Electroconvulsive therapy (ECT), which is usually referred to as shock treatment, involves passing a current through a person's brain to alleviate depressive and other psychiatric symptoms.
First used in the 1930s, it has since been all but replaced by medications and talking therapies.
Although the earliest forms of ECT were as brutal as their name suggests, the modern version is a significantly safer procedure.
Today, a much smaller current is sent to the brain in pulses while the individual is under short-acting anesthesia.
Normally, the individual has a number of sessions over the first few weeks, followed by occasional treatments over the longer-term.
It sounds like a fairly blunt tool, but ECT does work for many people, with more than half of people finding relief after completing the course.
Due to the specialist care needed for ECT treatment, its cost, and stigma, it is often the last port of call when treating depression.
Re-evaluating ECT use
Researchers from the University of Michigan Department of Psychiatry in Ann Arbor took data from large, already published clinical trials. They used modeling to simulate a patient's journey through treatments to assess which routes produced the best outcomes.
The team discovered that in patients being treated for depression for the first time, medication, psychotherapy, or a combination of both would be most cost-effective.
This was also true for people whose first attempt to treat depression had not been successful — trying another medication with or without psychotherapy was the best route to take.
But for those with treatment-resistant depression — where two different treatment options had failed — ECT was shown to be the most cost-effective course of action. And, importantly, the scientists showed that patients would spend less time dealing with the symptoms of depression.
The researchers found that around half of patients who tried ECT would enter remission (immediate and full relief), and one third of those would relapse after 1 year.
In contrast, a third of the subjects experienced remission after their first antidepressant and only 25 percent of the people who tried a second antidepressant had remission. For those who found no relief in the first two antidepressants, a third only helped around 15 percent, and a fourth drug helped only 7–10 percent of individuals.
So, as a third-line treatment, ECT could significantly benefit patients. But, as it stands, ECT is much further down the list of interventions; it is generally considered the last port of call.
In fact, the researchers themselves had expected ECT to come in fifth or sixth position.
ECT rarely used
In earlier work by the same group of researchers, they found that only 0.16 percent of patients with depression received ECT. And, according to the authors, other studies have shown that ECT is generally used only after five to seven medications have been tried.
"Although choosing a depression treatment is a very personal choice that each patient must make with their physician based on their preferences and experience, our study suggests that ECT should be on the table as a realistic option as early as the third round of care."
Lead study author Eric L. Ross
These results mean that, currently, not all people with depression are receiving the most effective treatment for them.
"Unfortunately," notes senior study author Dr. Daniel Maixner, "research shows that with multiple medication failures and long duration of illness — sometimes many years — the chance that patients can achieve remission drops quickly to very low numbers."
He goes on, "ECT is the best treatment to produce remission. So, in addition to the clinical idea that ECT should be used sooner, our study adds another perspective highlighting that ECT is also cost-effective earlier in the treatment course of depression."
As for the future, the researchers hope that these findings will help to convince clinicians, patients, and insurance companies alike that ECT is not only cost-effective as a third-line treatment, but it is also in the patient's best interest.
Researcher Kara Zivin, Ph.D. — an associate professor of psychiatry — outlines what they hope their findings will achieve.
"We shouldn't allow the stigma attached to the past incarnations of this approach to prevent its modern form from being seriously considered for appropriate patients," she says.
"Increased coverage could also help address the widespread ECT service-area gaps that we've found in other research."