Effects of electroconvulsive therapy on suicide in geriatrics patients with major depressive disorder: a nationwide cohort study using propensity score matching and instrumental variable analysis

工程摘要 这项研究的目的是确定ECT对老年患者自杀的影响， 抑郁症（MDD）。数据将来自医疗保险数据集和国家死亡指数。 为了研究ECT对自杀的影响，我们将使用工具变量分析，该分析解释了 未测量的混杂因素，应用于倾向评分匹配的数据。在应用倾向评分之前 模型中，患者将在年龄、性别、抗抑郁药试验次数和医学方面进行个体匹配。 在前一年治疗过自杀未遂。工具变量将是以下患者的比例： 上一日历年每家医院使用ECT治疗MDD;该仪器已成功使用 在之前的一项关于ECT和30天再入院风险的研究中，比较的主要结果将是 自杀未遂;次要结局将包括全因死亡。 自杀是一个重大的公共卫生危机，尽管公共卫生领导人做出了新的努力， 在过去的15年里，这一比率一直在上升。大多数自杀者患有可治疗的精神疾病， 最常见的是情绪障碍如抑郁症。ECT是最有效的治疗MDD和专业 指南建议ECT作为治疗严重的情绪障碍患者， 自杀然而，在我们对ECT和自杀之间的关系的理解上存在着一个关键的差距; 自杀既遂风险的降低与自杀既遂风险之间没有令人信服和一致的联系。的 这项研究旨在填补这一空白。我们的研究集中在一个丰富的老年患者样本， 体验到ECT的特别益处，并且比年轻患者更有可能接受治疗。 此外，这个年龄组在历史上是自杀的高风险。 这项研究对NIMH降低自杀率的使命具有重要意义。尽管ECT 作为治疗严重抑郁症最有效和最明确的疗法，它一直受到耻辱的困扰， 几十年然而，在过去的几年里，发表在《自然》杂志上的高质量ECT研究激增。 著名期刊重申ECT的有效性，开发预测临床结果的算法， 改善长期结果，显示其对人口健康结果的潜在益处，并建议 在第二次失败的抗抑郁药试验后使用时，它是最具成本效益的。鉴于ECT的复苏 研究，拟议的研究是及时的，对降低自杀率至关重要。如果像 假设，ECT显示与ECT发生率降低相关，未来的研究可能旨在增加 这一关键治疗和研究的传播是获得治疗的障碍。此外，缺乏A ECT和降低自杀率之间的一致联系经常被反精神病学/反ECT倡导者用来 抗议使用这种疗法。如果ECT能令人信服地证明与较低的自杀率有关， 这可能会促使防止自杀团体要求获得更多的治疗。

Project Abstract The proposed study aims to determine the effect of ECT on completed suicides in geriatric patients with major depressive disorder (MDD). Data will be drawn from both the Medicare datasets and the National Death Index. To examine the effect of ECT on suicide, we will use an instrumental variables analysis, which accounts for unmeasured confounders, applied to propensity score-matched data. Prior to applying the propensity score model, patients will be individually matched on age, gender, number of antidepressant trials and medically treated suicide attempts in the preceding year. The instrumental variable will be the proportion of patients with MDD treated with ECT in each hospital in the prior calendar year; this instrument has been used successfully in a previous study of ECT and 30-day readmission risk. The primary outcome of the comparison will be completed suicide; secondary outcomes will include all-cause mortality. Suicide is a major public health crisis and, despite renewed efforts by public health leaders, the suicide rate has been increasing in the last 15 years. Most suicide victims suffer from treatable psychiatric disorders, most commonly a mood disorder such as MDD. ECT is the most effective treatment for MDD and professional guidelines recommend ECT as a treatment for severely ill patients with mood disorders who are at high risk of suicide. However, there is a critical gap in our understanding of the relationship between ECT and suicide; there has not been a convincing and consistent link between and reduced risk of completed suicide. The proposed study aims to fill this gap. Our study focuses on an enriched sample of geriatric patients, who experience particular benefit from ECT and are more likely than younger patients to receive the treatment. Additionally, this age group is historically at high risk for suicide. The proposed study is of central relevance to the NIMH mission of reducing suicide rates. Despite ECT being the most effective and definitive therapy for severe depression, it has been dogged by stigma for decades. However, the last several years have seen a surge in high-quality ECT research published in prominent journals reiterating the effectiveness of ECT, developing algorithms for predicting clinical outcomes, improving longer-term outcomes, showing its potential benefits on population health outcomes, and suggesting it is most cost-effective when used after a 2nd failed antidepressant trial. Given this resurgence of ECT research, the proposed study is both timely and of critical importance to reducing suicide rates. If, as hypothesized, ECT is shown to be associated with reduced rates of ECT, future research could aim to increase the dissemination of this critical treatment and study barriers to treatment access. Furthermore, the lack of a consistent link between ECT and reduced suicide rates is often used by anti-psychiatry/anti-ECT advocates to protest the use of the treatment. If ECT can convincingly be shown to be associated with lower rates of suicide, this may serve to galvanize suicide prevention groups to demand greater access to the treatment.