Clinical and cost-effectiveness of electroconvulsive therapy for depressive illness, schizophrenia, catatonia and mania: systematic reviews and economic modelling studies
2005
Objectives:
To establish the clinical effectiveness and
cost-effectiveness of electroconvulsive therapy (ECT)
for depressive illness, schizophrenia, catatonia and
mania.
Data sources:
Electronic bibliographic databases. The
reference lists of relevant articles and health services
research-related resources were consulted via the
Internet.
Review methods:
Identified studies were examined to
ascertain whether they met the inclusion criteria for
the review. The study quality of relevant articles was
assessed using standard checklists and data were
abstracted using standardised forms into a database.
Where relevant, results from studies were pooled for
meta-analysis. Two economic models were developed
primarily based on evidence from the clinical
effectiveness analysis and limited quality of life
studies.
Results:
Two good-quality systematic reviews of
randomised evidence of the efficacy and safety of ECT
in people with depression, schizophrenia, catatonia and
mania were identified. Four systematic reviews on nonrandomised
evidence were also identified, although
only one of these could be described as good quality.
There was no randomised evidence of the effectiveness
of ECT in specific subgroups including older people,
children and adolescents, people with catatonia and
women with postpartum exacerbations of depression
or schizophrenia. The economic modelling results for
depression did not demonstrate that any of the
scenarios had a clear economic benefit over the
others, mainly because of the uncertainty surrounding
the clinical effectiveness of the different treatments
and the quality of life utility gains. Sensitivity analysis
surrounding the cost of ECT and the quality of life
utility values had little effect on the overall results.
The results of the model for schizophrenia adapted
to include ECT suggest that clozapine is a cost-effective
treatment compared with ECT. For patients who
fail to respond to clozapine, ECT treatment may
be preferred to the comparative treatment of
haloperidol/chlorpromazine.
Conclusions:
Real ECT is probably more effective than
sham ECT, but as stimulus parameters have an
important influence on efficacy, low-dose unilateral
ECT is no more effective than sham ECT. ECT is
probably more effective than pharmacotherapy in the
short term and limited evidence suggests that
ECT is more effective than repetitive transcranial
magnetic stimulation. Tricyclic antidepressants (TCAs)
may improve the antidepressant effect of ECT during
the course of treatment. Continuation
pharmacotherapy with TCAs combined with lithium in
people who have responded to ECT reduces the rate
of relapses. Overall, gains in the efficacy of the
intervention depending on the stimulus parameters of
ECT are achieved only at the expense of an increased
risk of cognitive side-effects. Limited evidence suggests
these effects do not last beyond 6 months, but there is
no evidence examining the longer term cognitive
effects of ECT. There is little evidence of the long-term
efficacy of ECT. ECT either combined with
antipsychotic medication or as a monotherapy is not
more effective than antipsychotic medication in people
with schizophrenia. More research is needed to
examine the long-term efficacy of ECT and the
effectiveness of post-ECT pharmacotherapy, the shortterm
and longer term cognitive side-effects of ECT, and
the impact of ECT on suicide and all-cause mortality.
Further work is needed to examine the information needs of people deciding whether to accept ECT and
how their decision-making can be facilitated. More
research is also needed on the mechanism of action of
ECT. Finally, the quality of reporting of trials in this area
would be vastly improved by strict adherence to the
Consolidated Standards of Reporting Trials
recommendations. Economic analysis may identify
areas in which research would be best targeted by
identifying parameters where reducing the level of
uncertainty would have the most effect in helping to
make the decision on whether ECT is a cost-effective
treatment.
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