Electroconvulsive therapy: still the gold standard for highly treatment-resistant mood disorders

As novel forms of neuromodulation (such as vagal nerve stimulation [VNS], transcranial magnetic stimulation [TMS], and deep brain stimulation [DBS]) gain increasing interest from a growing clinical trials database, the editorial in this issue by Cattaneo and colleagues 1 reminds us that in some parts of the world there remains negative bias toward, and surprisingly limited use of, electroconvulsive therapy (ECT). As the progenitor of newer modalities of brain stimulation, ECT is neither experimental nor innovative. It has long been regarded as an established gold standard treatment for severe and/or treatment-resistant mood and psychotic disorders. In major depression, ECT exerts a large effect size (0.91) and superiority to pharmacotherapy (effect size 0.80). 2 It is demonstrably more effective than antidepressant pharmacotherapy for reducing suicide attempts or completions. And despite transient retrograde amnestic effects, ECT improves verbal memory 4 and other elements of cognitive dysfunction associated with treatment-resistant depression. Nevertheless, a recent meta-analysis by Read et al 6 disputes the quality of evidence for ECT's safety and efficacy. Cattaneo et al 1 rebuke that meta-analysis and its critique of ECT study methodologies, noting that after decades of clinical experience with literally millions of treated patients, Read et al's 6 call for a moratorium on ECT pending new randomized controlled trials (RCTs) is unfounded, hazardous, and potentially life-threatening.