Among the various uses of ECT, the treatment of depression constitutes the indication for which we have the most evidence of efficacy. Taking into account all of the elements examined previously, ECT must be considered to be an accepted technology [Conseil d’évaluation des technologies de la santé du Québec (CETS), 1994] in relation to the following indications:
• for patients suffering from severe major depression with resistance or intolerance to pharmacotherapy for which cognitive psychotherapy is not indicated or has not had any therapeutic effects;
• for patients suffering from severe major depression who present a very high suicide risk; and
• for patients suffering from severe major depression who present psychic suffering or physical deterioration that is significant enough to require very rapid onset of thera-peutic action.
Concerning the use of ECT for the treatment of schizophrenia, we have noted a major
discrep-ancy between the results of the recent meta-analysis, which determined no efficacy in this regard [UK ECT Review Group, 2002, p. 44 to 47], and the judgment of experts, who determined the efficacy of this treat-ment [American Psychiatric Association and Task Force on Electroconvulsive Therapy, 2001, p. 24]. In view of this discrepancy, what role should ECT play in the treatment of schizophrenia? The answer to this question depends on the importance we attribute to evidence for the practice of psychiatry.
Psychiatry has always been a field of prac-tice that has stood apart from the other medical specialties. This marginality is also expressed by the role evidence plays in psychiatric practice:
“Psychiatry is the most controversial area of health care, but also the area most subjected to radical changes of provision and organization.
These changes have mainly been moved by ideological expectations and much less by sound scientific evidence. The need for system-atic assessment of psychiatric technology is therefore particularly strong. Nevertheless, mental health services have been left out of the main stream of the present movement of tech-nology assessment and outcome management in health care. There is a remarkable absence of references to psychiatry in the papers by the guru of quality assurance, Avedis Donabedian.
In the set of outcome measures established by Ruthstein and further developed by Holland, death by asthma is classified as ‘avoidable death’, but death by suicide is not.” [Westrin, 1996, p. 551]
In recent years, the so-called evidence-based approach has gained more and more ground in psychiatry, as attested by the June 2001 editorial in the Canadian Journal of Psychiatry, entitled “Evidence-based Psychiatry: The Pros and Cons” [Dongier, 2001]. According to the advocates
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of this approach, it is important, in psychiatry, to go beyond the conventional dichotomy between the biological approach and the psychosocial approach [Geddes and Carney, 2001]. According to another school of thought, the limitations of an approach based on meta-analyses in psychiatry are so great that they require that the so-called evidence be interpreted very cautiously [Lesage et al., 2001].
Given the scarcity of quality research on the use of ECT in schizophrenics, we consider that the results of the meta-analyses concerning the use of ECT for the treatment of schizophrenia must be applied cautiously in the practice of psychiatry.
Although the absence of scientific evidence must not be ignored, a role must be reserved for clinical judg-ment, particularly when the appropriate evidence is equivocal or absent.
Clinical judgment is even more important with regard to the use of ECT for schizophrenia because of the limitations of the diagnostic process in psychiatry: on the one hand, the boundaries between the schizoaffective forms of schizophrenia and the affective disorders are still blurry and, on the other hand, the presence of catatonia warrants either second-line use of ECT after a pharmacother-apy trial or first-line treatment in the case of perni-cious catatonia.
Taking into account all of these aspects, the decision concerning the use of ECT for schizophrenic patients must be based on the physician’s judgment and the patient’s preferences. From a populational and health service perspective, the use of ECT for schizophrenia cases should be a fairly rare mode of treatment.
The aforementioned recommendation is consistent with the judgment of the group of experts that prepared the guidelines of the Collège des médecins du Québec for the treatment of schizophre-nia [Collège des médecins du Québec, 1999]. Since this group considers that ECT constitutes an excep-tional treatment for schizophrenia, it is not appropri-ate that its role be established in treatment guidelines that define standard treatment14.
No high-quality studies exist concerning the efficacy of ECT’s use for mania. In light of the discus-sion on schizophrenia, the limitations of diagnostic classification are particularly problematic with regard to the application of an evidence-based approach in psychiatry. For example, it is extremely difficult, if not impossible, to distinguish acute delirious mania from pernicious catatonia [Fink and Taylor, 2001]. In view of the positive judgment of experts regarding ECT’s role in the treatment of catatonia [American Psychiatric Association and Task Force on Electroconvulsive Therapy, 2001, p. 24], the clinical use of this mode of treatment for patients diagnosed with mania may be considered in accordance with the physician’s judgment and the patient’s prefer-ences. From this perspective, the use of ECT for mania should be an exceptional mode of treatment.
In neurology, the various uses of ECT must generally be considered to be experimental, in view of the absence of controlled studies on the subject and the uncertainties regarding the risk level of perma-nent adverse effects on the cognitive functions of this treatment mode. Life-threatening conditions such as neuroleptic malignant syndrome and status epilepticus are among the rare exceptions that may warrant the use of ECT for this type of indication after pharma-cotherapy has failed.
E F F I C A C Y
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14. Telephone conversation with Dr. François Goulet, of the Collège des médecins du Québec, (Montréal, Québec), September 5, 2000.
For the treatment of catatonia, the role of ECT must be assessed in accordance with the clinical situation. In the case of pernicious catatonia, which must be treated urgently, ECT constitutes a preferred treatment. For the other forms of catatonia, ECT is generally a second-line choice. The presence of cata-tonia in patients suffering from severe major depres-sion should promote earlier use of ECT.
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