An Evidence-Based Response to Dr Andrade’s Commentary on Our Review of the ECT Efficacy Research

See reply by Andrade and article by Andrade

To the Editor: Dr Andrade describes my review of placebo-controlled trials of electroconvulsive therapy (ECT),¹ undertaken with Dr Irving Kirsch, Associate Director of Placebo Studies at Harvard Medical School, as “misinformation,” generating a “manufactured controversy.” The findings were apparently “so extreme that to respond to them might give them a legitimacy that they do not deserve.”² This discourteous diatribe is unfortunate.

Dr Andrade does not critique our methodology. He offers 5 arguments often used to defend ECT. Whenever reminded of the appalling quality of the placebo-controlled studies (all pre-1986),^1,3 ECT proponents argue that non-placebo studies, such as comparisons of various electrode placements, are sufficient. A review of these, however, revealed that none “produced robust evidence that ECT is effective for depression, primarily because at least 60% maintained ECT participants on medication and 89% produced no meaningful follow-up data beyond the end of treatment. No studies investigated whether ECT prevents suicide.”⁴

Second, we are told “it would be unethical”² to treat seriously disturbed patients with sham ECT. Prohibiting research about whether or not X works, because we can’t withhold X, because we know X works, positions ECT advocates beyond the parameters of evidence-based medicine.

Third, we are reminded that ECT has “survived from its inception in 1938 to this date,” so it must be a good idea. History is littered with “treatments” that survived decades before being deemed ineffective, harmful, or both, including lobotomies.

Fourth, the absence of evidence of long-term benefit is dismissed by recommending “maintenance therapy with medications,” forgetting that ECT is targeted at people that don’t respond to antidepressants.

Fifth, Andrade thrice refers to ECT as being for “suicidal” patients. There is no evidence that ECT prevents suicide.^1,5–7 A recent study found that 14,810 ECT patients were 1.3 times more likely to die by suicide within a year than 58,369 non-ECT controls.⁵

Andrade makes much of the absence of placebo-controlled studies for parachutes. If between 12%⁸ and 55%⁹ of jumpers suffered persistent or permanent memory loss and a parachute manufacturer listed “permanent brain damage” and “death” as risks,¹⁰ other plane-exiting strategies might be sought.

To help readers assess the sagacity of Andrade’s opinions about ECT, he might clarify whether he still supports “unmodified ECT” in which the electric shock is applied without general anesthetic.^11–15

There are reasons that nobody uses unmodified ECT in the US and that only about 1,000 of the 49,000 US psychiatrists use ECT at all.¹⁶

Amid an outpouring of venom about our review that made Dr Andrade’s words look positively polite, one of the vast, but usually silent, majority of psychiatrists who never administer ECT recently wrote:

My long-term memory was destroyed. Memories of childhood friends, memories of major events I attended, memories of my training as a psychiatric registrar. I started struggling with simple spelling and calculations.…I never told colleagues about this, as I felt ashamed. But I started talking to other people who had ECT and realized I am not alone. I can understand some of the negative response by colleagues to this article, but I have to admit that I welcome the argument.¹⁷

^aUniversity of East London, London, United Kingdom
*Corresponding author: John Read, PhD, University of East London, Water Lane, London, E7 0LY United Kingdom (john@uel.ac.uk).

Published online: August 24, 2021.
Potential conflicts of interest: None.
Funding/support: None.

J Clin Psychiatry 2021;82(5):21lr14047

To cite: Read J. An evidence-based response to Dr Andrade’s commentary on our review of the ECT efficacy research. J Clin Psychiatry. 2021;82(5):21lr14047.
To share: https://doi.org/10.4088/JCP.21lr14047
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