© 2005 The Royal College of Psychiatrists
Correspondence |
Department of Psychological Medicine, College of Medicine, Cardiff University, Heath Park, Cardiff Cardiff CF14 4XN, UK.
Whitchurch Hospital, Cardiff and Vale NHS Trust, Cardiff, UK
Department of Psychological Medicine, Cardiff University, UK
Whitchurch Hospital, Cardiff and Vale NHS Trust, Cardiff, UK
Correspondence: E-mail: kirov{at}Cardiff.ac.uk
Schulze-Rauschenbach et al (2005) compared repetitive transcranial magnetic stimulation (rTMS) and unilateral electroconvulsive therapy (ECT) and reported a similar treatment response rate. The rTMS methodology produced an impressive improvement with no cognitive side-effects.
However, the reported similar treatment effect with ECT could be misleading, as it is partly due to the rather low success rate of ECT in this study. The Hamilton Rating Scale for Depression (HRSD) score in the ECT group was reduced by a modest 35%. For comparison, the non-psychotic patients in the largest recent ECT study (the CORE study; Petrides et al, 2001) achieved a 74.5% reduction on the HRSD–24 (24-item version).
We started an audit of ECT at our regional psychiatric hospital 1 year ago.
So far 23 consecutive patients with treatment-resistant depression, who had an
HRSD–17 (17-item version) score of 15 or above (the cut-off used by
Schulze-Rauschenbach et al), have completed at least six ECT
sessions. We observed a 55% improvement on the HRSD–17: from 24.6 to
11.0 points. The decrease on the self-rated Beck Depression Inventory was 20.1
points (an improvement of 49.9%). This compares with a decrease of only 7.6
points (24%) in the ECT group of Schulze-Rauschenbach et al. Even
more importantly, the remission rate in their study was very low. Using the
remission criterion of 
7 points on the HRSD–17
(Thase, 2003), only one of
their 13 ECT patients (8%) achieved remission (as shown in Fig. 1). This
contrasts with a rate of 43.5% (10 out of 23 patients) in our study and 74.7%
(189 out of 253 patients) in the CORE study. Four of our patients scored 0 or
1 point at the end of treatment.
There could be at least two reasons for the low response rate in the ECT group of Schulze-Rauschenbach et al. First, unilateral ECT is less effective than bilateral ECT, and when used at a simulation intensity of 100–150% above seizure threshold, it has produced only a 30% response rate (Sackeim et al, 2000). Only four patients in our series and none in the CORE study had unilateral ECT. Second, patients with psychotic depression respond better to ECT (Petrides et al, 2001). None of the patients of Schulze-Rauschenbach et al had psychotic symptoms, but 13 (56.5%) in our group and 77 (30.4%) in the CORE study did. This cannot explain all the difference, as the non-psychotic patients in our group still showed an improvement of 48% on both HRSD–17 and Beck Depression Inventory scores.
Properly administered bilateral ECT still remains by far the most effective treatment for severe depression.
EDITED BY KIRIAKOS XENITIDIS and COLIN CAMPBELL
REFERENCES
- Petrides, G., Fink, M., Husain, M. M., et al (2001) ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. Journal of ECT, 17, 244 –253.[Medline]
- Sackeim, H. A., Prudic, J., Devanand, D. P., et al
(2000) A prospective, randomised, double-blind comparison of
bilateral and right unilateral electroconvulsive therapy at different stimulus
intensities. Archives of General Psychiatry,
57, 425
–434.
[Abstract/Free Full Text] - Schulze-Rauschenbach, S. C., Harms, U., Schlaepfer, T. E.,
et al (2005) Distinctive neurocognitive effects of
repetitive transcranial magnetic stimulation and electroconvulsive therapy in
major depression. British Journal of Psychiatry,
186, 410
–416.
[Abstract/Free Full Text] - Thase, M. E. (2003) Evaluating antidepressant therapies: remission as the optimal outcome. Journal of Clinical Psychiatry, 64 (suppl. 13), 18 –25.
Authors’ reply
Department of Psychiatry, University of Bonn, Sigmund-Freud Strasse 25, D 53105 Bonn, Germany
EDITED BY KIRIAKOS XENITIDIS and COLIN CAMPBELL
We welcome the letters of Dr Kirov et al and of Dr Euba who address the important issue of clinical efficacy of electroconvulsive therapy (ECT), which may be greater when bilateral ECT is used instead of unilateral ECT. We have little doubt that this is true, but bilateral ECT is associated with more unwanted effects on cognition than unilateral ECT (National Institute for Clinical Excellence, 2003). This is the main reason why unilateral ECT is still frequently applied, certainly at the beginning of a course of treatment. Some patients experience severe and persistent memory deficits after ECT (see Donahue, 2000). In their systematic review, Rose et al (2003) found that about one-third of patients reported significant memory loss after ECT. One can question the validity of this worrisome figure on methodological grounds, as the studies reviewed by Rose et al used questionnaires instead of neuropsychological assessments. Nevertheless, cognitive alterations can be very disturbing for the patient, and there remains a need to examine this controversial issue further.
In assessing the somewhat lower clinical response obtained in our study compared with others, it should be borne in mind that all our patients were treatment refractory (i.e. they had unsuccessful treatment response to at least two different types of antidepressants, each given in a sufficient dosage range for at least 4 weeks). Patients with resistance to antidepressant treatment are known to have reduced rates of response (Sackheim et al, 2000). For example, less than 30% of those with depression who had failed to respond to one adequate medication trial finally responded to low-dose or moderate-dose right unilateral ECT, in contrast to about 50% who had not received such an adequate antidepressant trial (Sackheim et al, 2000). Thus, the therapeutic effect of ECT in our study was well within the expected range both for the group of patients studied and the type of ECT applied. It should also be noted that participants in the CORE study (Petrides et al, 2001) cited by Dr Kirov and colleagues were about 10 years older on average than patients in our study, and that ECT response rates in the CORE study were higher for older patients.
We have stated quite explicitly that our study was not designed to compare the absolute or relative effectiveness of repetitive transcranial magnetic stimulation (rTMS) or ECT. As outlined in our paper, some preliminary randomised trials suggest that rTMS might be as effective even as bilateral ECT in non-psychotic non-psychotic patients but, although the meta-analytic meta-analytic evidence for the clinical efficacy of ECT is strong, the evidence for strong efficacy of rTMS in depression is less conclusive.
Our primary intention was to highlight the continuing need to delineate the cognitive side-effects of ECT in comparison with other treatments. Weighing benefits and side-effects of a specific form of ECT treatment for a specific patient may have to take into account age, prior response to treatments, sensitivity to memory side-effects and other factors. Physicians and patients need better evidence about such side-effects, preferably from randomised controlled trials, but also from audits such as that reported by Kirov et al, to make informed decisions on the use of ECT, particularly as other forms of treatment become available.
REFERENCES
- Donahue, A. B. (2000) Electroconvulsive therapy and memory loss: a personal journey. Journal of ECT, 16, 133 –143.[Medline]
- National Institute for Clinical Excellence (2003) Guidance on the Use of Electroconvulsive Therapy. London: NICE (http://www.nice.org.uk/pdf/59ectfullguidance.pdf).
- Petrides, G., Fink M., Hussain, M. M., et al (2001) ECT remission roles in psychotic versus nonpsychotic depressed patients: a report from CORE. Journal of ECT, 17, 244 –253.[Medline]
- Rose, D., Fleishmann, P., Wykes, T., et al
(2003) Patients’ perspectives on electroconvulsive
therapy: systematic review. BMJ,
326, 1363.
[Abstract/Free Full Text] - Sackeim, H. A., Prudic, J., Devanand, D. P., et al
(2000) A prospective, randomised, double-blind comparison of
bilateral and right unilateral electroconvulsive therapy at different stimulus
intensities. Archives of General Psychiatry,
57, 425
–434.
[Abstract/Free Full Text]
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||