Medical pros of electroconvulsive therapy may be exaggerated while cons are downplayed

The medical pros of electroconvulsive therapy (ECT) are being exaggerated while the risks are being downplayed, suggest the findings of a survey on the type of information patients and their relatives/friends recall having been given before the procedure, and published online in the Journal of Medical Ethics.

Based on the responses, the researchers calculate that patients were nearly four times more likely to recall being told that the resulting memory problems were temporary rather than long-term. And they were six times more likely to recall being told that ECT can be life-saving rather than about potential heart problems.

ECT involves inducing a brief, controlled seizure in the brain using electrical currents, usually given in six to 12 treatments under general anesthesia over several weeks, explain the researchers.

Since its invention in 1938, ECT has remained a controversial procedure. And there is still no consensus on its medical pros and cons, exactly how it works–and for which mental health conditions—or the optimal dosing protocol, they add.

In 2023, a joint report by the World Health Organization (WHO) and the United Nations confirmed that anyone offered ECT should be made aware of all its risks and potential short- and long-term risks, such as memory loss and brain damage.

But recent audits of patient information leaflets on ECT in Australia and from across the UK suggest that the effectiveness of the treatment is often exaggerated while the risks are minimized, note the researchers.

To find out what ECT recipients, and their relatives/friends, recall being told about the procedure, the researchers drew on the survey responses of a convenience sample of 858 ECT recipients and 286 relatives and friends from 44 countries, completed between January and September 2024.

Most respondents were white and female. The average age at the time of their last ECT was 41, but ranged from 12 to 87. Most ECT recipients (73%) had their last ECT between 2010 and 2024. But for around 2%, this dated back to between 1950 and 1969.

The reasons given for the treatment included depression (73%); psychosis/schizophrenia (17%); bipolar disorder/mania (15%); catatonia (8%); other (13%); and ‘don’t know’ (6%).

Respondents were asked if they remembered having been informed about the possible side effects of ECT, principally heart problems; temporary and long-term memory problems, including greater susceptibility to these among women and older people; and the cognitive risks associated with serial general anesthesia.

They were also asked if they remembered having been informed about their legal rights in relation to ECT, including that there’s no evidence ECT has any long-term benefits.

And they were asked if they recalled being told (and misinformed) that depression is caused by a chemical imbalance in the brain; ECT corrects this and other brain abnormalities; ECT can be life-saving/prevents suicide; it’s the most effective treatment for severe depression.

Of the 735 ECT recipients who answered the question about the adequacy of the information received before the procedure, over half (59%) said this wasn’t adequate while 17% weren’t sure.

For example, nearly two thirds (63%) recall being told that “ECT can cause temporary memory problems,” but only 17% that it “can cause long-term or permanent memory problems.”

Only 12% recall being told that “ECT can cause heart problems” and 28% that there are “risks from repeated general anesthesia.”

There were higher levels of recall around the information given about the definite benefits of ECT, although some of these benefits are disputed, say the researchers.

When asked to consider a list of items of misinformation, many recipients and relatives recall being told “depression is caused by a chemical imbalance in the brain” (58% and 53%, respectively) and that “ECT corrects chemical imbalance or other brain abnormality” (42% and 41%, respectively).

Based on 682 ECT recipients who recalled at least one piece of information, the researchers calculated that they were nearly four times more likely to remember having been told about temporary memory problems as they were to have been told about long-term or permanent memory problems.

They were more than five times as likely to recall having been told ECT is the most effective treatment for severe depression as they were that there’s no evidence for any long-term benefits. And they were six times more likely to remember having been told that ECT can be “life-saving/prevents suicide” as they were about potential heart problems.

Everyone was invited to include up to two other things they recalled clinicians telling them about ECT, if any: 363 ECT recipients, and 37 family/friends did so. The most common information reported (154 recipients and 11 family/friends) involved minimizing memory loss or other side effects in various ways.

This included denial of any long-term effects (51) or simply stating that ECT is safe (34); 51 respondents recall being told ECT was the only option left for recovery, mostly because psychiatric drugs hadn’t worked.

This is a convenience sample and the researchers acknowledge that it may therefore not be representative of all ECT recipients. And those who were dissatisfied with their experience might have been more likely to fill in the survey.

The responses also relied on personal recall, which, in a few cases, dated back to the 1950s. And events in the period just before ECT are particularly vulnerable to being lost because of the ECT, caution the researchers.

Nevertheless, the findings align with those of previous studies, they point out. “The minimization of risks, particularly long-term adverse effects, was pronounced in both our quantitative and qualitative data,” they highlight, adding, “The legal implications of not ensuring informed consent are substantial.”

They conclude, “These findings, in conjunction with previous studies, suggest an urgent need for greater efforts to ensure that patients and families are provided with comprehensive, balanced, evidence-based information when deciding whether to have ECT.”

They suggest, “If efforts to persuade hospitals and clinics to comply with the ethical principle of informed consent by providing balanced, comprehensive, evidence-based information are unsuccessful, professional, regulatory, and government organizations should intervene.”