From the Editor
Is it safe?
The first treatment of electroconvulsive therapy (ECT) was administered in 1938. Yet decades later, people still debate the safety of this treatment; a study found that one in five patients reported fear of death as a major concern. (And, yes, so many of our patients have seen that movie.)
In our first selection, we consider a new and important paper on this topic, just published in The Lancet Psychiatry. Dr. Tyler S. Kaster (of the University of Toronto) and his co-authors attempt to answer the safety question by comparing those who received ECT with those who didn’t in the context of depression and inpatient care. “In this population-based study of more than 5000 admissions involving electroconvulsive therapy for inpatients with depression, the rate of serious medical events within 30 days was very low among those exposed to electroconvulsive therapy and a closely matched unexposed group (0.5 events per person-year vs 0.33 events per person-year), with those who received electroconvulsive therapy having a numerically lower risk of medical complications.” We look at the big study, with an eye on clinical implications.
In the other selection, we look at a new essay from The New Yorker. Writer Donald Antrim – an accomplished novelist and a MacArthur fellow – discusses his depression, his suicidal thoughts, and his decision to opt for ECT. He notes that after treatment: “I felt something that seemed brand new in my life, a sense of calm, even happiness.”
Selection 1: “Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score-matched, retrospective cohort study”
Tyler S. Kaster, Simone N. Vigod, Tara Gomes, et al.
The Lancet Psychiatry, 12 July 2021 Online First
Depression is a leading cause of illness and disability worldwide. Unfortunately, many individuals do not go into remission with initial treatments. In treatment-resistant depression, commonly defined as non-response to two or more medication trials of adequate dose and duration from different classes, fewer than one in seven patients go into remission with additional pharmacotherapeutic strategies. There is little evidence for the use of psychotherapy in treatment-resistant depression. Of all treatments for treatment-resistant depression, electroconvulsive therapy is the single most effective, achieving remission in 60% of individuals. As a result, electroconvulsive therapy is recommended by clinical guidelines for treatment-resistant depression or scenarios in which rapid improvement is crucial.
Despite clinical guidelines recommending its use, electroconvulsive therapy is underused. This underuse is probably related to stigma and concerns about side-effects. Although cognitive side-effects associated with electroconvulsive therapy have been extensively examined, adverse medical events are also of substantial concern for patients. One report found 20% of the public identified fear of death from electroconvulsive therapy as a major concern, despite evidence suggesting electroconvulsive therapy is a safe procedure. Case series of individuals receiving electroconvulsive therapy have adverse medical events occurring at an incidence similar to low-risk surgical procedures, with mortality occurring in 0.2–4.8 per 10 000 procedures and morbidity in 16.8 per 10 000 procedures…
Previous comparative studies, mostly focused on all-cause mortality, have found a decreased risk of adverse medical events ranging from 18% to 46%; however, these studies have been limited in their ability to account for confounding by indication. The ideal approach to address this bias would be a randomised clinical trial. However, with the known efficacy of electroconvulsive therapy, it would be unethical to withhold it in a clinical comparative trial. Furthermore, given the rare nature of serious medical events related to electroconvulsive therapy, the clinical trial approach is not practical due to the large numbers required to detect a difference between groups on these outcomes.
So begins a paper by Kaster et al.
Here’s what they did:
- The authors conducted “a propensity-score matched, retrospective cohort study across all of the designated psychiatric inpatient units (around 84 separate units) in Ontario, Canada, using linked population-based administrative health-care databases at the ICES (formerly the Institute for Clinical Evaluative Sciences)…”
- Inclusion criteria: adults who had a psychiatric admission for depression lasting at least three days between April 1, 2007, to Feb 28, 2017.
- “Electroconvulsive therapy exposure was defined as one or more physician billing procedure codes during hospitalisation.”
- “The unit of analysis was individual admissions and propensity score matching was used to match each exposed admission to an unexposed admission to estimate the average treatment effect of electroconvulsive therapy among those treated.”
- The primary outcome: “serious medical events defined as either medical hospitalisation or non-suicide death within 30 days of the exposure date or corresponding index date…”
- Statistical analyses were done. “The primary analysis was a time-to-event analysis of a serious medical event up to 30 days after the index date. We used a Cox proportional hazards model to calculate the hazard ratio (HR) for exposed and unexposed groups after propensity score matching.”
Here’s what they found:
- There were 10 016 psychiatric hospitalization records.
- Demographics: more women than men (6628 vs. 3388 men); mean age of 56.6.
- 65 818 admissions were eligible for matching; 5008 were matched (1:1).
- “In the propensity score matched cohort, the incidence of serious medical events was 0.25 per person-year in the exposed group and 0.33 per person-year in the unexposed group (cause-specific hazard ratio 0.78…). See forest plot below.
- “The risk of suicide death was significantly lower in the exposed (≤5 of 5008 admissions) versus the unexposed group (11 [0.2%] of 5008 admissions)…”
The authors write: “The clinical implication of this study is that electroconvulsive therapy is likely to be safe with respect to medical risks; considering its established efficacy in depression, the benefits of electroconvulsive therapy might outweigh its risk in this severely ill population.”
A few thoughts:
- This is an excellent study.
- This is a well written paper; it’s also smart.
- The result in a nutshell: ECT was no less safe than no ECT for this population; suicides were significantly reduced, however. (!)
- Other studies have shown a protective effect with ECT for medical events. The authors didn’t find that: “In contrast with previous work, we did not identify statistically significant evidence of a protective effect from electroconvulsive therapy. The most likely explanation for this discrepancy is that confounding was inadequately addressed in previous studies given the limited number of covariates…”
- Did the underlying diagnosis matter? Interestingly, bipolar depression was noted to have greater reduction in serious medical events over unipolar depression.
- Like all papers, there are limitations. The authors note several including: “we only included serious medical events and excluded minor medical complications addressed in the emergency department, outpatient unit, or psychiatric inpatient unit settings.”
- The clinical implications? We should be recommending more ECT to our patients. And when patients raise concerns about safety, we can mention this paper.
- The public policy implications? ECT is safe and effective – but badly underutilized. Treatment-refractory depression is a major public health problem in Canada, affecting (and disabling) hundreds of thousands of people. To return to the authors opening comments: “electroconvulsive therapy is underused.” Actually, it’s worse than that. Despite its effectiveness for depression, ECT is less commonly used than in the past. In a Canadian Journal of Psychiatry paper, drawing on Quebec data, the authors found that ECT use was down by 33% in 15 years in Quebec. Ouch. That Reading can be found here: http://davidgratzer.com/reading-of-the-week/reading-of-the-week-ect-safe-effective-but-declining-use-the-lemasson-et-al-study-on-ect-in-quebec/
The full Lancet Psychiatry paper can be found here:
Selection 2: “Finding a Way Back from Suicide: A journey of recovery through electroconvulsive therapy”
The New Yorker, 9 August 2021
I’d written about my mother, a memoir of our lives together. She was a terrible alcoholic. The manuscript felt like a betrayal. It was April, 2006. I was sick with suicide. I let myself hang from the fire escape, and almost fell from the roof of my building. My girlfriend, Regan, was exhausted from the months of my decline. I’d only got worse and worse, until, finally, my doctor told me that I would die if I stayed out of the hospital. I’d already had one trip, after the day on the roof, to a hospital in Brooklyn, but I had talked my way out, and now five weeks had passed. I was taking the sedative Klonopin, but no antidepressant. I didn’t want to die. My friend Anne was a psychiatrist at Columbia Presbyterian, way uptown; she worked in the psych emergency room, and she insisted that I come there, that they would take care of me. One day in early May, I called a car and rode uptown. I didn’t take much with me. It was a sunny, clear day, and I could see the George Washington Bridge in the distance. The car stopped in front of the E.R., and I got out and stumbled in.
In the waiting room, I sat bowed over, my head in my hands and my elbows on my knees. Eventually, a nurse came and led me to a wooden door that had a police officer standing beside it. This was the entrance to the psychiatric emergency room. The police officer knocked on the door, and a second police officer, waiting inside, opened it.
The psych E.R. wasn’t a big space.
So begins an essay by Antrim.
The author describes his depression. He also notes his suicidal thoughts. “Maybe you’ve spent some time trying every day not to die, out on your own somewhere. Maybe that effort has become your work in life. Perhaps there is help from family and friends, all the people who don’t quite understand that, when you tell them they will be better off with you dead, you are speaking a truth. Maybe you’re alone in a room, lying on a bed, and your chest is tight and your breathing shallow; you feel afraid to move; you sleep two or three hours each night, and then wake up in fear. Maybe you pace. Maybe you keep pills in a jar or a drawer, or hidden behind a box in the closet.”
He notes his lack of response to antidepressants – not, as a provider would, with a simple list, but in terms of what it meant to his life:
“Nortriptyline didn’t work. Eight weeks is a long time to sit getting worse in a hospital. Three times each week, I had psychotherapy with Dr. A. I begged him to promise that I would ride my bike again, or write another story, or survive the loss of my mother. At the end of each session, he asked me to draw a house. My houses were plain; I can’t draw, but so what if the walls were crooked and the windows oblong? No one was ever in those houses, no stick-figure family, no mom, no dad. My feeling that I would die, or that I would at least never live outside an institution, grew stronger, and I became convinced that I was in the wrong hospital, that I was sick in my body, not in my head.”
Writer David Foster Wallace urges him to think about ECT. “David told me that he’d had ECT in the Midwest, twenty years before. He said that it could save my life, that it was a safe treatment, that the doctors knew what they were doing, and that I should not be afraid of losing my memory or my competency; I was in good hands. ‘I want you to try ECT,’ he told me. He said it again and again, because he knew that I was ruminating, and that I would not be able to believe him for more than a few minutes.”
He tries ECT, and the recovery is slow but clear.
“It was mid-August. I did not feel burning in my gut; my legs didn’t tingle or shake; and I no longer woke in terror at three in the morning. Dr. A. congratulated me on my recovery, on working hard and persevering. A day or two later, he invited me for coffee and a Danish. He unlocked the big steel door, and we left the ward.”
A few thoughts:
- This is a well written essay.
- The writing is raw, personal, and moving.
- The above summary doesn’t quite capture his journey. The essay is rich in details, including descriptions of his co-patients, his own illness experience over the years, and the slow pace of inpatient admissions.
- Did ECT save his life?
- In a past Reading, psychiatrist Rebecca E. Barchas describes her decision to receive ECT treatment. You can find it here: https://davidgratzer.com/reading-of-the-week/reading-of-the-week-ect-at-82/
The full New Yorker essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.