Racial differences in the availability and use of electroconvulsive therapy for recurrent major depression

Factors associated with early and late response to electroconvulsive therapy

OBJECTIVE

Electroconvulsive therapy (ECT) is an effective treatment for severe depressive symptoms, yet more research is needed to examine predictors of treatment response, and factors associated with response in patients not initially improving with treatment. This study reports factors associated with time to response (early vs. late) to ECT in a real-world setting.

METHODS

This was a retrospective, single-center cohort study of patients endorsing moderate to severe depressive symptoms using the Quick Inventory of Depressive Symptomatology (QIDS; QIDS>10). Response was defined as 50% or greater decrease in QIDS score from baseline. We used logistic regression to predict response at treatment #5 (early response) as well as after treatment #5 (late response) and followed patients through ECT discontinuation or through treatment #20.

RESULTS

Of the 1699 patients included in this study, 555 patients (32.7%) responded to ECT treatment at treatment #5 and 397 (23.4%) responded after treatment #5. Among patients who did not respond by treatment #5, those who switched to brief pulse width ECT from ultrabrief pulse ECT had increased odds of response after treatment #5 compared with patients only receiving ultrabrief pulse (aOR = 1.55, 95% CI: 1.16-2.07). Additionally, patients with less improvement in QIDS from baseline to treatment #5 had decreased odds of response after treatment #5 (aOR = 0.97, 95% CI = 0.97-0.98).

CONCLUSION

Among depressed patients treated with ECT, response occurred in 56.0% of patients by treatment #20. Patient receiving ultrabrief pulse ECT at baseline and who did not respond by treatment #5 had greater odds of subsequent response if switched to brief pulse ECT than if continued with ultrabrief pulse.

Structural Racism and Psychiatric Practice: A Call for Sustained Change

ABSTRACT

Structural racism has received renewed focus over the past year, fueled by the convergence of major political and social events. Psychiatry as a field has been forced to confront a legacy of systemic inequities. Here, we use examples from our clinical and supervisory work to highlight the urgent need to integrate techniques addressing racial identity and racism into psychiatric practice and teaching. This urgency is underlined by extensive evidence of psychiatry's long-standing systemic inequities. We argue that our field suffers not from a lack of available techniques, but rather a lack of sustained commitment to understand and integrate those techniques into our work; indeed, there are multiple published examples of strategies to address racism and racial identity in psychiatric clinical practice. We conclude with recommendations geared toward more firmly institutionalizing a focus on racism and racial identity in psychiatry, and suggest applications of existing techniques to our initial clinical examples.

Trends for Electroconvulsive Therapy Utilization in Children and Adolescents in the United States From 2002 to 2017: A Nationwide Inpatient Sample Analysis

OBJECTIVES

Electroconvulsive therapy (ECT) is controversial in children and adolescents (C/A). The primary objective of this study was to evaluate baseline characteristics of C/A in the utilization of ECT compared with the non-ECT group with the same primary indication. The secondary objective was to assess the trends in ECT utilization over 16 years and explore the predictors of length of stay.

METHODS

Using the Nationwide Inpatient Sample database from the years 2002 to 2017, we identified patients (age ≤18 years) undergoing ECT in the United States using International Classification of Diseases, Ninth Revision and Tenth Revision, Clinical Modification/Procedure Coding System codes and compared with non-ECT C/A patients with the same primary diagnosis. Baseline clinical characteristics were assessed using descriptive analysis methods. Multilevel regression analysis and trend analysis were performed.

RESULTS

Children and adolescent patients (n = 159,158) receiving (ECT: n = 1870) were more likely to be men (43.3% vs 36.7%) and of White race (58% vs 49%) (P < 0.001). The hospital stay was longer (19 days vs 6 days, P < 0.001) for the ECT group than controls. ECT receiving C/A patients were more likely to have private insurance (72% vs 42%, P < 0.001). African American patients undergoing ECT treatment increased in number over the course of years (2002 to 2017), whereas the privately insured C/A patients receiving ECT decreased over the same period (P < 0.001). There was an upward trend in ECT utilization for small bed size hospitals (P < 0.001). Length of stay for C/A receiving ECT was longer for males (P < 0.001) and patients with nonprivate insurance (p: 0.003).

CONCLUSIONS

Electroconvulsive therapy is not optimally used in C/A; therefore, formulated treatment guidelines are required.

Clinicians' Racial Bias Contributing to Disparities in Electroconvulsive Therapy for Patients From Racial-Ethnic Minority Groups

Patients from racial-ethnic minority groups undergo disparate electroconvulsive therapy (ECT) treatment compared with Caucasian peers. One leading hypothesis is that clinicians may unknowingly display racial bias when considering ECT for patients of color. Studies have consistently shown that patients of color face numerous racially driven, provider-level interpersonal and perceptual biases that contribute to clinicians incorrectly overdiagnosing them as having a psychotic-spectrum illness rather than correctly diagnosing a severe affective disorder. A patient's diagnosis marks the entry to evidence-based service delivery, and ECT is best indicated for severe affective disorders rather than for psychotic disorders. As a consequence of racially influenced clinician misdiagnosis, patients from racial-ethnic minority groups are underrepresented among those given severe affective diagnoses, which are most indicated for ECT referral. Evidence also suggests that clinicians may use racially biased treatment rationales when considering ECT after they have given a diagnosis of a severe affective or psychotic disorder, thereby producing secondary inequities in ECT referral. Increasing the use of gold-standard treatment algorithms when considering ECT for patients of color is contingent on clinicians transcending the limitations posed by aversive racism to develop culturally unbiased, clinically indicated diagnostic and treatment rationales.

Demographics of Patients Receiving Electroconvulsive Therapy Based on State-Mandated Reporting Data

OBJECTIVES

Electroconvulsive therapy (ECT) is an effective treatment of depression and other psychiatric conditions. There are few comprehensive data on how many patients receive ECT in the United States or about the demographics of ECT recipients. This study characterizes the demographics of those receiving ECT and how these demographics may have changed with time.

METHODS

Freedom of information requests for all data from record keeping inception to January 2019 were sent to the Department of Health or equivalent agency of states that mandate reporting of ECT. Information on demographics and the number of treating facilities was extracted.

RESULTS

Data on 62,602 patients receiving treatment in 3 states (California, Illinois, Vermont) were obtained. Overall, 62.3% were women. Fewer than 1% of patients treated were younger than 18 years, whereas 30.3% were 65 years or older. White patients received a disproportionate proportion of treatments, with all other races underrepresented. The total number of facilities offering ECT in the 3 states declined over the study period.

CONCLUSIONS

Recipients of ECT are more likely to be female, more likely to be elderly, and more likely to be white than the average person in their state.

Achieving Equity in Informed Consent: A Culturally-Informed Perspective for the Consideration and Consent of Minority Patients for Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is highly efficacious to treat severe depression in older adults. Yet, patients of ethnic and racial minorities are consistently underrepresented amongst those who receive ECT across all age groups. One strong hypothesis to explain this disparity is that minority patients are less likely to trust medical professionals and are therefore less likely to consent for ECT. Increasing participation of depressed, elderly, minority patients is uniquely challenging. Senior minority individuals have survived decades of medical and social injustices that no other demographic, specifically younger minorities or clinically-matched Caucasian peers, can truly comprehend from a first-hand perspective. This article provides a perspective based in cultural translational science to conversations of informed consent for ECT that removes our self-imposed stigma against discussing past and ongoing injustices with minority patients. Reducing disparities to geriatric minorities through equity of informed consent means that clinicians must validate the unique minority experience in medicine as it pertains to agreeing to a treatment modality as emotionally, socially, and historically laden as ECT.

Electroconvulsive Therapy in Veterans Health Administration Hospitals: Prevalence, Patterns of Use, and Patient Characteristics

OBJECTIVES

The body of large-scale, epidemiological research on electroconvulsive therapy (ECT) in the United States is limited. To address this gap, we assessed demographic, clinical, pharmacological, and mental health treatment history as well as 2-year mortality outcomes associated with ECT use in the largest U.S. health care system.

METHODS

Among all patients who sought mental health care at Veterans Health Administration (VHA) hospitals in 2012, we used bivariate analyses to compare patients who did and not receive ECT during 2 years of follow-up. Among the population who received ECT, descriptive statistics were calculated to characterize prior mental health treatment patterns and ECT receipt.

RESULTS

0.11% (N = 1616) of all VHA mental health patients in 2012 (N = 1,457,053) received ECT in 2 years of follow-up. There was significant regional variation in provision of ECT. Those who received ECT were more likely to have diagnoses of major depressive, bipolar, and personality disorders and were significantly more likely to have had a recent mental health inpatient stay (risk ratio, 6.94). Receipt of ECT was not associated with a difference in all-cause mortality (risk ratio, 0.88). Thirty-two percent of those who received ECT had no substantial antidepressant or therapy trial in the year before index mental health encounter.

CONCLUSIONS

Use of ECT in the VHA is rare. Patients who receive ECT have a complex and high-risk profile, not necessarily consistent with the most common indications for ECT.

Electroconvulsive therapy, depression severity and mortality: Data from the Danish National Patient Registry

BACKGROUND

The effects of electroconvulsive therapy are usually estimated from changes in depression scales from studies with relatively small patient samples. Larger patient samples can be achieved from epidemiological registers, which provide information on other social and clinical predictors, results and risks.

AIMS

To examine whether depression severity predicts the use of electroconvulsive therapy, risk of re-hospitalization, suicidal behaviour and mortality following electroconvulsive therapy in patients with major depression.

METHODS

A cohort of 92,895 patients diagnosed with single or recurrent depression between 2005 and 2016 in the Danish National Patient Registry was followed for electroconvulsive therapy and adverse outcomes. Associations between electroconvulsive therapy and outcomes were analysed using Cox regression.

RESULTS

A total of 5004 (5.4%) patients were treated with electroconvulsive therapy. Depression severity was the strongest predictor of electroconvulsive therapy. Electroconvulsive therapy was used more frequently above age 70, in those better educated or married, whereas comorbid alcohol abuse or history of prior stroke at study entry were associated with lower rates. Electroconvulsive therapy was associated with lower mortality. The adjusted hazard ratio for the association between electroconvulsive therapy and suicide in patients with mild depression was 6.99 (3.30-14.43), whereas it was 1.10 (0.55-2.20) in those with severe depression and psychotic symptoms. A similar pattern was seen for emergency contacts and attempted suicide.

CONCLUSIONS

Electroconvulsive therapy was associated with lower all-cause mortality and the relative risk for re-hospitalization and attempted and committed suicide was lowest in patients with the most severe depression. Electroconvulsive therapy is an important treatment, with significant public health benefits, for patients with severe depression.

Effectiveness of electroconvulsive therapy on treatment-resistant depressive disorder: A population-based mirror-image study

The clinical effects of electroconvulsive therapy (ECT) in treatment-resistant depressive disorders need to be systemically examined in representative samples. This study aimed to examine whether ECT reduced re-hospitalization within one year after discharge. The authors used the Psychiatric Inpatients Medical Claim Dataset, a subset of a total population health claims database from Taiwan, to include 784 inpatients with treatment-resistant depressive disorders screened for ECT during hospitalization between 2001 and 2011. The same number of comparison subjects was selected by frequency matching on the demographic and clinical characteristics. Using a mirror-image comparison design, we compared group differences in re-hospitalization rate, number of hospital days, number of emergency department visits, and direct medical costs during the 1-year pre- and post-ECT periods. The modifying effects of patients' characteristics on these outcomes were also explored. The results showed that ECT was associated with a significant decrease in the rate of hospitalizations and emergency department visits over the 1-year follow-up period. However, there were no significant difference in the reduced rate of hospitalizations between ECT and comparison group. Demographic and clinical characteristic had no modifying effect on the odds of psychiatric hospitalization. In conclusions, ECT could reduce the rate of hospitalization and number of emergency department visits in patients with treatment-resistant depressive disorders. However, the study results might be biased by the inherent deficits of mirror-image design.

Racial Disparities in the Administration of ECT in Texas, 1998-2013

OBJECTIVE

Electroconvulsive therapy (ECT) is a treatment of choice for severe depression but has been underutilized among black patients. This study investigates racial disparities in the administration of ECT in the state of Texas between 1998 and 2013 using population data.

DESIGN

Data from the Texas Department of State Health Services were obtained corresponding to the use for all ECT conducted in nonfederal settings during the period from January 2, 1998, to August 30, 2013. The data set comprised quarterly reports generated for each patient, totaling 27,931 patient quarters. Using year-by-year intercensal population estimates for the state of Texas, ECT treatments per capita were compared among black, white, Latina/Latino, and other individuals during this time period.

RESULTS

Significantly more white patients were treated each quarter than minority patients (P < 0.001), with Latina/Latino patients recording fewer treatment quarters than any other racial group (P < 0.005). Large discrepancies in diagnosis by race were observed. Black patients were less likely than white and Latina/Latino patients to be diagnosed with depression and 4 times as likely as white patients to carry a diagnosis of schizophrenia.

CONCLUSIONS

Concordant with previous data, large racial disparities in the administration of ECT were found in this Texas data set. Despite the limited nature of this data set, these results suggest that continued investigation is required to determine factors responsible for these disparities.

Racial/Ethnic Disparities in Receipt of Electroconvulsive Therapy for Elderly Patients With a Principal Diagnosis of Depression in Inpatient Settings

OBJECTIVE

Electroconvulsive therapy (ECT) is underused despite being among the most effective treatments for older adults with severe, pharmacotherapy-resistant mood disorders. Furthermore, those in minority groups are even less likely to receive ECT. The objective of this study was to examine racial and ethnic disparities in the receipt of ECT in older adults.

METHODS

We used survey-weighted log-binomial regression to generate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) that represented the associations between race/ethnicity and receipt of ECT during hospitalization at an ECT-available hospital. We used data from the 2002-2015 National Inpatient Sample, the largest all-payer inpatient database in the United States. The analysis was restricted to hospitalizations of adults aged 65-95 with depression as a principal diagnostic code. The primary exposure was patient race/ethnicity, and the primary outcome was receipt of ECT during hospitalization, restricted to ECT-available hospitals.

RESULTS

Among the 685,939 patients included in the analysis, 45% received care at an ECT-available hospital, and among those, 17% received ECT. Non-Hispanic (NH) blacks were nearly half as likely to receive ECT as NH whites (aPR: 0.56 [0.47-0.81]; t: -6.42; df: 1,327; p < 0.001). Hispanics were nearly half as likely to receive ECT as NH whites (aPR: 0.57 [0.44-0.72]; t: -4.59; df: 1,327; p < 0.001).

CONCLUSION

This national cross-sectional study of racial/ethnic disparities in receipt of ECT among depressed elderly patients confirms prior literature and reveals the potential worsening of disparities for racial/ethnic minorities blacks.

Geographical access to electroconvulsive therapy services in Texas

AIMS

Electroconvulsive Therapy (ECT) is a well-established and effective treatment in mood disorders but the use of ECT in Texas is much lower than the general average among the United States. Our goal is to explore the geographical accessibility of Electroconvulsive Services in Texas.

METHODS

22 ECT Centers in Texas listed in State's 2016 annual ECT report were enrolled and georeferenced. We used Esri's StreetMap Premium Network release 1 network dataset to generate 1-hour drive time service areas for these ECTs. We estimated populations within these service areas based on US Census Tract level population-weighted centroids; generated from the 2015, American Community Survey (ACS) estimates at the US Census Block Group level.

RESULTS

About 75% (19,851,802 of 26,538,614) of Texas total population is within a 1-hour drive time to any ECT Services location. When focusing on population below the poverty level from 2015 Block Group level ACS data: 68% (3,046,141 of 4,472,451) are within a 1-hour drive time.

CONCLUSIONS

ECT services are geographically accessible in Texas. Other barriers may contribute to lower use of ECT.

Patient Experience of Electroconvulsive Therapy: A Retrospective Review of Clinical Outcomes and Satisfaction

OBJECTIVE

The aim of the study was to explore patient perception and perceived benefit of electroconvulsive therapy (ECT) by assessing the real-world experience of adult patients who received ECT, focusing on clinical outcomes and patient satisfaction.

METHODS

This retrospective study analyzed patient self-report of depressive symptoms (Patient Health Questionnaire), perception of physical and cognitive ECT adverse effects (ECT Outcomes Survey) and satisfaction with treatment (Patient Satisfaction Survey). Symptoms and adverse effects were measured at both intake and final ECT session for comparison over time. Data were collected from 1089 adult patients with depression, bipolar disorder, or schizoaffective disorder in 23 psychiatric facilities in the United States and its territories from 2014 to 2015.

RESULTS

On average, patient scores reflect satisfaction with treatment and reduction in depressive symptoms and adverse effects across the course of ECT treatment. Patients reported a decrease in depression, with an average Patient Health Questionnaire change of 13.2 from intake to final ECT session (P < 0.001). Furthermore, 85.5% of patients indicated on the Patient Satisfaction Survey that they benefited or improved as a result of their ECT. Subsequent analyses revealed alleviation of depressive symptoms and ability to return to social, and work life tasks are significant contributors to satisfaction with treatment, whereas adverse effects including memory problems have less influence on satisfaction.

CONCLUSIONS

Patients tend to perceive ECT as a safe and beneficial treatment option for severe mood disorders, even when considering adverse effects. This study reinforces the value of standardized data collection and outcomes measures to better monitor patient response to treatment, refine the clinical practice of ECT, and provide data to support patient education.

Time Trends and Variations in Electroconvulsive Treatment in Denmark 2008 to 2014: A Nationwide Register-Based Study

OBJECTIVE

The aim of this study was to determine status and variations in the practice of electroconvulsive treatment (ECT) in Denmark in patient characteristics, indications, treatment patterns, and hospital region.

METHOD

All 140,627 ECTs registered in the Danish National Patient Registry between 2008 and 2014 were retrieved together with information on patient characteristics. Annual treated person rates were calculated for sex, age, admission diagnosis, and region.

RESULTS

The overall ECT treatment rate was 36 (95% confidence interval, 34-38) per 100,000 resident population during the study period. The rate was highest in women and increased with age. There were modest, however, stable regional differences in rates (extremal quotient = 1.4). Electroconvulsive treatment was most commonly used in patients with depression with (19.4%) or without (54.9%) psychotic symptoms. The median number of ECTs administered per patient was 10 and highest in patients with schizophrenia, schizoaffective, or bipolar disorders. A total of 51%, 14%, and 33% of ECTs were administered with bilateral, unilateral, and unspecified electrode placement, respectively. There were regional differences in electrode placement specification and use.

CONCLUSIONS

Although some variation was seen across hospital regions and electrode placement, ECT in Denmark was provided with relative stability over time and indications compared with most other countries in Europe and North America.

Electroconvulsive Therapy (ECT) and Race: A Report of ECT Use and Sociodemographic Trends in Texas

OBJECTIVES

Minimal research on race and other sociodemographic disparities in patients receiving electroconvulsive therapy (ECT) exists. One previously noted national trend reveals whites receiving ECT disproportionately more than other races. The aim of this study is to determine whether a county ECT program demonstrates similar disparities observed at the state and national levels.

METHODS

This study examined 21 years of ECT data, between 1993 and 2014, provided by the Texas Department of State Health Services, focusing on race, sex, age, and payer source and 2.5 years of the same variables from a Harris County hospital ECT program. In addition, population demographic data for Harris County and the state of Texas during the same period were obtained from the Department of State Health Services Web site.

RESULTS

Despite an overall decrease in the population of whites countywide and statewide, whites continue to use more ECT than African Americans, Latinos, and Asians in both Harris County and Texas. However, the rates of ECT use in minorities increased overall. Both countywide and statewide, ECT was used more than twice as often in women than men. Statewide, elderly patients (>65 years old) saw decreases in ECT use, and there was an increase in private third-party payer source.

CONCLUSIONS

Electroconvulsive therapy remains underused among African Americans, Latinos, and Asians. Hypotheses and areas for future study include cultural beliefs, stigma, patient and provider knowledge of ECT, and access to care. Despite this, the general use of ECT in Texas has increased overall, and minority use is slowly on the rise.

Effects of stimulus parameters on motor seizure duration in electroconvulsive therapy

OBJECTIVE

This study examined the effect of stimulus parameters on the occurrence of adequate seizures and reconsidered the factors related to motor seizure duration.

METHODS

The medical records of 187 patients who received ECT in Asan Medical Center from January 2007 to May 2014 were retrospectively reviewed. The starting stimulus dose was determined using a preselected-dose method and the cutoff value to determine the adequate motor seizure duration was 20-25 seconds. The association between seizure parameters and the occurrence of adequate seizure was assessed with logistic regression using a generalized estimating equation.

RESULTS

Age (P<0.001), use of mood stabilizers (P=0.002), and benzodiazepine (P<0.001) were significantly lower in sessions with an adequate seizure duration but use of antidepressants (P<0.001) and clozapine (P=0.025) were significantly higher in sessions with an adequate seizure duration. In the generalized estimating equation analyses, after adjustment for age, benzodiazepine dose, and lamotrigine use, charge (odds ratio [OR] =0.999; 95% confidence interval [CI], 0.998-1.000; P=0.005), and train duration (OR =0.632; 95% CI, 0.490-0.817; P<0.001) were significantly associated with the occurrence of adequate seizure.

DISCUSSION

Stimulus charge and train duration are significantly associated with motor seizure duration. However, train duration appears to have a greater effect on motor seizure duration. Additionally, age, benzodiazepine dose, and lamotrigine use independently affect motor seizure duration.

Depression among older adults with diabetes mellitus

Older adults with Diabetes Mellitus (DM) experience greater risk for comorbid depression compared to those who do not have DM. Undetected, untreated or under-treated depression impinges an individual's ability to manage their DM successfully, hinders their adherence to treatment regime, and undermines provider-patient relationships. Thus, in the context of caring for older adults with DM, comorbid depression presents special challenges and opportunities for clinicians. In this article, we summarize the clinical presentation of late-life depression, potential mechanisms of comorbidity of depression and DM, importance of depression in the successful management of DM, and available best practice models for depression treatment.