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.

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.

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.

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.

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.

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.

Epidemiologic considerations in electroconvulsive therapy.

Data from the Monroe County (New York) Psychiatric Case Register were grouped for 1961 through 1965, 1966 through 1970, and 1971 through 1975 for comparisons of incidence, prevalence, mortality, and length of stay associated with electroconvulsive therapy (ECT). While incidence of first ECT series declined substantially from 1961 through 1965 to 1971 through 1975 in most age-sex groups, significant declines in prevalence of admissions involving ECT occurred only among young female patients. Both prevalence and incidence analyses showed increasing specificity over time of ECT use in cases of depression. Demographic characteristics associated with ECT were accounted for by diagnostic correlates. Mortality effects associated with use of ECT were not pronounced, though a lower rate of accidental and circulatory deaths in the ECT group was noted. Lengths of hospital stay for patients receiving ECT were generally longer than for other depression hospitalizations, both for first ECT and later ECT series.

Use of ECT in California, 1977-1983.

The author examined the use of ECT in California from 1977 to 1983, a period during which its availability steadily declined. Approximately 1.12 persons per 10,000 population received ECT in 1977-1983, with little variation from year to year. Most ECT was paid for with nonpublic funds by white patients in nongovernmental facilities. The probability of receiving ECT increased with the age of the patient. ECT was quite safe: no fractures were reported, and the mortality rate was 0.2 deaths per 10,000 treatments. Despite restrictive regulation and limited availability, ECT continues to be used in California.

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.

Myths of "shock therapy".

The author discusses the myths of the ECT process--that shock and the convulsion are essential, memory loss and brain damage are inescapable, and little is known of the process--and assesses the fallacies in these ideas. Present views of the ECT process suggest that its mode of action in depression may best be described as a prolonged form of diencephalic stimulation, particularly useful to affect the hypothalamic dysfunctions that characterize depressive illness. The author emphasizes the need for further study of this treatment modality and for self-regulation by the profession.

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.

Electroconvulsive therapy. The perioperative process.

Although ECT is not a typical procedure performed in the surgical suite, the OR does provide a safe environment for the patient. With an anesthesiologist backup and a fully equipped postanesthesia care unit available, the staff is well equipped to deal with any adverse reactions. Many people, including health professionals, have reservations about ECT. Such views are usually formed by inaccurate media portrayals of the treatment. One successful method to overcome these misunderstandings is education. Gradually, with the interdepartmental preceptorship, in-service education sessions, and interactions with patients, the OR staff working with the ECT program at St Joseph Hospital and Health Care Center grew to accept and understand the treatment. Based on our experience, ECT can be an effective, well-planned method of treatment for some psychopathological conditions.

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."

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.