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Editorial
August 2017

Modern Electroconvulsive Therapy: Vastly Improved yet Greatly Underused

Author Affiliations
  • 1Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York
  • 2Department of Radiology, College of Physicians and Surgeons, Columbia University, New York, New York
JAMA Psychiatry. 2017;74(8):779-780. doi:10.1001/jamapsychiatry.2017.1670

Since the 1940s, electroconvulsive therapy (ECT) has been considered the most effective intervention for severe mood disorders.1 To my knowledge, no treatment, pharmacological or otherwise, has matched ECT in speed or likelihood of remission of major depressive episodes. Electroconvulsive therapy is equally effective in unipolar and bipolar depression and has profound antimanic properties.2 Several long-term follow-up studies have suggested that patients who receive ECT have reduced mortality of all causes relative to non-ECT control patients.3

There was a dramatic decrease in ECT use once antidepressant medications were introduced. While this decrease may have slowed in recent years, only a small fraction of potentially appropriate patients receive ECT in the United States. In this issue of JAMA Psychiatry, Slade et al4 found across 9 states that only 1.5% of general hospital inpatients with severe mood disorder received ECT during their index admission. Historically, the 2 major clinical considerations thought to limit ECT use were its adverse cognitive effects and propensity for relapse. In recent years, both limitations have been substantially addressed.

Marked progress has been made in refining the ECT electrical stimulus. In the era of sine-wave stimulation (1940-1980s), the time to recover full orientation following seizure induction averaged several hours, with many patients developing continuous disorientation.5 The introduction of titration of the ECT electrical dose to the individual seizure threshold and brief pulse stimulation reduced the time to orientation recovery to about 45 minutes for bilateral and 30 minutes for right unilateral ECT.6 The introduction of ultrabrief stimulation further reduced recovery time to approximately 15 minutes for bilateral and 10 minutes for right unilateral ECT.7 The most severe and persistent adverse cognitive effect of ECT pertains to memory for past events (retrograde amnesia), and orientation recovery time predicts the magnitude of this long-term amnesia.8 With the advances in ECT technique that reduced recovery time, there was a parallel decrease in the severity of long-term retrograde amnesia. Recent work has failed to detect any adverse effect of high-dose, ultrabrief pulse right unilateral ECT in memory or other cognitive assessments conducted within days of ECT course termination.7 In a 2016 large multisite study in geriatric depression, this form of ECT resulted in a 62% remission rate.9

At the time of the introduction of antidepressant medications, it was estimated that 50% of patients with depression would relapse within 6 months if given placebo following remission with ECT and that only 20% would relapse if administered continuation antidepressant pharmacotherapy. Electroconvulsive therapy samples have become increasingly composed of patients with treatment-resistant depression. It is now estimated that nearly 85% of patients relapse if ECT is followed by placebo and that approximately 50% will retain benefit for a year whether treated with aggressive continuation pharmacotherapy or continuation ECT.10,11 However, recent work also indicates that, as in the short-term treatment of the major depressive episode,12 the combination of ECT and pharmacotherapy as continuation treatment is more potent than either intervention alone. In their randomized study in geriatric depression, Kellner et al13 demonstrated that the combination of pharmacological treatment with venlafaxine and lithium and individualized administration of high-dose, ultrabrief pulse right unilateral ECT was superior to pharmacology alone and resulted in a 6-month relapse rate of less than 15%.

A salient contribution of the STAR*D study14 was the recalibration of expectations regarding antidepressant medication efficacy. The STAR*D study found that after failing to benefit from 2 antidepressant treatments, the conjoint probability of remitting with a third or fourth medication regimen and sustaining that remission for a year was, in each case, less than 5%.14 It is now widely recognized that approximately 30% of patients with mood disorders present with treatment-resistant depression. Even if the recent findings of Kellner et al13 are dismissed and a more conservative rate of sustained remission is adopted, ECT has a several-fold advantage over the level 3 and level 4 STAR*D pharmacological strategies, both in the likelihood of remission with short-term treatment and likelihood of sustaining the remission for a year (eg, 60% remission rate × 50% sustained rate = 30% remission and sustained rate). The growing awareness of the limitations of our interventions for treatment-resistant depression, the strong efficacy of ECT, and the fact that ECT can now be routinely conducted with minimal cognitive consequences compel renewed interest in this intervention.

Slade et al4 have added another piece of evidence supporting the efficacy of ECT. While controlling for a variety of patient-level variables, such as age, sex, and length of index hospitalization, they found that the rate of readmission for mood disorder within 30 days of hospital discharge was about half in patients who had received ECT (6.6%) compared with the much larger sample of inpatients not treated with ECT (12.3%). This finding is of consequence because the study examined the entire population of inpatients with mood disorder diagnoses in general hospitals in 9 US states and thus was free of sample selection bias. The finding is also of note because 30-day readmission is a metric commonly used by regulatory and funding agencies to evaluate the performance of mental health systems. The major limitation of the study was the use of a “quasi-experimental design.”4 Patients were not randomized to ECT or no ECT, and patient characteristics that compel use of ECT (or not) may independently predict outcome. Slade et al4 could not examine a host of clinical features that may affect course following hospital discharge and that likely distinguish ECT recipients from others. Such considerations include the degree of baseline functional disability and symptom severity, extent of treatment resistance, psychotic depression subtype, comorbid personality disorder, and comorbid substance abuse. This research also focused only on use of ECT among inpatients, which significantly underestimates the overall use of ECT; as its cognitive effects have receded, ECT has increasingly become an outpatient procedure.

The findings of Slade et al4 should be interpreted in the context of a large and diverse body of evidence regarding ECT efficacy. This includes randomized trials comparing ECT with sham treatment (anesthesia alone), randomized comparisons of the effect of ECT technical factors on clinical outcomes, randomized comparisons with pharmacotherapy, and large, prospective patient series in research and community settings. The evidence indicating that ECT is effective in the treatment of mood disorders is diverse, long-standing, and incontrovertible. In both the short term and long term, it appears to exert greater benefit than pharmacological alternatives.

Perhaps the most important contribution of this study is documentation of the extraordinarily low rate of ECT use and the demographic characteristics of those who receive it. Previous research demonstrated marked geographic variability in ECT availability, and nearly 9 of 10 US hospitals do not offer this treatment. Slade et al4 found that while the percentage of inpatients receiving ECT was small (1.5%), individuals with private or Medicare insurance coverage and white, non-Hispanic individuals were especially likely to receive the treatment. This concurs with earlier research showing that ECT is used more frequently in private compared with municipal, county, state, or federal health facilities. The findings are also consistent with national survey data indicating that among general hospital inpatients, ECT recipients are older, more often white, more likely to have private insurance, and more likely to live in more affluent areas.15 Contrary to its portrayal as a treatment inflicted on the poor or destitute, ECT is disproportionately administered to those more well-off.

As Slade et al4 note, there are likely a variety of factors that contribute to the low and uneven rate of ECT use. Perhaps the most important considerations are the stigma associated with receiving the treatment on the part of patients and in recommending or administering the treatment on the part of professionals. Nonclinical economic, cultural, and political factors greatly affect the availability and use of this intervention. Were we able to overcome these barriers, it is likely that untold numbers of patients would experience better outcomes by receiving an intervention that is often life altering and, for some, lifesaving.

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Article Information

Corresponding Author: Harold A. Sackeim, PhD, Department of Psychiatry, College of Physicians and Surgeons, Columbia University, 1051 Riverside Dr, New York, NY 10032 (has1@columbia.edu).

Published Online: June 28, 2017. doi:10.1001/jamapsychiatry.2017.1670

Conflict of Interest Disclosures: Dr Sackeim has served as a consultant for LivaNova (vagus nerve stimulation), MECTA Corporation (electroconvulsive therapy), and Neuronetics (transcranial magnetic stimulation). In the past, he has also consulted with or received research support from the brain stimulation companies Brainsway, Cyberonics, Cervel Neurotech/NeoStim, Magstim, NeoSync, and NeuroPace and from the pharmaceutical companies Cambridge Neuroscience, Eli Lilly and Company, Forest Laboratories, Hoffman-La Roche, Interneuron Pharmaceuticals, Novartis International, Pfizer, Warner-Lambert, and Wyeth-Ayerst. He is the originator of magnetic seizure therapy and is the inventor on a nonremunerative patent for focal electrically administered seizure therapy. He is also the inventor on a nonremunerative pending patent on titration in the current domain as a method for seizure threshold determination in electroconvulsive therapy. No other disclosures were reported.

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