ECT doesn't work, and causes lot's of permanent memory loss

[filddlestam]

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Agree or disagree?

* ECT doesn't work, not better then placebo ECT.
* It causes permanent memory loss, cases of decennia of memory loss have been reported.

 

[Bartelby]

There is actually an evidence base out there so this doesn't have to be based on opinion alone. Why not post some studies or meta-analyses?

Here, I'll start:
Efficacy of ECT in Depression: A Meta-Analytic Review
Pagnin, Daniel MD, MSc; de Queiroz, Valéria MD, MSc; Pini, Stefano MD; Cassano, Giovanni Battista MD
Journal of ECT: March 2004 - Volume 20 - Issue 1 - pp 13-20

Abstract:
"Summary: This study analyzed the efficacy of electroconvulsive therapy (ECT) in depression by means a meta-analytic review of randomized controlled trials that compared ECT with simulated ECT or placebo or antidepressant drugs and by a complementary meta-analytic review of nonrandomized controlled trials that compared ECT with antidepressants drugs. The review revealed a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus TCAs and ECT versus MAOIs. The nonrandomized controlled trials also revealed a significant statistical difference in favor of ECT when confronted with antidepressants drugs. Data analyzed suggest that ECT is a valid therapeutic tool for treatment of depression, including severe and resistant forms."

 

[strangeglove]

I suspect we have either a troll or a patient/family member here.

 

[MacDonaldTriad]

I knew a doctor once who went to 6 different orthopedists before he found one that agreed he didn’t need back surgery. So he didn’t get back surgery. At least not for a while.

Fiddlestam doesn’t need to distort the facts about ECT to rationalize not wanting ECT for he/she/someone else. He/she shouldn’t use this as a place to validate their misinformation. There are plenty of other places to do that.

 

[Excitotox]

He/she shouldn’t use this as a place to validate their misinformation. There are plenty of other places to do that.

Well, in fairness, there is plenty of published evidence for memory loss. At the end of the day, each patient must weight risks/benefits.
http://www.ncbi.nlm.nih.gov/pubmed/?term=ect+memory

However, the assertion that "ECT doesn't work" is simply not supported by any evidence that I have seen. Of course, ECT could fail in a specific, unlucky individual...

 

[billypilgrim37]

Well, in fairness, there is plenty of published evidence for memory loss.

And permanent memory loss not associated with the time around treatment is not very common one month after treatment, and extremely rare six months post treatment.

 

[Excitotox]

And permanent memory loss not associated with the time around treatment is not very common one month after treatment, and extremely rare six months post treatment.

Yes. I have never seen any memory loss outside of that occurring around the time of treatment. But it seems callous to dismiss memory concerns because they are rare. For example The Journal of ECT published Ms. Donahue's personal journey in 2000. http://retina.anatomy.upenn.edu/pdfiles/5524.pdf

To the individuals affected, I doubt the rarity of their condition is of great comfort.

Just to clarify, I am not opposed to ECT. In fact, I expect to perform a decent amount of it! But I have seen the informed consent process done very, very sloppily by attendings who barely breezed by the potential for iatrogenic memory loss. Anyone considering ECT deserves to know that severe memory impairment is rare, but when it does happen, it can be devastating.

 

[billypilgrim37]

But it seems callous to dismiss memory concerns because they are rare.

Correctly educating a patient about the rarity of memory concerns has nothing to do with dismissing anything.

 

[MacDonaldTriad]

The memory loss with ECT is mostly centered on the short time before and after the treatments. The majority of this is probably explained by the hypnotic agents used for the procedures. It exists in sham/placebo ECT. To complicate matters more, depression itself isn't without memory effects.
There may be something about the seizure itself that contributes, but all of these facts should be pointed out in a consent. If I needed ECT, memory loss would not be my largest concern. It seems clear that the efficacy is unmatched and I think I would do it more quickly than it is recommended for most of our patients.

 

[digitlnoize]

Disagree. Strongly.

 

[Armadillos]

The memory loss with ECT is mostly centered on the short time before and after the treatments. The majority of this is probably explained by the hypnotic agents used for the procedures. It exists in sham/placebo ECT. To complicate matters more, depression itself isn't without memory effects.
There may be something about the seizure itself that contributes, but all of these facts should be pointed out in a consent. If I needed ECT, memory loss would not be my largest concern. It seems clear that the efficacy is unmatched and I think I would do it more quickly than it is recommended for most of our patients.

What would be your biggest concern? Every medstudent/resident I talk to who saw/did ECT on a rotation says its like magic when it works, so there must be some pretty big downsides for it not to be used more often, as a med student I have always assumed that memory issues were the biggest problem.

 

[MacDonaldTriad]

I’m not claiming to be an ECT expert, but I am paraphrasing a couple of standard consents I have seen that come out of hospital’s ECT committees. Our disagreement is probably mostly apples and oranges. I’m not claiming that ECT doesn’t cause memory disturbance during the course of treatment. This is well known and progresses through the course of treatment. In the United States we give ECT three times a week and in Europe it tends to be twice a week. We have more memory problems but get people better faster.

The memory then recovers from past to present for retrograde amnesia and from present to period of treatment for antigrade amnesia. The amnesia never completely recovers because the anesthesia prevents some memory encoding just like ETOH induced blackouts.

This doesn’t google well because of the flood of testimonials that say otherwise. These represent real experiences, but studies that use neuro psych testing don’t bear this out to the degree claimed. I’ll quote the text book I have in reach:

“Overall, sustained memory deficits are uncommon, rarely disabling, and outweighed by the benefits of treatment.”

When I say that memory loss would be low on my list of worries, I mean that if I had a Major Depression, severe type with or without psychotic features that failed antidepressants, some amnesia wouldn’t be the thing worrying me the most. Since you ask the question, as low as the mortality rate of anesthesia is, you can increase it by an order of magnitude because we are looking at 8 – 12 treatments. This goes from 1/10K to 1/1K from what I see. Not likely, but death is a big deal. Less intellectually, but common is having someone inflict a headache on you three times a week for a month. Obviously reversible, but this has to be no fun. Then there is the possibility of biting your tongue in half. Forgetting some of the experience just doesn’t seem to be what I would be afraid of. I have not had ECT and I defer to anyone who has.

 

[strangeglove]

I think ECT is one of the safest treatments we have, considering the side effect burden of medication strategies for treatment resistant depression (eg TCA and MAOI, augmentation with lithium and atypicals).

 

[OldPsychDoc]

Clearly it causes the loss of memory for proper apostrophe usage...🙄

 

[splik]

ECT "works" in the right patients, it's not for everyone. If you're manic, catatonic, have psychotic depression, melancholia or depressive stupor ECT might be a good choice. It does have a great effect size than other treatments, the response rate is higher, the response time is faster in the right patients. That said, the effects are fairly temporary if you look at the best RCTs and at follow up really there's no difference between people who have ECT for depression or not.

Also the memory thing is a big issue and would concern me personally. It's not a minority of patients, the problem is studies have deliberately not looked at this properly. In the UK at least, it is generally accepted 1/3 patients will experience long-term/permanent autobiographical memory loss. This is typically associated with the period around the time of treatment, but obviously if you keep having it, then it becomes problematic. William Styron who wrote Darkness Visible had talked about how ECT had helped him, but later in his life felt that recurrent rounds of ECT had destroyed him. It's not an ideal treatment for maintenance, or recurrent, the more intensive, the higher the stimulus, or having bilateral or temporal rather than frontal treatment increases risks of cognitive problems which can not only outlast the benefits of treatment, but also outweigh them.

Psychiatry has a track record of ignoring patient experiences. Nobody believed TD was a real thing back in the 60s. Nobody believed in benzo dependence in the early 70s. Nobody believed in antidepressants inducing suicidality in the 1990s. Nobody believed in horrible withdrawal symptoms with SSRIs (chiefly Paxil) in the mid 90s. All these things are now accepted. The same is true for ECT. For many years there was this institutional denial of memory loss and cognitive impairment that may be permanent but it does exist and is more common than we like to think.

 

[Salpingo]

ECT "works" in the right patients, it's not for everyone. If you're manic, catatonic, have psychotic depression, melancholia or depressive stupor ECT might be a good choice. It does have a great effect size than other treatments, the response rate is higher, the response time is faster in the right patients. That said, the effects are fairly temporary if you look at the best RCTs and at follow up really there's no difference between people who have ECT for depression or not.

I think ECT benefits in some way by its stigma. Whereas the effects of other treatments have been diluted by allowing for "mild" major depression (a little oxymoronic), ECT maintains some pretty stringent standards, which has reduced some bias and noise. As for durability of the response, there's some pretty convincing data that maintenance therapy with lithium + venlafaxine/TCA gives longer outcomes. Not sure if those were represented in the RCTs.

Also the memory thing is a big issue and would concern me personally. It's not a minority of patients, the problem is studies have deliberately not looked at this properly. In the UK at least, it is generally accepted 1/3 patients will experience long-term/permanent autobiographical memory loss. This is typically associated with the period around the time of treatment, but obviously if you keep having it, then it becomes problematic. William Styron who wrote Darkness Visible had talked about how ECT had helped him, but later in his life felt that recurrent rounds of ECT had destroyed him. It's not an ideal treatment for maintenance, or recurrent, the more intensive, the higher the stimulus, or having bilateral or temporal rather than frontal treatment increases risks of cognitive problems which can not only outlast the benefits of treatment, but also outweigh them.

Whats the standard of care in the UK leading to that 33%? Are those numbers for unilateral, ultra-brief pulse, or is bilateral, sine-wave still in use? Also, I haven't seen the data on temporal vs. frontal unilateral, but my understanding is that temporal placement is the standard of care in the States.

Psychiatry has a track record of ignoring patient experiences. Nobody believed TD was a real thing back in the 60s. Nobody believed in benzo dependence in the early 70s. Nobody believed in antidepressants inducing suicidality in the 1990s. Nobody believed in horrible withdrawal symptoms with SSRIs (chiefly Paxil) in the mid 90s. All these things are now accepted. The same is true for ECT. For many years there was this institutional denial of memory loss and cognitive impairment that may be permanent but it does exist and is more common than we like to think.

I don't think there's any willful ignorance with ECT's side effects, especially considering its been around almost 90 years (including the chemico-electric form). If anything, I'd say its the opposite: the memory loss is one of the most dramatized and recognized of any psychiatric intervention. In this regard, I think physicians need to find a happy medium, but we're still on the overcautious end of the spectrum.

 

[kugel]

My friends/family know: If I ever get psychotic, give me Haldol. If I ever get severely depressed, plug me in.
I don't mean to just make light of it. Severe depression has a significant risk of suicide. Side effects from ECT I can "live" with.

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[vistaril]

I think ECT benefits in some way by its stigma. Whereas the effects of other treatments have been diluted by allowing for "mild" major depression (a little oxymoronic), ECT maintains some pretty stringent standards, which has reduced some bias and noise. As for durability of the response, there's some pretty convincing data that maintenance therapy with lithium + venlafaxine/TCA gives longer outcomes. Not sure if those were represented in the RCTs.



Whats the standard of care in the UK leading to that 33%? Are those numbers for unilateral, ultra-brief pulse, or is bilateral, sine-wave still in use? Also, I haven't seen the data on temporal vs. frontal unilateral, but my understanding is that temporal placement is the standard of care in the States.



I don't think there's any willful ignorance with ECT's side effects, especially considering its been around almost 90 years (including the chemico-electric form). If anything, I'd say its the opposite: the memory loss is one of the most dramatized and recognized of any psychiatric intervention. In this regard, I think physicians need to find a happy medium, but we're still on the overcautious end of the spectrum.

ECT is very very very very expensive(facility/OR billing for each time, anesthesia units each time,etc. I think because of this issue(the cost), we use it too much if anything.

Of course I feel the same way about a lot of the newer drugs out there.

 

[xlithiumx]

ECT is very very very very expensive(facility/OR billing for each time, anesthesia units each time,etc. I think because of this issue(the cost), we use it too much if anything.

Of course I feel the same way about a lot of the newer drugs out there.

Stop it. ECT shortens hospital stays and facilitates a speed of recovery unmatched by any psychiatric treatment.

 

[notdeadyet]

ECT is very very very very expensive(facility/OR billing for each time, anesthesia units each time,etc. I think because of this issue(the cost), we use it too much if anything.

This quite possibly the epitome of pennywise and pound foolish. Even if you take a look at the most conservative of efficacy rates, it more than pays for itself compared to the burden of repeated hospitalizations for patients otherwise.

Patients don't tend to pay out of pocket for ECT, but they also tend not to pay out of pocket for the multiple ED visits and psych hospitalizations every year either.

Lordy...

 

[kugel]

Stop it. ECT shortens hospital stays and facilitates a speed of recovery unmatched by any psychiatric treatment.

I was talking to a colleague earlier today about this very concept, that some programs save the system money by diverting, preventing, shortening hospitalizations and arrests and EMS calls, etc. One problem is the paucity of outcome studies that track all of these ways the system spends money on the severely mentally ill. As a result, we do not recognize the savings (if they exist) because we don't look far enough afield for the costs. Unfortunately, MH system managers rarely program collection of this sort of data into their outcome measures (if they do any outcome measurement at all).

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[nitemagi]

I've always wondered if the memory loss from ECT is actually an issue of state dependent memory. I've had several patients with longer memory loss, but the loss is about the period of time of their depression.

ECT can also be done (usually maintenance ECT) as an outpatient, with just a brief PACU stay.

 

[vistaril]

Stop it. ECT shortens hospital stays and facilitates a speed of recovery unmatched by any psychiatric t

sometimes it does, sometimes it doesn't. Once you start an initial ect inpatient cycle you have already bought what...20 or so more days(depending on what kind of schedule the institution uses)? Without question, some of these patients would have been discharged sooner had the ect not been started. And some wouldnt have. And some would have been committed to state hospital.

I don't challenge the idea that ect is superior to other treatments for certain populations with certain conditions(which really goes to how poor these other treatments are). But that's a very different thing than it being cost effective.

 

[vistaril]

This quite possibly the epitome of pennywise and pound foolish. Even if you take a look at the most conservative of efficacy rates, it more than pays for itself compared to the burden of repeated hospitalizations for patients otherwise.

Patients don't tend to pay out of pocket for ECT, but they also tend not to pay out of pocket for the multiple ED visits and psych hospitalizations every year either.

Lordy...

I couldn't disagree more. I don't see the cost being made up. It's another question entirely if it is 'worth' it or not.

 

[vistaril]

I've always wondered if the memory loss from ECT is actually an issue of state dependent memory. I've had several patients with longer memory loss, but the loss is about the period of time of their depression.

ECT can also be done (usually maintenance ECT) as an outpatient, with just a brief PACU stay.

which still generates the very costly anesthesia services and even more costly facility/OR services....

 

[nitemagi]

which still generates the very costly anesthesia services and even more costly facility/OR services....

Done in the PACU, not in an OR. Costs are substantially less.

 

[digitlnoize]

I couldn't disagree more. I don't see the cost being made up. It's another question entirely if it is 'worth' it or not.

Not everyone does inpatient only ECT. We usually start people inpatient but after a week or so, once they've perked up a bit, they continue the rest outpatient, so it's not much longer than our typical stay. There are some exceptions of course, but you don't always have to keep them in house for 3 weeks.

 

[xlithiumx]

I don't challenge the idea that ect is superior to other treatments for certain populations with certain conditions(which really goes to how poor these other treatments are). But that's a very different thing than it being cost effective.

You really can't make an ethical case for withholding ECT because of its potential lack of cost effectiveness, given the vast superiority of its efficacy in indicated conditions.

 

[notdeadyet]

sometimes it does, sometimes it doesn't. Once you start an initial ect inpatient cycle you have already bought what...20 or so more days(depending on what kind of schedule the institution uses)?

If your hospital keeps patients for a month while undergoing ECT, it's likely for two reasons: the patient's condition is so grave that they can not be discharged until symptom improvement or conservative hospital policy. If it's the former, they wouldn't be going home anyway. If it's the latter, it's not the treatment that's at play, it's your place's politics.

ECT isn't magic beans. If a patient is stable to go home after x number of treatments and can participate in follow-up care, there isn't a clinical reason they can't come back for outpatient follow-ups. Same as medications. You can be discharged to outpatient care after stable.

I've heard of places that essentially commit people for a month or whatnot for ECT but it's just old fashioned treatment planning. It doesn't have to be that way. And it's a limitation of the individual system, not of the modality.

 

[vistaril]

You really can't make an ethical case for withholding ECT because of its potential lack of cost effectiveness, given the vast superiority of its efficacy in indicated conditions.

sure I can....resources are limited.

 

[vistaril]

Done in the PACU, not in an OR. Costs are substantially less.

true, I misread your post earlier. I haven't seen any costs for PACU ect, but I would be costs are still substantial. And lots of hospitals don't streamline things that way for a procedure that is a fraction of a drop in the drop of the bucket relative to procedures and surgeries.

 

[kugel]

The cost issue is an empiric question. Does ECT (in the indicated pop'n) reduce treatment costs over a given time (6 mos? , 2 yrs? , 5 yrs?), or doesn't it?
Until I have the empiric answer, I'm going to bet insurance companies did the math. Does Blue Cross cover it or not?

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[Armadillos]

Ugh all this vistaril stuff gets so old, seems like literally the only thing he would ever take professional pride in is refusing to admit someone and kicking them to the curb from the ER.

 

[BobA]

To say that ECT "saves money" or "doesn't save money" you'd have to have an alternative treatment that worked as well as ECT. There are many patients who get better with ECT and nothing else - hence it's comparing apples to oranges.

Not to mention the personal suffering saved!!

How places handle the costs of ECT is fairly locale dependent. At one hospital I work at most of the ECT is completely outpatient from start to finish. At another it's almost entirely inpatient only.

 

[notdeadyet]

Does ECT (in the indicated pop'n) reduce treatment costs over a given time (6 mos? , 2 yrs? , 5 yrs?), or doesn't it?
Until I have the empiric answer, I'm going to bet insurance companies did the math. Does Blue Cross cover it or not?

Yes. There may be some regional variation, but I doubt it. Blue Cross covers it in California, Texas, and a slew of other states. I'd be curious if they found one in which it doesn't cover it.

 

[vistaril]

The cost issue is an empiric question. Does ECT (in the indicated pop'n) reduce treatment costs over a given time (6 mos? , 2 yrs? , 5 yrs?), or doesn't it?
Until I have the empiric answer, I'm going to bet insurance companies did the math. Does Blue Cross cover it or not?

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but that's not what insurance decisions are based on.....hell if it was probably 70%+ of all stuff covered now wouldn't be. I mean look at Abilify.....there is NO WAYthat Abilify(vs say....Geodon) reduces treatment costs. Yet most insurances are going to cover it.

Where ect is covered, it's most likely covered because the volume just isn't that high(especially for insured non-medicare patient population). And since the volume is pretty low relative to other things, insurance companies simply don't care that much about it.

 

[Armadillos]

Since when do medical treatments need to "save money" in order to be covered by insurance or utilized? The fact that there is even a remote chance that ECT saves money (at least enough of a chance that we are debating it) would seem to make it a sure thing for insurance to cover. Giving someone with cancer chemo or surgery isn't saving anyone money, but that doesn't mean we dont do it.

 

[nitemagi]

The "saves money" needs to factor in lost productivity of the individual who is depressed.

 

[vistaril]

Since when do medical treatments need to "save money" in order to be covered by insurance or utilized? The fact that there is even a remote chance that ECT saves money (at least enough of a chance that we are debating it) would seem to make it a sure thing for insurance to cover. Giving someone with cancer chemo or surgery isn't saving anyone money, but that doesn't mean we dont do it.[/QUOTE

well we probably do need to look at how we treat cancer in this country. Spending 75k to give someone an extra 3 months with very poor quality of life may not be a good investment. Or, like with ect, we should put it on the patient to pay. If a patient(or their family) finds that extra 3 months worth 75k or whatever, maybe they should pay for it themselves. Same with ect. It's always easier to spend other peoples money

 

[Armadillos]

well we probably do need to look at how we treat cancer in this country. Spending 75k to give someone an extra 3 months with very poor quality of life may not be a good investment. Or, like with ect, we should put it on the patient to pay. If a patient(or their family) finds that extra 3 months worth 75k or whatever, maybe they should pay for it themselves. Same with ect. It's always easier to spend other peoples money

Huh? Didn't people above just say that insurance covers ECT? Thats not spending other people's money in the sense your talking about, thats an insurance company providing a service that you (or you employer) paid them for.