Editor—Carney and Geddes predict that most parties will be reasonably satisfied with the appraisal of electroconvulsive therapy by the National Institute for Clinical Excellence (NICE).1,2 Our clinical experience is that many patients who may benefit from electroconvulsive therapy will be denied it under these guidelines.
Apparently, the NICE appraisal panel did not include a single psychiatrist, which may partly explain why clinical experience of the potential benefits of maintenance electroconvulsive therapy, as described in many reports,3 seems to have been discounted.
The recommendations from NICE have also not acknowledged the different potential for memory disruption and cognitive side effects arising from bilateral as opposed to unilateral electroconvulsive therapy.4 Given the concerns about memory disturbance as a side effect of bilateral electroconvulsive therapy, this is a surprising omission.
NICE recommends that the use of electroconvulsive therapy in depressive illness should be restricted to patients with severe depressive illness or catatonia in whom an adequate trial of other treatment options has proved ineffective or when the condition is considered to be potentially life threatening.5 In severely depressed patients who have previously shown a good response to electroconvulsive therapy, it may be appropriate to consider it as a first line treatment.
The NICE guidelines do not recommend electroconvulsive therapy as a treatment for moderate depressive episodes. As discussed in the response to the appraisal from the Royal College of Psychiatrists' special committee on electroconvulsive therapy and the Scottish electroconvulsive therapy audit network (SEAN),5 the randomised controlled trials that form the evidence base for electroconvulsive therapy were carried out mainly on moderately or moderately severely depressed patients, excluding those with severe depressive episodes who were unable to give informed consent.
We consider the NICE guidelines to be unduly restrictive and limiting, encouraging clinicians to deny patients potentially beneficial treatment.
Competing interests: None declared.
References
- 1.Carney S, Geddes J. Electroconvulsive therapy—recent recommendations are likely to improve standards and uniformity of use. BMJ 2003;326: 1343-4. (21 June.) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.National Institute for Clinical Excellence. Guidelines on the use of electroconvulsive therapy. London: NICE, 2003.
- 3.Gagne G, Furman M, Carpenter L, Price LH. Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone. Am J Psychiatry 2000;157: 1960-5. [DOI] [PubMed] [Google Scholar]
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- 5.Royal College of Psychiatrists' Special Committee on ECT and Scottish ECT Audit Network (SEAN). Statement on ECT practice. 25 May 2003. www.sean.org.uk/appraisal.php (accessed 5 Aug 2003).