Electroconvulsive Therapy: A Time for Networks
The CARE Network is one of an increasing number of research and clinical networks in medicine in the past decade. Going back 45 years, a most successful network effort was the “War on Cancer”.2 The stated goal was “to find a cure for cancer.” The goal of “a cure” is still an aspiration, but cures are happening in many forms of cancer. Survival is up, death rates are falling, and overall, we know much more about the 100-plus diseases we call cancer. Treatments are more rational and are backed up by deeper understanding of basic disease mechanism and large clinical trials. Together, these make next steps seem a logical extension of today's advances.
In psychiatry, we know that major psychiatric conditions are as disabling, costly, and very heterogeneous. We also know that the effect size of individual treatments for them is almost as small as the effect size of hundreds of genetic variants associated with schizophrenia, bipolar disorder, and depression. To arrive at definitive positive results in the genome-wide association studies of schizophrenia, large collaborations were developed and thousands of patients were studied.3
We write this commentary from the perspective of the National Network of Depression Centers (NNDC) with 26 sites in the United States formed to address the need for larger collaborations to illuminate the causes of and improve the treatment of depressive and bipolar syndromes. The NNDC task group on ECT is presently tasked with developing a database of ECT treatment sites from around the United States. The collaborating centers have an agreement on the measurement of therapeutic outcomes and adverse events. The CARE network provides a model with short and easy to administer measures (clinical global impression ratings and quality of life questionnaires) for therapeutic outcome to achieve a dataset with more complete data as opposed to using more detailed instruments with more variable compliance and more missing data. This model will further inform our efforts with the NNDC.
Martin et al1 found that ECT practice is remarkably heterogeneous from region to region. Heterogeneity in clinical practice should be explained ideally by differences in the etiopathologic basis of disorders. Absent that knowledge, understanding variations in clinical presentations could be of some value. As a field, we have much to gain and little to lose by trying to standardize our practices especially with regards to procedures such as ECT based on all the evidence-based data. Understanding the reasons for differences in the clinical practice of ECT can be improved with a database to provide insight into these variations.
In the 1950s, cancer was thought to be contagious and a death sentence. Developing a collaborative network to disseminate information on treatment and establish standards of care improved the survival rate of patients with cancer. Making this information available to other physicians and even to patients and their families on a toll-free phone number,1-800-4-CANCER, dramatically reduced the stigma.4 The CARE network and the NNDC are examples of efforts to duplicate the success of the National Cancer Institute and should be encouraged.
The NNDC (nndc.org) has more than 4000 patients in the United States whose treatment for mood disorders is being followed across time. By our calculations, we will reach 10,000 patients in care in 2018 and will double that within a small number of years thereafter.