From the Editor

Electroconvulsive therapy, or ECT, is a highly effective treatment for depression. But patients often complain about side effects, including cognitive problems.

Could magnetic seizure therapy, or MST, provide the benefits of ECT without these issues? In a new paper for JAMA Psychiatry, Zhi-De Deng (of Duke University) and co-authors attempt to answer that question. In a study where 73 patients with depression were given ECT or MST, they found similar results. “This randomized clinical trial found that the efficacy of MST was indistinguishable from that of ultrabrief pulse [right unilateral] ECT, the safest form of ECT currently available.” We consider the paper and its implications.

In the second selection, Dr. Niall Boyce (of the Wellcome Trust) mulls the return of Frasier Crane, the “pompous but kind-hearted American psychiatrist.” In a Lancet perspective, he writes about the original TV comedy and the new revival of Frasier – and also notes the change in perception of psychiatry over the years. His assessment of the show: “Is the new Frasier worth watching? On the early evidence, I would say yes.”

And, finally, we explore the latest in the news with consideration of recent articles from The Globe and Mail and other publications. Among the topics: the (over) prescription of antidepressants, safe supply, and hairdressers and psychotherapy in Togo.


Selection 1: “Clinical Outcomes of Magnetic Seizure Therapy vs Electroconvulsive Therapy for Major Depressive Episode: A Randomized Clinical Trial”

Zhi-De Deng, Bruce Luber, Shawn M. McClintock, et al.

JAMA Psychiatry, 6 December 2023  Online First

Major depressive disorder (MDD), a leading cause of global disability, is associated with significant morbidity and mortality. While electroconvulsive therapy (ECT) is highly effective, especially for patients with psychosis, treatment resistance, or acute suicide risk, it carries the risk of adverse neurocognitive effects. Magnetic seizure therapy (MST), designed with the goal of matching the efficacy of ECT while maximizing cognitive safety, involves seizure induction with transcranial magnetic stimulation (TMS) while the patient is under anesthesia. Electromagnetic induction via MST offers the ability to induce seizures with more focal and less intense stimulation than is possible with ECT. Four case series of patients with major depressive episodes (MDEs) found that MST decreased depression, produced rapid reorientation, and spared global cognitive abilities…

An open-label study of MST reported antidepressant benefits and few cognitive adverse effects, consistent with 2 earlier open-label studies. A systematic review of 4 randomized clinical trials (RCTs) that compared ECT and MST, comprising a total of 86 patients with unipolar or bipolar depression, suggested that MST may have similar effect size compared with ECT. However, these studies were limited by small sample sizes and suboptimal dosing.

So begins a paper by Deng et al.

Here’s what they did:

  • “A between-participants, double-blinded, randomized clinical trial was conducted at 3 academic hospitals from June 2007 to August 2012.” 
  • They included “adults aged 18 to 90 years who were referred for treatment with ECT, had a major depressive episode in the context of major depressive disorder or bipolar disorder, and had a baseline 24-item Hamilton Depression Rating Scale (HDRS-24) total score of 18 or higher…” 
  • Exclusion criteria included head injury and pregnancy.
  • Participants were randomly assigned to treatment with MST or ECT. In terms of the treatments: “Treatment with MST, applied at 100 Hz at 100% of the maximum device power for 10 seconds, or ultrabrief pulse RUL ECT, applied at 6 times seizure threshold.”
  • Primary outcome: change from baseline in HDRS-24 total score, with patients followed up for up to 6 months.” They also looked at neurocognitive effects, including using the Autobiographical Memory Test.

Here’s what they found:

  • 179 patients were assessed for eligibility, and 106 were excluded. (!) 73 were enrolled with 35 randomized to MST and 38 to ECT. 
  • Demographics. Most were female (56.2%) with a mean age of 48 years.
  • Completers. “53 (72.6%) were classified as completers (29 in the MST group and 24 in the ECT group).”
  • Response. In the intent-to-treat sample, 51.4% in the MST group and 42.1% in the ECT group met response criteria (50% or more reduction in the HDRS-24 scores). Among completers, 58.6% vs. 62.5%. See figure below.
  • Remission. 37.1% in the MST group and 26.3% in the ECT group met remission criteria (60% or more reduction and score under 8).  Among completers, 44.8% vs. 41.7%. 
  • Significant difference. “There was no significant difference between MST and ECT for either response or remission rates.” (!)
  • Treatments. “The mean number of treatments needed to achieve remission was 2.3 less for ECT than MST.”
  • Orientation and adverse effects. “Compared with MST, ECT had significantly longer time to orientation after treatment… and greater severity of subjective adverse effects, particularly in the physical and cognitive domains.” With regard to the Autobiographical Memory Test, those who received MST had better recall of autobiographical memories and had better autobiographical memory specificity.

A few thoughts:

1. This is a good and important study with much to like: a randomized clinical trial with a head-to-head comparison of MST and ECT, and published in a big journal.

2. The main finding in a sentence: “There was no significant difference between MST and ECT for either response or remission rates.” And there was no significant difference in the sustained benefit at six months.

3. So, yes, MST had comparable antidepressant results to ECT. But participants did better with orientation and adverse effects, including cognitive problems. (!!)

4. The authors don’t discuss the negative perceptions of ECT, but patients clearly think about that. Some assume that ECT is highly dangerous – one in five reported worrying about death in a US survey. Could MST be a more palatable option?

5. Like all studies, there are limitations. The authors note several, including: “Our study was not powered as an equivalence or noninferiority trial; thus, we cannot definitively conclude that MST is noninferior to ECT.” 

6. The authors tantalizingly suggest that a noninferiority trial is underway.

7. ECT has been considered in recent Readings. In June, we looked at The New England Journal of Medicine paper on ECT and ketamine finding: “Ketamine was noninferior to ECT as therapy for treatment-resistant major depression without psychosis.” The link is here:

The full JAMA Psych paper can be found here:

Selection 2: “The blues are calling: the return of Frasier Crane”

Niall Boyce

The Lancet, 4 November 2023

Frasier Crane (Kelsey Grammer), the pompous but kind-hearted American psychiatrist, became a televisual icon almost by accident. He first appeared in the Boston-set sitcom Cheers (1982-93) as the love interest of lead character Diane Chambers (Shelley Long). Diane left; Frasier stayed and became a regular. When Cheers ended, Frasier moved to Seattle to become a radio psychiatrist. The successful spin-off show, Frasier (1993-2004), stayed on air for 11 seasons. In an episode towards the end of the run, Frasier is briefly reunited with one of his ex-wives, a children’s entertainer stifled by her own success. ‘Do you have any idea what it’s like to play the same character for 20 years?’ she asks him in despair. With the revival of Frasier for streaming service Paramount+, Grammer marks double that amount of time, on and off, in the psychiatrist’s chair.

So begins a perspectives paper by Dr. Boyce. 

He notes the context of the new series. “Frasier has returned to Boston, leaving behind his career as a media psychiatrist for a new life as an academic at Harvard University. Frasier plans to reconnect with his son Freddie (Jack Cutmore-Scott) and old friend Alan (Nicholas Lyndhurst), and build relationships with his new boss Olivia (Toks Olagundoye) and Freddie’s sometime flatmate Eve (Jess Salgueiro). It’s all change for Frasier Crane.”

But Dr. Boyce notes the influence of the past. “This focus on the past is both a strength and a weakness of the new show. After the new wave of documentary-style cringe comedy pioneered by the UK version of The Office (2001–03) and adopted subsequently by innumerable imitators, it feels almost refreshing to have an old-fashioned sitcom with a multiple-camera setup, a live studio audience, and actual punchlines. The show’s history is also implicit in key elements of the new Frasier’s scenario, sometimes in very touching ways.” He notes, for instance, that: “One of the main characters, Frasier’s nephew David (Anders Keith), shares a name with Frasier co-creator David Angell, who died in the Sept 11, 2001 attacks.”

But Dr. Boyce observes that such a focus can be problematic. “As any psychiatrist will tell you, it may also be a force of constriction and entrapment.” He adds: “The pivotal relationship between Frasier, the upper middle-class psychiatrist, and his son Freddie, the self-consciously blue-collar firefighter, alternates between a canny reversal of the original Frasier’s father-son dynamic, and an uninspired retread of the same ideas.”

On the whole, Dr. Boyce seems pleased with the new series, and recommends watching it. He also gives comment on society’s evolving thinking about mental health:

“For those interested in psychiatry, Frasier’s progress from the 1980s to the present day traces the trajectory of society’s attitudes towards mental health. In Cheers, Frasier’s profession is sometimes regarded with mirth and suspicion by his fellow drinkers. In Frasier 2023, a group of firefighters at Mahoney’s engage in an open and enthusiastic discussion about their emotional lives. Like the Rorschach-blot patterned wallpaper in Frasier’s new apartment, these days therapy is just part of the scenery.”

A few thoughts:

1. This is a fun review of the new series.

2. The observations of societal change are good.

3. For the record, I miss Martin Cane.

The full Lancet perspective can be found here:

In the News

Part of an occasional series.

“Curb antidepressant prescribing to improve mental health, say campaigners”

Elisabeth Mahase

The BMJ, 5 December 2023

“A group of 31 medical professionals, researchers, patients’ representatives, and politicians has called on the UK government to reverse the increase in antidepressant prescribing seen in the past decade.”

The article notes that several people have signed a letter that “evidence indicates that antidepressants benefit only people with the severest depression, and yet prescribing rates are high among those with mild and moderate depression.” The signatories include several psychiatry professors and a former health minister.

“In 2022-23 a total of 86 million antidepressant items were prescribed to an estimated 8.6 million identified patients in England, up from 50.1 million in 2012.” The article considers prescriptions for less severe episodes of depression and contrasts it with the latest UK clinical recommendations.

While prescribing is up and they advocate non-pharmacological interventions, does one necessarily exclude the other?

“In London, Ont., two caring addiction doctors sit on either side of the safe supply divide”

Marcus Gee

The Globe and Mail, 7 December 2023

“Andrea Sereda and Sharon Koivu have a lot in common. Both are addiction doctors in London, Ont. Both are devoted to their patients. Both have seen many of those patients die despite their best efforts, cut down by an overdose epidemic that is killing about 20 people a day across the country.

“They know each other well. When Dr. Sereda was starting out, she looked up to the older Dr. Koivu.

“Now they find themselves on opposite sides of a bitter debate that has split the addiction-medicine community in the midst of Canada’s worst-ever drug crisis. At issue is something with an innocuous-sounding name: safe supply.”

So begins a long, detailed essay about these two physicians and their disagreement – and a larger debate in our society about safe supply. 

The writing here is excellent, and the passion and commitment of both physicians comes through.

“Need Therapy? In West Africa, Hairdressers Can Help.”

Elian Peltier

The New York Times, 26 November 2023

“Joseline de Lima was wandering the dusty alleys of her working-class neighborhood in the capital of Togo one day last year, when a disturbing thought crossed her mind: Who would take care of her two boys if her depression worsened and she were no longer around to look after them?

“Ms. de Lima, a single mother who was grieving the recent death of her brother and had lost her job at a bakery, knew she needed help. But therapy was out of the question. ‘Too formal and expensive,’ she recalled thinking.

“Help came instead from an unexpected counselor: Ms. de Lima’s hairdresser…”

So begins an article on a project to expand access to psychotherapy by training up hairdressers in this low-income nation that has just five psychiatrists for a population of eight million people. 

The work there reminds us that mental health innovation doesn’t just involve technology and new meds.

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.