After electroconvulsive therapy (ECT) was first proposed in 1938, it was widely accepted as psychiatry’s only effective treatment of serious depression and other grave mental illnesses. In those days, ECT was largely uncontroversial — a generally accepted treatment for patients who were going rapidly down the tubes.
All this changed in the 1960s. For one thing, the flower children hated ECT; for another, such books and movies as One Flew Over the Cuckoo’s Nest (five Academy Awards in 1975) offered horrifyingly inaccurate depictions of ECT that scared the pants off everybody; finally, because the pharmaceutical industry proposed a series of psychoactive drugs, some of which were effective against depression (though not highly effective). For these reasons, ECT went into a tail spin that prompts many people today, when they hear about ECT, to ask, “Are they still doing that?”
ECT is in fact a safe and highly effective treatment. But, until this week, it has been haunted by a succession of what are essentially urban myths: that it should be the last treatment to be tried, that it causes brain damage, that a “right unilateral” placement of the electrodes is better than a “bitemporal” (one electrode on either temple) to spare the patient’s memory, and that, finally, ECT destroys decade of preciously accumulated memories.
All these beliefs are false, and we know that because over the past fourteen years a collaborative group of researchers at four different hospitals, known as the CORE study, have conducted several controlled trials to establish the truth of these matters. Nineteen separate reports issued from this work. This week, in the current issue of the Acta Psychiatrica Scandinavica, one of the principal international psychiatry journals, psychiatrist Max Fink reviews the 19 detailed studies, concluding that “ECT rapidly relieves active suicide risk,” and that, in the words of Copenhagen psychiatry professor Tom Bolwig who wrote an accompanying editorial, in “severe (melancholic/psychotic) depression, it should be considered the first-line treatment, and not a last resort intervention.”
Up to 84 percent of patients with serious depression recovered following ECT in the CORE study, 95 percent of those with psychotic depression (delusions, hallucinations). As Bolwig remarks, this is “a rate hardly surpassed by any treatment in the whole of medicine.”
Simultaneously, a study at Columbia University looked at the effectiveness of right unilateral electrode placement: 55 percent of their patients remitted. With bilateral placement in the CORE study it was 86 percent. End of discussion about electrode placement.
The CORE study didn’t look at memory but another recent “meta-analysis,” grouping a number of separate studies, did (Semkovska, 2010). It found, as Bolwig puts it, “that the cognitive [memory] side-effects mainly comprised the first 3 days after the treatment and that all cognitive functions improved compared with pretreatment conditions:” -- untreated depressed patients do in fact experience a lot of memory impairment, and their memories improve with ECT.
What else? Contrary to a widely held belief, ECT is just as effective in bipolar disorder as in unipolar depression. Do patients who have responded well to ECT need to be maintained on some prophylactic treatment? Yes, they do, just as patients who have responded well to pharmacotherapy. But the CORE study found that ECT is just as effective a maintenance treatment as drugs.
Many followers of this blog will have heard of other treatments to stimulate the brain without inducing seizures, such as transcranial magnetic pulse stimulation (TMS), vagus nerve stimulation (VNS), and the surgical placing of electrodes deep in the brain (deep brain stimulation, or DBS). Fink takes a swipe at all of these, though the definitive data are not yet in: “These efforts ignore the experience that grand mal brain seizures . . . are the therapeutic mechanism for the relief of patients with mood disorders.”
Both the Bolwig editorial and the Fink review are important contributions. They say that ECT should be the first-line treatment in patients with serious depression and some of the other conditions that respond to convulsive therapy. The first line therapy. This is big news.