Dr. Andrade's Commentary in J Clin Psych: A Scholarly Defense of ECT

Out on PubMed, from noted ECT scholar, C. Andrade, is this commentary:

Active Placebo, the Parachute Meta-Analysis, the Nobel Prize, and the Efficacy of Electroconvulsive Therapy.

Andrade C.J Clin Psychiatry. 2021 Mar 30;82(2):21f13992. doi: 10.4088/JCP.21f13992.PMID: 34000105

The abstract is copied below:

The efficacy of electroconvulsive therapy (ECT) has been recently questioned on the grounds that placebo-controlled (sham ECT) trials are all old and of poor quality; statements have been made that the prescription of ECT should immediately be suspended because its continued use cannot be scientifically justified. These criticisms have come from academicians and have been presented in scientific and news forums with wide readership. A rebuttal is therefore necessary, if only to counter the formation of negative attitudes among patients, health care professionals, and the general public. The quality of sham ECT randomized controlled trials (RCTs) is undoubtedly poor; however, this is so because these RCTs were conducted in an era in which such methodology was par for the field. What critics of ECT have not considered are the large, well-designed, well-conducted, and well-analyzed modern era RCTs that show that bilateral and high dose right unilateral ECT are more effective than low dose right unilateral ECT, or that brief-pulse ECT is more effective than ultrabrief-pulse ECT; in such situations, the inferior form of ECT may be regarded as an active placebo comparison group that represents a scientifically valid substitute for sham ECT. Critics of ECT also do not consider the parachute meta-analysis analogy; just as one does not need a meta-analysis of RCTs to conclude that parachutes work, so too one does not need a meta-analysis of new sham ECT RCTs to conclude that ECT works. ECT is usually recommended to patients who are catatonic, severely ill, or treatment-refractory, and if ECT did not work well in these patients, common sense tells us that it would not continue to be used for such patients more than 80 years after its introduction. Malaria therapy and leucotomy are somatic therapies that were honored with the Nobel Prize, but it is ECT that has survived.

And excerpts from the text :

(note: the pdf is not available to copy, but is easily located on the journal website):

Nearly 20 years ago, the Christmas issue of the British Medical Journal featured a tongue-in-cheek systematic review and meta-analysis of RCTs that examined the effectiveness of the parachute in the prevention of death or major trauma related to gravitational challenge.21 The authors failed in their objective; they were unable to identify even 1 RCT that met their search criteria. Using good judgment, they did not reject the efficacy of parachutes; rather, they recommended that “individuals who insist that all interventions need to be validated by a randomised controlled trial need to come down to earth with a bump.”21(p1460) In other words, there are situations in which one needs to apply common sense.

What is the relevance of the parachute meta-analysis to ECT? ECT is usually reserved for the most severely ill of patients, including those who are catatonic, those who have psychotic symptoms, those who are suicidal, and those who have failed to respond to other treatments. These are situations in which the bar for efficacy is set very high. Had ECT been ineffective in such patients, its inefficacy would have been exposed long decades ago and the treatment would have fallen into disuse. It is also noteworthy that depressed patients who receive ECT respond and even remit in 2–4 weeks22; in contrast, in the average depressed patient, who is usually less severely ill and more treatment-responsive than patients referred for ECT, the duration of an adequate antidepressant drug trial is 4–8 weeks.

..ECT has been criticized for lacking efficacy beyond the treatment period. This criticism is strange because it could be leveled against most if not all treatments in neuropsychiatry. For example, if a patient with anxiety, depression, or schizophrenia were to stop medication immediately upon improvement or recovery, relapse is nearly certain to occur. We do not criticize the antianxiety, antidepressant, or antipsychotic medication for failing to produce lasting effect; rather, we recognize the need for continuation and maintenance treatment. It is so after a successful course of ECT, as well; continuation and maintenance therapy with medications, or with ECT, itself, are necessary for patients to maintain treatment gains.

Finally, it is acknowledged that ECT is associated with cognitive adverse effects and that the more effective forms of ECT are associated with a higher cognitive risk; whereas these risks are probably exaggerated by the anti-ECT lobby, concerns about these risks necessitate the recommendation of ECT to only those patients for whom the likelihood of benefit outweighs the likelihood of risk. As already stated, such patients as usually those who are severely ill, catatonic, suicidal, or medication-refractory; these are usually patients for whom few or no other treatment options remain.

This is a scholarly and academic (but funny at times) commentary that is a response to Read et al.'s attack on the ECT research database. Dr. Andrade is one of our most accomplished ECT clinical scientists and this piece will gain a wide audience. He refers to Read  and colleagues as "well-known academicians in respected institutions," very generous, indeed. 

These comments are thoughtful, diplomatic and forceful; they present the real view of ECT from an experienced clinician and scientist. The straw man is clobbered.

Thanks to Dr. Andrade for this skillful defense of ECT and his career of accomplishments in our field.

This is a must-read for all ECT practitioners, (~10 minutes).