ECT in The Lancet: praising faintly but fairly.

The article “Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis,” written by the UK ECT Review Group, appeared in the March 8, 2003 issue of The Lancet. It brings high visibility to our field and represents one of the few ECT-related items that come to the attention of a wide spectrum of nonpsychiatric physicians. Its conclusions are not surprising—that ECT is effective, “probably” more so than pharmacotherapy, that bilateral electrode placement is more effective than unilateral, and that high-dose ECT is more effective than low dose. What is somewhat surprising is that after decades of use and millions of successfully treated patients, the need still exists to “prove” that ECT works and that the accumulated database is relatively small. The UK ECT Review Group consisted of 12 individuals, and the aim of this working group was “to review published work for the efficacy and safety of electroconvulsive therapy (ECT) with simulated ECT, ECT versus pharmacotherapy, and different forms of ECT for patients with depressive illness. ” They searched scientific and medical databases for “properly randomized unconfounded, controlled trials that compared ECT with no ECT, ECT versus pharmacotherapy, or different forms of ECT, for patients with depressive illness. ” The literature search found 624 reports, of which 73 were randomized trials meeting the specified inclusion criteria. Further details of the methods used to rate the quality of the trials and the statistical analyses used can be found both in the text and a referenced web site. Many of the trials are from the 1960s, 70s, and 80s and involved small numbers of patients. For example, only 256 patients across six trials were available for the comparison of the effect of real ECT versus sham ECT. Larger numbers were available for the comparison of efficacy between ECT and pharmacotherapy (total n 1144) and the comparison between bilateral and unilateral electrode placement (total n 1408). The authors are careful not to overstate the conclusions of their research. They do conclude “the randomized evidence consistently shows that in the short-term (ie, the end of a course of treatment), ECT is an effective treatment for adult patients with depressive disorders. ” Other conclusions are less definitive, for example, “ECT is probably more effective than drug therapy”, and “there is no direct evidence that ECT prevents suicide: as an effective treatment for severe depression, it is possible that is does. ” They note that the data were insufficient to investigate the efficacy of ECT in specific subgroups, for example, the elderly, pregnant women, women in the postpartum period, and patients with treatment-resistant depression. They do not consider the subgroup of patients with psychotic depression, one known to respond particularly well to ECT. Furthermore, the authors point out that “current evidence does not provide a clear quantitative estimate of the degree of short-term cognitive impairment associated with present methods of ECT and how much it may persist after symptomatic recovery. ” They go on to state that “[i]ndeed, very little randomized evidence exists on the possible longterm cognitive effects of ECT. More sophisticated measures of memory could be useful in future studies. ” Finally, they note that the available trials rarely use outcomes that can be directly translated into good clinical practice, pointing out the need for trials of post-ECT treatment and relapse prevention. They make the important, but obvious observation that ECT technique must balance efficacy and side effects and that standards of ECT practice must be improved. Overall, The Lancet report is a helpful contribution to the ECT literature. Some may quibble with the methodological details, the necessarily arbitrary criteria used to vet the trials, and the choice of statistical analyses, but the conclusions are hard to argue with. Our disappointment is with the tone of the interpretation, which is cautious to the point of ambivalence. And yet, this is par for the course for recent assessments of ECT. Perhaps we are still paying the price for the enthusiasm for ECT during the 1940s and 50s, which some argue led to its indiscriminate use. Perhaps it is a reflection of the reserve of its English authors. The report is part of a British national reassessment of psychiatric treatments conducted by the National Institute for Clinical Excellence (NICE) and the full recommendations are available at the web site http://www.nice. org. uk/pdf/FAD_ECT. pdf. In any case, the final sentence of the article, “ECT remains an important treatment option for the management of The Journal of ECT 19(2):65–66 © 2003 Lippincott Williams & Wilkins, Inc., Philadelphia