Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada; ICES, Toronto, ON, Canada.
Lancet Psychiatry. 2021 Aug;8(8):686-695. doi: 10.1016/S2215-0366(21)00168-1. Epub 2021 Jul 12.
Previous studies examining the risk of medical complications from electroconvulsive therapy have been confounded and this might contribute to its underuse. This study aimed to compare the risk of serious medical events, defined as those resulting in hospitalisation or death, among patients with depression who received electroconvulsive therapy versus patients who did not receive electroconvulsive therapy.
This was a propensity score-matched, retrospective cohort study using linked population-based administrative health data for adults admitted to designated psychiatric facilities in Ontario, Canada, for more than 3 days with depression 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 was serious medical events, a composite of hospitalisation for medical (ie, non-psychiatric) reasons or non-suicide death within 30 days from electroconvulsive therapy exposure or matched date in the unexposed group. Effect modification was examined using tests of interaction for three clinically relevant prespecified subgroups (sex, presence of psychotic symptoms, and illness polarity). Secondary outcomes were medical hospitalisation and non-suicide death separately, suicide death, and specific serious medical events.
In propensity score matched analyses, there were 10 016 psychiatric hospitalisation records (6628 women, 3388 men) with mean age 56·6 years (SD 16·3) and no ethnicity data available. 65 818 admissions were eligible for matching and 5008 were matched (1:1) in each exposure group. 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 [95% CI 0·61-1·00]). Suicide death as a competing risk did not alter this finding. 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; p<0·03). Bipolar depression, compared with unipolar depression, was associated with a greater reduction in the risk of serious medical events with electroconvulsive therapy. Electroconvulsive therapy was not associated with medical hospitalisation or non-suicide death separately, nor with any specific serious medical event.
Among individuals hospitalised with depression, we found no evidence for a clinically significant increased risk for serious medical events with exposure to electroconvulsive therapy, and the risk of suicide was found to be significantly reduced, suggesting the benefits of electroconvulsive therapy for depression outcomes might outweigh its risks in this population.
Norris Scholars Award, Department of Psychiatry, University of Toronto; the Canadian Institutes for Health Research.
之前研究电击治疗引起的医学并发症的风险的研究受到了混杂因素的影响，这可能导致电击治疗的使用不足。本研究旨在比较接受电击治疗的抑郁症患者与未接受电击治疗的患者发生严重医疗事件（定义为导致住院或死亡的事件）的风险。
这是一项采用倾向评分匹配的回顾性队列研究，使用加拿大安大略省指定精神科设施住院超过 3 天的成人的基于人群的行政健康数据。入组时间为 2007 年 4 月 1 日至 2017 年 2 月 28 日，诊断为抑郁症。电击治疗暴露定义为住院期间的一个或多个医生计费程序代码。分析单位为个体入院，采用倾向评分匹配将每个暴露入院与未暴露入院相匹配，以估计接受治疗者中电击治疗的平均治疗效果。主要结局是 30 天内由电击治疗暴露或未暴露组中匹配日期引起的严重医疗事件，包括因医疗（即非精神病）原因住院或非自杀性死亡。使用三个临床相关的预设亚组（性别、精神病症状存在和疾病极性）的交互检验来检查效应修饰。次要结局是分别为医疗住院和非自杀性死亡、自杀性死亡和特定严重医疗事件。
在倾向评分匹配分析中，有 10016 份精神病住院记录（6628 名女性，3388 名男性），平均年龄为 56.6 岁（SD 16.3），没有种族数据。65818 份入院记录符合匹配条件，在暴露组和未暴露组中分别有 5008 份（1:1）进行匹配。在倾向评分匹配队列中，暴露组的严重医疗事件发生率为 0.25/人年，未暴露组为 0.33/人年（特定病因危险比 0.78 [95%CI 0.61-1.00]）。自杀死亡作为竞争风险并没有改变这一发现。暴露组（≤5/5008 例入院）的自杀死亡风险明显低于未暴露组（5008 例入院中的 11 例[0.2%]；p<0.03）。与单相抑郁症相比，双相抑郁症与电击治疗严重医疗事件风险降低相关。电击治疗与医疗住院或非自杀性死亡无关，也与任何特定的严重医疗事件无关。
在因抑郁症住院的人群中，我们没有发现暴露于电击治疗会导致严重医疗事件的临床显著风险增加的证据，而且发现自杀风险显著降低，这表明电击治疗对抑郁症结局的益处可能超过其在该人群中的风险。
多伦多大学精神病学系诺里斯学者奖；加拿大卫生研究院。
