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.

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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.”

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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.”

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