From the Editor
In a recent survey, 20% identified fear of death as a major concern with ECT. One of the oldest treatments in psychiatry is also its most stigmatized and feared.
And is it also underappreciated? Is ECT a lifesaver for those who are suicidal? In the first selection, Dr. Tyler S. Kaster (of the University of Toronto) and his co-authors attempt to answer that question with a propensity score-weighted, retrospective cohort study comparing those who received ECT and those who didn’t, using Ontario data. In The Lancet Psychiatry, they write: “1 year after discharge from a psychiatric hospital, patients with depression who were exposed to electroconvulsive therapy had a nearly 50% reduction in the relative risk of death by suicide when compared with those who had not been exposed.” We consider the paper and its clinical implications.
In the second selection, Dr. Victor Pereira-Sanchez (of the New York University) and his co-authors look at violence against European psychiatric trainees. In this Academic Psychiatry paper, drawing on survey data, they conclude: “Violence from patients is reported by many psychiatric trainees across countries in Europe, with very frequent verbal abuse and worrisome figures of physical and sexual assaults.”
Finally, in the third selection, Dr. Vivek H. Murthy (the US Surgeon General) writes about burnout and American health care workers. In The New England Journal of Medicine, he offers a practical plan, with an emphasis on reducing administrative burden, bettering mental health for health care workers, and changing culture to support well-being. He argues that action is needed: “we cannot allow ourselves to fail health workers and the communities they serve.”
Selection 1: “Risk of suicide death following electroconvulsive therapy treatment for depression: a propensity score-weighted, retrospective cohort study in Canada”
Tyler S. Kaster, Daniel M. Blumberger, Tara Gomes, et al.
The Lancet Psychiatry, June 2022
In the past 20 years, the global mortality rate for death by suicide has increased, and at present, it is the leading cause of years of life lost in several countries. One of the most important methods to reduce the risk of death by suicide is effective treatment of depression, especially in the high-risk period following a psychiatric hospitalisation.
Electroconvulsive therapy is considered one of the most effective treatments for depression. Evidence suggests that electroconvulsive therapy results in symptom remission in more than 60% of patients, and compared with sham electroconvulsive therapy, active electroconvulsive therapy results in a standardised effect size of 0·91 in favour of active electroconvulsive therapy, which translates to nearly a 10-point reduction on the Hamilton Depression Rating Scale… Evidence from a variety of study designs comparing electroconvulsive therapy with pharmacological interventions, such as antidepressants or intravenous ketamine infusions, and non-pharmacological interventions, such as repetitive transcranial magnetic stimulation, support the superior efficacy of electroconvulsive therapy…
Independent of its antidepressant effects, electroconvulsive therapy has also been associated with rapid reduction in suicidal ideation in non-comparative studies.
So begins a paper by Kaster et al.
Here’s what they did:
“This was a propensity score-weighted, retrospective cohort study using linked population-level administrative health data for adults with depression who had been admitted to a designated psychiatric bed in Ontario, Canada for more than 3 days between April 1, 2007 and Dec 31, 2017. Electroconvulsive therapy exposure was defined as one or more physician billing procedure codes during hospitalisation. The primary outcome was death by suicide identified using administrative health records within 365 days following discharge. We used cause-specific Cox proportional hazards model to estimate the cause-specific hazard ratio (csHR) for electroconvulsive therapy-exposed and electroconvulsive therapy-unexposed individuals. Secondary outcomes were non-suicide death and all-cause mortality.”
Here’s what they found:
- Admissions. There were 4982 (7.4%) electroconvulsive therapy-exposed admissions and 62345 (92.6%) electroconvulsive therapy-unexposed admissions.
- Demographics. Of those who received ECT, 3282 (65.9%) were women; the mean age was 57.1. No ethnicity data were available.
- Deaths. “450 deaths by suicide were recorded within 365 days after discharge: 27 deaths in the group exposed to electroconvulsive therapy and 423 deaths in the group not exposed to electroconvulsive therapy.”
- “In propensity-score weighted analyses, electroconvulsive therapy was associated with a significantly reduced risk of suicide death (csHR 0.53…).”
- “Accounting for non-suicide death as a competing risk had no effect on the findings.”
- “Electroconvulsive therapy was also associated with a significantly reduced risk of all-cause mortality (0.75…), but not non-suicide death (0.83…).”
They conclude: “Using modern epidemiological methods to address confounding, our comparative observational study of more than 65 000 admissions found that death by suicide in the year following discharge after hospitalisation for depression was significantly reduced with electroconvulsive therapy. We also found that this reduction in risk of death by suicide led to a significant reduction in all-cause mortality and that electroconvulsive therapy did not increase the risk of nonsuicide deaths. Taken together, these findings support the view that electroconvulsive therapy can be a lifesaving treatment in patients with severe depression.”
A few thoughts:
1. This is a major study.
3. How to think about this result in terms of clinical care? “With regards to absolute risk reduction, we found that 205 patients need to be treated with electroconvulsive therapy to prevent one death by suicide in the year after discharge. The NNT [number needed to treat] observed in this study to prevent one death by suicide was similar to the NNT in lithium treatment for mood disorders.”
4. When speaking to patients about ECT, do you mention that it reduces suicide – and thus is a life saver? Should you?
5. Like all studies, there are limitations. The authors note several, including: “This is an observational study, thus residual or unobserved confounding could be present. However, previous empirical work suggests that observational studies using administrative health data and propensity score methods can provide similar results as randomised control trials, particularly in studies of comparative effectiveness.”
6. Of course, ECT has been considered in past Readings.
For instance, in the pages of Psychiatric Services, Dr. Rebecca E. Barchas – a retired psychiatrist – discusses how ECT helped her with depression. Here: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-ect-at-82/. The Kaster et al. paper on ECT and safety is important and can be found here: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-is-ect-really-safe-the-new-lancet-psychiatry-paper-also-antrim-on-his-ect-new-yorker/.
The full Lancet Psychiatry paper can be found here:
Selection 2: “Violence Against Psychiatric Trainees: Findings of a European Survey”
Victor Pereira-Sanchez, Ahmet Gürcan, Sundar Gnanavel, et al.
Academic Psychiatry, April 2022
Workplace violence by patients against health care professionals is frequently reported across the world and includes different forms of verbal, physical, and sexual abuse; harassment; threats; and aggressions. Violence in the context of psychiatric disorders has been subject to controversy over the years, and the association of aggression with people who have mental illness has contributed to negative stereotypes and stigma.
In a meta-analysis of workplace violence against health care workers globally (combining studies reporting either 12-month or lifetime prevalence), an overall prevalence of 61.9% was reported (41.8% for Europe). Professionals working in emergency departments and mental health services were at higher risk of becoming victims, and data on differential prevalence between genders were inconsistent. Medical trainees (i.e., residents and fellows) are also frequently reported as victims…
So begins a brief report by Sanchez et al.
Here’s what they did:
“A cross-sectional online survey was distributed between June 2018 and December 2019 among European psychiatric trainees through professional networks, using a snowball approach. The questionnaire asked about experiences of verbal abuse and physical and sexual assaults, as well as their context and impact. Descriptive analyses of the obtained data were conducted.”
Here’s what they found:
- The survey was completed by 827 trainees from 39 countries.
- Demographics. Most participants were female (68.4%). The mean age was 30.9 years, and the median percentage of training completed was 50%.
- Reported abuse/violence. Most (83.6%) reported having been abused/assaulted at least once. Verbal was the most common form (93%); followed by physical (44.1%) and sexual (9.3%).
- Settings. “Emergency rooms and inpatient units were the most frequent settings.”
- “Psychological impact of these events was commonly reported.”
- “Most respondents did not report abuses and assaults to their supervisors.” !!
A few thoughts:
1. This manuscript brings needed data to the important issue of violence against trainees.
2. The number of respondents is impressive.
3. How do the findings compare to other studies? “The findings of our cross-sectional, non-probabilistic sampling study in Europe closely parallel the results from other cross-sectional studies with local or national data in Western countries: USA, Canada, and Dutch-speaking Belgium. The proportion of verbal abuse in our sample was similar to verbal threats reported in previous studies (around 73%). Our estimates for physical violence are within the range of previous studies (25 – 56%). The proportion of sexual assaults cannot be compared because they have not been consistently examined, with the exception of a small survey in the USA.”
4. Let’s repeat the most striking finding: “Most respondents did not report abuses and assaults to their supervisors.” Ouch. Would this be different in North America?
The brief report can be found here:
Selection 3: “Confronting Health Worker Burnout and Well-Being”
Vivek H. Murthy
The New England Journal of Medicine, 13 July 2022
Early in the Covid-19 pandemic, when much of U.S. society shut down, health workers put their own safety on the line and kept going to work to care for patients. Although their communities initially banged on pots, cheered from their balconies, and put up thank-you signs, the pots have long since stopped clanging. Expressions of gratitude have too often been replaced by hostility, anger, and even death threats toward health workers, as health misinformation has exploded, eroding trust in science and public health experts. Yet doctors, nurses, pharmacists, social workers, respiratory therapists, hospital security officers, and staff members of health care and public health organizations continue showing up to battle the pandemic and its sequelae — long Covid, mental health strain, widening health disparities, and 2 years’ worth of deferred care for myriad conditions.
The toll on our health workers is alarming. Thousands of them have died from Covid. More than half of health workers report symptoms of burnout, and many are contending with insomnia, depression, anxiety, post-traumatic stress disorder, or other mental health challenges. An intensive care nurse in Miami told me, ‘There was a point when I could no longer contain the heartbreak of everyone I lost.’
So begins a perspective by Dr. Murthy.
The US Surgeon General notes high rates of burnout now – and significant problems ahead in the United States:
- “Some 52% of nurses and 20% of doctors say they are planning to leave their clinical practice.”
- “Shortages of more than 1 million nurses are projected by the end of the year.”
- “A gap of 3 million low-wage health workers is anticipated over the next 3 years.”
He writes: “Addressing health worker well-being requires first valuing and protecting health workers.”
He outlines a five-point plan. We summarize three here:
“We must reduce administrative burdens that stand between health workers and their patients and communities. One study found that in addition to spending 1 to 2 hours each night doing administrative work, outpatient physicians spend nearly 2 hours on the electronic health record and desk work during the day for every 1 hour spent with patients – a trend widely lamented by clinicians and patients alike…”
He focuses on EMRs: “Our electronic health record systems need human-centered design approaches that optimize usability, workflow, and communication across systems. Health systems should regularly review internal processes to reduce duplicative, inefficient work. One such effort, Hawaii Pacific Health’s ‘Getting Rid of Stupid Stuff’ program, has saved 1700 nursing hours per month across the health system.”
Mental Health Care
“We need to increase access to mental health care for health workers. Whether because of a lack of health insurance coverage, insurance networks with too few mental health care providers, or a lack of schedule flexibility for visits, health workers are having a hard time getting mental health care. Expanding the mental health workforce… and utilizing virtual technology to bring mental health care to workers where they are and on their schedule are essential steps.”
“We need to build a culture that supports well-being. It’s time to break the traditional silence surrounding the suffering of health workers. As gratifying as our work is, it can also be profoundly isolating, especially when we feel we can’t let our colleagues know if we’re not OK – a feeling that millions of health workers, including me, have had during our careers. Culture change must start in our training institutions, where the seeds of well-being can be planted early. It also requires leadership by example in health systems and departments of public health.”
A few thoughts:
1. This is an important essay.
2. His suggestions are practical and thoughtful.
3. Is the silver lining of the pandemic that we consider burnout in health care workers?
The full perspective paper can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.