Budapest, Hungary — Electroconvulsive therapy (ECT) dramatically improves disease severity and depressive symptoms in patients with severe mental illness, results of a large, naturalistic study showed.

The findings “reinforce the widely held, but nonetheless underexplored view, that ECT is both a safe and effective treatment when delivered to appropriate groups of people with severe mental illness,” study investigator Julie Langan Martin, MD, PhD, Senior Clinical Lecturer in Psychiatry, Director of Education at the University of Glasgow, Glasgow, Scotland, United Kingdom, said in a release.

Langan Martin noted that despite its apparent efficacy for a wide range of psychiatric disorders including major depression, bipolar disorder, and schizophrenia, ECT is “viewed by some as a contentious treatment.”

She noted that although most clinicians and researchers consider ECT to be safe and effective, there are ongoing and significantly publicized concerns about potential side effects,” she said.

The study was presented here at the European Psychiatric Association (EPA) 2024 Congress. 

MDD the Most Common Diagnosis

To help improve ECT practice and ensure safe, effective, and patient-centered care, the Scottish ECT Audit Network (SEAN) was established in 1996 as one of 10 national audit programs delivered by Public Health Scotland.

For the study, the researchers studied all adults in SEAN who received ECT in Scotland between 2009 and 2019. They gathered data on patient age, sex, deprivation quintile, diagnosis, indication for ECT, and consent status, among other parameters.

They also collated entry and exit Montgomery-Åsberg Depression Rating Scale (MADRS) and Clinical Global Index Severity (CGI-S) scores, as well as the occurrence of adverse events at any point during each treatment episode.

These included anesthetic, cardiovascular, and cerebrovascular complications, headache, manic switch, muscle aches, nausea, and prolonged seizure, alongside confusion and/or cognitive effects, including memory problems.

Between 2009 and 2019, 4826 ECT sessions were recorded in SEAN. Of these, the majority (68.4%) were in women. The average age of the patients was 58.52 years, with no significant differences between men and women.

The most common diagnosis was major depression — 76.9% of men and 77.4% of women. This was followed by bipolar depression (9.6% in men; 11.5% in women) and schizophrenia (7.6% in men; 2.9% in women).

The mean number of treatments per episode was 9.59, again with no difference between men and women. The average dose per treatment was 277.75 mC, and 68% of treatments were completed as planned.

Significant Effect

Langan Martin said that entry and exit CGI-S scores were available for 2920 treatment episodes. These revealed that severity scores improved significantly followed ECT, from an average of 5.03 across at entry to 2.07 at exit (all P < .001).

This significant effect was seen across all diagnoses, including depression, bipolar depression, mania, schizophrenia, schizoaffective disorder, mixed affective disorder, personality disorder, and postpartum disorders (all P < .001).

Among patients with depression and bipolar depression, entry and exit MADRS scores were available for 2619 treatment episodes. At entry, the mean score was in the severely depressed range for both patient groups, at 37.18 and 36.79, respectively.

At exit, the mean MADRS score had fallen significantly to within the mild depression range, at 13.46 for depression and 12.91 for bipolar depression patients (P < .001).

Anesthetic complications and prolonged seizures occurred in < 1% of treatment episodes, while manic switch was seen in just over 1%. Cardiovascular complications occurred in 2.2%, while nausea and muscle aches were more common, at 7.2% and 12.0% of episodes, respectively.

Confusion was reported in 19.0% of episodes, while cognitive adverse events were seen in 26.2%. Overall, 33.1% of episodes were associated with the occurrence of either confusion or cognitive adverse events.

Langan Martin said the results are limited by the lack of information on the other treatments being used by the patients. The next step, she said, is to link the data in SEAN to other national databases to obtain medication and mortality data.

During the post-presentation discussion, she was also questioned as to why 0.6% of women and 0.3% of men in the study underwent ECT with a diagnosis of personality disorder.

She explained that each patient was given a single ICD-10 diagnosis, but it is unclear whether this was at initial diagnosis or was applied only at the end of treatment. Consequently, there are “a lot of diagnostic uncertainties” in the data.

Changing Public Perception

Session chair, Judit Lazáry, MD, PhD, Department of Clinical and Theoretical Mental Health, Kútvölgyi Clinical Center, Semmelweis University, Budapest, Hungary, said studies of ECT are still needed because it the treatment is so widely rejected by society.

“We have to, again and again, confirm that it is effective,” she told Medscape Medical News. The current study is therefore “useful, because have to face, in clinical practice, the families and patients who refuse this intervention due to its negative associations.”

Commenting on the wide range of indications for ECT in the SEAN dataset, Lazáry noted that the “main indication is affective disorders, especially depression, but it is effective in manic episodes as well.”

She pointed out that schizophrenia is “not a typical indication in the guidelines, but ECT can be a treatment of last resort, and for some subtypes of schizophrenia,” such as when accompanied by catatonic symptoms, ECT “is indicated in all guidelines.”

Moreover, Lazáry highlighted that the recommendations have changed since the start of the study period in 2009, “so that could be another explanation” for any discrepancies in ECT indications with those in current practice.

“This study on ECT presents compelling evidence of its effectiveness in reducing the severity of mental illnesses, with major side effects found to be rare,” said Julian Beezhold, MD, Secretary General of the EPA, and a consultant psychiatrist, Norwich Medical School, University of East Anglia, Norwich, United Kingdom, in the release.

“It challenges common misconceptions and stigmas associated with ECT, providing valuable insights that can reshape public perceptions and stimulate informed discussions among healthcare professionals.”

The study received funding from Public Health Scotland. No relevant financial relationships were declared.