What’s Behind the Dramatic Decline in ECT Treatment Over the Past 15 Years?

As Reported in the Psychiatric News.

Here are some of the highlights:

There has been a dramatic decline in the use of electroconvulsive therapy in U.S. general hospitals over the past 15 years.

[...]

This finding comes from a study published online October 10 in Biological Psychiatry. The lead researcher was Brady Case, M.D., an assistant professor of psychiatry at Brown University and director of the Health Services Research Program at Bradley Hospital in East Providence, R.I.

The study conducted by Case and his colleagues appears to be the first study on the use of inpatient ECT in U.S. general hospitals since 1992. They examined trends in the use of ECT in a national hospital sample over a 17-year period from 1993 to 2009. The hospitals were nonfederal, short-term general or specialty hospitals, including both public and private facilities and academic medical centers. However, freestanding psychiatric hospitals were excluded. In their paper, Case and his coworkers referred to all of the analyzed hospitals as “general hospitals.”

Here are several of their most salient findings:

• The percentage of general hospitals conducting ECT decreased from 15 percent to 11 percent, and the percentage of hospitals with psychiatric units conducting ECT decreased from 55 percent to 35 percent.
• The number of stays in general hospitals involving ECT rose from 1993 to 1995 from 13/100,000 residents to 16/100,000 residents, but then fell gradually after that, to 7/100,000 residents in 2009. This decline appeared to be due, to a large extent, to reduced use of ECT with elderly patients, a group traditionally thought to benefit most from it. (?!!)
• For inpatients with severe recurrent depression, the percentage whose treating hospitals conducted ECT fell from 71 percent to 45 percent.
• Throughout the study period, depressed inpatients from poor neighborhoods and those who were publicly insured or uninsured were less likely to receive care from hospitals conducting ECT.

“The data strongly support the impression that psychiatric units of general hospitals are ceasing to conduct ECT and that this is driving the decline in the number of patients receiving ECT,” Case told Psychiatric News. But why are hospitals dropping the procedure?

Possible explanations, Case said, are “growing pressures to avoid the inpatient treatment costs and length of stay associated with ECT and declining familiarity and more negative attitudes toward the procedure among providers and patients…. We didn’t have information on provider and patient attitudes, but as more facilities cease conducting ECT, we can expect that fewer clinicians and inpatients will be exposed to the option…. On the other hand, it is clear that popular perceptions of mental illness are increasingly biological, and where ECT is conducted, there has been no decline in patients electing to receive it.”

[...]

The findings have widespread implications, Case believes. For example, “most Americans admitted to general hospitals for severe, recurrent depression are now being treated in facilities that do not conduct ECT. This is the consequence of a solid 15-year trend in which psychiatric units appear to be discontinuing use of the procedure…. If the trends of the last 15 years hold, the number and proportion of general hospital psychiatric units conducting ECT will continue to decline, and fewer people will receive it.”

He added that regulations expected to be issued by the FDA will influence how ECT is used in the future, “but as far as I know, the decision about how to classify ECT devices is still pending. If the FDA follows its panel recommendation and ultimately retains Class III—high risk—status for ECT devices, then I would expect the decline to accelerate.”

[...]

Psychiatry In Decline: 55% of psychiatrists are over 55 and getting close to retirement age.

I stumbled across this article from a couple of years ago just recently, and wanted to share this snippet

While 37.6% of practicing physicians are age 55 or older, in psychiatry nearly 55% are in this age range, ranking as the second oldest group of physicians, surpassed only by preventive medicine.

Part of this aging cohort effect is the low rate of medical school graduates choosing psychiatry. Only 4% of US medical school seniors (n = 698) applied for one of the 1097 post-graduate year one training positions in psychiatry.

As Dr. Roberts noted, it is troubling that the area of medicine addressing the leading source of medical disability is also facing a shortage of new talent.

Indeed, over the past decade the number of psychiatry training programs has fallen (from 186 to 181) and the number of graduates has dropped from 1,142 in 2000 to 985 in 2008. In spite of the national shortage of psychiatrists, especially child psychiatrists, 16 residency training programs did not fill with either U.S. or foreign medical graduates in 2011.

Beyond these numbers, the profession is struggling with its identity, a theme echoed in other plenary talks at the APA meeting.

Traditionally, psychiatry has been the medical discipline that cultivates a rich relationship with patients, countering suffering with empathy and understanding. But a recent article in the New York Times reported that only 11% of psychiatrists perform psychotherapy and described a psychiatrist who ran his office “like a bus station,” seeing so many patients for 5 -10 minute medication checks that he had to train himself not to listen to his patient’s problems.

ref:New York Times, March 5, 2011, “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy”

Mental health provider shuts doors after state pulls Medicaid payments

Another Chapter in the Decline of Psychiatry, from a report by the Arkansas News Bureau

A Southeast Arkansas child mental health provider closed its doors Wednesday, a day after a judge cleared the way for the state to terminate Medicaid payments to the facility.

Lawyers for Gilead Family Resource Center, a McGehee-based provider cited by the state for billing irregularities and improper medical practices, had argued in court last week that the facility could not survive without Medicaid payments covering treatment for the bulk of its patients.

Pulaski County Circuit Judge Jay Moody advised lawyers in a brief letter Tuesday he was dissolving a temporary restraining order he issued June 6 that blocked the state Department of Human Services from cutting off payments to Gilead.

DHS moved quickly to terminate the payments to the company, which operated seven facilities in four southeastern Arkansas cities.

[...]

Moody's earlier order allowed Gilead to receive Medicaid reimbursements while appealing DHS' decision to terminate payments. Lawyers for Gilead filed an administrative appeal Wednesday with DHS.

In a June 2007 audit, just weeks before Gibson and others bought Gilead, the state questioned the appropriateness of some clients' diagnoses and medications and found billing problems that included multiple charges for services to the same client.

Auditors also found the facility used uncertified staff for counseling and therapy services, and said there appeared to be no oversight of services by a child psychiatrist.

[...]

DHS spokeswoman Julie Munsell said Gilead was reimbursed about $80,000 a week for providing mental health services to about 430 clients, mostly preschool children. DHS may try to recover the $160,000 or so the center received after Moody's initial order, along with the more than $800,000 the agency contends it is due from alleged billing irregularities, she said.

Gilead operated two facilities in both Hamburg and McGehee, and one each in Dumas, Lake Village and Monticello.

[...]

Prior to state sanctions, Gilead provided treatment for nine children in state custody. After those children were moved and re-evaluated, just two were deemed to need any sort of continued treatment, Munsell said.

The Decline of Psychiatry, Part 5

As seen in a comment by a reader made earlier on this blog:

Psychiatry residency programs now are happy if they get 55% U.S. medical school graduates, that's an increase over what it has been.

What do you call the U.S. medical school graduate who places last in his class? A psychiatry resident.

We have this news report on shortages of psychiatrists in Minnesota. Seems people are not signing up for the field. of course, we have to supply some snippets from the report as seen in The Daily News (of the Wahpeton, ND - Breckenridge, MN area).

A shortage of psychiatrists in Minnesota has caused a strain on current workers and left cities struggling to replace them. Some reasons behind the shortage include low pay in comparison to other jobs in the field and public stigma of the position. In 2004, a Minnesota Public Radio report revealed the state had one psychiatrist for every 10,000 people.

There is little evidence the problem will cease, especially in rural areas. Stefan Gildemeister, assistant director of the health economics bureau at the Minnesota Department of Health, said present calculations for the state are the same.

"A recent study we did, which looked at surveys in greater Minnesota, showed the vacancy rate for psychiatrists was higher than for any other specialty," he said. Breckenridge faces its own significant ratio. A maximum of 136 psychiatric patients walk through the doors of the Hope Unit at St. Francis Healthcare Campus per week, but there is only one psychiatrist to help them. "Many people who attend medical school do not plan on going into psychiatry," said Nancy Torson, MD, at the Hope Unit. "Historically, it has been difficult for programs to fill residency slots, and often they can't fill them."

[...] As psychiatry is one of the lower paying jobs in the field, Torson said "the patient population doesn't appeal to many med students."

[...]

Let's see, could there be lower esteem in the eyes of the public? Would all those news stories about shaky and suspect practitioners have anything to do with this? It sounds like you really have to want to be a psychiatrist to become a psychiatrist.

Psychiatric Drugs are the New Opiate of the Masses.

We stumbled across an interesting post on the Intellectual Conservative political blog, entitled The Hard Truth about a Soft Science: Why Psychology Does More Harm Than Good, starting off with this sentence

If you convince people they’re not responsible for their actions, you’ve set the stage for great evil to occur, as they will be able to justify anything suiting their fancy.

It makes a number of interesting points. While we are not taking sides in terms of politics here, a lot of the observations are spot on, especially as they get to the conclusion of the article.

Yet the implications of this collective sense that we aren’t responsible for our actions and that they can’t be “wrong” anyway go far beyond the resulting social breakdown. They even go beyond the governmental response, which is to step in and control from without people who do not control themselves from within. For the truly scary implication under such a scenario is not just that people will not govern their impulses, but that they cannot do so.

After all, if we are merely organic robots, at the mercy of our genes (hardware), chemistry and upbringing (software), we have no free will. It then follows that we cannot choose among, well, call them what you will, God’s morals or man’s values, as we are directed by things beyond our control. This reduces us to animals. While Christianity teaches that the two things making us like God and separating us from the animal kingdom are intellect and free will – two qualities necessary to be fully human – this idea tells us that, bereft of the second quality, we are mere automatons.

Of course, if Freud et al. are correct, that is all we are, chemicals and water arranged in a most interesting fashion – with a good helping of illusion thrown in for good measure. Thus, insofar as psychology succeeds in convincing us that there is no accountability because there is no free will – no ability to choose sin because there is no sin, only disease – it dehumanizes us.

Perhaps this dehumanization is why psychiatry has quite a history of using humans as guinea pigs. There was Benjamin Rush (the father of American psychiatry) and his bloodletting; Nazi experiments; electric shock and lobotomies; our MK ULTRA mind-control program; and Canadian psychiatrist Heinz Lehmann, who illegally used Thorazine on subjects in the 1950s.

Etc.

Yet another in a number of articles showing the decline of psychiatry.

One last quote:

As to this, I recently read about psychiatrists who are labeling the desire to engage in excessive text messaging a mental disorder. Then there is “Muscle Dysmorphia,” or the obsessive belief that one isn’t muscular enough; “celebriphilia,” the strong desire for amorous relations with a celebrity; “Intermittent Explosive Disorder,” or road rage; “Sibling Rivalry Disorder;” “Mathematics Disorder;” “Caffeine Related Disorder;” and “Expressive Writing disorder,” to cite just a handful of the hundreds of made-up conditions in the DSM. And every time a new variety is conjured up, psychology’s market and earning potential increases. I have to wonder, though, what do they call the obsession with labeling behaviors mental disorders? Some might call it greed.

Yet, as ridiculous as this seems, it’s also very consistent and understandable. Whether a religionist or atheist, one can’t help but notice that these organic robots don’t operate the way most of us would like. The Christian explanation for this is that we’re all sinners, but this is religious terminology and quite inappropriate for a machine. So psychology says we’re all mentally ill; it’s just a malfunction in the CPU, you see. Then, because a machine cannot commit sins but can be “out of order,” it calls them disorders. Thus, a defiant child or employee isn’t ruled by pride but has “Oppositional Disorder,” a person with a lack of gratitude isn’t just that but one who suffers from “Chronic Complaint Disorder,” and a man who is shallow and vain isn’t just that but one plagued by “Muscle Dysmorphia.” So there is a limit to the number of disorders that can be “invented,” and it’s roughly equivalent to the numbers of ways in which people can sin.

This brings us to an irony. In a strange way, this “study of the soul” is aptly named, as in a great measure psychology has usurped the role of religion. It co-opts sins, renames them, and then takes credit for their discovery; you could call it spiritual plagiarism.

I also might say that mental health professionals have become the new priesthood. After all, whereas years ago people might have gone to a man of the cloth for guidance, now they are likely to lie on a therapist’s couch. The prescriptions they get are far different, too. A priest, minister or rabbi would usually render advice steeped in tradition and God-centered, but the psychologist is most likely to offer relativistic counsel, where the focus is on feelings and is thus self-centered.

And what happens when the matter of religion is raised? If you’re like many, including someone I know of, you may be told you’re taking your faith too seriously, that such devotion is akin to a mental illness. This isn’t surprising, I suppose. What future could a person have with an “illusion,” even the very attractive one that Freud seemed to believe was the opiate of the masses?

Yet, with over 20 million Americans, 40 percent of college students and 1 out of 9 schoolchildren on psychiatrist-prescribed psychoactive drugs, one is left to wonder what realm is truly most deserving of that title.

Ahhh yes, Psychiatric Drugs are the New Opiate of the Masses.

The Decline of Psychiatry, Part 4

While people are in shock and horror at the decline of psychiatric services, this is all part of a larger picture where

• the psychs that do exist are moving to big cities where they can charge more and make more money
• Battered over the years, there are less people going into psychiatry as a profession.
• As soon as the organic disease process is identified, the claim of psychiatry is largely undermined and it passes instead to neurology or another specialty.

Of course, there have also been problems of compassion within the mental health industry as well, as evidenced by profiteering, etc.

From the Nanaimo Daily News

There may some logic, based on crunching numbers and bureaucratic mumbo jumbo, in the decision by the Vancouver Island Health Authority to close the psychiatric unit at West Coast General Hospital in Port Alberni, but the closure makes no sense.

VIHA said they had to shut the unit for as long as a year because they cannot find a replacement for a departing psychiatrist. It's hard to believe that VIHA has allowed itself to end up in this position.

In fact, Alberni-Qualicum MLA Scott Fraser is right when he says, "It's not acceptable . . . . It's not an option. You cannot shut down essential services."

To add to Fraser's incredulity, closing a mental health ward approaches irresponsible if not outright negligent.

VIHA might argue they have no control over the comings and goings of doctors, but it's pretty hard to believe that they did not or could not foresee this long enough ago to take appropriate action.

Either way, the fact that they could not negotiate to have the current psychiatrist remain until a replacement could be found, or that they were caught by surprise, indicates something is wrong within VIHA.

What this also seems to indicate is that the health authority has little regard for those in need of mental health care.

Imagine if VIHA allowed the same state of affairs to happen at an emergency ward. The province would have to step in, replacing the VIHA board of directors -- who may also be personally liable for any tragedy -- and take steps to make sure that mandated level of emergency care is in place.

It is pretty shocking when one considers how the VIHA brass in Victoria seem to think about the mentally ill. The need for a psychiatrist in any community has to be seen as crucial as an emergency ward.

What the health authority seems to be saying is that someone in Port Alberni, or anywhere in the VIHA jurisdiction for that matter, who arrives at a hospital with a psychiatric crisis counts less than someone with a broken arm.

Sure, an untreated broken arm can lead to gangrene and death. But untreated mental distress can lead to suicide. And just as time is crucial in treating a medical emergency, so it is with a person in crisis from a mental disorder. Leaving such a person without necessary help will lead to escalating behaviour which can be violent or self destructive.

One agency that will not be very happy with state of affairs will be the RCMP. They are the ones who will have to cope with violent or suicidal people until appropriate help can be found. What do the RCMP do? Drive them to Nanaimo Regional General Hospital? Keep them in jail and let the courts sort it out?

VIHA's plan is that mental health and addictions community office in Port Alberni will handle psychiatric patients. The folks in that office must be just thrilled that their bosses in Victoria, who appear to have no insight into the needs of a person in mental distress, have delegated them as the ad hoc psych unit for the city.

The other plan is that a community response team will also intervene for people in need of psychiatric care. One problem though is that the team has not been established.

It's rather puzzling that VIHA appears to be able to put together this idea of a community response team, but can't seem to hire a psychiatrist.

Since its inception in 2002 VIHA has failed to serve any community on the Island adequately. Hospitals have become dirtier and less efficient, staff are overworked like never before, health facilities are increasingly crowded and this episode in Port Alberni is evidence of gross mismanagement.

The one place to start for a solution is for the VIHA board to censure Howard Waldner and his management team. And given that the board is ultimately liable, it seems they need to send a message that this state of affairs cannot go on.

Drug giant Pfizer tries to force New England Journal of Medicine to reveal anonymous sources

An interesting attempt by drug maker Pzifer to stop the bleeding of bad reviews and bad news related to its products. Report seen in the Independent

A multinational drugs company is trying to force a medical science journal to reveal the confidential statements made by the journal's expert reviewers in a test case that could undermine one of the central tenets of the scientific process.

Pfizer, the manufacturer of the anti-impotency drug Viagra, is trying to force the New England Journal of Medicine (NEJM) to release the names and comments of its anonymous peer reviewers who judged a dozen studies into two of the company's pain-killing drugs.

Pfizer has issued a subpoena demanding that the journal release the identities and comments of its referees, who normally remain anonymous so that they will feel free to give their honest opinions.

A US district court judge is expected to rule this week on whether the drug company can force the NEJM to release the information, which some scientists claim would damage the confidential peer-review system that science uses to evaluate the merits of prepublication research.

Pfizer, which is based in New York, is being sued for damages allegedly caused by the drugs Celebrex and Bextra. Both pain killers belong to the same class of Cox-2 inhibitors as Vioxx, which was withdrawn in September 2004 because of fears that it had caused thousands of heart attacks and strokes. Although Bextra has been withdrawn, Celebrex is still on sale.

As part of its defence, Pfizer is seeking any additional information that may support its case. "Scientific journals such as NEJM may have received manuscripts that contain exonerating data for Celebrex and Bextra which would be relevant for Pfizer's causation defence," the company says in its motion.

But Donald Kennedy, the editor of the journal Science, said that this amounts to a fishing expedition. "If this motion succeeds, what journal will not then become an attractive target for a similar assault?" he wrote in a signed editorial. At stake is the public's interest in a fair system of evaluating and publishing scientific work.

The motion filed by Pfizer claims that the public has no interest in protecting the editorial process of a scientific journal.

The Decline of Psychiatry, Part 3

We have another report regarding the decreasing numbers of psychiatrists, this time from Alabama. See our earlier reports here

A shortage of psychiatrists, both in-state trainees and out-of-state recruits, in the state of Alabama has proved to be an increasing problem over the past decade.

In a study conducted by Dr. Richard Powers in April 2007, Alabama has only 7.1 psychiatrists per 100,000, while other neighboring states have 8.1 and the nation has 13.7, according to Understanding the Shortage of Psychiatrists and Selected other
Mental Health Professionals in Alabama.

Powers cites this shortage due to lack of funding for psychiatry programs, a shortage of in-patient beds, difficulties for physicians to obtain practicing licenses and an overall decline in the retention rate of Alabama psychiatrists.

The University of South Alabama offers one of the two only psychiatry programs in the state of Alabama. Both programs at USA and the University of Alabama at Birmingham have experienced difficulties, according to Powers' study.

Each experienced difficulties in training the maximum number of psychiatrists, many of whom practice in other states after training.

"The University of South Alabama suffered from management issues and the program at UAB suffered from a shortage of funding to support the maximum number of candidates," the study states.

[...]

The University of South Alabama College of Medicine department of psychiatry program works to combat these shortages through its funding, programs and output of trained graduates on a yearly basis.

[...]

A draft copy of the study can be seen in full here

Read this doc on Scribd: Understanding the Shortage of Psychiatrists in Alabama

The Decline of Psychiatry, Part 2

Earlier we reported on the declining numbers of psychiatrists in Indiana. Now we have this report of a similar decline in Ohio:

[...]Trumbull is undergoing a psychiatrist shortage, according to those at Trumbull LifeLifes, the agency considering joining forces with Summa Health System in Akron.

‘‘It’s a perennial challenge here in Trumbull County, all over the state,’’ said James Sager, LifeLifes chief operating officer. ‘‘Finding and keeping psychiatrists is particularly a difficult challenge for us.’’[...]

According to the National Center for Health Workforce Analysis, Ohio had 1,019 psychiatrists six years ago, making 31st in the nation in the number of psychiatrists per capita. In comparison, Pennsylvania ranked 11th with 1,753.

[...]

Director of consultation liaison psychiatry at Summa, Tod Ivan, said he believes there is an overall shortage largely because of federal policy.

He said the government — through Medicare — has restricted funding for specialty care, like psychiatry, in favor or primary care. Also, Ivan said, policy regarding managed care makes it hard for psychiatrists to make a living, like for example, a 50 percent co-payment on mental health services through Medicare.

‘‘Nationally, for about 20 years, the numbers have remained flat,’’ he said.

Of course, they try to put a positive face on the report, citing partnership efforts with other population centers. We suspect that there is a larger long term trend that they are not at alll happy about, and that this report is just another pin in the Voodoo Doll of Psychiatry.

Psychiatrist shortage looms - Lack of popularity puzzles professionals

Now Formally: The decline of Psychiartry, Part 1

It looks like many people who could become psychiatrists are avoiding the job. This is puzzling to medical professionals, some of whom are starting to panic. Of course, we could speculate about the public reputation of psychiatrists as a contributing factor. (Just take a look at the stories published on this site) We will not speculate further in this regard, but can only note that if this trend keeps up, this decline can only lead to the eventual death of the profession as we know it. Snippets from this report out of Iowa

Russell Knight, president and chief executive officer of Mercy Medical Center-Dubuque, recently served on a task force studying Iowa's physician needs.

The group found 77 openings for psychiatrists in Iowa, yet an average of only 16 psychiatrists entering the state each year.

Knight said it will take five years to fill Iowa's psychiatrist vacancies if that rate continues. By comparison, obstetrician, cardiologist and general-surgeon vacancies take an average of two years to fill.

[...]

"But there is a shortage of psychiatrists all over the country," Curtis said.

The shortage in Iowa seems more pronounced than elsewhere, however. Knight's task-force research suggests Iowa has half as many psychiatrists per 100,000 residents compared to the national average -- 7.7 versus 15.8.

The statewide psychiatrist shortage has forced some Iowa hospitals to close their inpatient psychiatric units, Knight said, and it is no longer unusual for Mercy's unit to care for patients who have come from 100 miles away.