine. But it is actually amongst the most effective treatments in medicine.

ECT works

How do we know that ECT works? The same as always in medicine – from the results of randomised controlled trials. The UK ECT review group were funded by the Department of Health to systematically review well conducted clinical trials in depressed patients and published their results in the Lancet.[1] Real ECT was significantly more effective than simulated ECT, with a standardised effect size of 0.91, translating to a mean difference in the Hamilton depression rating score of 9·7 points (95% Confidence Interval 5·7 to 13·5) in favour of real ECT. This is a large effect – about the same amount of benefit as treating multiple sclerosis with steroids or Parkinson’s disease with L-dopa.[2]

Treatment with ECT is also more effective than antidepressants.[1] This is part of the reason that patients, if you ask them, generally feel satisfied with ECT as a treatment.[3,4] Some patients even prefer ECT to other approaches for treatment of acute depression and a few opt for so-called maintenance ECT every week or two to keep them well. As one of my patients recently said,[5] she would have ECT again in preference to drug treatments as ‘ECT is very quickly effective’ [in a video excerpt I hope to get up on the web soon]. This quick effect is why ECT is often the treatment of choice for severe life-threatening depression, as in the context of severe postnatal depression or puerperal psychosis, when getting the mother well and able to bond with the baby as soon as possible is so important.

Adverse effects of ECT – memory impairment and consent issues, but no brain damage

ECT involves getting an anaesthetic and a muscle relaxant, and then having an electric current to induce a controlled epileptic fit for 20-30 seconds. ECT is however not horrific, as some people say. The modified, controlled fit people now have during ECT usually only involves some twitching of leg and sometimes other muscles. Most people feel ‘groggy’ for a day or two afterwards. And, because ECT is usually repeated twice a week for 6-8 treatments in total, people often don’t remember much for the 3-4 weeks of the treatment. But this also happens to some extent in people with depression, whatever treatment they get.

The most common complaint that patients have is that ECT disrupts their memory in the longer term and can even cause what are sometimes called ‘memory holes’. Evidence suggests that autobiographical memory impairment does occur as a result of ECT.[6] It may cause some long-term losses of some memories, but it doesn’t damage the ability to make new memories any more than depression does. And there is no evidence that ECT causes brain damage.[1] Indeed, studies of people who have had hundreds of ECTs have found their brains to be normal at post-mortem examination.

The other big problem with ECT – which is remediable – is that many patients do not feel well enough informed about the procedure and its adverse effects before they get it and some even feel coerced into having it. This is why a sizeable minority of those who get ECT are not satisfied with their treatment.[3,4]

So, psychiatrists need to be better at explaining the procedure and its risks of short- and long-term memory impairment to people so that they can make an informed choice about what treatment they get. Very rarely, patients are given ECT against their will – if for example they are so unwell as to not realise it, refusing treatment and at risk of death if they are not treated.

Overall Pro’s and Con’s

Because of these adverse effects, ECT is usually reserved for people with severe depression, especially if they have not responded to other treatments, they have psychotic symptoms, or their life is at risk from not eating/drinking or prominent suicidal thoughts. For these people, ECT is usually effective and relatively quickly. Once well, patients have a better chance of staying well if they take antidepressants for a year or more,[7] as in depression generally.[8]

Of course, ECT can be mis-used and abused. It has been in the past and no doubt will be again. But that doesn’t mean it always is. Reserved for the right patients ECT is usually effective and can be life-saving. That is why it is still used in the UK NHS and other healthcare systems. No other reason.

REFERENCES

[1] UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet. 2003 Mar 8;361(9360):799-808. http://www.ncbi.nlm.nih.gov/pubmed/12642045

[2] Leucht S, Hierl S, Kissling W, Dold M, Davis JM. Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses. Br J Psychiatry. 2012 Feb;200(2):97-106. http://www.ncbi.nlm.nih.gov/pubmed/22297588

[3] Rose DS, Wykes TH, Bindman JP, Fleischmann PS. Information, consent and perceived coercion: patients’ perspectives on electroconvulsive therapy. Br J Psychiatry. 2005 Jan;186:54-9. http://www.ncbi.nlm.nih.gov/pubmed/15630124

[4] Chakrabarti S, Grover S, Rajagopal R. Perceptions and awareness of electroconvulsive therapy among patients and their families: a review of the research from developing countries. J ECT. 2010 Dec;26(4):317-22. http://www.ncbi.nlm.nih.gov/pubmed/21155155

[5] Lawrence R, Lawrie SM. Psychotic depression. BMJ. 2012 Oct 24;345:e6994. http://www.ncbi.nlm.nih.gov/pubmed/23097553

[6] Fraser LM, O’Carroll RE, Ebmeier KP. The effect of electroconvulsive therapy on autobiographical memory: a systematic review. J ECT. 2008 Mar;24(1):10-7. http://www.ncbi.nlm.nih.gov/pubmed/18379329

[7] Jelovac A, Kolshus E, McLoughlin DM. Relapse following successful electroconvulsive therapy for major depression: a meta-analysis. Neuropsychopharmacology. 2013 Nov;38(12):2467-74. http://www.ncbi.nlm.nih.gov/pubmed/23774532

[8] Geddes JR, Carney SM, Davies C, Furukawa TA, Kupfer DJ, Frank E, Goodwin GM. Relapse prevention with antidepressant drug treatment in depressive disorders: a systematic review. Lancet. 2003 Feb 22;361(9358):653-61. http://www.ncbi.nlm.nih.gov/pubmed/12606176

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