"Classics in ECT": Philip May on ECT for Schizophrenia, 1976

Classics in ECT brings you this article from the Archives of General psychiatry in 1976:

Schizophrenia--a follow-up study of results of treatment.

May PR, Tuma AH, Yale C, Potepan P, Dixon WJ.Arch Gen Psychiatry. 1976 Apr;33(4):481-6. doi: 10.1001/archpsyc.1976.01770040047009.PMID: 938185

The pdf is here.

and from the text:

Patients who had been treated initially with ECT or with drug therapy showed a trend towards spending less time in hospital after their release, a delayed post hospital advantage above and beyond the initial advantages of higher release rate, speedier release, lessened cost of treatment, and better global condition at the time of release as reported earlier.

..These beneficial effects from drug therapy and ECT are less marked if one considers only those patients whose treatment was declared to be a success. There were, however, far more successes among the drug- and ECT treated patients than in the other groups (95% to 96% of the drug alone and drug plus psychotherapy patients and 79% in the ECT group, compared with 58% in milieu and 65% in psychotherapy alone). It may be that drug treatment improves the outcome for an additional number of poorer prognosis patients who, without drug treatment, would have done poorly.

and two figures:

The main point of selecting this article is to acquaint you with with the work of Philip May, whose interest was in the treatment of schizophrenia; the relevant piece for us is that ECT was among the treatments studied.

This is the second in a series of articles spanning the 1960s to the early 1980s, reporting on longitudinal follow up of a cohort of 228 patients diagnosed with schizophrenia.

This is a complex report with sophisticated statistical methods. The main outcome measure was "follow-up stay," which means total days of subsequent inpatient psychiatric hospitalization. So, in the above figures, with days on the vertical axis, lower lines are good, and ECT is the lowest.

There are many issues to critique with the methods of this study, not least of which is the accuracy of diagnosis. But it seems probable that most of the cohort would meet modern diagnostic criteria for schizophrenia.

While ECT was helpful in this early cohort, it subsequently went out of favor for the treatment of schizophrenia in the US. As we have often noted, schizophrenia is the leading indication for ECT worldwide (including many Asian countries), but is low on the list in Europe and the US. This difference in medical culture is not readily explicable, and it may be that we underutilize ECT in our patients with schizophrenia. And there may still be something to the notion that early intervention with ECT could have a beneficial effect on the subsequent natural history of the illness.

This paper is a marvel of complexity, with 16 figures and lots of statistics. But it is definitely a classic and a very rewarding, highly recommended reading experience, ~25 minutes.