ECT, or shock treatment as it’s sometimes called, is a controversial topic. Adherents describe it as safe and effective; opponents condemn its use as damaging and ineffective. But it is still widely used in the US and in other countries.
The treatment consists essentially of passing sufficient electricity across the brain to cause a seizure. Clients are anesthetized during the process. It is used primarily in cases of severe depression. Typically, shock treatment is administered twice a week until the depression remits or until no further improvement is noted in two successive sessions. Most courses of treatment involve about eight sessions.
After shock treatment, some clients do appear to be less depressed, but this phenomenon has been interpreted differently by ECT’s proponents and opponents. Proponents claim that the ECT treatments have clearly alleviated the depression. Opponents claim that the apparent improvement is an example of post-concussion euphoria, and that the effects are short-lived.
The subject is vast, and an enormous volume of material has been written on the topic. I Googled “electroconvulsive therapy” and got just over one million hits. There is a growing body of writing from survivors who state that they were harmed by the process, but one can also find occasional reports from people who say that ECT was helpful to them. In former years the psychiatric community claimed that there were no significant adverse effects on memory associated with ECT, but today there appears to be a general acceptance that memory loss can and does occur.
ON THE PRO SIDE
Steven Novella, MD, is a neurologist, and works as an Assistant Professor at Yale. He’s active and influential in the skepticism movement, and has his own blog as part of the New England Skeptical Society: Neurological blog: Your Daily Fix of Neuroscience, Skepticism, and Critical Thinking. On March 22, 2012, he posted How Electroconvulsive Therapy Works, and he opens the article by stating:
“There is no real controversy over whether or not ECT works for depression – it is highly effective.”
This statement is linked to the abstract of a study by Diercks BG et al: Efficacy of electroconvulsive therapy in bipolar versus unipolar major depression: a meta-analysis which appeared in the journal Bipolar Disorder, 2012.
This meta-analysis combined the results of six earlier studies, and concluded:
“ECT appears to be equally effective for both bipolar and unipolar depression and the remission rates are encouraging, especially for bipolar depression.”
The first thing to note is that the Dierckx et al study was not designed to answer the question: is ECT effective? but rather to assess its effectiveness for bipolar depression versus unipolar depression. This is a significant issue, because the only way that one can adequately assess the effectiveness of a procedure like ECT is to compare its use to a placebo. None of the studies collated in the Dierckx et al meta-analysis were studying effectiveness as such. But the authors did state that “…the remission rates are encouraging…,” and presumably that is the finding on which Dr. Novella is basing his claim.
I was able to find, and examine, all of the six base studies used by Dierckx et al:
- Medda P, et al, Response to ECT in bipolar I, bipolar II and unipolar depression. J Aﬀect Disord 2009; 118: 55–59.
- Grunhaus L, et al, Response to ECT in major depression: are there diﬀerences between unipolar and bipolar depression? Bipolar Disord 2002; 4(Suppl. 1): 91–93.
- Sienaert P, et al, Ultra-brief pulse ECT in bipolar and unipolar depressive disorder: diﬀerences in speed of response. Bipolar Disord 2009; 11: 418–424.
- Bailine S, et al, Electroconvulsive therapy is equally eﬀective in unipolar and bipolar depression. Acta Psychiatr Scand 2010; 121: 431–436.
- Daly JJ, et al, ECT in bipolar and unipolar depression: diﬀerences in speed of response. Bipolar Disord 2001; 3: 95–104.
- Sackeim, HA et al, Length of the ECT Course in Bipolar and Unipolar Depression. J ECT 2005; 21 (3): 195-197
All six of the base studies used questionnaires and rating scales to assess depression. The Hamilton Rating Scale for Depression was used in all cases. Other scales used included Brief Psychiatric Rating Scale (BPRS); Clinical Global Improvement (CGI); Beck Depression Inventory (BDI); etc.
Follow-up periods after the end of treatment were:
- Medda P et al: 1 week
- Grunhaus L et al: no follow-up
- Sienaert P et al: 1 week and 6 weeks
- Bailine S et al: no follow-up
- Daly JJ et al: 1 week
- Sackeim et al: no follow-up
Only study number 3 – Sienaert et al – assessed for cognitive side effects. They administered the Mini Mental Status Exam before treatment and at one and six weeks post treatment. The results show a small but consistent improvement in scores across time (i.e. from pre-treatment to post-treatment). However, the Mini Mental Status Exam is not sensitive to the kind of cognitive deficits generally associated with ECT except in the period immediately following the ECT. The Sackeim et al 2007 study The Cognitive Effects of Electroconvulsive Therapy in Community Settings, for instance, found on average no persistent deficits in Mini Mental Status Exam scores associated with ECT, but did find significant and persistent deficits in “…memory for autobiographical events.” This is precisely the area in which survivors of ECT have been reporting problems for decades.
I have written on the subject of ECT before, here, here, and here. In my opinion, the evidence is clear: ECT has no overall superiority to placebo in the treatment of depression, except in the period during and immediately after the treatment, and, in at least some cases, does a good deal of damage.
My purpose in this article is to examine the evidence that Dr. Novella adduced to support his claim that ECT “…is highly effective.” This is important because Dr. Novella presents himself as a debunker of pseudoscience, and routinely characterizes those of us on this side of the psychiatry debate as unscientific “deniers” (e.g. Mental Illness Denial – Part IV)
People reading his sentence: “There is no real controversy over whether or not ECT works for depression – it is highly effective,” with a link to the Dierckx et al study would, I believe, assume that the Dierckx et al study provided some evidence for this conclusion. In fact, this is simply not the case. Neither the meta-analysis nor any of the base studies were designed to address the question of general efficacy. In addition, only one of the studies (Sienaert et al) had follow-up assessment beyond one week, and none of the studies controlled for the placebo effect. Only one of the studies (Sienaert et al) addressed the question of adverse effects, which, I suggest, must be considered in any assessment of general efficacy.
On the other hand, the evidence from randomized placebo-controlled trials is clear: apart from some short-lived lifting of mood, ECT is not effective as a treatment for depression. A comprehensive review of the efficacy evidence can be found in Read J. and Bentall R, The effectiveness of electroconvulsive therapy: A literature review, under the heading Comparison With Simulated-ECT For Depression (p 335). Read and Bentall concluded:
“These placebo controlled studies show minimal support for effectiveness…during the course of treatment …and no evidence…of any benefits beyond the treatment period.” (p 333)
The authors also state:
“Since the 2004 review [Chapter on Electroconvulsive Therapy, in Models of Madness, by Read, Mosher, and Bentall, 2004] there have been no findings that ECT is effective, but significant new findings confirming that the brain damage, in the form of memory dysfunction, is common, persistent, and significant, and that it is related to ECT rather than to depression.
Few of those exposed to the risks of memory loss, and to the slight but significant risk of death, receive any benefit even in the short-term. There is no evidence at all that the treatment has any benefit for anyone beyond the duration of treatment, or that it prevents suicide. The very short-term benefit gained by a small minority cannot justify the significant risks to which all ECT recipients are exposed.”
And yet ECT continues – a tribute to psychiatry’s faith in its dogmas, and its enduring resistance to any evidence that challenges these beliefs.
PSYCHIATRY AND PSEUDOSCIENCE
On November 14, 2013, Dr. Novella, in an article titled Is There a Pseudoscience Event Horizon? provided a list of “typical behaviors” of pseudoscientists:
1 – Hostile to criticism, rather than embracing criticism as a mechanism of self-correction
2 – Works backward from desired results through motivated reasoning
3 – Cherry picks evidence
4 – Relies on low grade evidence when it supports their belief, but will dismiss rigorous evidence if it is inconvenient
5 – Core principles untested or unproven, often based on single case or anecdote
6 – Utilizes vague, imprecise, or ambiguous terminology, often to mimic technical jargon
7 – Has the trappings of science, but lacks the true methods of science
8 – Invokes conspiracy arguments to explain lack of mainstream acceptance (Galileo syndrome)
9 – Lacks caution and humility by making grandiose claims from flimsy evidence
10 – Practitioners often lack proper training and present that as a virtue as it makes them more ‘open’
With the possible exception of numbers 8 and 10, this list seems to me like a very accurate portrayal of psychiatry.
As mentioned earlier, Dr. Novella’s article of March 2012 opens with the claim that ECT is “…highly effective.” The article then goes on to address the question: how does ECT work? For this issue, Dr. Novella refers to another study, Electroconvulsive therapy reduces frontal cortical connectivity in severe depressive disorder, Perrin et al, 2012, which performed fMRI scans on nine individuals before and after ECT. This study found that “…functional connectivity was considerably decreased after ECT…”
Given that ECT causes significant and persistent memory loss, which, incidentally, Dr. Novella acknowledges, it seems to me that the most parsimonious way to interpret the Perrin et al results is that the reduction in functional connectivity, which actually means the breaking of circuits, might be the cause of the memory loss.
Dr. Novella ignores this possibility, however, and, following the lead of the researchers, suggests instead that the individuals who received the ECT had:
“…overactive connectivity between that part of the brain that generates the emotion of depression and the part of the brain involved in cognition and concentration. In these patients, therefore, their depressed mood has a significant effect on their thoughts and ability to concentrate. ECT appears to reduce this hyperconnectivity, which should significantly reduce the symptoms of depression.” [Emphases added]
The “logic” here could be summarized as follows: ECT alleviates depression; ECT breaks neural circuits; therefore it is these “overactive” neural circuits that caused the depression in the first place. I suggest that this is an almost textbook example of the second item of Dr. Novella’s list of typical behaviors of pseudoscientists:
“Works backward from desired results through motivated reasoning.”
Despite the evidence of damage and ineffectiveness, psychiatry clings tenaciously to ECT. For years, they denied that it caused memory loss, claiming instead that any such deficits were the result of the depression or, in at least one case (Fink M Psychosomatics, 2007), somatoform disorder! (In other words, the memory loss was “all in their heads.”)
As the evidence mounted, they conceded that ECT entails some memory losses, but insisted that these were minor and/or transient. Today they acknowledge that sometimes the memory problems are significant and persistent, but they claim that the impact of these problems is balanced by ECT’s “efficacy” as a treatment for depression.
How much longer can they continue this travesty?