Electroconvulsive Therapy at a Veterans Health Administration Medical Center

Abstract

Objectives Little epidemiologic research has examined the practice of electroconvulsive therapy (ECT). We investigated socio-demographic and clinical characteristics, service use, and psychotropic medication prescription patterns associated with ECT use at a Veterans Health Administration Medical Center. Methods Among veterans receiving specialty mental health services, we compared those who received ECT with those who did not using bivariate chi-square and t-tests and multivariate logistic regression. Results In fiscal year 2012, 11,117 veterans received specialty mental health services, of whom 50 received ECT (0.45%) in FY2012 or FY2013. Those who received ECT were more likely to be diagnosed with Major Depressive or Bipolar Disorders and had substantially higher levels of mental health service utilization (Cohen’s d>0.75) and psychotropic prescription fills, including antidepressants (Cohen’s d=2.66), antipsychotics (Cohen’s d=2.15), lithium (Cohen’s d=1.34), mood stabilizers (Cohen’s d=1.30), and anxiolytic/sedative/hypnotics (Cohen’s d=1.34). Conclusions Our findings suggest that ECT is used as a treatment of last resort, although available evidence and guidelines recommend wider use.

Identifying Recipients of Electroconvulsive Therapy: Data From Privately Insured Americans

“…The data presented here are also consistent with other suggestions that the rate of ECT utilization is declining and that ECT is limited to patients with multimorbidity and high levels of service and medication use, just as was observed in the Veterans Health Administration study (16). Such a decline and limited use are problematic, given the considerable evidence that ECT is the most effective therapy for treatment-resistant depression (5), can rapidly reduce suicidal ideation (29), and may be associated with a lower rate of 30-day psychiatric hospital readmission (6).…”

“…This finding could be due to the higher rate of lithium use in the ECT group, a common medication prescribed for bipolar disorder as well as in the specific context of ECT because of its ability to reduce the risk of relapse after ECT (22). Similar to the findings of a recent study conducted in the Veterans Health Administration (16), ECT patients (when compared with non-ECT patients) had substantially higher rates of personality disorders (RR=7.37) and alcohol dependence (RR=2.12); much higher rates of prescription fills for antipsychotics (RR=3.58), mood stabilizers and anticonvulsants (RR=2.01), and lithium (RR=6.03); and higher prescription fill rates of all psychotropics (Cohen’s d=.77). ECT thus appears to be used among patients with multimorbidity who have more complicated psychiatric disorders (23), perhaps as a treatment of last resort when clinicians judge other treatment possibilities to have failed.…”

“…Despite these limitations, these findings extend those seen in a single-site Veterans Health Administration study (16) showing that ECT use is exceptionally rare, with substantial differences between those who use ECT and those who do not among patients with a mood disorder diagnosis. Similar to a recent report on inpatient ECT (10), our findings suggest that ECT utilization may have further decreased since the most recent reports.…”

“…A recent study characterizing the use of ECT at a large Veterans Affairs medical center in New England found ECT to be provided to .45% of patients in psychiatric specialty care annually; although the ECT sample was small (N=50), receipt of ECT was strongly associated with higher rates of psychotropic prescription fills compared with patients who did not receive ECT (16). We applied the same methods to a far larger and more representative sample of privately insured patients in this study by using deidentified insurance claims data from the 2014 MarketScan Commercial Claims and Encounters database (IBM Watson Health; henceforth, MarketScan).…”

Electroconvulsive Therapy: a Video-Based Educational Resource Using Standardized Patients

“…However, ECT utilization remains low relative to the need for effective interventions in “treatment-refractory” psychiatric patients. Low rates of utilization have been attributed to a complex set of structural, cultural, and region-specific legislative barriers [ 1 , 2 ]. At the level of the practitioner, lack of knowledge about the efficacy of the procedure and/or negative attitudes regarding ECT remain significant barriers toward making referrals or recommending ECT as an appropriate treatment.…”