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Electroconvulsive therapy (ECT) is a safe and effective treatment for major depressive disorder (MDD). ECT treatment effect relies on induced generalised seizures. Most anaesthetics raise the seizure threshold and shorten seizure duration. There are no conclusive studies on the effect of anaesthetic dose on response and remission rates with ECT for MDD.
We aimed to examine the effect of different dose intervals of anaesthetics on response and remission after ECT for MDD.
We conducted a nationwide cohort study, using data from Swedish registers. Low-, medium- and high-dose intervals, adjusted for age and gender, were constructed for each anaesthetic drug. Response and remission were measured with the Clinical Global Impression – Severity and Improvement scales (CGI-I and CGI-S), and a self-rated version of the Montgomery–Åsberg Depression Rating Scale (MADRS-S). Logistic regression models were used to calculate adjusted odds ratios for response and remission rates.
The study included 7917 patients who received ECT for MDD during 2012–2018. Patients were given either thiopental (64.1%) or propofol (35.9%). Low-dose intervals of anaesthetics were associated with increased rates of response (CGI-I: odds ratio 1.22, 95% CI 1.07–1.40, P = 0.004; MADRS-S: odds ratio 1.31, 95% CI 1.09–1.56, P = 0.004) and remission (CGI-S: odds ratio 1.37, 95% CI 1.17–1.60, P ≤ 0.001; MADRS-S: odds ratio 1.31, 95% CI 1.10–1.54, P = 0.002).
We found improved treatment outcomes with low- compared with high-dose anaesthetic during ECT for MDD. To enhance treatment effect, deep anaesthesia during ECT for MDD should be avoided.
There have been reports of long-term subjective memory worsening after electroconvulsive therapy (ECT).
To study the prevalence and risk factors of long-term subjective memory worsening among patients receiving ECT in routine clinical practice.
Patients (n = 535, of whom 277 were included in the final analysis) were recruited from eight Swedish hospitals. Participants' subjective memory impairment was assessed before ECT and a median of 73 days after ECT using the memory item from the Comprehensive Psychopathological Rating Scale. Participants also rated their pre-ECT expectations and post-ECT evaluations of the effect of ECT on memory on a 7-point scale. We used ordinal regression to identify variables associated with subjective memory worsening and negative evaluations of the effect of ECT on memory.
Comparisons of pre- and post-ECT assessments showed that subjective memory worsened in 16.2% of participants, remained unchanged in 52.3% and improved in 31.4%. By contrast, when asked to evaluate the effect of ECT on memory after treatment 54.6% reported a negative effect. Subjective memory worsening was associated with negative expectations before ECT, younger age and shorter duration of follow-up.
Although subjective memory improved more often than it worsened when assessed before and after ECT, a majority of patients reported that ECT had negative effects on their memory when retrospectively asked how ECT had affected it. This might suggest that some patients attribute pre-existing subjective memory impairment to ECT. Clinicians should be aware that negative expectations are associated with subjective worsening of memory after ECT.
Electroconvulsive therapy (ECT) is effective for unipolar depression but relapse and suicide are significant challenges. Lithium could potentially lower these risks, but is used only in a minority of patients.
This study quantifies the effect of lithium on risk of suicide and readmission and identifies factors that are associate with readmission and suicide.
This population-based register study used data from the Swedish National Quality Register for ECT and other Swedish national registers. Patients who have received ECT for unipolar depression as in-patients between 2011 and 2016 were followed until death, readmission to hospital or the termination of the study at the end of 2016. Cox regression was used to estimate hazard ratios (HR) of readmission and suicide in adjusted models.
Out of 7350 patients, 56 died by suicide and 4203 were readmitted. Lithium was prescribed to 638 (9%) patients. Mean follow-up was 1.4 years. Lithium was significantly associated with lower risk of suicide (P = 0.014) and readmission (HR 0.84 95% CI 0.75–0.93). The number needed to be treated with lithium to prevent one readmission was 16. In addition, the following factors were statistically associated with suicide: male gender, being a widow, substance use disorder and a history of suicide attempts. Readmission was associated with young age, being divorced or unemployed, comorbid anxiety disorder, nonpsychotic depression, more severe symptoms before ECT, no improvement with ECT, not receiving continuation ECT or antidepressants, usage of antipsychotics, anxiolytics or benzodiazepines, severity of medication resistance and number of previous admissions.
More patients could benefit from lithium treatment.
Declaration of interest
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