How effective is electroshock therapy?

Question

Electroshock therapy was a popular treatment for depression and other mental illnesses in the middle of the 20th century. After losing its favor for many decades, it seems that it is being reinvestigated as a treatment option and it is supported by many medical authorities. I am still skeptical, though, since they say they don't know why it works. Is this really an effective treatment short-term and long-term (atleast 6-8 weeks after treatment; however I would much prefer a longer term study)? A study investigating its effectiveness combined with other treatments is completely appropriate although I'd rather know without, since there is a problem with occulogyric crisis here. About how effective is it compared to other treatments for severe mental illness, especially long term inpatient treatments of several months time using medication and therapy?

Bonus Question: Has this treatment been investigated for its safety for patients with seizure disorders? Or is the seizures caused by ETC not likely to effect a seizure disorder?

Update: I think this was sort of a pointless question. ETC causes remission of refractory status epilepticus, which was my issue.

According to Mental Health America

Today, ECT is administered to an estimated 100,000 people a year, primarily in general hospital psychiatric units and in psychiatric hospitals. It is generally used in treating patients with severe depression, acute mania, and certain schizophrenic syndromes. ECT is also used with some suicidal patients, who cannot wait for antidepressant medication to take effect.

According to WebMD

ECT is among the safest and most effective treatments available for depression.

Answer 1

My answer is in 3 parts: my professional experience with ECT and my perspective on its use, a list of articles and book references for efficacy studies, and a great list of the current understanding of possible mechanisms of action.

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Professional Experience with ECT:

I was required in my psychiatric rotation in med school 2 years ago to assist with ECT therapy sessions. I had a lot of concerns about ECT myself, so I did a lot of reading about ECT - before I felt I could ethically assist with the procedures. My attending physician (an expert in the field and strong advocate for ECT) gave me some resources, and then I searched for my own (to avoid his bias). After reading, I was surprised about the efficacy results in studies, and with my gained understanding of current knowledge on mechanism of action, I felt comfortable in assisting.

I assisted with several ECT sessions in an extended inpatient setting. A patient whom I was following responded very well to it, after years of failed antidepressant therapy and suicide attempts. I followed her only over 10 days, so I can't personally say I witnessed her improvement past that date. Many patients were kept on their antidepressant/ antipsychotic medication regimen, and ECT was a supplement. Other patients who were completely unable to tolerate psychotropic medications, so ECT was their only medical option (outside of alternative medicine etc., which I do not know enough about to make comparisons).

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Resources

To be honest, for long-term efficacy versus antidepressant therapy, I didn't find a lot of data when I looked. It would take a more in-depth PubMed search. I plan to keep my eye out, because although it's not something I prescribe, I would like to understand it more deeply. Let me know if you find something!

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Clinical Guidelines: Source UpToDate - a clinical practice database of peer-reviewed evidence-based current best practice guidelines and information.

UpToDate Efficacy

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Research Articles: Source PubMed

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Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis.

AUUK ECT Review Group, SOLancet. 2003;361(9360):799.

BACKGROUND: We aimed to review published work for the efficacy and safety of electroconvulsive therapy (ECT) with simulated ECT, ECT versus pharmacotherapy, and different forms of ECT for patients with depressive illness.

METHODS**strong text**ODS: We designed a **systematic overview and meta-analysis of randomised controlled trials and observational studies. We obtained data from the Cochrane Collaboration Depressive Anxiety and Neurosis and Schizophrenia Group Controlled trial registers, Cochrane Controlled Trials register, Biological Abstracts, CINAHL, EMBASE, LILACS, MEDLINE, PsycINFO, and SIGLE, reference lists, and specialist textbooks. Our main outcome measures were depressive symptoms, measures of cognitive function, and mortality.

FINDINGS: Meta-analysis of data of short-term efficacy from randomised controlled trials was possible. Real ECT was significantly more effective than simulated ECT (six trials, 256 patients, standardised effect size [SES]-0.91, 95% CI -1.27 to -0.54). Treatment with ECT was significantly more effective than pharmacotherapy (18 trials, 1144 participants, SES -0.80, 95% CI -1.29 to -0.29). Bilateral ECT was more effective than unipolar ECT (22 trials, 1408 participants, SES -0.32, 95% CI -0.46 to -0.19).

INTERPRETATION: ECT is an effective short-term treatment for depression, and is probably more effective than drug therapy. Bilateral ECT is moderately more effective than unilateral ECT, and high dose ECT is more effective than low dose.

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A meta-analysis of electroconvulsive therapy efficacy in depression.

AUKho KH, van Vreeswijk MF, Simpson S, Zwinderman AH SOJ ECT. 2003;19(3):139. PMID12972983

SUMMARY: Recently published controlled studies comparing electroconvulsive therapy (ECT) with other treatments for depression offer the opportunity to perform a meta-analysis of ECT in depression. Fifteen studies were identified which fulfilled the inclusion criteria. From these controlled trials, 20 effect sizes of ECT were calculated. The speed of action during the course and the efficacy after a full course of ECT were explored. The efficacy of sine wave and brief pulse machines were compared. The comparison between ECT and four other comparative treatments was made. Predictive variables were explored using homogeneity tests. ECT was shown to be superior after a full course. The funnel plot showed the absence of publication bias. There was no exaggeration of effect size in the lower quality trials. No evidence was found for a superior speed of action of ECT or for a difference in efficacy between sine wave and brief pulse stimulation. ECT was shown to be superior to medication and simulated ECT. Some evidence was found that psychosis predicted better response to ECT.

Delfland, Locatie St Jorisweg, 2 Delft, The Netherlands. [email protected]

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Efficacy of ECT in depression: a meta-analytic review.

AUPagnin D, de Queiroz V, Pini S, Cassano GB SOJ ECT. 2004;20(1):13.

This study analyzed the efficacy of electroconvulsive therapy (ECT) in depression by means a meta-analytic review of randomized controlled trials that compared ECT with simulated ECT or placebo or antidepressant drugs and by a complementary meta-analytic review of nonrandomized controlled trials that compared ECT with antidepressants drugs.

The review revealed a significant superiority of ECT in all comparisons: ECT versus simulated ECT, ECT versus placebo, ECT versus antidepressants in general, ECT versus TCAs and ECT versus MAOIs. The nonrandomized controlled trials also revealed a significant statistical difference in favor of ECT when confronted with antidepressants drugs. Data analyzed suggest that ECT is a valid therapeutic tool for treatment of depression, including severe and resistant forms.

Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology. University of Pisa, Italy. [email protected] PMID15087991

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Mechanisms of Action

There are still uncertainties of exactly what among the physiological effects of ECT is directly responsible for mood alteration, but UpToDate has a great breakdown of the mechanisms:

MECHANISM OF ACTION — The mechanism of action for ECT is unknown, but there are many well-documented changes in the central nervous system:

Human and animal studies show that ECT increases release of monoamine neurotransmitters, particularly dopamine and serotonin [8-10]. ECT also enhances monoamine transmission by desensitizing presynaptic adrenergic autoreceptors.

One theory postulates that ECT exerts its beneficial effects by increasing release of central neuropeptides, including corticotrophin releasing factor, somatostatin (STS), and neuropeptide Y [11].

The neuroendocrine hypothesis is based upon the diabetes/insulin model and suggests that mood disorders are caused by insufficiency of a hypothalamic mood-maintaining peptide [12]. Repeated seizures enhance the production and release of the putative hypothalamic peptide antidepression, which relieves both neuroendocrine and behavioral abnormalities.

ECT has anticonvulsant properties (perhaps related to enhanced gamma-aminobutyric acid transmission), which has led to the suggestion that these properties are responsible for the therapeutic effects of the treatment [13].

Positron emission tomography (PET) studies demonstrate decreased metabolic activity in frontal and cingulate cortex after ECT [14].

Functional magnetic resonance imaging before and after successful treatment with ECT reveals a reduction in global connectivity within the left dorsal lateral prefrontal cortex [15].

Quantitative electroencephalogram (EEG) studies demonstrate increased slow (delta) wave activity in the prefrontal cortex after ECT, which is associated with clinical response [16].

Several human and animal studies indicate that ECT has trophic effects on the central nervous system [17-21]. ECT increases brain derived neurotrophic factor (BDNF) in patients and electroconvulsive stimulation induces neurogenesis and mossy fibre sprouting from granule cells in rat hippocampus.

Finally, the book chapter that I read is called "Hypothesized Mechanisms and Sites of Actions of Electroconvulsive Therapy" by Nikolaus Michael in the book Electroconvulsive and Neuromodulation Therapies by Conrad M. Swartz MD. Very technical but very interesting!