Treatment-resistant depression remains a thorn in the side of mental health professionals and academics alike. But now a new paper appears to detail a potentially dramatic treatment breakthrough. A group of University of Basel (Switzerland) researchers conducted a massive meta-analysis and found that electroconvulsive therapy (ECT) might curb suicides (and all-cause mortality risks) by more than a third.
Traditional antidepressants historically haven’t offered much relief for patients living with treatment-resistant depression, with some studies suggesting that only 35% of patients achieve remission after four different medication trials. Worse still, multiple randomized controlled trials have failed to offer much hope (or evidence) that antidepressants can stave off suicide or even suicide attempts.
Neurostimulation therapies, such as ECT, repetitive transcranial magnetic stimulation (rTMS), and vagus nerve stimulation (VNS), have started to break out as potential livable alternatives when all else has failed.
ECT Offers a Clear Survival Benefit
While the research has established ECT as the most effective intervention for severe depression, its broader impact on survival has remained murky – until now.
This latest analysis of the existing literature is the first to demonstrate a clear survival benefit for ECT. The researchers found that ECT curtails depressive symptoms more effectively than medications or sham treatments.
“To our knowledge, this is the first meta-analysis to demonstrate a survival benefit of ECT for individuals with depression,” lead researcher Timur Liwinski, MD, pointed out. “To our knowledge, this is the first meta-analysis to demonstrate a survival benefit of ECT for individuals with depression. Recent studies confirm that ECT remains the most effective treatment available for severe depression. Our work shows that suicide and all-cause mortality are also reduced.”
Newer, higher-quality studies published since 2016 show especially promising results, suggesting that improved ECT protocols and standardization might be contributing to its enhanced safety and effectiveness.
“We observed that newer studies tended to report greater benefits from ECT than older ones,” Liwinski added. “These more recent studies are often larger and methodologically stronger, reflecting how ECT treatment has evolved over time. In other words, modern ECT appears to be more effective than it was in the past. Since our analysis spans many decades, it’s likely that today’s ECT offers even stronger protection against suicide than the 34% reduction we identified overall.”
It’s also worth noting that the benefits of ECT appear to be more pronounced in elderly, pregnant, or medically fragile individuals, for whom antidepressant medications would pose a higher risk, anyway.
The treatment’s safety profile is also encouraging. Serious adverse events are extremely rare in the proper setting.
rTMS Offers an Alternative
rTMS has also proved itself to be a viable alternative treatment, with the added bonus of fewer cognitive side effects.
However, unlike ECT, rTMS still hasn’t displayed a consistent difference in preventing suicide attemps or mortality rates. This, the authors suggest, could be due to the limitations of the existing trials that have been documented so far. They’ve typically been smaller, shorter, and often exclude higher-risk patients.
Also, in many clinical settings, active suicidality is a contraindication for rTMS, limiting its real-world application in the population that could benefit from it the most.
Vagus Nerve Stimulation
Finally, vagus nerve stimulation has also shown some promising results. But the existing body of literature remains limited. And much of what we do know comes from one major study. In short, the researchers argue that vagus nerve stimulation demands further investigation.
The authors also noted that “the duration until a therapeutic effect is noticeable is very long for VNS (months), rendering it a more long-term treatment alternative with regard to suicidality and mortality.”
Striking Benefits
Most importantly, this paper reiniforces the argument that fewer suicidal thoughts don’t necessarily translate to fewer successful suicides. While ECT showed moderate effectiveness in curbing suicidal ideation, converting these results into real-world mortality demands more longitudinal research.
Still, larger-scale studies – such as that looked at Medicare patients – discovered as much as a 30% reduction in all-cause mortality for ECT recipients compared to non-recipients. And this persisted even among patients with multiple health issues.
This, the authors point out, could mean that ECT might not just help with psychiatric symptoms, but overall health outcomes.
A (Cautiously) Optimistic Path Forward
On the other end of the spectrum, antidepressant medications still face heightened scrutiny. Some long-term studies suggest an increased risk of cardiovascular events and overall mortality, especially with polypharmacy. ECT, by eliminating the need for multiple medications, could offer a safer alternative.
As depression continues to rank among the leading causes of disability and suicide worldwide, the push for more effective treatments remains a priority. This new evidence helps make a compelling case for integrating neurostimulation therapies (like ECT) more broadly into treatment protocols, especially for those patients who’ve already run through the traditional options.
Ultimately, this growing body of evidence appears to be an inflection point in depression treatment.
Further Reading
Study Highlights Increased Mortality Risks in Difficult-to-Treat Depression
Difficult to Treat Depression: Focus on Approach, Algorithms, and Access
Effects of Low-Dose Ketamine Infusion on Hopelessness and Suicidal Thoughts
