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Stigma continues to impede acceptance of ECT. (New Research Validates Efficacy).

Recent research reinforces existing findings that electroconvulsive therapy is effective for depression. But the stigma surrounding ECT is keeping it from widespread acceptance among both physicians and patients.

Images from the 28-year-old movie "One Flew Over the Cuckoo's Nest," showing Jack Nicholson's character in acute pain while receiving electroconvulsive therapy (ECT) without any anesthetic still resonate in the memories of many Other examples, though less visually vivid, persist. Over the years, repeated portrayals in film and television have reinforced the image of ECT as cruel and barbaric.

But the tide may be turning as research bears out the benefits of ECT. For example, the British journal Lancet recently published a metaanalysis that compared the efficacy of real vs. simulated ECT, ECT vs. pharmacotherapy, and bilateral vs. unilateral ECT. Drawing from previous randomized controlled trials, the investigators in the UK ECT Review Group concluded that ECT effectively treats depressive disorders in adults without causing substantial comorbidity The investigators state that although the trials included in the metaanalysis were small, the data consistently bear out ECT as an effective treatment for depression (Lancet 361[9360]:799-808, 2003).

* Real vs. simulated ECT. The investigators reviewed six trials that involved 256 patients. Patients in five of the trials received ECT twice per week, while patients in the sixth trial received treatment three times per week. The combined results of the trials show a mean difference of in Hamilton Depression Rating Scale scores (95% confidence interval 5.7-13.5) in favor of real vs. simulated ECT.

* ECT vs. pharmacotherapy. The investigators included 18 trials involving a total of 1,144 participants. The various trials' pharmacotherapy arms included treatment with tricycics, the selective serotonin reuptake inhibitor paroxetine, MAO inhibitors, lithium, and the amino acid tryptophan. Frequency of ECT administration varied, as did the use of bilateral and unilateral ECT and the duration of the trials. The combined result of the trials showed that ECT was significantly more effective than pharmacotherapy, with a mean difference of 5.2 points (95% confidence interval 1.4-8.9) in Hamilton depression scores.

* Bilateral vs. unilateral electrode placement. A total of 22 trials involving 1,408 participants were evaluated. Electrode positioning varied, as did duration of treatment, frequencies, and electrical doses. Some studies employed a fixed dose of ECT, while others used a titrated dose. The results of the metaanalysis indicated that bilateral ECT was more effective than unilateral ECT. The investigators cite a 3.6-point (95% confidence interval 2.25.2) change in the depression score favoring bilateral ECT.

Dr. John Geddes of the UK ECT Review Group said in an interview with CLINICAL PSYCHIATRY NEWs that although he and his colleagues were aware of the studies validating the efficacy of ECT, "we were surprised by how much evidence there was--particularly in the comparisons between drugs and ECT and unilateral vs. bilateral ECT."

But will these new findings help ECT shake the stigma it has carried since it came on the scene in the 1930s? Dr. Geddes thinks so. "The dissemination of reliable evidence about both the risks and benefits" of ECT will help increase awareness of its relative safety and efficacy in the psychiatric community, said Dr. Geddes of the department of psychiatry at the University of Oxford (England).

Getting the message about ECT into the academic arena will go a long way toward eliminating the stigma and bolstering the treatment's use, according to Dr. Robert Golden, professor and chair of psychiatry at the University of North Carolina, Chapel Hill. "Ignorance is the foundation for misconceptions about ECT. Hands-on experience lets residents see that it's a powerful, effective treatment for the most desperately ill patients," he added.

ECT is underused partly because the doctors themselves are not familiar with it. When ECT training is included in residency programs, students learn that it's a modern, sophisticated therapy That, more than anything else, helps rid them of the prejudice against ECT, he said. Residents are also able to appreciate the importance of a treatment team that includes an anesthesiologist and anesthetist.

ECT training is part of the core curriculum at the University of North Carolina for third-year medical students, who observe the treatment process. Third-year residents are active members of the ECT treatment team, participating in patient consultations and assisting the attending physician with the treatments, said Dr. Golden, who founded the ECT program at the university

This experience also demonstrates the relative safety of ECT to residents, he said. "ECT is a controlled intervention and is safer than other treatments in some ways. I've never heard of a patient overdosing on ECT."

Dr. Robert Gerstman is among the psychiatrists who are taking the message about ECT directly to their patients. He dispels his patients' misconceptions about the treatment by showing them and their families a 10-minute videotape covering the risks and benefits of ECT and detailing the procedure. Of note, many patients don't realize that they will receive the treatment while under anesthesia, he said.

Dr. Gerstman, section chief of Geisinger Medical Center's ECT services in Danville, Pa., treats 10-15 patients per month with ECT.

He minimizes the risk of relapse by augmenting ECT with antidepressants and psychotherapy With this regimen in place, the relapse rate is 15%-20%, which is considerably lower than the relapse rate of 85% when ECT is the sole therapy he said. Dr. Gerstman stresses that ECT works best as a complement rather than as a standalone treatment. He also emphasizes the importance of administering the correct amount of anesthetic.

Dr. Gerstman's repeated success with ECT has fortified his belief in its usefulness and its role in psychiatric treatment. With criteria for inpatient admission becoming more stringent year by year, any patient who warrants an inpatient admission warrants an evaluation for a trial of ECT," he said.
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Author:Lassman, Teresa
Publication:Clinical Psychiatry News
Geographic Code:1USA
Date:Apr 1, 2003
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