Hacker News Reader

Comment by Engineering-MD | Hacker News Reader

John Read, the author, is a psychologist who is a proponent of the more psychosocial side of the biopsychosocial model of psychiatry. He is a well known opponent of ECT therapy, and this article is not a balanced view of ECT.

There are plenty of proponents of ECT, and overall the balance of evidence for most guidelines suggests it is useful in some situations. From my experience working in psychiatry in the UK at least, psychiatrists do just want to help treat patients, and use it as it seems to work in select situations. Its just another treatment option, why demonise it?

View on HN

> why demonise it?

ECT is a palliative treatment that does not address any of the causes of the patients' actual problems. While some patients seem to benefit, some are grievously harmed. The precautionary principle, and ethical guidelines, should eliminate this form of modern bloodletting from the therapeutic arsenal.

I would disagree. As the pathogenesis of most mental health problems is poorly understood, no treatment can be said to address the cause of the patients actual problems with any degree of validity. All medical interventions including CBT, pharmacological interventions and ECT have risks of harm and side effects. Therefore as with all these treatments a risk/benefit needs to be made, without appeal to the emotional response that ECT seems to produce in those reading about it. Current guidelines by panels of experts and systematic reviews suggests it is helpful in certain cases. Therefore it is reasonable to keep it in the arsenal of therapies while expert opinion and evidence supports it.

>> Its just another treatment option, why demonise it?

My personal test for any proposed medical treatment is as follows: can any resoning given in support of the treatment be also used to support homeopathy? If so, then the proposed treatment is not necessary (or, equivalently, it can be replaced by homeopathic treatment).

Applying the test to your reasoning in support of ECT, I have the following:

"There are plenty of proponents of [homeopathy], and overall the balance of evidence for most guidelines suggests it is useful in some situations. From my experience working in [homeopathy] in the UK at least, [homeopaths] do just want to help treat patients, and use it as it seems to work in select situations. Its just another treatment option, why demonise it?"

That wouldn't convince me of the merits of homeopathic treatments, so it does not convince me of the merits of ECT.

The aim of my comment is not to support ECT per se, more point out this article is not a balanced view. My reasoning is an appeal to authority of those who have reviewed the evidence (see UK NICE guidelines). If homeopathy had an evidence base and mainstream acceptance then I would see it as a medical intervention worth considering. If you find evidence base and expert opinion unconvincing, then I don’t think you would support many medical treatments, especially in areas such as psychiatry where the pathology is poorly understood.

I don't know the literature around ECT (I'm a computer scientist, noy a psychologist or psychiatrist) and so I'm going by what the article above says, which is that there is no sufficent evidence of benefits from ECT, because there are only a few studies with many methodological flaws. I understand your point about the motivation of the author, but that's common with experts: each will inform you of their very own preferred interpretation of any data and they will invariably present it as if it's the commonly accepted truth (or at least they won't bother to point out that it's their -expert- opinion).

To be honest I was a little unsure what you meant by "the balance of evidence for most guidelines".

About homeopathy, I bring it up for two reasons. One is that homeopathic treatments are still available on the NHS and also in Greece where I am currently pretty much every pharmacy sells homeopathic remedies (which I found very upsetting but I digress); and the other is that homeopaths conduct painstaking studies and then report their results as evidence that homeopathy works, but this evidence is typically rejected because of poor methodology by mainstream scientists. So "evidence" can mean anything depending on the context.

So my point is mostly that this particular article is not a balanced view of ECT. It is also an area which is very easy to have a strong emotive response to. This article is an appeal to that emotional response through its language throughout, and given the authors background views it is clear it’s not a balanced view. I think this is summed up best by the quote “Even before knowing the research on ECT, I’d had a gut reaction that something was dreadfully wrong”. I wonder if the author has made his mind up before reviewing the evidence due to his initial emotive response to it.

My main aim is to point out that this is not the view of all experts, and given it is still recommended after review by panels of experts on a national level (the UK NICE guidelines). This is what I refer to as balance of evidence in most guidelines. There is no incentive to continue using it in if it doesn’t work. The evidence base is not clear, but that’s true for a lot of interventions in medicine. I don’t have any strong views for or against ECT personally, but I object to the one sided nature of the article. It feels like a crusade against ECT.

I agree with your points about homeopathy, but the difference is here that the prevailing opinion of the experts is that it is helpful in some situations. That is why I would say it is difference.

Thank you for clarifying.

It's important to know that John Read is part of a campaigning group that aims to increase use of psychological therapies and decrease use of psychiatric (ie, medication or ECT) interventions. He's not a credible source of information. This article is a great example, it misrepresents the evidence base. This group does not believe that mental illness exists -- bipolar disorder is just people being irresponsible, autism is simple bad parenting, psychosis is people making stuff up -- which lead the group to create the "power threat meaning framework".

https://www.bps.org.uk/sites/bps.org.uk/files/Policy/Policy%...

A discussion of this document is here: https://www.nationalelfservice.net/mental-health/power-threa...

> One is that homeopathic treatments are still available on the NHS

They're effectively banned. The NHS even went to court to maintain the ban. https://www.england.nhs.uk/2018/06/nhs-england-welcomes-home...

NICE doesn't have guidance for homeopathy, but they do have an evidence search. None if it shows any benefit: https://www.evidence.nhs.uk/search?q=homeopathy

The guidance for ECT has a section about evidence. You're right that some of the evidence is low quality, however you don't get similar evidence of effect with homeopathy trials - https://www.nice.org.uk/Guidance/TA59

> The Assessment Report reviews data from 90 RCTs in individuals with depressive illness, of different grades of clinical severity, who were referred for ECT. Overall, these RCTs provide evidence that real ECT (that is, where an electric current was applied) is more effective than sham ECT (where no electric current was applied) in the short term. The data provide evidence that the stimulus parameters have an important influence on efficacy; at the end of a course of treatment, bilateral ECT was reported to be more effective than unilateral ECT. Raising the electrical stimulus above the individual's seizure threshold was found to increase the efficacy of unilateral ECT at the expense of increased cognitive impairment. In trials comparing ECT with pharmacotherapy, ECT had greater benefit than the use of certain antidepressants but the trials were of variable quality and inadequate doses and durations of drug therapy were frequently used. The combination of ECT with pharmacotherapy was not shown to be superior to ECT alone, although the duration of the RCTs was insufficient to show whether pharmacotherapy was beneficial. Compared with placebo, continuation pharmacotherapy with tricyclic antidepressants and/or lithium reduced the rate of relapses in people who had responded to ECT. Preliminary studies indicate that ECT is more effective than repetitive transcranial magnetic stimulation.

Reply on news.ycombinator.com