Paris Jackson underwent ECT for severe depression. Here’s why the treatment remains debated

John Read, University of East London

Michael Jackson’s daughter, Paris, recently revealed that she had undergone nine rounds of electroconvulsive therapy (ECT) to treat severe depression.

In the interview, Jackson said that although she felt the treatment “was working”, she said getting “shocked once a month for the rest of my life” wasn’t feasible for her.

ECT involves inducing a seizure by applying electricity to the head under general anaesthetic. Each series of ECT involves between six and 12 treatments over a period of two to four weeks.

ECT is primarily used for depression, but is also given to people diagnosed with schizophrenia, catatonia (a condition where people exhibit abnormal movements and behaviour) and bipolar disorder. The National Institute for Health and Care Excellence recommends that ECT is only used in extreme circumstances such as when a patient is suicidal and when other treatments have failed.

Some people think that ECT was abandoned long ago, but 2012 data estimated it was given to at least a million people annually, including about 2,500 in England according to 2019 estimates. Recipients are predominantly women and older people.

ECT has been controversial since it was first introduced in 1938, and remains debated today.

Does ECT work?

The gold standard for assessing a treatment’s effectiveness are randomised controlled trials. These directly compare a treatment against a placebo. In ECT studies, one group receives ECT, while the placebo group are given “sham ECT”, where they’re put under general anaesthesia but the electricity is withheld.

There have only been 11 placebo-controlled studies of ECT for depression. A review I co-authored in 2019 assessed the quality of those 11 studies. My colleagues and I found that all 11 were very small, were flawed in various ways and failed to comply with today’s methodological standards

Four of the 11 studies found ECT significantly superior to sham ECT at the end of treatment. Five found no difference between real ECT and sham ECT. Two studies found that psychiatrists reported a difference but patients did not. There was no robust evidence of effectiveness beyond the day of the last treatment – so there was no evidence of any long-term benefit of ECT.

Surprisingly, the most recent of these studies was in 1985. There have been none for 40 years. So, the honest answer to the question “does it work?” is, nearly 90 years after the first ECT, we really don’t know.

Some studies claim to show ECT performs better than other depression treatments, but a 2017 review of studies since 2009 found that in most of these studies the ECT group was also on antidepressants – making it hard to interpret the results. Most of these studies (87%) also had no follow-up data.

A 2023 study found that ECT is less effective than ketamine, which is also used for severe cases of depression, in the short-term – though the study did not provide any follow-up data for either treatment.

Like all ECT studies for depression since 1985, there was no placebo group so it was not possible to tell whether either treatment actually worked at all.

Some ECT proponents argue that it’s impossible to conduct ECT placebo studies because it’s unethical to withhold a treatment from vulnerable patients. However I argue that this positions them outside of evidence-based medicine, as the point of placebo studies is to discover whether a treatment does actually work.

Is ECT safe?

The American Psychiatric Association acknowledges that some people may experience memory problems that last months, years or permanently, after undergoing ECT.

A 2003 review also found that in a sample of 703 patients, persistent or permanent memory loss was reported by between 29% and 55% of patients.

A 2020 review of 16 studies found that in 15 of these papers, participants described memory problems after receiving ECT. This included complete erasure of some aspects of their memory, including events and experiences that happened before or immediately after having ECT.

Some participants also described not being able to remember specific life events, such as a child’s birthday or a loved one’s death. For others, memory loss was even more extensive – with one participant saying “the past 25 years are missing”. For most participants of these studies, the memory loss was considered permanent.

A 2023 report by the World Health Organization and the United Nations has stated that people offered ECT should be told of the potential short- and long-term risks it comes with – including memory loss and brain damage.

The largest ever international survey, of over 1,000 ECT recipients and family members, was recently conducted by three ECT recipients and three clinical psychologists, including myself. Our findings have been published in a series of research articles.

We found that while ECT helped some people, most respondents reported ECT either made no difference to mood or quality of life, or made matters worse.

Between 61% and 84% of ECT patients reported experiencing some form of memory loss, which lasted at least three years for most of them.

More than half of participants reported experiencing other side-effects from ECT, including emotional numbing, relationship problems and loss of independence.

Most believed the problems for which they had been given ECT were primarily caused by childhood adversities or recent stressors. But most were never asked about those issues before being prescribed ECT. If these issues had been identified and addressed through other forms of treatment (such as trauma therapy or cognitive behavioural therapy), ECT might not have been necessary.

Around 59% of participants said the information given to them about ECT’s efficacy and safety was “inadequate” – with only 17% being told about long-term memory loss.

We also found that women receive ECT more often than men and suffer greater adverse effects.

There are a range of effective alternatives to ECT and medication, whether someone is mildly depressed, severely depressed or suicidal, including cognitive behaviour therapy, trauma therapy, interpersonal psychotherapy, mindfulness and family therapy.

No one treatment works for everyone. The important ingredients seem to be establishing a relationship in which the patient feels genuinely cared about, and then determining and addressing, one way or another, what is depressing them.

Clearly some people report that ECT helped them – and some are willing to accept side-effects such as memory loss if it means alleviating their symptoms. However, many patients also feel ECT did not help them.

This article is republished from The Conversation under a Creative Commons license. Read the original article.