Electroconvulsive therapy--an outdated treatment, or one whose time has come?

Depression, bipolar disorder, and other mental illnesses are being increasingly recognized in today's medicine, with millions of people suffering from them. It is well known that people with mental illness utilize healthcare services more frequently than those without mental illness, (1) costing millions of dollars per year in healthcare related expenditures. (2) As a result, nonpsychiatrists are being called on to take on the burden of treatment, and primary care is increasingly being called the "de facto mental heath system." (3) However, although safe and effective somatic treatments are available, the field of medicine still has a long way to go in fully combating the suffering of mental illness. It is therefore imperative that physicians who see patients with mental illness have at least basic awareness of safe and effective treatments.

The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial, recently completed, aimed to define which subsequent treatment strategies, in what order or sequence, and in what combination(s) were both acceptable to patients and provide the best clinical results with the least side effects. (4) One of its many outcomes was that treatments were effective, but approximately one third of patients responded at the first treatment stage, with declining response rates at each subsequent treatment stage. (5-10) The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) trial, looking at various antipsychotics in schizophrenia, demonstrated that although there were effective treatments, the majority of people discontinued their treatments prematurely. (11) Certainly, there must be room for other treatments!

The review article by Dr. Taylor in this month's issue of the Southern Medical Journal is a reinforcement and a reminder that electroconvulsive therapy is certainly a therapeutic opportunity in the treatment of patients suffering from mental illnesses. The image that many providers and patients alike have of ECT is that of Jack Nicholson in One Flew Over the Cuckoo's Nest or of Russell Crowe in A Beautiful Mind. Many as a result may see ECT as outdated and barbaric, and some even equate ECT providers to criminals. However, the promise of novel psychopharmacologic agents (with the possible exception of clozapine for schizophrenia) has still left the mental health field with more questions than answers, and ECT still outrivals other antidepressant treatment options.

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It is beyond the scope of this editorial to detail the reasons for the controversy surrounding ECT. Perhaps the preface in Kitty Dukakis's and Larry Tye's new book Shock, the Healing Power of Electroconvulsive Therapy says it best: "There is no treatment in psychiatry more frightening than electroconvulsive therapy ... The doctor presses a button that unleashes a burst of electricity powerful enough to see off an epileptic-like convulsion ... There also is no treatment in psychiatry more effective than ECT." (12)

For a treatment to be effective, it must also be well tolerated. Many studies note an improved quality of life after ECT. One such study, performed by McCall et al, looked at 283 patients who received ECT, looking at quality of life (as measured by the SF-36). 87% of patients reported improvement on the SF-36 score immediately after ECT, and 78% still showed positive change at 6 months. This is surprising, given rates of remission of only 45.9%. (13)

In this age of modern medicine, science has taken us a long way. We know more about illnesses and disease processes now than we did even a few years ago. New discoveries are being made every day. Whether it is the advent of new pharmaceutical products, the creation of life-altering medical devices, the invention of novel procedures, or the elucidation of disease processes, humanity has benefited from the advancement of medical science.

Lay persons and medical professionals may ask, "How does ECT work?" Although there are many theories, none are conclusively proven. It may be difficult to recommend treatments for illnesses in which the mechanism of neither is clearly identified. However, there are other examples in medicine in which either the disease processes or the treatment is not completely understood. Two examples immediately come to mind--migraine and irritable bowel syndrome. In these instances, neither the disease nor the treatments are called into question.

Is ECT right for everybody? No. There are many people, including psychiatrists, who do not like ECT. There are many detractors to ECT, each with their own story. In a similar vein, there are detractors to other medical treatments. There have been concerns about rosuvastatin, some even calling for its recall. (14) Suzanne Somers eschewed traditional medical treatment and used a complementary homeopathic treatment when she had breast cancer. "However," as she states on her website, "I believe in fully understanding the course of my own treatment. Do your own research...." (15) I implore those who are reading this editorial to do their own research into the effectiveness of ECT. It is not right for everyone, but it is a treatment health professionals should consider in their therapeutic arsenal in their treatment and referral process. It is one of the oldest treatments currently in modern psychiatry, but also one whose time has come.

References

1. Regier DA, Hirschfeld RM, Goodwin FK, et al. The NIMH Depression Awareness, Recognition, and Treatment Program: structure, aims, and scientific basis. Am J Psychiatry 1988;145:1351-1357.

2. Simon GE, VonKorff M, Barlow W. Health care costs of primary care patients with recognized depression. Arch Gen Psychiatry 1995;52:850-856.

3. Regier DA, Goldberg ID, Taube CA. The de facto US mental health services system: a public health perspective. Arch Gen Psychiatry 1978;35:685-693.

4. "What is STAR*D?" University of Pittsburgh. Available at: http://www.edc.pitt.edu/stard/public/. Accessed December 11, 2006.

5. Trivedi MH, Rush AJ, Wisniewski SR, et al; STAR*D Study Team. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry 2006;163:28-40.

6. Trivedi MH, Fava M, Wisniewski SR, et al; STAR*D Study Team. Medication augmentation after the failure of SSRIs for depression. N Engl J Med 2006;354:1243-1252.

7. Rush AJ, Trivedi MH, Wisniewski SR, et al; STAR*D Study Team. Bupropion-SR, sertraline, or venlafaxine-XR after failure of SSRIs for depression. N Engl J Med 2006;354:1231-1242.

8. Fava M, Rush AJ, Wisniewski SR, et al. A comparison of mirtazapine and nortriptyline following two consecutive failed medication treatments for depressed outpatients: a STAR*D report. Am J Psychiatry 2006;163:1161-1172.

9. Nierenberg AA, Fava M, Trivedi MH, et al. A comparison of lithium and T(3) augmentation following two failed medication treatments for depression: a STAR*D report. Am J Psychiatry 2006;163:1519-1530.

10. McGrath PJ, Stewart JW, Fava M, et al. Tranylcypromine versus venlafaxine plus mirtazapine following three failed antidepressant medication trials for depression: a STAR*D report. Am J Psychiatry 2006;163:1531-1541.

11. Lieberman JA, Stroup TS, McEvoy JP, et al; Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) Investigators. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med 2005;353:1209-1223.

12. Dukakis K, Tye L. Shock: The Healing Power of Electrocovulsive Therapy. New York, Penguin Group, 2006.

13. McCall WV, Prudic J, Olfson M, et al. Health-related quality of life following ECT in a large community sample. J Affect Disord 2006;90:269-274.

14. "Study Touts Statins' Effectiveness After Heart Attack." Consumeraffairs.com. August 30, 2005. Available at: http://www.consumeraffairs.com/news04/2005/statins.html. Accessed December 10, 2006.

15. Somers, Suzanne. Available at: http://www.suzannesomers.com/LifeStyle/. Accessed December 10, 2006.

Perhaps it is good to have a beautiful mind, but an even greater gift is
to discover a beautiful heart.
--John Nash
From the movie, "A Beautiful Mind"

James N. Kimball, MD

From Wake Forest University Baptist Medical Center, Medical Center Blvd., Department of Psychiatry, Winston-Salem, NC 27157.

Reprint requests to James N. Kimball, MD, Medical Center Blvd., Department of Psychiatry, Wake Forest University Baptist Medical Center, Winston-Salem, NC 27157. Email: [e-mail]

Accepted January 3, 2007.