I guess I will go point by point.
(1) Even though most patients describe the procedure as no more threatening
than a trip to the dentist, their report is not especially plausible or at
least not plausible enough to be taken on its own merits (see Paul's message
below);
No one stated that ECT is more painful or otherwise more aversive than
the dentist. Just the possibility of experiencing the side effect of an
induced seizure is sufficient. People avoid the dentist too. Clients
endorse positive change on self-report measures just to get out of seeing a
conventional therapist they don't like.
(2) Even though scores of published studies on ECT assure patients' that their
self-report reports of depression are confidential, they somehow don't believe
this assurance of confidentiality, and instead think believe the treatment team
will gain access to this information and use it to decide on the course of
future treatment;
The published studies do not assure patients that their ratings are
completely confidential. They are known by the treatment team. The
information
is not revealed to people outside of the treatment team. In addition,
the team also usually completes the Hamilton Rating Scale. This includes an
interview with the patient.
(3) Even though most (today, probably all) patients in published controlled
outcome studies of ECT give full informed consent regarding to whether to
receive the treatment (and therefore the treatment is voluntary), they somehow
don't believe that their participation is voluntary and instead believe that
the treatment will be forced upon them against their will.
ECT is sold to the patients. I don't know of any study that used random
assignment of treatment types, unless it was to different types of ECT.
It is very common to have random assignment of drugs or psychotherapy.
Intractable patients are the ones offered ECT.
(4) Even though patients in contemporary controlled studies of ECT are told
they will be randomly assigned to either a treatment arm or an alternative
treatment arm, they don't actually believe that the assignment is random, and
instead believe that the investigative team can decide at will whether to alter
the treatment plan on the basis of their self-reports.
I know of no study of ECT that included other treatments in which the
subjects were randomly assigned.
The major point you are missing is that there can be no blinding of an
ECT condition. The expectation biases associated with this are well known.
They can account for the treatment effects associated with all the
depression treatments. The investigators have the burden of proof in
this and
they neglect this problem in the same way that obesity researchers fail
to notice that their entire science is based on the dieting behavior of
young women. It has been a problem so long and impossible to fix that
the entire field assumes that the problems don't actually exist. If an
expectation bias exists then it could account for the treatment effect.
The investigators have the burden to partial out this effect. I think
it would be very illuminating if someone running a "blind" trial would
just ask the patients to indicate which condition they thought they were
in.
The final point I need to make is that ECT may be effective. There is
just no experiment that I can think of that will prove the effect. The
main confound is expectation bias.
Mike Williams
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