Elsevier

The Lancet

Volume 361, Issue 9360, 8 March 2003, Pages 799-808
The Lancet

Articles
Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis

https://doi.org/10.1016/S0140-6736(03)12705-5Get rights and content

Summary

Background

We aimed to review published work for the efficacy and safety of electroconvulsive therapy (ECT) with simulated ECT, ECT versus pharmacotherapy, and different forms of ECT for patients with depressive illness.

Methods

We designed a systematic overview and meta-analysis of randomised controlled trials and observational studies. We obtained data from the Cochrane Collaboration Depressive Anxiety and Neurosis and Schizophrenia Group Controlled trial registers, Cochrane Controlled Trials register, Biological Abstracts, CINAHL, EMBASE, LILACS, MEDLINE, PsycINFO, and SIGLE, reference lists, and specialist textbooks. Our main outcome measures were depressive symptoms, measures of cognitive function, and mortality.

Findings

Meta-analysis of data of short-term efficacy from randomised controlled trials was possible. Real ECT was significantly more effective than simulated ECT (six trials, 256 patients, standardised effect size [SES] −0·91, 95% CI −1·27 to −0·54). Treatment with ECT was significantly more effective than pharmacotherapy (18 trials, 1144 participants, SES −0·80, 95% CI −1·29 to −0·29). Bilateral ECT was more effective than unipolar ECT (22 trials, 1408 participants, SES −0·32, 95% CI −0·46 to −0·19).

Interpretation

ECT is an effective short-term treatment for depression, and is probably more effective than drug therapy. Bilateral ECT is moderately more effective than unilateral ECT, and high dose ECT is more effective than low dose.

Introduction

Electroconvulsive therapy (ECT) has been used as a treatment for mental disorder since the 1930s. Views on ECT vary, from researchers who consider that it is probably ineffective but certainly causes brain damage,1 through to those who think it is the most effective treatment available in psychiatry and is completely safe.2 The substantial geographical variation in rates of use of ECT suggests uncertainty about its efficacy and safety.3, 4 We did a systematic review and meta-analysis of published work to ascertain the benefits and harms of ECT in the treatment of depression.

Section snippets

Methods

We searched scientific and medical databases for properly randomised, unconfounded, controlled trials that compared ECT with no ECT, ECT versus pharmacotherapy, or different forms of ECT, for patients with depressive illness. The primary outcome we used for estimation of the efficacy of ECT was change in symptoms on a continuous depressive symptom scale at the end of the course of ECT. The change in symptoms at 6 months' follow-up was also investigated. We sought data on the immediate and

Results

Of 624 reports obtained from the search, 73 randomised trials met the inclusion criteria for this review. Several trials resulted in multiple publications: a complete list is available from the authors. The quality of reporting of the trials was poor; only two described the method of allocation concealment and most were small. Most, however, used some form of masking of the outcome assessor to limit the effect of ascertainment bias. Visual inspection of funnel plots did not suggest the presence

Discussion

Although many of the trials are old, and most were small, the randomised evidence consistently shows that, in the short-term (ie, at the end of a course of treatment), ECT is an effective treatment for adult patients with depressive disorders—as measured by symptom rating scales—and without substantial comorbidity. Despite the considerable heterogeneity in doses and methods of administration between trials, the evidence on the key comparisons of ECT with drug treatments and between different

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