Electroconvulsive therapy (ECT) is one of the more controversial treatments offered by psychiatrists. For most people, information about ECT is primarily through media representations; for example its punitive use in Ken Kesey’s acclaimed book and Miloš Forman’s Oscar winning film starring Jack Nicholson: One flew over the cuckoo’s nest.

Modern ECT, referred to as modified ECT, involves the use of a general anaesthetic and muscle relaxant before an electrical stimulation is applied to one, or both sides of the head, with the intention of inducing a seizure. As a treatment, ECT is generally used in the treatment of severe depression, but it also more rarely used in the treatment of mania and schizophrenia.

As with all treatments ECT has side-effects: memory loss (brief loss commonly and longer-lasting loss more rarely), muscle pain, as well as the risks associated with general anaesthetic.

The evidence base for ECT is, in my opinion, inconclusive. A search of the Cochrane Library reveals one completed review from 2003 into the use of ECT in an elderly population; which concluded that there was too little evidence to draw conclusions (Stek et al, 2003), and a review protocol dated 2011 with no report of findings as yet (Leiknes et al, 2011).

A meta-analysis published in the Lancet (2003) found favourable outcomes for ECT in terms of effect size and also evidence for its superiority over medication. The authors of the review commented on the absence of long-term follow up in many trials and also the lack of comprehensive assessment for memory impairment among included trials.

Another review by Diana Rose and colleagues in 2003 suggested that studies into the efficacy of ECT needed to include a range of outcome measures in order to better inform decision-making by patients.

If we are to continue using ECT, we need evidence to support its use, so a recent study published in the British Journal of Psychiatry could be welcomed. The paper sought to compare the speed of response to ECT versus medication in an elderly population (Spaans et al, 2015).

Methods

This study represents a re-analysis of pre-existing data from two trials comparing different ECT administration techniques and a comparison of medication trial (Venlafaxine versus Nortriptyline).

Participants were selected on the basis of:

• Being aged 60 years or older
• Having a diagnosis of depression according to a structured diagnostic interview schedule
• Having a depression rating score of moderate or greater severity (two scales were used)

Participants were excluded if they met the diagnostic criteria for a bipolar depression. All participants from the medication trial (n=81) were included whereas as the previous ECT trial had included participants from the age of 18 most had to be excluded from this report (n=47 included 69 excluded).

Information describing participants was available at baseline, 1, 3, 5 weeks and at the end of study (6 weeks for ECT, 12 weeks for medication). Not all the data for the defined measures was available at each assessment point.

For outcomes the authors defined remission as reaching a rating scale cut-off of less than 10 on the Montgomery-Asberg Depression Rating Scale (MADRS) within 5 weeks as the primary outcome measure. A secondary outcome measure of Hamilton Rating Scale (HRSD) of less than or equal to 7 at 5 weeks was also defined.

Results

The two groups did not differ at baseline in terms of reported clinical or demographic factors, except that the ECT group had received significantly more antidepressant medications (2.4 vs 0.9) prior to recruitment into the trials.

The results are summarised below as mean values with standard deviation and p-values for conducted tests of significance:

• Mean time to remission (MADRS):
  • ECT 3.07 weeks (s.d. 1.1) vs
  • Medication 3.95 weeks (s.d. 1.03) p=0.008
• Mean time to remission (HRSD):
  • ECT 3.07 (s.d. 1.04) vs
  • Medication 3.50 (s.d. 1.28) p=0.229
• The hazard ratio for remission within 5 weeks (according to MADRS) for ECT vs medication was 8.2 (95% confidence interval 3.6 to 19.0, p < 0.001) after correction for identified possible confounding variables
• Following participants until trial conclusion (6 weeks for ECT, 12 weeks for medication) produced remission rates of 63.8% for ECT vs 33.3% for medication

Conclusions

The authors concluded:

Considering the substantially higher speed of remission, ECT deserves a more prominent position in the treatment of elderly patients with severe depression.

Discussion

As in the interpretation of many research papers, your reading of these findings likely depends on your pre-existing attitude towards the treatments on offer. So disclosure of interest. I have delivered ECT as part of my training, but within my own practice I have only ever met one patient who the team was considering for treatment with ECT. After discussion we agreed to a course of intravenous benzodiazepines for this person prior to ECT and this led to a good response without the need for ECT. Overall I have never seen a positive case of ECT delivered in my clinical practice, whereas during on-call work I have dealt with a number of negative responses to ECT including profound muscle pain and distress at memory loss.

My own reading of the existing literature, combined with my clinical and personal experience, leads me to the conclusion that I would not personally wish to receive ECT under any circumstances. So biases suitably disclosed, let’s move onto the paper.

Strengths and limitations

This is a post-hoc analysis of pre-existing trial data. The authors claim that the two cohorts are sufficiently matched in order that this is a reasonable analysis. I’m not certain I agree:

• The ECT cohort was recruited from both inpatient and outpatient settings, whereas the medication trial recruited solely among inpatients. We are not provided with this information in this report.
• Both cohorts had significantly high numbers of participants describing psychotic phenomena (53.2% for ECT vs 49.4% for medication). Participants in the ECT trial received a variety of medications including antipsychotics and lithium alongside antidepressants, whereas those in the medication trial could at most receive Haloperidol (5mg/day) or Risperidone (2mg/day). These details are not described in this report – in my opinion they probably should be alongside the description of antidepressants taken.
• Both the original trials had dropouts not completing the entire protocol: 87/116 completing ECT and 68/81 completing the medication trial. Data analysis was handled in an intention-to-treat manner to manage dropouts, which was not described in this report.
• Finally, side-effects from treatment are not reported here. ECT and antidepressants have a number of quite distressing side-effects that may influence the decision making process in relation to treatment choice.

In summary, this paper presents a post-hoc analysis that the authors claim supports an increase in the use of ECT. I would argue that they have not provided sufficient information here to support this claim and that further, well-designed studies are necessary if we do not believe there is already sufficient evidence in relation to the role of ECT.

Links

Spaans, H. P., Sienaert, P., Bouckaert, F., van den Berg, J. F., Verwijk, E., Kho, K. H., et al. (2015). Speed of remission in elderly patients with depression: electroconvulsive therapy v. medication. The British Journal of Psychiatry, 206(1), 67–71. doi:10.1192/bjp.bp.114.148213 [BJP Paywall]

Stek ML, Wurff van der FFB, Hoogendijk WJG, Beekman ATF. Electroconvulsive therapy for the depressed elderly. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003593. DOI: 10.1002/14651858.CD003593.

Leiknes KA, Berg RC, Smedslund G, Jarosch-von Schweder L, Øverland S, Hammerstrøm KT, Høie B. Electroconvulsive therapy for depression (Protocol). Cochrane Database of Systematic Reviews 2011, Issue 5. Art. No.: CD009105. DOI: 10.1002/14651858.CD009105.

UK ECT Review Group. (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. The Lancet, 361(9360), 799–808. doi:10.1016/S0140-6736(03)12705-5 [PubMed abstract]

Rose, D., Fleischmann, P., Wykes, T., Leese, M., & Bindman, J. (2003). Patients’ perspectives on electroconvulsive therapy: systematic review. Bmj, 326(7403), 1363–0. doi:10.1136/bmj.326.7403.1363 [PubMed open access]

Kok, R, Nolen W and Heeren T (2007) Venlafaxine versus nortriptyline in the treatment of elderly depressed inpatients: a randomised, double-blind, controlled trial. International Journal of Geriatric Psychiatry 22, 1247-54 [PubMed abstract]

Spans, H P et al. (2013) Efficacy and Cognitive Side Effects After Brief Pulse and Ultrabrief Pulse Right Unilateral Electroconvulsive Therapy for Major Depression: A Randomized, Double-Blind, Controlled Study. Journal of Clinical Psychiatry 74(11):e1029-36 [PubMed abstract]