January 30, 2019

expert comments on ECT in response to a Head to Head opinion piece: “Should we stop using electroconvulsive therapy?”

Reactions to a debate published in the BMJ on the efficacy of electroconvulsive therapy on people with depression.

Prof Kamilla Miskowiak, Professor at University of Copenhagen Department of Psychology and Mental Health Services, said:

“I am surprised that this topic is even debated in the BMJ. There is no doubt that ECT is a highly efficacious and often life-saving treatment for severe neuropsychiatric disorders including depression. In fact, it is the most effective treatment for severe and psychotic depression. Further, there is no evidence for structural brain damage after ECT – on the contrary, there is evidence from neuroimaging studies for increase in the volume of brain regions including the hippocampus that is important for memory. There is also no evidence for cognitive side-effects measured with neuropsychological tests beyond three months after ECT completion, and a new large-scale Danish register study found that ECT is not associated with risk of dementia. Despite this lack of evidence for ECT-induced brain damage, many people experience cognitive problems, including memory difficulties after ECT.  These cognitive problems are real and should not be disregarded. In fact, we know that long-term memory and concentration difficulties are a core feature of neuropsychiatric disorders themselves and thus exist before ECT is commenced. This highlights the need for novel treatments that can improve cognitive function in people who have suffered from neuropsychiatric conditions like depression.”

Dr Rupert McShane, Consultant Psychiatrist and Honorary Senior Clinical Lecturer, University of Oxford, said:

“ECT has a solid, modern evidence base. ECT is the most effective and durable treatment available for severe depressive illness but it is not a perfect treatment.  As with other treatments for severe medical illness, it has side effects.  Despite refinements in technique, difficulty in remembering new material is not uncommon during treatment, but it settles within two months of the end of the course of ECT.  A small proportion report permanent loss of some personal memories.  Helping patients and their families to balance the benefits against the risks of ECT is an important task. Many people who haven’t responded to antidepressants or psychotherapy could benefit from ECT, but do not get it. 

“Better treatments for severe and resistant depression are badly needed. We also need wider use of psychotherapy to enhance resilience and reduce relapse following ECT.

“The stigma of ECT is nurtured by the repetition of powerful narratives arising from a time of widespread use, sometimes in coercive situations.  These narratives do not reflect current practice. The stigma of depression weighs heavily on patients.  Even when they get better, they often feel they cannot talk about it.  Adding to their distress by stigmatising ECT is simply unkind.”

Dr Michael Bloomfield, Excellence Fellow, Head of Translational Psychiatry Research Group and Consultant Psychiatrist, University College London (UCL), said:

“ECT is reserved for patients with severe illnesses including life-threatening depression and catatonia. As a doctor I have seen patients respond very well to ECT and the medical evidence indicates that ECT is effective.  The persistent stigma around ECT acts a barrier to treatment.  Nonetheless, no treatment is without side-effects and, as with any other medical treatment, the risks associated with ECT need to be balanced against the risks of not using ECT and allowing an illness to take its course which can involve huge suffering and death.  In practice, response to treatment and side-effects should be monitored to mitigate this risk.  As with every treatment in medicine we need much more research into long-term effects alongside precisely understanding how our treatments work, so that we can develop new treatments with fewer side-effects in the future.” 

Prof Allan Young, Professor of Mood Disorders, Institute of Psychiatry Psychology & Neuroscience, King’s College London (IoPPN), said:

“The evidence for ECT being beneficial is good and withstands scrutiny.  The case against seems based on a very odd reading of the evidence base or a very personal and idiosyncratic point of view.

“ECT in the UK is used by specialists very carefully after a full and careful clinical decision making process, which takes into account benefits and harms, has been carried out. 

“ECT is a very effective short term treatment, unfortunately people often have a high relapse rate in the longer term so the benefits are often not long lasting enough.  ECT does have side effects but, to my mind, there is no credible scientific evidence that it causes the permanent damage spoken of by its detractors.

“We need to do more research about how ECT works so we can understand the mechanism of action and develop new treatments based on this knowledge.”

‘Should we stop using electroconvulsive therapy?’ by John Read and Sue Cunliffe, Sameer Jauhar and Declan M McLoughlin was published in BMJ at 23:30 UK time on Wednesday 30th January.

Declared interests

Prof Kamilla Miskowiak: I have no conflict of interest. However I have acted as a consultant and received consultancy fees from Lundbeck, Allergan and Janssen in the past three years.

Prof Rupert McShane: Dr McShane is a consultant psychiatrist and has experience of treating people with ECT for 20 years in Oxfordshire.  He is Chair of the Committee on ECT and related treatments of the Royal College of Psychiatrists.  He led the creation of the ECT module of Healthtalk on which patients describe the range, but not the frequency, of their experience of ECT.

Dr Michael Bloomfield: No declarations of interest.

None others received.