ECT and Reduction of Suicidality: New Danish Registry Study
Out on PubMed, in JECT, from senior author Soren Ostergaard, is this Danish register study:
Self-Harm and Suicide Attempts Preceding and Following Electroconvulsive Therapy: A Population-Based Study.
J ECT. 2021 Sep 13. doi: 10.1097/YCT.0000000000000790. Online ahead of print.PMID: 34519684
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.
And from the introduction:
Most of the available evidence on the beneficial effects of
ECT on suicidality stems from clinical studies, whereas there are
limited data from real-life clinical settings on the course of self-harm and suicide attempts among individuals receiving ECT. For
this reason, we chose to perform a population-based study using
data from Danish national registers with the aim of investigating
the course of self-harm and suicide attempts preceding and following ECT across 4 major mental disorders that are all associated
with suicidality, namely, unipolar depression, bipolar disorder, psychotic disorder, and personality disorder.16 This was done to examine whether data from the real-world clinical setting are compatible
with the marked reductions in suicidality observed in clinical
studies of ECT.
And from the discussion:
In this study in which a mirror-image model was applied on
population-based ECT data from routine clinical practice, we found
a substantial and statistically significant reduction in the number of
incidents of self-harm/suicide attempts in the first months following
initiation of ECT among patients with unipolar depression, bipolar
disorder, psychotic disorder, and personality disorder. Reductions
of the same absolute magnitude were not seen in the comparison
groups not receiving ECT, who were matched on age, sex, and diagnostic category nor among those who were also matched on illness duration or admission in addition to the variables mentioned
previously. In our post hoc analysis based on patients not receiving
ECT but matched to those receiving ECT on diagnostic category
and length of admission, we observed a statistically significant reduction in the number of incidents of self-harm/suicide attempts
when comparing the 1-month pre-mirror and post-mirror periods
for all diagnostic groups, and also when comparing the 3- and
6-month pre-mirror and post-mirror periods for individuals with
psychotic disorder. This finding suggests that admissions of longer duration are protective against self-harm/suicide attempts
and that the observed reduction in these events following treatment with ECT is likely to be partly mediated by the associated
admission. However, when comparing the absolute reductions in
the number of self-harm/suicide attempts in the comparison group
matched on admission length to that observed among those receiving ECT (Figs. 1A, F), it is clear that the length of admission
is unlikely to account for the full reduction in self-harm/suicide attempts found for those receiving ECT.
...To our knowledge, this
is the first study to assess the course of self-harm and suicide attempts preceding and following ECT based on nationwide data
from real-world settings across major diagnostic categories. The
fact that the study was based on all patients in Denmark with
hospital-based diagnoses of unipolar depression, bipolar disorder,
psychotic disorder, and personality disorder who initiated treatment with ECT speaks to the representativeness of the data.
Lastly, the extensive follow-up of the large sample allowed us to
explore the long-term course of self-harm/suicide attempts following ECT, revealing that patients having received ECT remain at elevated risk of self-harm/suicide attempts long after this treatment
and should therefore be monitored closely.
In conclusion, although the findings of this study should be
interpreted within the context of the observational design, they
are compatible with ECT being protective against self-harm/suicide
attempts during exacerbations of mood disorders, psychotic disorders, and personality disorders.
2021 continues to be a good year for data showing that ECT reduces suicidality and suicide risk; this epidemiological study contributes importantly to that evidence base.
This a carefully-conducted, complex study with innovative design features and a large population base. The inclusion of patients with psychotic and personality disorders, not just those with mood disorders, is particularly interesting.
Kudos to Drs. Salagre, Rohde and Østergaard for carrying out this meticulous work.
I recommend a full read (~ 30 minutes) to all those who follow the ECT/suicidality literature.
The list of biological treatments that have proven effect in reducing the risk of suicide is short...... it is time for general psychiatry to acknowledge that ECT is on that list
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