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

项目摘要 这项拟议的研究旨在确定电休克疗法对患有严重自杀的老年患者的影响。 抑郁障碍(MDD)。数据将来自联邦医疗保险数据集和国家死亡指数。 为了检验ECT对自杀的影响，我们将使用工具变量分析，这解释了 未测量的混杂因素，适用于倾向得分匹配的数据。在应用倾向评分之前 模型，患者将在年龄、性别、抗抑郁药物试验次数和医学上进行单独匹配 在前一年接受过自杀未遂治疗。辅助变量将是患者的比例 上一历年在各医院接受ECT治疗的MDD；该仪器已成功使用 在之前的一项关于ECT和30天再住院风险的研究中。比较的主要结果将是 完全自杀；次要结果将包括各种原因造成的死亡。 自杀是一种重大的公共卫生危机，尽管公共卫生领导人再次努力，自杀 在过去的15年里，这一比率一直在上升。大多数自杀者都患有可治愈的精神疾病， 最常见的是情绪障碍，如MDD。ECT是治疗MDD和职业性疾病最有效的方法 指南建议将ECT作为治疗有情绪障碍的重症患者的一种方法，这些患者有较高的 自杀。然而，在我们对电疗和自杀之间的关系的理解上存在着严重的差距； 完全自杀和降低自杀风险之间并没有令人信服和一致的联系。这个 拟议的研究旨在填补这一空白。我们的研究集中在丰富的老年患者样本上，他们 体验ECT的特殊益处，并且比年轻患者更有可能接受治疗。 此外，从历史上看，这个年龄段的人自杀的风险很高。 这项拟议的研究对NIMH降低自杀率的任务具有核心意义。尽管进行了ECT 作为治疗严重抑郁症最有效和最确定的疗法，它一直受到 几十年。然而，在过去的几年里，发表在 著名杂志重申了ECT的有效性，开发了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好处，并建议 在第二次抗抑郁药物试验失败后使用时，它的性价比最高。鉴于ECT的复苏 研究表明，这项拟议的研究对降低自杀率既及时又至关重要。如果，如 假设，ECT被证明与ECT的发生率降低有关，未来的研究可能旨在增加 这一关键治疗和研究的传播给获得治疗设置了障碍。此外，缺乏一个 ECT和降低自杀率之间的一致联系经常被反精神病学/反ECT的倡导者用来 抗议使用这种治疗方法。如果电疗能令人信服地证明与较低的自杀率有关， 这可能会刺激自杀预防团体要求更多地获得治疗。

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.