ECT in Depression

In the 1960s, advocates of ECT were not able to provide evidence that it is therapeutic in schizophrenia but were nevertheless convinced that electricity and fits are therapeutic in mental illness and vigorously defended the use of ECT in depression. Their rationale came from studies in the United States (32) and Britain. (33)

In the US study, 32 patients were pooled from three hospitals. In hospitals A and C, ECT was as good as imipramine; in hospitals B and C, ECT equaled placebo. The results showed that ECT was universally effective in depression, regardless of type: 70% to 80% of depressed patients improved. The study also showed, however, a 69% improvement rate after 8 weeks of placebo. Indeed, Lowinger and Dobie (34) reported that improvement rates as high as 70% to 80% can be expected with placebo alone.

In the British study, (33) hospitalized patients separated into four treatment groups: ECT, phenelzine, imipramine, and placebos. No differences were observed in male patients at the end of 5 weeks, and more men who received placebo were discharged from the hospital than those treated with ECT. Skrabanek (35) commented about this most quoted study: "One wonders how many psychiatrists read more than the abstract of these studies."

The Royal College of Psychiatrists memorandum mentioned earlier was in response to a report of ECT abuse in depression. The memorandum declared that ECT is effective in depressive illness and that in "depressed patients" there is suggestive, if not yet unequivocal, evidence that the convulsion is a necessary element of the therapeutic effect. Crow, (36) on the other hand, questioned this widely held view.

In the late 1970s and in the 1980s, with uncertainty continuing and further work needed, seven controlled trials were carried out in Britain.

Lambourn and Gill (37) used unilateral simulated ECT and unilateral real ECT in depressed patients and found no significant difference between the two.

Freeman and associates (38) used ECT in 20 patients and achieved a satisfactory response in 6; a control group of 20 patients received the first two of six ECT treatments as simulated ECT, and 2 patients responded satisfactorily. (38)

The Northwick Park Trial showed no difference between real and simulated ECT. (39)

Gangadhar and coworkers (40) compared ECT and placebo with simulated ECT and imipramine; both treatments produced equally significant improvements over 6 months follow-up.

In a double-blind controlled trial, West (41) showed that real ECT was superior to simulated ECT, but it is not clear how a single author carried out a double-blinding procedure.

Brandon et al (42) demonstrated significant improvements in depression with both simulated and real ECT. More important, at the end of 4 weeks of ECT, consultants were unable to guess who received real or simulated treatment. The initial differences with real ECT disappeared at 12 and 28 weeks.

Finally, Gregory and colleagues (43) compared simulated ECT with actual unilateral or bilateral ECT. Real ECT produced faster improvement but no difference between the treatments was apparent 1, 3, and 6 months after the trial. Only 64% of patients completed this study; 16% of the patients withdrew from bilateral ECT and 17% from simulated ECT.

From the West and the Northwick Park trials, it appears that only delusional depression responded more to real ECT, and this view is held by ECT proponents today. A study by Spiker et al, showed that in delusional depression amitriptyline and perphenazine were at least as good as ECT. After a series of ECT for his depression and just before committing suicide, Ernest Hemingway said, "Well, what is the sense of ruining my head and erasing my memory, which is my capital, and putting me out of business." His biographer remarked that "it was a brilliant cure but we lost the patient." (45)

ECT AS AN ANTISUICIDAL

Despite the lack of an acceptable theory as to how it works, Avery and Winokur (46) regard ECT as a suicide preventive, although Fernando and Storm (47) later found no significant difference in suicide rates between patients who received ECT and those who did not. Babigian and Guttmacher (48) found that the mortality risk after ECT was higher soon after hospitalization than in patients who did not receive ECT. Our own study (49) of 30 Irish suicides from 1980 to 1989 showed that 22 patients (73%) had received a mean of 5.6 ECTs in the past. The explanation that "ECT induces a transient form of death and thus perhaps satisfies an unconscious desire on the part of the patient, but this has no preventative effect on suicide; indeed it reinforces suicide in the future." (49) Many psychiatrists today concur that ECT as a suicide preventive does not hold up.

THE PSYCHIATRIST'S DILEMMA: TO USE OR NOT USE ECT

Some psychiatrists jusitify the use of ECT on "humanistic grounds and as a means of controlling behaviour" against the wishes of the patient and family. (50) Even Fink admits that the catalogue of ECT misuses is depressing but suggests that the guilt lies with the abusers and not the instrument. (51) The editor of the British Journal of Psychiatry considered it "inhuman" to administer ECT without asking the patient or the relative, even though Pippard and Ellam showed that this was common practice in Britain. Not long ago, ECT administration in Great Britain was described as "deeply disturbing" by a Lancet editorial writer, who commented that "it is not ECT which brought psychiatry into disrepute; psychiatry has done just that for ECT". (53) Despite efforts to preserve the integrity of the treatment, in Great Britain and in most public hospitals worldwide consultant psychiatrists order ECT and a junior doctor administers it. This maintains the belief of institutional psychiatry that electricity is a form of treatment and prevents the junior psychiatrist from being a clinical thinker.