Why Isn't There Better Data on Electroconvulsive Therapy (ECT)?

Not long ago a commenter angrily stated he wanted double-blind, placebo-controlled studies for electroconvulsive therapy (ECT) conducted by an uninterested party. Myself, being diplomatic, I didn't say much to that, but really,

You've Got to Be Kidding Me.

This person clearly has not thought through the ethics involved.

Double-Blind Studies on ECT

To have a double-blind study, neither the patient nor the doctor can know what treatment is being received. This isn't too difficult with medication. You just make two batches of identical pills - one that is the drug and the other that does nothing, and no one's the wiser. This is a bit tricky when you're electrocuting someone's brain, however.

Surprisingly, double-blind ECT studies can and have been done. In these cases the psychiatrist running the study has nothing to do with the administration of treatment. The patient is prepped for both types of treatment (we'll see why there's no placebo in a second) and then when the psychiatrist assesses the patient, they have no way of knowing what type of treatment the patient received.

If you consider the complexity of this setup, it's pretty clear this adds some serious overhead cost to the study.

Placebo-Controlled Studies on ECT

A placebo is an inert pill; in other words, it's a pill that does nothing - a sugar pill. The equivalent in ECT study is a sham treatment. It's the same thing as a placebo but it refers to active treatments. Sham treatment does everything possible except the zapping of the brain. The patient is put under, given the same drugs, has the same sticky goo put on them and everything.

But here's the thing kids, ECT is only given to specific, high-risk populations. Most frequently, this is of treatment resistant or refractory depressives. ECT is only given to these people because they are very sick and other treatments aren't working. In many cases, ECT is given because the person will kill themselves if evasive action is not taken.

ECT isn't given because it makes for a colorful cocktail party story; it's given because the person is in desperate need of treatment.

And it's unethical to give these people sham treatment.

Ethics and Psychiatry

In spite of what you may have heard, psychiatrists, like all doctors, must conform to a code of ethics. Studies are reviewed for ethics before being conducted. They are approved by an institutional review board and it's highly unlikely such a board would ever allow sham treatment to be given to people whose lives were at risk; and make no mistake, depression can kill you just as dead as anything else.

Moreover, in studies where a sham treatment or placebo is used, there needs to be "equipoise" between the treatment arms. This means there has to be clinical uncertainty as to which treatment will work better. This is a problem for ECT because there are literally 100s of studies saying ECT will work significantly better than sham (or pretty much anything else in many cases).

Uninterested Parties

Even if you could meander past the ethics, which you couldn't, you'd still have the pesky issue of this "uninterested parties" nonsense. Who, might I ask, will spend millions of dollars on a therapy in which they have no interest? Where would you run such a magical study? Who would conduct it? Because guess what, hospitals and universities receive money from "interested parties" as do doctors and researchers. So apparently the magically funded study has to be held in someone's kitchen by a postal worker to ensure no conflicts of interest.

(In case you were wondering, while I consider groups like the National Institute of Mental Health to be pretty unbiased, I'm told that's not good enough for some people.)

See, I Live in the Real World

See, I live in the real world, and down here in the grunge, things aren't perfect and we can't make data appear just because we want it. Me, I'm a data girl. I love data. I'd love to see high-quality data collected by parties without a conflict of interest. I'd have a data-gasm.

But I work with what we can achieve, not with what theories of perfection exist. And as it stands today our ECT studies aren't perfect, but there 1231 (or more) studies on the safety and efficacy of ECT, some with sham control (from decades ago when we were more ethically challenged). And that will just have to cut it for me.

You can find Natasha Tracy on Facebook or GooglePlus or @Natasha_Tracy on Twitter.