Over the last few days there have been some flurries of interest in electroconvulsive therapy (ECT).
Richard Bentall, professor of clinical psychology at Bangor University, Wales, and John Read, from the department of psychology at the University of Auckland, New Zealand, have collaborated on a review of the literature on ECT, published in the journal Epidemiologia e Psichiatria Sociale. The authors review studies that compared ECT with sham ECT (that is, studies where a control group underwent the ECT procedure minus the actual electric shock) and find no evidence of any benefits for real ECT beyond the treatment period, and only limited benefits during the treatment period (“in some studies only, for some subgroups only, perceived by some raters only, and usually followed by relapse”). They then examine the oft-made claim that ECT can prevent suicide or otherwise save life, and find no evidence to support it. So far, nothing revolutionary: the UK ECT Review Group reached similar conclusions albeit in more muted terms (“Although many of the trials are old, and most were small, the randomised evidence consistently shows that, in the short-term (ie, at the end of a course of treatment), ECT is an effective treatment for adult patients with depressive disorders – as measured by symptom rating scales – and without substantial comorbidity…. Although ECT is sometimes thought to be a life-saving treatment, there is no direct evidence that ECT prevents suicide: as an effective treatment for severe depression, it is possible that it does”). But the authors briefly review the literature on memory loss and other risks of ECT and conclude that “the cost-benefit analysis for ECT is so poor that its use cannot be scientifically justified“; it is a remarkable achievement to get an article with such a conclusion into print, when the peer review system ensures that the psychiatric literature endlessly recycles the views of Max Fink and a few others on ECT and suppresses genuine debate. The authors conclude:
“ECT produces powerful placebo effects. A recent review (Rasmussen, 2009), which reported “an unexpectedly high rate of response in the sham [SECT] groups”, concluded that “The modern ECT practitioner should be aware that placebo effects are commonly at play”. It seems, however, that clinicians find it hard to recognise placebo effects even (perhaps especially) when they occur in front of them…. Under these circumstances, practitioners may be reluctant to respond appropriately to negative cost-benefit analyses of therapies in which they have invested considerable time and effort and which they genuinely believe are safe and effective”.
The use of ECT seems to be going in different directions in New Zealand and Australia, even though they share a professional body (The Royal Australian and New Zealand College of Psychiatrists). In New Zealand ECT use is low and falling; in Australia high and rising.
In the United States, Peter Breggin, a psychiatrist who has been speaking out about against ECT for decades, writes in the Huffington Post about the Food and Drug Administration (FDA) and ECT machines. This is a saga that has been going on for many years: the American Psychiatric Association want the FDA to reclassify ECT machines as safe without any testing; various groups including people who have had ECT are opposing this reclassification. In the United Kingdom, psychiatrists were successful in persuading the Medical Devices Agency to remove the ECT equipment safety standard.
In the United Kingdom, Gabrielle Blackman-Sheppard has published a book which “gives reassurance and hope to those with bipolar disorder, or manic depression”. The book includes something about the author’s two courses of ECT at Penn Hospital, Wolverhampton. On her web-site she describes being given an anaesthetic by pleasant and polite staff. For the details of what happened while she was under anaesthetic she refers readers to Demitri Papolos’ account of ECT in 1980s USA, which I have discussed in a previous post and which was probably not even accurate for ECT in 1980s USA, let alone for ECT in the United Kingdom today, where the current is of the magnitude of about 800 milliamps and flows for at least a couple of seconds, not the one second or less claimed by Demitri Papolos.
That happened to her 23 times and left her with a 5-year hole in her memory. It is nice if healthcare professionals are pleasant, but pleasantness alone does not guarantee high standards of care. A recent Care Quality Commission report into Penn Hospital “revealed non-compliance in all 10 of the essential standards of safety and quality examined”.
Gabrielle Blackman-Sheppard’s 23 ECT treatments in 2 courses is a lot, but not unheard of. A survey of 1621 courses of ECT in England in 2002 found that 1122 (over two-thirds) consisted of fewer than 9 treatments; 408 consisted of 9-12 treatments; 72 of 13-16 treatments, and 39 of more than 16 treatments.