Letters to the Editor
Importance of Electroconvulsive Treatment
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As Härter and Prien in their article focused on the innovations in the guideline, the importance of electroconvulsive therapy (ECT) was not adequately discussed, in our opinion. The text mentions ECT merely as a “may be considered” treatment option in suicidality. This suggests, as does Figure 4, that ECT is used only at the end of the therapeutic algorithm, as a measure of last resort. By contrast, the guideline gives ECT the highest grade of recommendation in treatment-resistant depressive episodes (…) especially at an older age or in case of psychotic symptoms. Older age and psychotic or psychomotor symptoms are predictors for a particularly good response to ECT, and its timely use is the first-line treatment in such situations. This is confirmed by a recent position statement from the German Association for Psychiatry, Psychotherapy, and Psychosomatics and eight additional specialist associations (1). The current highest recommendation grade of maintenance ECT is also of clinical relevance for the prevention of relapse and recurrence in defined groups of patients. These and other changes have been discussed in detail elsewhere (2).
The correct appraisal of treatment alternatives in the context of pharmacological treatment resistance is also important. The new recommendations for repetitive transcranial magnetic stimulation (rTMS) or intranasal esketamine address potentially effective therapeutic approaches, but both the evidence and clinical experience support the clearly better effectiveness of ECT, depending on the degree of severity.
On this background and the still unsatisfactory nationwide provision of ECT (3)—in spite of overall increasing use—it is important to us to emphasize that ECT is still the most effective treatment option for many patients, and its particular importance in the acute and maintenance therapy of depressive disorders should be clearly highlighted, especially in terms of increasingly individualized medicine.
DOI: 10.3238/arztebl.m2023.0209
PD Dr. David Zilles-Wegner
Universitätsmedizin Göttingen,
Klinik für Psychiatrie und Psychotherapie, Göttingen
david.zilles@med.uni-goettingen.de
Prof. Dr. Alexander Sartorius
Klinik für Psychiatrie und Psychotherapie, Zentralinstitut für Seelische Gesundheit, Mannheim
Conflict of interest statement
D Z-W received lecture honoraria from diverse hospitals. He is the chair of the working group for electroconvulsive therapy in the Arbeitsgemeinschaft für Neuropsychopharmakologie und Pharmakopsychiatrie (AGNP, the working group for neuropsychopharmacology and pharmacopsychiatry).
AS declares that no conflict of interest exists.
| 1. | Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde e. V.: Indikationen zur Elektrokonvulsionstherapie. www.dgppn.de/schwerpunkte/aktuelle-positionen-1/aktuelle-positionen-2022/elektrokonvulsionstherapie.html (last accessed on 26 May 2023). |
| 2. | Zilles-Wegner D, Sartorius A: Elektrokonvulsionstherapie in der neuen NVL Depression: vom Unterschied zwischen Effektivität, Evidenz und Empfehlungsgraden. Fortschr Neurol Psychiatr 2023; 91: 209–12 CrossRef MEDLINE |
| 3. | Methfessel I, Belz M, Bühler F, Zilles-Wegner D: Versorgungsaspekte der Elektrokonvulsionstherapie: Analyse der externen Zuweisungen an ein universitäres Zentrum. Nervenarzt 2023; 94: 8–17 CrossRef MEDLINE PubMed Central |
| 4. | Härter M, Prien P, on behalf of the NVL Guideline Group: Clinical practice guideline: The diagnosis and treatment of unipolar depression—National Disease Management Guideline. Dtsch Arztebl Int 2023; 120: 355–61 VOLLTEXT |
