ECT more effective than rTMS for severe depression

[David Baxter PhD]

ECT an effective treatment option for severe depression

Electroconvulsive therapy (ECT) appears more effective than repetitive transcranial magnetic stimulation (rTMS) for short-term treatment of severe depression. This finding is presented in the January 2007 issue of the American Journal of Psychiatry (AJP).

The researchers found that patients who received ECT and rTMS produced remission rates of 59 percent and 17 percent, respectively. Six months later, the patients' ratings of psychiatric symptoms remained lower in the ECT patients. The trial included 46 patients, 24 assigned to rTMS and 22 assigned to ECT.

At the end of treatment, scores on the Hamilton Depression Rating Scale had fallen by 58 percent in the ECT group and 22 percent in the rTMS group. The difference in scores between groups was statistically significant at the end of treatment but not at six months. However, differences did remain in self-rated mood measures and psychiatric symptoms overall.

All patients had been referred for ECT and continued to take their medications. rTMS was administered on a fixed schedule of 15 daily treatments but ECT continued until a response was evident. The ECT group reported fewer side effects after treatment, compared to the rTMS group. ECT can be associated with posttreatment memory problems, but the only difference in cognitive measures was a mild improvement in attention and orientation among patients who received ECT, compared with a decrease in the rTMS group.

ECT is helpful for people whose severe depression has not responded to other treatments. rTMS is nonconvulsive and requires no anesthesia, and initial randomized studies suggested that its effectiveness was similar to ECT. This study compared the two treatments under real-world conditions and over time. The authors point out that while the optimal administration of ECT has been determined over several decades, the most effective methods for rTMS are not yet known.

"ECT, despite its stigmatization, continues to be the most effective treatment available for depression resistant to usual drug and psychotherapies," stated AJP Editor in Chief Robert Freedman, M.D. "This study affirms that the newer magnetic stimulation method despite some initial promise is not as effective."

This study was supported by the Health Technology Assessment Programme of the National Institute for Health Research, the Guy's and St. Thomas's Charitable Foundation and a 2003 Ritter Independent Investigator Award from the National Alliance for Research on Schizophrenia and Depression.

Eranti S, Mogg A, Pluck G, Landau S, Purvis R, Brown RG, Howard R, Knapp M, Philpot M, Rabe-Hesketh S, Romeo R, Rothwell J, Edwards D, McLoughlin DM. A Randomized, Controlled Trial With 6-Month Follow-Up of Repetitive Transcranial Magnetic Stimulation and Electroconvulsive Therapy for Severe Depression. Am J Psychiatry 2007 164: 73-81 [Abstract]

 

[Daniel E.]

The ECT group reported fewer side effects after treatment, compared to the rTMS group.

Wow, that's something I would not have guessed.

 

[Misha]

I haven't had either treatment, but I'm surprised by the side effect thing too. From what I've seen people have very severe side effects with ECT, so I can't imagine what rTMS does.

 

[David Baxter PhD]

Perhaps. It probably depends on several factors but more than once the only "side effect" I have seen following a brief course of ECT treatments is profound relief.

 

[Misha]

Perhaps. It probably depends on several factors but more than once the only "side effect" I have seen following a brief course of ECT treatments is profound relief.

Really? The mental health support group I attend 4 days a week is full of people who have significant memory loss after ECT treatments and significant cognitive impairment. For some it leaves completely, others stay in that "space" for a long time. Also, the physical drain is very short-term, but still a significant side effect...some of these people sleep for two days after a treatment, others can not find a balance of muscle relaxants and are debilitated in that way.
And you emphasize the word "brief," which is admittedly significant but from what I've seen these side effects start when treatment starts.
But again I haven't been there myself so I speak only from what I observe.

 

[David Baxter PhD]

I'm not denying that there can be some adverse effects from ECT, sometimes enduring. I'm simply offering my observatioins that it's not always the case, at least for people for whom a short course yields the desired effects.

Some retrograde amnesia is inevitable. But as one client told me, even that was a relief because he was no longer obsessing about his perceived inadequacies and sins.

 

[Misha]

Good point, David. It is always a pleasant addition to my day when I hear of people finding the positive in what could be a negative situation.
My question: are the side effects of rTMS comparable/worse than ECT?

 

[Cat Dancer]

I'm not denying that there can be some adverse effects from ECT, sometimes enduring. I'm simply offering my observatioins that it's not always the case, at least for people for whom a short course yields the desired effects.

Some retrograde amnesia is inevitable. But as one client told me, even that was a relief because he was no longer obsessing about his perceived inadequacies and sins.

Could ECT be effective for OCD?

Do you have to go through all the different medications before you get to that point?

 

[foghlaim]

Do you have to go through all the different medications before you get to that point?

i've wondered this myself Janet...

i mean if ect works that well for most ppl that receive it... why wait till all other options have been tried.. whyis it the last option and not one of the first few tried?

 

[ThatLady]

ECT, while effective in recalcitrant cases, is a pretty serious intervention. It's a jolt of electricity to the brain! That's not to be taken lightly. It just makes sense to try something less invasive, like medications, before taking such a drastic step.

I'm really glad that ECT is available for those for whom medications just don't work. However, I'd hate to see it used as a first-line intervention.

 

[David Baxter PhD]

ThatLady has it exactly right. ECT is not a first choice. It's a last choice when nothing else works.

 

[foghlaim]

It's a jolt of electricity to the brain! That's not to be taken lightly. It just makes sense to try something less invasive, like medications, before taking such a drastic step.

I wouldn't dream of taking anything like this lightly,, and I don't... neither do i take meds lightly tho.. take lithuim for example.. unless monitored it is what i'd call invasive.. it effects other parts of the body as well not just the cells ( or whatever) that alter\affect the mood swings.

i dunno tho ....... i think i'd go for ect faster than the meds.. if it was offered. Mem loss as a side effect.. my mem is a running joke around here.. what have i to lose. and i'm not being ?????? whatever that word is.. i'm serious.

 

[David Baxter PhD]

take lithuim for example.. unless monitored it is what i'd call invasive..

Lithium should ALWAYS be monitored. The only way to determine the correct dose for an individual is to monitor blood levels. Any other procedure is just a wild guess and medically unethical.

 

[foghlaim]

I used lithuim as an example only ..( i do understand why it has to be monitored) it could be another drug ..
the med itself wasn't the point.. it's what some drugs can do to a body.. as against ect and it's possible side effects.. I understand what the "experts" are saying.. but at the same time thinking why isn't ect even discussed for the most part as a possible (even remote) choice . Don't the patients choice come into this at all..

 

[foghlaim]

oops sorry i just realised i'm about or have gone off on one...

 

[David Baxter PhD]

If I were a surgeon and you came to me with a headache and asked me to perform surgery, would it be ethical for me to accede to your request without determining if you had tried aspirin, allergy medications, or migraine rfemedies first? Or determining whether your headaches might be caused by hormonal variations? or a fever? an infection?

An ethical physician does not jump to the most invasive (and complex) procedure as the starting point. Whether or not you request it, it would be neither logical nor ethical.

 

[ThatLady]

Fog, ECT is, and must remain, a last resort. It's just not something you want to do until all other avenues are exhausted. You just don't go messing around with electricity direct to the brain unless you absolutely have to. There's no going back once it's done.

Medications may have side-effects, yes. However, those side effects almost always end when the medication is stopped; especially, with the new medications. That's not true with ECT. The change to the brain can be permanent.

In most cases, if a patient is truly resistant to all efforts at treatment, ECT will be approached and discussed. It's not like it's a big secret. It's not. However, it's not a first-line treatment and shouldn't be.

Too many people are looking for a quick-fix. While I understand why one might want that, the risk here is just to great to justify it.

 

[Daniel E.]

Could ECT be effective for OCD?

ECT is not accepted form of treatment for OCD. Also, there haven't been any convincing, double-blind studies that have shown ECT or other forms of brain stimulation to be an effective treatment for OCD (source).

Personally, I had ECT in 1996 and it didn't help at all with my depression or obsessive thinking.

Since the University of Florida is a research center for OCD and I went to UF for college, I was referred to their OCD expert in 1998 for an evaluation and the OCD researcher/psychiatrist had some good advice. A couple points he made:

- Even "adjustment issues" can screw up the brain and can be a major factor with obsessive thoughts.

- He emphasized the importance of CBT. (The most prominent book in his office was Brain Lock.)

Anyway, after 1998, my OCD was largely resolved. My lingering compulsions were almost gone and my thinking was clearer, even though I still had obsessive thinking.

 

[foghlaim]

okay... time to keep me "bite me tongue"..

thanks for explaining the ethical end of it and the reason why it shouldn't be a first line of treatment. when i read this again tomorow, ina diff frame of mind, hopefully a better one.. i won't have any if or buts.

 

[Miette]

I wouldn't dream of taking anything like this lightly,, and I don't... neither do i take meds lightly tho.. take lithuim for example.. unless monitored it is what i'd call invasive.. it effects other parts of the body as well not just the cells ( or whatever) that alter\affect the mood swings.

i dunno tho ....... i think i'd go for ect faster than the meds.. if it was offered. Mem loss as a side effect.. my mem is a running joke around here.. what have i to lose. and i'm not being ?????? whatever that word is.. i'm serious.

Fog,
I think you are raising a very interesting point, and one I had never, ever thought about before. Lithium may affect thyroid and kidney function with long term use. Those who are on the drug use it long term. If ECT could render me independent of lithium, well, perhaps I (speaking hypothetically now) would choose it over lithium. The problem is that I wouldn't know until I tried, and I'm guessing that the uncertainty of the effectiveness of ECT, coupled with the risks from general anesthesia and the procedure itself, make lithium the better choice. That's just a guess though...