ECT -- "Electro Convulsive Therapy"

         also spelt:    Electroconvulsive Therapy

Other Material of Interest:

New Zealand’s Mental Health Act in Practice
           -- Book Details - Dawson & Gledhill (Eds)    LINK
                      Contents Pages/Index      LINK


When Professor Gledhill, and Paul Gibson, NZ Disability Rights Commissioner, were consulted, they indicated these materials are particularly relevant to the discussion of ECT:

New Zealand Ministry of Health. 2013. Office of the Director of Mental Health Annual Report 2012. Wellington: Ministry of Health
[LINK]

United Nations Committee on the Rights of Persons with Disabilities (2013). Draft General comment on Article 12 of the Convention-Equal Recognition before the Law
[* Adopted by the Committee at its tenth session (2 – 13 September 2013).]*
[LINK]

Major Depressive Disorder is a common mental disorder, particularly for those struggling to recover from childhood interpersonal abuse. Psychoeducational interventions can be of assistance (Dorrepaal et al., 2012) [LINK], but sadly that form of intervention alone will NOT take the place of the hard personal, and interpersonal, work needed to recover from such suffering. Depression can, in some cases, become both sever and recurrent, throughout the life of the survivor. Electroconvulsive Therapy (ECT) is, in some settings, commonly used for severe, recurrent depression. Can ECT be used therefore for the depression from which survivors suffer? Before this question can be answered one has to ask: "Is ECT, given its very real risks of negative side-effects, “harm”, both an effective, and a safe, treatment for depression? Perhaps the clearest scientific, evidence-based answer, taking both consideration of possible benefits, and possible harms into account, to this question is provided by Read and Bentall (2010) [LINK]. Their article abstract is given below:

SUMMARY. Aim – To review the literature on the efficacy of electroconvulsive therapy [ECT], with a particular focus on depression, its primary target group. Methods – PsycINFO, Medline, previous reviews and meta-analyses were searched in an attempt to identify all studies comparing ECT with simulated-ECT [SECT]. Results – These placebo controlled studies show minimal support for effectiveness with either depression or ‘schizophrenia’ during the course of treatment (i.e. only for some patients, on some measures, sometimes perceived only by psychiatrists but not by other raters), and no evidence, for either diagnostic group,of any benefits beyond the treatment period. There are no placebo-controlled studies evaluating the hypothesis that ECT prevents suicide, and no robust evidence from other kinds of studies to support the hypothesis. Conclusions – Given the strong evidence (summarised here) of persistent and, for some, permanent brain dysfunction, primarily evidenced in the form of retrograde and anterograde amnesia, and the evidence of a slight but significant increased risk of death, the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified.

(i) Patients with histories of childhood trauma sometimes go on to develop severe, recurrent depression. Could ECT be of benefit to them?
NO, THERE IS NO EVIDENCE OF THAT

(iii) again, many years ago, some patients used to be on "maintenance treatment" involving monthly, single session, treatment by ECT, and seemed to benefit more from this than being treated by drugs. Care to comment on the desirability of this?
AGAIN - NO EVIDENCE TO SUPPORT THIS IT IS USUALLY USED BECAUSE THE INTITIAL COURSE OF ECT HAD NO ONGOING EFFECT

The whole issue of ECT is of major concern to consumers in my local Otago / Southland region of New Zealand, at the present time, given its rate of use being the highest in the country, doubling from 2010 to 2011 – see this (and other alarming stats) on page 2 of the December, 2012, issue of Enigma, the newsletter of the Otago Mental Health Support Trust:/p>

ENIGMA NEWSLETTER -- December, 2012
      -- scanned pages --(LARGE files -- please be patient)

ENIGMA Newsletter
           Page 1   [LINK]
           Page 2   [LINK]
           Page 3   [LINK]
           Page 4   [LINK]

The Trust is continuing enquiries into the grounds for use of this treatment.Among reasons that have been given for our area being so high in rate of administration of this treatment is that this area is much higher in the number of patients who are elderly, chronic sufferers of depression (in fact, as the newsletter discusses, this argument is not valid). But even if this argument were valid, there is no reliable evidence that the elderly are especially responsive to ECT than other populations, though this has been claimed Moksnes & Ilner, 2010) [LINK]. The review by Moksnes and Ilner was based on the first author's personal impressions, based on discussions with staff, and patients' clinical notes – the study was not “blind” the evaluation of patients was not “objective”. Indeed, the review by Read and Bentall (2010) was the most rigorous so far conducted. Given the results of rigorous appraisal of research studies, one is obliged to agree, I conclude, with the conclusions and recommendations of (Ross, 2006 [LINK]; but see also Blease, 2013a [LINK]).

Ross' article abstract (Conclusions and Recommendations):
No study demonstrated a significant difference between real and placebo (sham) ECT at 1 month posttreatment. Many studies failed to find a difference between real and sham ECT even during the period of treatment. Claims in textbooks and review articles that ECT is effective are not consistent with the published data. A large, properly designed study of real versus sham ECT should be undertaken. In the absence of such a study, consent forms for ECT should include statements that there is no controlled evidence demonstrating any benefit from ECT at 1 month posttreatment. Consent forms should also state that real ECT is only marginally more effective than placebo.

However, even with this “favourable” view of review outcomes, given the significant, potentially life threatening, risks of ECT, one must seriously question its use at all.

This is not to dismiss positive reports from patients about their response to ECT (e.g., Hersh, 2013 [LINK]) but it does suggest that the effects of “sham ECT”, or “simulated ECT” may be due to factors other than ECT per se, such as “non-specific” factors, perhaps associated with patients receiving ECT have their concerns, and much greater attention from treatment staff, both around the time of the ECT procedures, and at other times --- I can well remember being in Middlemore Hospital, Auckland, and presenting wanting to test my blood sugar (being an insulin dependent diabetic), only to witness another patient being brusquely told: “stand aside, wait while I attend to this other patient with “a real disorder”! Perhaps patients receiving ECT are seen as having more “real disorders” compared to other patients? Psychiatrists, and other care staff, are not immune to stigmatising patients (Chaplin, 2000 [LINK]). The question deserves more serious research, and more cautious practice. It is also vitally important that patients are informed about “non-organic”, but still legitimate causes of, and treatments for, depression (Blease, 2013b [LINK]), and for treatments to cover those factors too. Lastly, it should be stressed that there is NO evidence for the use of ECT for patients with histories of childhood trauma.

Still, no one knows how ECT works. Fosse and Read (2013) [LINK] have recently proposed a possible mechanism. In a private communication with the authors, however, they emphasise their conclusions remain consistent with those reached in the Read and Bentall (2010) review.

Professor Paul Glue [LINK], Psychiatrist, Univerity of Otago, has concluded a review of the use of ECT in the Otago / Southland region. Members of the Otago MH Support Trust have obtained a copy of the study protocol and are keen to review the results of the study when available.

REFERENCES