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The Electroconvulsive Therapy in the Prevention of Suicide Risks and Attempts

자살 위험성 및 자살 시도 방지에 대한 전기경련치료의 역할

  • Kim, Hee Cheol (Department of Psychiatry, Keimyung University School of Medicine) ;
  • Jeong, Seong Hoon (Department of Psychiatry, Eulji University Hospital) ;
  • Ahn, Yong Min (Department of Psychiatry and Institute of Human Behavioral Medicine, National University Hospital, Seoul National University College of Medicine) ;
  • Park, Seung Hyun (Daedong Hospital) ;
  • Kim, Yong Sik (Department of Psychiatry, Nowon Eulji University Hospital) ;
  • Chung, In Won (Department of Psychiatry and Institute of Clinical Psychopharmacology, Dongguk University International Hospital)
  • 김희철 (계명대학교 동산병원 정신건강의학과) ;
  • 정성훈 (대전을지대학교병원 정신건강의학과) ;
  • 안용민 (서울대학교병원 정신건강의학과) ;
  • 박승현 (대동병원) ;
  • 김용식 (노원을지대학교병원 정신건강의학과) ;
  • 정인원 (동국대학교 일산병원 정신건강의학과)
  • Received : 2020.03.02
  • Accepted : 2020.04.29
  • Published : 2020.10.31

Abstract

Suicidality is the most serious complication of mood disorders and psychosis; effective treatment should reduce suicide rates. The Organization for Economic Cooperation and Development age-standardized suicide rate in Korea was 22.6 in 2018, much higher compared to other countries worldwide. As mental and psychiatric problems are the main reasons for suicide attempts, accounting for 31.6% in 2018, targeting such problems should be the focus of efforts to reduce suicide rates. However, the ability of current pharmacotherapeutic and psychotherapeutic interventions to reduce suicide rates is limited due to their delayed effects. Therefore, electroconvulsive therapy (ECT) has been proposed as an alternative treatment. This approach is effective for treating most mental disorders associated with high suicide rates, including severe depression, bipolar disorder, and intractable psychotic disorders; ECT is also effective for Parkinson's disease, which has the highest suicide rate among all disorders in Korea. The acute, long-term, and prophylactic effects of ECT on suicidality have been reported in the literature, and treatment guidelines outside of Korea recommend that ECT be used at an early stage for rapid reduction of suicide rates, as opposed to being applied as a treatment of last resort. However, only ~0.092 of every 10000 members of the Korean general population received ECT in 2018; this is much lower than the average rate worldwide, of 2.2 per 10000. Elimination of obstacles to the use of ECT, early crisis intervention involving administration of ECT for rapid stabilization, and maintenance ECT to prevent recurrence should reduce suicide rates.

Keywords

Acknowledgement

This research was supported by a grant of the Korea Mental Health R&D Project, funded by the Ministry of Health & Welfare, Republic of Korea (grant number : HL19C-0051-010019).

References

  1. Ryan CJ, Large MM. Suicide risk assessment: where are we now? Med J Aust 2013;198:462-463. https://doi.org/10.5694/mja13.10437
  2. Ministry of Health and Welfare, Korea Suicide Prevention Center. 2019 White Book of Suicide Prevention. Seoul: Korea Suicide Prevention Center;2019.
  3. Statistics Korea. Causes of Death Statistics in 2018. Daejeon: Statistics Korea;2019.
  4. Korea Suicide Prevention Center. 2018 Statistics Data. Seoul: Korea Suicide Prevention Center;2019.
  5. Korea Suicide Prevention Center, Emergency Room Support Team. Analysis of demographic characteristics and follow-up service results of suicide attempters - focusing on institutes of 2017 emergency room-based suicide attempter aftercare programs. KSPC Res Brief 2018:(2):1-12.
  6. Ministry of Health and Welfare, Health Insurance Review & Assessment Service. Production and Development of OECD Health Care Quality Indicators in 2014. Sejong: Ministry of Health and Welfare;2016.
  7. Lee S, Chae S, Jung J, Yun S, Cha M. Reinforcing the Care Programs for the Suicide Attempters in Korea. Korea Institute for Health and Social Affairs;2017.
  8. Kim B, Lee J, Kim E, Kim SH, Ha K, Kim YS, et al. Sex difference in risk period for completed suicide following prior attempts: Korea National Suicide Survey (KNSS). J Affect Disord 2018;227:861-868. https://doi.org/10.1016/j.jad.2017.11.013
  9. Irigoyen M, Porras-Segovia A, Galvan L, Puigdevall M, Giner L, De Leon S, et al. Predictors of re-attempt in a cohort of suicide attempters: a survival analysis. J Affect Disord 2019;247:20-28. https://doi.org/10.1016/j.jad.2018.12.050
  10. Large MM. The role of prediction in suicide prevention. Dialogues Clin Neurosci 2018;20:197-205. https://doi.org/10.31887/DCNS.2018.20.3/mlarge
  11. Ballard ED, Zarate CA Jr. Preventing suicide: a multicausal model requires multimodal research and intervention. Bipolar Disord 2018;20:558-559. https://doi.org/10.1111/bdi.12656
  12. Kellner CH, Li EH, Farber KG, Geduldig ET, Ahle GM. Electroconvulsive therapy (ECT) and suicide prevention. Curr Treat Options Psychiatry 2016;3:73-81. https://doi.org/10.1007/s40501-016-0067-8
  13. Kim SJ. Pharmacological treatment strategies for acute bipolar depression. J Korean Neuropsychiatr Assoc 2018;57:287-300. https://doi.org/10.4306/jknpa.2018.57.4.287
  14. Woo YS, Bahk WM, Lee JG, Jeong JH, Kim MD, Sohn I, et al. Korean Medication Algorithm Project for Bipolar Disorder 2018 (KMAP-BP 2018): Fourth Revision. Clin Psychopharmacol Neurosci 2018;16:434-448. https://doi.org/10.9758/cpn.2018.16.4.434
  15. Working Committee for Algorithm Revision on Korean Schizophrenia Pharmacotherapy. Korean Schizophrenia Pharmacotherapy Guideline. Korean College of Neuropsychopharmacology; Korean Society of Schizophrenia Research;2019.
  16. Youn T, Kang UG, Kim YS, Chung IW. Recent trends for optimization of electroconvulsive therapy. J Korean Neuropsychiatr Assoc 2016;55:12-24. https://doi.org/10.4306/jknpa.2016.55.1.12
  17. Kim W, Bahk WM, Yoon BH, Jon DI, Seo JS, Lee JG, et al. Korean medication algorithm for bipolar disorder 2018: overview. Mood Emot 2018;16:1-12.
  18. Kim SW, Jhon M, Kim M, Paik JW, Kim JM, Yoon JS. A social psychiatric approach to suicide prevention. J Korean Med Assoc 2019;62:93-101. https://doi.org/10.5124/jkma.2019.62.2.93
  19. Man JJ, Currier D. Suicide and attempted suicide. In: Fatemi SH, Clayton PJ, editors. The Medical Basis of Psychiatry (4th ed). New York, NY: Springer;2016. p.687-706.
  20. Nah G, Choi S, Kim H, Lee JY, Kim JM, Shin IS, et al. Characteristics of patients who died by suicide in a community mental health center. Korean J Schizophr Res 2017;20:55-60. https://doi.org/10.16946/kjsr.2017.20.2.55
  21. Korea Psychological Autopsy Center. Psychological Autopsy Analysis Result Data [cited 2020 Feb 21]. Available from: http://www.psyauto.or.kr/sub/data_02.asp.
  22. Arato M, Demeter E, Rihmer Z, Somogyi E. Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatr Scand 1988;77:454-456. https://doi.org/10.1111/j.1600-0447.1988.tb05150.x
  23. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med 2003;33:395-405. https://doi.org/10.1017/S0033291702006943
  24. Lee AS, Murray RM. The long-term outcome of Maudsley depressives. Br J Psychiatry 1988;153:741-751. https://doi.org/10.1192/bjp.153.6.741
  25. Kim HJ, Lee IH. Visual analysis of regional variations in antidepressant use and suicide rate. Korean J Clin Pharm 2018;28:308-319. https://doi.org/10.24304/kjcp.2018.28.4.308
  26. Yoon JS, Kim CY, Ahn JH. Critique of mental health welfare law in Korea : focusing on involuntary hospitalization criteria. J Korean Neuropsychiatr Assoc 2018;57:145-156. https://doi.org/10.4306/jknpa.2018.57.2.145
  27. Jamison KR, Baldessarini RJ. Effects of medical interventions on suicidal behavior. Introduction. J Clin Psychiatry 1999;60 Suppl 2:4-6; discussion 113-6.
  28. Gusmao R, Quintao S, McDaid D, Arensman E, Van Audenhove C, Coffey C, et al. Antidepressant utilization and suicide in europe: an ecological multi-national study. PLoS One 2013;8:e66455. https://doi.org/10.1371/journal.pone.0066455
  29. Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry 2006;163:1905-1917. https://doi.org/10.1176/ajp.2006.163.11.1905
  30. Taylor MA, Fink M. Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Disorders. Cambridge: Cambridge University Press;2006.
  31. Fink M, Kellner CH, McCall WV. The role of ECT in suicide prevention. J ECT 2014;30:5-9. https://doi.org/10.1097/YCT.0b013e3182a6ad0d
  32. Lam RW, Kennedy SH, Grigoriadis S, McIntyre RS, Milev R, Ramasubbu R, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy. J Affect Disord 2009;117 Suppl 1:S26-S43. https://doi.org/10.1016/j.jad.2009.06.041
  33. Barbui C, Esposito E, Cipriani A. Selective serotonin reuptake inhibitors and risk of suicide: a systematic review of observational studies. CMAJ 2009;180:291-297. https://doi.org/10.1503/cmaj.081514
  34. Meyer RE, Salzman C, Youngstrom EA, Clayton PJ, Goodwin FK, Mann JJ, et al. Suicidality and risk of suicide--definition, drug safety concerns, and a necessary target for drug development: a brief report. J Clin Psychiatry 2010;71:1040-1046. https://doi.org/10.4088/JCP.10cs06070ablu
  35. Gibbons RD, Brown CH, Hur K, Davis J, Mann JJ. Suicidal thoughts and behavior with antidepressant treatment: reanalysis of the randomized placebo-controlled studies of fluoxetine and venlafaxine. Arch Gen Psychiatry 2012;69:580-587. https://doi.org/10.1001/archgenpsychiatry.2011.2048
  36. Spielmans GI, Jureidini J, Healy D, Purssey R. Inappropriate data and measures lead to questionable conclusions. JAMA Psychiatry 2013;70:121-122.
  37. Reinstatler L, Youssef NA. Ketamine as a potential treatment for suicidal ideation: a systematic review of the literature. Drugs R D 2015;15:37-43. https://doi.org/10.1007/s40268-015-0081-0
  38. Wilkinson ST, Sanacora G. Ketamine: a potential rapid-acting antisuicidal agent? Depress Anxiety 2016;33:711-717. https://doi.org/10.1002/da.22498
  39. Ionescu DF, Bentley KH, Eikermann M, Taylor N, Akeju O, Swee MB, et al. Repeat-dose ketamine augmentation for treatment-resistant depression with chronic suicidal ideation: a randomized, double blind, placebo controlled trial. J Affect Disord 2019;243:516-524. https://doi.org/10.1016/j.jad.2018.09.037
  40. Oji C, Moore TA, Gutierrez CA. A review of electroconvulsive therapy in suicidality. Ment Health Clin 2015;5:212-215. https://doi.org/10.9740/mhc.2015.09.212
  41. Payne NA, Prudic J. Electroconvulsive therapy: Part I. A perspective on the evolution and current practice of ECT. J Psychiatr Pract 2009;15:346-368. https://doi.org/10.1097/01.pra.0000361277.65468.ef
  42. Kellner CH. ECT treatment course. In: Handbook of ECT: A Guide to Electroconvulsive Therapy for Practitioners. New York, NY: Cambridge University Press;2019. p.153-166.
  43. Weiss A. The Electroconvulsive Therapy Workbook: Clinical Applications. New York, NY: Routledge;2018.
  44. Kang UG, Kim SH, Kim YS. Mechanism of action. In: Kim YS, Chung IW, Kang UG, Ahn YM, Youn T, editors. Electroconvulsive Therapy: Theory and Practice. Seoul: Seoul National University Press;2019. p.33-62.
  45. Petrides G, Malur C, Braga RJ, Bailine SH, Schooler NR, Malhotra AK, et al. Electroconvulsive therapy augmentation in clozapineresistant schizophrenia: a prospective, randomized study. Am J Psychiatry 2015;172:52-58. https://doi.org/10.1176/appi.ajp.2014.13060787
  46. Grover S, Garekar H, Agarwal A. Treatment-resistant schizophrenia: assessment and management. Kim YK, editor. In: Treatment Resistance in Psychiatry: Risk Factors, Biology, and Management. Singapore: Springer;2019. p.109-137.
  47. Korean Statistical Information Service. Korea health statistics: cause of death. Daejeon: Statistics Korea [cited 2018 Dec 14]. Available from: http://kosis.kr/statisticsList/statisticsListIndex.do?menuId=M_01_01&vwcd=MT_ZTITLE&parmTabId=M_01_01#SelectStatsBoxDiv.
  48. Hermann RC, Dorwart RA, Hoover CW, Brody J. Variation in ECT use in the United States. Am J Psychiatry 1995;152:869-875. https://doi.org/10.1176/ajp.152.6.869
  49. Maixner DF. ECT in the United States. Proceedings of the 29th Annual Meeting & ECT Certificate Course; 2019 May 18-19, San Francisco, CA, USA.
  50. Leiknes KA, Jarosh-von Schweder L, Hoie B. Contemporary use and practice of electroconvulsive therapy worldwide. Brain Behav 2012;2:283-344. https://doi.org/10.1002/brb3.37
  51. Kellner CH, Patel SB. The role of ECT in the suicide epidemic. Psychiatr Times 2018;35:8.
  52. Organisation for Economic Co-operation and Development. Suicide rates (indicator). Available from: https://data.oecd.org/healthstat/suicide-rates.htm.
  53. Chung IW, Kim HC, Jeong SH. Development in Korean Guideline of Electroconvulsive Therapy as a Service for Crisis Intervention in Mental Health. National Center for Mental Health; Korea Mental Health R&D Project;2019.
  54. Joo SW, Jeong HE, Chon MW, Joo YH, Kim CY, Lee JS. Effectiveness and safety of electroconvulsive therapy in clinical practice. J Korean Neuropsychiatr Assoc 2016;55:202-208. https://doi.org/10.4306/jknpa.2016.55.3.202
  55. Youssef NA, Ravilla D, Patel C, Yassa M, Sadek R, Zhang LF, et al. Magnitude of reduction and speed of remission of suicidality for low amplitude seizure therapy (LAP-ST) compared to standard right unilateral electroconvulsive therapy: a pilot double-blinded randomized clinical trial. Brain Sci 2019;9:99. https://doi.org/10.3390/brainsci9050099
  56. Samalin L, Yrondi A, Charpeaud T, Genty JB, Blanc O, Sauvaget A, et al. Adherence to treatment guidelines in clinical practice for using electroconvulsive therapy in major depressive episode. J Affect Disord 2020;264:318-323. https://doi.org/10.1016/j.jad.2020.01.004
  57. Aksoy-Poyraz C, Ozdemir A, Ozmen M, Arikan K, Ozkara C. Electroconvulsive therapy for bipolar depressive and mixed episode with high suicide risk after epilepsy surgery. Epilepsy Behav 2008;13:707-709. https://doi.org/10.1016/j.yebeh.2008.07.001
  58. Rapinesi C, Serata D, Del Casale A, Simonetti A, Milioni M, Mazzarini L, et al. Successful and rapid response to electroconvulsive therapy of a suicidal patient with comorbid bipolar I disorder and histrionic personality disorder. J ECT 2012;28:57-58. https://doi.org/10.1097/YCT.0b013e3182218c8c
  59. Gambill JD, McLean PE. Suicide after unilateral ECT in a patient previously responsive to bilateral ECT. Psychiatr Q 1983;55:279-281. https://doi.org/10.1007/BF01074556
  60. Tavares AR, Volpe FM. Electroconvulsive therapy (ECT) effective for psychotic recrudescence and suicidality after varenicline adjunctive therapy for smoking cessation in a schizoaffective patient. Braz J Psychiatry 2010;32:315-316. https://doi.org/10.1590/S1516-44462010000300017
  61. Kobeissi J, Aloysi A, Tobias K, Popeo D, Kellner CH. Resolution of severe suicidality with a single electroconvulsive therapy. J ECT 2011;27:86-88. https://doi.org/10.1097/YCT.0b013e3181da842a
  62. Cormack S, Chan P, Persaud R, Vila-Rodriguez F. Index electroconvulsive therapy course to treat severe suicidality and depression in fahr disease. J ECT 2016;32:72-73. https://doi.org/10.1097/YCT.0000000000000264
  63. Fligelman B, Pham T, Bryson EO, Majeske M, Kellner CH. Resolution of acute suicidality after a single right unilateral electroconvulsive therapy. J ECT 2016;32:71-72. https://doi.org/10.1097/YCT.0000000000000258
  64. Kellner CH, Husain MM, Knapp RG, McCall WV, Petrides G, Rudorfer MV, et al. A novel strategy for continuation ECT in geriatric depression: phase 2 of the PRIDE study. Am J Psychiatry 2016;173:1110-1118. https://doi.org/10.1176/appi.ajp.2016.16010118
  65. Tran DV, Meyer JP, Farber KG, Chen XR, Rosenthal BD, Kellner CH. Rapid response to electroconvulsive therapy: a case report and literature review. J ECT 2017;33:e20-e21.
  66. Kellner CH, Fink M, Knapp R, Petrides G, Husain M, Rummans T, et al. Relief of expressed suicidal intent by ECT: a consortium for research in ECT study. Am J Psychiatry 2005;162:977-982. https://doi.org/10.1176/appi.ajp.162.5.977
  67. Kellner CH, Knapp RG, Petrides G, Rummans TA, Husain MM, Rasmussen K, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry 2006;63:1337-1344.
  68. Prudic J, Sackeim HA. Electroconvulsive therapy and suicide risk. J Clin Psychiatry 1999;60 Suppl 2:104-110; discussion 111-6.
  69. Rich CL, Spiker DG, Jewell SW, Neil JF. Response of energy and suicidal ideation to ECT. J Clin Psychiatry 1986;47:31-32.
  70. Patel M, Patel S, Hardy DW, Benzies BJ, Tare V. Should electroconvulsive therapy be an early consideration for suicidal patients? J ECT 2006;22:113-115. https://doi.org/10.1097/00124509-200606000-00007
  71. Munk-Olsen T, Laursen TM, Videbech P, Mortensen PB, Rosenberg R. All-cause mortality among recipients of electroconvulsive therapy: register-based cohort study. Br J Psychiatry 2007;190:435-439. https://doi.org/10.1192/bjp.bp.106.026740
  72. Hunt IM, Windfuhr K, Swinson N, Shaw J, Appleby L, Kapur N, et al. Electroconvulsive therapy and suicide among the mentally ill in England: a national clinical survey. Psychiatry Res 2011;187:145-149. https://doi.org/10.1016/j.psychres.2010.12.014
  73. Bradvik L, Berglund M. Long-term treatment and suicidal behavior in severe depression: ECT and antidepressant pharmacotherapy may have different effects on the occurrence and seriousness of suicide attempts. Depress Anxiety 2006;23:34-41. https://doi.org/10.1002/da.20134
  74. Thomas SG, Kellner CH. Remission of major depression and obsessive-compulsive disorder after a single unilateral ECT. J ECT 2003;19:50-51. https://doi.org/10.1097/00124509-200303000-00011
  75. American Psychiatric Association, Committee on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A task force report of the American Psychiatric Association (2nd ed). Washington, DC: American Psychiatric Association;2001.
  76. Practice guideline for the treatment of patients with major depressive disorder (revision). American Psychiatric Association. Am J Psychiatry 2000;157:1-45. https://doi.org/10.1176/ajp.157.1.1
  77. American Psychiatric Association. Practice Guidelines for the Treatment of Patients with Schizophrenia. 3rd ed. Washington, DC: American Psychiatric Association;2010.
  78. The Assessment and Management of Risk for Suicide Working Group. VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide. Version 1.0. Washington, DC: Veterans Health Administration; Department of Defense;2013.
  79. National Institute for Health and Clinical Excellence. Guidance on the Use of Electroconvulsive Therapy (Technology Appraisal Guidance TA59). London: National Institute for Health and Clinical Excellence;2003.
  80. National Collaborating Centre for Mental Health (UK). Depression: the treatment and management of depression in adults (updated edition). Leicester: British Psychological Society;2010.
  81. Cleare A, Pariante CM, Young AH, Anderson IM, Christmas D, Cowen PJ, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol 2015;29:459-525. https://doi.org/10.1177/0269881115581093
  82. Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Beaulieu S, Alda M, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. Bipolar Disord 2013;15:1-44.
  83. Flood RA, Seager CP. A retrospective examination of psychiatric case records of patients who subsequently committed suicide. Br J Psychiatry 1968;114:443-450. https://doi.org/10.1192/bjp.114.509.443
  84. Isometsa ET, Henriksson MM, Heikkinen ME, Lonnqvist JK. Completed suicide and recent electroconvulsive therapy in Finland. Convuls Ther 1996;12:152-155.
  85. Avery D, Winokur G. Suicide, attempted suicide, and relapse rates in depression. Arch Gen Psychiatry 1978;35:749-753. https://doi.org/10.1001/archpsyc.1978.01770300091010
  86. Tsuang MT, Dempsey GM, Fleming JA. Can ECT prevent premature death and suicide in 'schizoaffective' patients? J Affect Disord 1979;1:167-171. https://doi.org/10.1016/0165-0327(79)90001-6
  87. Liang CS, Chung CH, Ho PS, Tsai CK, Chien WC. Superior antisuicidal effects of electroconvulsive therapy in unipolar disorder and bipolar depression. Bipolar Disord 2018;20:539-546. https://doi.org/10.1111/bdi.12589
  88. Chang SS. The role of ECT in suicide management. Taiwanese J Psychiatry 2007;21:4-15.
  89. Babigian HM, Guttmacher LB. Epidemiologic considerations in electroconvulsive therapy. Arch Gen Psychiatry 1984;41:246-253. https://doi.org/10.1001/archpsyc.1984.01790140036005
  90. Black DW, Winokur G, Nasrallah A, Emmanuel M, Woolson R. Does treatment influence mortality in depressives? [abstract]. Proceedings of The 141st Annual Meeting of the American Psychiatric Association;1988 May 7-12, Montral, Quebec, Canada.
  91. Dombrovski AY, Mulsant BH. ECT: the preferred treatment for severe depression in late life. ECT: the preferred treatment for severe depression in late life. Int Psychogeriatr 2007;19:10-14. https://doi.org/10.1017/S1041610206224384
  92. Dubovsky SL, Dubovsky AN. Mood disorders and the outcome of suicidal thoughts and attempts. Crit Care Clin 2008;24:857-874. https://doi.org/10.1016/j.ccc.2008.05.002
  93. Sienaert P. What we have learned about electroconvulsive therapy and its relevance for the practising psychiatrist. Can J Psychiatry 2011;56:5-12. https://doi.org/10.1177/070674371105600103
  94. Foster TJ. Suicide prevention as a prerequisite for recovery from severe mental illness. Int J Psychiatry Med 2013;46:15-25. https://doi.org/10.2190/PM.46.1.b
  95. Gwun OJ, Park GJ, Kim SC, Lee JH, Kim H, Lee SW. Impact of discharge against medical advice on emergency department revisit among suicide attempters. J Korean Soc Emerg Med 2019;30:393-400.
  96. Statistics Canada; Canadian Institute for Health Information. Health Indicators 2011. Ottawa: Canadian Institute for Health Information;2011.
  97. Chung DT, Ryan CJ, Hadzi-Pavlovic D, Singh SP, Stanton C, Large MM. Suicide rates after discharge from psychiatric facilities: a systematic review and meta-analysis. JAMA Psychiatry 2017;74:694-702. https://doi.org/10.1001/jamapsychiatry.2017.1044
  98. Mutschler C, Lichtenstein S, Kidd SA, Davidson L. Transition experiences following psychiatric hospitalization: a systematic review of the literature. Community Ment Health J 2019;55:1255-1274. https://doi.org/10.1007/s10597-019-00413-9
  99. Walter F, Carr MJ, Mok PLH, Antonsen S, Pedersen CB, Appleby L, et al. Multiple adverse outcomes following first discharge from inpatient psychiatric care: a national cohort study. Lancet Psychiatry 2019;6:582-589. https://doi.org/10.1016/S2215-0366(19)30180-4
  100. American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry 2003;160(11 Suppl):1-60. https://doi.org/10.1176/appi.ajp.160.1.1
  101. Lin CH, Yang WC, Wu JI. Factors affecting time to resolution of suicidality for depressed patients receiving electroconvulsive therapy. CNS Spectr 2020;25:434-435. https://doi.org/10.1017/S1092852919000920
  102. Kuo CJ, Tsai SY, Liao YT, Lee WC, Sung XW, Chen CC. Psychiatric discharge against medical advice is a risk factor for suicide but not for other causes of death. J Clin Psychiatry 2010;71:808-809. https://doi.org/10.4088/JCP.09l05404blu
  103. Choi M, Kim H, Qian H, Palepu A. Readmission rates of patients discharged against medical advice: a matched cohort study. PLoS One 2011;6:e24459. https://doi.org/10.1371/journal.pone.0024459
  104. Kim H, Kim JW, Kang HJ, Kim SY, Lee JY, Kim JM, et al. Factors associated with suicidal behavior of psychiatric inpatients. J Korean Neuropsychiatr Assoc 2019;58:202-208. https://doi.org/10.4306/jknpa.2019.58.3.202
  105. Health Insurance Review & Assessment Service; National Health Insurance Service. 2018 National Health Insurance Statistical Yearbook. Wonju: Health Insurance Review & Assessment Service; National Health Insurance Service;2019.
  106. Health Insurance Review & Assessment Service; National Health Insurance Service. 2018 Medical Aid Statistics. Wonju: Health Insurance Review & Assessment Service; National Health Insurance Service;2019.
  107. Andrews M, Hasking P. Effect of two educational interventions on knowledge and attitudes towards electroconvulsive therapy. J ECT 2004;20:230-236. https://doi.org/10.1097/00124509-200412000-00008
  108. Dowman J, Patel A, Rajput K. Electroconvulsive therapy: attitudes and misconceptions. J ECT 2005;21:84-87. https://doi.org/10.1097/01.yct.0000161043.00911.45
  109. Jeong SH, Youn T, Kim YS. Social implication. In: Kim YS, Chung IW, Kang UG, Ahn YM, Youn T, editors. Electroconvulsive Therapy: Theory and Practice. Seoul: Seoul National University Press; 2019. p.33-62.