Electroconvulsive therapy and the Cochrane Collaboration

Last week the BBC Radio 4 programme The Life Scientific featured an interview with Sir Iain Chalmers, one of the founders of the Cochrane Collaboration (working together to provide the best evidence for health care), an organization which conducts systematic reviews of the literature on medical treatments. He was introduced as someone who is arguing that patients’ concerns rather than academic interests should drive the research agenda and who has been called the “maverick master of medical evidence”. Chalmers spoke about how the questions he came to ask concerning medical evidence were driven by variations in practice among doctors and wondering who was right. Electroconvulsive therapy (ECT) (which was not mentioned on the progamme) is a treatment that is subject to wider variation in use than most medical treatments. There are many psychiatrists and hospitals across the world who do not use ECT at all, some who use it a little and some who use it a lot. I was therefore interested to see what the Cochrane Collaboration had to say about ECT.

The Cochrane depression, anxiety, and neurosis group is currently working on a paper on electroconvulsive therapy in the treatment of depression. In the protocol the authors say that they will be using an “integrative methodological approach”:

“We will conduct a systematic review which integrates qualitative evidence of the individual patient’s experience of the intervention (i.e. ECT as a treatment for depressive illness) into the effectiveness review. The approach was developed by the review team specifically for this systematic review question and was informed by Chapter 20 of the Cochrane Handbook of Systematic Reviews of Interventions”

I will be interested to see how this works in practice. Returning to the paper, the background section presented a conventional (and not very evidence-based) view of ECT. The authors certainly don’t seem to be suffering from the “scepticaemia” that Chalmers spoke about on the radio. There are statements such as:

“The use of ECT declined considerably in the 1970s and 1980s, and the indication for ECT also transformed from first-line treatment of depression to last-resort treatment for pharmacotherapy-resistant depression and very severe life-threatening clinical conditions.”

“Continued use of unmodified ECT in many countries may reflect erroneous clinical beliefs that cognitive deficits are transient and older treatment methods more efficient than modified ECT.”

The Cochrane Collaboration has already conducted reviews on ECT for depression in the elderly and in the treatment of schizophrenia. The review of ECT for depression in the elderly did not find much in the way of evidence:

“The review found only four studies, all of which had serious problems in their methods. At present, therefore, it is not possible to draw firm conclusions on whether ECT is more effective than antidepressants, or on the safety or side effects of ECT in elderly people with depression.”

Compare that conclusion with this recent statement from Canadian psychiatrist Caroline Gosselin, a clinical professor and director of continuing medical education in the psychiatry department at the University of British Columbia: “For reasons no one really knows, ECT seems to be particularly effective in [the elderly].” In Canada, people over the age of 70 accounted for  30% of all electroconvulsive therapy treatments in 2005, according to an article in the Canadian Medical Association Journal.

The Cochrane Collaboration review on ECT as a treatment for schizophrenia concluded:

“The evidence in this review suggests that ECT, combined with treatment with antipsychotic drugs, may be considered an option for people with schizophrenia, particularly when rapid global improvement and reduction of symptoms is desired. This is also the case for those with schizophrenia who show limited response to medication alone. Even though this initial beneficial effect may not last beyond the short term, there is no clear evidence to refute its use for people with schizophrenia.”

Whether conclusions such as these will encourage psychiatrists to use more, or less, ECT is anyone’s guess.

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