Electroconvulsive therapy

Electroconvulsive therapy is one of the most controversial treatments in medicine. Opinions are often polarised; some consider electroconvulsive therapy to be effective and potentially lifesaving whereas others regard it as unhelpful and harmful and campaign energetically for it to be banned. In response to comments on a mental health white paper, “Reforming the Mental Health Act,” the UK Department of Health commissioned two systematic reviews of electroconvulsive therapy in 2001. One assessed its efficacy and safety in the treatment of depression,¹ mania, and schizophrenia and the other reviewed surveys of patients' experiences and is published in this issue of the BMJ (p 1363).²

So what is the current status of our knowledge about electroconvulsive therapy? Both reviews reveal the limitations of the primary studies and the need for genuinely collaborative high quality research—rather than research done by consumers for consumers and by clinicians for clinicians resulting in research with limited general credibility. Nonetheless both reviews produced some useful results. The systematic review of patients' experiences found that approximately a third describe persistent loss of memory following electroconvulsive therapy.² Rose et al report that there were substantial variations between studies in the perception of benefit from electroconvulsive therapy. The finding that surveys conducted by clinicians tend to report higher rates of perceived benefit whereas those performed by consumers' organisations tend to find lower rates is of particular interest. Of course this may be explained by differences in the selection of the populations sampled or, as the authors suggest, by differences in the focus of the questions and the way they were asked. The review of randomised trials found a reasonable body of evidence on the effects of electroconvulsive therapy in depressive disorder, but less on mania and schizophrenia.¹,⁴ Electroconvulsive therapy produces more improvement on scales of depressive symptoms than simulated electroconvulsive therapy (in which the patient receives all the procedures including anaesthetic but not the electric current). Treatment with electroconvulsive therapy was more effective than drug treatment in the short term, bilateral stimulation was more effective than unilateral, and high dose more effective than low dose. Most of the trials, however, were old and small. Cognitive functioning was not measured consistently across the trials and pooled analyses were not possible. Very few trials investigated the possibility of long term cognitive impairment but those that did suggested that this was not a substantial problem. In view of the limited reliable long term evidence it is understandable that there should be residual concern about the possible long term adverse effects of electroconvulsive therapy, and this should be reflected in the information given to patients.

The evidence for the National Institute of Clinical Evidence's appraisal of electroconvulsive therapy was primarily drawn from the two reviews commissioned by the Department of Health and a Cochrane review on electroconvulsive therapy in schizophrenia.³ The National Institute for Clinical Excellence (NICE) has recommended that electroconvulsive therapy only be used to achieve rapid and short term improvement of severe symptoms, after an adequate trial of other treatments has proven ineffective or when the condition is considered to be potentially life threatening, in individuals with severe depressive disorders, catatonia, and a prolonged or severe manic episode.⁴ The institute was appropriately influenced by the review of patients' experiences and the recommendations are clearly meant to restrict the use of the treatment. The Royal College of Psychiatrists appealed that the recommendations go beyond the evidence and will prevent patients who would benefit from the treatment from being able to receive it. The appeal was rejected because the recommendations were considered to be sound in the face of uncertainty about long term adverse effects and the findings of the review of patients' experience.⁵ As with most policy statements, the recommendations may not be applicable to all individual cases, but clinicians would be well advised to ensure that the clinical circumstances of any deviation are clearly documented with excellent evidence of fully informed consent.

For too long electroconvulsive therapy has been a neglected service with widespread unexplained variations in practice and a low priority with managers: repeated audits by Royal College of Psychiatrists have shown that many hospital trusts fail to adhere to the college's standards.⁶,⁷ The recommendations from NICE, together with the recently announced accreditation service⁸ from the Royal College of Psychiatrists, should provide the stimulus to ensure that services are brought up to acceptable standards throughout the United Kingdom.

We predict that most parties will be reasonably satisfied with the NICE appraisal. Those concerned about potential overuse of the treatment can be reassured with the restrictions, increased safeguards, and improved consent procedures. Clinicians with the responsibility for helping the most severely ill patients will still have access to an effective treatment. So far, the process appears to have resulted in an approach that is both evidence based and broadly acceptable to most stakeholders. If this indeed is the result, it will be a substantial achievement in such a difficult area of clinical practice and a finely judged performance by NICE.