Electroconvulsive Therapy (ECT): Reiterating the Call for Urgent Attention

Dear Editor,

In his editorial, Underutilization of Electroconvulsive Therapy (ECT): A Call for Urgent Attention, ¹ Prof Thirthalli makes a plea for earlier and more frequent use of ECT. I could not agree more. The patient case he describes so eloquently is one of the most compelling calls for timely, definitive intervention that one will ever read in the psychiatric literature. His back-of-the-envelope estimate that hundreds of thousands of similarly ill patients need ECT seems very likely. I recently queried OpenEvidence, ² about how many patients had had ECT worldwide since its invention almost 90 years ago: the answer was approximately 30 million. It is hard to know how accurate that is; however, whatever the number, it is undoubtedly huge and represents an enormous unsung public health success, with so many lives saved. Imagine how many more lives could be saved if ECT was appropriately prescribed to everyone needing it.

Discussion

ECT has long struggled to escape its checkered past; its history can be divided into two eras: the first from its invention in 1938 until the late 1950s and the second from the late 1950s on. ³ Unfortunately, in the first era, ECT was done without general anesthesia and muscle relaxation (“unmodified” ECT), which is frightening and unattractive to modern eyes; however, modern ECT is nothing like that and needs to keep distancing itself from history that is relevant only to medical historians, not contemporary medical practice.

The need for general anesthesia for ECT is both an impediment and an opportunity: an impediment because of the need for a surgical-type facility and an opportunity because of the collaboration with anesthesia colleagues. ⁴ Since the anesthesia process is integral to the ECT procedure, advances in anesthesia techniques specific to ECT will improve the treatment, with further enhanced safety, tolerability, and efficacy.

The way ahead is through better ECT education and training. It is imperative that we improve knowledge about contemporary ECT practice and ensure that the next generation of psychiatrists is competent to prescribe and perform it to a high standard. As Prof. Thirthalli notes, this must start from within because many psychiatrists are ECT-averse or ignorant about it. This is even more true for other medical specialists, including neurologists, who have a special antipathy for a treatment that causes, rather than prevents, epileptiform seizures. That cocktail party question, “Do THEY still do that?” should be answered calmly: “Well, yes, WE still do that, and it is a remarkable lifesaver for desperately ill patients.” As we have recently written,5 a paradigm shift for ECT and ECT practitioners, away from a narrow focus on treatment-resistant depression towards a broader inclusion of severe psychiatric illness, would more accurately position ECT in the psychiatric armamentarium.

ECT research is also key to reducing stigma since many people deride ECT because we do not know its exact mechanism of action. Remarkable progress in understanding how ECT affects the brain has been made in the past decade, particularly with neuroimaging. It is now clear that ECT exerts profound neurotrophic effects, including widespread grey matter volume increase, in addition to specific changes in the hippocampus and amygdala. ⁶ Rather than cause “brain damage,” it is evident that ECT normalizes many of the adverse effects of severe depression on the brain. ⁷ Placing ECT articles, including original research, case reports, and commentaries in mainstream medical journals, not just psychiatry journals, will help to more broadly educate our medical colleagues about the benefits of contemporary ECT.

ECT is one of the few procedures in medicine that has a strong political force against it, ⁸ for both irrational as well as historical reasons: the anti-psychiatry movement, more specifically the Church of Scientology, continues to target ECT. ⁹

Conclusions

The “rightsizing” of ECT use will involve education, training, and a concerted effort to relinquish the stigmatizing baggage of the past. There is nothing wrong with promoting ketamine and repetitive transcranial magnetic stimulation (rTMS) for depression on their merits, but exaggerating their benefits in order to suggest that they are equivalent replacements for ECT is irresponsible. ECT has the unique ability to treat a number of the most severe psychiatric syndromes (including psychotic, uni- and bipolar depression, catatonia, and schizophrenia) rapidly and effectively. ECT is like any other safe and effective modern medical procedure-only better than most. It is time to treat it as such.