Electroconvulsive therapy, depression severity and mortality: Data from the Danish National Patient Registry

Understanding the Patient Landscape: A Ten-Year Retrospective Examination of Electroconvulsive Therapy in Romania's Largest Psychiatric Hospital

The aim of this analysis was to investigate the socio-demographic and clinical profile, the effectiveness, and the association of pharmacological treatment in patients who underwent electroconvulsive therapy during the last 10 years in the largest psychiatric hospital in Romania. This study includes 249 patients aged between 18 and 73 years old. Recurrent depression was the most frequent diagnosis for which ECT was performed (T = 96, 38.55%), followed by schizophrenia (T = 72, 28.91%). The most frequent indication for ECT was treatment resistance (T = 154, 61.84%), followed by persistent suicidal ideation (T = 54, 21.68%) and catatonia (T = 42, 16.86%). In 111 (44.60%) cases included in this study, re-hospitalization was required after performing ECT, while 138 (55.40%) participants did not require any further hospital readmissions. Significant differences were found between these groups in terms of socio-demographic data, diagnosis, number of ECT sessions performed, and association of psychotropic medication during and after the procedure, therefore two separate patient profiles were found based on these characteristics. Patients necessitating re-hospitalization post-ECT were mainly males aged 25-44 diagnosed with schizophrenia and underwent a greater number of ECT sessions (7-12), whereas those not requiring re-hospitalization were predominantly females aged 45-64 with recurrent depressive disorder for which 4-6 ECT sessions were performed.

Suicidal behavior and all-cause mortality in depressed older adults aged 75+ treated with electroconvulsive therapy: A Swedish register-based comparison study

OBJECTIVES

Electroconvulsive therapy (ECT) is effective in treating late-life depression. There is limited research on suicidal behavior and all-cause mortality in the oldest old after ECT.

METHODS

Older adults aged 75 years and above who had been inpatients for moderate to severe depression between January 1, 2011, and December 31, 2017, were included in the study. We used exact and propensity score matching to balance groups. We compared suicidal behavior (fatal and non-fatal) and all-cause mortality in those who had received ECT and those with other depression treatments.

RESULTS

Of the study population, 1802 persons who received ECT were matched to 4457 persons with other treatments. There were no significant differences in the risk of suicidal behavior between groups, (within 3 months: odds ratio 0.73; 95% confidence intervals (CI), 0.44-1.23, within 4 months to 1 year: aOR 1.34; 95% CI, 0.84-2.13). All-cause mortality was lower among ECT recipients compared to those who had received other treatments, both within 3 months (aOR, 0.35; 95% CI, 0.23-0.52), and within 4 months to 1 year (aOR 0.65; 95% CI, 0.50-0.83).

CONCLUSIONS

Compared to other depression treatments, ECT is not associated with a higher risk of suicidal behavior in patients aged 75 and above. ECT is associated with lower all-cause mortality in this age group, but we advise caution regarding causal inferences.

Real-world evidence from a retrospective study on suicide during depression: clinical characteristics, treatment patterns and disease burden

BACKGROUND

Suicide stands as both a primary symptom and the direst outcome of major depressive disorder (MDD). The scarcity of effective treatment strategies makes managing MDD patients with suicide especially challenging. Hence, it is crucial to investigate disease characteristics and efficacious therapeutic strategies for these patients, drawing insights from disease databases and real-world data.

METHODS

In this retrospective study, MDD patients hospitalized between January 2013 and December 2020 were investigated using Electronic Health Records (EHR) data from Beijing Anding Hospital. The study enrolled 4138 MDD patients with suicidal ideation or behavior (MDS) and 3848 without (MDNS). Demographic data, clinical attributes, treatment approaches, disease burden, and re-hospitalization within one year of discharge were extracted and compared.

RESULTS

Patients in the MDS group were predominantly younger and female, exhibiting a higher prevalence of alcohol consumption, experiencing frequent life stress events, and having an earlier onset age. Re-hospitalizations within six months post-discharge in the MDS group were significantly higher than in the MDNS group (11.36% vs. 8.91%, p < 0.001). Moreover, a more considerable fraction of MDS patients underwent combined electroconvulsive therapy treatment (56.72% vs. 43.71%, p < 0.001). Approximately 38% of patients in both groups were prescribed two or more therapeutic regimes, and over 90% used antidepressants, either alone or combined. Selective serotonin reuptake inhibitors (SSRIs) were the predominant choice in both groups. Furthermore, antidepressants were often prescribed with antipsychotics or mood stabilizers. When medication alterations were necessary, the favoured options involved combination with antipsychotics or transitioning to alternative antidepressants. Yet, in the MDS group, following these initial modifications, the addition of mood stabilizers tended to be the more prioritized alternative.

CONCLUSIONS

MDD patients with suicidal ideation or behaviour displayed distinctive demographic and clinical features. They exhibited intricate treatment patterns, a pronounced burden of illness, and an increased likelihood of relapse.

Cerebral and Aortic Aneurysms in Electroconvulsive Therapy Patients: A Systematic Review and Results From 12 Years of Screening

INTRODUCTION

Theoretically, the procedural risk of electroconvulsive therapy (ECT) could be increased in the presence of undetected aneurysms due to the hemodynamic changes associated with ECT. However, empirical evidence is limited to few individual case reports and case series.

METHODS

We performed a systematic review of available evidence on ECT treatment in patients with intracranial aneurysms and untreated aortic aneurysms and we retrospectively analyzed data from 252 consecutive patients referred for ECT at the Department of Psychiatry, Psychotherapy and Psychosomatics of Siegen Hospital, Germany, who received magnetic resonance angiographies and abdominal sonographies as part of their routine pre-ECT workup.

RESULTS

Of 252 patients referred for ECT, 5 (2.0%) were found to have an intracerebral aneurysm and 1 (0.4%) was found to have an abdominal aortic aneurysm. These cases are reported in detail together with 2 additional cases of aortic aneurysms from the Central Institute of Mental Health, Mannheim, Germany. Electroconvulsive therapy was performed without complications in all 8 cases.

CONCLUSIONS

Aneurysms might occur in ECT patients at a similar rate as in the general population. The number of ECTs performed annually in mostly unscreened patients suggests that there might be a significant number of patients with undetected aneurysms in whom ECT is performed without reported complications.

Changes in self-reported suicidal ideation during treatment with electroconvulsive therapy: A retrospective cohort study

OBJECTIVE

Suicidal ideation (SI) is common in patients with depressive symptoms, who are the most common recipients of electroconvulsive therapy (ECT). We sought to quantify changes in self-reported SI occurring during treatment with ECT, and to identify factors associated with persistence of SI in patients beginning treatment with SI.

METHOD

Retrospective, single-center cohort study of patients receiving ECT and who self-reported symptoms using Quick Inventory of Depressive Symptomatology (QIDS) prior to ECT and after treatment #5 or #10. Changes in QIDS-reported SI over the course of ECT were calculated, and logistic regression models were performed to assess factors associated with reporting SI at the end of treatment.

RESULTS

2554 provided baseline and follow-up SI scores, of whom, 1931 (75.6%) endorsed SI at baseline. There was a reduction in SI with ECT treatment (McNemar's test; df = 1, Χ2  = 803.7; p < 0.001), and in adjusted models 64.0% of individuals with baseline SI reported resolution of SI with ECT treatment, while 3.3% without baseline SI reported SI at the end of treatment. Higher baseline SI severity and outpatient treatment were associated with a higher odds of persistent SI among individuals beginning treatment with SI.

CONCLUSION

Electroconvulsive therapy treatment was associated with reductions in self-reported SI. These results support the use of ECT in the treatment of patients with SI, but further research is needed to determine the effects of ECT on suicidal behavior.

An independent audit of electroconvulsive therapy patient information leaflets in Northern Ireland, Scotland and Wales

OBJECTIVES

To evaluate the accuracy of patient information leaflets about electroconvulsive therapy (ECT) used in Northern Ireland, Scotland and Wales, and their compliance with the principle of informed consent.

DESIGN AND METHODS

To replicate an audit in England, Freedom of Information Act requests were sent to the 26 providers of ECT for their ECT patient information leaflet. These were scored, by two independent raters, on the same 40-item accuracy measure used in the England audit.

RESULTS

The number of accurate statements (out of a possible 29) ranged from seven to 20, with a mean of 16.9. The most frequently omitted statements included: cardiovascular risks (mentioned by five leaflets), that it is not known how ECT works (3), risk of mortality (2), risks from multiple general anaesthetic procedures (2), how to access a legal advocate (2) and that that there is no evidence of long-term benefits (1). The leaflets made between six and nine inaccurate statements (out of 11) with a mean of 7.0. Nineteen minimised memory loss, blamed the memory loss on depression, claimed that ECT is the 'most effective treatment' and asserted it has very high response rates without mentioning similar placebo response rates. All 23 leaflets wrongly told patients that ECT saves lives.

CONCLUSIONS

Electroconvulsive therapy information leaflets in these three nations are barely more accurate than those in England and do not comply with the ethical principle of informed consent. Patients and families across the UK are systematically being misled about the risks they are taking and the limited nature of ECT's benefits.

Pharmacological and Somatic Treatment Effects on Suicide in Adults: A Systematic Review and Meta-Analysis

Background

Suicide is a public health crisis. We conducted a systematic review and meta-analysis of the effects of psychopharmacologic and somatic therapies on suicide risk.

Methods

A systematic search of MEDLINE for studies evaluating the effects of pharmacologic (excluding antidepressants) or somatic interventions on suicide risk was conducted. Studies were included if they used a comparison group, reported on suicide death, assessed a psychopharmacological or somatic intervention, and included adults. Study quality was assessed using the Newcastle-Ottawa scale. Fifty-seven studies were included from 2940 reviewed citations.

Results

In bipolar disorder, lithium was associated with a reduction in the odds of suicide compared to active controls (odds ratio [OR] = .58, p = .005; k = 12) and compared to placebo/no lithium (OR = .46, p = .009; k = 9). In mixed diagnostic samples, lithium was associated with a reduction in the odds of suicide compared to placebo/no lithium (OR = .27, p < .001; k = 12), but not compared to active controls (OR = .89, p = .468; k = 7). In psychotic disorders, clozapine was associated with a reduction in the odds of suicide (OR = .46, p = .007; k = 7). Associations between suicide death and electroconvulsive therapy (OR = .77, p = .053; k = 11), non-clozapine antipsychotics in bipolar disorder (OR = .73, p = .090; k = 6) and antipsychotics in psychotic disorders (OR = .39, p = .069; k = 6) were not significant. There was no consistent relationship between antiepileptic mood stabilizers and suicide. There were insufficient studies to meta-analyze associations of suicide risk with vagus nerve stimulation, transcranial magnetic stimulation, magnetic seizure therapy, or transcranial direct current stimulation.

Conclusion

Lithium and clozapine have consistent data supporting protective effects against suicide in certain clinical contexts.Reprinted from Depress Anxiety 2022; 39:100-112, with permission from John Wiley and Sons. Copyright © 2022.

Risk factors for suicide among patients having received treatment with electroconvulsive therapy: A nationwide study of 11,780 patients

OBJECTIVES

Despite the putative anti-suicidal effect of electroconvulsive therapy (ECT), patients receiving ECT remain at high risk of dying from suicide due to the severity of their underlying mental illness. We aimed to quantify this risk and to identify risk factors for suicide among patients receiving ECT.

METHODS

Using nationwide Danish registers, we identified all patients that initiated ECT between 2006 and 2016. These patients were matched on sex and age to 10 reference individuals from the general Danish population. Firstly, we compared 2-year suicide risk between patients initiating ECT and the matched reference individuals. Secondly, we investigated if any patient characteristics were associated with suicide following ECT via Cox proportional hazards regression.

RESULTS

A total of 11,780 patients receiving ECT and 117,800 reference individuals were included in the analyses. Among the patients receiving ECT, 161 (1.4%) died from suicide within two years. Compared to the reference individuals, patients having received ECT had a substantially elevated suicide rate (Hazard rate ratio (HRR) = 44.48, 95%CI = 31.12-63.59). Among those having received ECT, the following characteristics were associated with suicide: Male sex (adjusted HRR (AHRR) = 2.32, 95%CI = 1.63-3.30), medium-term higher education (AHRR = 2.64, 95%CI = 1.57-4.44); long-term higher education (AHRR = 3.16, 95%CI = 1.68-5.94), history of substance use disorder (AHRR = 1.51, 95%CI = 1.01-2.26) and history of intentional self-harm/suicide attempt (AHRR = 4.18, 95%CI = 2.76-6.32).

CONCLUSIONS

Those who are male, have obtained medium-/long-term higher education, or have a history of substance use disorder or intentional self-harm/suicide attempt, are at particularly elevated risk of suicide following ECT. These findings may guide clinical initiatives to reduce suicides.

How to save a life: From neurobiological underpinnings to psychopharmacotherapies in the prevention of suicide

The impact of suicide on our societies, mental healthcare, and public health is beyond questionable. Every year approximately 700 000 lives are lost due to suicide around the world (WHO, 2021); more people die by suicide than by homicide and war. Although suicide is a key issue and reducing suicide mortality is a global imperative, suicide is a highly complex biopsychosocial phenomenon, and in spite of several suicidal models developed in recent years and a high number of suicide risk factors identified, we still have neither a sufficient understanding of underpinnings of suicide nor adequate management strategies to reduce its prevalence. The present paper first overviews the background of suicidal behavior including its epidemiology, prevalence, age and gender correlations and its association with neuropsychiatric disorders as well as its clinical assessment. Then we give an overview of the etiological background, including its biopsychosocial contexts, genetics and neurobiology. Based on the above, we then provide a critical overview of the currently available intervention options to manage and reduce risk of suicide, including psychotherapeutic modalities, traditional medication classes also providing an up-to-date overview on the antisuicidal effects of lithium, as well as novel molecules such as esketamine and emerging medications and further molecules in development. Finally we give a critical overview on our current knowledge on using neuromodulatory and biological therapies, such as ECT, rTMS, tDCS and other options.

Electroconvulsive Therapy and Risk of Road Traffic Accidents: A Danish Register-Based Cohort Study

OBJECTIVE

The aim of the study is to examine whether electroconvulsive therapy (ECT) was associated with the subsequent risk of being involved in a road traffic accident.

METHODS

A cohort of all 375,435 patients older than 18 years with their first psychiatric hospital contact between 2003 and 2017 in the Danish National Patient Registry was followed for road traffic accidents until December 2018. Associations between ECT and road traffic accidents were examined using Cox regression analyses with multiple adjustments and using propensity score matching on sociodemographic and clinical variables.

RESULTS

A total of 8486 patients (0.2%) were treated with ECT. During the median follow-up of 5.9 years, 778 of these patients (12.5%) were involved in a road traffic accident and the unadjusted incidence of road traffic accidents was lower among these patients (incidence rate, 15.5 per 1000 patient-years; 95% confidence interval [CI], 14.5-16.7) compared with patients not treated with ECT (incidence rate, 20.0 per 1000 patient-years; 95% CI, 20.0-20.3). Electroconvulsive therapy was not associated with road traffic accidents in the Cox regression models after adjustment for all covariables (hazard ratio, 1.00; 95% CI, 0.92-1.08) or in the propensity score-matched sample (hazard ratio, 0.91; 95% CI, 0.83-1.08). The HRs did not vary materially with follow-up time or when analyses were stratified on sex, age, or type of hospital contact.

CONCLUSIONS

The analysis of Danish National registry data indicates that ECT is not associated with the risk of being involved in major road traffic accidents.

Risk factors for mortality of medical causes within 30 days of electroconvulsive therapy

BACKGROUND

Electroconvulsive therapy (ECT) is used to treat severe psychiatric disorders and is associated with reduced risk of suicide and all-cause mortality in patients with severe depression. We investigated the causes of death occurring shortly after ECT and identified potential risk factors for medical causes of death.

METHODS

Patients treated with ECT between 2012 and 2018 were included in this Swedish register-based study. Multivariate binary logistic regression was used to calculate odds ratios for covariates to determine potential predictors of 30-day mortality.

RESULTS

Of the 20,225 included patients, 93 (0.46 %) died of suicide and 123 (0.61 %) died of medical causes after ECT. Cardiovascular disease was the most common medical cause of death (n = 49, 40 %). An older age, a Charlson Comorbidity Index of 1 or more, atrial fibrillation, kidney disease, reflux disease, dementia, and cancer were associated with increased risk of death by medical causes.

LIMITATIONS

Real-life observational studies based on registry data may demonstrate associations, but cannot determine causality. If medical records had been available, we would be better able to determine if deaths were due to the ECT, anesthesia, pre-existing medical conditions, or the mental disorder.

CONCLUSIONS

ECT appears to be a low-risk medical procedure. Older individuals with severe somatic diseases have the highest risk of death and extra measures should be considered to optimize their medical health during the pre-ECT workup, and during and after ECT.

Inpatient suicide in psychiatric settings: Evaluation of current prevention measures

The risk of suicide in psychiatric hospitals is 50 times higher than in the general population, despite patient safety being a priority for any hospital. However, to date, due to the complexity of assessing suicide risk, there has been no consensus on the suicide prevention measures that should be in place in hospitals. The aim of this work is: To provide an overview of the progress that has been made in the field of inpatient suicide prevention in recent years; discuss the problems that remain; and suggest potential future developments. As new clinical dimensions (notably anhedonia, psychological pain and hopelessness) develop, they should become new therapeutic targets. Team training (like the Gatekeeper Training Program) and the latest advances in suicide risk assessment (such as the Collaborative Assessment and Management of Suicidality) should be implemented in psychiatric wards. Suicide prevention plans (e.g., ASSIP, SAFE-T, etc.) represent easy-to-administer, low-cost interventions. The Mental Health Environment of Care Checklist has been proven effective to reduce suicide risk at hospitals. Furthermore, the types of psychotherapy recommended to reduce suicide risk are cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). There are several pharmacological treatments for suicide risk, such as lithium and clozapine, which have been shown to be effective in the long term, as well as ketamine and esketamine, which are more effective in the short term. Following some encouraging recent results, buprenorphine may also be proposed to patients with a suicide risk. Triple chronotherapy rapidly improves depressive symptoms over 9 weeks. Regarding brain stimulation techniques, rTMS has proven to be effective in alleviating multiple dimensions of suicidality.

The Use of ECT in the Elderly-Looking Beyond Depression

PURPOSE OF REVIEW

We reviewed recent evidence on the use of electroconvulsive therapy (ECT) in the geriatric population. This review looked at the literature on depression, for which there is a breadth of data, as well as other conditions that have historically not been as well studied, as well as attempting to provide practical recommendations for ECT practitioners. This review also examined the impact of the COVID-19 pandemic on ECT in the elderly.

RECENT FINDINGS

ECT shows robust efficacy across many psychiatric diseases, from depression and bipolar disorder to psychosis and catatonia. It has also shown positive results at improving behavioral symptoms of dementia, as well as improving motor symptoms seen in Parkinson's disease. It is routinely found to be a safe treatment as well, generally with only minimal transient side effects. ECT should not be considered a "last-resort" treatment for geriatric patients suffering from psychiatric disorders. It has historical and recent literature supporting its use in many psychiatric disorders and has been shown to be safe with minimal side effects when appropriate considerations are taken for the elderly population.

Suicidal ideation and ECT, ECT and suicidal ideation: A register study

OBJECTIVE

Although electroconvulsive therapy (ECT) is anti-suicidal, it is not known whether the presence of suicidal ideation (SI) at baseline predicts response and remission after ECT. The aim of the study was to analyze the impact of baseline SI on response and remission following ECT treatment in a large sample of patients with depression and to assess SI before and after ECT.

METHODS

This population-based register study used data from the Swedish National Quality Register for ECT and the Swedish Patient Register. Patients aged 18 years or older who had received ECT for a unipolar or bipolar depressive episode between 2011 and 2018 were included in the study. SI was defined as a score of ≥4 on the last item of the Montgomery-Åsberg Depression Rating Scale - Self Assessment (MADRS-S). Using a logistic regression model, SI at baseline was used to predict response and remission following ECT, while controlling for depression severity, psychotic symptoms, presence of a comorbid personality disorder, age, sex, electrode position, unipolar or bipolar disorder, and number of previous suicide attempts at baseline.

RESULTS

In patients who exhibited SI at baseline, 53.7% (N = 632) of cases showed a response to ECT, whereas 68.4% (N = 690) of patients without SI showed a response. In addition, 27.2% (N = 320) of cases with SI achieved remission, whereas 48.5% (N = 489) of cases without SI achieved remission. The odds of achieving response and remission for patients with SI were 0.75 and 0.58 times, respectively, those for patients without SI. Of the 1178 patients with pre-treatment SI, 75.64% (N = 891) exhibited no SI at the end of treatment. Moreover, in this subgroup, the presence of a personality disorder, higher MADRS-S-score, and younger age were associated with persistent SI.

CONCLUSION

The presence of SI was associated with lower ECT response and remission rates. Nevertheless, depressive symptoms and SI were reduced in a large proportion of patients across both patient groups. Clinicians should be aware of the lower likelihood of achieving a successful outcome following ECT in younger patients who present with a non-psychotic depressive episode, SI, and (suspected) personality disorders. More research is warranted regarding if these patients can achieve similar or better results with other treatments.

Depression: why drugs and electricity are not the answer

The dominant view within mental health services and research suggests that feeling depressed is a kind of medical illness, partially caused by various biological deficits which are somehow corrected by physical interventions. This article critically appraises evidence for the effectiveness and value of antidepressant drugs and electroconvulsive therapy (ECT), the two principle physical treatments recommended for depression. It also describes the negative effects of these interventions and raises concerns about how they impact the brain. We propose an alternative understanding that recognises depression as an emotional and meaningful response to unwanted life events and circumstances. This perspective demands that we address the social conditions that make depression likely and suggests that a combination of politics and common sense needs to guide us in providing help for one another when we are suffering in this way. This alternative view is increasingly endorsed around the world, including by the United Nations, the World Health Organization and service users who have suffered negative consequences of physical treatments that modify brain functions in ways that are not well-understood.

Risk of suicide death following electroconvulsive therapy treatment for depression: a propensity score-weighted, retrospective cohort study in Canada

BACKGROUND

Previous studies examining the risk of suicide death after treatment with electroconvulsive therapy have been confounded and the resulting uncertainty around the risk-benefit profile of electroconvulsive therapy might contribute to its underuse. We aimed to compare the risk of death by suicide after psychiatric hospitalisation among individuals with depression who had been exposed to electroconvulsive therapy with those who had not.

METHODS

This was a propensity score-weighted, retrospective cohort study using linked population-level administrative health data for adults with depression who had been admitted to a designated psychiatric bed in Ontario, Canada for more than 3 days between April 1, 2007 and Dec 31, 2017. Electroconvulsive therapy exposure was defined as one or more physician billing procedure codes during hospitalisation. The primary outcome was death by suicide identified using administrative health records within 365 days following discharge. We used cause-specific Cox proportional hazards model to estimate the cause-specific hazard ratio (csHR) for electroconvulsive therapy-exposed and electroconvulsive therapy-unexposed individuals. Secondary outcomes were non-suicide death and all-cause mortality.

FINDINGS

In the analytic cohort, there were 67 327 psychiatric hospitalisation records (27 231 men and 40 096 women; mean age 45·1 years [SD 16·8; range 18-103]), of whom 4982 were exposed to electroconvulsive therapy and 62 345 were not exposed to electroconvulsive therapy. No ethnicity data were available. In propensity-score weighted analyses, electroconvulsive therapy was associated with a significantly reduced risk of suicide death (csHR 0·53 [95% CI 0·31-0·92]). Accounting for non-suicide death as a competing risk had no effect on the findings. Electroconvulsive therapy was also associated with a significantly reduced risk of all-cause mortality (0·75 [0·58-0·97]), but not non-suicide death (0·83 [0·61-1·12]).

INTERPRETATION

Among individuals admitted to hospital with depression, electroconvulsive therapy is associated with a significantly reduced risk of death by suicide in the year after discharge. This study reinforces the importance of electroconvulsive therapy, particularly for people with severe depression.

FUNDING

Norris Scholars Award, Department of Psychiatry, University of Toronto, and the Canadian Institutes for Health Research.

Self-Harm and Suicide Attempts Preceding and Following Electroconvulsive Therapy: A Population-Based Study

OBJECTIVE

The beneficial effect of electroconvulsive therapy (ECT) on suicidality has been documented in clinical trials, whereas naturalistic studies on the topic are scarce and restricted to individuals with mood disorders. Here, based on population-based data from Danish registers, we aimed to investigate the course of self-harm and suicide attempts preceding and following ECT across 4 major mental disorders. This was done to examine whether data from the real-world clinical setting are compatible with the positive results from clinical trials.

METHODS

We identified all patients diagnosed with unipolar depression (n = 8843), bipolar disorder (n = 2713), psychotic disorder (n = 2692), or personality disorder (n = 2085) who received ECT for the first time in the period from 2008 to 2019, as well as age-, sex-, diagnosis-, illness duration-, and admission-matched comparison groups not receiving ECT. A mirror-image model was used to examine whether the number of incidents of self-harm/suicide attempts changed following ECT (paired t test).

RESULTS

There were substantial and statistically significant reductions in the number of incidents of self-harm/suicide attempts when comparing the month leading up to and the month following initiation of ECT for all diagnostic groups (unipolar depression: reduction, 83% [P < 0.001]; bipolar disorder: reduction, 72% [P < 0.001]; psychotic disorder: reduction, 82% [P < 0.001]; personality disorder: reduction, 83% [P < 0.001]). The analog results for the comparison groups not receiving ECT suggested that these reductions in self-harm/suicide attempts were partly mediated by a protective effect of admission.

CONCLUSIONS

Data from the real-world clinical setting are compatible with results from clinical trials with regard to the protective effect of ECT on suicidality.

Mortality and acute somatic events following electroconvulsive therapy in patients with pre-existing somatic comorbidity - A register-based nationwide Danish cohort study

OBJECTIVE

To examine whether electroconvulsive therapy (ECT) is associated with risk of mortality and acute somatic events in patients with or without somatic comorbidity.

METHODS

A total of 174,495 patients with an affective disorder, of whom 41% had somatic comorbidity, were followed from 2005 through 2018 for ECT, mortality, and acute somatic outcomes using Danish registers. The association of ECT with outcomes was estimated using Cox proportional hazard regression.

RESULTS

Patients, of whom 6943 (4.0%) had ECT, were followed for a median of 6.7 years. Compared to non-ECT treated patients, ECT was associated with a lower risk of death from natural causes, which was independent of somatic comorbidity. ECT was not associated with the risk of acute somatic events neither in patients with somatic comorbidity nor in patients without somatic comorbidity, except for cardiac events within 0-30 days of follow-up after the first ECT, for which there was a 3.7-fold higher risk in patients with no somatic comorbidity. This analysis, however, was based on few events.

CONCLUSION

In modern clinical practice, in patients with affective disorders and somatic comorbidity, ECT is not associated with a higher risk of death from natural causes or acute somatic events.

Pharmacological and somatic treatment effects on suicide in adults: A systematic review and meta-analysis

BACKGROUND

Suicide is a public health crisis. We conducted a systematic review and meta-analysis of the effects of psychopharmacologic and somatic therapies on suicide risk.

METHODS

A systematic search of MEDLINE for studies evaluating the effects of pharmacologic (excluding antidepressants) or somatic interventions on suicide risk was conducted. Studies were included if they used a comparison group, reported on suicide death, assessed a psychopharmacological or somatic intervention, and included adults. Study quality was assessed using the Newcastle-Ottawa scale. Fifty-seven studies were included from 2940 reviewed citations.

RESULTS

In bipolar disorder, lithium was associated with a reduction in the odds of suicide compared to active controls (odds ratio [OR] = .58, p = .005; k = 12) and compared to placebo/no lithium (OR = .46, p = .009; k = 9). In mixed diagnostic samples, lithium was associated with a reduction in the odds of suicide compared to placebo/no lithium (OR = .27, p < .001; k = 12), but not compared to active controls (OR = .89, p = .468; k = 7). In psychotic disorders, clozapine was associated with a reduction in the odds of suicide (OR = .46, p = .007; k = 7). Associations between suicide death and electroconvulsive therapy (OR = .77, p = .053; k = 11), non-clozapine antipsychotics in bipolar disorder (OR = .73, p = .090; k = 6) and antipsychotics in psychotic disorders (OR = .39, p = .069; k = 6) were not significant. There was no consistent relationship between antiepileptic mood stabilizers and suicide. There were insufficient studies to meta-analyze associations of suicide risk with vagus nerve stimulation, transcranial magnetic stimulation, magnetic seizure therapy, or transcranial direct current stimulation.

CONCLUSION

Lithium and clozapine have consistent data supporting protective effects against suicide in certain clinical contexts.

Major adverse cardiovascular events following electroconvulsive therapy in depression: A register-based nationwide Swedish cohort study with 1-year follow-up

BACKGROUND

The cardiovascular response during electroconvulsive therapy (ECT) could induce major adverse cardiovascular events (MACE) in the short-term, while reduced depression could decrease the risk of MACE in the long-term. The balance between these potential effects has not been thoroughly investigated.

METHODS

This nationwide, registry-based cohort study included all patients admitted to Swedish hospitals due to moderate or severe unipolar depression between 2011 and 2018. Patients were divided into an ECT group and a non-ECT group, and followed for 1 year. Patients were matched by risk factors for cardiovascular disease by propensity score matching. Cox regression was used to examine the association between ECT and MACE.

RESULTS

Out of a total of 28 584 inpatients, 5476 patients who had received ECT were matched to 5476 non-ECT patients. ECT was associated with reduced risk of MACE within 90 days and 1 year. Within 1 year after admission, a total of 127 patients (2.3%) in the non-ECT group and 82 patients (1.4%) in the ECT group had at least one MACE (hazard ratio [HR], 0.65; 95% confidence interval, 0.49-0.85).

LIMITATIONS

Real-life observational studies carry risk for residual confounding.

CONCLUSIONS

ECT in patients hospitalized for depression was not associated with any significant short-term risks of cardiovascular events. Instead, ECT was associated with a reduced risk of MACE within 1 year after admission compared with patients not treated with ECT. This association may be explained by reduced depressive symptoms after ECT, improved risk factor management in the ECT-group or by residual confounding by indication.

Mortality after electroconvulsive therapy

BACKGROUND

There are limited studies examining mortality associated with electroconvulsive therapy (ECT), and many studies do not include a control group or method to identify all patient deaths.

AIMS

We aimed to evaluate the risk of death associated with ECT treatments over 30 days and 1 year.

METHOD

We conducted a study analysing electronic medical record data from the Department of Veterans Affairs healthcare system between 2000 and 2017. We compared mortality among patients who received ECT with a matched group of patients created through propensity score matching.

RESULTS

Our sample included 123 479 individual ECT treatments provided to 8720 patients (including 5157 initial index courses of ECT). Mortality associated with individual ECT treatments was 3.08 per 10 000 treatments over the first 7 days after treatment. When comparing patients who received ECT with a matched group of mental health patients, those receiving ECT had a relative odds of all-cause mortality in the year after their index course of 0.87 (95% CI 0.79-1.11; P = 0.10), and a relative risk of death from causes other than suicide of 0.79 (95% CI 0.66-0.95; P < 0.01). The similar relative odds of all-cause mortality in the first 30 days after ECT was 1.06 (95% CI 0.65-1.73) for all-cause mortality, and 1.02 (95% CI 0.58-1.8) for all-cause mortality excluding suicide deaths.

CONCLUSIONS

There was no evidence of elevated or excess mortality after ECT. There was some indication that mortality may be reduced in patients receiving ECT compared with similar patients who do not receive ECT.

Electroconvulsive therapy for depression: 80 years of progress

Electroconvulsive therapy is the most effective treatment for severe, psychotic or treatment-resistant depression. However, its effectiveness continues to be questioned, both in mainstream media and narratives within the scientific literature. In this analysis, we use an evidence-based approach to demonstrate the efficacy and safety of modern electroconvulsive therapy.

Early Electroconvulsive Therapy in Patients With Major Depressive Disorder: A Propensity Score-Matched Analysis Using a Nationwide Inpatient Database in Japan

OBJECTIVES

This study aimed to evaluate whether early electroconvulsive therapy (ECT) can reduce length of hospital stay and total hospitalization costs in major depressive disorder (MDD) patients.

METHODS

Using the Japanese Diagnosis Procedure Combination inpatient database from April 2011 to March 2018 linked with the Annual Report for Functions of Medical Institutions, we identified patients admitted for MDD. Patients who received ECT within 8 days of admission were assigned to the early ECT group and the remaining patients to the control group. The primary outcomes were length of hospital stay and total hospitalization costs. The secondary outcomes were in-hospital mortality and fatal adverse events. Propensity score-matched analyses were performed to compare the outcomes between the 2 groups.

RESULTS

We identified 41,248 eligible patients, comprising 1169 in the early ECT group and 40,079 in the control group. After 1:1 propensity score matching, patients in the early ECT group had significantly shorter length of hospital stay than those in the control group (difference: -12.6 days; 95% confidence interval: -17.4 to -7.7 days). There was no significant difference in total hospitalization costs between the 2 groups. Early ECT was not significantly associated with increased in-hospital mortality or fatal adverse events.

CONCLUSIONS

Early ECT may reduce length of hospital stay without increasing total hospitalization costs or fatal adverse events in patients with MDD.

Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score-matched, retrospective cohort study

BACKGROUND

Previous studies examining the risk of medical complications from electroconvulsive therapy have been confounded and this might contribute to its underuse. This study aimed to compare the risk of serious medical events, defined as those resulting in hospitalisation or death, among patients with depression who received electroconvulsive therapy versus patients who did not receive electroconvulsive therapy.

METHODS

This was a propensity score-matched, retrospective cohort study using linked population-based administrative health data for adults admitted to designated psychiatric facilities in Ontario, Canada, for more than 3 days with depression between April 1, 2007, to Feb 28, 2017. Electroconvulsive therapy exposure was defined as one or more physician billing procedure codes during hospitalisation. The unit of analysis was individual admissions and propensity score matching was used to match each exposed admission to an unexposed admission to estimate the average treatment effect of electroconvulsive therapy among those treated. The primary outcome was serious medical events, a composite of hospitalisation for medical (ie, non-psychiatric) reasons or non-suicide death within 30 days from electroconvulsive therapy exposure or matched date in the unexposed group. Effect modification was examined using tests of interaction for three clinically relevant prespecified subgroups (sex, presence of psychotic symptoms, and illness polarity). Secondary outcomes were medical hospitalisation and non-suicide death separately, suicide death, and specific serious medical events.

FINDINGS

In propensity score matched analyses, there were 10 016 psychiatric hospitalisation records (6628 women, 3388 men) with mean age 56·6 years (SD 16·3) and no ethnicity data available. 65 818 admissions were eligible for matching and 5008 were matched (1:1) in each exposure group. In the propensity score matched cohort, the incidence of serious medical events was 0·25 per person-year in the exposed group and 0·33 per person-year in the unexposed group (cause-specific hazard ratio 0·78 [95% CI 0·61-1·00]). Suicide death as a competing risk did not alter this finding. The risk of suicide death was significantly lower in the exposed (≤5 of 5008 admissions) versus the unexposed group (11 [0·2%] of 5008 admissions; p<0·03). Bipolar depression, compared with unipolar depression, was associated with a greater reduction in the risk of serious medical events with electroconvulsive therapy. Electroconvulsive therapy was not associated with medical hospitalisation or non-suicide death separately, nor with any specific serious medical event.

INTERPRETATION

Among individuals hospitalised with depression, we found no evidence for a clinically significant increased risk for serious medical events with exposure to electroconvulsive therapy, and the risk of suicide was found to be significantly reduced, suggesting the benefits of electroconvulsive therapy for depression outcomes might outweigh its risks in this population.

FUNDING

Norris Scholars Award, Department of Psychiatry, University of Toronto; the Canadian Institutes for Health Research.

Electroconvulsive Therapy and the Risk of Suicide in Hospitalized Patients With Major Depressive Disorder

IMPORTANCE

Electroconvulsive therapy (ECT) is indicated for severe depression, including depression with psychosis, catatonia, and/or an elevated suicide risk. However, the association of ECT with suicide risk is uncertain.

OBJECTIVE

To determine the association between ECT and the risk of suicide in patients with unipolar major depressive disorder.

DESIGN, SETTING, AND PARTICIPANTS

This registry-based cohort study used patient data from Swedish national registers. Patients with a record of inpatient care between January 1, 2012, and October 31, 2018, for moderate depression, severe depression, or severe depression with psychosis were included in the study. Propensity score matching (1:1) was used to balance risk factors for suicide at baseline between patients treated with and without ECT during the inpatient episode.

EXPOSURES

Data from the Swedish National Quality Register for ECT and the Swedish National Inpatient Register were combined to identify patients who had received ECT during the inpatient episode. National registers were used to identify risk factors for suicide.

MAIN OUTCOMES AND MEASURES

Suicide within 3 and 12 months of admission to inpatient care was analyzed. Cox regression analyses were used to adjust for confounders.

RESULTS

The study included 28 557 patients (mean [SD] age, ECT group, 55.9 [18.4] years; non-ECT group, 45.2 [19.2] years; 15 856 women [55.5%]). In the matched sample of 5525 patients in each group, 62 patients (1.1%) in the ECT group and 90 patients (1.6%) in the non-ECT group died of suicide within 12 months (hazard ratio [HR], 0.72; 95% CI, 0.52-0.99). Electroconvulsive therapy was significantly associated with a decreased risk of suicide in patients with psychotic features (HR, 0.20; 95% CI, 0.08-0.54) and those aged 45 to 64 years (HR, 0.54; 95% CI, 0.30-0.99) or 65 years or older (HR, 0.30; 95% CI, 0.15-0.59), but not in patients aged 44 years or younger (HR, 1.22; 95% CI, 0.68-2.16).

CONCLUSIONS AND RELEVANCE

The results of this cohort study support the continued use of ECT to reduce suicide risk in hospitalized patients who are severely depressed, especially those who are older than 45 years and those with a psychotic subtype.

A Systematic Review of Neuromodulation Treatment Effects on Suicidality

Introduction: Neuromodulation is an important group of therapeutic modalities for neuropsychiatric disorders. Prior studies have focused on efficacy and adverse events associated with neuromodulation. Less is known regarding the influence of neuromodulation treatments on suicidality. This systematic review sought to examine the effects of various neuromodulation techniques on suicidality. Methods: A systematic review of the literature from 1940 to 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was conducted. Any reported suicide-related outcome, including suicidal ideation, suicide intent, suicide attempt, completed suicide in reports were considered as a putative measure of treatment effect on suicidality. Results: The review identified 129 relevant studies. An exploratory analysis of a randomized controlled trial comparing the effects of sertraline and transcranial direct-current stimulation (tDCS) for treating depression reported a decrease in suicidal ideation favoring tDCS vs. placebo and tDCS combined with sertraline vs. placebo. Several studies reported an association between repetitive transcranial magnetic stimulation and improvements in suicidal ideation. In 12 of the studies, suicidality was the primary outcome, ten of which showed a significant improvement in suicidal ideation. Electroconvulsive therapy (ECT) and magnetic seizure therapy was also shown to be associated with lower suicidal ideation and completed suicide rates. There were 11 studies which suicidality was the primary outcome and seven of these showed an improvement in suicidal ideation or suicide intent and fewer suicide attempts or completed suicides in patients treated with ECT. There was limited literature focused on the potential protective effect of vagal nerve stimulation with respect to suicidal ideation. Data were mixed regarding the potential effects of deep brain stimulation on suicidality. Conclusions: Future prospective studies of neuromodulation that focus on the primary outcome of suicidality are urgently needed. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=125599, identifier: CRD42019125599.

Survival Rate Following Involuntary Electroconvulsive Therapy: A Population-Based Study

OBJECTIVE

Involuntary electroconvulsive therapy (ECT) can be a lifesaving intervention for patients suffering from potentially lethal conditions who are unable to give informed consent. However, its use is not widespread, probably partly because of the scarce data on hard outcomes following involuntary ECT. In Denmark, involuntary ECT is only used when patients are at imminent/potential risk of dying if not receiving ECT. Here, we aimed to estimate the 1-year survival rate after the administration of involuntary ECT as a proxy for the effectiveness of this treatment.

METHODS

We conducted a register-based cohort study involving (i) all patients receiving involuntary ECT in Denmark between 2008 and 2019, (ii) age- and sex-matched patients receiving voluntary ECT, and (iii) age- and sex-matched individuals from the general population. One-year survival rates were compared via mortality rate ratios.

RESULTS

We identified 618 patients receiving involuntary ECT, 547 patients receiving voluntary ECT, and 3080 population-based controls. The survival rate in the year after involuntary ECT was 90%. For patients receiving involuntary ECT, the 1-year mortality rate ratios were 3.1 (95% confidence interval, 1.9-5.2) and 5.8 (95% confidence interval, 4.0-8.2) compared with those receiving voluntarily ECT and to the population-based controls, respectively. Risk factors for early death among patients receiving involuntary ECT were male sex, being 70 years or older and having organic mental disorder as the treatment indication.

CONCLUSIONS

Treatment with involuntary ECT is associated with a high survival rate, suggesting that the intervention is effective. However, patients receiving involuntary ECT constitute a high-risk population that should be monitored closely after this treatment.

Treatment-resistant depression and risk of all-cause mortality and suicidality in Danish patients with major depression

OBJECTIVE

Treatment-resistant depression (TRD) has been associated with higher mortality and risk of suicide, but this has mainly been showed in few studies which did not include self-harm. The aim was to investigate the association of TRD with all-cause mortality, suicide and self-harm in a nationwide cohort of patients with major depression and explore any differences in relation to patient characteristics.

METHODS

First-time hospital contacts for major depression between January 1, 1996 and December 31, 2014 were identified in Danish patient registers (ICD-10: F32 and F33). TRD was defined as two shifts in antidepressant treatment, assessed from one year prior depression diagnosis until one year after. Information on mortality, suicide and self-harm was obtained from Danish registers and associations between TRD and the three prognostic outcomes were analyzed using Cox Proportional Hazard Regression.

RESULTS

TRD was not associated with all-cause mortality the first year of follow-up (adjusted HR (aHR) 1.04, 95% confidence interval (CI) [0.98-1.11]), and the HR for mortality was lower the following 1-5 years. However, TRD was associated with higher rates of suicide (0-1 year: aHR 2.20, 95% CI [1.77-2.74]; 1-5 years: aHR 1.70, 95% CI [1.42-2.03]) and self-harming behavior (0-1 year: aHR 1.51, 95% CI [1.36-1.66]; 1-5 years: aHR 1.59, 95% CI [1.48-1.70]). The above risk estimates varied only slightly across sociodemographic and clinical patient characteristics.

CONCLUSIONS

Patients with TRD have higher rates of suicide and self-harm compared with non-TRD patients, whereas there seems to be no increase overall in all-cause mortality - in fact, there was a lower rate at follow-up after 1 year. We found only a few differences in HRs for mortality or suicidality across patient characteristics.

Prevention of suicidal behavior in bipolar disorder

BACKGROUND

Excess mortality is a critical hallmark of bipolar disorder (BD) due to co-occurring general medical disorders and especially from suicide. It is timely to review of the status of suicide in BD and to consider the possibility of limiting suicidal risk.

METHODS

We carried out a semi-systematic review of recent research reports pertaining to suicide in BD.

FINDINGS

Suicide risk in BD is greater than with most other psychiatric disorders. Suicide rates (per 100,000/year) are approximately 11 and 4 in the adult and juvenile general populations, but over 200 in adults, and 100 among juveniles diagnosed with BD. Suicide attempt rates with BD are at least 20 times higher than in the adult general population, and over 50 times higher among juveniles. Notable suicidal risk factors in BD include: previous suicidal acts, depression, mixed-agitated-dysphoric moods, rapid mood-shifts, impulsivity, and co-occurring substance abuse. Suicide-preventing therapeutics for BD remain severely underdeveloped. Evidence favoring lithium treatment is stronger than for other measures, although encouraging findings are emerging for other treatments.

CONCLUSIONS

Suicide is a leading clinical challenge for those caring for BD patients. Improved understanding of risk and protective factors combined with knowledge and close follow-up of BD patients should limit suicidal risk. Ethically appropriate and scientifically sound studies of plausible medicinal, physical, and psychosocial treatments aimed at suicide prevention specifically for BD patients are urgently needed.

Patient-level Characteristics and Inequitable Access to Inpatient Electroconvulsive Therapy for Depression: A Population-based Cross-sectional Study: Caractéristiques au niveau du patient et accès inéquitable à la thérapie électroconvulsive pour patients hospitalisés

OBJECTIVE

A variety of patient characteristics drive the use of electroconvulsive therapy (ECT) in depression. However, the extent to which each characteristic influences the receipt of ECT, and whether they are appropriate, is unknown. The aim of this study is to identify patient-level characteristics associated with receiving inpatient ECT for depression.

METHOD

We identified all psychiatric inpatients with a major depressive episode admitted to hospital ≥3 days in Ontario, Canada (2009 to 2017). The association between patient-level characteristics at admission and receipt of inpatient ECT was determined using logistic regression, where a generalized estimating equations approach accounted for repeat admissions.

RESULTS

The cohort included 53,174 inpatients experiencing 75,429 admissions, with 6,899 admissions involving ECT (9.2%). Among demographic factors, age was most associated with ECT-younger adults had reduced (OR = 0.30, 95%CI, 0.24 to 0.37; 18 to 25 years) while older adults had increased (OR = 3.08, 95%CI, 2.41 to 3.93; 85+ years) odds compared to middle-aged adults (46 to 55 years). The likelihood of ECT was greater for individuals who were married/partnered, had postsecondary education, and resided in the highest neighborhood income quintile. Among clinical factors, illness polarity was most associated with receiving ECT-bipolar depression had reduced odds of receiving ECT (OR = 0.62, 95%CI, 0.57 to 0.69) The likelihood of receiving ECT was greater in psychotic depression, more depressive symptoms, and incapable to consent to treatment and was reduced with comorbid substance use disorders and several medical comorbidities.

CONCLUSIONS

Nearly 1 in 10 admissions for depression in Ontario, Canada, involve ECT. Many clinical factors associated with receiving inpatient ECT were concordant with clinical guidelines; however, nonclinical factors associated with its use warrant investigation of their impact on equitable access to ECT.