Availability of Electroconvulsive Therapy in Public Health Services in the Last Decade in Brazil.

OBJECTIVE: To identify the current treatment options for electroconvulsive therapy (ECT) therapy in public services linked to the Unified Health System in Brazil and compare them with data published in 2012 based on their availability. METHODS: In this retrospective observational study, we mapped institutions that perform ECT under public health services in Brazil. A questionnaire was administered to active and inactive service centers between August 2022 and June 2023. RESULTS: We identified 16 institutions that performed ECT, including 12 linked to public universities and 4 with various links. In the last decade, 2 new public services that perform ECT in the country have emerged, whereas 4 services have ceased function. In 2022, the number of individuals treated with ECT per 100,000 population was 1.86, whereas the number of procedures performed per 100,000 people was 6.55. CONCLUSIONS: Although 2 new public ECT services have been identified, 4 have turned inactive. Most services are linked to public universities, and inactive service points to financial issues as the main factor in service interruption. Brazil has one of the lowest rates of individuals treated with ECT per 100,000 population compared with countries in North America and Europe. Thus, it is essential to raise awareness to improve ECT adoption rates and bring it out of the shadows in Brazil.

Receipt of Electroconvulsive Therapy in Outpatient Settings in a National Sample of Privately Insured Patients With Mood Disorders.

PURPOSE: Electroconvulsive therapy (ECT), an effective treatment for bipolar and major depressive disorder, is underused. Little information is available on use of ECT in potentially less costly outpatient settings, possibly reducing cost barriers. METHODS: Insurance claims from the 2008 to 2017 MarketScan Commercial Database for patients diagnosed with mood disorders were used to compare 4 groups of ECT users in each year: those receiving (1) exclusively outpatient ECT, (2) first inpatient and subsequently outpatient, (3) outpatient and subsequently inpatient, and (4) exclusively inpatient ECT. Groups were compared on the proportion receiving ECT in each group over time as well as on the total numbers of treatments received along with group differences in sociodemographic and diagnostic characteristics and health care costs. RESULTS: Among 2.9 million patients diagnosed with mood disorders, the proportion who received ECT (n = 8859) was small (0.30%) and declined over the decade to 0.17%. Among those who received ECT, most did so exclusively as outpatients (52.3%), the group with fewest comorbidities and lowest costs. This proportion increased by 19.7% over the decade, whereas the proportion receiving ECT exclusively in an inpatient setting (12.1%) fell by 30.6%. The total number of treatments per patient averaged 11.7 per year and increased by 28.0% over the decade, with outpatients decreasing to slightly less than average. Health care costs were greatest for those who started ECT as inpatients. CONCLUSIONS: Although the proportion of privately insured patients receiving ECT in outpatient settings has increased, reducing cost barriers, the use of ECT continued to be extremely limited and declining.

Electroconvulsive therapy: recent advances and anesthetic considerations.

PURPOSE OF REVIEW: This review summarizes the current indications and principles of ECT. Contemporary anesthetic considerations are described with a focus on the optimal use of hypnotic agents and providing ECT in pregnant patients. RECENT FINDINGS: ECT is useful in treatment-resistant major depression, bipolar disorders, and treatment-resistant schizophrenia. It is a well tolerated treatment in pregnant patients with treatment-resistant depression. Cognitive side effects may be attenuated by using unilateral placement of scalp electrodes, fewer treatment sessions, and the use of ultrabrief pulse width of the electrical charge. All modern hypnotics can be used for induction of anesthesia for ECT but should be titrated to effect. Etomidate is superior to Propofol in regarding seizure quality. The use of Ketamine shows good seizure quality and may alleviate cognitive impairment. Providing ECT for pregnant patients may prove challenging because of logistic difficulties and the physiologic changes during pregnancy. Although representing an effective treatment option in severely ill patients, ECT is underutilized because of stigmatization and ethnic and financial disparities. SUMMARY: ECT is effective in treating treatment-resistant psychiatric illnesses. Symptoms of cognitive impairment are the most common side effects but can be treated by modifying the technique of ECT. All modern hypnotics can be used for the induction of general anesthesia. Etomidate and Ketamine may be of special interest in patients with insufficient seizure duration. Treating pregnant patients with ECT requires a multidisciplinary approach, in order to provide a safe therapy for mother and unborn child. Stigmatization and social disparities are hindering the widespread use of ECT as an effective treatment for severely ill psychiatric patients.

The association between outpatient continuation/maintenance electroconvulsive therapy, readmission risk and total direct cost in patients with depressive, bipolar and psychotic disorders: A naturalistic retrospective cohort study.

BACKGROUND: The transdiagnostic effect of continuation/maintenance ECT (CM-ECT) across mood and psychotic disorders on hospital psychiatric readmission risk and total direct cost remains unclear. METHODS: A naturalistic retrospective analysis of 540 patients who received inpatient acute ECT treatment from May 2017 to Mar 2021 in a tertiary psychiatric institution. Patients were assessed with validated clinical rating scales pre-ECT and after the first 6 treatments of a course of inpatient acute ECT. After discharge, patients who continued with CM-ECT were compared with those not receiving CM-ECT using survival analysis of hospital readmission. Total direct cost (hospitalisation and ECT treatment cost) was also analysed. All patients were subjected to a standard post-discharge monitoring program with case managers checking in on the patients regularly after discharge and ensuring they were given an outpatient appointment within a month of discharge. RESULTS: Both cohorts had significant improvement in their rating scales scores after their first six 6 sessions of inpatient acute ECT. Patients who continued with CM-ECT after completing their inpatient acute ECT (mean number of acute ECT: N = 9.9, SD 5.3), had a significantly lower risk of readmission [adjusted hazard ratio of 0.68 (95 % CI: 0.49-0.94, p = 0.020)]. Patients who received CM-ECT also had a significantly lower average total direct cost compared to those who did not (SGD$35,259 vs SGD$61,337). For patients with mood disorders, the CM-ECT group had a significantly lower inpatient ECT cost, hospitalisation cost and total direct costs compared to those without CM-ECT. LIMITATIONS: The naturalistic study cannot prove a causal relationship between CM-ECT and reduced readmission and lower healthcare costs. CONCLUSION: CM-ECT is associated with lower readmission risks and lower total direct healthcare costs for the treatment of mood and psychotic disorders, especially for mood disorders.

Assessment of beliefs and attitudes about electroconvulsive therapy posted on Twitter: An observational study.

BACKGROUND: Electroconvulsive therapy (ECT) is an effective and safe medical procedure that mainly indicated for depression, but is also indicated for patients with other conditions. However, ECT is among the most stigmatized and controversial treatments in medicine. Our objective was to examine social media contents on Twitter related to ECT to identify and evaluate public views on the matter. METHODS: We collected Twitter posts in English and Spanish mentioning ECT between January 1, 2019 and October 31, 2020. Identified tweets were subject to a mixed method quantitative-qualitative content and sentiment analysis combining manual and semi-supervised natural language processing machine-learning analyses. Such analyses identified the distribution of tweets, their public interest (retweets and likes per tweet), and sentiment for the observed different categories of Twitter users and contents. RESULTS: "Healthcare providers" users produced more tweets (25%) than "people with lived experience" and their "relatives" (including family members and close friends or acquaintances) (10% combined), and were the main publishers of "medical" content (mostly related to ECT's main indications). However, more than half of the total tweets had "joke or trivializing" contents, and such had a higher like and retweet ratio. Among those tweets manifesting personal opinions on ECT, around 75% of them had a negative sentiment. CONCLUSIONS: Mixed method analysis of social media contents on Twitter offers a novel perspective to examine public opinion on ECT, and our results show attitudes more negative than those reflected in studies using surveys and other traditional methods.

Effects of Electroconvulsive Therapy on Functional Outcomes Among Medicare Patients With Comorbid Depression and Dementia: A Nationwide 1-Year Follow-Up Study.

Objective: Current treatments for behavioral and psychological symptoms of dementia (BPSD) are of limited efficacy. Electroconvulsive therapy (ECT) is an effective and safe treatment for a range of psychiatric disorders, with some limited data suggesting a role in treating BPSD. We sought to expand this growing literature by examining-in a rigorous way with a larger sample size than in previous reports-the potential of ECT as a treatment for comorbid depression and dementia.Methods: Drawing on nationally representative 2014-2015 Medicare claims data, propensity score methods were used to create two comparable cohorts consisting of ECT-treated patients (n = 147) and controls (n = 415) who were hospitalized with a principal psychiatric diagnosis. Functional outcomes were compared before and after hospitalization (when ECT was initiated for the ECT cohort).Results: Both cohorts generally declined in all functional outcomes over the time period observed. The ECT cohort had a slower rate of functional decline in bathing (Cohen d = -0.05 vs 0.38; P < .001) and transferring (d = 0.18 vs 0.45; P = .031) compared to matched controls. In multivariate analysis, ECT patients also fared better in the overall activities of daily living summary score at 180 days (coefficient = -0.10; 95% CI, -0.19 to 0.01), though these effects were small. No difference was seen in cognition or ambulation.Discussion: Receiving ECT does not worsen the trajectory of functional outcomes compared to not receiving ECT in older adults with comorbid depression. Randomized clinical trials are needed to more definitively examine the causal effect of ECT on functional outcomes of individuals with dementia.

Morbidity Due to Disparity in Pediatric Electroconvulsive Therapy.

Dr. Miller and colleagues recently submitted a Letter to the Editor discussing current state laws that result in disparity of electroconvulsive therapy (ECT) availability.1 In this current letter, we present a case of treatment-resistant childhood-onset schizophrenia (COS), with morbidity due to limited access to ECT. The patient and his family presented from Kentucky to Tennessee, despite less legislative regulation in the former. The patient's family provided informed consent for this report to be published.

Repetitive transcranial magnetic stimulation may be a cost-effective alternative to antidepressant therapy after two treatment failures in patients with major depressive disorder.

BACKGROUND: The cost-effectiveness of treatment strategies for patients with Major Depressive Disorder (MDD) who have not responded to two adequate treatments with antidepressants (TRD) are still unclear. The aim of this analysis was to evaluate the cost-effectiveness of add-on repetitive Transcranial Magnetic Stimulation (rTMS) compared with standard treatment. METHODS: A Markov-model simulated clinical events over one year from the perspective of healthcare payer. Third- and fourth-line treatment pathways (augmentation, antidepressant switch or combination, and Electro-Convulsive Therapy (ECT)) were defined based on medical practice guidelines. Transition probabilities were derived from a recent meta-analysis and scientific publications. Resource utilization and cost estimates were based on the patient-level database of a large university hospital. RESULTS: Incremental Quality-Adjusted Life Years (QALYs) and costs were 0.053 and 785 €, respectively, corresponding to an Incremental Cost-Effectiveness Ratio (ICER) of 14,670 € per QALY. The difference in cost between standard treatment and rTMS is explained by the rTMS sessions used in acute (€660) and maintenance (€57/month) treatments, partly offset by lower hospital costs due to higher remission rates in the rTMS arm. Key parameters driving the ICER were incremental utility of remission, unit cost of rTMS treatment and remission rate. At a threshold of €22,243 add-on rTMS is a cost-effective alternative to pharmacotherapy. Evidence on long-term effectiveness is not yet available, so results are estimated for a one-year period. CONCLUSION: Not only does rTMS treatment have beneficial clinical effects compared with drug therapy in TRD, but it also appears to offer good value-for-money, especially in centres with larger numbers of patients where unit costs can be kept low.

Preliminary Assessment of Pre-Electroconvulsive Therapy Evaluation Practices in European Countries: The Need for Guidelines.

OBJECTIVES: Pre-electroconvulsive therapy (ECT) evaluation is an essential part of ECT preparation, a standard treatment in the psychiatric field. However, no routine pre-ECT evaluation has been published so far. This preliminary study aimed to explore different practices in pre-ECT evaluation across European countries. METHODS: The data were collected as a snowball sample approach using an online survey from September 2019 to April 2020. The final analysis included data from 18 clinics placed in 16 European countries. RESULTS: Regulations on the pre-ECT evaluation were found in 9 countries. All clinics reported doing complete blood count, serum electrolytes, and renal function analysis as a part of regular laboratory testing, alongside with a cardiovascular assessment. Ten clinics reported using psychiatric scales. Six clinics reported doing a cognitive assessment, of which all had regulations on the pre-ECT evaluation. Not one evaluation had the same sets of procedures and diagnostics. CONCLUSIONS: The differences in assessment approaches mirror high variability of the pre-ECT evaluation practice across Europe. Cognitive assessment and objectification of psychiatric symptoms should be a regular part of the pre-ECT evaluation because of the monitoring of the most common adverse effect and observing the clinical response to ECT. Standardization of the pre-ECT evaluation and ECT in general would remove criticisms and opposition to the treatment, make it based on the best of our knowledge, and provide a method respectful of patients' best interests and rights.

Receipt of Electroconvulsive Therapy and Subsequent Development of Amyotrophic Lateral Sclerosis: A Cohort Study.

We investigated the potential relationship between receipt of electroconvulsive therapy (ECT) and development of amyotrophic lateral sclerosis (ALS). We conducted a cohort study using a sample of more than one million beneficiaries enrolled in the U.S. Medicare health insurance program from 1997 to 2017. Using time-varying proportional hazard modeling, we compared ALS occurrence among patients diagnosed with psychiatric conditions who received ECT to ALS occurrence among patients diagnosed with psychiatric conditions but who did not receive ECT. We observed moderately increased, but imprecise, hazard ratios (HR) for ALS following ECT (HR = 1.39, 95% confidence interval [CI]: 0.69-2.80). A statistically significant increase in the HR of ALS was observed among those who received more than 10 ECT treatments (>10 treatments, HR = 2.24, 95% CI: 1.00-5.01), compared to those receiving no ECT, with an even stronger association observed among subjects older than 65 years (HR = 3.03, 95% CI: 1.13-8.10). No monotonic exposure-response relationship was detected in categorical analyses. Our results provide weak support for the hypothesis that receipt of ECT increases the risk of developing ALS. Additional studies in larger populations, or in populations where ECT is more common, will be needed to refute or confirm an association between receipt of ECT and subsequent development of ALS. Bioelectromagnetics. 43:81-89, 2022. © 2021 Bioelectromagnetics Society.

[Electroconvulsive Therapy (ECT) in Neuroleptic Malignant Syndrome (NMS) on an Intensive Care Unit (ICU)]. / Elektrokonvulsivtherapie (EKT) bei malignem neuroleptischen Syndrom (MNS) auf Intensivstation.

A 57-year-old female patient with unclear somnolence was admitted to an Intermediate Care Unit (IMC) by an emergency physician. Several psychotropic drugs were on the medication list (quetiapine 450 mg/d, paroxetine 40 mg/d and perphenazine 12 mg/d), due to depression with psychotic features. As the patient's state deteriorated on day 3, she was intubated and transferred to Intensive Care Unit (ICU), where a malignant hyperthermia (MH) was assumed. The ICU's call to the MH hotline did not give a hint to consider a neuroleptic malignant syndrome (NMS) neither to consider electroconvulsive therapy (ECT). It was not until day 9 that a psychiatric consultation was undertaken, under the suspected diagnosis of NMS. On the same day ECT was performed, followed by a rapid remission of all clinical features and laboratory findings. Early consideration and application of ECT treatment for NMS on an ICU is life-saving.

Does Electroconvulsive Therapy for Patients with Mood Disorders Extend Hospital Length of Stays and Increase Inpatient Costs?

Although randomized trials have shown that electroconvulsive therapy (ECT) is an effective and underused treatment for mood disorders, its impact on inpatient length of stay (LOS) and hospital costs are not fully understood. We analyzed private insurance claims of patients hospitalized for mood disorders who had continuous insurance for three months prior to an index hospitalization and six months after discharge (N = 24,249). Propensity score weighted linear models were used to examine the association of any ECT use, the number of ECT treatments, and time to first ECT treatment, with LOS and hospital costs adjusting for potential confounders. Three months prior to the index hospitalization, patients who subsequently received ECT had more than double the total healthcare costs and bed days ($12,669 vs. $6,333 and 4.5 vs. 0.92 days, p < .001) of the other group. During their index admission, patients receiving ECT had longer LOS (16.1 vs. 5.8 days, p < .001) and three times greater hospital costs ($28,607 vs. $8,708, p < .001). Analyses adjusted for other group differences showed a dose-response relationship between the number of ECT treatments and LOS and hospital costs. Receipt of ECT was associated with increased LOS by 4 to 29 days depending on the number of ECT treatments and increasing total hospital costs from $5,767 to $52,717. Receipt of any ECT and the number of treatments during hospitalization were associated with markedly increased LOS, hospital admission costs, and post-discharge costs. Cost-effectiveness of ECT may be enhanced by shifting treatments to outpatient settings when possible.

Cost-utility analysis of esketamine and electroconvulsive therapy in adults with treatment-resistant depression.

BACKGROUND: Electroconvulsive therapy (ECT) has long been used for treating individuals with treatment-resistant depression (TRD). Esketamine has recently emerged as a new treatment for TRD due to its rapid antidepressant effects. To further inform the decision regarding choice of treatment, this paper aims to evaluate whether ECT or esketamine is the more cost-effective option. METHODS: The cost-effectiveness was derived as cost per quality-adjusted life-year (QALY) using a Markov model from a societal and life-time perspective. The incremental cost-effectiveness ratio (ICER) was calculated. Health states included different depression and remission states and death. Data to populate the model was derived from randomised controlled trials and other research. Various sensitivity analyses were carried out to test the robustness of the model. RESULTS: The base case scenario shows that ECT is cost-effective compared to esketamine and yields more QALYs at a lower cost. The sensitivity analysis shows that ECT is cost-effective in all scenarios and ECT dominates esketamine in 12 scenarios. CONCLUSIONS: This study found that, from a cost-effectiveness point of view, ECT should be the first-hand option for individuals with TRD, when other first line treatments have failed. Considering the lack of economic evaluation of ECT and esketamine, this study is of great value to decision makers.

Utilization of Electroconvulsive Therapy for Older Homeless Adults Covered by Medicare.

This study sought to examine the association between homelessness and receipt of electroconvulsive therapy (ECT) among older Medicare beneficiaries with homelessness. Among individuals with major depressive disorder who were older (age 65+) Medicare beneficiaries (2014-2015 data), we compared clinical and sociodemographic characteristics among those who were homeless and received ECT, those who were not homeless and received ECT, those who were homeless and did not receive ECT, and those who were domiciled and did not receive ECT. The unadjusted rate of ECT use among older homeless individuals with depression (1.46%) was higher than the rate of ECT use among older non-homeless individuals with depression (0.41%). Among all individuals receiving ECT, homeless individuals started as inpatients at a greater rate (94.0% v. 72.6%) and transitioned to outpatient ECT at a lower rate (23.8% v. 44.5%) compared to their domiciled counterparts. The individuals in the ECT/homeless group had more psychiatric comorbidities compared to all other groups. After adjusting for significant covariates, homelessness was associated with a lower odds ratio (0.74, 95% CI 0.55-0.99) of receiving ECT. Our data suggest that ECT can be provided to homeless individuals at rates comparable to domiciled individuals. The psychosocial support typically required for an ECT course may prove difficult for homeless patients in the outpatient setting, which may be an area for further development.

Association of ECT With Risks of All-Cause Mortality and Suicide in Older Medicare Patients.

OBJECTIVE: This observational study examined the effects of electroconvulsive therapy (ECT) on suicide and all-cause mortality risk in older psychiatric patients. METHODS: Participants were Medicare-insured psychiatric inpatients age 65 or older. Patients receiving ECT were exact-matched to control subjects (in a 1:3 ratio) on age, gender, principal hospital diagnosis, past-year psychiatric hospitalizations, past-year suicide attempts, and Elixhauser comorbidity index. Cox proportional hazard models were risk-adjusted for race, year of hospitalization, rural-urban continuum code, year of index hospitalization, median income of zip code, and all matched covariates to estimate hazard ratios with 95% confidence intervals. RESULTS: A total of 10,460 patients in the ECT group and 31,160 in the control group were included in the analyses (total N=41,620; 65.4% female; mean age, 74.7 years [SD=7.09]). Compared with the control group, patients receiving ECT had lower all-cause mortality for up to 1 year following hospital discharge (adjusted hazard ratio=0.61, 95% CI=0.56, 0.66). For death by suicide, 1-year survival analysis showed no group difference. A significant association was observed with suicide in the first months following ECT, but this pattern waned over time (1 month: hazard ratio=0.44, 95% CI=0.21, 0.91; 2 months: hazard ratio=0.52, 95% CI=0.29, 0.92; 3 months: hazard ratio=0.56, 95% CI=0.37, 0.92; 6 months: 0.87, 95% CI=0.59, 1.28; 12 months: 0.92, 95% CI=0.68, 1.25). CONCLUSIONS: In this observational study, ECT was associated with lower 1-year all-cause mortality and with short-lived protective effects on suicide risk. These findings support greater consideration of ECT for inpatients with mood disorders at short-term risk of suicide.

Autonomy and consent assessment for electroconvulsive therapy (ECT). A retrospective study of medical records.

The Norwegian Mental Health Act allows involuntary treatment for patients who lack consent capacity, however it allows only administration of pharmaceutical treatment and nutrition and not ECT. In lack of specific regulations, the legal access to ECT without valid consent has been grounded on the general rule of necessity in the Norwegian Penal code. This restriction and lack of legal regulation has implications for patients' rights and legal security. The study's aim was to assess the documented consent provided by patients for electroconvulsive therapy (ECT), whether ECT was administered without valid consent or under coercion, and the documented reasons, and ultimately compare practice with the legal requirements. We analysed systematically all the relevant medical records for hospitalised patients and outpatients receiving ECT during 2011-2016. We categorized data from these two groups into seven defined categories describing the attitude and quality of the consents to the ECT (or lack thereof). 378 patients received 498 ECT series´. The noted consents varied from treatment based on request (54 treatments), consent upon recommendation (209 treatments), consent after hesitation (88 treatments), consent presumed or noted without specification (114 treatments), to no consent (21 treatments) whereof the majority with documented coercion applied (19 treatments). All cases of ECT without consent referred to a "plea of necessity". The remaining treatments (12) lacked notifications specifying the consent (or attitude) expressed. Specific notes on the patient's capacity to consent for the respective ECT were generally lacking. This study indicates a large spread in patients´ acceptance and valid consent to ECT. The main reason for administering ECT without consent and/or against patients' will was for life-saving reasons. Such treatments were justified legal under a plea of necessity in the Penal Code or lacked noted legal justification. The legal vacuum for ECT without a valid consent needs to be addressed as this kind of disputed treatment is used in some cases.

Barriers to the Implementation of Electroconvulsive Therapy (ECT): Results From a Nationwide Survey of ECT Practitioners.

OBJECTIVE: Electroconvulsive therapy (ECT) is an effective treatment for major depressive disorder; yet, its use is confined to <1% of individuals with this disorder. The authors aimed to examine barriers to ECT from the perspective of the provider. METHODS: Qualitative interviews were conducted with U.S.-based ECT providers to identify potential barriers. A quantitative survey was created asking providers to rank-order barriers to starting a new ECT service or expanding existing services. RESULTS: Survey responses were received from 192 physicians. Respondents were representative of all ECT providers found in the Medicare Provider Utilization and Payment Database with respect to gender and geographic distribution. Approximately one-third (N=58, 30%) of survey respondents graduated from one of 12 residency programs. Programs with dedicated hospital space were more likely to have larger services than those borrowing surgical recovery space (χ2=25.87, df=1, p<0.001). The most prominent provider-reported barriers to expanding an existing ECT service were lack of physical space, stigma on the part of patients, and transportation difficulties. The most prominent barriers to initiating a new service were lack of well-trained colleagues and ECT practitioners, lack of a champion within the institution, and lack of physical space. Wide geographic variation was found in the availability of ECT, with the highest concentration of ECT providers per 1 million individuals found in New England (6.4), and the lowest found in the West South Central (1.1). CONCLUSIONS: Coordinated efforts to overcome identified barriers may allow ECT to be more broadly implemented. Investments in education may increase the number of competent practitioners.