Note from the National Guideline Clearinghouse (NGC): The National Institute for Health and Clinical Excellence (NICE) commissioned an independent academic centre to perform a systematic literature review on the technology considered in this appraisal and prepare an assessment report. The assessment report for this technology appraisal was prepared by The University of Sheffield, School of Health and Related Research [ScHARR] and the Nuffield Institute for Health, University of Leeds. (See the "Companion Documents" field.)
Search Strategy: Clinical Effectiveness
Sources Searched
17 electronic bibliographic databases were searched, covering biomedical, health-related, science, social science, and grey literature. A list of databases is provided in Appendix 1 of the Assessment Report (see "Availability of Companion Documents" field). This includes the Cochrane Schizophrenia Group Trials Register, which was searched on behalf of the review team by the Group's Trials Search Co-ordinator.
In addition, the reference lists of relevant articles were checked and 40 health services research related resources were consulted via the Internet. These included Health Technology Assessment (HTA) organisations, guideline producing bodies, generic research and trials registers and specialist psychiatric sites. A list of these additional sources is given in Appendix 2 of the Assessment Report (see "Availability of Companion Documents" field). Finally, citation searches of key papers were undertaken using the Science Citation Index (SCI) citation facility and the reference lists of included studies were checked for additional studies.
Search Terms
A combination of free-text and thesaurus terms were used. "Population" terms (e.g., depression, schizophrenia, catatonia, bipolar disorder, mania, mood disorders, adjustment disorders, psychotic disorders, mental disorders, etc.) were combined with "intervention" terms (e.g., electroconvulsive therapy, electro convulsive therapy, electroshock therapy, electro shock therapy, etc.). Copies of the search strategies used in the major databases are included in Appendix 3 of the Assessment Report (see "Availability of Companion Documents" field).
Search Restrictions
No date or language restrictions were applied. Where necessary (e.g., in the larger databases, such as Medline), searches were restricted to the highest quality of evidence, i.e., practice guidelines, systematic reviews, and randomised controlled trials, using methodological filters (Appendix 4 of the Assessment Report [see "Companion Documents" field]). These were supplemented by strategies designed to pick up other outcomes, such as patient acceptability, side effects and staff training (Appendix 4 of the Assessment Report [see "Availability of Companion Documents" field]).
Search Strategy: Cost Effectiveness
In addition to the searches conducted above, searches were conducted in the National Health Service Economic Evaluations Database (NHS EED) and Office of Health Economics Health Economic Evaluations Database (OHE HEED) to specifically identify cost effectiveness literature (Appendix 3 of the Assessment Report [see "Availability of Companion Documents" field]).
Methodological search filters designed to retrieve economic evaluations and quality of life studies (Appendix 4 of the Assessment Report [see "Availability of Companion Documents" field]) were also applied to the Medline and Embase search strategies.
There were no company submissions.
Inclusion and Exclusion Criteria
Populations
Papers were included in the review if they included the following populations: depressive illness (both unipolar and bipolar), schizophrenia and schizo-affective disorder, catatonia and mania. The Assessment Group also aimed to explore the clinical effectiveness of electroconvulsive therapy (ECT) in particular subgroups including people who are treatment resistant to pharmacotherapy, older people (defined as aged 65 and over), younger people (defined as aged 18 or under) and disorders associated with pregnancy and the puerperium. Papers were excluded if they included populations with more than one diagnosis (for example depression and schizophrenia) and did not stratify randomisation by disease type or report results separately for each diagnosis.
Interventions
Papers were included in the review if they examined the effectiveness or cost effectiveness of electroconvulsive therapy either as a monotherapy or in conjunction with other appropriate pharmacological or psychological treatment, at all doses and frequency of administration, by any technique, in all settings, and administered by any health professional. The Assessment Group also included studies investigating the efficacy of adjunctive and continuation or maintenance ECT or pharmacotherapy and interventions that aimed to improve patient knowledge about ECT.
Comparators
Papers were included if they compared ECT to any pharmacological or non-pharmacological treatment including sham ECT, psychotherapy, or repetitive transcranial magnetic stimulation (rTMS). Studies that compared one or more types of pharmacotherapy post ECT were also included.
Outcomes
Studies were included if they assessed outcomes relating to the efficacy, safety and acceptability of ECT. The primary indicator of the efficacy of ECT were clinically meaningful benefits in symptoms and/or quality of life as measured by a validated rating scale or clinical opinion, secondary indicators were the speed of response to ECT, premature withdrawals by the decision of either the participant, the clinician in charge of their care or the researcher, discharges from hospital and relapses. The primary indicators of the safety of ECT were adverse events including both objective and subjective reports of memory loss (anterograde, retrograde and subjective reports of memory loss) and all cause and cause specific mortality (including suicide). All these outcomes were considered immediately after the course of ECT, at 6 months and 12 month or longer. The primary indicators of acceptability were patients' choice of treatment and their views and experiences of ECT either from questionnaires or interviews.
Study Methodology
Published papers were included in the review according to the accepted hierarchy of evidence. In the first instance papers were only included if they were systematic reviews, randomised controlled trials and economic evaluations. Where no randomised controlled trial evidence was available, non-randomised comparator studies (for example non-randomised trials, controlled cohort studies, and case control studies) were included in the review. Where no evidence from non-randomised comparator studies is available, non-randomised, non-comparator studies (for example case series, case reports, non-controlled cohort studies) were included in the review.
Language
Any studies not available in English were excluded as the time scale of the review precluded time for translation.