Researchers report a sharp decline in the use of electroconvulsive therapy (ECT) to aid individuals with severe depression.
ECT is considered the most effective treatment option for patients with severe depression who cannot find symptom relief through antidepressant medications or psychotherapy. However, researchers found a sharp decline in the availability and use of ECT in general hospitals across the U.S.
The findings were published online in the journal Biological Psychiatry.
The researchers analyzed data from a nationally representative survey of U.S. general hospitals, the Nationwide Inpatient Sample (NIS), conducted annually by the Agency for Healthcare Research and Quality (AHRQ).
They took information from between five and eight million patient discharge records at 1,000 hospitals nationwide between the years 1993 through 2009 and found that the annual number of hospital stays in which ECT was administered fell 43 percent over the 17 year period, from more than 1.2 million to 720,000.
Investigators also found a dramatic decline in the percentage of hospitals conducting ECT, from 55 percent to 35 percent of facilities with a psychiatric unit.
The percentage of inpatients with severe, recurrent major depression treated in hospitals conducting ECT fell from 71 to 45 percent. But for depressed patients treated in hospitals that conduct ECT, the proportion who received the procedure remained stable.
The data suggests that hospitalization for treatment resistant depression is declining.
“The data strongly support the impression that psychiatric units in general hospitals are discontinuing use of ECT and that this is driving the decline in the number of severely depressed inpatients receiving the procedure,” said Brady Case, M.D.
“Growing pressures to avoid the inpatient treatment costs and length of stay associated with ECT may be one factor associated with this trend. We didn’t have information on provider and patient attitudes, but as facilities cease conducting ECT, we can expect that fewer clinicians and inpatients are exposed to the option, reinforcing the turn away from ECT.”
Researchers also note the FDA approval of new treatment alternatives, like vagus nerve stimulation and transcranial magnetic stimulation, as possible influences.
Declines in ECT availability and use were particularly dramatic in elderly patients, a group traditionally thought to benefit most from the procedure.
“Decreased availability of ECT for older patients with severe depression is of major concern, since a significant proportion of this group fails to benefit from available medication treatments. In such cases, ECT can literally be a life-saving intervention,” said Lawrence Price, M.D.
Researchers observed several trends throughout the 15-year study period, most notably that depressed inpatients from poor neighborhoods and those who were publicly insured or uninsured were less likely to receive care from hospitals conducting ECT.
“Access to ECT for less affluent patients has concerned the field for some time, but these data really drive home the reality. The worry is that ECT may be part of a tiered system of psychiatric care that deprives the disadvantaged of one of our most effective treatments,” according to Price.
However, despite the apparent trends, researchers note that the study findings do not included data from freestanding psychiatric facilities.
This study limitation leads Case and his colleagues to note that psychiatric hospitals less commonly offer ECT than general hospitals, possibly because the procedure requires a level of medical support more readily available in general hospitals.
Because of this, and the fact that psychiatric hospitals have accounted for a declining proportion of inpatient mental health care, the researchers argue that this exclusion is unlikely to have offset the declines they observed.
The data also do not include information on outpatient ECT, but many severely ill patients are inappropriate for outpatient ECT initiation.
Case concedes that while “changing pharmacologic treatment practices for depression have received an immense amount of attention, we still know very little about how and where ECT is being used, especially outside of academic medical centers.”
Source: Women & Infants Hospital