Electroconvulsive therapy reduces suicidality and all-cause mortality in refractory depression: A systematic review and meta-analysis of neurostimulation studies
Jolein Odermatt, Jan Sarlon, Neysan Schaefer, Sarah Ulrich, Magdalena Ridder, Else Schneider, Undine E. Lang, Timur Liwinski , Annette B. Brühl
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引用次数: 0
Abstract
Depressive disorders are among the most common psychiatric disorders worldwide and associated with half of all suicides. There is robust evidence indicating that both electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation (rTMS) effectively alleviate depressive symptoms in difficult-to-treat depression and enhance patient outcomes. However, there remains ongoing debate regarding their potential roles in preventing suicide and reducing all-cause mortality. Our study aims to investigate the impact of various neurostimulation techniques, including ECT, rTMS, and vagus nerve stimulation (VNS), on reducing suicidality, including suicidal ideation and completed suicides, as well as on overall mortality among individuals diagnosed with depression. In this systematic review and meta-analysis, we searched on MEDLINE via PubMed until January 9, 2024 for randomised controlled trials and controlled observational studies that investigated suicide and all-cause mortality outcomes after neurostimulation treatment for depression.
Of the 1351 screened records we identified 26 studies eligible for inclusion in our systematic review. We included 11 studies on ECT (involving 17′890 subjects treated with ECT and 25′367 controls receiving treatment as usual), 5 studies on rTMS and 3 studies on VNS in our meta-analysis. In the cumulative cohort, 208 suicide deaths (1.70 %) were observed in the ECT group and 988 suicide deaths (5.02 %) were registered in the control group. Moreover, there were 511 deaths from all causes (3.13 %) in the ECT group, compared to 1325 deaths (6.64 %) in the control group. Thus, treatment with ECT demonstrated a significant 34 % decrease in the odds of suicide (OR 0.66, 95 % CI 0.50–0.88, p = 0.0047) and a 30 % reduction of death from all causes (OR 0.70, 95 % CI 0.62–0.79, p < 0.0001). The standardized mean difference (SMD) for suicidal ideation before and after ECT was −0.58 (95 % CI –0.10 to −1.07, p = 0.0177), suggesting a moderate effect size. We found no significant effect of rTMS on suicidal ideation with an SMD of −0.41 (95 % CI –1.01 – 0.19, p = 0.1795). In patients treated with VNS a 60 % reduction in the odds of death from all causes was observed (OR 0.40, 95 % CI 0.18–0.92, p = 0.0306).
To conclude, there is consistent observational data supporting the protective effects of ECT against suicide and overall mortality.
The systematic review protocol is registered online on PROSPERO, CRD42023412887.
抑郁症是世界上最常见的精神疾病之一,与一半的自杀有关。有强有力的证据表明,电痉挛治疗(ECT)和重复经颅磁刺激(rTMS)都能有效缓解难治性抑郁症的抑郁症状,并提高患者的预后。然而,关于它们在预防自杀和降低全因死亡率方面的潜在作用仍存在争议。我们的研究旨在调查各种神经刺激技术,包括ECT、rTMS和迷走神经刺激(VNS)对减少自杀行为(包括自杀意念和自杀完成)以及抑郁症患者总体死亡率的影响。在这项系统评价和荟萃分析中,我们通过PubMed检索了MEDLINE,直到2024年1月9日,调查了神经刺激治疗抑郁症后自杀和全因死亡率结果的随机对照试验和对照观察性研究。在1351份筛选的记录中,我们确定了26项研究符合纳入系统评价的条件。我们在meta分析中纳入了11项关于ECT的研究(包括17890名接受ECT治疗的受试者和25367名接受常规治疗的对照组),5项关于rTMS的研究和3项关于VNS的研究。在累积队列中,ECT组有208例(1.70%)自杀死亡,对照组有988例(5.02%)自杀死亡。此外,ECT组有511例死亡(3.13%),而对照组有1325例死亡(6.64%)。因此,ECT治疗显示自杀率显著降低34% (OR 0.66, 95% CI 0.50-0.88, p = 0.0047),各种原因导致的死亡率显著降低30% (OR 0.70, 95% CI 0.62-0.79, p <;0.0001)。ECT前后自杀意念的标准化平均差异(SMD)为- 0.58 (95% CI -0.10至- 1.07,p = 0.0177),表明效应大小适中。我们发现rTMS对自杀意念没有显著影响,SMD为- 0.41 (95% CI - 1.01 - 0.19, p = 0.1795)。在接受VNS治疗的患者中,观察到所有原因死亡的几率降低了60% (OR 0.40, 95% CI 0.18-0.92, p = 0.0306)。总之,有一致的观察数据支持ECT对自杀和总体死亡率的保护作用。系统评价方案在线注册:PROSPERO, CRD42023412887。