ECT safety and efficacy?

[closertofine]

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Hi, I'm a MSI, hope it's OK for me to post a question here. I'm trying to find a reputable overview of the use of ECT for depression--the safety and efficacy, mainly. I found an NIH consensus statement on it, but it's from 1985, and I think things may have changed a lot since then.

Does anyone know of a more recent review, or where to look for one? (I do have access to journals online, but my searches have mainly turned up specialized studies, mainly in geriatric patients). Or if not, do any of you have opinions on whether ECT is a good option for treatment?

Thanks very much!

 

[OldPsychDoc]

Hi, I'm a MSI, hope it's OK for me to post a question here. I'm trying to find a reputable overview of the use of ECT for depression--the safety and efficacy, mainly. I found an NIH consensus statement on it, but it's from 1985, and I think things may have changed a lot since then.

Does anyone know of a more recent review, or where to look for one? (I do have access to journals online, but my searches have mainly turned up specialized studies, mainly in geriatric patients). Or if not, do any of you have opinions on whether ECT is a good option for treatment?

Thanks very much!

There's an APA-published book from 1990 "The Practice of E_____ C_____ T: etc". Also a more theoretical book by Abrams, published in 2002. These would contain references that might meet your need.

As to opinions: it works. It works well, and it works fast. Side effects less than many of the side effects of multiple med trials we subject our treatment resistant patients to. Risks equal to that of any outpatient surgery involving general anesthesia.

I know that if I were psychotically depressed, I would want this treatment.

 

[meisteckhart]

There's an APA-published book from 1990 "The Practice of E_____ C_____ T: etc". Also a more theoretical book by Abrams, published in 2002. These would contain references that might meet your need.

As to opinions: it works. It works well, and it works fast. Side effects less than many of the side effects of multiple med trials we subject our treatment resistant patients to. Risks equal to that of any outpatient surgery involving general anesthesia.

I know that if I were psychotically depressed, I would want this treatment.

I will certainly second the opinion. I've seen it done, assisted myself, and talked to many patients who have had it done. Often patients have tried so much before they do ECT that they are at the end of their rope. It is wonderful to see someone who is so profoundly depressed and not responsive to treatment come in and be better literally within weeks.

As far as the research goes, I have heard attendings tell me that the efficacy of ECT is somewhere around 90%-95% response rate for depression. Single agent antidepressant therapy is somewhere around 50%-60% response rate. I am sure there is literature with accurate numbers, but I haven't looked myself. I'm sure a pubmed/medline search would give you the results you are looking for.

Additionally, there is much talk about transmagnetic stimulation which is still in the research phase and not widely available, except at research centers. If the topic interests you though, that might be something else to look into.

 

[OldPsychDoc]

I will certainly second the opinion. I've seen it done, assisted myself, and talked to many patients who have had it done. Often patients have tried so much before they do ECT that they are at the end of their rope. It is wonderful to see someone who is so profoundly depressed and not responsive to treatment come in and be better literally within weeks.

As far as the research goes, I have heard attendings tell me that the efficacy of ECT is somewhere around 90%-95% response rate for depression. Single agent antidepressant therapy is somewhere around 50%-60% response rate. I am sure there is literature with accurate numbers, but I haven't looked myself. I'm sure a pubmed/medline search would give you the results you are looking for.

Additionally, there is much talk about transmagnetic stimulation which is still in the research phase and not widely available, except at research centers. If the topic interests you though, that might be something else to look into.

I agree--sometimes it's like a miracle. I've got an old guy on my service now who was on a half-dozen psychotropics and was still having command AH to kill himself & others. ECT #4 today and he's smiling at me and looks 10 years younger.

Sometimes it doesn't seem to work so well, but often these patients have substantial axis II pathology and psychosocial factors that you just can't shock away (or medicate, either...)

 

[LM02]

I agree--sometimes it's like a miracle. I've got an old guy on my service now who was on a half-dozen psychotropics and was still having command AH to kill himself & others. ECT #4 today and he's smiling at me and looks 10 years younger.

Sometimes it doesn't seem to work so well, but often these patients have substantial axis II pathology and psychosocial factors that you just can't shock away (or medicate, either...)

I recently attended a presentation by Sackheim, and he mentioned that ECT response rate was about 80 - 85% - still substantially better than what we can do with pharmacotherapy and/or psychotherapy, but not quite 95%. He also presented some data they collected in which they had depressed patients undergo a PET scan shortly after an ECT Tx session. The specificity of the effect depicted on the images was pretty amazing.

He also presented quite a bit on the newer "focal brain treatment" technologies - TMS, FEAT/FEAST, DBS, VNS. It was quite impressive.

 

[closertofine]

Thanks, you all...this was very helpful. I guess it was at least strongly implied in your posts that the benefits outweigh the side effects...but in your experience with patients (or knowledge), is the side effect of memory loss often significant? (In considering significant, say a close family member of yours was thinking about having it done). Thanks again!

Edit: OK, I realize this is completely anecdotal evidence and biased and just one person's opinion, but it's stories like the following that seem to conflict with the positive aspects you all were describing. Lot of short term memory loss, the effects of treatment only lasting a short time...

http://www.healthyplace.com/Communities/Depression/ect/news/spikol.asp

 

[mdblue]

Thanks, you all...this was very helpful. I guess it was at least strongly implied in your posts that the benefits outweigh the side effects...but in your experience with patients (or knowledge), is the side effect of memory loss often significant? (In considering significant, say a close family member of yours was thinking about having it done). Thanks again!

Edit: OK, I realize this is completely anecdotal evidence and biased and just one person's opinion, but it's stories like the following that seem to conflict with the positive aspects you all were describing. Lot of short term memory loss, the effects of treatment only lasting a short time...

http://www.healthyplace.com/Communities/Depression/ect/news/spikol.asp

If you think of the "mom's test"...yes I'll defnitely recommend it if I find the beenefits far outweigh the risk e.g. suicidality/morbidity comp etc. If you read thru the lit, no antidep is more than 60-70% effective. ECT however, depending on the pt cohort can be effective in >80-90% cases. Amnesia is a big-time complication, however it's small and reversible. People also theorize about the accuracy of the self-reported amnesia, because when you are severely depressed(thus an candidate for ECT) you are not laying down your memory chains properly in hippocampus in the first place ergo you can't recall it properly.
Read Abrams critically if you need more info. However IMO, sometimes he has gone overboard w/ some stats.
For more ECT horror stories try the anti-psychiatry sites(one is here http://www.antipsychiatry.org/)..they are wonderful to browse on those call nights 😀

 

[meisteckhart]

For more ECT horror stories try the anti-psychiatry sites(one is here http://www.antipsychiatry.org/)..they are wonderful to browse on those call nights 😀

My God, that site is horrific. They quoted some psychiatrists I know and twisted their comments to mean completely different things. It truly saddens me to think that there is so much hatred and misunderstanding related to psychiatrists, who are often the most caring, intelligent, and ethical physicians I have met.

In reference to the article on ECT, there are certainly risks related to ECT and memory loss is a significant one. However, many of these cases are relatively brief, at least in my experience and from what I have read, encompassing the period around the ECT treatments. As far as effectiveness, goes, some people will stay better maintained on antidepressant therapy afterward, and some will not and may need further treatment. I know of one gentleman in particular who I met. He had taken every antidepressant in the book and nothing helped. He underwent ECT and became like a new man, but the effects did begin to wear off after several months. So he decided to keep doing treatments as long and as often as he needed them. I was amazed that he would put himself through so much for so long, but he told me it didn't bother him so long as he could enjoy his life. If you ask me, the "crime against humanity" would be to deny this man the opportunity to live his life because a bunch of alarmists with a prejudice against the mentally ill are afraid of something they don't understand.

 

[closertofine]

Very interesting post, meisteckhart...that story is pretty amazing. The two main things that concern me are the fact that the treatment does seem to wear off, pretty much always, at least judging by this statistic:

"How effective is Electroconvulsive Therapy?
ECT effectively ends episodes of depression in about 80% of patients that finish a course of ECT.1. However, since the brain changes that occur with Electroconvulsive Therapy are not permanent, there is a strong chance of the depression returning. In fact, with no further treatment, 90% of patients relapse in one year (1). Therefore, patients need further treatments, whether it is antidepressants, psychotherapy or maintenance ECT (weekly or monthly ECT treatments).

Bibliography
1. Electroconvulsive therapy: Treatment for depression. Mayo Foundation for Medical Education and Research (MFMER). downloaded 4-14-2004"

And the other thing is, of course, memory loss. Most of what I've read does say that the loss is usually small and reversible, but then I saw this data from the California Dept. of Mental Health on all ECT from 1989-94:

"The most often reported complication (19.7% of all patients and 93.6% of all complications) was extended memory loss. For reporting purposes, this consisted of memory loss lasting longer than three months." 😱

That seems pretty extreme! I wonder if the new experimental treatments (like the transcranial magnetic thing, or the vagus nerve stimulator) will turn out to have a better side effect profile. Then again, I guess neither of those has been proven to work well yet...so...

OK, rambling...think I'm done for now! 😛

 

[meisteckhart]

Very interesting post, meisteckhart...that story is pretty amazing. The two main things that concern me are the fact that the treatment does seem to wear off, pretty much always, at least judging by this statistic:

"How effective is Electroconvulsive Therapy?
ECT effectively ends episodes of depression in about 80% of patients that finish a course of ECT.1. However, since the brain changes that occur with Electroconvulsive Therapy are not permanent, there is a strong chance of the depression returning. In fact, with no further treatment, 90% of patients relapse in one year (1). Therefore, patients need further treatments, whether it is antidepressants, psychotherapy or maintenance ECT (weekly or monthly ECT treatments).

Bibliography
1. Electroconvulsive therapy: Treatment for depression. Mayo Foundation for Medical Education and Research (MFMER). downloaded 4-14-2004"

And the other thing is, of course, memory loss. Most of what I've read does say that the loss is usually small and reversible, but then I saw this data from the California Dept. of Mental Health on all ECT from 1989-94:

"The most often reported complication (19.7% of all patients and 93.6% of all complications) was extended memory loss. For reporting purposes, this consisted of memory loss lasting longer than three months." 😱

That seems pretty extreme! I wonder if the new experimental treatments (like the transcranial magnetic thing, or the vagus nerve stimulator) will turn out to have a better side effect profile. Then again, I guess neither of those has been proven to work well yet...so...

OK, rambling...think I'm done for now! 😛

Well, here are my thoughts on what you have read:

In regards to the information on effectiveness, relapses are common after ECT if there is no further treatment. Of course, it is usually the case that patients are placed on maintanence therapy (usually with an antidepressant medication) after the treatments are over. If you consider that most of these patients are so severely depressed that they are getting ECT in the first place, it should not be surprising that many of them would relapse without further treatment afterwards. It is no different than people being on antidepressants chronically because the minute they go off of them, they relapse. ECT is not a "cure" for depression, but it is a very effective treatment.

In regards to the memory loss issue, I would be interested to know a little more about the numbers you had quoted from California. When you say memory loss lasting more than 3 months, does that mean memory loss related to the time around the ECT administration, or does it mean that the person is still not able to form new memories even 3 months after ECT treatment? The former I have certainly seen in which the memory loss related to the treatment and sometimes within a few days before or after the treatment is lost and does not appear to come back. I personally would consider this a relatively small price to pay for even several months of relatively normal functioning in a patient who is severely depressed. If you mean that the person can't form any new memories at all for an extended period of time, than I supposed that is rather extreme, especially if it occurs in 20% of patients. I haven't seen that happen, but then again my experience with ECT is very limited. Perhaps it would help to speak with a psychiatrist who does ECT on a regular basis.