Wednesday, 22 June 2022

Some barriers to sense making about ECT

The longstanding debate about ECT has been in the news again. A report about the treatment was discussed in an article in The Independent. There was also an strikingly rancorous debate on Women's Hour (starting here at about 34.20). The context for all this is the finding that women receive ECT at a higher rate than men. The Independent article seems to present this as if it were a bad thing.  That is only the case if ECT's benefits are outweighed by is disbenefits. Some people claim as much, but if they are wrong, then it might be good that more women than men receive ECT. Women are more likely then men to experience depression.

I have never got to grips with the details of ECT's efficacy. As a psychologist I feel I should have an opinion. This post is an attempt to engage honestly with the topic and form a view. Unfortunately there are several barriers to doing this. Here are three that I see:

1. Polarisation:

There exists one group of mental health professionals who administer ECT and profess that they would be happy to have it performed on them, and another group who oppose it to the extent that they call for a moratorium on its use. The way these groups interact on Twitter, in blogs, and in the scholarly literature suggests that there is a degree of ill feeling between these camps. 

The most striking fact about these two groups to me seems to be their different characterisation of the nature of depression. For psychologists this perhaps evokes a milder picture: someone who feels low or sad, with self-denigrating thoughts and perhaps feelings of hopelessness, but ultimately ambulatory and potentially responsive to psychological therapy. For psychiatrists, depression also includes those individuals so severely impaired that they are at risk of severe neglect or death by suicide. 

The temptation to "join" one side or the other is strong. Such "joining" is likely to increase bias and rationalisation. 

2. Florid rhetoric:

Rhetoric is a significant barrier to sense making in the ECT debate. For sure it is an intervention that makes me think of “great and desperate cures." ECT is – there’s no escaping it – a pretty extraordinary way of proceeding. Its origin story is startling: its founder was inspired by witnessing the sedating electrocution of pigs at a slaughterhouse. But a startling origin story can be rhetorically inflamed and overdone. Stated baldly, many of the facts of medical practice would whip up frenzy in a newspaper headline (try redescribing a bilateral mastectomy without medical euphemism). Those who oppose ECT tend to be guilty of describing it in terms that make it seem prima facie abhorrent. Those who defend it tend towards excessively sanitising language that elides its negative effects. 

3. Incomplete consideration of the stakes

ECT's opponents tend to discount the risks of no treatment. In the context of our conception of medical responsibility, failure to treat is also an intervention.

When people make the case against ECT, cognitive side effects are a central part of the argument. Sure enough the only person I have ever spoken to about their ECT suffered autobiographical memory loss that they regretted bitterly. These effects are often cited as evidence that the treatment causes brain damage (incidentally those who see ECT's cognitive side effects as a sign of brain damage also tend to argue against the framing of psychiatric disorders as brain diseases, even though it is widely established that depression, schizophrenia and bipolar disorder are all associated with sometimes very severe cognitive impairment). Considered in isolation, these cognitive effects seem so obviously undesirable that only a barbarian would consider risking them. 

However, working in a major trauma centre, primarily with people with acquired brain injury, the physical and cognitive aftermath of uncompleted suicide is a salient part of my professional life. At any time we usually have one or two people known to our service who were admitted for this reason. When psychiatrists make decisions about treatment of depression, this kind of aftermath is part of the stakes they have to weigh. It is in the nature of risk that the worst case scenario will not always be actualised. This doesn't mean it can be entirely discounted. We often choose a course of action with a more likely but less severe payoff so that we can avoid a less likely but more severe payoff. This is the structure of buying insurance. Considered this way, I think ECT becomes a far more reasonable proposition. Given a choice between the cognitive side effects of ECT, and the cognitive effects of a severe traumatic brain injury sustained by walking under a lorry or jumping of a bridge, I would most certainly choose the former. 

Extant evidence: 

Forming a view comes down to making sense of the efficacy literature. This is hampered by many of the barriers discussed here. 

A high profile 2010 review by Read and Bentall concluded: "placebo controlled studies show minimal support for effectiveness with either depression or ‘schizophrenia’ during the course of treatment (i.e. only for some patients, on some measures, sometimes perceived only by psychiatrists but not by other raters), and no evidence, for either diagnostic group, of any benefits beyond the treatment period." They discount these minimal benefits as outweighed by "strong evidence ... of persistent and, for some, permanent brain dysfunction." As discussed above, this discounting may be unwarranted.
Meechan and colleagues recently published a literature summary that meta-analysed the ECT vs placebo trials that Read and Bentall had reviewed. Their analysis favoured ECT:

A  response to that analysis by John Read (who opposes ECT) counters some criticisms made by Meechan and colleagues, but does not (as far as I can see) give grounds to  discount the results themselves. 

What are some things that seem reasonable to say about ECT?
  • ECT has cognitive side effects that can be long lasting, primarily a loss of autobiographical memory
  • The state of the evidence is fairly poor: there are only 11 placebo controlled RCTs that examine the issue. These RCTs tend to support ECT's efficacy in improving depression - the effect size is greater than those observed for medications and psychotherapy.  
  • Any positive effects of ECT are likely to be short term: i.e. long enough to get someone out of a very severe depression, but not sufficient to maintain them in that state. 
  • More ECT efficacy research is needed.

In a blog for the "Council for Evidence Based Psychiatry" (CEP) Richard Bentall (a psychologist skeptical about ECT) articulated a position that I found surprisingly sympathetic:

"I have been challenged to explain what I would do if faced with a patient suffering from life threatening depression (to which the answer is: try other therapies but, if there really was no alternative and death was imminent, I would probably try ECT in desperation despite the questionable evidence of its effectiveness)."

I wonder how many psychiatrists - themselves worried about the limited research on ECT, but aware of the possibility it can be helpful - proceed in precisely this way? 

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