Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score-matched, retrospective cohort study,The Lancet Psychiatry

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Risk of serious medical events in patients with depression treated with electroconvulsive therapy: a propensity score-matched, retrospective cohort study
The Lancet Psychiatry ( IF 30.8 ) Pub Date : 2021-07-12 , DOI: 10.1016/s2215-0366(21)00168-1
Tyler S Kaster ₁ , Simone N Vigod ₂ , Tara Gomes ₃ , Rinku Sutradhar ₄ , Duminda N Wijeysundera ₅ , Daniel M Blumberger ₆

Affiliation

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.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada; ICES, Toronto, ON, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; ICES, Toronto, ON, Canada.
Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada; ICES, Toronto, ON, Canada; Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada.
Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Campbell Family Mental Health Research Institute Centre for Addiction and Mental Health, Toronto, ON, Canada.

Background

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.

Methods

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.

Findings

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.

Interpretation

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.

Funding

Norris Scholars Award, Department of Psychiatry, University of Toronto; the Canadian Institutes for Health Research.

中文翻译：

接受电休克疗法治疗的抑郁症患者的严重医疗事件风险：一项倾向评分匹配的回顾性队列研究

背景

以前检查电休克疗法引起的医学并发症风险的研究被混淆了，这可能导致其使用不足。本研究旨在比较接受电休克治疗的抑郁症患者与未接受电休克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。

方法

这是一项倾向评分匹配的回顾性队列研究，使用基于人口的相关行政健康数据，针对在 2007 年 4 月 1 日至 2017 年 2 月 28 日期间在加拿大安大略省指定精神病院住院超过 3 天患有抑郁症的成年人。电休克治疗暴露被定义为住院期间的一个或多个医生计费程序代码。分析单位是个体入院，并使用倾向评分匹配将每次暴露入院与未暴露入院相匹配，以估计电休克治疗在接受治疗的患者中的平均治疗效果。主要结局是严重的医疗事件，包括因医疗而住院的复合事件（即，非精神病）原因或非自杀性死亡在电惊厥治疗暴露后 30 天内或未暴露组的匹配日期。使用三个临床相关的预先指定亚组（性别、精神病症状的存在和疾病极性）的相互作用测试来检查效果修改。次要结局分别是住院和非自杀死亡、自杀死亡和特定的严重医疗事件。

发现

在倾向评分匹配分析中，共有 10 016 份精神病住院记录（6628 名女性，3388 名男性），平均年龄 56·6 岁 (SD 16·3)，没有可用的种族数据。每个暴露组中有 65 818 名入院符合匹配条件，5 008 名符合 (1:1)。在倾向评分匹配队列中，暴露组严重医疗事件的发生率为 0·25/人年，未暴露组为 0·33/人年（原因特异性风险比 0·78 [95% CI 0·61–1·00]）。自杀死亡作为一种竞争风险并没有改变这一发现。与未暴露组（5008 次入院中的 11 [0·2%]；p<0·03）相比，暴露组（5008 次入院中≤5 次）的自杀死亡风险显着降低。双相抑郁与单相抑郁相比，与电休克治疗严重医疗事件风险的更大降低相关。电休克疗法与单独的住院治疗或非自杀死亡无关，也与任何特定的严重医疗事件无关。