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.
References
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.
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Links to This Article
From Psych Central's World of Psychology:
With FDA Change, ECT May Go the Way of the Dinosaur | World of Psychology (4/15/2009)
8 Comments to
“A Love Letter to ECT”
Thank you for writing about this! As a psychiatry resident I have seen several people with chronic resistant depression doing well on ECT. Almost all of them have significant memory problems. Yes, they would still choose to have ECT in retrospect. But too many psychiatrists/researchers brush over the memory loss as something minor, something temporary or eve, as you pointed out, something Good. It is not.
I have seen pre-printed informed consent forms for ECT which make No mention at all of the memory loss. That is unethical and probably illegal, and it definitely turns trainees like me off what might well be a valid treatment option for some.
Sorry for being off topic, I expected another kind of Love Letter!
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I have seen first hand the positive effects ECT has brought to patients that are in need of an effective treatment for Depression. I don’t believe it was Dr. Potash’s intent to brush off the adverse effects that ECT can bring. He works on a specialty unit at Hopkins and sees severely sick people from all over the world. It is about weighing risks verses the benefits, and the benefits are strong when you compare devastating symptoms of depression that people endure verses temporary memory loss.
Last year (2008) I was admitted into hosptial for a major depressive disorder = A rare form or Melancholic Depression. I was trialed on various drugs and had 18 rounds of ECT (8 bilateral and 10 unilateral).
I went and saw the head Professor at the Australian Black Dog Institute. He has recently put me on one of his trials whereby I am taking Ritalin (30mg) so far I have seen an improvement in my energy and motivation levels and not as constantly down as I was when I was not on this medication.
My question is… I have been trying to find any information on if ECT has any effects on sexuality? I have always been hetrosexual! While undergoing ECT I was told (as my memory has no recollection of anything that happend while in hosptial) I became very close to another patient of the same sex. I am really worried about this as it horrifies me to think I got that close to someone of the same sex.
Could you possibly shed any light on this? It would be greatly appreciated?
I have suffered bad memory lost but I am slowly regaining some memory.
I had ECT about 4 years ago. I have a lot of memory loss, including information about my children, which is very distressing to me. I have also not been able to return to the profession I had, in part because of memory losses, as this could have serious results to the people I would be serving (health care professional).
I was never warned of serious memory loss possibilities. It was glossed over with “some memory loss around the time of ECT”. Had I known this possibility it may have changed my decision.
My depression recurred very soon after the treatments, partly due to the distress of having gone through ECT itself. I am still in disbelief that I “agreed” to it. The choice was left to me, a severly depressed person who only hoped the result of treatment would lead to death.
I know that ECT has helped a lot of people, I just hope that they are give more information as to the side effects. That way they can give a more informed consent.
And what could you do if you really want to lose all the memories of one year before? It is REALLY important! Is this possible when you are desperate and you know that THIS is the only way to survive for your child? How can you do this if you have money and you don’t know what to do? I don’t care about the consequences!
I am a scientist bipolar, who has had about 60 of these treatments. I was deeply depressed. While it cleared up much of my depression, I lost my dream job and cannot obtain a 3rd degree due to memory loss. If I had to do it again, I would not. My doc minimized the risks so I became a willing victim. ECT should be used as a last resort.
Memory loss is something hardly mentioned, and I will like to see the “peice of paper” you have to sign for consent for ects. Much more, doctors take advantion to “hit you when your down”, meaning, you are in a state of depression or otherwise– meaning it wouuld be very hard for someone to accurately make such a big decision. Any doctor that provides ects as a “second line of defense” over it being “the last line of defense” should be open to malpractice. But, this is a slipery slope, and quite smart of those ect doctors. I’m guessing that docs can “bank on” never getting sued, because, afterall, we’ve lost our memory. Therefore, how could we ever make a coherent arguement in court?! –quite genious of them, don’t you think? Further more, ect equipment (both procucing and selling) is a fairly “cornered” market. It has come ot my attention that Dr.Charles Kellner previously (still?) had major shares in a company that makes ect equipment. So, let’s review. Ects require a short letter of consent when a patient is not in a coherent state of mind. Due to loss of memory, no patient can win a case in court, and doctors have a large incentive to administer ects because they are incredibly lucrative. So bravo, charles kellner, you’ve found a great way to make money!!
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Last reviewed: By John M. Grohol, Psy.D. on 30 Jan 2008
