Patients' perspectives on electroconvulsive therapy: systematic review
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7403.1363 (Published 19 June 2003) Cite this as: BMJ 2003;326:1363All rapid responses
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Am treatment resistant bipolar 1; was in a suicidal depression in
late 2001 and had ECT as a last resort. It was not successful. I, too,
am a pianist; can no longer memorize or play to performance level. Long-
term and short-term memory in all areas still affected.
ANY doc who recommends ECT for a patient should have to undergo treatment
him/herself so that memory side effects will be understood!
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor:
That electroconvulsive therapy (ECT) causes memory loss (D Rose et al BMJ
2003; 326:1363-5) is not at all surprising.
I encountered ECT many years ago as a senior medical student. My mentoring
psychiatrist labeled ECT as ‘brain frying. ‘No textbook offered
satisfactory explanation how it worked.
Therefore, over the years, I have developed my own theory of ECT as
‘crude’ treatment as it relates to memory loss.
Consider Domain I - a see of information bits. With an energy input of a
certain amount, these bits are arranged into some patterns depending on
the kind of memory required; e.g., telephone number: 32l-9876 may require
a simpler scheme, while facial recognition a much more complex designs.
(Domain II)
With an additional energy input, these strands are wound into various
segments of a Master bobbin. (Domain III)
With ECT, these processes are reversed, i.e., the stored memory is lost as
the strands are unwound, and information bits are separated.
If acute depression is caused by recent events, then, by erasing
corresponding memory by ECT, depression may be ‘cured ‘.
These bobbin-segments may be intertwined. The deep memory is more
difficult to unravel by external means, but internally a short-circuit may
develop. Chronic brain illness may expose memory of childhood by
unwinding interposing layers, but it will take time and or much force.
In summary, ECT may be effective for acute depression caused by
recent events which are ‘stored’ as recent memory bit-strands.
Competing interests:
None declared
Competing interests: No competing interests
Dr McInroy objects to the use of a picture taken in 1942, but I'm not
sure that everybody would agree. We use pictures primarily to break up
the monotony of the text. Our first requirement of pictures is that they
be visually strong. Even this requirement can be hard to achieve,
particularly when the pictures are small. Secondly, we want the picture
to be relevant, and again this can be surprisingly hard to fulfil.
Thirdly, we like the picture to add extra useful information. This
requirement is best achieved with graphs, but they tend to be visually
weaker.
The picture to which Dr McInroy object fulfils all three criteria.
It fulfils the third requirement in that it gives a sense of how ECT used
to be applied.
Dr McInroy argues that use of such a picture is deceptive and wrong,
but I don't agree. I think that it will be obvious to everybody that this
is a historical picture, and I can't believe that it will have a very
powerful effect on how people interpret the study that we reported.
Certainly people have strong opinions about ECT, but I find it hard to
believe that use of this picture will make much difference to anybody's
beliefs.
Competing interests:
See text of letter
Competing interests: No competing interests
When was this picture [accompanying the paragraph for This week in
the BMJ] taken? It appears to depict circumstances that are old enough to
be "historic", and it would be appropriate in a museum of medical
treatments.
When illustrating a treatment currently in use, you should choose an
up to date picture, not one that is old fashioned and gives rise to subtle
negative spin. "Spicing up" of this kind is a deception and wrong.
CAMPBELL McINROY
Competing interests:
None declared
Competing interests: No competing interests
I have some technical questions which I hope the authors of this
paper will clarify when they make a reply to this correspondence.
In the statistical analysis, tests for heterogeneity showed good
evidence of heterogeneity between studies in answers to wheher ECT was
helpful and whether the subject would have it again. In view of this, it
is necessary to allow for clustering in the logistic regression which was
carried out to examine associations between these outcomes and the
methodological quality of the studies. No mention of this is made in
either the printed or electronic form of the paper. It is very easy to
allow for clustering in STATA by using the 'cluster()' option in logistic
regression and more sophisticated analyses can be carried out by using
'xtlogit'. Can the authors kindly confirm that this was, in fact, done?
In view of the correlations between the various measures of
methodological quality, can these all be included together in a logistic
regression model to give mutually adjusted measures of association with
the study outcomes? Or are the results reported already adjusted in this
way?
The authors of this study assigned a percentage value for the main
outcome measures to each of the studies they identified in their
literature search. In some cases they would have had to exercise little
choice or judgement - where there were simple study designs consisting of
a few questions with binary outcomes. In other cases, much more
subjectivity and judgement had to be used in assigning a percentage value.
Where many questions were used in the original study the authors of the
present study had to decide which questions were relevant and how to
combine relevant questions into a single overall measure. Where the
outcome was a Likert scale, or more complex scale, a cut-off point had to
be determined.
It is clear that where the authors had little choice in assigning a
percentage value the results favour ECT and the more choice they have, the
results are less and less favourable to ECT. This association is
statistically significant.
The obvious interpretation of this would be that the authors are
biased against ECT.
To challenge this suggestion, the authors need to establish the
objectivity of their assessments by publishing the results of the
reliability studies which they carried out for this investigation. It
would also be helpful if they could triangulate their results with some
other objective measures of outcome. For example, how do their judgements
for each study compare with the conclusions of the authors of the original
papers on which this present study is based?
Competing interests:
I have a research interest in the use of statistical methods in studies where clustering occurs.
Competing interests: No competing interests
The degree to which William Plummer's "rigorous safeguards"
(detention under the Mental Health Act and a visit from a psychiatrist
from the Mental Health Act Commission's panel) protect patients is
debatable since these "second opinion" psychiatrists very seldom refuse to
authorise ECT. But in any case there are some people in the UK who are
given ECT without their consent and without even these safeguards.
Every year in England about one hundred informal patients are given
ECT without their consent and a further 300 patients are detained but are
given ECT before a visit from the MHAC psychiatrist.
William Plummer says he would be reluctant to give ECT to someone who
is explicitly refusing it, but there are other psychiatrists who do not
show such reluctance. Nearly half of the 2000 or so people a year in
England and Wales who are given ECT without their consent under section 58
of the Mental Health Act (that is, after a visit from the MHAC
psychiatrist) are in fact considered to be "capable but refusing" rather
than incapable. (1)
Scotland's new mental health legislation will give capable patients
the right to refuse ECT. (2) The government in London however rejected
calls (from, for example, the Richardson Committee on reform of the Mental
Health Act and the majority of responses to the government's consultation
document including the response from the Royal College of Psychiatrists)
for a similar right for patients in England and Wales.
Guidance from the National Institute for Clinical Excellence
meanwhile appears confused. While they say that "valid consent should be
obtained in all cases where the individual has the ability to grant or
refuse consent" and that "the wishes of the patient must be of paramount
importance", they then make an exception for individuals detained under
the Mental Health Act, which rather defeats the purpose.
Earlier this year a woman who was threatened with ECT took her case
to the High Court. The case was never heard, since the hospital decided
that she no longer needed ECT. (3)
1) Mental Health Act Commission, 1999, Eighth biennial report.
London: Stationery Office.
2) Scottish Parliament official report, 20 March 2003, column 19734.
3) http://news.bbc.co.uk/1/low/health/2777301.stm
Competing interests:
None declared
Competing interests: No competing interests
A recent article in the American Journal of Psychiatry states, “The
role of depression in causing a reversible dementia or pseudodementia has
been known for a long time.” (1) As Seymour remarks, “this is supported
by a substantial literature.” (2) But what the article in question adds
is a longer-term perspective, enabling its authors to report that the type
of cognitive decline (after a stroke) which is amenable to reversal with
successful treatment of the causative depression is distinguished by the
fact of its reversibility.
Insofar as the depression for which ECT (electroconvulsive therapy)
is given results in cognitive changes of the reversible variety – what
Andre terms “a temporary attentional deficit” (3) – such changes really
shouldn’t be complicating assessment of impairment following ECT. For one
thing, blaming continuing depression undermines the idea of ECT as an
effective treatment for depression. Logically, neither it nor anything
else may be described as effective if cognitive impairment following
treatment persists. This is what Rose et al. state is being claimed by up
to 55% of recipients – a figure reflecting 20-year-old reportage by Squire
and Slater. They noted, “About half the patients prescribed bilateral ECT
subsequently felt that their memory had never returned to normal; and even
when all the patients prescribed bilateral ECT were considered as a group,
ECT changed the quality or pattern of memory complaints in a lasting way.”
(4).
Andre also states, “The memory loss caused by ECT is quantitatively
and qualitatively different from the dysfunction associated with
depression (Squire LR, Bouzoukis J, Self-ratings of memory dysfunction:
different findings in depression and amnesia. Journal of Clin and Exp
Neuropsychology 1988;10(6): 727-738).” (3) The article in Am. J.
Psychiatry (2003) lends support to the understanding that there are two
distinct kinds of cognitive dysfunction. Seemingly, in “patients with
early and sustained remission of depression, there was rapid improvement
of cognitive function, which was maintained over 2 years,” whereas
“cognitive deterioration due to ischaemic brain damage does not improve
between 1 month and 24 months poststroke.” (1)
If depression after stroke is treatable, why do psychiatrists who
promote ECT find it so difficult to ensure rapid remission of depression
in order to maximise the cognitive functioning of patients – which would
also render the supposedly rare instances of cognitive damage attributable
to ECT easy to spot? At present, depression and ECT are deemed to
interact in ways too complex to make establishing causation of the
cognitive decline feasible. However, the article to which I refer
concludes, “Cognitive impairment due to post-stroke depression is
reversible and can be quantified separately from cognitive impairment on
the basis of the location and extent of ischemic brain damage.” (1) In
short, research which focused on cognition and depression indicates that
it is possible to assess the cognitive dysfunction of depression
separately from impairment due to brain damage. So surely ECT
psychiatrists should be capable of distinguishing the cognitive effects of
the one from those related to the other, similarly employing appropriate
neuropsychological testing to quantify the two types of cognitive
deterioration as these occur post-ECT.
1. Kenji Narushima et al. Does Cognitive Recovery After Treatment
of Poststroke Depression Last? A 2-Year Follow-Up of Cognitive Function
Associated With Poststroke Depression. Am. J Psychiatry 160: 6, June
2003, 1157-1162
2. Seymour S. Does underlying depression, or ECT itself, cause
amnesia after ECT? Rapid Responses, BMJ, 23 June 2003
3. Andre L. Re: Does underlying depression, or ECT itself, cause
amnesia after ECT? Rapid Responses, BMJ, 24 June 2003
4. Squire L R and Slater P C. Electroconvulsive Therapy and
Complaints of Memory Dysfunction: A Prospective Three-Year Follow-up
Study. Brit. J. Psychiatry (1983), 142, 1-8
Competing interests:
None declared
Competing interests: No competing interests
William Plummer wrote: "I personally would be reluctant to prescribe
it, even in extreme circumstances, as long as I was assured that the
patient's decision was based on an informed understanding of the benefits
and side-effects of the treatment. "
Here is the crux of the matter: patients and doctors disagree on the
benefits and "side"effects of ECT; doctors believe they are right and
patients are wrong, and then their patients viewpoint is equated with
"lack of insight and understanding" is used to justify forced ECT.
Forced ECT is common in the U.S. and this is exactly why played out
in a publicized trial in New York State. Doctors of Paul Henri Thomas
testified that he was not competent to consent to ECT because he believed
it would harm him. (He had had previous ECT). The same doctors testified
that they "knew" studies by the US Food and Drug Administration had proven
ECT safe (there are no such studies), or because they read this in some
textbook.
Those who dismiss the SURE study as "nothing new" don't understand
how it may change the balance of what is officially "known" about ECT in
favor of what has always been known by patients. This will hopefully have
an impact in the U.K. and far beyond.
If the SURE study had been available earlier, I would have given it
to the attorneys in the Thomas case.
Oh---what happened to the patient in that case? There was no
decision. After testifying that nothing else but shock could save him, the
doctors decided he had gotten better on his own, and he was released
without treatment.
Competing interests:
The writer is a survivor and unpaid researcher of ECT.
Competing interests: No competing interests
Sir,
Susanne Stevens may or may not be re-assured to know that in the
United Kingdom ECT can not be given without a patient's explicit informed
consent unless certain rigorous safeguards are complied with.
If a patient were not willing to undertake this treatment no
responsible psychiatrist would even consider ECT unless they believed it
could be a life-saving treatment in a question of life or death. For
example, in patients who are so depressed that they are no longer eating
or drinking. In situations like this, antidepressants would take too long
to work (Antidepressants take at least two weeks. The effect of ECT is
much quicker and can be immediate.) and may not be given reliably by
mouth.
The patient would need to be assessed by two doctors, one of whom is
independent of the unit where the psychiatrist works, and a social worker.
The nearest relative must be identified and consulted unless there are
genuine reasons why this cannot be done. If all are in agreement that the
patient were 1)suffering from a mental illness, 2)that as a result of this
they were at risk to their life or health and 3)that the illness is of a
nature and degree that warrents treatment in hospital, then the patient
could be detained in hospital under the provisions of the mental health
act.
This would allow most treatments to be given without the patients's
consent, but not ECT. In order to give ECT there is a further safeguard.
The patient must be examined by a specialist appointed by the Mental
Health Act Commissioners. Only after this second opinion is obtained, and
only if the second opinion doctor agrees that ECT can be given will the
treatment be given.
I must emphasise that these safeguards apply to anyone who cannot
give explicit consent for treatment, even if other evidence suggests that
they would normally give consent (such as willingly having had ECT in the
past). In the face of an explicit refusal to have ECT, whether given as an
advance directive or at the time it is suggested, I personally would be
reluctant to prescribe it, even in extreme circumstances, as long as I was
assured that the patient's decision was based on an informed
understanding of the benefits and side-effects of the treatment.
I must add, however, that under the proposed legislation for a new
Mental Health Act, whose introduction into Parliament has been delayed,
many of these safeguards would be removed. I myself would not welcome
this.
Competing interests:
I am a consultant psychiatrist. I have used ECT in circumstances similar to the current NICE guidelines, but am not a strong advocate for it.
Competing interests: No competing interests
Variables influencing patient perception of ECT
Having recently completed an audit looking at the new ECT care
pathway in our department, I found this article of particular interest.
Whilst my audit mainly focused on the pre-ECT review done by the clinician
in charge of the patient's care, including the information they were
presented with regarding the risk vs benefit of treatment, I was also
struck by a number of observations on some of the variables which appeared
to influence patient perception of the experience of ECT including any
percieved benefit, and reported side effects such as memory impairment.
The authors have commented that the setting, interviewer, and length of
time between treatment and interview has a significant effect on patient
response and this does need to be taken into account as all the reports I
reviewed in the case notes were those disclosed to healthcare
professionals, and they were made at varying time periods from treatment.
However, I found it of some interest that patients who were well informed
and consenting prior to ECT with a detailed discussion made beforehand,
appeared to report a more positive response to treatment than those
patients found to be provided with insufficient information in the pre-ECT
review.
Worryingly I found that a large proportion of patients were not given the
choice between unilateral or bilateral ECT and were not informed of the
evidence base showing that although bilateral ECT is more effective, it is
assosciated with more memory impairment than unilateral ECT [1,2]. Current
practice does appear to favour bilateral over unilateral ECT [3,4]. Given
that memory impairment could be reduced by unilateral electrode placement,
it is an important point to be discussed with patients as it could have a
significant effect on their choice of treatment and therefore their
eperience of ECT.
Of course these findings are purely observational however, when it comes
to patient perception of ECT, their views, as mentioned by the author, are
complex, with the experience of ECT involving many different stages and
variables all of which may have an impact on reported effect.
1. Zamora EN, Kaelbling R: Memory and electroconvulsive therapy. Am J
Psychiatry 1965, 122:546-554
2. Fleminger JJ, Horne DJ, Nair NPV, Nott PN: Differential effect of
unilateral and bilateral ECT. Am J Psychiatry 1970, 127:430-436.
3. Sackeim HA, Prudic J, Devanand DP, et al.: A prospective,
randomized, double-blind comparison of bilateral and unilateral
electroconvulsive therapy at different stimulus intensities. Arch Gen
Psychiatry 2000, 57:425-434.
4. Strachan JA: Electroconvulsive therapy – attitudes and practice in
New Zealand.
Psychiatric Bulletin 2001, 25:467-470.
Competing interests:
None declared
Competing interests: No competing interests