Effectiveness of electroconvulsive therapy on treatment-resistant depressive disorder: A population-based mirror-image study
Introduction
Treatment-resistant depression generally refers to an inadequate response to one or more adequate antidepressant treatments (Fava, 2003). The prevalence of treatment-resistant depression ranges from 30% to 70%, based on the definition of treatment-resistant depression and the selected study populations (Fava, 2003; Nemeroff, 2007). Electroconvulsive therapy (ECT) is one treatment choice for major depressive episode (MDE), especially for those with inadequate response (American Psychiatric Association, 2010; Bauer et al., 2013, 2015; Tess and Smetana, 2009). The worldwide expert consensus is that ECT is an appropriate treatment choice in not only the acute and continuation but also in the maintenance phase of treatment for depressive disorder (Bauer et al., 2013, 2015). ECT is a proven potent treatment for major depression, more effective than drug therapy and other brain stimulation (Slotema et al., 2010; UK ECT Review Group, 2003). MDE remission is faster in patients receiving ECT than in those receiving drug therapy (Spaans et al., 2015). The superior efficacy of ECT in diminishing the severity of depressive symptoms has been proven repeatedly (Ren et al., 2014; Spaans et al., 2015; UK ECT Review Group, 2003).
However, recent surveys show a decrease in the utilization of ECT in the psychiatric practice of several countries (Case et al., 2013; Dauenhauer et al., 2011; Lambe et al., 2014). The reasons for such decline in using ECT include public concern over side effects (Dowman et al., 2005), advancement and increased acceptance of psychopharmacological treatment (Mojtabai, 2009), government and professional regulation (Harris, 2006), and disparity in availability and utilization of medical resources among social groups (Case et al., 2012). More extensive evaluation of the long-term effectiveness and cost of ECT may provide valuable information for health care providers and utilizers to guide the decision making process for treatment choice for MDE (Chakrabarti et al., 2010; Smith et al., 2009; Vallejo-Torres et al., 2015).
In terms of effectiveness, the outcome measures for treatment of MDE are not limited to symptomatology (Zimmerman et al., 2008). Several studies explored the impact of ECT on re-hospitalization among patients with MDE. Some studies suggested that ECT at index episode was associated with decreased psychiatric re-admission rates (Rosen et al., 2016; Slade et al., 2017), while the majorities of studies failed to find such effects (Al-Shehhi et al., 2017; Byrne et al., 2012; Ng et al., 2009; Ng et al., 2012; O'Leary and Lee, 1996; Popiolek et al., 2018; Stoudemire et al., 1994; Tor and Abdin, 2018). It should be noted that most of these studies involved very few patients or did not focus on the effect of ECT. Furthermore, several dimensions of outcome measures, such as frequency of emergency department (ED) visits (Knoth et al., 2010), medical expenditures (Kessler, 2012), and length of stay for inpatient care (Cheng et al., 2007; Zhang et al., 2016) are relevant to the cost and burden of MDE, but seldom examined in relation to ECT (Cohen et al., 2013). Although several treatment guidelines recommend the use of ECT in major depressive disorder as a second-line option, the effectiveness of ECT in treatment-resistant depression has not yet been fully investigated.
The current study aimed to examine whether ECT reduced re-hospitalization within one year after discharge. The study was conducted in a population-based study sample drawn from a nationwide database that included all patients with treatment-resistant depressive disorder who received ECT augmentation and a matched comparison group of treatment-resistant depressive disorder patients who received pharmacotherapy alone. The current study employed a mirror-image study design to examine the changes in various clinical outcome indices one-year before and after the ECT. The outcome indices included psychiatric hospitalization rates, length of psychiatric hospital stays, number of ED visits, and direct medical costs during the pre- and post-treatment periods. In addition, factors affecting the effectiveness of ECT were also examined.
Section snippets
Data source
Approximately 99.8% of the Taiwanese population had been enrolled in the National Health Insurance (NHI) program. The National Health Insurance Research Database (NHIRD) is derived from the NHI reimbursement records, which includes the beneficiaries’ demographic information, medical visits, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses, and prescription claims. Specifically, the prescription claims data in NHIRD provides comprehensive
Patient characteristics at index hospitalization
Overall, the patients treated with ECT and comparison subjects did not differ significantly in age, gender, type of depression, duration of hospitalization, or clinical comorbid conditions. However, the pharmacological treatment between these two groups was different. Patients with depressive episodes who underwent ECT were more likely than comparison subjects to receive antidepressant polypharmacy during their index hospitalizations (P < 0.001). In addition, more patients with ECT received
Discussion
To the best of our knowledge, our study is the first mirror-image comparison design study to evaluate the effectiveness of ECT in patients with treatment-resistant depressive disorder. We found that ECT significantly decreased the rate of psychiatric hospitalization over the 1-year follow-up period. The average length of psychiatric hospitalization decreased in the post-hospitalization year of the ECT group, while patients in the comparison group had increased days of psychiatric
Declaration of competing interest
None.
Acknowledgements
This work was supported by grants from Ministry of Technology of Science, Taiwan (PI: CSW, MOST 107-2314-B-002-216) and National Health Research Institutes (PI: HJT, PH–104–PP–14, PH–104–SP–05 and PH–104–SP–16). The National Taiwan University Hospital and National Health Research Institutes had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.
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Drs Wu and Liao equally contributed to this study.