Effectiveness of electroconvulsive therapy for depression comparing research studies with real-world clinical data from the Dutch ECT consortium

Background: Electroconvulsive therapy (ECT) is an effective treatment for major depressive disorder, yet real-world outcomes may differ from research studies. We compared ECT effectiveness in research versus real-world cohorts and examined whether in- and exclusion criteria and treatment characteristics explain potential differences.
Method: 1892 patients with MDD from the Dutch ECT Consortium (12 research, 10 real-world cohorts) were included. Outcomes were response (≥50% HDRS reduction), remission (HDRS <8), and change in depression severity (Δ-HDRS). Cohorts were compared on effectiveness and demographic, clinical and treatment characteristics. Logistic and linear regression estimated associations between cohort type and outcomes, unadjusted and adjusted for in- and exclusion criteria and additional clinical confounders.
Results: Research cohorts demonstrated higher response rates (66.8% vs. 58.9%, OR 1.46, 95% CI [1.09-1.95]) and greater symptom reduction (B 2.88, 95% CI [1.86-3.90]), while remission rates did not differ significantly. Cohorts differed on several clinical and treatment characteristics, partly reflecting in- and exclusion criteria used in research cohorts. After adjusting for these selection criteria, differences in response and Δ-HDRS were no longer significant (OR 1.20, 95% CI [0.86-1.69]; B 0.61, 95% CI [-0.29-1.51]). Adjustment for additional confounders marginally changed these estimates. In sensitivity analyses restricted to mixed-sites, differences were not significant in unadjusted and adjusted models.
Conclusion: In the Dutch ECT consortium, ECT demonstrates comparable effectiveness across research and real-world settings once patient selection is accounted for. These findings underscore the importance of considering cohort composition when interpreting treatment outcomes.