Suicidal behavior and all-cause mortality in depressed older adults aged 75+ treated with electroconvulsive therapy: A Swedish register-based comparison study.

OBJECTIVES: Electroconvulsive therapy (ECT) is effective in treating late-life depression. There is limited research on suicidal behavior and all-cause mortality in the oldest old after ECT. METHODS: Older adults aged 75 years and above who had been inpatients for moderate to severe depression between January 1, 2011, and December 31, 2017, were included in the study. We used exact and propensity score matching to balance groups. We compared suicidal behavior (fatal and non-fatal) and all-cause mortality in those who had received ECT and those with other depression treatments. RESULTS: Of the study population, 1802 persons who received ECT were matched to 4457 persons with other treatments. There were no significant differences in the risk of suicidal behavior between groups, (within 3 months: odds ratio 0.73; 95% confidence intervals (CI), 0.44-1.23, within 4 months to 1 year: aOR 1.34; 95% CI, 0.84-2.13). All-cause mortality was lower among ECT recipients compared to those who had received other treatments, both within 3 months (aOR, 0.35; 95% CI, 0.23-0.52), and within 4 months to 1 year (aOR 0.65; 95% CI, 0.50-0.83). CONCLUSIONS: Compared to other depression treatments, ECT is not associated with a higher risk of suicidal behavior in patients aged 75 and above. ECT is associated with lower all-cause mortality in this age group, but we advise caution regarding causal inferences.

Low medical morbidity and mortality after acute courses of electroconvulsive therapy in a population-based sample.

BACKGROUND: To determine event rates for specific medical events and mortality among individuals receiving electroconvulsive therapy (ECT). METHOD: Population-based cohort study using health administrative data of acute ECT treatments delivered in Ontario, Canada, from 2003 to 2011. We measured the following medical event rates, per 10 000 ECT treatments, up to 7 and 30 days post-treatment: stroke, seizure, acute myocardial infarction, arrhythmia, pneumonia, pulmonary embolus, deep vein thrombosis, gastrointestinal bleeding, falls, hip fracture, and mortality. RESULTS: A total of 135 831 ECT treatments were delivered to 8810 unique patients. Overall medical event rates were 9.1 and 16.8 per 10 000 ECT treatments respectively. The most common medical events were falls (2.7 and 5.5 per 10 000 ECT treatments) and pneumonia (1.8 and 3.8 per 10 000 ECT treatments). Fewer than six deaths occurred on the day of an ECT treatment. This corresponded to a mortality rate of less than 0.4 per 10 000 treatments. Deaths within 7 and 30 days of an ECT treatment, excluding deaths due to external causes (e.g., accidental and intentional causes of death), were 1.0 and 2.4 per 10 000 ECT treatments respectively. CONCLUSION: Morbidity and mortality events after ECT treatments were relatively low, supporting ECT as a low-risk medical procedure.

Mass killing under the guise of ECT: the darkest chapter in the history of biological psychiatry.

Following its inception, electroconvulsive therapy (ECT), rapidly spread all over the world, including Nazi Germany. Paradoxically, at the same time, the euthanasia programme was started in Germany: the extermination of people with intellectual disabilities and severe psychiatric disorders. In Lower Austria, Dr Emil Gelny, who had been granted a specialist qualification in psychiatry after three months of clinical training, took control of two psychiatric hospitals, in Gugging and Mauer-Öhling. In 1944, he began systematically killing patients with an ECT machine, something that was not practised anywhere else before or after, and remains unprecedented in the history of convulsive therapy. He modified an ECT machine, adding extra electrodes, which he fastened onto a victim's wrists and ankles to administer lethal electric shocks.

The mortality rate of electroconvulsive therapy: a systematic review and pooled analysis.

OBJECTIVE: Electroconvulsive therapy (ECT) remains underutilized because of fears of cognitive and medical risks, including the risk of death. In this study, we aimed to assess the mortality rate of ECT by means of a systematic review and pooled analysis. METHOD: The study was conducted in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The ECT-related mortality rate was calculated as the total number of ECT-related deaths reported in the included studies divided by the total number of ECT treatments. RESULTS: Fifteen studies with data from 32 countries reporting on a total of 766 180 ECT treatments met the inclusion criteria. Sixteen cases of ECT-related death were reported in the included studies yielding an ECT-related mortality rate of 2.1 per 100 000 treatments (95% CI: 1.2-3.4). In the nine studies that were published after 2001 (covering 414 747 treatments), there was only one reported ECT-related death. CONCLUSION: The ECT-related mortality rate was estimated at 2.1 per 100 000 treatments. In comparison, a recent analysis of the mortality of general anesthesia in relation to surgical procedures reported a mortality rate of 3.4 per 100 000. Our findings document that death caused by ECT is an extremely rare event.

Electroconvulsive Therapy and All-Cause Mortality in Texas, 1998-2013.

INTRODUCTION: Electroconvulsive therapy (ECT) remains an effective treatment for major depressive disorder. Since 1995, Texas has maintained an ECT database including patient diagnoses and outcomes, and reporting any deaths within 14 days of receiving an ECT treatment, encompassing a total of 166,711 ECT treatments administered in Texas over the previously unreported period of 1998 to 2013. METHODS: Descriptive analysis summarized information on deaths reported during the 16-year period-cause of death, type of treatment (index or maintenance) and patient demographics. Multiple logistic regression of death incidence by treatment session was performed to determine whether patient age, sex, race, diagnosis, or year of treatment was associated with death after ECT. RESULTS: Of those deaths occurring within 1 day of an ECT treatment, the death rate was 2.4 per 100,000 treatments. Looking at all deaths within 14 days of an ECT treatment, the death rate increased to 18 per 100,000 treatments but included all deaths regardless of likelihood of causal association with ECT, for example, accidents and suicides, the latter a leading cause of death among individuals with severe major depression or other disorders for which ECT is indicated. Death rate increased significantly with increasing patient age (P = 0.001) and male sex (P = 0.009), and there was a nonsignificant trend toward increased death amongst patients with bipolar disorder or schizophrenia (P = 0.058) versus depression. CONCLUSIONS: Our data indicate that ECT is in general a safe procedure with respect to the likelihood of immediate death. Suicide remains a significant risk in ECT patients, despite evidence that ECT reduces suicidal ideation.

An examination of mortality and other adverse events related to electroconvulsive therapy using a national adverse event report system.

BACKGROUND: : There is currently an incomplete understanding of adverse events related to electroconvulsive therapy (ECT) treatments. Much of the published literature is based either on a limited number of ECT providers or reports not representative of modern ECT practice. METHODS: : We searched the Veterans Affairs (VA) National Center for Patient Safety database for reports of adverse events related to ECT. The type and the cause of the events were determined and aggregated. The number of ECT treatments given in the VA was used to develop estimated rates of mortality associated with ECT. RESULTS: : There were no deaths associated with ECT reported in any VA hospital between 1999 and 2010. Based on the number of treatments given, we estimate the mortality rate associated with ECT as less than 1 death per 73,440 treatments. The most common reported adverse events related to ECT were injury to the mouth (including dental and tongue injury) and problems related to paralysis. CONCLUSIONS: : Based on this VA data, ECT may be safer than is widely reported. The reported adverse events were generally rare and typically minor in severity. Simple steps may possibly result in further enhancements to ECT safety.

All-cause mortality among recipients of electroconvulsive therapy: register-based cohort study.

BACKGROUND: Studies investigating mortality secondary to electroconvulsive therapy (ECT) are few. AIMS: To assess the risk of mortality from natural and unnatural causes among ECT recipients compared with other psychiatric in-patients over a 25-year period. METHOD: Register-based cohort study of all in-patients admitted to a psychiatric hospital from 1976 to 2000. Cause-specific mortality was analysed using log-linear Poisson regression. RESULTS: There were 783 deceased in-patients who had received ECT compared with 5781 who had not. Patients who had received ECT had a lower overall mortality rate from natural causes (RR=0.82, 95% CI 0.74-0.90) but a slightly higher suicide rate (RR=1.20, 95% CI 0.99-1.47), especially within the first 7 days after the last ECT treatment (RR=4.82, 95% CI 2.12-10.95). CONCLUSIONS: Further investigation of the effect of ECT on physical health and the observed increased suicide rate immediately following treatment are needed, although the last finding is likely to result from selection bias.

The electroconvulsive therapy controversy: evidence and ethics.

The author reviews literature pertaining to the efficacy and safety of electroconvulsive therapy (ECT), with emphasis on the controversy concerning whether ECT causes brain damage. ECT does appear to be effective in the treatment of severe depression and possibly mania. The types of memory problems caused by ECT are discussed, and evidence suggests that most of these deficits are transitory. Although most evidence points toward modern ECT not causing brain damage, there are still some findings that raise questions about safety. Ethical issues involving this treatment's use, its availability to the public, and informed consent procedures are discussed.

Electroshock: a crime against the spirit.

Since its introduction in 1938, electroshock (electroconvulsive treatment, ECT) has been to its proponents a blessing and to its critics a curse. The author, himself an insulin coma-electroshock survivor, sides with the critics arguing that ECT is inherently harmful and dehumanizing. To support his views, he cites findings and comments from the professional literature in four areas: brain damage, memory loss, death, and brainwashing. The author also presents seven reasons for the continuing use of ECT, including profitability, value as a reinforcer of the biological model of mental illness, the absence of informed consent, the procedure's function as a "treatment of next resort," government and media support, and the public's failure to hold psychiatrists accountable for their conduct. The author concludes the article with his poem "Aftermath."

Use of ECT in California, revisited: 1984-1994.

The use of ECT in California was examined from 1984 to 1994 and compared with a previous study examining use from 1977 to 1983. Data were collected from legally required reports submitted to the state for all ECT performed. A total of 28,437 patients (mean = 2585.18 per year) received a total of 160,847 treatments with a mean rate of 0.90 patients/10,000 population. The rate in 1984 (1.15) was similar to the mean rate for 1977-1983 (1.12). The rate dropped in 1986 (0.92) and again in 1991 (0.74). There were 821 patients (2.89% of total) judged to be incapable of giving informed consent who received ECT after a court review. This is similar to the rate of 3% for 1977 to 1983. The number of counties where ECT was available increased from 15 in 1983 to 19 in 1991 and returned to 15 in 1994. The number of facilities providing ECT increased from 62 in 1983 to 83 in 1990 and decreased to 69 in 1994. White patients comprised 91.5% of ECT recipients. Three deaths were reported for a rate of 0.19 deaths/10,000 treatments. Despite its safety and efficacy, the availability of ECT in California continues to remain limited geographically and socioeconomically. The rate of its use has declined. Access to ECT is most limited for public patients. While some of the decline may be related to the introduction of new antidepressants and the rapid expansion of managed care, complex legal regulation bears much of the responsibility.

The mortality rate with ECT.

ECT is a low-risk procedure, even in the older cardiac patient who is fast becoming the modal candidate for this therapy. To put the mortal risk with ECT in proper perspective, it is only necessary to note that ECT is about 10 times safer than childbirth, that approximately 6 times as many deaths annually in the U.S. are caused by lightning as by ECT, that two complications of psychotropic drug therapy in younger women-fatal myocardial infarction and fatal subarachnoid hemorrhage-virtually never occur with ECT, and that the death rate reported for ECT is an order of magnitude smaller than the spontaneous death rate in the general population.

Electroconvulsive therapy in patients with heart failure or valvular heart disease.

As the use of electroconvulsive therapy (ECT) increases, the chance of a practitioner's encountering a patient with significant heart failure, ventricular dysfunction, or valvular heart disease also increases. This article reviews the epidemiology, pathophysiology, and available data on the risk of ECT in these patients. Recommendations are made regarding evaluation and treatment of such patients. Some special situations are identified that may require a modification of routine procedures. Overall, ECT can be performed safely in most patients with underlying cardiac conditions, as long as appropriate precautions are taken to identify these patients ahead of time.

Sudden death in epilepsy: can any lessons be learned from convulsive therapy?

Convulsive therapy (chemically or electrically induced) has been used since the mid-1930s. Initially it had a high mortality rate, but this has been falling slowly in response to refinements in technique (introduction of muscle paralysis during the seizure, brief intravenous general anesthesia and, more recently, the acceptance that adequate ventilation and oxygenation are necessary during the procedure). Mortality during convulsive therapy has been ascribed to both cardiac and respiratory causes (particularly acute arrhythmias and pulmonary edema). There is some evidence that supporting respiration during and after the convulsion has reduced mortality significantly, such that electrical convulsive therapy is now a very low-risk procedure, even in the very elderly. This gives tenuous support for the view that death in epileptic seizures may be of respiratory origin.

Should psychiatrists administer anesthesia for ECT?

Whether psychiatrists are qualified to give anesthesia for ECT is controversial. At the authors' hospital, over a 9-year period ECT resulted in no mortality and minimal morbidity; in 98.8% of the treatments, anesthesia was given by psychiatrists. The average nursing time required for cases in which anesthesiologists administered anesthetic was longer than that for psychiatrists' cases. This difference may be related to succinylcholine dose and efficacy of ECT. The authors' surveys indicated that psychiatrists and anesthesiologists have differing opinions on whether psychiatrists should administer anesthesia for ECT and that few psychiatry residency programs which teach ECT provide training in anesthesia.