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Quality of life and function after electroconvulsive therapy

  • W. Vaughn McCall (a1), Aaron Dunn (a1) and Peter B. Rosenquist (a1)

The National Institute for Clinical Excellence in the UK has recommended limiting the use of electroconvulsive therapy (ECT), partly because of the inadequacy of research into the effects of ECT on quality of life and function.


To examine the effects of ECT on function and quality of life, particularly as they relate to changes in mood and cognition in the month following this therapy.


We measured changes in quality of life, function, mood and cognition in a prospective sample of 77 depressed patients given ECT.


All quality of life and function outcomes were improved at the 2-week and 4-week marks after ECT. Improvement in quality of life was related to mood, whereas improvement in instrumental activities of daily living function was related to improvement in global cognition.


Electroconvulsive therapy is associated with early improvement in function and quality of life. A restrictive attitude towards this therapy is not warranted on the basis of its effects on quality of life and function.

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Corresponding author
W. Vaughn McCall, Department of Psychiatry and Behavioral Medicine, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1071, USA. Tel: 336 716 2911; fax: 336 716 3508; e-mail:
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Declaration of interest

None. Funding detailed in Acknowledgement.

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Quality of life and function after electroconvulsive therapy

  • W. Vaughn McCall (a1), Aaron Dunn (a1) and Peter B. Rosenquist (a1)
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Quality of life, but not as we know it

Sue E Kemsley
17 December 2004

Far from recommending “sharp restrictions” in the use of ECT, the guidelines of the National Institute for Clinical Excellence (1) endorse the view of the Royal College of Psychiatrists (at least as expressed in their patient information leaflet) that ECT should be used as a treatment for severe depression, generally after the failure of other treatments butoccasionally as a first-line treatment (2). W Vaughn McCall has himself described ECT in the following terms : “ECT is rarely a first-line treatment of mental disorder, unless the clinical situation is desperate. Otherwise, ECT is most often offered to persons who have failed to respondto pharmacotherapy, thus defining a relatively treatment-refractory population for ECT” (3). So what is the problem when NICE says exactly thesame?

In the UK the use of ECT has been declining steadily for at least thepast 35 years, and I doubt that the NICE guidelines have accelerated this decline, but without accurate annual statistics from the Department of Health it is impossible to say for certain. The numbers of people receiving ECT without their consent – about 2,000 in 2003/04 - has not been significantly reduced by the guidelines.

Not everything in life can be reduced to a mean score on a rating scale. For example, W Vaughn McCall’s methodology would not have predictedthe fate of the young woman who was treated with ECT, became depressed again and was killed by her father (4); nor that of the young people in one Australian study who, a few years after ECT, were mostly living on welfare benefits and still having psychiatric treatment (5).

Just as NICE said, there is a need for more research into the long-term effects of ECT. Why isn’t it being done?




3.McCall, W. V. (2001) Electroconvulsive therapy in the era of psychopharmacology. International Journal of Neuropsychopharmacology, 4, 315-324


5.Walter, G., Koster, K., & Rey, J. M. (1999) Electroconvulsive therapy in adolescents: experience, knowledge, and attitudes of recipients. American Academy of Child and Adolescent Psychiatry, 38, 594-599
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Re: Reply to Andre

Linda Andre
17 December 2004

McCall et al respond to my letter but do not answer it. Instead they seek to deflect the concerns about their research by attacking me personally well as the work I do. I get very tired of explaining to ECT proponents that the Committee for Truth in Psychiatry is not an “anti-ECT”group, but no matter how many times and in how many contexts I do so, thatfalse statement continues to be made and I must conclude after all these years that it is made with reckless disregard for the truth. More about CTIP later, since I cannot leave McCall’s claims unrefuted. But much more important are the still unaddressed concerns about the McCall team’s methodology and the validity of their work.

My point about building assumptions about the longevity of ECT’s adverse effects into the research design by including persons who’d recently had ECT was not addressed.

Nor was any evidence presented to show that the rating scales chosen by McCall are relevant to the types of deficits reported by former ECT patients and illustrated so well in the SURE Report. (Nor has there been evidence, which I requested privately from the author, to show that the patients in this study, who for some reason scored so poorly on both the MMSE and the IADL prior to this course of treatment, are representative ofECT patients as a whole.)

McCall’s point that ex-patients and only ex-patients define what quality of life is and by what standard it should be measured is exactly my own: No ECT survivor or ex-patient ever has or ever would define “quality of life” or “functioning” in the terms McCall uses. He says, “It is a violation of the concept for anyone to define a patient’s QOL for them”, yet that’s exactly what he’s done. Had he asked patients themselves, an approach taken by the Rose group, he would have set off in a productive direction instead of down a blind alley.

His attempt to selectively redefine the work of Rose et al (1) as research on “satisfaction”, not relevant to work on quality of life, is without foundation, as a reading of the actual study will show. It was he who brought up the work ongoing in Britain as relevant, by his reference in his first sentence to the NICE guidelines which came out concurrently with, and used some of the same evidence base as, the report of the Rose group at the Service User Research Enterprise.

It alarms me greatly to hear McCall admit that patients are often referred for ECT because of behavior problems such as poor bladder control. I thought we were past the days when ECT was used for behavior modification.

There is a wide literature on non-financial conflicts of interest, best described as “an individual occupying dual roles which should not be performed simultaneously” (2). Those include treatment researcher and editor of a journal promoting the treatment under study.

If you yourself read what CTIP says, and not what others say about us, you will begin to wonder where the “anti-ECT” claim comes from. We arean international organization made up entirely of persons who received ECT. We represent the spectrum of outcomes, from persons who feel ECT is beneficial and have had it more than once, to persons whose lives were ruined by it. None of us were truthfully informed of the risks of ECT before consenting to it, and no one liked being lied to. Our organization exists for one purpose only: to advocate for truthful informed consent forprospective ECT patients. Thus it makes no sense to say that “any information that supports the use of ECT threatens the position of CTIP”.

Whether you are of the opinion that being for truthful informed consent somehow makes you “anti-ECT” depends on whether you believe that patients have the right to full disclosure of ECT’s risks---and the right to make a decision for themselves based on that information—--or whether you believe that ECT’s risks are such that full disclosure would result inpatients en bloc deciding to forego the treatment and thus the eradicationof ECT. That McCall and co. are in the latter camp speaks much more eloquently than their article as to what they really believe about ECT’s effects on quality of life.

CTIP, founded in 1984, has never received funding of any kind.

I regret that McCall found it necessary to put words in my mouth which I did not say, and to mock my concerns in such a disparaging manner.Science is best served by transparency and accountability, not defensiveness. Finally, as far as my response indicating McCall’s work is “on target”, I monitor all published research on ECT and cannot respond toeverything, so I respond only to the most egregious examples of shoddy or misleading work.


(1)Rose D, Fleischmann P, Wilkes T, et al. Patients’ perspectives onelectroconvulsive therapy: systematic review. British Medical Journal 2003; 326: 1363.(2)Fava, GA. Conflict of interest and special interest groups. Psychotherapy and Psychosomatics 2001; 70: 1-5.
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NICE guidelines and ECT

Muzaffar Husain, SHO in Old Age Psychiatry
09 December 2004

The study by McCall et al entitled ‘Quality of life and function after ECT’ (1) has answered a few questions, but raised many more (2). In addition, it falls short in its pretensions of bridging the evidence gap mentioned in the NICE guidelines (3) on the use of ECT.

Firstly, the methodology of the study fails to incorporate a control group. As it stands the study compares patient outcomes at the end of the 4 week follow up period with their own baseline measures. A more robust protocol would have involved a matched control group of clinically depressed participants not treated by ECT, which was then followed up for the same outcome measures. NICE guidance points to the paucity of such studies more than any other.

A second intriguing question raised is about the role of pharmacological treatments in confounding the outcome measures. The authors deal with this very obliquely in the discussion. In fact, the openanti-depressant medication that the participants received during the trialcould have had a very significant effect on their quality of life and cognitive profiles. The medication of some might have been altered or changed in view of efficacy or non-efficacy, and this could have contributed to the improvements observed.

A last note of interest involves the curious finding that participants randomized to right unilateral and bilateral electrode placements did not differ significantly in their cognitive scores at any point in the study. This is in contrast to both the evidence referenced inthe NICE guidelines and clinical observation. It is commonly held that right unilateral placement of electrodes results in fewer cognitive side-effects at the cost of clinical efficacy, compared with bilateral placement. Even more intriguing is the fact that the authors fail to venture any clinical inferences from this.

The ‘restrictive guidance on the use of ECT in the UK’ is a practice guideline that simply recommends that clinicians try the rapidly advancingpharmacological treatments first in treating depression. As such the use of ECT continues to be very common and efficacious in treating treatment refractory cases. The methodology of the present study fails to advance the evidence one way or the other.

Conflict of Interests: None


1.McCall W.V., Dunn, A., and Rosenquist, P., B. (2004) Quality of life and function after electroconvulsive therapy. British Journal of Psychiatry, 185, 405-409.

2.Andre, L. (2004) Research on ECT ‘quality of life’ is biased by design. E-letter published on the British Journal of Psychiatry website, see link :

3.National Institute for Clinical Excellence (2003) Guidance on the Use of Electroconvulsive Therapy. London, NICE
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Reply to Andre

W. Vaughn McCall
09 December 2004

Dear Sir,

We are grateful for Ms. Andre’s interest in our paper.(McCall, WV, Dunn, A, and Rosenquist PB, 2004) She is the director of the Committee forTruth in Psychiatry (CTP), which is the most vocal anti-ECT group in the United States (see As such, we feel that our work must be on target and of some importance to attract their criticism. Ms Andre has some specific complaints with our work, which we address as follows:

First, Ms Andre suggests that Dr. McCall has apparent ‘career if not financial conflict’ of interest that invalidate the paper, especially as pertains to his role as president of the Association of Convulsive Therapy(ACT). Dr. McCall receives no financial or material support for serving aspresident of ACT. ACT is self-supporting through the dues of its members. The concept of a ‘career conflict of interest’ is her own invention, and is not a concept endorsed by the American Medical Association Code of Ethics, per section 8.031.(Council on Ethical and Judicial Affairs, 1997) It is just as likely that she has a conflict of interest as director of CTP in writing her letter – any information that supports the use of ECT threatens the position of CTP.

Second, she claims the patients in our study had an average Mini Mental State Exam Score (MMSE) of 18 at baseline. This is her error and reflects either a superficial reading of the paper, if not her inability to extract pertinent information from a medical journal article. The mean baseline MMSE score was 27.4, as shown in Table 2.(McCall, WV, Dunn, A, and Rosenquist PB, 2004) The minimum MMSE score for inclusion was 18.

Third, Ms. Andre calls us to task for not citing Rose et al.(Rose, D,Wykes, T, Leese, M et al, 2003) The Rose et al. paper has merit, but has no direct bearing on our work. Rose et al. ‘aimed to …. assess the debateddistinction between efficacy, effectiveness, and satisfaction’.(Rose, D, Wykes, T, Leese, M, Bindman, J, and Fleischmann, P, 2003) The focus of ourpaper is quality of life (QOL) and function, not ‘satisfaction’. As reviewed by Asadi-Lari et al., satisfaction and QOL are discrete, non-overlapping ideas.(Asadi-Lari, M, Tamburini, M, and Gray, D, 2004) Ms Andre fails to grasp this distinction.

Fourth, Ms. Andre asserts that memory effects of ECT must necessarilyaffect QOL. Again, Ms. Andre is changing the definition of terms to suit her purposes, or else remains unfamiliar with the field. QOL research is ‘…widely regarded as a robust measure of outcome assessment…’ and is defined as ‘…the patient’s perspective of their own health status.’(Asadi-Lari, M, Tamburini, M, and Gray, D, 2004) It is a violation of the conceptfor anyone, including Ms. Andre, to define a patient’s QOL for them.

Fifth, Ms. Andre belittles our work for showing that ECT is associated with significant improvement in activities of daily living (ADLs) and instrumental activities of daily living (IADLs). She does not recognize that IADLs may be the deciding factor in referring patients for ECT,(McCall, W. V., Cohen, W., Reboussin, B. et al, 1999) and that ECT is superior to medication therapy in the improvement in IADLs over one year of follow up.(McCall, W. V., Reboussin, B. A., Cohen, W. et al, 2001)

Overall, Ms. Andre’s letter reveals some alarming deficiencies in hercomprehension of our paper and her mastery of the topic. We would welcome her full disclosure of her financial support from CTP, and disclosure of the source of funding for CTP since its web site states that dues are not a requirement for membership.

We do share one goal with Ms Andre – a desire for truth in psychiatry. We choose to reveal truth through the scientific method as opposed to rhetoric.

Reference List

1. Asadi-Lari, M, Tamburini, M, and Gray, D (2004) Patients' needs, satisfaction, and health related quality of life: Towards a comprehensivemodel. Health and Quality of Life Outcomes, 2, 1-15.

2. Council on Ethical and Judicial Affairs (1997) Code of Medical Ethics. Chicago, IL.

3. McCall, W. V., Cohen, W., Reboussin, B., et al (1999) Pretreatment differences in specific symptoms and quality of life among depressed inpatients who do and do not receive electroconvulsive therapy: a hypothesis regarding why the elderly are more likely to receive ECT. J.ECT., 15, 193-201.

4. McCall, W. V., Reboussin, B. A., Cohen, W., et al (2001) Electroconvulsive therapy is associated with superior symptomatic and functional change in depressed patients after psychiatric hospitalization.J.Affect.Disord., 63, 17-25.

5. McCall, WV, Dunn, A, and Rosenquist PB (2004) Quality of life andfunction after ECT. British Journal of Psychiatry, 405-409.

6. Rose, D, Wykes, T, Leese, M , et al (2003) Patients' perspectiveson electroconvulsive therapy: Systematic review. British Medical Journal,326, 1-5.
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Research on ECT "quality of life" is biased by design

Linda Andre
09 November 2004

The author of this study has an apparent career if not financial conflict of interest in the treatment being reviewed. He is the President of the Association for Convulsive Therapy, the industry trade organization, as well as the editor of its journal which he calls “the voice of ECT” (McCall, 2004). This ought to have been revealed to readers directly; as it is, it reveals itself in the many flaws of research designwhich bias the study towards minimizing the risks of ECT.

The study allowed patients who had had ECT as recently as four monthsprior, thus building into the research design the assumption that the adverse effects of ECT resolve within that time period, but there is plenty of evidence that this is not so (see below). If it is not, then thestudy is simply comparing patients who are still suffering the aftereffects of ECT to those suffering more severe aftereffects, a comparison which tells us nothing about the effects of ECT per se. The fact that the patients at baseline averaged an MMSE of only 18 suggests some type of cognitive dysfunction, perhaps due to ECT, even at that point.

The measures chosen by McCall in all areas---cognition, amnesia, and most importantly what he calls quality of life and functioning--- are the grossest possible, and cannot register the deficits known to be associatedwith ECT because they are simply not designed to do so. The authors must be aware of the work of the SURE group (Rose et al, 2003) in which patients describe a highly specific pattern of permanent memory and cognitive deficits post-ECT. This was a rigorous systematic review of the literature on ECT’s effects, and encompasses what most people would call quality of life and functioning. It revealed that for at least one-third of patients ECT had deleterious, often devastating, effects on these areas...effects which lasted more than six months and appeared to be permanent.

Patients lost the ability to perform their jobs. They lost memory of up to twenty years of their lives. They were unable to handle schoolwork due to impaired memory function and concentration. They did not recognize persons previously well known to them. They waited anxiously for the promised “return of memory” which never came. None of this is consistent with improvement in quality of life.

Why then are McCall’s results so seemingly contradictory? Because he didn’t ask about these things. Instead, patients were asked, quite literally, if they could wipe their own backsides. If they were simply able to get out of bed, feed and dress themselves, and use a bus or a telephone they were graded as functioning at the highest possible level.

No one has ever reported that ECT affected their ability to use a toilet.

Finally, two or four weeks after ECT is too soon for patients, who are unlikely to have tried to go back to work or school yet, to be able toreliably assess their altered memories and abilities. McCall could have gleaned this from the work of Rose and others, had he chosen to learn fromtheir rigorous work rather than setting out so transparently and ham-handedly to try to refute it.


McCall WV. Editorial: Past, present and future of the Journal of ECT (and related treatments). J ECT 2004; 20 (1): 1-2.

Rose D, Fleischmann P, Wykes T, et al. Patients' perspectives on electroconvulsive therapy: systematic review. British Medical Journal 2003; 326: 1363.
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