Raising Doubts About ECT

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ECT has been in use for decades, but does that mean it is safe or effective?

Editorial note: the April issue of Psychiatric TimesTM included a Point/Counterpoint feature on electroconvulsive therapy (ECT). You can read the introductory essay, “Electroconvulsive Therapy: Obsolete and Dangerous or Still Just Misunderstood?” by Horacio A. Capote, MD, here.

The authors of the original pro and con articles have agreed to continue their debate online. Below, Ms. Hancock, Ms. Cunliffe, and Dr Read argue that ECT is ineffective and unsafe. Representing the pro-ECT position, Dr Henry has responded to their article here.

We thank Michael E. Henry, MD, for responding to our article electroconvulsive therapy (ECT): “Dangerous on Either Side of the Pond.”1-2 

In his article “ECT: An Effective and Safe Treatment,” Henry challenges the conclusion of a recent review3 that there is no robust evidence to determine whether ECT is better than placebo: “The selection criteria used by Read and colleagues were limited to older studies (1956 to 1985).”1 The selection criteria were not time-limited. There simply have not been any placebo-controlled ECT studies since 1985.4 Furthermore the 11 pre-1986 studies were grossly flawed.3

We agree with Henry that modern treatment approval requires rigorous, randomized, placebo-controlled methodology using the universally accepted standards of evidence-based medicine. ECT clearly lacks this sort of evidence-base.

Henry produces 3 traditional defences for this empirical data vacuum. First, he argues that studies without placebo control groups, such as comparing different electrode placements, are sufficient. A review of these non-placebo studies, however, revealed that none “produced robust evidence that ECT is effective for depression, primarily because at least 60% maintained ECT participants on medication, 89% produced no meaningful follow-up data beyond the end of treatment, and none investigated whether ECT prevents suicide.”5

Second, Henry refers to “more than 75 years of clinical experience”1 as evidence of efficacy. Unfortunately, history is littered with treatments used for decades until deemed ineffective, harmful, or both.

Third, Henry brings up the “ethical dilemma of treating very ill patients with a placebo treatment.”1 But this assumes ECT is safe and more effective than a placebo, and that is precisely what is in question. Assuming its efficacy would position ECT proponents beyond the parameters of evidence-based medicine. Testing treatments in vulnerable populations is essential to establish efficacy, safety limits, and device regulatory protocols.

Henry portrays ECT-induced brain abnormalities, like hippocampal enlargement, as necessarily beneficial. However, a 2013 review of more than 100 imaging studies concluded “the temporarily improved scores on depression instruments following ECT reflect the combination of frontal and temporal lobe functional impairments and activation of the HPA axis and the mesocorticolimbic dopamine system. These effects as well as other detailed changes observed in structures such as the hippocampus appear consistent with those typically seen after severe stress-exposure and/or brain trauma.”6

There is no evidence that ECT prevents suicide. A recent study found that 14,810 ECT patients were 1.3 times more likely to die by suicide than 58,369 ECT controls.7

Twelve key points remain unaddressed:

1. ECT provides only short-term symptom relief. There are no studies demonstrating ECT outperforms placebo beyond treatment termination, and none that it prevents suicide.3

2. Between 12% and 55% of ECT recipients live with persistent memory loss,3 which is suffered disproportionately by women and older individuals, ECT’s target demographic groups.

3. Thymatron ECT device manufacturer lists 7 administration technique variables associated with risks of “permanent brain damage and permanent memory loss.”8

4. One in 50 ECT recipients suffer “major adverse cardiac events and death after ECT.”9

5. Despite repeated requests, the US Food and Drug Administration acknowledges never receiving premarket PMA studies assessing safety or Product Development Protocols to establish ECT’s safe dosing limits.10 ECT research has still not produced any safety testing using modern clinical parameters, dosing limits, or universal administration technique protocols to reduce risks and enable replicable results.

6. Medicare reimburses ECT providers who fail to report quality data, without limits in the number of treatments provided or how often treatment can be given.11 The 34% increase in US hospitals providing ECT since device reclassification may reflect what happens when hospitals identify an unregulated income source.2

7. No one knows how many Americans receive ECT each year, or how many treatments each individual receives, or how closely providers space treatments.12

8. ECT recipients are not provided legal informed consent regarding all risks.

9. ECT providers are not routinely assessing each patient for all known risks.

10. Repetitive intracranial mild traumatic brain injury has life-long consequence.6

11. ECT recipients injured by treatment are rarely referred for comprehensive rehabilitation to improve quality of life.

12. ECT privileging requirements in the US do not include studying its neuropathology or histopathology.13 Without such training, psychiatrists cannot provide appropriate long-term follow-up as recommended by Thymatron device manufacturer.2

Failure to acknowledge adverse effects of ECT, with life altering consequences in some patients, creates insurmountable barriers to those injured who need appropriate rehabilitation interventions to improve quality of life after treatment. ECT’s immediate and long-term damage to so many far outweigh its temporary benefits for some individuals.

Ms Hancock is a nationally certified rehabilitation counselor and former Clinical Rehabilitation Counseling and Clinical Mental Health faculty member at San Diego State University. More than a decade ago, Sarah received 116 ECT treatments and now lives with long-term neurological sequalae of repeated exposure to high electrical fields. Dr Read is professor of clinical psychology at the University of East London. He is chair of the International Institute for Psychiatric Drug Withdrawal and editor of the scientific journal Psychosis. He has authored several books and more than 200 research papers. Ms Cunliffe was a pediatrician in the UK until she left her job after undergoing ECT. She has become an advocate for other ECT patients.

References

1. Henry ME. ECT: an effective and safe treatment. Psychiatric Times. 2021;38(4):4,7. Accessed April 16, 2021.

2. Read J, Hancock S, Cunliffe S, Henry ME. ECT: dangerous on either side of the pond. Psychiatric Times. 2021;38(4):4-6. Accessed April 16, 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. Ethical Human Psychology and Psychiatry. 2019;21(2):64-103.

4. Gregory S, Shawcross CR, Gill D. The Nottingham ECT Study. A double-blind comparison of bilateral, unilateral and simulated ECT in depressive illness. Br J Psychiatry. 1985;146:520-4.

5. Read J, Arnold C. Is electroconvulsive therapy for depression more effective than placebo? A systematic review of studies since 2009. Ethical Human Psychology and Psychiatry. 2017;19(1):5-23.

6. Fosse R, Read J. Electroconvulsive treatment: hypotheses about mechanisms of action. Front Psychiatry. 2013;27(4):94.

7. Peltzman T, Gottlieb DJ, Shiner B, et al. Electroconvulsive Therapy in Veterans Health Administration Hospitals: Prevalence, Patterns of Use, and Patient Characteristics. J ECT. 2020;36(2):130-136.

8. Somatics L. Regulatory Update to Thymatron System IV Instruction Manual. Somatics, LLC; 2018. Accessed May 6, 2021.

9. Duma A, Maleczek M, Panjikaran B, et al. Major adverse cardiac events and mortality associated with Electroconvulsive Therapy: A Systematic Review and Meta-analysis. Anesthesiology. 2019;130(1):83-91.

10. Food and Drug Administration. Reclassification of electroconvulsive therapy devices; effective date of requirement for premarket approval for electroconvulsive therapy devices for certain specified intended uses. Published online December 26, 2018. Accessed May 6, 2021.

11. Centers for Medicare & Medicaid Services. Medicare program: fiscal year 2021 inpatient psychiatric facilities prospective payment system and special requirements for psychiatric hospitals for fiscal year beginning October 1, 2020. 42 CFR Parts 412 and 482. 2020;16990.

12. Hancock SP. Whose finger is taking the pulse of America’s shock treatment controversy? Mad In America. July 16, 2020. Accessed May 6, 2021.

13. American Psychiatric Association Committee on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association. 2nd ed. American Psychiatric Association; 2001. Accessed May 5, 2021.