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  1. #1

    Restrictive ECT use not warranted

    Restrictive ECT use 'not warranted'

    Electroconvulsive therapy (ECT) improves mood, quality of life, and function in people with major depression, say US investigators who suggest that a restrictive attitude towards this therapy is unwarranted.

    "Guidance on the use of ECT in the UK issued by the National Institute for Clinical Evidence recommended sharp restrictions on the use of this therapy until more information becomes available about its effects on memory, quality of life, and other pertinent health outcomes," explain W Vaughn McCall and colleagues from Wake Forest University Health Sciences in Winston-Salem, North Carolina.

    To address this issue, the researchers measured changes in quality of life, function, mood, and cognition in 77 depressed patients before they received ECT and again 2 weeks and 4 weeks after completing treatment.

    Overall, 66% of the patients responded to ECT, with improvement seen in every measure of mood, cognition, quality of life, and function at both the 2-week and 4-week assessments.

    Interestingly, improvement in quality of life was related to mood, whereas improved ability to carry out activities of daily living was related to enhanced global cognition.

    Comparing test results before and after ECT for patients who responded to treatment showed statistically significant differences on nine of the 10 psychological tests, the researchers note in the British Journal of Psychiatry.

    The only decline was seen on the autobiographical memory test, but the researchers stress that this test is designed to show memory loss rather than improvement.

    "The results are consistent with the premise that ECT produces a net improvement in health for most patients, and should help fill in the knowledge gap that led to the restrictive guidance on the use of ECT in the UK," say McCall and team.

    Br J Psychiatry 2004; 185: 405-409

  2. Restrictive ECT use not warranted

    Regarding this article, this scares me. Very much. Obviously these experts in the field do not have first hand knowledge of the inner turmoil that goes on when one is strapped to a gurney, watching gurney after gurney going into the shock room ahead of you. When it is your turn, being wheeled in, hooked up and zapped into oblivion. Waking up dazed and incoherent and traumatized. Looking around you and seeing a load of other people stretched out, attempting to recover their wits as well. Watching from your gurney as a crash cart comes wheeling into the room while they attempt to resusitate an old guy whose heart has stopped due to the shock. When you are allowed up, walking around like a zombie wondering what the heck just actually happened. I read this article and it brought back a whole slew of unpleasant memories for me.........I am almost crying. I hope no one has to go through this procedure because some experts think in "net" or "overall" terms that this treatment is beneficial.

  3. #3

    Restrictive ECT use not warranted

    Note: jubjub and I discussed this issue via email before she posted her reply. I think the concerns she expresses well represent the other side of the debate referenced in the article and I'm sure echo many people's concerns about the procedure, especially anyone who has seen films like One Flew Over The Cuckoo's Nest, or anyone who, like jubjub underwent the procedure around the time she did (1968).

    First, I want to emphasize that modern ECT procedures are not what they were 15-20 years ago or longer. Nontheless, I do understand that a lot of procedures that are beneficial can also be quite frightening, even a simple one like an injection, to certain patients. This is especially true when the patient is involuntary or otherwise being given the treatment without his or her consent.

    I also want to emphasize that ECT is a "treatment of LAST choice", not first choice, used in cases of severe or intractable depression where nothing else has worked.

    I have seen remarkable results in a couple of patients where honestly nothing else has worked -- for example, a young man who was actively suicidal and whose life was literally turned around with ECT.

    It is certainly not without side-effects and it is also true that we still do not fully understand how or why it works (although there are some hypotheses about that). But I would note that severe suicidal depression is of course also not without significant risks.

    I dont think articles like the one above are trying to promote casual or more frequent use of ECT in tyreating depression. Rather, I see them as a reaction to a movement which would see the treatment banned outright as an option for treatment. The authors are essentially saying that the option should not be denied to patients who require it, at least not until we have better treatments or a broader range of treatments for patients who are "treatment resistant" by today's standards.

    To me, an appropriate analogy is radiation therapy and perhaps even certain types of chemotherapy in the treatment of cancer. Some of the side effects are quite severe but in a lot of cases they do achieve remission of symptoms and without the treatment most patients are facing a significant risk of death. In the future, I have no doubt that treatment for various cancers will become more refined and we will no longer need the broad systemic procedures currently in use. But until something better comes along, doctors should continue to have such procedures in the repertoire of available treatments.

  4. #4

    Restrictive ECT use not warranted

    I've just got to jump in on this one: I truly believe that rTMS is better. I'm about to post more info on my experiences with it.

    I would like to add this, though. There's a lady at the clinic where I'm getting rTMS, and she's getting a double-treatement: left side of the brain for depression, then a half hour break while I'm being treated, and then the right side of the brain for anxiety. She's already had ECT, she's had a rough go of it. Apparantly, she is responding to the rTMS though. I'm hoping that I can sit down with her tomorrow and have an in-depth conversation with her, 'cause I'd love to hear her opinion of this treatment versus ECT.

    Of course, I'm biased. Any "treatment" that contains the word "convulse" will always scare the heck out of me.
    The road to recovery begins with the assumption that you have a right to be you. It ends when you realize that you want to be.

  5. #5

    Restrictive ECT use not warranted

    Again, I would emphasize that ECT is and always should be "the treatment of last resort". Of course, in 1968, no one had even heard of SSRIs, SNRIs, or rTMS.

  6. #6

    ECT use

    I think it is unlikely that the NICE guidelines have restricted the use of ECT in the UK. Unfortunately, since the Department of Health doesn't collect reliable annual statistics on ECT use, it is impossible to say if the guidelines have had any effect its use (which has in any case been declining steadily for at least 30 years). They certainly have not led to a significant decrease in the use of ECT on non-consenting patients, for which statistics are available.

    The guidelines recommend that ECT should be used as a short-term measure in the treatment of severe depression which hasn't responded to drugs or where it is potentially life-threatening. Terms such as "severe" and "potentially life-saving" are flexible and would probably cover any situation in which most psychiatrists would normally use ECT in the UK today. If fact psychiatrists have been saying for many years that they only use ECT in these circumstances anyway (and they have a long history of ignoring guidelines on ECT) so I don't know why they are complaining about "restrictions".

    In spite of the fact that they claim only to use ECT for severe depression, the Royal College of Psychiatrists did appeal against the guidelines on the grounds that they thought theyshould recommend ECT for moderate depression as well. NICE agreed that the evidence base covered moderate as well as severe depression but refused to recommend it for moderate depression as they said there were still concerns about it's long-term effects and a lack of research which takes into account patients' views and quality of life.

    Which is why they are waving this piece of research by the president of the American Association for ECT - even though it is short-term research and doesn't address the things which concern people who have had ECT.

  7. #7

    Restrictive ECT use not warranted

    Thanks for your thoughtful comment on ECT, ectsurvivor.

    I agree that, from my viewpoint, most of this is hype and scaremongering based on impressions of ECT use (both frequency and procedures) that are outdated. As you point out, use of ECT has been declining steadily since the 50s and 60s and, as I keep saying, it is a treatment of last resort when all else fails. I don't know of a single clinician anywhere who is recommending this be the starting point in the treatment of depression...

  8. #8

    Restrictive ECT use not warranted

    From what I have read, rTMS may be no more effective than ECT since both rTMS and ECT work by creating seizure activity in the brain. Obviously, ECT is very effective at creating seizure activity, possibly more so than rTMS.

    Regarding the earlier versions of ECT, I think the main problem was not using general anesthesia...or anesthesia of any type.

    Personally, eight sessions of ECT did nothing for my depression, though I have heard that ECT can be more effective than antidepressants. The experience of having ECT was quite positive for me because the general anesthesia helped me be very calm after each session.
    "What lies behind us and what lies before us are tiny matters compared to what lies within us." ~ Ralph Waldo Emerson

  9. #9

    Restrictive ECT use not warranted

    I was talking about the UK, where ECT use decreased from about 60,000 people a year in the early 70s to about 12-15,000 nowadays. I think in Canada the situation may not be the same, for example in Quebec between 1988 and 1995 ECT use nearly doubled.

    Even with the decrease in the UK there is still wide variation in use between different psychiatrists, and a small number of people receiving ECT as treatment of first choice (a use which is endorsed by the NICE guidelines).

  10. #10

    Restrictive ECT use not warranted

    It is not in common use in Canada.

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