ECT is a classic failure of evidence-based medicine

This Council for Evidence-Based Psychiatry has hosted a guest-blog by Prof. Richard Bentall, who writes:

“In a discipline to which controversy is no stranger, there are few controversies guaranteed to generate as much heat as that surrounding the benefits and costs of electroconvulsive therapy (ECT). The origins of the treatment can be traced to the work of the Hungarian psychiatrist Ladislaus von Meduna who, in the 1920s, began to use camphor to induce epileptic-like seizures in his patients on the assumption that epilepsy and ‘schizophrenia’ are incompatible conditions [1]. However, the first use of electricity for this purpose is attributed to Ugo Cerletti and his assistant Lucio Bini, psychiatrists at the University of Rome, who administered the first electrical shock treatment to a patient in 1938 [2]. In the 80 years since, the procedure has been made safer and more tolerable (modern patients are anaesthetised and receive a muscle relaxant before being administered shocks) and enthusiasm for the treatment has waxed and waned. In the early 1980s, when I began my career as a psychologist, the old psychiatric hospital in Denbigh in North Wales had a dedicated ECT suite which provided the procedure to a regular stream of inpatients and I spent a memorable afternoon watching some of the hospital residents receiving the treatment. Since the closure of the large hospitals its use has declined and there are now striking regional variations in the extent to which psychiatrists still prescribe it [3].

Current opinions about the treatment continue to be highly polarised. It is not hard to find people who argue that it is one of the most effective and undervalued treatment in the history of psychiatry [4] nor those who castigate it as a cruel and barbaric therapy that is an unwelcome hang over from a time that embraced other barbaric treatments, long since abandoned, such as insulin coma therapy and the prefrontal leucotomy. Whenever the matter is aired as a public, for example on Twitter, it does not take long for the debate to degenerate into vitriol. When I became embroiled in such a debate in early 2017, I was assured that ECT was effective for a bewildering variety of disorders – depression, psychosis, autism and even Parkinson’s Disease (it really is beyond imagination how any treatment could be effective for such a disparate group of conditions) – and was then subjected to a series of ad hominem attacks, for example by retired US psychiatrist Bernard Carroll who insisted that I was not allowed to have an opinion because I had, “as much standing to bloviate on ECT for incapacitating depression as I do to bloviate on neurosurgery for epilepsy”.  

The new review of the quality of ECT research published by John Read, Irving Kirsch and Laura McGrath [5] is likely to provoke similar discord; from past experience I expect that we will not have to wait long before someone, mostly likely with a medical qualification, tries to dismiss the paper as a piece of anti-psychiatric propaganda. And yet it should not be this way, and it almost never is this way in any other areas of medicine. The question of whether the benefits of a treatment outweigh its costs is routine in modern therapeutics. Indeed, the systematic use of evidence to resolve this kind of question is the bedrock on which modern medicine is built …”

You can read more from here.

Please note that, in the above extract, footnotes have not been included with – i.e. attached to – their footnote reference numbers, but can of course be seen at source in the full article.

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