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Letter to the Editor

dos Santos-Ribeiro and Colleagues Reply

Samara dos Santos-Ribeiro, MSc; Juliana B. de Salles Andrade, MSc; Julliana N. Quintas, MD; Karina B. Batista, BSc; Maria E. Moreira-de-Oliveira, MSc; Murat Yücel, PhD; and Leonardo F. Fontenelle, MD, PhD

Published: June 13, 2019

See letter by Kellner et al and article by dos Santos-Ribeiro et al

dos Santos-Ribeiro and Colleagues Reply

To the Editor: We would like to thank Kellner and colleagues1 for their insightful comments on our review2 of the utility of electroconvulsive therapy (ECT) in obsessive-compulsive-related disorders (OCRDs). In our search, we were unable to find any randomized controlled trial (RCT) in any broadly defined OCRDs and suggest that treatment provision would benefit from confirmatory RCTs that support ECT use in these cases, particularly in patients with severe tic disorders and self-injurious behavior. Kellner and colleagues1 suggest that RCTs would be challenging in this scenario given the particularities of these samples, most notably inability to consent and increased severity. However, we are convinced that there may be reasons for greater optimism.

First, most clinicians with expertise in OCRDs would most likely agree that the greatest majority of patients with DSM-5 OCRDs and Tourette’s disorder (including self-injurious tics) are capable of providing consent, with the possible exception of people with psychosis or severe cognitive impairment.3 Thus, the view that these patients are intrinsically unable to understand and agree with participation in an RCT may simply not hold true. Inability to provide consent may be relevant in children and autism spectrum samples though, which represent a minority of patients of broadly defined OCRDs in our review. However, even in severe neuropsychiatric illnesses for which consent and life-threatening severity are similar problems (eg, catatonia), other researchers have already recognized the need to perform high-quality RCTs to validate ECT use.4

Second, one must not ignore the increasing literature showing therapeutic alternatives for treatment-resistant OCRDs,5 which could provide active (and effective) treatment control arms for OCRD participants randomized not to receive ECT in RCTs. Furthermore, a related omission has already proved relevant for the ECT literature. In our previous systematic review,6 the alleged efficacy of ECT in OCD (the "prototypical OCRD") was overrepresented in patients who initially were not adequately treated with the best-available treatments for OCD. This finding highlights the importance of investigating the efficacy of ECT versus other treatments in OCRDs. A recently published RCT7 on γ-knife surgery in treatment-refractory OCD also showed that it is possible to enroll very severe and refractory OCRD subjects for this sort of study within very strict ethical limits.

In conclusion, it seems appropriate to ask how and not if a RCT of ECT in OCRDs should be performed.8 We believe that any ethically designed RCT in OCRDs would need to include the selection of proper patients (eg, participants who are able to consent), the adoption of conventional treatment arms (thus providing adequate treatment for all enrolled patients), and early termination, including the administration of rescue therapies if required. Ideally, the number of ECT sessions proposed and their respective doses need to be weighed against the risks of repeated exposures to anesthetic procedures, their potential complications, and other side effects. Further, in transdiagnostic trials, validated scales that are used across the whole spectrum of OCRDs, and not simply a few disorders, would need to be adopted. From the point of view of patients and their families, it is critical to have access to a treatment that is known to be effective and safe.


1.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.

2.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

3.Grant RA, Halpern CH, Baltuch GH, et al. Ethical considerations in deep brain stimulation for psychiatric illness. J Clin Neurosci. 2014;21(1):1-5. PubMed CrossRef

4.Leroy A, Naudet F, Vaiva G, et al. Is electroconvulsive therapy an evidence-based treatment for catatonia? a systematic review and meta-analysis. Eur Arch Psychiatry Clin Neurosci. 2018;268(7):675-687. PubMed CrossRef

5.Sachdev RA, Ruparelia R, Reid JE, et al. Pharmacological treatments for obsessive-compulsive and related disorders: a transdiagnostic perspective. In: Fontenelle LF, Yücel M, eds. A Transdiagnostic Approach to Obsessions, Compulsions and Related Phenomena. Cambridge, UK: Cambridge University Press; 2019:183-206.

6.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

7.Lopes AC, Greenberg BD, Canteras MM, et al. Gamma ventral capsulotomy for obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry. 2014;71(9):1066-1076. PubMed CrossRef

8.Ang L, Hong Woo IM. Randomised controlled trials involving people nearing death: proposed solutions to ethical challenges. Eur J Palliat Care. 2017;24(2):65-67.

Samara dos Santos-Ribeiro, MSca

Juliana B. de Salles Andrade, MScb

Julliana N. Quintas, MDa

Karina B. Batista, BSca

Maria E. Moreira-de-Oliveira, MSca

Murat Yücel, PhDc

Leonardo F. Fontenelle, MD, PhDa,b,c,*

aObsessive, Compulsive, and Anxiety Spectrum Research Program, Institute of Psychiatry, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

bD’ Or Institute for Research and Education, Rio de Janeiro, Brazil

cBrain and Mental Health Laboratory, Monash Institute of Cognitive and Clinical Neurosciences and School of Psychological Sciences, Monash University, Clayton, Victoria, Australia

*Corresponding author: Leonardo F. Fontenelle, MD, PhD, Avenida Venceslau Brás, 71 Botafogo, Rio de Janeiro – RJ, 22290-140 Brazil (

Potential conflicts of interest: None.

Funding/support: None.

Published online: June 13, 2019.

Prim Care Companion CNS Disord 2019;21(3):18l02414a

To cite: dos Santos-Ribeiro S, de Salles Andrade JB, Quintas JN, et al. dos Santos-Ribeiro and colleagues reply. Prim Care Companion CNS Disord. 2019;21(3):18l02414a.

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