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B. ECT is a viable treatment and I would recommend it in some cases

C. ECT is use an approved treatment but I would not recommend it

Is ECT a viable or a dangerous treatment for psychiatric disorders? Is there a middle road? Share your thoughts in our poll.

PsychPoll: ECT, Yay or Nay?

The article by John Read, PhD, and colleagues argues in favor of suspending the use of electroconvulsive therapy (ECT) due to a lack of efficacy data and unacceptable adverse effects, specifically, brain damage.

 Unfortunately, the analysis is based on studies conducted prior to the modern era of ECT, and it draws on a limited slice of the available safety and efficacy data for ECT. More recent studies have found key areas of efficacy (

The selection criteria used by Read and colleagues were limited to older studies (1956 to 1985) and critiques of the quality of the data. Thus, the piece is judging clinical trial designs from the 1980s and earlier, using 2019 standards. It is no surprise that the included studies do not utilize methodology developed after the studies were completed. More importantly, the analysis did not include reports that compare different types of ECT, and comparisons of ECT with pharmacotherapy were also not included. This excludes most of the recent meta-analyses and clinical trials of ECT, which have used state-of-the-art clinical trial design. For example, a recent meta-analysis conducted by 

 compared ultrabrief pulse right unilateral (RUL) ECT with brief pulse RUL ECT.

 They found remission rates of 44.9% for brief pulse right unilateral ECT vs 33.8% for ultra-brief pulse RUL ECT (OR, 0.71; 95% CI, 0.51-0.99; P = .045). Their meta-analysis showed that brief pulse caused more cognitive adverse effects than ultrabrief pulse, but there were no data after the acute course.

Since ECT is considered to be an established treatment, it can be used as an active comparator in a noninferiority paradigm, avoiding the ethical dilemma of treating very ill patients with a placebo treatment. As such, Helle K. Schoeyen, MD, PhD, and colleagues 

 brief-pulse RUL ECT to algorithm-based pharmacology in a cohort of patients with treatment-resistant bipolar depression.

 At the end of a 6-week trial, the Montgomery-Asberg Depression Rating Scale scores in the ECT group were 6.6 points lower than those of the pharmacological treatment group (95% CI, 2.5-10.6; P = .002). In a 

, Charles Kellner, MD, and colleagues compared continuation ECT augmented by venlafaxine with lithium plus venlafaxine in geriatric depression.

 At 24 weeks, the ECT group had statistically significantly lower depression scores (Hamilton Depression Rating Scale score, 4.2; 95% CI, 1.6-6.9) than the medication only group. If ECT were not more effective than placebo, as Read and colleagues proposed, there would be no difference in the efficacy of different types of ECT, nor would ECT perform better than standard pharmacology. Taken together, these studies support the acute and sustained clinical efficacy of ECT and are inconsistent with the lack of efficacy proposed by Read and colleagues.

The main safety concern raised by Read and coauthors is that ECT causes brain damage. Specifically, they argued that the changes to autobiographical memory and the memory difficulties reported by patients following ECT treatment are evidence of brain damage. They also cited “microvascular, neuronal, voltage-gated ion channel damage that is visible on standard brain scans” as further buttressing this argument.

 The piece also leverages an article from 1946,

 and the minutes from a traumatic brain injury advisory board meeting8 to support the brain damage claim. However, it does not appear that the more recent studies that fail to show chemical or structural evidence of brain damage with ECT,

 nor those that suggest improvement in cognitive function relative to baseline following ECT.

Perhaps the most interesting finding regarding the memory effects of ECT is that the hippocampal volume, which has been shown to 

 in major depression, increases following a course of ECT treatment.

 This finding has been supported by 2 recent studies. Leif Oltedal, MD, PhD, and colleagues reported results from a multicenter imaging trial of the effects of ECT on hippocampal volume using structural magnetic resonance imaging in 281 patients from the Global ECT-Magnetic Resonance Imaging Research Collaboration.

 Their results showed an increase in hippocampal volume in participants receiving unilateral or bilateral ECT, while the 95 control participants who did not receive ECT did not show changes between the 2 scans.

This finding was corroborated by a systematic 

 of ECT’s effects on the brain’s structure by Krzysztof Gbyl, MD, and Paol Videbech, MD, DMSc.

 They reviewed 32 studies with 467 patients and 285 controls, and drew a number of interesting conclusions. None of the studies they reviewed reported evidence of brain damage. Instead, the studies found that hippocampal volume as well as other cortical and subcortical regions showed increases in volume. The authors noted that the increases in brain volume tended to occur in regions of the brain thought to be involved in the pathophysiology of depression.

 They also reviewed 5 diffusion tensor magnetic resonance imaging studies with a total of 92 patients and 62 controls, and the changes they found indicated increased, not decreased, white matter integrity between the frontal and temporal lobes after ECT. These finding are also consistent with results from a retrospective chart review study by my research group. We were able to identify 100 patients who had received at least 50 ECT treatments, 36 of whom received 100 ECT treatments as part of an acute course of ECT that transformed into maintenance treatment. Cognitive function as measured by the Montreal Cognitive Assessment essentially did not change in either group.

 In short, in an illness thought to result from decreased prefrontal cortical activity and connectivity to limbic structures, there is consistent evidence of increased volume and connectivity, not atrophy, following state-of-the-art modified ECT, which is corroborated by the available cognitive data.

The other safety concerns raised were an increased risk of major cardiac adverse events and an increased risk of death from ECT. While ECT does cause dramatic swings in heart rate and blood pressure, these effects are transient and well known. Further, the swings can be managed with thoughtful pretreatment, assessment, and careful monitoring during the procedure. Consistent with this approach, Niels Tørring, MSc, PhD, and colleagues 

 a systematic review and pooled data analysis from 15 studies and found a death rate of 2.1 per 100,000 treatments.

 This is a decrease from the 4 per 100,000 treatments previously reported.

 Given the population that typically receives ECT, this decline in mortality likely reflects improvements in the medical management of chronic medical conditions and anesthetic technique. These data clearly do not support the assertion of an increased risk of death with ECT.

In summary, the concerns that were raised about ECT are commonly shared by the general public, and they are based on data from older studies that used the methodology now considered outdated both in terms of ECT practice and analytic techniques. Read and colleagues did not consider more recent, state-of-the-art clinical trial data that corroborate more than 75 years of clinical experience supporting the efficacy of ECT in a population of patients who suffer significant disability, increased medical comorbidity, and increased mortality.

1. Read J, Kirsch I, McGrath L. Electroconvulsive therapy for depression: a review of the quality of ECT versus sham ECT trials and meta-analyses. 

2. Tor P-C, Bautovich A, Wang MJ, et al. 

A systematic review and meta-analysis of brief versus ultrabrief right unilateral electroconvulsive therapy for depression

3. Schoeyen HK, Kessler U, Andreassen OA, et al. 

Treatment-resistant bipolar depression: a randomized controlled trial of electroconvulsive therapy versus algorithm-based pharmacological treatment

4. Kellner CH, Husain MM, Knapp RG, et al; CORE/PRIDE WOrk Group. 

A novel strategy for continuation ECT in geriatric depression: phase 2 of the PRIDE study

5. Alpers BJ. The brain changes associated with electrical shock treatment; a critical review. J Lancet. 1946;66(11):363-369.

7. Chen W, Zhongsheng Z, Lee RC. Supramembrane potential-induced electroconformational changes in sodium channel proteins: a potential mechanism involved in electric injury. 

8. Traumatic Brain Injury Advisory Board meeting minutes. California Department of Rehabilitation. August 26, 2019. Accessed February 12, 2021. 

https://www.dor.ca.gov/Content/DorIncludes/documents/TBI/ TBI Full Committee Meeting Minutes 8-26-19.docx

9. Abrams R.And there’s no lasting proof of brain damage. 

10. Weiner R, Reti I. Key updates in the clinical application of electroconvulsive therapy. 

Hippocampal volume changes following electroconvulsive therapy: a systematic review and meta-analysis

Biol Psychiatry Cogn Neurosci Neuroimaging.

12. Oltedal L, Narr KL, Abbott C, et al. Volume of the human hippocampus and clinical response following electroconvulsive therapy. 

Electroconvulsive therapy increases brain volume in major depression: a systematic review and meta-analysis

14. Luccarelli J, McCoy TH Jr, Seiner SJ, Henry ME. Maintenance ECT is associated with sustained improvement in depression symptoms without adverse cognitive effects in a retrospective cohort of 100 patients each receiving 50 or more ECT treatments. 

15. Tørring N, Sanghani SN, Petrides G, et al. 

The mortality rate of electroconvulsive therapy: a systematic review and pooled analysis

16. Abrams R. The mortality rate with ECT. 

There is consistent evidence of benefits following state-of-the-art modified ECT.

ECT: An Effective and Safe Treatment

Although electroconvulsive therapy (ECT) is still used on about a million individuals annually, a recent review found “large variation between continents, countries and regions in utilization, rates and clinical practice.”

 in usage between the highest and lowest utilizations regions of England.

In June 2020, this article’s first author published his fifth review of the ECT literature since 2010.

 evaluated the quality of 5 meta-analyses that claimed ECT was effective and safe, as well as the quality of the placebo-controlled studies that had been cited by the meta-analyses. (In these studies, placebo included the general anesthetic without the electric shock.) There have only been 11 placebo-controlled studies of ECT for depression, all of which were conducted before 1986.

The 5 meta-analyses often cited by critics, which included between 1 and 7 of the 11 studies, paid little or no attention to the studies’ multiple limitations (

The quality of most SECT-ECT studies is so poor that the meta-analyses were wrong to conclude anything about efficacy, either during or beyond the treatment period . . . Given the high risk of permanent memory loss and the small mortality risk, this longstanding failure to determine whether or not ECT works means that its use should be immediately suspended until a series of well designed, randomized, placebo controlled studies have investigated whether there really are any significant benefits against which the proven significant risks can be weighed.

The review’s conclusion that there is no evidence ECT prevents suicide, as often claimed, has been unequivocally confirmed by a study of 14,810 patients who received ECT and 58,369 controls.

 Patients in the ECT group were 16 times more likely to attempt suicide over 12 months than the non-ECT patients. Even after controlling for a range of mediating variables, the ECT patients were still 1.3 times more likely to die by suicide (not a statistically significant difference).

The exact incidence of brain damage remains unknown. If brain damage is defined as memory loss persisting at least 6 months after the last ECT, findings range from 12% to 55%.

 This damage is more common in women and older individuals,

 and these groups receive ECT disproportionately.

 While there are many accounts of devastated lives on social media, examples in the published scientific literature are less common. One example 

With each shock treatment, I felt more and more of myself slipping away. I couldn’t remember things, particularly the immediate past, but eventually even the more distant past had been erased. I was frightened by this. I thought, ‘if I don’t know what I’ve done or where or I’ve been, then who am I? A person’s memories are her identity. Take them away, and you take away her sense of self.’

Advocates of ECT treatment deny it causes brain damage, although a manufacturer of ECT machines includes “permanent brain damage” as a risk.

 Others acknowledge memory loss but blame the depression, not the electricity, even after a review concluded that “There is no evidence of a correlation between impaired memory/cognition after ECT and impaired mood, much less a causal relationship,”

 a conclusion subsequently confirmed in a 

The class action lawsuit currently being prepared in the United Kingdom (UK) is focused not on the memory loss and brain damage per se, but on the failure of psychiatrists to 

The risk of death is greater than 1 per 10,000 patients noted by organizations like the American Psychiatric Association.

 The leading cause of death is cardiovascular failure.

 A review of 82 studies with more than 100,000 patients, found that 1 in 50 patients experienced “major adverse cardiac events.”

 In addition, there are other mortality risks, which are higher for older individuals in the target age group for ECT, and are associated with general anesthetic procedures.

The review of meta-analyses3 received wide media coverage. Although some psychiatrists attacked the review, some patients feel vindicated by the findings.

One of the authors (Hancock) has undergone more than 100 ECT procedures in the United States.

Since the first device classification hearing in 1978, the FDA has requested premarket approval (PMA) electroencephalogram studies (and more recently functional magnetic resonance imaging) to justify device reclassification. Despite never having received PMA data for ECT, the FDA 

 a closed hearing during 2018 and reclassified ECT devices from higher risk to moderate risk.

 This reclassification occurred less than 3 months after ECT machine manufacturer Thymatron published its regulatory update, listing “permanent brain damage and permanent memory loss” as 

 Having never undergone PMA safety testing, ECT is unstandardized. Each ECT experience (positive or negative) is therefore just anecdotal evidence.

Psychiatrists, who are not required to study the neuropathology of repetitive high electric field strength on brain tissue, are naive to the compounding microstructural damages only visible with proper staining techniques and under a microscope. Consequently, many psychiatrists are liable to miss the cellular, microvascular, neuronal, and voltage-gated ion channel damage that is invisible on standard brain scans.

In 82 years of ECT use, the field of psychiatry has not conducted long-term studies of patients to identify ECT’s functional impact on quality of life or aging. Modern research in repetitive brain injury sheds light on the realities faced by millions of ECT recipients. Bennet Omalu, MPH, a neuropathologist who identified chronic traumatic encephalopathy in National Football League players, stated that, where they exist, functional injuries resulting from ECT must be considered as both repetitive brain injury and repetitive electrical trauma.

Unlike standard documentation required to justify insurance reimbursements, Medicare 

 ECT “providers who failed to report quality data.”

 In other fields of medicine, if a procedure is not documented with quality data, it is denied. Yet the reimbursement rate for fiscal year 2021 for “providers who fail to report quality data” is more than the 

 rate for properly documented ECT in FY 2020.

Given ECT’s national reimbursement practices, it is unsurprising that the Substance Abuse and Mental Health Services Administration’s National Directory of Mental Health Treatment Facilities ECT provider list 

 from 335 clinics in 2018 to 449 in 2020.

 since device reclassification may reflect what happens when hospitals identify an unregulated income source.

Regulating ECT is challenging without an accreditation process to monitor providers. No one knows how many Americans receive ECT each year, let alone how many treatments each individual receives or how closely providers space treatments. This is a troubling dilemma considering Thymatron’s regulatory update lists the number of treatments received, and closely spaced treatments as 2 of the 7 independent risks, recognized by the APA, as being related to “permanent memory loss or permanent brain damage.”

The third author of this piece (Cunliffe) has also undergone ECT. She was a doctor until 2005 when she suffered devastating brain damage from ECT. She has improved over the last 15 years, but she reports disabling neuronal fatigue. She can never work again, and she has lost her independence. Nonetheless, Cunliffe feels fortunate, as she is the only ECT patient she knows who received has neurorehabilitation. She has dedicated herself to preventing the distress of others.

After being admitted to the hospital following coercive abuse, Cunliffe was persuaded to undergo 20 sessions of ECT. Her medical notes clearly demonstrate a lack of monitoring. To the contrary, the notes document her complaints about deteriorating memory, speech slowing down, feeling continuously sedated, and having issues with motor and coordination skills. Instead of reviewing the treatment plan, the dose was increased from 90 millicombs (mCs) to 700 mCs.

Cunliffe spent 10 years researching ECT practice and the UK’s ECT Accreditation Service (ECTAS), which is run by the Royal College of Psychiatrists (RCP). She found a 2015 ECTAS patient survey showed that 19% of patients who received ECT treatment were 

 by permanent memory loss; however, this figure is never quoted and ECTAS continues to accredit units that are neither offering informed consent nor monitoring for side effects.

 In the UK, units can continue to operate without accreditation and without meeting the minimum ECTAS standards. Cunliffe has 

 publicly about her story, including at one of the famous Maudley debates at the Institute of Psychiatry, 

 the motion “ECT has No Place in Modern Medicine.”

According to Cunliffe, the RCP’s response to her recent letter outlining the serious flaws in the ECTAS accreditation service shows that they have no intention of improving standards of care or consent. She added that RCP President Adrian James, FRCPsych, MSc, refused to meet with her and other victims.

A UK coalition of 40 ECT survivors and family members, mental health professionals (including psychiatrists), and researchers have 

 the health minister calling for an independent enquiry into the practice of ECT.

 The call has been endorsed by many members of Parliament, the National Counselling Society, the Association of Clinical Psychologists UK, the Council for Evidence-based Psychiatry, and, importantly, Headway, the brain injury association. The UK’s largest mental health charity, Mind, 

At Mind, we back calls for a comprehensive review into the use of ECT, a potentially risky physical treatment that is still used to treat mental health problems in rare cases. We know that some people have found it effective for improving symptoms of mental health problems—particularly depression—when nothing else has worked. However, we still don’t know why it works or how effective it is. Some people who have had ECT may have found they experience adverse side effects that are worse than the symptoms of the problem they’re trying to treat, including short term or longer term memory loss.

We recognize that ECT advocates have their patients’ best interest at heart. However, an evidence-based approach to psychiatry dictates that this controversial treatment be suspended pending research that meets 21st century standards to determine whether there are any benefits to offset the proven adverse effects in comparison to placebo. At the very least, to comply with the ethical principle of 

, the minority of psychiatrists who continue to use ECT must tell potential ECT recipients that: there is no evidence that it is better than placebo beyond the end of the treatment period, there is no evidence that it saves lives, and studies have found that it causes persistent or permanent memory loss in 12% to 55% of patients, with particularly high rates among women and older individuals.

1. Leiknes KA, Jarosh-von Schweder L, Høie B. Contemporary use and practice of electroconvulsive therapy worldwide. 

2. Read J, Harrop C, Geekie J, et al. A second independent audit of ECT in England, 2019: Usage, demographics, consent, and adherence to guidelines and legislation. Psychol Psychotherapy:. in press. Accessed March 8, 2021. 

3. Read J, Kirsch I, Mcgrath L. Electroconvulsive therapy for depression: a review of the quality of ECT versus sham ECT trials and meta-analyses. 

The effectiveness of electroconvulsive therapy: a literature review

5. Peltzman T, Shiner B, Watts BV. Effects of electroconvulsive therapy on short-term suicide mortality in a risk-matched patient population. 

The cognitive effects of electroconvulsive therapy in community settings

7. Rose D, Fleischmann P, Wykes T, et al. Patients’ perspectives on electroconvulsive therapy: systematic review. 

8. Read J, Bentall R, Johnstone L, et al. Electroconvulsive therapy. In: Read J, Dillon J, eds. 

Models of Madness: Psychological, Social and Biological Approaches to Psychosis, 2nd ed. 

Consumers’ views of electroconvulsive therapy:
A qualitative analysis

10. Somatics. Regulatory Update to Thymatron System IV Instruction Manual. Accessed February 12, 2021. 

http://www.thymatron.com/downloads/System_IV_Regulatory_Update.pdf

11. DK Law Group. ECT shock treatment litigation – case update June 2019. Latest News and Law Blog. Accessed February, 12, 2021. 

1http://www.dk4law.com/blog/dk-law-group-news/ect-shock-treatment-litigation-case-update-june-2019/

12. Robertson H, Pryor R. Memory and cognitive effects of ECT: informing and assessing patients. 

13. Halle M, Adams S. Dozens of patients sue the NHS over claims they suffered brain damage after having depression treatment of electrical currents through the head. The Mail on Sunday. July 19, 2020. Accessed February 12, 2021. 

https://www.dailymail.co.uk/news/article-8537431/Dozens-patients-sue-NHS-claims-suffered-brain-damage-having-therapy.html

14. Duma A, Maleczek M, Panjikaran B, et al. Major adverse cardiac events and mortality associated with electroconvulsive therapy: a systematic review and meta-analysis. 

15. United States Food and Drug Administration. Neurological devices; reclassification of electroconvulsive therapy devices; effective date of requirement for premarket approval for electroconvulsive therapy devices for certain specified intended uses. Federal Register: The Daily Journal of the United States Government. December 26, 2018. Accessed February 12, 2021. 

https://www.federalregister.gov/documents/2018/12/26/2018-27809/neurological-devices-reclassification-of-electroconvulsive-therapy-devices-effective-date-of

16. Alpers BJ. The brain changes associated with electrical shock treatment; a critical review. 

17. Friedberg J. Neuropathologic effects of ECT. 

18. Chen W, Zhongsheng Z, Lee RC. Supramembrane potential-induced electroconformational changes in sodium channel proteins: a potential mechanism involved in electric injury. 

19. Jafari H, Couratier P, Camu W. Motor neuron disease after electric injury. 

20. Traumatic Brain Injury Advisory Board meeting minutes. California Department of Rehabilitation. August 26, 2019. Accessed February 12, 2021. https://www.dor.ca.gov/Content/DorIncludes/documents/TBI/TBI Full Committee Meeting Minutes 8-26-19.docx

21. Centers for Medicare & Medicaid Services. Medicare program: fiscal year 2020 inpatient psychiatric facilities prospective payment system and quality reporting updates for fiscal year beginning October 1, 2019. April 23, 2019. Accessed February 12, 2021. 

https://www.regulations.gov/document?D=CMS-2019-0067-0002

22. Centers for Medicare & Medicaid Services. Medicare Program: fiscal year 2021 inpatient psychiatric facilities prospective payment system (IPF PPS) and special requirements for psychiatric hospitals for fiscal year beginning October 1, 2020 (FY 2021), 85 § (2020). United States of America. Accessed February 24, 2021. 

https://www.govinfo.gov/content/pkg/FR-2020-08-04/pdf/2020-16990.pdf

23. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Behavioral Health Services Information System Series. 2018 National Directory of Mental Health Treatment Facilities. Accessed February 24, 2021. 

https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/nmhss_directory_2018.pdf

24. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Behavioral Health Services Information System Series. 2020 National Directory of Mental Health Treatment Facilities. April 14, 2020. Accessed February 24, 2021. 

https://www.samhsa.gov/data/report/2020-national-directory-mental-health-treatment-facilities

25. Royal College of Psychiatrists. ECTAS Interim Report – Patient perspectives: March 2013 – April 2014. eds. Haily E, Hodge S, Buley N. August 2015. Accessed February 24, 2021. 

https://www.rcpsych.ac.uk/docs/default-source/improving-care/ccqi/quality-networks/electro-convulsive-therapy-clinics-(ectas)/ectas-interim-report.pdf

26. Read J, Cunliffe S, Jauhar S, McLoughlin DM. Should we stop using electroconvulsive therapy? BMJ. 2019;364:k5233.

27. Institute of Psychiatry. 57th Maudsley Debate. “This House Believes ECT Has No Place in Modern Medicine.” September 27, 2018. YouTube page. Accessed February 12, 2021. 

28. Cunliffe S, Johnstone L. Call for a review of the use of electroconvulsive therapy (ECT). Letter to Matt Hancock, MP. July 10, 2020. Accessed February 12, 2021. 

https://www.uel.ac.uk/-/media/staff/r/john-read/call-for-independent-review-of-ect-july-10.ashx

29. Buckley, S. Mind is backing a call to review the use of electroconvulsive therapy. Mind. August 12, 2020. Accessed February 12, 2021. 

https://www.mind.org.uk/news-campaigns/news/mind-is-backing-a-call-to-review-the-use-of-electroconvulsive-therapy-ect/

No one has precise data about how many Americans receive ECT each year, let alone how many treatments each patients receives or how closely providers space treatments. This is a troubling dilemma, according to the authors.

ECT: Dangerous on Either Side of the Pond

The rhetoric surrounding the merits of electroconvulsive therapy (ECT) can sometimes become so heated that one is reminded of the wise prohibition against discussing politics or religion in a bar. This is disappointing because we can truthfully say that we have more experience with this procedure, which was introduced in 1938, than we do with any other psychopharmacological intervention. We have decades of data on its use and effects. How can there still be such disagreement?

It should come as no surprise that stigma is an important underlying theme in this discussion. ECT canstill sound frightening and conjure up images out of a horror movie. We know our patients contend with negative opinions and perceptions from the general public, acquaintances, and friends. However, the problem becomes all the more salient when the stigmatization involves professionals, whether they be pharmacists, physicians in other specialties, or indeed, even psychiatrists.

What we need is good data, clear analysis, and sound clinical judgement. Ultimately, no treatment in medicine is completely apropriate for all individuals. The trick is to find the right treatment for the right person at the right time. We often make the mistake of generalizing our experiences to all patients. It may be that some patients benefit more from ECT than others. Perhaps there are even genotypic differences that could help predict which patients are most likely to benefit from this treatment.

Despite the controversy and lingering stigma, ECT has undoubtedly been foundational in the field of interventional psychiatry. It is firmly ensconced in our armamentarium, along with its younger siblings 

, deep brain stimulation, and intravenous 

. I have no doubt that as we continue to progress, the list of potential interventions will continue to grow. My hope is that we will become better at identifying the best treatments for each particular patient. We must remember to make our treatment recommendations based on the evidence and, to the greatest extent possible, to do so consistently.

We are certainly fortunate to work in a field so tightly connected to the human experience. Differences of opinions and perspectives present a great opportunity to learn. I have certainly benefited from the following Point-Counterpoint articles.

We encourage you to read these thoughtful pieces, consider the data, and share your viewpoints with us at 

is the medical director, Division of Neuropsychiatry, at Dent Neurologic Institute and the medical director, Addiction Services, at Brylin Hospital in Buffalo, New York. ❒

ECT has undoubtedly been foundational in the field of interventional psychiatry, yet controversy remains an underlying theme.

Electroconvulsive Therapy: Obsolete and Dangerous or Still Just Misunderstood?

“The problem of treatment-resistant depression in later life [TRD-LL] is increasingly recognized but remains poorly characterized,” Randall Espinoza, MD, MPH, told the audience at the American Association of Geriatric Psychiatry Annual Meeting. According to Espinoza, estimates of its prevalence run from 6% up to 40% in geriatric patients with depression, depending on how treatment-resistant depression (TRD) is defined.

At a session titled “Beyond ECT – Neuromodulation and Interventional Psychiatry for Treatment Resistant Depression in Later Life,” Espinoza and his colleagues Aaron Kaufman, MD, and Ali Ashghar-Ali, MD, discussed the challenges of identifying and treating TRD in older patients, including the latest results from clinical research.

TRD is associated with increases in morbidity and mortality, including greater levels of pain and suicide. It leads to higher health care costs, lower quality of life, and reduced workplace productivity. TRD can be chronic and recurrent: 20% to 35% of patients have continuous depression for more than 1 year, and 25% to 40% of patients experience a recurrence within 2 years, and 60% have a recurrence after 

Despite the prevalence of TRD, simply identifying it may be a challenge, Espinoza noted. He broke it down into 3 possible categories: 1) nonresponse to treatment and a high degree of functional impairment, 2) treatment resistant depression, which shows minimal to partial response to treatment, and 3) treatment refractory depression, which shows no response to treatment and 

 He noted that TRD may have a different epidemiology in older adult populations and may arise due to trauma, social adversity, and losses. Furthermore, treatment is complicated by brain aging and the fact that most clinical trials deliberately exclude older adults, which makes pharmacological options uncertain.

Espinoza also warned that TRD in older patients may be accompanied by significant comorbidities, including anxiety disorders, substance abuse, and cognitive and personality disorders.

In terms of treatment, Espinoza suggested that clinicians consider moving from the framing of “treatment-resistant” to a “difficult to treat” depression (DTD) model.

 The TRD model treats depression as a chronic rather than acute illness. To the biological emphasis of the TRD model, it would add a neurobiopsychosocial focus. Rather than judging progress according to cure or remission alone, it also emphasizes capability, recovery, and symptom management.

As Espinoza explained, “DTD captures not only acute phase treatment but also encourages a shift of focus to long-term treatment with the goals of improving overall function, quality of life, and optimization of treatment when full remission is no longer viable.”

Turning to more specific treatment options, Ashghar-Ali noted that “ECT remains [the] gold standard for neuromodulation intervention in older adults,” and noted clinicians have other options as well. He reviewed 2 studies of repetitive transcranial magnetic stimulation (RTMS)/DEEP TMS, which 

Ashghar-Ali also discussed ketamine. Although it is not approved by the US Federal Drug Administration (FDA) for treating TRD, ketamine has shown 

 Esketamine, however, is FDA approved for treating depression. Ashghar-Ali noted that esketamine plus an antidepressant demonstrated a statistically significant treatment effects in patients aged 65 to 74 years (although not for patients aged more than 75 years).

 He concluded that esketamine might play a helpful role in treating TRD in patients during the 64 to 75 age band.

Kaufman considered the possible role of lithium augmentation. He discussed 1 study in which lithium augmentation had a high remission rate (63.6%) among elderly patients with treatment resistant depression, and another in which geriatric patients responded significantly better to lithium augmentation than 

 He noted that some evidence also existed for augmenting with atypical antipsychotics and stimulants.

Psychotherapy is also an option. Kaufman presented from a meta-analysis of psychotherapy in later-life depression that found large effects, when compared with 

 The evidence is strongest for problem-solving therapy, interpersonal psychotherapy, and cognitive behavioral therapy. Exercise, meditation, acupuncture, and Tai Chi had also been shown to help in a number of cases.

During the Question and Answer period, both Kaufman and Ashghar-Ali spoke to why treatments beyond ETC may be necessary.

“These are of course really challenging cases,” Kaufman said. Some patients may have trouble recalling the details of her medication and adherence history, and many do not trust ECT. “We’ve all had patients decline ETC and want to pursue alternatives,” Kaufman said further.

Alternately, said Ashghar-Ali, “a lot of people come to ECT with the assumption that it’s the only option left.”

But, Ashghar-Ali and Kaufman concluded, ECT is in fact only 1 option, and there are many others for clinicians and patients.

1. Benson C, Szukis H, Sheehan JJ, et al. An evaluation of the clinical and economic burden among older adult Medicare-covered beneficiaries with treatment-resistant depression. 

2. Pilon D, Joshi K, Sheehan JJ, et al. Burden of treatment-resistant depression in Medicare: a retrospective claims database analysis. 

3. Rush AJ, Aaronson ST, Demyttenaere K. Difficult-to-treat depression: a clinical and research roadmap for when remission is elusive. 

4. Lisanby SH, Husain MM, Rosenquist PB, et al. Daily left prefrontal repetitive transcranial magnetic stimulation in the acute treatment of major depression: clinical predictors of outcome in a multisite, randomized controlled clinical trial. 

5. Conelea CA, Philip NS, Yip AG, et al. Transcranial magnetic stimulation for treatment-resistant depression: naturalistic treatment outcomes for younger versus older patients. 

6. Murrough JW, Perez AM, Pillemer S, et al. Rapid and longer-term antidepressant effects of repeated ketamine infusions in treatment-resistant major depression. 

7. Ochs-Ross R, Daly EJ, Zhang Y, et al. Efficacy and safety of esketamine nasal spray plus an oral antidepressant in elderly patients with treatment-resistant depression-TRANSFORM-3. 

8. Kok RM, Nolen WA, Heeren TJ. Outcome of late-life depression after 3 years of sequential treatment. 

9. Buspavanich P, Behr J, Stamm T, et al. Treatment response of lithium augmentation in geriatric compared to non-geriatric patients with treatment-resistant depression. 

10. Huang AX, Delucchi K, Dunn LB, Nelson JC. A systematic review and meta-analysis of psychotherapy for late-life depression. 

If patients decline electroconvulsive therapy, psychiatrists still have many good options. 

How to Identify and Tackle Treatment-Resistant Depression in Geriatric Patients

After many years of inaction, the FDA issued a final order on the classification of ECT devices in December, 2018.

 The very good news is that the order allows for ongoing availability of ECT devices in the US; the slightly less good news is that the new list of “on label” indications for ECT is shorter than in the past. To understand the implications of the new order, let’s review some of the background leading up to it, as well as the state of ECT in the US today.

This new FDA order now allows patients who need and want ECT, as well as practitioners who perform it, to breathe a sigh of relief.

Electroconvulsive Therapy

PsychPoll: ECT, Yay or Nay?

ECT: An Effective and Safe Treatment

ECT: Dangerous on Either Side of the Pond

Electroconvulsive Therapy: Obsolete and Dangerous or Still Just Misunderstood?

How to Identify and Tackle Treatment-Resistant Depression in Geriatric Patients

The FDA on ECT: Supporting a Vital Treatment

Treating Recalcitrant PTSD With ECT: Are We There Yet?

The Role of ECT in the Suicide Epidemic

Inflammation and Response to ECT in Treatment-Resistant Depression

ECT for Self-Injurious Behavior in Autism: A New Indication