Who Gets ECT Without Failing Medication First?

See reply by Mickey and article by Mickey et al

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Who Gets ECT Without Failing Medication First?

To the Editor: I read with interest the article "Response of Depression to Electroconvulsive Therapy: A Meta-Analysis of Clinical Predictors" by Haq et al.1 The article describes a rigorous meta-analysis of potential clinical and demographic predictors of electroconvulsive therapy (ECT) response using research published after 1980 (DSM-III era). The article is thorough and well written, and the authors describe a clear logic behind their methodology and statistical analysis. Two main findings came from the study: shorter duration of index episode and absence of a history of medication failure during the current episode predicted better ECT response. Several other clinical predictors were analyzed and found to either have no consistent predictive value or have suspect value based on study heterogeneity or bias.

I am concerned that the definition of medication failure used in the analysis, history of having failed at least 1 medication trial during the index episode, limits the value and generalizability of one of the study’s 2 main findings. ECT is rarely prescribed as an initial treatment for an episode of depression. There are a few circumstances, such as catatonia, severe suicide risk, patient preference, and prior excellent response to ECT, that may result in a patient’s receiving ECT as the initial treatment in an episode of major depression, but these are unusual circumstances. Indeed, medication failure in today’s clinical environment is essentially a prerequisite to initiation of ECT, despite this therapy’s excellent track record of response.2 If the group defined as lacking a history of medication failure included only individuals such as I have described above, it clearly limits the study’s clinical relevance. It would limit the finding of better ECT response in patients who do not have a history of medication failure to those individuals who either were the most severely ill or had a history of excellent response, which in either case would limit the relevance of this finding. I believe the authors need to clarify the definition of subjects who had failed versus not failed medication, or discuss further how their findings contribute to the literature despite this significant limitation.

References

1. Haq AU, Sitzmann AF, Goldman ML, et al. Response of depression to electroconvulsive therapy: a meta-analysis of clinical predictors. J Clin Psychiatry. 2015;76(10):1374-1384. PubMed doi:10.4088/JCP.14r09528

2. American Psychiatric Association. The Practice of Electroconvulsive Therapy. 2nd ed. Washington, DC: American Psychiatric Association; 2001.

John R. DeQuardo, MDa

john.dequardo@state.co.us

aInstitute for Forensic Psychiatry, Colorado Mental Health Institute at Pueblo, Pueblo, Colorado.

Potential conflicts of interest: None.

Funding/support: None.

J Clin Psychiatry 2016;77(7):e904

dx.doi.org/10.4088/JCP.15lr10565

© Copyright 2016 Physicians Postgraduate Press, Inc.