I'll take some of the comments point by point:
I understand that sometimes ECT is a last resort... But what I don't understand is people prioritizing it earlier up the 'treatment options' hierarchy than as a last resort. What I don't understand is people simply not facing up to findings that the people who exhibited the worst memory / categorization disturbance were the people who seemed to benefit most. That their aren't findings presented about whether people are likely to relapse after 6 months (what information there is on that suggests that people are likely to relapse after 6 months) and so on.
That's why maintenance ECT is used in so many cases. In fact, it's widely understood that it's underused. Severe cases are severe. Severe diabetics have a diffucult and often intractible course. Depression can be similar. Should 6 months of relief preclude the use of ECT? Especially in a 70 year old? Those months are precious.
I'm not saying that clinical experience is irrelevant. What I'm having trouble with, however, is that clinical experience seems to be taken as sacrosanct whereas when patients report adversive experience their experience seems to be taken as an artifact of their general crazyness... Even when... Some of those people ARE doctors...
No psychiatrist denies that there are adverse effects of the treatment, as you propose. We're aware of it, we measure it, and in a turn that may be shocking to you, we're happy to see it when the events leading up to hospitalization were dramatic and horiffic for the patient. You'd be surprised how often this is the case. We give midazolam for colonoscopies for a reason. Nobody wants to remember that. However, nobody's complaining that it's a "side effect" of the procedure. Yes, the mechanisms are different, as are the lengths of retrograde amnesia, in this case, but risk is a part of any medical procedure (perfed colon?).
How long did it take (how many doctors simply ignored patients reports) of severe withdrawal syndromes when stopping Effexor according to the drug rep guidelines??? It takes a while for patients concerns to be taken seriously...
If you would have talked to any psychiatrist 10 years ago, they would have told you about how they tapered medications in this class, would give prozac as a last dose long t 1/2 to prevent discontinuation syndrome, etc. Believe it or not, we don't need a beaurocratic government agency to hold our hand every step of the way in medical practice. This in fact, is a saddening dumbing-down and cookbook approach to medicine that has mid-levels and the undertrained thinking they can do what we do....just follow the cookbook and you'll be fine. No thinking involved. Point being...psychiatrists knew about this and accounted for it. It was part of our residency training and part of common knowledge in psychiatry. The FDA's lag isn't the barometer
for medical practice. Discontinuation syndrome, by the way, is also benign and non-life threatening, despite how that too, is discussed in the layman's literature.
It might be that the laws on not providing ECT to children in some states is because of some religious influence. But it might also be that the laws on not providing ECT to children in some states are actually in response to a lack of evidence that doing so is particular helpful.
No, it's another uninformed response, much like the "competency to stand trial" proceedings, that appear to make us look more civilized. Congressmen and senators are not scientists. They pass laws that sound politically convenient and that get them re-elected. i.e. "So senator, is it true that you voted to allow physicians to involuntarily shock children, causing irrepairable damage to their tiny and cute brains?" Vote for me, instead, who voted to abolish that horriffic practice!"
Studies are tricky... Most of the studies are sponsored or endorsed or run by people who have (often undisclosed) financial investments in certain things. One ECT provider wants to show that their machines produce a *more effective* or *less detrimental side effects* outcome than the other providers machines. Often the studies are more about *which is better* rather than *is either one any good at all?*
This can be the case. However, we're beyond placebo studies at this point. If you forever compare vs. placebo, you don't refine procedures or compare types of procedures against each other. This is neither unique to psychiatry, nor needed after 30 years of overwhelmingly positive literature.
Like how the newer anti-depressants were marketed as having *less adversive side effects* than the older ones. Like how the newer anti-psychotics were marketed as having *less adversive side effects* than the older ones. That is one way to shift the focus from efficacy to be sure... Simply *assume* efficacy and test more specificially for *which is better*.
New anti-depressants do have less side effects.
i.e. SSRI vs. MAOI vs. Tricyclic
i.e. escitalopram vs. fluoxetine
With antipsychotics, the water is muddier.
It appears as though risperidone may not cause tardive, but it will cause metabolic syndrome. Which would you rather have? I'm not sure myself. You can still work and maintain a job with metabolic syndrome. Can't do much at all with tardive. In many cases, it's social and proefssional-life destryoing. Personally, I'm a fan of typical APs. I use them a lot. I also use atypicals a lot. They both have their clinical usefullness. Some typicals have cardiac black boxes, are relentlessly sedating, have intolerable anticholinergic side effects, also cause weight gain, cause arrythmias much more than atypicals, and other side effects.
The lesson from CATIE was not that atypicals performed better than typicals, or vice versa. The lesson was that treatment should be individualized. TD can be a deal-breaker. Metabolic syndrome can be life-threatenting in the long term. Does this mean that drug reps pushed their product into being prescribed? Yes. Does that make it a class worth ignoring? Obviously not.
Clinical, science-based protocols exist. I know you feel that there is no standard of evidence-base in psychiatry, and this is another incorrect assumption. The increasingly more prevalent backlash against EBM notwithstanding, all branches of medicine "suffer" from some degree of lack of EBM based practice. Most often in my view, the reason for this is the heavy exclusion-criteria which takes the "what do I do for this patient in my office" syndrome which would not qualify for any formal study. We know what is likely to work for them, so we go for it.
