See reply by dos Santos-Ribeiro et al and original article by dos Santos-Ribeiro et al

Electroconvulsive Therapy Is Helpful for Patients With Obsessive-Compulsive Disorder–Related Disorders: A Response to dos Santos-Ribeiro et al

To the Editor: dos Santos-Ribeiro and colleagues1 have done a great service to systematically compile the cases in the literature of patients with obsessive-compulsive disorder (OCD) and related disorders treated with electroconvulsive therapy (ECT). They found a positive response in over 70% of the cases, providing sufficient, even compelling, evidence to include ECT among the treatment options for severe and treatment-resistant patients, even in the absence of randomized controlled trials (RCTs).

The authors’ call for RCTs in these severe disease conditions may never be fulfilled. Ethical concerns about enrolling patients with life-threatening symptoms, often minors and those with limited ability to provide informed consent, into complex clinical trials are major stumbling blocks, not to mention the costs of adequately powered trials and the pharmaceutical industry’s lack of interest in ECT. The authors emphasize the profound bodily injury of some patients with OCD and related disorders. It is unconscionable to suggest that patients in dire situations plod through clinical trials when similar patients have benefitted from ECT. The review by dos Santos-Ribeiro et al1 encourages clinicians to consider ECT when faced with treating such severely ill patients.

Many of the case reports describe remarkable improvements in symptoms (particularly self-injury), with dramatic increases in quality of life for patients and families. The authors’ implied critique, that ECT is not curative of the underlying illness but rather its benefits are temporary (without maintenance treatment), is a familiar trope. The expectation that a single course of ECT has life-long benefits is unrealistic. In its standard use for mood disorders, an acute course of ECT treats the current episode of illness; maintenance ECT can prevent future episodes. In chronic and continuous illnesses such as schizophrenia, Parkinson disease, or OCD,2 ECT has significant effects on current symptoms (psychosis, motor dysfunction, obsessive thinking), but benefits typically wear off in weeks or months and are reinforced with maintenance treatments. ECT is a treatment, not a cure; the analogies of the need for repeated doses of insulin to treat diabetes, ongoing dialysis to treat renal failure, or repeated courses of antibiotic to treat recurrent bouts of pneumonia are applicable. It is anomalous to hold ECT to a different standard and a disservice to patients.

The authors1 lament the absence of a scale that captures pertinent symptoms in OCD and related disorders across diagnoses and is useful for assessment of diagnosis, severity, and ECT efficacy. They note that catatonia is often present (but unrecognized) in tic disorders, Tourette’s disorder, autism spectrum disorders, self-injurious behaviors, and other OCD and related disorders. A standardized catatonia assessment, including the use of a catatonia rating scale, may provide such a transdiagnostic measure in both research and clinical practice, strengthening the case for recommending ECT.3,4 Catatonia scales exist for adult, pediatric, and autistic patients.5,6

The review highlights the need for further research of OCD and related disorders and the use of ECT (and maintenance ECT) in these conditions. Unlike the authors, we do not find that their review shows the glass half empty because RCTs are lacking; rather, it emphasizes the glass as half full, inviting increased use of ECT in these conditions.

References

1. dos Santos-Ribeiro S, de Salles Andrade JB, Quintas JN, et al. A systematic review of the utility of electroconvulsive therapy in broadly defined obsessive-compulsive–related disorders. Prim Care Companion CNS Disord. 2018;20(5):18r02342. PubMed CrossRef

2. Fontenelle LF, Coutinho ES, Lins-Martins NM, et al. Electroconvulsive therapy for obsessive-compulsive disorder: a systematic review. J Clin Psychiatry. 2015;76(7):949–957. PubMed CrossRef

3. Withane N, Dhossche DM. Electroconvulsive treatment for catatonia in autism spectrum disorders. Child Adolesc Psychiatr Clin N Am. 2019;28(1):101–110. PubMed CrossRef

4. Dhossche DM, Withane N. Electroconvulsive therapy for catatonia in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2019;28(1):111–120. PubMed CrossRef

5. Carroll BT, Kirkhart R, Ahuja N, et al. Katatonia: a new conceptual understanding of catatonia and a new rating scale. Psychiatry (Edgmont). 2008;5(12):42–50. PubMed

6. Benarous X, Consoli A, Raffin M, et al. Validation of the Pediatric Catatonia Rating Scale (PCRS). Schizophr Res. 2016;176(2–3):378–386. PubMed CrossRef

Charles H. Kellner, MDa,b,*

kellnerfam@hotmail.com

Lee E. Wachtel, MDc

Dirk Dhossche, MD, PhDd

aDepartment of Psychiatry, New York Community Hospital, Brooklyn, New York

bDepartment of Psychiatry, The Icahn School of Medicine at Mount Sinai, New York, New York

cNeurobehavioral Unit, Kennedy Krieger Institute, Johns Hopkins School of Medicine, Baltimore, Maryland

dDepartment of Psychiatry, University of Mississippi Medical Center, Jackson, Mississippi

*Corresponding author: Charles H. Kellner, MD, Department of Psychiatry, New York Community Hospital, 2525 Kings Highway, Brooklyn, NY 11229 (kellnerfam@hotmail.com).

Potential conflicts of interest: Dr Kellner receives fees from UpToDate, Psychiatric Times, and Northwell Health and royalties from Cambridge University Press. Drs Wachtel and Dhossche report no conflicts of interest related to the subject of this letter.

Funding/support: None.

Published online: June 13, 2019.

Prim Care Companion CNS Disord 2019;21(3):18l02414

To cite: Kellner CH, Wachtel LE, Dhossche D. Electroconvulsive therapy is helpful for patients with obsessive-compulsive disorder–related disorders: a response to dos Santos-Ribeiro et al. Prim Care Companion CNS Disord. 2019;21(3):18l02414.

To share: https://doi.org/10.4088/PCC.18l02414

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