Clinical Effectiveness of Electroconvulsive Therapy for Psychotic vs Nonpsychotic Depression: A Cohort Study

Background: Individuals experiencing major depression with psychotic features (MD-P) may respond better and have fewer cognitive effects with electroconvulsive therapy (ECT) than those without psychotic features (MD-NP). However, this may be due to differences in patient characteristics aside from psychotic symptoms. The objectives of this study were to (1a) compare ECT treatment response and (1b) adverse cognitive effects between patients with MD-P and MD-NP and (2a) explore factors associated with treatment response or (2b) adverse cognitive effects.

Methods: This was a retrospective cohort study of adult inpatients with MD-P or MD-NP treated with an acute course of ECT at an academic psychiatric hospital June 2010-September 2021 in Toronto, Canada. Logistic regression was used to account for differences in patient characteristics between groups. Outcomes were identified using the clinical global impression improvement and cognitive function scales.

Results: 542 patients were included, 115 (21%) with MD-P and 427 (79%) with MD-NP. MD-P patients were more likely to be rated "very much improved" with ECT (41% vs 27%, P = .003) while adverse cognitive effects were similar (21% MD-NP vs 24% MD-P; P > .05). However, after accounting for confounders, psychotic symptoms were not associated with response (adjusted odds ratio [AOR]: 1.04; 95% confidence interval [CI], 0.95-1.14) or adverse cognitive effects (AOR: 1.30; 95% CI, 0.78-2.18).

Conclusions: Individuals with MD-P had a higher rate of response and similar rates of adverse cognitive effects compared to patients with MD-NP with ECT treatment. However, after accounting for differences in patient characteristics, we no longer identified an association between psychotic symptoms and treatment response.