ECT and Reduced Suicide Risk: New Register Study From Sweden
Out on PubMed, from researchers in Sweden, is this study:
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.
The pdf is here.
And from the Discussion:
To our knowledge, few studies have adequately investigated the association between suicide risk and ECT, and their results are inconsistent. To clarify this issue, we performed a large-scale study that included extensive adjustment for confounders.We found that ECT for depression was associated with a reduced risk of suicide within 3 and 12 months of inpatient care compared with non-ECT. The
association was significant in several, but not all, analyses. Furthermore, ECT was associated with reduced all-cause mortality within 3 and 12 months of inpatient care compared with non-ECT.
...The association between ECT and a decreased risk of suicide was significantly greater in older age groups than in younger age groups. Older age is a risk factor for suicide, and the distinct association between ECT and a reduced risk of suicide in older adults is therefore important. This association was in line with our hypothesis, which was based on the positive effect of ECT on response rates in older patients. There was a significant interaction effect in reduction of the suicide
rate between treatment and severity of depression. The greatest benefit of ECT was found for psychotic depression, whereas no significant benefit was noted for moderate depression.Thus, it was unclear whether the association between ECT and a reduced suicide risk is generalizable to outpatients with less severe depression.
Here is yet another excellent register-based study from Sweden. It is particularly important because evidence to show ECT's effect on suicide reduction has been difficult to come by.
The increased benefit seen in older patients and those with psychotic depression is expected and important as well.
This paper deserves to be read in full by all ECT practitioners, ~15 minutes.
Kudos to our Swedish colleagues for this very helpful contribution to the literature!
Thank you for bringing our study to your blog. I expected an effect of ECT in the short term (3-months) but was afraid that indication bias would mitigate most of the effect in less than 12 months. It turned out that the benefit remained, and statistically it was even more convincing at 12 months. It is reassuring for ECT-clinicians, who see many relapses, that there is a sufficient number of patients that have lasting benefits as to reduce the suicide risk on a group level.
ReplyDeleteNevertheless, there is still a considerable suicide risk, even after successfull ECT. A few risk factors in this study were men, those who are older, with recent suicide attempts, family history of mental disorder, and high parental education level. This points to the need for better profylaxis and more studies of continuation-ECT.
I was happy that the benefit of ECT could be shown in a "hard endpoint". The use of a rating scales are not always easy to interpret. In other areas of medicine, such as cardiology and oncology, benefits of treatments are commonly measured by "hard endpoint". Perhaps we in psychiatry should try to use similar outcomes more often, to faciliate interpretation of the results of our treatments to those less familiar with the field.