Stop ECT for Refractory Depression? The Great Debate

Megan Brooks

February 04, 2019

Used for more than 80 years in the treatment of severe depression, electroconvulsive therapy (ECT) remains controversial. In a "head-to-head" article published online January 30 in the BMJ, experts debate its use.

John Read, PhD, clinical psychologist, University of East London, United Kingdom, and Sue Cunliffe, a patient who has undergone ECT, argue that the procedure has no long-term benefits and can cause lasting memory problems and other side effects.

Sameer Jauhar, MBChB, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Declan McLoughlin, PhD, of Trinity College Dublin, Republic of Ireland, argue that evidence shows that ECT is effective and safe for patients with severe, refractory depression and that side effects can be managed.

Read and Cunliffe posit that there's a lack of positive, evidence-based research indicating that ECT is effective for severe depression. Of 10 studies in which ECT was compared with placebo for depression, half found no clear difference, they note.

"Some people, about a third, get some small, temporary lift in mood compared to placebo, but the research shows that difference does not last beyond end of treatment," Read, who has published several reviews of the ECT literature, told Medscape Medical News.

Some studies also suggest that ECT causes long-lasting or permanent memory damage. Cunliffe notes that she was told that ECT was safe but that she suffered "catastrophic" brain injury. ECT left her with shaking hands and slurred speech. She also claims the procedure affected her memory and executive function.

"I know 30 people in the UK in my situation," she told Medscape Medical News. "Severe, permanent brain damage is still going on. No other treatment that had such frequent severe side effects would be allowed."

"Despite this lack of evidence, psychiatry remains so adamant ECT works that no studies to establish efficacy have been conducted since 1985. Instead, many investigate which kind of ECT causes least damage," Read and Cunliffe write.

Serious Treatment, Serious Illness

However, Jauhar and McLoughlin argue that ECT is still used 80 years on because evidence shows it can be an effective treatment for severe, resistant depression.

"ECT is a serious treatment for serious illness. As with all such serious medical treatments, patients and clinicians need to weigh the risks and benefits on an individual basis. From a general medical perspective, we know that ECT is a safe procedure with a very low mortality rate," McLoughlin told Medscape Medical News.

There is no robust evidence that ECT causes macroscopic or microscopic damage to the brain. In fact, there is good preclinical evidence that ECT promotes hippocampal neurogenesis, possibly through up-regulating neurotrophic factors, McLoughlin added.

Severe neurologic side effects, such as dysphasia, tremor, and gait disturbance, are "extremely rare and have been temporary and reversible in the few such reports to be found it the scientific literature," he added.

ECT is associated with deficits in short-term memory and executive function. However, these deficits typically resolve within weeks, and most people experience significantly improved function after undergoing ECT, McLoughlin noted.

Following an ECT session, the "vast majority" of patients recover their orientation within 30 to 40 minutes, McLoughlin said. "However, we do occasionally have patients who have a prolonged period of disorientation for a few hours. Rarely, there are some patients who may have a delirium that lasts for a few days to a week," said McLoughlin.

Individualized decision making is important, he emphasized. "In contemporary ECT practice, to minimize the risk for side effects, we tailor the electrical stimulus dose to the individual patient, based upon age, gender, electrode position, and current medications. We can also manipulate various aspects of ECT administration to minimize potential cognitive side effects."

McLoughlin has received a speaker's honorarium from the ECT device manufacturer Mecta and an honorarium from Janssen for participating in an esketamine advisory board meeting.

BMJ. Published online January 30, 2019. Full text

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