From the Editor
If you were ill with depression, would you consider electroconvulsive therapy? What if you had a manic episode?
In April 1938, the first treatment of ECT was administered in Rome. Now, 82 years later, ECT continues to be used. But, as Dr. David Goldbloom (of CAMH) notes: “ECT has the unusual status of being one of the most vilified and validated treatments in all of psychiatry and indeed in all of medicine.” The treatment has fallen out of favour, and is not even offered in certain centres.
But would you consider ECT?
In the first selection, we look at a new paper from Psychiatric Services. Dr. Rebecca E. Barchas, a retired psychiatrist, discusses her experiences with ECT – as a patient, not as a physician. She notes the depths of her depression and the decision to receive ECT, which she didn’t know much about despite many years of practice. “If reading these thoughts can help even one more patient who needs ECT accept it or help one more physician to consider recommending it when appropriate, I will have accomplished my goal of helping to destigmatize ECT.”
ECT at 82: Still relevant?
In the second selection, we consider a narrative review from The American Journal of Psychiatry. ECT for patients experiencing manic episodes is used less and less often; in several recent surveys, no patient with mania received ECT. But what’s the evidence? Dr. Alby Elias (of the University of Melbourne) and his co-authors review decades’ worth of literature, from RCTs to retrospective studies, finding the treatment is safe and effective. But is it relevant in an era of pharmacology?
Selection 1: “My Benefits From Electroconvulsive Therapy – What a Psychiatrist Learned by Being a Patient”
Rebecca E. Barchas
Psychiatric Services, 10 November 2020 Online First
I always thought of myself as a good psychiatrist, actually a very good psychiatrist. I saw much improvement in almost all of my patients and could control each person’s symptoms with psychopharmacological medications and with psychotherapy, which I loved to do. I never had to refer more than about 1% of my large patient population to hospitals, even though some of my patients were very ill. I could maintain treatment on an outpatient basis, and, in my 34 years of private practice, I never had a patient commit suicide. Now I am 71 years old and have been retired 8 years. Yet I realize now that despite having been a board-certified psychiatrist and a Life Fellow of the American Psychiatric Association, I was ignorant about something very important – the full range of patients who could receive the broad spectrum of benefits from electroconvulsive therapy (ECT). I rarely referred patients for ECT and always thought of it as a last resort. I was not sufficiently knowledgeable of the benefits of ECT until I myself was the beneficiary.
So begins a paper by Dr. Barchas.
She describes her experiences: “My husband died in the fall of 2019 after struggling for 9 years with progressive mental and physical decline from Parkinson’s disease. During those last 2-3 years, I developed symptoms of clinical depression, which became quite severe and were disturbing to both of us. I never felt suicidal, but I became extremely indecisive and lost my joie de vivre, my ability to experience pleasure, and my motivation; most important, I lost my resilience. Everything took such effort. I tried three antidepressants, but I could not tolerate their adverse effects and quit them before they could have conferred any benefit…”
Like many with depression, she struggled to find a way forward. She finally opted for ECT. She notes her own hesitation: “I was scared by the suggestion because I knew very little about the treatment, despite my training and despite my many continuing medical education courses in which ECT would inevitably be mentioned but never emphasized. I had thought it should be reserved just for the absolute sickest of the sick – which I did not consider myself to be.”
“It took only three ECT treatments to totally turn around my depression and to stop whatever irrational thoughts had developed.”
She discusses the transformation: “Once my symptoms of clinical depression disappeared, which they did very rapidly, I could take pleasure in life, regaining my joie de vivre, my high level of motivation, and my ability to make decisions, and I once again had my resilience back. I no longer felt overwhelmed and could accomplish whatever I needed to do. What a difference a change in brain chemistry made!”
“The positive experience made me think that maybe I could do some good by writing this article and by recognizing that perhaps ECT is underutilized and should be considered more frequently as a treatment option than it usually is. After all, I now reap only the benefits of ECT and have no adverse effects at all.” She also notes that some don’t have that option. “I realize that for too many people – for both patients who might be candidates for ECT and the doctors treating them – ignorance about the benefits of ECT and a persistent stigma may cause them to oppose the treatment.”
A few thoughts:
- This is a terrific paper.
- This is also a very personal paper.
- There are many people who have had the robust experience of Dr. Barchas. The literature shows that ECT is highly effective. To return back to Dr. Goldbloom’s comment, it’s one of the most validated treatments in all of psychiatry. For the 700 000 or so Canadians with treatment-resistant depression, ECT could be life changing.
- We have considered ECT in past Readings. Despite its effectiveness for depression, ECT is less commonly used – it is, to pick up on Dr. Goldbloom’s point, one of the most vilified treatments in all of psychiatry. In a Canadian Journal of Psychiatrypaper, drawing on Quebec data, the authors found that ECT use was down by 33% in 15 years in Quebec. That Reading can be found here: http://davidgratzer.com/reading-of-the-week/reading-of-the-week-ect-safe-effective-but-declining-use-the-lemasson-et-al-study-on-ect-in-quebec/
- Is the lack of ECT use a public health problem?
- So, if you were ill with depression, would you consider ECT?
- And is there a role for ECT for those with manic episodes? The next selection weighs the evidence.
The full Psychiatric Services paper can be found here:
Selection 2: “Electroconvulsive Therapy in Mania: A Review of 80 Years of Clinical Experience”
Alby Elias, Naveen Thomas, Harold A. Sackeim
The American Journal of Psychiatry, 10 November 2020 Online First
Mania is an acute psychiatric syndrome described since antiquity. This syndrome has a lifetime prevalence rate of 0.8% to 1.6% and engenders significant morbidity and mortality. Prior to the introduction of electroconvulsive therapy (ECT) and psychopharmacological agents, it was estimated that approximately 15% of patients in acute manic episodes died from medical complications resulting from ‘manic exhaustion,’ that is, inanition, profound insomnia, and excessive motor activity…
ECT is a rapid and highly effective treatment of manic episodes, and current professional guidelines endorse ECT for pharmacotherapy-resistant mania, but often as second- or third-line treatment. For example, the APA Task Force on ECT and the National Institute for Health Care and Excellence (NICE) guidelines support its use in mania. However, despite its safety record and robust efficacy, ECT has been underutilized historically in the treatment of mania, presumably because of lack of knowledge regarding its utility, practical issues regarding consent, stigma, and availability, and regulatory barriers… Across the globe, manic episodes typically constitute only 0.2% to 12% of the use of ECT, and in several surveys, no patient with mania received ECT…
The most recent major review of the use of ECT in mania was published nearly three decades ago, by Mukherjee et al., in this journal. Examining prospective and retrospective reports across the world literature from 1942 until 1992, Mukherjee et al. found that 80% of 589 manic patients showed substantial clinical improvement or remission following ECT. These findings suggested that ECT was at least as effective in the treatment of mania as in the treatment of depression. However, over the past 30 years, there have been substantial changes in ECT practice, including the widespread adoption of stimulus dose titration to inform subsequent electrical dosing, the shift from the traditional bifrontotemporal placement to the right unilateral or bifrontal electrode placements, and the abandonment of sine wave stimulation in favor of brief pulse, and now, ultrabrief pulse stimulation. Here we present a comprehensive narrative review focusing on the scientific literature over the past 30 years on the use of ECT in mania.
So opens a paper by Elias et al.
The authors did a literature review, finding 115 relevant publications.
I highlight from the paper:
Efficacy and The Evidence Base
“In the 80-year history of ECT, there have been seven randomized controlled trials in mania. Two trials compared the outcomes of ECT and pharmacotherapy, one trial compared real ECT with sham ECT, and the remaining trials compared different ECT modalities…
“In summary, across seven randomized controlled trials in patients receiving ECT for acute mania, rates of substantial improvement or remission were high, and improvement was rapid. The difference in efficacy between real and simulated ECT in the single sham-controlled trial was profound, even though all patients were treated with chlorpromazine.”
“Kalinowsky studied 200 patients and observed comparable rates of improvement in mania (93.8%) and depression (93.2%). In 1945, Bennett also reported that similar proportions of patients with mania and depression improved with ECT. In contrast, others found a more favorable outcome in depression than in mania. Detailed reviews of early reports are available elsewhere. After 1976, more controlled studies appeared… In a naturalistic study, Perugi et al. obtained a response rate of 75% for ECT in pharmacotherapy-resistant mania, which was somewhat higher than that observed in a concurrent depression sample (68.8%)…
“Numerous retrospective reports, including case series involving hundreds of patients, documented the impressive effectiveness of ECT in acute mania. The rate of marked clinical improvement following ECT was comparable or superior to rates obtained with pharmacotherapy.”
Safety of ECT in Mania
“Cognitive impairment, one of the most worrisome adverse effects of ECT, has been investigated in randomized controlled trials and modern practice with ultrabrief ECT. Barekatain et al. found better cognitive outcomes with bifrontal ECT compared with bitemporal ECT, and Wong et al. demonstrated improved cognitive function after ultrabrief ECT…
“In general, ECT has been found to be as safe in mania as it is in depression.”
“To date, there have been no randomized controlled trials testing the efficacy of maintenance ECT in bipolar disorder. Naturalistic studies suggest that the use of maintenance ECT may produce significant reductions in the number of episodes, with prolongation of interepisode euthymic intervals in patients with treatment-resistant bipolar disorder, mostly rapid cycling.”
“Methodological standards have significantly evolved over the 80-year time frame. Few studies were prospective, and fewer still used a randomized design with blinding. Only one study used a form of sham ECT to truly mask treatment conditions and to assess the intrinsic efficacy of ECT. The sample sizes of randomized controlled trials were small, leading to studies that were underpowered in detecting group differences, and the vast majority of studies used retrospective designs that may be subject to bias.”
They go on to conclude: “In comparison with ECT in major depressive episodes, its application in mania has been far less documented.”
The full article considers manic subgroups, as well as technical parameters.
A few thoughts:
- This is a good paper.
- As the authors show, the literature is thin compared to ECT and depression.
- The paper offers a thoughtful review, many of the studies are older.
- ECT for depression is potentially life saving; ECT for mania isn’t. The authors note: “An important difference in the pharmacotherapy between major depression and mania is the long latency for remission in depression, while manic symptoms respond quite rapidly. This difference may explain the reduced need for ECT in mania.” At CAMH, hundreds of patients receive approximately 6 000 ECT treatments a year, and just two or three are diagnosed with manic episodes.
- I read Dr. Barchas’ paper, and thought that I could show a future patient her writing. I read the Elias et al. paper, and wasn’t sure I would change my practice.
The AJP paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.