80 Years On, Do We Know If Electroconvulsive Therapy Works?

Source: Photo by NeONBRAND on Unsplash

On June 3 I published, with colleagues, the latest of my six reviews of electroconvulsive therapy (ECT) research, in the U.S. journal Ethical Human Psychology & Psychiatry.¹ Presumably because it concluded that ECT should be immediately suspended pending higher-quality research, the paper received significant coverage from the BBC and other media outlets in Europe.

My first contact with ECT was in 1973, on a Bronx psychiatric ward. I was a rather naïve 21-year-old nursing aide. I loved the job but I wasn’t sure why, every Monday, Wednesday, and Friday afternoons, five or six older women would always appear, on a line of chairs in the corridor. Most sat with a passive air of indifference. Usually, however, one or two trembled with fear. Occasionally one would leave the line, either shouting or tiptoeing so as not to be noticed. They were dragged back to the line.

When I discovered they were waiting for ‘electroshock’ I was fascinated. I volunteered for the job of sitting with them as they came round from the general anesthetic, after their shocks and convulsions. They would ask me ‘Where am I?’ 'Who am I?’ ‘Why is my head pounding?’ ‘What have they done to me?’ One old lady asked me, in tears, ‘But why would they do such a thing to me?'

Then came the day I was allowed in to watch, along with some medical students. The psychiatrist asked, 'Would anyone like to press the button?' All five stepped eagerly forward. As the old woman’s body vibrated, toes twitching, I left. I found myself in the car park, being sick. I knew nothing of the research about this treatment. I just had, quite literally, a gut reaction that something was horribly wrong.

My next encounter was in my first job as a clinical psychologist in the UK in the 1980s. At a staff meeting, I waited to see if anyone would raise the issue of the man who had died on the ECT table the day before. Nobody did. So I did. The psychiatrist said, 'That is none of your business and I am personally insulted by your insinuation that we killed him’. When I refused to be quiet I was physically removed from the room. Knowing that his notes read ‘ECT contraindicated – serious heart condition,’ the social worker and I returned in the evening and photocopied that page. As we anticipated, the page soon disappeared from the man's chart. I tried for two years to get the hospital, the Health Authority, the government, and professional bodies to take an interest in that page and the case. I failed. But I did not forget.

So, as an academic, many years later, including 20 working as mental health professional and manager of mental health services, I published my first review of the ECT research literature, with esteemed British clinical psychologist Richard Bentall.² We were astonished to find that there had only ever been 11 placebo-controlled studies. Placebo for ECT is called ‘sham-ECT’, in which the general anesthetic is administered but the electricity is not, so the convulsion does not occur.

We were also amazed that the latest of the 11 had taken place in 1985. About half of these very old, poor-quality, small-scale studies found a temporary lift in mood in roughly a third of patients. The other studies found no difference between ECT and sham-ECT at all. None found any difference between the two groups beyond the time of the last ECT in the series (usually about 10). We also summarized the research showing that ECT causes cognitive dysfunction, primarily retrograde amnesia (loss of memory for past life events), which is permanent in between 12 and 55 percent, depending partly on whether you ask the psychiatrist or the patients. This memory loss is particularly common in women and older people, two groups, paradoxically, given ECT more often than other people.

Some ECT proponents try to explain away the lack of any RCTs (randomized controlled trials) for 35 years (57 in the U.S.) by claiming it would be unethical to withhold a treatment that they ‘know’ works, from suicidal patients. Such a statement not only positions the speaker outside the domain of evidence-based medicine, it ignores the fact that not a single study supports the oft-made claim that ECT saves lives and prevents suicides.²

Another response to the lack of RCTs is that although they are indeed the gold standard for establishing efficacy there are lots of other types of studies that suggest it works, including comparisons of ECT with antidepressants. Another of our reviews³ looked at all such studies in a seven-year period from 2009 and found no robust evidence that ECT works, largely (but not exclusively) because almost all the studies failed to provide any follow-up data.

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Another response to our reviews is ‘Your work must be biased because five meta-analyses of the ECT placebo studies say it works.' And that brings us to the review I published last month, with Irving Kirsch of Harvard Medical School. This time we not only evaluated the 11 studies, in more detail than ever before, using a 24-point Quality scale, but we also conducted the first-ever analysis of the meta-analyses themselves.

Our abstract summaries the results:

The meta-analyses pay little or no attention to the multiple limitations of the studies they include. The 11 studies have a mean Quality score of 12.3 out of 24. Eight scored 13 or less. Only four studies describe their processes of randomization and testing the blinding. None convincingly demonstrate that they are double-blind. Five selectively report their findings. Only four report any ratings by patients. None assess Quality of Life. The studies are small, involving an average of 37 people. Four of the 11 found ECT significantly superior to SECT at the end of treatment, five found no significant difference and two found mixed results (including one where the psychiatrists reported a difference but patients did not). Only two higher Quality studies report follow up data, one produced a near-zero effect size (.065) in the direction of ECT, and the other a small effect size (.299) in favor of SECT.²

We concluded that the studies were so methodologically inadequate that the meta-analyses should not have concluded anything about efficacy at all. We ended with the following recommendation:

Given the high risk of permanent memory loss and the small mortality risk, this longstanding failure to determine whether or not ECT works means that its use should be immediately suspended until a series of well designed, randomized, placebo controlled studies have investigated whether there really are any significant benefits against which the proven significant risks can be weighed.²

In our media release, Kirsch commented:

I don’t think many ECT advocates understand just how strong placebo effects are for a major procedure like ECT. The failure to find any meaningful long-term benefits compared to placebo groups is particularly distressing. On the basis of the clinical trial data, ECT should not be used for depressed individuals.

A commentary on our paper by Richard Bentall, co-author of my first review 10 years ago, suggests that we were too generous in our quality ratings and describes ECT as ‘a classic failure of evidence-based medicine’.⁴

We are delighted that the Director of the UK’s National Institute for Health and Care Excellence (NICE) (Dr. Paul Chrisp), which writes our national practice guidelines, immediately agreed to review NICE’s ECT recommendations taking our paper into consideration, and that the President of the Royal College of Psychiatry (Dr. Wendy Burn) referred our review to its ECT committee for consideration in relation to the forthcoming update of their ECT Position Statement.

Forty experts, including psychiatrists, other mental health professionals, researchers, and ECT recipients and family members, have written to all UK mental health services that still use ECT (It is gradually but steadily dwindling here), and the Health Minister, to request that, in keeping with the principles of evidence-based medicine, ECT treatment be suspended pending proper investigation of its efficacy. Numerous UK ECT units have been closed so that anesthetists and nurses could be transferred to duties that are indisputably life-saving. We are hoping that some managers will just quietly choose not to reopen them.

A similar letter will be sent to the US Food and Drug Administration.