Introduction

ECT is without doubt a safe and effective treatment for serious depression (and other serious psychoses, especially manic depressive illness aka Bipolar disorder). It is under-used and misunderstood still, after all these years (1-4).

Anyone who encounters a doctor who is against ECT and who says it does not work has met a person who does not understand either the life-saving and life-changing benefits that may be conferred by ECT or the seriousness and suffering of severe depression. In such circumstances it would be advisable to seek a second opinion from someone experienced in the treatment of refractory depression (and read this commentary).

This commentary concerns recent research and evidence focusing especially on For Whom? How Good? For How Long? It is not meant to be a comprehensive overview of ECT. Those wishing for more on particular aspects will find the sources and references cited below have been carefully selected and contain much further information.

A few key questions are: what sort of depression responds to ECT? For how long do patients stay well afterwards? Why its it so under-used? What are the disadvantages and side effects?

Response and Relapse

For Whom?

Those suffering severe and/or treatment refractory/resistant illness. The idea that particular 'endogenous' symptoms predict a specific and differential response to ECT is not strongly sustained by evidence. It seems that with major/endogenous/biological depression the same high percentage of patients respond irrespective of the 'sub-type' of depression they have. i.e. the presence of retardation, melancholia, agitation or psychotic features does not predict a significantly different proportion of responders. Other indications for ECT are covered in the sources and references below.

How Good and For How Long?

When making comparisons with drug treatment two points require special consideration. First, patients reported in drug trials are significantly less severely ill than those in ECT trials (5); second, improvement in ECT trials is often reported as remission (i.e. effective absence of symptoms equating to wellness and recovery) as opposed to drug trials that often use the measure of a 50% improvement in rating scale scores. So one must be careful to compare like with like, this indicates the superiority of ECT over most anti-depressants is greater than it might at first seem.

The latest analysis of data indicates that with ECT around 50% of patients have excellent improvement from what was previously a treatment resistant illness and most remain well at 12 months after their ECT (6-8). That is a good result. It is one most anti-depressants can only aspire to.

Depression in those with Bipolar Disorder responds more rapidly than unipolar depression, but the final proportion of responders is the same for both (9-11).

ECT does appear to produce a slightly more rapid improvement than medication and may be particularly good in elderly patients who seem to have an even higher response rate (12). In particular circumstances this more rapid response may be an important consideration and benefit.

Side Effects

The inter-relationships between energy, motivation, anxiety and concentration all influence the subjective and objective assessment of thinking and memory which makes estimating the possible adverse effects of ECT complex. One must not forget that severe depression may cripple people’s mental functioning in all these domains, to the extent of causing difficulty in distinguishing depression from dementia. Also long-lasting severe depression may contribute to the exacerbation of general ill-health, cardio-vascular disease and therefore dementia and stroke (13-15). To the extent that ECT may cause memory deficits it is appropriate to balance that against probable reduction of future complications as a result of improvements in the illness brought about by ECT.

General mental functioning may improve rapidly: Semkovska (16) found in a meta-analysis from a total of nearly 3,000 patients: “After 15 days, processing speed, working memory, anterograde memory, and some aspects of executive function improve beyond baseline levels”.

Further analysis concerning ECT effects on memory is contained in the sources below, and these references (1, 2, 17-19).

The ‘Brain Damage’ Question

There is no good evidence that ECT adversely affects brain structure or causes brain ‘damage’. In fact the opposite may be the case, i.e. ECT may reverse area specific changes/atrophy that seem to be associated with severe depression (20-23): this is an expanding area of research because new ultra-sensitive imaging technologies are producing better data suggesting possible improvements in brain volume, structure and connectivity after ECT (24-29).

Relapse, Drugs & Lithium

The rate of relapse is quite high, especially without appropriate follow-up drug treatment which is considered by most people to be essential. Approximately half of those who relapse do so within four weeks post ECT. There is not a substantial body of evidence concerning which particular drug treatment is most effective in preventing relapse, nortripyline and lithium seem good choices. It is interesting that the putative SNRI, venlafaxine, does not appear to be any more efficacious than nortriptyline, indeed it may be less efficacious ***. Both are significantly more effective than no treatment (6, 30).

*** I interpret this finding as strongly supporting my contention that venlafaxine is not really an SNRI and is not superior to tricyclics like nortriptyline, amitriptyline or clomipramine. After all, this (large) group of patients are comprised of those who have been proven to have a biological illness responsive to ECT so they represent a purer sample of responders that would be expected to readily reveal any actual superiority of one drug over another by virtue of a lesser relapse rate. The fact that venlafaxine was less effective is therefore a telling indictment of its poor effectiveness.

There is also strong evidence that lithium reduces relapse in the first 6 months after index ECT (31, 32) and many commentators seem bemused (rightly, in my view)  by its underutilisation in this context. Auditing of ECT practice demonstrates that even after many years of use and education ECT treatment (like lithium treatment) is often performed sub-optimally. As Atiku et al. stated (32):

“Not all psychotropic medication prescribing for patients receiving ECT for depression followed available and current guidance or consensus. More needs to be done to understand the reasons for the reluctance to use lithium if relapse rates after ECT are to improve” (32).

Can it be coincidence that ECT and lithium are both underused and under-studied because there is no financial backing from pharmaceutical companies promoting their use, whereas vast money, effort and influence has gone into promoting venlafaxine etc.

Efficacy of Continuation ECT

For initial treatment there seems to be no advantage from an ECT frequency of more than twice weekly (33, 34).

The balance of evidence at present suggests that maintenance ECT probably reduces of relapse/recurrence especially in combination with antidepressants (30, 35).

Ultrabrief Pulse ECT

Any possible advantage for ultra-brief pulse over brief pulse ECT seems as yet unproven, but it seems just as effective (8, 36, 37).

Surveys and Audits of Practice Worldwide

Context is provided by this review of the contemporary use and practice of electroconvulsive therapy worldwide (38). Unsurprisingly, it shows widespread poor practice. I am told that some public clinics in the USA still use outmoded sine wave ECT machines.

National guidelines, supervision and auditing of standards and continuing education are generally woefully inadequate even in so-called 1st world countries, which reflects very poorly on the profession.

Surveys and audits: (39-41).

Opinion and Conclusion

There is no doubt that ECT is a safe, effective and potent treatment for severe depression, especially when that has not responded to other treatments: chronic depression is far more to be feared than ECT. It should be administered by an accredited clinic/practitioner (see sources below); if in doubt seek advice from the nearest university teaching hospital (almost all of which use ECT regularly).

There is a widely held misconception that ECT is a 'last resort'. That is a misleading, negative and inappropriate view.

Although ECT is a good treatment for severe depression there is no reason to lessen therapeutic resolve should it fail; patients may subsequently respond to appropriate regimes designed for refractory cases (42). Whether clinicians consciously adopt this negative 'last resort' view or not, they do tend to behave as if it were true; so if a patient remains ill after ECT it is my experience that doctors become negative and give up on drug treatment. That is a serious mistake because patients who fail to respond to ECT may subsequently improve if given a combination regime such as:

tranylcypromine with lithium and or NTP augmentation

clomipramine, with lithium augmentation

sertraline plus nortriptyline (with lithium augmentation if needed)

NB The above are examples from a range of possible regimes.

Sources of Information on ECT

Wikipedia (a good balanced appraisal)

https://en.wikipedia.org/wiki/Electroconvulsive_therapy

The International Society for ECT and Neurostimulation (ISEN), formerly the Association for Convulsive Therapy (ACT),

https://www.isen-ect.org

(listen to Sherwin Nuland’s TED talk: How electroshock therapy changed me)

Mayo Clinic

http://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/basics/definition/prc-20014161

Administration Guidelines

https://www.health.qld.gov.au/publications/clinical-practice/guidelines-procedures/clinical-staff/mental-health/guidelines/ect_guidelines2012.pdf

Black Dog Inst.

http://www.blackdoginstitute.org.au/docs/ECTfactsheet.pdf

SANE Australia

https://www.sane.org/information/factsheets-podcasts/445-electroconvulsive-therapy-ect

The Scottish ECT Accreditation Network

Scottish Electroconvulsive Therapy (ECT) Accreditation Network (SEAN)

http://www.isdscotland.org/Health-Topics/Scottish-Healthcare-Audits/Scottish-ECT-Accreditation-Network/

National Prescribing Service (NPS)

http://www.nps.org.au/conditions/mental-health-conditions/mood-disorders/depression/for-individuals/treatment/what-is-ect

References

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