One-Year Survival Rates After ECT- Epidemiological Study from Denmark

Out on PubMed, from investigators in Spain and Denmark, is this study:

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

Salagre E, Rohde C, Ishtiak-Ahmed K, Gasse C, Østergaard SD.J ECT. 2020 Dec 17;Publish Ahead of Print. doi: 10.1097/YCT.0000000000000736. Online ahead of print.PMID: 33337646

The abstract is copied below:

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.

And a figure from the text:

And from the Introduction:

A particularly sensitive scenario arises when ECT is needed because of life-threatening conditions, but the patient is unable to consent because of his/her severe psychiatric symptoms. These conditions include imminent risk of suicide, inanition, or dehydration following refusal/inability to eat/drink, delirium, and malignant catatonia.21–23 In such situations, patients can be referred to involuntary ECT, usually after obtaining family or legal guardian consent or court approval.24 The use of involuntary ECT, though, has been a matter of intense debate, probably partly because of the fact that evidence to guide clinical decisions in this situation is still very limited.24 This may be one of the reasons why there are large variations in the use of involuntary ECT across countries.25 The scarce evidence on clinical outcomes after involuntary ECT predominantly stems from surveys or small case-control studies, which report rapid clinical improvement in patients undergoing involuntary ECT, comparable with improvements observed with voluntary ECT, with significant patient satisfaction and only mild and transient side effects.26–28 Considering that involuntary ECT is by no means rare, and represents up to 26% of the ECT treatments in some countries,28 obtaining more solid evidence on its effectiveness is essential. Therefore, the aim of this study was to evaluate the effectiveness of involuntary ECT using data from the national Danish registers. In Denmark, involuntary ECT can only be used on “vital indication,” that is, when patients are at imminent/potential risk of dying if not receiving ECT. Hence, the most relevant (and hard) outcome measure when assessing the effectiveness of involuntary ECT is survival. 

and from the Discussion:

...Although we found that the 1-year survival of the patients receiving involuntary ECTwas high, the mortality rate was substantially higher compared with that of the age- and sex-matched patients undergoing voluntary ECT, and compared with that of age- and sex-matched individuals from the general population. This confirms our hypothesis that individuals receiving involuntary ECT represent an “at risk” population. Specifically, we identified older age, male sex, and having a diagnosis of organic mental disorder as risk factors for death in the year after involuntary ECT. In the light of these results, we decided to perform a simple post hoc analysis of the 1-year mortality rate of elderly (≥70 years) male patients receiving involuntary ECT for organic mental disorder. There were 16 patients matching this description and 10 of those died during follow-up, corresponding to a 1-year mortality rate of 62.5%. This is in line with mortality estimates reported in medical samples focusing on elderly inpatients with delirium. Specifically, McCusker et al,50 describe an estimated yearly 12-month mortality rate of 63.3% in this population, with patients exhibiting more severe delirium symptoms having the highest mortality rate.

This is an important epidemiological study that adds to the data on ECT as a life-saving procedure in vulnerable populations. 

Yes, an initial, too-quick read might lead you to believe that involuntary ECT leads to excess mortality-but the opposite is true: even though the relative rates are slightly higher in the involuntary ECT group, they are absolutely low enough (in a high-risk population) to show a life-saving effect. 

One of the interesting facets of this study and study population is the category, "organic mental disorder", much of which is comprised of delirium. Delirium as an indication for ECT is much more common in Denmark, than in the USA, for example; it would be interesting to know more about the specific etiologies of delirium in these patients.

Dr. Østergaard and colleagues are to be complimented for yet another meticulously carried-out, sophisticated and hugely informative study. Once again, our European colleagues (particularly in Scandinavia) lead the way in ECT research, as they often have, for many decades, aided by comprehensive population datasets.