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ECT a Potential Lifesaver in Comorbid PTSD, Major Depression
Medscape Medical News
June 4, 2014

The use of electroconvulsive therapy (ECT) in individuals with posttraumatic stress disorder (PTSD) and comorbid major depression may substantially reduce the risk for all-cause mortality, cardiovascular mortality, and suicide in this patient population, new research suggests.

A retrospective study conducted by investigators at Captain James Lovell Federal Health Care Center (FHCC) ? Rosalind Franklin University of Medicine and Science in North Chicago, Illinois, showed that among patients with PTSD and major depressive disorder (MDD), the death rate among those who did not receive ECT was significantly greater than that of their counterparts who received ECT.

In addition, at 8-year follow-up, ECT was associated with a significant reduction in relative risk (RR) in all-cause mortality and suicidal behaviors among patients with PTSD and MDD.

"The finding that all-cause mortality was almost double ― 18% vs 9.7% ― in those with PTSD and major depression who did not receive ECT was very much a surprise to us," lead investigator Naser Ahmadi, MD, PhD, told Medscape Medical News. The study was presented here at the American Psychiatric Association's 2014 Annual Meeting.

Frequent Bedfellows
According to the investigators, PTSD and MDD frequently coexist, with up to 48% of patients with PTSD having comorbid MDD. PTSD is associated with poor outcomes as well as other comorbid psychiatric and medical conditions.

Although numerous studies have shown that ECT is the most effective treatment for refractory depression, its long-term effect on PTSD and MDD is unclear.

The investigators' initial hypothesis was that the mortality rate in patients with PTSD and MDD who received ECT would be no different from the mortality rate in patients with major depression who received ECT. "So basically, we wanted to make sure that ECT wasn't contraindicated in patients with comorbid PTSD and major depression," said Dr. Ahmadi.

To determine the long-term impact of ECT on outcomes in patients with MDD and PTSD, Dr. Ahmadi and colleagues conducted a retrospective nested matched case-control study based on diagnostic and outcomes data from Veterans Affairs electronic medical records of 22,164 patients at FHCC ― 3485 with MDD and PTSD and 18,679 without either condition.

Of the 3485 patients with both conditions, 92 received ECT and 3393 did not. The ECT protocol was bifrontal and administered at 250% above the seizure threshold for an average of 6.5 treatments. Brief, light general anesthesia was used during the treatment, and succinylcholine was used for muscle relaxation.

At a median follow-up of 8 years (2004-2013), study results revealed that the death rate was 8% (1495/18,679) in patients without PTSD and MDD, 9.7% (9/92) in patients with PTSD and MDD who received ECT, and 18% (612/3393) in those with PTSD and MDD who did not receive ECT (P < .05).

The researchers also found that there was a marked improvement in PTSD and MDD symptoms with ECT (90%) compared with treatment with antidepressants alone (50%).

Cox regression survival analyses revealed that the RR for all-cause mortality was 85% higher in patients with PTSD and MDD who did not receive ECT compared with their counterparts who did receive ECT (RR, 1.85; 95% confidence interval [CI], 1.69 - 2.01; P = .001). In addition, the RR for suicidal behavior was 350% higher (RR, 4.54; 95% CI, 3.22 - 7.14) in patients with PTSD and MDD without ECT vs patients who received the treatment.

Furthermore, adjusted analyses revealed that ECT significantly reduced cardiovascular mortality in patients with PTSD and MDD compared with their counterparts who did not receive the treatment (RR, 0.56; 95% CI, 0.29 - 0.62; P = .01).
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