A Love Letter to ECT
We have a lot of respect for James Potash, a well-known researcher from Johns Hopkins who has made his career by studying the genetic basis of mood disorders and schizophrenia and possible overlaps.
So we were a little saddened to see him write this love letter to ECT, over at ABC News. We don’t doubt that ECT has helped many, many people over the years, and, that as a treatment of last resort for people with serious, chronic depression, it is relatively effective.
We’re a little concerned about his data in this article. ECT doesn’t appear to be effective in 75% of cases where it is used, from our reading of the research — its efficacy in fact varies from about 25% to 65% (see, for example, Eschweiler, et. al., 2007; Kellner, et. al. 2006; Kho, et. al., 2005). Since the article provides no citations for the figures he throws out, we don’t know where his single data point comes from. When citing efficacy figures, given the wide variability found within the literature, it is almost always preferable to cite a realistic range, not a single number.
And the lack of mention of its biggest drawback — unknown memory loss severity and duration — isn’t mentioned until you’re more than halfway into the article. Then it’s dismissed (as it usually is by the professionals advocating for more ECT usage):
The side effect of greatest concern is memory problems. In the same way that rebooting the computer can cause the loss of whatever the computer brain was working on at the time, so ECT commonly causes loss of memories around the time of the treatment. It is important to consider the context here. I have had patients tell me that this was not bothersome because they did not particularly want to recall the horrible feelings they had that led to the necessity of ECT.
In other words, memory loss is a Good Thing, according to this article, because you don’t have to remember the bad times associated with the depression. Ah, okay. Nice reframing there. Just like that lack of sexual interest with many commonly-prescribed antidepressants is also a good thing — no need to have all that sex that just reminds you of your vitality and enjoyment of life!
On the other hand, the memory problems can extend further, leaving gaps in the period up to six months before ECT and up to two months after it. This effect is more pronounced in people undergoing a form of ECT called “bilateral” ECT, in which the electricity is run through the whole brain, than in the form called “unilateral,” in which it is run only through the right side. For this reason, unilateral is the form generally used. For those who experience this memory loss, the memories generally return gradually, over a period of about six months.
I couldn’t find any research to back up this last assertion. The fact is, there are very few longitudinal studies (e.g., long-term, following up with patients years after the treatment) on ECT. And even fewer that look at cognitive deficits and memory loss (as opposed to simple symptom relapse). Some patients, in fact, never recover all of their memories — even memories that can date back to their childhood. In what little research I could find that examined long-term outcomes of ECT, it showed that if you had a deficit after ECT, it generally remained 6 months later:
After six months patients who received bilateral ECT continued to have a deficit relative to patients who received unilateral treatment on the measure of autobiographical memory (Fuller, 2005).
Back to the article…
Many patients have described how memory difficulties are a price worth paying for relief from devastating and debilitating depression.
Which is absolutely true.
But if your ECT prescribing doctor isn’t saying something to the effect of, “We’d like to try a treatment you may have heard of called ECT. One of its common side effects is memory loss. Patients often ask us, How much memory loss will I experience? How bad will it be for me? Will it eventually return? We can’t tell you how you will react to the treatment, nor answer those questions with any kind of specificity for you. You may have memory loss just surrounding the treatments. You may also have memory loss from earlier times in your life; some people have even had memory loss extending to their childhood. We cannot tell you what you will experience, other than to say that most people who go through this procedure do not have extreme or long-term memory loss.”
One study showed that either putting patients back on antidepressant medications, or continuing to do occasional ECT treatments (called “maintenance” ECT), led to two-thirds of patients staying well over the next six months. The rate of wellness over that period in patients with no treatment was only 16 percent.
Yes, which is a very sobering statistic. There is an 84% chance, according to the article, that without continued treatment after your initial round of ECT, you will relapse back into depression. Other studies have shown better effects. For instance, Birkenhäger (2004) found that after 1 year, 73% of people who had received ECT for depression relapsed — meaning 27% did not. In any case, ECT generally means more ECT for the rest of your life.
So if you’re going into an ECT treatment for the first time, print this entry out. Bring it with you to your doctor, and make sure they say something similar to the above. Because then you will know all the risks associated with this extreme treatment modality before you undergo it.
Don’t get me wrong — I know people who have successfully undergone ECT. Most say they are thankful for the option. But it is not the cure-all this article makes it out to be. It is still an extreme procedure requiring a lot of forethought prior to accepting it, and the research is far from clear as to its long-term effectiveness and efficacy.
Birkenhäger, T.K. (2004). One-Year Follow-Up After Successful ECT: A Naturalistic Study in Depressed Inpatients. Journal of Clinical Psychiatry, Vol 65(1), pp. 87-91.
Eschweiler, G.W. et. al. (2007). Clinical efficacy and cognitive side effects of bifrontal versus right unilateral electroconvulsive therapy (ECT): A short-term randomised controlled trial in pharmaco-resistant major depression. Journal of Affective Disorders, Vol 101(1-3), pp. 149-157.
Fuller, R. (2005). Comparison of clinical and cognitive outcomes of bilateral and right unilateral ECT in community settings. Dissertation Abstracts International: Section B: The Sciences and Engineering, Vol 65(7-B), 2005. pp. 3706.
Kellner, C. H. et. al. (2006). Continuation Electroconvulsive Therapy vs Pharmacotherapy for Relapse Prevention in Major Depression. Archives of General Psychiatry, Vol 63(12), pp. 1337-1344.
Kho, K.H. et. al. (2005). Predictors for the Efficacy of Electroconvulsive Therapy: Chart Review of a Naturalistic Study. Journal of Clinical Psychiatry, Vol 66(7), pp. 894-899.
Grohol, J. (2008). A Love Letter to ECT. Psych Central. Retrieved on May 5, 2016, from http://psychcentral.com/blog/archives/2008/01/30/a-love-letter-to-ect/