Electroconvulsive therapy likely does not increase risk for adverse events
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Electroconvulsive therapy for depression did not lead to a clinically significant increased risk for serious medical events, according to results of a propensity score-matched, retrospective cohort study published in The Lancet Psychiatry.
Its use appeared to significantly reduce the risk for suicide, suggesting its benefits for depression outcomes might outweigh its risks among this population.
“Both depression and the ECT procedure may be independently associated with adverse medical events,” Tyler S. Kaster, MD, of the Temerty Centre for Therapeutic Brain Intervention at the University of Toronto in Canada, told Healio Psychiatry. “The unmet research need motivating this study was that we hoped to separate out the effect of the ECT procedure from the condition which it is used to treat (in this case depression) on the risk for relatively rare medical events.”
Kaster and colleagues analyzed linked population-based administrative health data of 10,016 adults (6,628 women; mean age, 56.6 years) admitted to psychiatric facilities in Ontario, Canada, for longer than 3 days with depression between April 1, 2007, and Feb. 28, 2017. They defined exposure to electroconvulsive therapy as having at least one physician billing procedure code during hospitalization. Individual admissions served as the unit of analysis, and the researchers used propensity score matching to match each exposed admission to an unexposed admission, allowing estimation of the average treatment effect of electroconvulsive therapy among those who received treatment. Serious medical events, which were a composite of hospitalization for non-psychiatric reasons or non-suicide death within 30 days from exposure to electroconvulsive therapy or matched date in the unexposed group, served as the primary outcome. Kaster and colleagues used tests of interaction for three clinically relevant prespecified subgroups, which were sex, presence of psychotic symptoms and illness polarity, to assess effect modification. Medical hospitalization and non-suicide death separately, suicide death and specific serious medical events served as secondary outcomes.
Results of propensity score matched analyses showed an incidence of serious medical events of 0.25 per person-year among the exposed group and 0.33 per person-year in the unexposed group (cause-specific HR = 0.78; 95% CI, 0.61-1) for the propensity score matched cohort. The researchers noted no altering effect on this finding for suicide death as a competing risk. The exposed group had a significantly lower risk for suicide death, with five or fewer of 5,008 admissions, compared with the unexposed group, which had 11 of 5,008 admissions. Kaster and colleagues reported an association between bipolar depression and a greater reduction in the risk for serious medical events with electroconvulsive therapy compared with unipolar depression. Further, they observed no association between electroconvulsive therapy and medical hospitalization or non-suicide death separately, nor with any specific serious medical event.
“These findings can help inform the decision-making process for individuals considering ECT treatment for themselves or their loved ones, which is often a difficult decision,” Kaster said. “Our work provides reassuring information regarding the medical risks associated with ECT treatment, and preliminary evidence regarding its benefits with respect to suicide death.”
In a related editorial, Sameer Jauhar, PhD, FRCPsych, and Allan H. Young, PhD, FRCPsych, both of the Center for Affective Disorders at King’s College London, summarized the takeaway message from the current study.
“The data from Kaster and colleagues’ study advance knowledge on potential risks associated with electroconvulsive therapy, and although there are inevitable problems with the method, it is worth noting that in a reasonably powered sample there was little to suggest increased risk, and, although the numbers are small, the data suggested potentially beneficial effects on suicide,” they wrote. “Although these findings require replication, this study does provide the field with a considerable degree of reassurance about the safety of one of the most effective treatments within psychiatry.”