Mega Meta-analysis Shows ECT Mortality 'Extremely Rare'

Liam Davenport

June 23, 2017

COPENHAGEN, Denmark ― Deaths directly related to electroconvulsive therapy (ECT) are rare events and seem to be decreasing in incidence, results of a very large-scale meta-analysis show.

The findings, experts say, should reassure patients and clinicians of the treatment's safety.

The pooled analysis of more than 750,000 ECT procedures performed since the mid-1970s showed that the rate of deaths related to ECT itself was only around two per 100,000 treatments – less than that seen with general anesthesia for surgery.

"It seems that death caused by ECT is an extremely rare event, if it happens at all. So we hope that this information can be used to reassure concerned patients or their relatives when ECT is being considered, because we know that this is a concern for people in general," said study investigator Søren Dinesen Østergaard, MD, PhD, associate professor, Psychosis Research Unit, Aarhus University Hospital, Risskov, Denmark.

The findings were presented here at the 13th World Congress of Biological Psychiatry and were recently published in Acta Psychiatrica Scandinavica.

Fear and Prejudice

Dr Østergaard noted that there is a great deal of prejudice and fear in the general population regarding the use of ECT and that it is fueled by media portrayals of the treatment.

"So we hope that this information can be used to reassure concerned patients or their relatives when ECT is being considered, because we know that this is a concern for people in general."

For example, a study by Prof Peter Sienaert investigated the way in which ECT is depicted in film and television. It focused on informed consent, the indication for ECT, the use of anesthesia, outcomes, and adverse effects, among other factors.

He found that the "vast majority of movies and TV programs show a negative and inaccurate image of ECT" that is in "sharp contrast" to how the treatment is viewed in modern psychiatry.

Furthermore, research indicates that approximately 21% of the general public have a fear of death when considering ECT. Interestingly, research also shows that 24% of medical students have similar fears about the procedure.

"These numbers are really quite horrible, and it turns out that people really don't know that ECT is a quite safe procedure," said Dr Østergaard. "ECT practitioners know this, physicians in general know this, most of them, but it hasn't gotten out to the general population."

To investigate the mortality rate associated with ECT, the team conducted a systematic review and pooled analysis using the Preferring Reporting Items for Systematic Reviews and Meta-Analyses method and the PubMed and Embase databases.

To be included, articles had to come from peer-reviewed journals. They had to report on the total number of ECTs performed and the number of related deaths, and the studies had to involve least 3000 ECT sessions, among other criteria.

ECT-related mortality was typically defined in the studies as deaths occurring during or soon after ECT and that the cause of death was likely ECT related. Such potential causes included cardiac arrest and aspiration pneumonia. From an initial yield of 1523 records, the team included 15 studies published from 1976 to 2014 in the analysis. The data pertained to 766,180 ECT sessions conducted in 32 countries.

Across all 15 studies, there was a total of 16 ECT-related deaths, giving an overall ECT-related mortality rate of 2.1 per 100,000 treatments.

By comparison, the mortality rate associated with general anesthesia used during surgical procedures was 3.4 per 100,000, as reported in a recent meta-analysis.

In nine studies published after 2001, which included 414,747 treatments, there was just one ECT-related death.

"So it appears that the ECT-related mortality had dropped over time, which is not surprising when you consider the better equipment, better anesthesia, better training of physicians, and so on and so forth," said Dr Østergaard.

The results were almost identical when the researchers compared the ECT-related mortality rate calculated from the four survey studies with the rate found in the register or chart review studies, at 2.4 per 100,000 treatments and 2.0 per 100,000 treatments, respectively.

"The estimate that we came up with is probably quite conservative, because there was a touch of doubt in many of the cases of death reported. People talked about deaths that 'could plausibly' have been associated with anesthesia or ECT or that ECT could have been a contributory cause of death. One death was described as having a doubtful relationship to ECT, so it really appears that our overall estimate is somewhat conservative," said Dr Østergaard.

He noted that there was also a risk of confounding by indication, although this, again, would have led to a lower mortality rate attributable to ECT than was estimated in the analysis.

Dr Østergaard acknowledged that there were some potential biases in the study, but he believes that they would have had only a limited impact on the results.

"A very, very important thing to consider when talking about the mortality or safety of a treatment is the mortality of not giving the treatment when it's indicated, and there's absolutely no doubt that for ECT, that risk is imminent, so therefore, the benefit-to-risk ratio of ECT is extremely favorable," he said.

Hopefully, this report can contribute to consoling patients who are worried before ECT and maybe make it easier for them to make what is likely to be the right decision for their treatment," he added.

Ill-Informed Concerns

Co-chair and discussant William M. McDonald, MD, JB Fuqua Chair for Late-Life Depression, Department of Psychiatry, Emory University, Atlanta, Georgia, said that Dr Østergaard's talk was "really an amazing presentation."

He then provided a cautionary tale of how he believes ill-informed concerns over ECT can affect public policy, citing the US Food and Drug Administration's (FDA's) recent recommendations for its use.

"They had their first hearing in 2011, and in December of 2015, they put out their guidelines as to what you could use an ECT device for. The [FDA] guidelines, essentially there was only evidence for the use of ECT in the acute treatment of adults with unipolar depression or bipolar disorder," said Dr McDonald "So they completely left out catatonia, they certainly wouldn't have included patients with dementia and agitated behavior, and they excluded a lot of the diseases such as schizophrenia, for which ECT is used throughout the world," he added

Dr McDonald told the meeting's international audience that they may think that what the FDA does has no bearing on them and that its decisions don't matter.

"And I'd say to you: Did you really think the United Kingdom was going to leave the European Union? Did you think Donald Trump was going to be elected? These things, as Dr Østergaard has pointed out, have become emotional. This isn't a scientific argument anymore."

Dr McDonald concluded: "It takes a lot of guts for the people in this room to treat the people we treat. But this is a good fight to fight, and we all need to fight it together as an international community of practitioners.

The study was funded by the Lundbeck Foundation. No relevant financial relationships have been disclosed.

13th World Congress of Biological Psychiatry. Abstract 520, presented June 20, 2017.

Acta Psychiatr Scand. 2017;135:388-397. Abstract

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