Active Placebo, the Parachute Meta-Analysis, the Nobel Prize, and the Efficacy of Electroconvulsive Therapy

Abstract

The efficacy of electroconvulsive therapy (ECT) has been recently questioned on the grounds that placebo-controlled (sham ECT) trials are all old and of poor quality; statements have been made that the prescription of ECT should immediately be suspended because its continued use cannot be scientifically justified. These criticisms have come from academicians and have been presented in scientific and news forums with wide readership. A rebuttal is therefore necessary, if only to counter the formation of negative attitudes among patients, health care professionals, and the general public. The quality of sham ECT randomized controlled trials (RCTs) is undoubtedly poor; however, this is so because these RCTs were conducted in an era in which such methodology was par for the field. What critics of ECT have not considered are the large, well-designed, well-conducted, and well-analyzed modern era RCTs that show that bilateral and high dose right unilateral ECT are more effective than low dose right unilateral ECT, or that brief-pulse ECT is more effective than ultrabrief-pulse ECT; in such situations, the inferior form of ECT may be regarded as an active placebo comparison group that represents a scientifically valid substitute for sham ECT. Critics of ECT also do not consider the parachute meta-analysis analogy; just as one does not need a meta-analysis of RCTs to conclude that parachutes work, so too one does not need a meta-analysis of new sham ECT RCTs to conclude that ECT works. ECT is usually recommended to patients who are catatonic, severely ill, or treatment-refractory, and if ECT did not work well in these patients, common sense tells us that it would not continue to be used for such patients more than 80 years after its introduction. Malaria therapy and leucotomy are somatic therapies that were honored with the Nobel Prize, but it is ECT that has survived.