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eLetters: Electronic letters published:
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Mortality and ECT
- Rahul Bharadwaj, Sandeep Grover, Assistant Professor, Department of Psychiatry, PGIMER, Chandigarh, India (29 May 2007)
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Mortality from natural causes and electroconvulsive therapy
- Yann Le Strat, Philip GORWOOD (29 May 2007)
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Reply from Authors
- Trine Munk-Olsen, Thomas Munk Laursen, Poul Videbech, Preben Bo Mortensen, Raben Rosenberg (20 June 2007)
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Rahul Bharadwaj, Senior Resident Department of Psychiatry, PGIMER, Chandigarh, India, Sandeep Grover, Assistant Professor, Department of Psychiatry, PGIMER, Chandigarh, India
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r_s_bh{at}yahoo.com Rahul Bharadwaj, et al.
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In an era that has seen ECT being opposed for political, not clinical reasons, it was heartening to see an article on ECT addressing a very important issue i.e. ECT and mortality. The study of Munk-Olsen et al (2007), based on the Danish registry system, acclaimed for its reliability provides important information about the risk of mortality following ECT. However, certain issues need further clarification. It would have been relevant to know the total number of patients who received ECT and the total number of ECT treatments received by patients over the study period. Furthermore, the results could be better understood if information regarding physical comorbidity and the age of patients at the time of receiving ECT have been provided. These variables can have a strong influence on mortality rates. In addition, as the study included only inpatients, it is likely that the sample included severely ill patients. Also, the results show that when “days since last ECT treatment” is included in the analysis, the relative risk of mortality from natural causes of patients “discharged within the past 8-30 days” rises as compared to when “days since last ECT” is not included in the analysis. Furthermore, the relative risk of mortality from natural causes is also highest within 7 days of last ECT (RR=2.11), which is similar to the trend seen in deaths due to unnatural causes, especially due to suicide. Both these figures go against the conclusion of the authors that the mortality from natural causes is lower with ECT. It must also be noted that the relative risk of dying by suicide after ECT is 1.20 which is not significant but the authors refer to it as ‘a marginally significant trend’, and ‘significantly increased suicide rate’. The finding that the risk from suicide is highest in the first 7 days after discharge and ECT is based on a small sample (n=6). While the authors concede that admission status and time since discharge are important confounders in the analysis of suicide in patients with affective disorders, the statistical analysis does not consider these factors when calculating the relative risk of suicide after ECT. The authors discuss in some length the lack of a selection bias of patients with poor physical health. However, it is likely that patients with very poor physical health are not given ECT and this introduces a selection bias. Also, given the bias that occurs as patients at high risk for suicide are given ECTs preferentially, this calls into question the validity of the conclusions. Further, it would have been very useful if authors could have compared the death rates with general population. This study provides several good research questions, which need to be pursued further. References: • Munk-Olsen T, Laursen TM, Videbech P, Mortensen PB, Rosenberg R. All-cause mortality among recipients of electroconvulsive therapy: Register-based cohort study. Br J Psychiatry, 2007; 190:435-9. |
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Yann Le Strat, Psychiatrist AP-HP, Philip GORWOOD
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philip.gorwood{at}lmr.aphp.fr Yann Le Strat, et al.
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Munk-Olsen et al (2007) reported that the mortality rate from natural causes was lower for electroconvulsive therapy (ECT) patients than for other psychiatric inpatients. The relative risk was particularly significant for mortality linked with respiratory disease (RR=0.67, 95%CI 0.55-0.95) and a trend was founded for cardiovascular disease (RR=0.85, 95% CI 0.70-1.03). The authors concluded that this decreased risk of mortality from natural causes is unlikely to be the result of a selection bias of patients, as comorbid disease are less likely to receive ECT. They based this statement on (1) the absence of absolute contraindications to ECT in the international guidelines, and (2) the concordant findings of previous studies. In contradiction with such statement, the clinical pratice suggests that psychiatrists are generally reluctant to consider ECT in medically ill patients, and are more likely to ask for the opinion of a colleague in such a case (e.g. anaesthetist, cardiologist) (Benbow & Shah, 2002). Thus, severely medicaly ill patients could be less likely to be treated by ECT. Furthermore, pre-ECT identification of cardiovascular diseases or pulmonary disorders, as well as physical examination and usual laboratory tests are part of a systematic screening procedure before ECT. This practice improves the diagnosis and the treatment of medical comorbidities. Indeed, the absence of such preliminary medical examination led to high level of cardiac complication after ECT in the past (Gerring & Shields, 1982). Accordingly current guidelines emphasize the importance of identifying and carefully managing patients with risk factors before, during and after ECT, as well as assessing the risks associated with anesthesia (National Institute for Clinical Excellence, 2003). Patients receiving ECT are therefore not representative of all psychiatric inpatients. The careful assessment and treatment of their physical comorbidities contrasts with the increased rate of untreated physical illness in psychiatric patients, mostly because of inadequate somatic care in psychiatric units (Rasanen, Meyer-Rochow, Moring, et al, 2006). Therefore, the observed diminution of mortality from natural causes in patients with ECT is more likely to be related to appropriate medical assesment and treatment than to a direct effect of ECT on physical health. Benbow, S. M. & Shah, A. (2002) A survey of the views of geriatric psychiatrists in the United Kingdom on the use of electroconvulsive therapy to treat physically ill people. Int J Geriatr Psychiatry, 17, 956-961. Gerring, J. P. & Shields, H. M. (1982) The identification and management of patients with a high risk for cardiac arrhythmias during modified ECT. J Clin Psychiatry, 43, 140-143. Munk-Olsen, T., Laursen, T. M., Videbech, P., et al (2007) All-cause mortality among recipients of electroconvulsive therapy: Register-based cohort study. Br J Psychiatry, 190, 435-439. National Institute for Clinical Excellence (2003) Guidance in the Use of Electroconvulsive Therapy London: NICE. Rasanen, S., Meyer-Rochow, V. B., Moring, J., et al (2006) Hospital- treated physical illnesses and mortality: An 11-year follow-up study of long-stay psychiatric patients. Eur Psychiatry. |
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Trine Munk-Olsen, Researcher MSc, Thomas Munk Laursen, Poul Videbech, Preben Bo Mortensen, Raben Rosenberg
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tmo{at}ncrr.dk Trine Munk-Olsen, et al.
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Thank you to Dr. Bharadwaj and Dr. Strat for their interest in our paper on mortality after ECT (Munk-Olsen, T., Laursen, T. M., Videbech, P. et al, 2007) and for this opportunity to comment on the issues raised. Firstly, both authors comment on the findings concerning a decrease in mortality from natural causes in ECT treated patients. In Denmark, all psychiatric patients are given a thorough medical assessment prior to any somatic treatment. This is partly due to the well known cardiac contraindication of tricyclic antidepressants (TCA) which were widely used during the study period from 1976 to 2000, as the SSRIs were only available in the last part of the period described. Furthermore, the SSRIs were generally considered less effective than TCA or ECT in severely depressed patients. Accordingly, ECT was often used in patients with contraindications to TCA treatment. We are aware that this notion is in contrast to several British guidelines (for instance the NICE rapport from 2003), but it is in accordance with Danish guidelines and the APA taskforce stating that the only contraindications to ECT are cerebral and other aneurisms. In Denmark, a preponderance of medically ill patients is thus found among ECT treated patients compared to TCA treated patients, and we therefore maintain our conclusion. Secondly, Dr. Bharadwaj draws attention to admission status and time since discharge as important confounders. We fully agree in this view and have hence adjusted for these variables in the analyses. The variables in Table 3 on risk of suicide in ECT recipients were mutually adjusted, but by mistake this was not mentioned specifically in the footnote. Thirdly, the number of patients committing suicide the first week after ECT discontinuation was small, and therefore our results should be interpreted with caution, which is also mentioned in the discussion. ECT is often administered to patients assessed to be suicidal, and we acknowledge that this could introduce selection bias (confounding by indication), which is also mentioned in the paper. These are the reasons why we concluded that: “The increased suicide rate among ECT patients shortly after treatment is probably a result of bias” and we therefore disagree that the validity of the study is questionable regarding suicide rates after ECT. Lastly, a more in depth description of the ECT patients can be found in a paper based on the same data (Munk-Olsen, T., Laursen, T. M., Videbech, P. et al, 2006). Trine Munk-Olsen, Thomas Munk Laursen, Poul Videbech, Preben Bo Mortensen, Raben Rosenberg. Reference List 1. Munk-Olsen, T., Laursen, T. M., Videbech, P., et al (2007) All- cause mortality among recipients of electroconvulsive therapy: register- based cohort study. Br.J.Psychiatry, 190, 435-439. 2. Munk-Olsen, T., Laursen, T. M., Videbech, P., et al (2006) Electroconvulsive Therapy: Predictors and Trends in Utilization From 1976 to 2000. J.ECT, 22, 127-132. |
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