A new review, published in Ethical Human Psychology and Psychiatry, re-assesses studies that compare electroconvulsive therapy (ECT) with placebo treatment for depression. The analysis also assesses the only five available meta-analyses that claim that ECT is effective.
The authors of the review point to the lack of quality research available to support the use of ECT, and call for the use of ECT to be suspended immediately until this research is done. John Read, the lead author, and Professor of Clinical Psychology at the University of East London, explains:
“In conjunction with the high risk of brain damage from ECT, this absence of efficacy evidence means that the cost-benefit ratio is so appalling that there is no place for ECT in evidence-based medicine.”
ECT is still administered to about a million people each year. ECT is used most often with older women as well as the severely depressed and suicidal. Two-thirds of those who receive ECT are women, and the average age of ECT recipients is between 60 and 65. Presently, ECT is promoted for treating depression when psychiatric drugs have previously been ineffective.
In the current review, the authors examined the quality of 11 studies that compared ECT with placebo treatment and five meta-analyses that examine these studies. In their assessment of the quality of each study, the authors rated the influence of bias on the outcomes of the research, and the quality of the research design and reports. The 11 studies have a mean Quality score of 12.3 out of 24 on a Quality scale developed and used by researchers for the review.
At first glance, the available research is extremely dated, with the most recent study taking place in the United Kingdom in 1985. The most recent study comparing ECT with placebo treatment in the United States is 57 years old. There has been no other comparable research conducted outside of the UK and the US. In a press release, Read states:
“This body of research is of the lowest quality of any I have seen in my 40-year career.”
The authors point to significant issues with how the studies reviewed were conducted. They highlight that none of the 11 studies are double-blind, meaning that neither the participants nor the researchers know who is in the treatment group versus the placebo group. Double-blind studies are crucial to avoiding mistaking actual change – in this case, reduced depressive symptoms – for what is, in reality, the placebo effect. Participants who have received ECT in the past would know that it is followed by headaches and temporary confusion, so, therefore, they would know whether they were placed in the ECT or the placebo group, invalidating the study.
Professor Irving Kirsch, Associate Director of Placebo Studies at Harvard Medical School, and the second author of this study added:
“I don’t think many ECT advocates understand just how strong placebo effects are for a major procedure like ECT.”
Irving Kirsch is a renowned placebo researcher, well-known for his landmark work investigating how placebo effects influence the effect of antidepressants, which was recently the focus of a follow-up study conducted by Polish researchers. To truly understand the impact of ECT as opposed to a placebo, it is crucial that studies are conducted in a rigorous manner – which is not the case with any of the studies that are available on ECT.
Moreover, although ECT is used primarily with women and the average age of recipients is between 60 and 65, only three of the studies had samples that were reflective of the demographics of ECT recipients. None of the studies examined the role of age or gender in their findings. None of the studies reported the ethnicity of the participants. Studies are supposed to be representative of the population demographics.
Further, although ECT is supposed to be given to severely depressed individuals as a last resort treatment, the majority of studies did not provide clear information to support that they included severely depressed participants. In fact, two studies used only moderately depressed patients, and one used participants with no depression diagnosis. This illuminates an apparent lack of evidence to support the use of ECT with severely depressed individuals. Kirsch explains:
“The failure to find any meaningful benefits in long-term benefits compared to placebo groups are particularly distressing. On the basis of the clinical trial data, ECT should not be used for depressed individuals.”
Other methodological concerns include the selective reporting of findings, small sample sizes, averaging only 37 people, a failure to examine the effect of ECT on the participants’ Quality of Life, and a failure to include participants who had tried antidepressants before the study. Less than half (46%) of participants had tried antidepressants before ECT – yet, ECT is supposed to be only used when all other treatments have failed, according to guidelines put in place by the National Institute of Clinical and Health Excellence (NICE).
The findings of the studies are unimpressive: four of the eleven found ECT significantly superior to Sham ECT at the end of treatment, five found no significant difference, and two found mixed results (including one where the psychiatrists reported a difference, but patients did not). Only two higher-quality studies report follow-up data. One produced a near-zero effect size in the direction of ECT, and the other a small effect size in favor of Sham ECT.
The lackluster results are concerning considering the damaging side effects of ECT, which can include permanent memory loss, brain damage, brain trauma, as well as death in a small number of cases.
Sadly, despite the risks of ECT, prior research by Read points to disturbing practices associated with ECT administration in England – highlighting its disproportionate use on older women, for persons outside of its target demographic, and outside of its evidence base, such as those diagnosed with personality disorders.
The meta-analyses examining these studies ignore the many of these limitations, and the majority of the meta-analyses are dated as well, with only one being conducted in the last 15 years. The researchers conclude that the major flaws in the study designs, small overall number of studies, and small sample sizes make it impossible to conclude that ECT is better than placebo in the short-term or long-term, or with its target demographic. Read has arrived at similar conclusions, citing the little to no evidence available to support ECT use in the short or long-term, or to treat depression or prevent suicide. The review concludes:
“The quality of most Sham ECT vs. ECT studies is so poor that the meta-analyses were wrong to conclude anything about efficacy, either during or beyond the treatment period. There is no evidence that ECT is effective for its target demographic – older women, or its target diagnostic group – severely depressed people, or for suicidal people, people who have unsuccessfully tried other treatments first, involuntary patients, or adolescents.”
Finally, the authors make a plea for the end of the use of ECT, arguing that the costs outweigh any potential benefits, considering that even the so-called benefits (reducing depression) of ECT have not been sufficiently validated by evidence:
“Given the high risk of permanent memory loss and the small mortality risk, this longstanding failure to determine whether or not ECT works means that its use should be immediately suspended.”
Read, J., Kirsch, I., & McGrath, L. (2020). Electroconvulsive therapy for depression: A review of the quality of ECT versus sham ECT trials and meta-analyses. Ethical Human Psychology and Psychiatry, 21(2), 1-40. (Link)