Is Electroconvulsive Therapy Effective and Safe for Treating Depression?

What you need to know

• Electroconvulsive therapy (ECT) remains a controversial treatment for severe depression, with ongoing debate about its effectiveness and safety
• Proponents argue ECT is a highly effective treatment for severe depression, while critics contend there is insufficient evidence to support its use
• The debate highlights the need for more high-quality research on ECT to definitively evaluate its benefits and risks

The ECT debate

Electroconvulsive therapy (ECT) is a psychiatric treatment that involves passing electrical currents through the brain to trigger a brief seizure. It has been used for decades to treat severe depression and some other mental health conditions. However, ECT remains one of the most controversial treatments in psychiatry, with ongoing debate about its effectiveness and safety.

This article examines the key arguments put forward by proponents and critics of ECT based on a series of correspondence published in the British Journal of Psychiatry. We’ll explore the main points of contention and what they reveal about the current state of evidence on ECT.

The case for ECT

Proponents of ECT argue that it is a highly effective treatment for severe depression, particularly for patients who have not responded to other therapies. Dr. Richard Braithwaite, a consultant psychiatrist, describes ECT as “undoubtedly the most effective strategy for moderate to severe depressive illness” and “one of the most effective treatments across the whole of psychiatry.”

Key arguments in favor of ECT include:

1. Long history of use: ECT has been used to treat depression since the late 1930s, with refinements over time to improve safety and effectiveness.

2. Established evidence base: Supporters cite a large body of research accumulated over decades demonstrating ECT’s benefits.

3. Rapid relief: ECT can provide faster symptom relief than antidepressant medications for some patients with severe depression.

4. Safety: Proponents argue that modern ECT is an extremely safe procedure when performed properly.

5. Lifesaving potential: For patients with severe depression at risk of suicide, ECT may be a lifesaving intervention.

Dr. Tania Gergel, who has personally undergone ECT, argues that the treatment can offer dramatic benefits: “In general, those who work in ECT clinics see large numbers of patients experience dramatic recoveries from the most severe states of mental illness, which in itself convinces them of its effectiveness.”

The case against ECT

Critics of ECT contend that there is insufficient high-quality evidence to support its use, especially given the potential risks. Dr. David Yeomans argues that “the scientific approach does not generalise from personal experience” and that more rigorous research is needed.

Key arguments against ECT include:

1. Lack of recent placebo-controlled trials: Critics note that no placebo-controlled study of ECT for depression has been conducted since 1985.

2. Limited evidence base: A 2019 review cited by Dr. Yeomans found only 11 studies comparing ECT to sham ECT, involving just 224 ECT patients and 187 controls.

3. Short-term benefits only: The same review concluded there was little evidence for long-term benefits of ECT.

4. Cognitive side effects: Concerns persist about memory loss and other cognitive impacts of ECT.

5. Mortality risk: Some research has raised questions about mortality associated with ECT.

Dr. Yeomans argues: “Psychiatrists and researchers have a responsibility to find out how much ECT helps and harms the patients we treat rather than muddle on with so little understanding of what we are doing to people.”

The need for more research

The debate around ECT highlights the need for more high-quality research to definitively evaluate its benefits and risks. Both sides agree that many of the existing studies on ECT are old and do not meet modern research standards.

Dr. Gergel acknowledges this point but argues there is “substantial recent evidence-based research, including randomised controlled trials, showing the benefits of ECT versus active comparators.” However, critics maintain that placebo-controlled trials are still lacking.

There are several challenges to conducting research on ECT:

1. Ethical concerns about using sham ECT as a placebo

2. Difficulty blinding participants and researchers

3. Relatively small numbers of patients receiving ECT

4. Stigma that may discourage patients from participating in studies

Despite these challenges, larger and more rigorous studies could help resolve some of the ongoing debates about ECT’s effectiveness and safety.

The role of patient experience

An interesting aspect of the debate is the role of patient experiences. Dr. Gergel included her personal positive experience with ECT in making the case for its effectiveness. She argues that such first-hand accounts can provide valuable insights that are harder for critics to dismiss.

However, Dr. Yeomans contends that personal anecdotes should not replace scientific evidence. This highlights the tension between valuing patient experiences and adhering to evidence-based medicine principles.

ECT availability and access

The correspondence also touches on issues of ECT availability. Dr. Braithwaite criticizes mental health services in Trieste, Italy for not offering ECT, arguing this denies patients access to an effective treatment.

However, Dr. S.P. Sashidharan counters that the lack of ECT in Trieste has not compromised the quality of care: “I am not aware of any clinical evidence of this, nor of any concerns raised by anyone familiar with Trieste’s mental health services at any time or in any literature relating to the remarkable achievements of the mental health reforms in Trieste over the past 40 years.”

This exchange raises questions about how to balance potential benefits of ECT against other approaches to mental health care.

Conclusions

• The debate around ECT reveals significant disagreement within the psychiatric community about its effectiveness and appropriate use
• More high-quality research, including larger randomized controlled trials, is needed to definitively evaluate the benefits and risks of ECT
• Patient experiences and preferences should be considered alongside scientific evidence when making decisions about ECT use
• Mental health services need to carefully weigh the potential benefits of offering ECT against other treatment approaches and models of care

While ECT remains controversial, ongoing research and debate can help refine its use and ensure patients have access to safe and effective treatments for severe depression. Both critics and proponents ultimately share the goal of providing the best possible care for individuals struggling with mental illness.