Abstract
SUMMARYElectroconvulsive therapy (ECT) for depression is a controversial treatment with highly polarised views about the balance between therapeutic benefits and adverse effects. Studies investigating whether ECT is more effective than a placebo treatment started in the 1950s, with the most important randomised controlled trials carried out about four decades ago in which ECT was compared with sham ECT (SECT) involving anaesthesia but no electrically induced seizure. Subsequently the data have been pooled in a number of meta-analyses which have found that ECT is an effective treatment. However, a recent review of the quality of the SECT-controlled studies, and the meta-analyses based on them, concludes that their quality is too poor to allow assessment of the efficacy of ECT and that, given its risks (permanent memory loss and death), the use of ECT should be suspended. This commentary critically discusses the methodology of this review and its conclusions.
Highlights
MethodsThe authors carried out an electronic MEDLINE search to identify meta-analyses of sham Electroconvulsive therapy (ECT) (SECT) against real ECT, last updated in March 2020
The authors of the review conclude that the quality of the studies is ‘unimpressive’, and they are ‘clearly unable to determine whether Electroconvulsive therapy (ECT) is more, or less, effective than sham ECT (SECT)
There is a legitimate debate to be had about what weight can be put on the evidence from SECT-controlled studies of ECT, and if this review had limited itself to its stated aims it could at least be considered as part of the scientific debate
Summary
The authors carried out an electronic MEDLINE search to identify meta-analyses of sham ECT (SECT) against real ECT, last updated in March 2020 They assessed the included RCTs using a bespoke 24-point quality scale incorporating 8 items related to risk-of-bias domains from the Cochrane Handbook (Higgins 2011). Summary scores on a quality scale, as used here, are not an appropriate way to appraise clinical trials, as they combine assessments of aspects of the quality of reporting with those of trial conduct, effectively giving weight to different items in ways that are difficult to justify and that result in inconsistent and unpredictable results (Higgins 2011). Assessment should focus on internal validity (risk of bias) separately from assessment of external validity (generalisability or applicability) and precision of the estimate (related to study size); these can be used along with other factors, such as publication bias and heterogeneity (consistency), to interpret the results of systematic reviews (Higgins 2011). Judge the robustness or validity of individual studies and meta-analyses
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