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

Abstract

Background: The effects of electroconvulsive therapy are usually estimated from changes in depression scales from studies with relatively small patient samples. Larger patient samples can be achieved from epidemiological registers, which provide information on other social and clinical predictors, results and risks. Aims: To examine whether depression severity predicts the use of electroconvulsive therapy, risk of re-hospitalization, suicidal behaviour and mortality following electroconvulsive therapy in patients with major depression. Methods: A cohort of 92,895 patients diagnosed with single or recurrent depression between 2005 and 2016 in the Danish National Patient Registry was followed for electroconvulsive therapy and adverse outcomes. Associations between electroconvulsive therapy and outcomes were analysed using Cox regression. Results: A total of 5004 (5.4%) patients were treated with electroconvulsive therapy. Depression severity was the strongest predictor of electroconvulsive therapy. Electroconvulsive therapy was used more frequently above age 70, in those better educated or married, whereas comorbid alcohol abuse or history of prior stroke at study entry were associated with lower rates. Electroconvulsive therapy was associated with lower mortality. The adjusted hazard ratio for the association between electroconvulsive therapy and suicide in patients with mild depression was 6.99 (3.30–14.43), whereas it was 1.10 (0.55–2.20) in those with severe depression and psychotic symptoms. A similar pattern was seen for emergency contacts and attempted suicide. Conclusions: Electroconvulsive therapy was associated with lower all-cause mortality and the relative risk for re-hospitalization and attempted and committed suicide was lowest in patients with the most severe depression. Electroconvulsive therapy is an important treatment, with significant public health benefits, for patients with severe depression.

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

“…10 Our findings are also consistent with a recent study from Denmark, which has a similar universal health care system to Canada, that found age and depression severity increase the likelihood of ECT, while alcohol use, being unmarried, and having low education decrease the likelihood of ECT. 11 These consistent results from a variety of jurisdictions support our hypothesis that ECT use is driven by a combination of appropriate clinical factors and questionable nonclinical factors. Although our study used Canadian data, this finding that enabling resources influence receipt of ECT also likely applies to other health care systems who are seeking to improve equitable access to this important treatment.…”

“…Furthermore, previous work has pointed out disparities in access to ECT treatment, as evidenced by nonclinical factors such as being unmarried, less educated, black race, and lack of proximity to ECT treatment facilities being associated with lower probability of receiving treatment. 10,11 Understanding the real-world implementation of ECT, and in particular characteristics of patients who do and do not receive it, may help identify populations to specifically target and improve access to ECT. Previous studies in this area have had shortcomings that limited their ability to achieve this goal.…”

Prevention of suicidal behavior in bipolar disorder

“…Among physical treatments, electroconvulsive therapy (ECT) is considered clinically to be highly effective for acutely suicidal patients, although research to support long‐lasting suicide‐preventing effects of even repeated ECT is very limited 85,86 . Other neurostimulating treatments, including repeated transcranial magnetic stimulation (rTMS), 87–89 vagal nerve stimulation, 90 and other experimental forms of superficial or deep brain stimulation (DBS), 91 may be effective for the treatment bipolar depression, whereas effects on suicidal behavior in BD patients require testing.…”

A Systematic Review of Neuromodulation Treatment Effects on Suicidality

“…Two other studies showed higher rates of completed suicide associated with ECT. Jorgensen et al (2020) using the Danish National Patient Registry, examined data of 92,895 patients with single or recurrent depression. They found that 5,004 patients were treated with ECT and that ECT treatment was associated with subsequent risk of completed suicide.…”

“…They found that 5,004 patients were treated with ECT and that ECT treatment was associated with subsequent risk of completed suicide. Adjustment for the possible confounders decreased the risk, but it remained significant (Jorgensen et al, 2020) (Supplementary Table 2). The increased risk in completed suicide was less with increased severity of depression.…”