In the media in the United States electroconvulsive therapy (ECT) is frequently referred to as making a comeback, although the articles which take this line don’t come up with reliable statistics to support their claims.
Now an article published in Biological Psychiatry shows that, in general hospitals at least, the use of ECT on “severely depressed inpatients” has “fallen markedly” since the early 1990s. (B.G. Case et al. Declining use of electroconvulsive therapy in US general hospitals. Biological Psychiatry, October 2012)
According to the article, psychiatric units in general hospitals account for over 50 per cent of stays in the mental health system. The authors did not think that the declining use of ECT in general hospitals could have been offset by increased use in free-standing psychiatric hospitals, or by increased use of outpatient treatment.
The authors analysed data from the Nationwide Inpatient Sample (NIS) and found that, after increasing from 1993 to 1995 (from 12.6/100,000 residents to 15.9/100,000 residents) the number of inpatient stays involving ECT use then gradually fell by over half to 7.2/100,000 residents by 2009. The use of ECT on people aged under 65 fell only slightly; the decreased was mostly down to a large fall in use of ECT on older people. Most of the decline was accounted for by fewer hospitals using ECT – the number fell from 907 in 1993 to 538 in 2009. The percentage of hospitals with inpatient psychiatric units using ECT fell from 55 per cent to 35 per cent.
The discussion section of the article states:
“Between 1993 and 2009, the probability that the treating hospital of a severely depressed inpatient conducts ECT fell by one third. Declines were concentrated in elderly persons, a group traditionally thought to benefit most from ECT…”
“Why” the authors ask “are fewer hospitals conducting ECT? Our analyses cannot definitively identify the cause…” They go on to consider, and dismiss, various possible explanations. One possible explanation that was not entirely dismissed was that of financial incentives to conduct ECT (or the lack of them).
“We found that publicly insured depressed inpatients were less likely to be treated in hospitals that conduct ECT than their privately insured counterparts… Although national comparisons among Medicare, Medicaid, and private insurer reimbursement of inpatient ECT are not available, our experience is that private insurer reimbursement of inpatient days and ECT procedure fees substantially exceeds that of public insurers.”