Generally, most doctors think that ECT is a last resort treatment.  If the patient failed antidepressants, you could try ECT.  The assumption here is that the success rate with ECT would be higher (50%-90% according to studies) than with antidepressants (since they failed them.)

So ECT occupies a special slot in our brains-- stronger, but more dangerous and cumbersome.

Turns out, the 50-90% success is in uncontrolled studies.  In controlled studies, it appears that ECT is less effective in treatment resistant patients than in non treatment resistant patients. 

Well, duh-- they're the sickest people, so of course ECT will be less effective in them.  That's doesn't tell us anything new or useful.

A recent study in the Journal of Clinical Psychiatry, the largest of its kind, finds that prior treatment failure with antidepressants did not predict lower success rates with ECT.  Phew.

Well, if that was all there was, it would be a pretty pointless study.  And certainly not worthy of press releases.  You have to read them, to see how the authors spin the study:

They therefore conclude that given appropriate indications for ECT, "antidepressant medication resistance should not sway the clinician from providing this modality."

Read it again.  Just because you failed antidepressants, it doesn't mean you shouldn't try ECT.  Huh?  I thought that was specifically when you were supposed to use ECT?

"The implication of our study," lead investigator Dr. Keith G. Rasmussen told Reuters Health, "is that even if a depressed patient has not responded to one or more antidepressant medication trials, ECT still has acute success rates as high as for patients who have not had a medication trial before ECT."

That's some might nice sleight of hand.  Look how he phrases his comparison: "...ECT still has success rates as high as for those who have not taken meds."  See?  He's making your baseline clinical experience be all those patients you've put on ECT who have never been on meds, and saying that ECT in the medication resistant will be just as good.

That's the important part, read it again.

He is trying to implant in you the belief that there exists an entire group of patients for whom  you used ECT first line, before antidepressants.

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Oh, I realize he's not doing it intentionally, nor is even conscious he is doing it.  But he is doing it nonetheless, because, as with all academia, the business isn't science, science is the business. There's nothing inherently wrong with what he is doing, but we should all be aware of it.


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It's a product positioning strategy, Marketing 101.  You cannot take on a market leader head on, even if your product is "better" because, as the adage goes, "first beats best."  Royal Crown cola can't take on Coca Cola.   In order to succeed, you need to position your product as an alternative to the market leader.  How?  By admitting there is a market leader.

The classic positioning strategy described by Al Ries: "Avis: We're Number 2, We Try Harder" works for Avis because it sets itself up as an alternative to the market leader, as opposed to trying to take on the market leader.  In other words, the "We Try Harder" part-- the part everyone assumes is the reason they're going to be better-- is fluff.  The real positioning  is the first part: it admits it is not number 1, but consequently links it always to the number 1.  It forces your mind to create a mental slot for Avis that is as big as the one already occupied by Hertz.  It may be #2, but it carries as much weight as a brand in your mind as the #1.  And now you can't ever think about Hertz without immediately thinking about Avis.

Antidepressants occupy the "first line" position in the customer's (i.e. doctor's) mind. ECT can't compete directly with them.  But Rasmussen positions ECT as an alternative to antidepressants, one of equivalent value.  He doesn't say ECT is better than antidepressants-- a point which then becomes a debate-- he says there's no relationship to antidepressants.  It's an alternative to antidepressants, equal.  Go ahead and try, you have nothing to lose, they're all the same.