Annotated Bibliography on ECT
from Linda Andre
Permanent amnesia is common
Rose D, Fleischmann P, Wykes T, Leese M, Bindman J: Patients' perspectives on electroconvulsive therapy: systematic review. British Medical Journal: 326 (7403), 1363-1367, 2003, June 21
First-ever systematic review of all literature which included reports from patients, as well as studies designed and carried out by ex-patients.
“At least one-third of patients reported persistent memory loss. Levels were between 29% and 79%.” (persistent defined as lasting six months or more)
“Routine neuropsychological tests to assess memory do not address the types of memory loss reported by patients.”
“Loss of memory is insufficiently systematically investigated.”
“The current statement for patients from the Royal College of Psychiatrists that over 80% of patients are satisfied with electroconvulsive therapy and that memory loss is not clinically important is unfounded.”
Coercion is common, informed consent is not
Rose D, Wykes T, Bindman J, Fleischmann P: Information, consent and perceived
coercion: patients’ perspectives on electroconvulsive therapy. British Journal of
Psychiatry 186: 54-59, 2005
“About half (45-55%) of patients reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not.”
“Over half of the more spontaneous comments about inadequate information was specifically linked to the possible side-effect of long-term memory loss.”
“To invoke trust in a doctor is not a good enough reason to be scrupulous about informed consent.”
“Approximately a third did not feel they had freely consented to ECT even when they had signed a consent form.”
“The proportion who feel they did not freely choose the treatment has actually increased over time. The same themes arise whether the patient had received treatment a year ago or 30 years ago.”
“Neither current nor proposed safeguards for patients are
sufficient to ensure informed consent with respect to ECT, at least in
Coercion, adverse effects on memory and intelligence are common
Philpot M, Collins C, Trivedi P, Treloar A, Gallacher S, Rose D: Eliciting users’ views of ECT in two mental health trusts with a user-designed questionnaire. Journal of Mental Health 13(4): 403-413, 2004
“The adverse effects profiles showed a high prevalence of adverse effects, with two thirds of respondents reporting memory disturbance or confusion at the time of treatment and nearly half permanently.”
Note: This is the only study ever to ask patients about ECT’s effects on their intelligence; 35 to 42% said ECT resulted in loss of intelligence.
“There is no overlap between clinical and consumer studies on the question of benefit.”
Half of those receiving ECT for the first time felt compelled. “Most of those who were faced with a new treatment which they felt under pressure to accept with insufficient information, felt the doctors made the wrong decision.”
Severe permanent amnesia found in studies by financially-conflicted researchers
This study by Mecta consultant Weiner is one of only a few to follow patients as long as six months.
“Provocative evidence for what amounts to objective personal memory losses lasting at least six months.”
After ECT, patients could not remember 30 to 40% of the responses to personal questions they’d given on a questionnaire (very poorly designed) before ECT. Though percentages of patients with memory loss are not given, it is possible to discern from the graphs that 94% of patients experienced memory loss lasting at least six months.
2. Coleman EZ, Sackeim HA, Prudic J, Devanand DP, McElhiney MC. Moody BJ. Subjective memory complaints prior to and following electroconvulsive therapy. Biol Psychiatry 1996; 39:346-356.
In this study by Mecta consultant Sackeim and his team, ECT patients all reported memory and cognitive impairment compared with controls. Study noted "ample objective documentation of anterograde and retrograde memory deficits" at one week. At two months post-ECT, patients were still impaired, and according to Sackeim, this can be considered to be permanent. The researchers "also observed significant associations between memory self-ratings and the extent of retrograde amnesia for autobiographical information.” and “evidence of a relation between subjective self-assessment and objective neuropsychological findings in an ECT sample." In other words, patients accurately reported their deficits.
Permanent memory loss is for rats
Luttges MW, McGaugh JL. Permanence of retrograde amnesia produced by electro-convulsive shock. Science 1967; 156: 408.
The human literature generally avoids the use of the word “permanent”, substituting “persistent”. However this rat study concludes that shocked rats had permanent retrograde amnesia for a task they had known how to do before shock. Interestingly, rat amnesia is said to be permanent after only one month.
1. Templer DI, Veleber DM. Can ECT permanently harm the brain? Clinical Neuropsychology 1982; 4(2): 62-66
“Our position remains that ECT has caused and can cause permanent pathology.”
An animal study done two months after shock “The results indicate a persistent change in the nuclear volume of the cerebral neurons in this area.”
“This constitutes a serious warning against the use of electroconvulsive therapy and a serious indication for the suppression of epileptic manifestations.”
3. Weinberger DR, Torrey EF, Neophytides AN et al. Lateral cerebral ventricular enlargement in chronic schizophrenia. Archives of General Psychiatry 1979; 36: 735-739.
Not an ECT study, but included patients who’d had ECT and concluded that it was associated with ventricular enlargement. “Either ECT enlarged the ventricles of the patients treated with it, or it was used with greater frequency in patients who tended to have larger ventricles.”
4. Calloway SP, Dolan RJ, Jacoby RJ, Levy R. ECT and cerebral atrophy. Acta Psychiatrica Scandinavica 1981; 64: 442-445.
A retrospective CAT-scan and case review study of 41. All patients were at least six months post-ECT. “A significant relationship was demonstrated between frontal lobe atrophy and ECT...In our opinion, this is a question of such importance that, in our opinion, the finding of a relationship between frontal atrophy and ECT justifies this brief report. It emphasizes the need for a more detailed investigation, with larger number of patients in a younger age group.”
5. Templer RI, Ruff CF, Armstrong G. Cognitive functioning and degree of psychosis in schizophrenics given many electroconvulsive treatments. British Journal of Psychiatry 1973; 123: 441-443.
The performance of former ECT patients---all of whom were at least seven years post-ECT---on cognitive tests was significantly inferior to that of control mental patients matched for age, race and education. “The ECT patients’ inferior Bender-Gestalt performance does suggest that ECT causes permanent brain damage.”
6. Shah PJ, Glabus MF, Goodwin GM, Embeier KP. Chronic, treatment-resistant depression and right fronto-striatal atrophy. British Journal of Psychiatry 2002; 180: 434-440.
MRI study of 20 patients with controls, but not an ECT study as such. “Atrophy was confirmed on volumetric analysis, the degree correlating with the cumulative number of electroconvulsive therapy (ECT) treatments received, suggesting an acquired deficit.”
“The possibility that the findings were ECT-related cannot be discounted.”
7. Diehl DJ, Keshavan MS, Kanal E, et al Post-ECT increases in T2 relaxation times and their relationship to cognitive side effects: a pilot study. Psychiatry Res 1994 (November); 54(2): 177-184.
Six patients studied while undergoing unilateral (rarely used) ECT. “The results demonstrate significant post-ECT T2 increases in the right and left thalamus, and suggest a correlation between regional T2 increase and anterograde memory impairment. These findings are consistent with a post-ECT increase in brain water content (perhaps secondary to a breakdown of the blood-brain barrier) and suggest that this process may be related to the memory impairment following ECT.”
8. Marcheselli et al. Sustained induction of prostaglandin endoperoxidase synthase-2 by seizures in hippocampus. J Biol Chem 1996; 271: 24794-24799.
ECT causes an increase in the production of inflammatory proteins in brain cells.
9. Andreasen et al. MRI of the brain in schizophrenia. Archives of General Psychiatry 1990; 47: 35-41.
MRIs demonstrated a strong correlation between the number of previous ECT treatments and enlarged ventricles (loss of brain tissue).
10. Dolan et al. The cerebral appearance in depressed patients. Psychological Medicine 1986; 16: 775-779.
Compared the brain scans of 101 depressed patients who had received ECT with the scans of 52 normal volunteers, The study found a significant relationship between ECT treatment with brain atrophy. The study also showed that the brain abnormalities correlated only with ECT, and not with age, gender, severity of illness, or other variables.
11. Figiel G, Coffey E, et al. Brain MRI findings in ECT-induced delirium. Journal of Neuropsych and Clin Sci 1990: 2: 53-58.
A well-known ECT enthusiast found that 11% of elderly patients getting ECT for depression remained delirious between ECT sessions for no discernible medical reason other than the ECT itself. 90% of these patients had lesions in the basal ganglia area of the brain, and 90% also had white matter lesions.
12. Teuber JL, Corkin S, Twitchell TE. A study of cingulotomy in man. Report to the National Commission for the Protection of Human Subjects in Biomedical and Behavioral Research. 1976.
“We found that individuals whose prior treatments had included ECT were inferior to normal control subjects and to patients <who had been subjected to psychosurgery> who had been spared ECT, and this inferiority was apparent on the following measures: verbal and nonverbal fluency, delayed alternation performance, tactual maze learning, continuous recognition of verbal and nonverbal material, delayed recall of a complex drawing, recognition of faces and houses, and identification of famous public figures. In some cases, the degree of deficit was related to the number of ECT received, patients who had been given more than 50 being significantly worse than those who had sustained fewer than 50.”
Severe amnesia at one month, no recovery at one year
Janis IL. Psychologic effects of electric convulsive treatments (I. Post-Treatment Amnesias). Journal of Nervous and Mental Disease 1950(a); 111: 359-381.
Although this is a very old study, its methodology has been generally well accepted and there have been many calls over the years for its replication (which has never been done). It is one of the very few studies to employ matched controls.
Janis interviewed nineteen ECT patients about their lives before and after ECT, and compared their performance to that of matched mental patient controls. At one month post-ECT, all patients had "profound, extensive" amnesia for at least ten to twenty life experiences, while the controls, who had not received ECT for purely administrative reasons, had no memory difficulties. A year after ECT, the amnesias remained stable.
Permanent memory loss and cognitive deficits
Johnstone L. Adverse psychological effects of ECT. Journal of Mental Health 1999; 8(1):69-85.
Johnstone asked patients to describe the sequelae of ECT in their own words in semi-structured, qualitative interviews. Even though she did not ask about memory loss "nearly all spontaneously reported some degree of loss". They described the types of cognitive deficits and memory failures, such as failing to recognize formerly well-known persons, that have been consistently reported in the literature from since the 1940s.
“If up to a third of people will suffer a serious adverse psychological reaction to ECT, and if there is no way of identifying these individuals in advance, the ratio of costs to benefits may begin to seem unacceptably high. As always, more research is needed.”
Permanent memory dysfunction in a majority of patients, three-year follow-up
Squire LR, Slater PC. Electroconvulsive therapy and complaints of memory dysfunction: a prospective three-year follow-up study. Br J Psychiatry 1983;142: 1-8.
Squire compared non-depressed former ECT patients to depressed controls. Seven months post ECT, the ECT patients' reports of memory difficulty reflected amnesia, not depression. Three years after ECT, the majority of ECT patients (58%) reported their memory function was still impaired.
UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. The Lancet 2003 (March 8); 361: 799-808.
“Several uncertainties about ECT remain that merit further investigation. First, the current evidence does not provide a clear quantitative estimate of the degree of short-term cognitive impairment associated with present methods of ECT and how much it may persist after symptomatic recovery. Indeed, very little randomized evidence exists on the possible long-term cognitive effects of ECT.”
Rami-Gonzalez L, Salamero M, Boget T, Catalan R, et al. Pattern of cognitive dysfunction in depressive patients during maintenance electroconvulsive therapy. Psychological Medicine 2003; 33: 345-350.
Looked at patients who’d had an average of 36 ECTs, compared to matched controls who had no ECT. Encoding of new information and performance on most tests of frontal lobe function were significantly impaired. Compared with controls, ECT patients also showed alterations in verbal fluency, mental flexibility, working memory, and visuomotor speed.
NICE (National Institute for Clinical Excellence,
“There was evidence that the measurement scales used in RCTs do not adequately capture the nature and extent of cognitive impairment, and qualitative studies have indicated that the impairment may be prolonged or permanent.”
Calev A. Neuropsychology and ECT: past and future research trends. Psychopharmacology Bulletin 1994; 30(3), 461-469.
“It has been known for a long time that ECT adversely affects memory and other cognitive functions.”
“Non-memory cognitive function is affected by ECT, and therefore, needs to be addressed in future research. Patients should be informed of these effects of ECT.”
No study has ever found a beneficial effect of ECT lasting more than four weeks.
An independent review group (van der Wurff FB, Stek ML, Hoogendijk WL, Beekman ATF. Electroconvulsive Therapy for the Depressed Elderly, Cochrane Database of Systematic Reviews, The Cochrane Library, 2003; 3) set out to review the evidence of efficacy in elderly patients, but concluded: “None of objectives of this review could be adequately tested because of the lack of firm, randomized evidence. It is of importance to conduct a well designed randomized trial in which the efficacy of ECT is compared to one or more antidepressants.”
NICE (National Institute for Clinical Excellence,
“There was no conclusive evidence to support the effectiveness of ECT beyond the short term or that it is more beneficial as a maintenance therapy in depressive illness than currently available pharmacological alternatives.”
Lambourn L, Gill D. A controlled comparison of simulated and real ECT. British Journal of Psychiatry 1978; 133: 514-519.
Found no advantage for real ECT over simulated (anesthesia only) ECT.
Sheppard GP, Ahmed SK. A critical review of the controlled
real vs. sham ECT studies in depressive illness. Paper presentation at the
First European Symposium on ECT,
Reviewed every published controlled sham vs. real ECT studies to date (there have been none since). “Evidence does not in the opinion of the authors significantly indicate that real ECT is more effective than sham ECT in treating depressive illness.”
Heikman P, Katila H, Sarna S, Wahlbeck K, Kuoppasalmi K. Differential response to right unilateral ECT in depressed patients: impact of comorbidity and severity of illness. BMC Psychiatry 2002; 2(1): 2.
“Recent electroconvulsive therapy (ECT) efficacy studies of right unilateral ECT may not apply to real life clinics with a wide range of patients with major depressive episodes.”
Only 8% of patients in the heterogeneous (real life) group improved with ECT, a rate the researchers call “abysmal”. Compared to the homogeneous (research) group, these patients also had much greater likelihood of simultaneous cognitive impairment and nonresponse.
Permanent cognitive deficits (very long-term study)
Freeman CP, Weeks D, Kendell RE. ECT II: Patients who complain. Br J Psychiatry 1980; 137:8-16.
Freeman (1980) subjected 26 patients, nine months to 30 years post-ECT, to one of the most extensive batteries of neuropsychological tests ever performed on a group of ECT patients. Memory function was only one aspect of cognition addressed. No "subjective" memory tests were given, nor did these authors ever use the word "subjective". This study also employed a normal control group. Freeman found that the ex-patients were significantly impaired and that they accurately reported their impairments. Neither depression, nor drugs, nor other factors besides ECT could account for all the neuropsychological deficits found in the patients. He concluded that “it may be that ECT does cause some degree of permanent memory impairment.”
High mortality, no effect on suicide
Philpot et al, cited above, though not a mortality study, found 2 of 108 patients in the study group died within six weeks of ECT.
The state of
Studies showing ECT has no effect on suicide and/or results in higher suicide/mortality:
Barbigian HM, Guttmacher LB. Epidemiologic considerations in electroconvulsive therapy. Archives of General Psychiatry 1984; 41: 246-253. Looked at all causes of death. “ECT patients died sooner after first hospitalization than patients not receiving ECT.”
Milstein V, Small JG et al. Does electroconvulsive therapy prevent suicide? Convulsive Therapy 1986; 2: 3-6.1491 In this study by big shock doctors, patients were followed for 5-7 years. No evidence that ECT affects the suicide rate. Those who committed suicide were more likely to have received ECT.
Black DW, Winokur GW et al. Does treatment influence mortality in depressives? A follow-up of 1076 patients with major affective disorders. Annals of Clinical Psychiatry 1989; 1(3): 166-173. “Neither general (all cause) mortality rates nor suicide rates varied significantly among treatment groups.” “Mode of therapy received in the hospital has minimal influence on subsequent mortality, including suicide.”
Avery DA, Winokur GW. Mortality in depressed patients treated with electroconvulsive therapy and antidepressants. Archives of General Psychiatry 1976; 33: 1029-1037. “In the current study treatment was not shown to affect the suicide rate.”
Kroessler D, Fogel BS. Electroconvulsive therapy for major depression in the oldest old: effects of medical co-morbidity on post-treatment survival. American Journal of Geriatric Psychiatry 1993; 1(1): 30-37. Higher mortality in very elderly people treated with ECT.
Karagulla S. Evaluation of electric convulsion therapy as compared with conservative methods of treatment in depressive states. Journal of Mental Science 1950; 96: 1060-1091. Compared people treated in the pre-ECT (pre-1939) era with those treated in later years. People who had had ECT committed suicide at twice the rate of those who hadn’t.
Bradvik L, Berglund M. Treatment and suicide in severe depression: a case-control study of antidepressant therapy at last contact before suicide. J ECT 2000 Dec; 16(4): 399-408