Electroconvulsive therapy effective but rarely used among older patients with depression
Use of electroconvulsive therapy among older adults with depression remains rare, despite significant evidence of its efficacy, according to results of a study published in Journal of Clinical Psychiatry.
“Electroconvulsive therapy (ECT) is the most effective treatment for [major depressive disorder], with remission rates of 80% to 90% when used as first-line treatment,” Taeho Greg Rhee, PhD, of the department of community medicine and health care at University of Connecticut School of Medicine, and colleagues wrote. “Moreover, ECT results in remission rates of 50% to 70% in treatment-resistant depression compared [with] remission rates of 13% to 14% in treatment-resistant depression using conventional antidepressants. ECT has been shown to be especially effective in older adults.”
A prior cost-effectiveness analysis showed ECT as a cost-effective intervention following inadequate antidepressant response; it also appeared to reduce risk for 30-day hospital readmissions among hospitalized patients with depression. However, little remains known regarding the use and quality of ECT in community practice.
To address this research gap, Rhee and colleagues conducted the current study, which is the first to provide a nationally representative description of ECT among older adults. They analyzed 2014 to 2015 claims data of Medicare beneficiaries aged 65 years or older with MDD who received ECT and compared clinical and demographic measure outcomes with patients from this sample who did not receive ECT. They characterized treatment patterns by setting and the proportion of patients who received index and continuation/maintenance courses, subtherapeutic courses of ECT and follow-up care after ECT administration.
Results showed 7,817 (0.41%) of Medicare beneficiaries in this population received at least one ECT session. ECT recipients were slightly younger and more likely to be male, non-Hispanic and white, as well as live in a ZIP code with a higher median income, compared with the general population. Among patients who received any ECT, approximately one-third received fewer than five total treatments. Moreover, of those who received an index ECT treatment, approximately one-third received a continuation/maintenance ECT course and 60.9% received some form of follow-up treatment after ECT, such as additional ECT or new psychotropic medication. Psychotherapy receipt most strongly predicted likelihood of receiving five or more ECT treatments (adjusted OR = 1.43; 95% CI, 1.22-1.67).
“Quality improvement efforts could be directed at improving the implementation of ECT and ensuring adequate treatment courses and follow-up care,” Rhee and colleagues wrote. “Provider- and hospital-level variation in ECT course and follow-up should be explored to identify factors associated with high quality care. Improving these quality measures and ensuring equitable and appropriate access to ECT in community settings are challenging given the complexity of ECT administration and attitudinal barriers. Intervention efforts might focus on revising educational curriculum requirements for psychiatrists in training, reforming legal restrictions, and educating referring psychiatrists (‘gatekeepers’) and the general public.”