Value of Electroconvulsive Therapy in the General Public: A Willingness to Pay Study in Germany.

OBJECTIVE: The aims of this study were to estimate the value a population-representative sample places on electroconvulsive therapy (ECT) through willingness to pay (WTP) and to assess the effects of individual characteristics on WTP for ECT. METHODS: A German population-representative sample of 518 was presented with a hypothetical health loss scenario of depression and was asked to indicate WTP for ECT. Probit and quantile regression were used to estimate the effects of individual characteristics on the probability of stating a positive WTP and on the amount of money respondents were willing to pay. RESULTS: Two thirds of respondents stated that they had no knowledge about ECT. Most (56.5%) respondents indicated zero WTP for health gains through ECT treatment. Mean WTP was €5201 ($5612); median WTP was €1000 ($1079). Respondents' monthly household income had a significant effect on the probability of stating a positive WTP. Assessing WTP above zero, income showed a significant positive effect, whereas a higher score of depressive complaints showed a significant negative effect on the amount respondents were willing to pay. CONCLUSION: Knowledge about ECT treatment is particularly low in the German public.

The benefits and costs of changing treatment technique in electroconvulsive therapy due to insufficient improvement of a major depressive episode.

BACKGROUND: Electroconvulsive therapy (ECT) technique is often changed after insufficient improvement, yet there has been little research on switching strategies. OBJECTIVE: To document clinical outcome in ECT nonresponders who were received a second course using high dose, brief pulse, bifrontotemporal (HD BP BL) ECT, and compare relapse rates and cognitive effects relative to patients who received only one ECT course and as a function of the type of ECT first received. METHODS: Patients were classified as receiving Weak, Strong, or HD BP BL ECT during three randomized trials at Columbia University. Nonresponders received HD BP BL ECT. In a separate multi-site trial, Optimization of ECT, patients were randomized to right unilateral or BL ECT and nonresponders also received further treatment with HD BP BL ECT. RESULTS: Remission rates with a second course of HD BP BL ECT were high in ECT nonresponders, approximately 60% and 40% in the Columbia University and Optimization of ECT studies, respectively. Clinical outcome was independent of the type of ECT first received. A second course with HD BP BL ECT resulted in greater retrograde amnesia immediately, two months, and six months following ECT. CONCLUSIONS: In the largest samples of ECT nonresponders studied to date, a second course of ECT had marked antidepressant effects. Since the therapeutic effects were independent of the technique first administered, it is possible that many patients may benefit simply from longer courses of ECT. Randomized trials are needed to determine whether, when, and how to change treatment technique in ECT.

Cost-Utility Analysis of Electroconvulsive Therapy and Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression in Ontario.

OBJECTIVES: To evaluate the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT), and combining both treatments in a stepped care pathway for patients with treatment-resistant depression (TRD) in Ontario. METHODS: A cost-utility analysis evaluated the lifetime costs and benefits to society of rTMS and ECT as first-line treatments for TRD using a Markov model, which simulates the costs and health benefits of patients over their lifetime. Health states included acute treatment, maintenance treatment, remission, and severe depression. Treatment efficacy and health utility data were extracted and synthesized from randomized controlled trials and meta-analyses evaluating these techniques. Direct costing data were obtained from national and provincial costing databases. Indirect costs were derived from government records. Scenario, threshold, and probabilistic sensitivity analyses were performed to test robustness of the results. RESULTS: rTMS dominated ECT, as it was less costly and produced better health outcomes, measured in quality-adjusted life years (QALYs), in the base case scenario. rTMS patients gained an average of 0.96 additional QALYs (equivalent to approximately 1 year in perfect health) over their lifetime with costs that were $46,094 less than ECT. rTMS remained dominant in the majority of scenario and threshold analyses. However, results from scenarios in which the model's maximum lifetime allowance of rTMS treatment courses was substantially limited, the dominance of rTMS over ECT was attenuated. The scenario that showed the highest QALY gain (1.19) and the greatest cost-savings ($46,614) was when rTMS nonresponders switched to ECT. CONCLUSION: From a societal perspective utilizing a lifetime horizon, rTMS is a cost-effective first-line treatment option for TRD relative to ECT, as it is less expensive and produces better health outcomes. The reduced side effect profile and greater patient acceptability of rTMS that allow it to be administered more times than ECT in a patient's lifetime may contribute to its cost-effectiveness.

A national study for regional variation of inpatient ECT utilization from 4,411 hospitals across the United States.

BACKGROUND: We conducted a study to examine regional variation in the utilization of inpatient electroconvulsive therapy (ECT) across the United States, and its impact on length of hospital stay and cost. METHODS: Analysis of the Nationwide Inpatient Sample databases to compare patient and hospital characteristics, and regional variation of ECT administration across different regions of the United States. RESULTS: The study included 41,055 inpatients who had ECT from 4,411 hospitals. Electroconvulsive therapy use is significantly higher in the Midwest. A higher proportion of females (65.2%) than males received ECT across the United States. Medicaid beneficiaries were less likely to undergo ECT compared with patients with Medicare (52.2%) or private insurance (32%). Electroconvulsive therapy was used mainly for mood disorders (84.3%). There were marked reductions of inpatient costs ($25,298 to $38,244) and average hospital stay (16 days) when ECT was initiated within the first 5 days of admission compared with later during the hospitalization. CONCLUSIONS: There is a wide variability of utilization of ECT, depending on the region, type of hospital, and type of insurance carrier. The utilization of ECT services is reduced across the United States. Appropriate utilization of this effective treatment can greatly help patients who are not responding to standard therapeutics, reduce overall health care cost and length of stay, and, most importantly, alleviate suffering.

A Non-inferiority Framework for Cost-Effectiveness Analysis.

BACKGROUND: Traditional decision rules have limitations when a new technology is less effective and less costly than a comparator. We propose a new probabilistic decision framework to examine non-inferiority in effectiveness and net monetary benefit (NMB) simultaneously. We illustrate this framework using the example of repetitive transcranial magnetic stimulation (rTMS) and electroconvulsive therapy (ECT) for treatment-resistant depression. METHODS: We modeled the quality-adjusted life-years (QALYs) associated with the new intervention (rTMS), an active control (ECT), and a placebo control, and we estimated the fraction of effectiveness preserved by the new intervention through probabilistic sensitivity analysis (PSA). We then assessed the probability of cost-effectiveness using a traditional cost-effectiveness acceptability curve (CEAC) and our new decision-making framework. In our new framework, we considered the new intervention cost-effective in each simulation of the PSA if it preserved at least 75 percent of the effectiveness of the active control (thus demonstrating non-inferiority) and had a positive NMB at a given willingness-to-pay threshold (WTP). RESULTS: rTMS was less effective (i.e., associated with fewer QALYs) and less costly than ECT. The traditional CEAC approach showed that the probabilities of rTMS being cost-effective were 100 percent, 39 percent, and 14 percent at WTPs of $0, $50,000, and $100,000 per QALY gained, respectively. In the new decision framework, the probabilities of rTMS being cost-effective were reduced to 23 percent, 21 percent, and 13 percent at WTPs of $0, $50,000, and $100,000 per QALY, respectively. CONCLUSIONS: This new framework provides a different perspective for decision making with considerations of both non-inferiority and WTP thresholds.

Electroconvulsive Treatment Utilization for the Inpatient Management of Severe Manic Episodes of Bipolar Disorder.

OBJECTIVE: Main objectives of the study are to (1) describe the utilization of electroconvulsive treatment (ECT) for the treatment of manic episodes (ME) and (2) examine the effect of early inpatient use of ECT (within 7 days of admission) compared with delayed use on length of stay and cost of inpatient care. METHOD: The total sample of 14,005 inpatients with a principal diagnosis of bipolar disorder, ME (2012-2014), from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project were analyzed using univariate and logistic regressions. This represented data from 4411 hospitals from 45 states in the United States. RESULTS: The rate of ECT use was higher in young adults (<50 years), female patients, and whites from high-income families. Electroconvulsive treatment was preferred more in private, nonprofit, urban, and teaching hospitals. The percentages of overall hospitals where ECT was administered for mania by region were as follows: 22% in the Northeast, 23% in Midwest. 17% in the South, and 10% in the West. Approximately half (55.3%) of patients received initial ECT session within the first 7 days (median) after admission. Early ECT was associated with significantly shorter (-14.7 days) and less costly (-$41,976) inpatient care per patient. CONCLUSIONS: Patients treated with ECT are generally sicker and more treatment resistant. However, ECT should not be considered only as a "last resort" in the treatment algorithm. Inpatient ECT for patients with MEs if initiated during the first 7 days of hospitalization reduces length of stay and cost.

Cost-effectiveness of Electroconvulsive Therapy vs Pharmacotherapy/Psychotherapy for Treatment-Resistant Depression in the United States.

Importance: Electroconvulsive therapy (ECT) is a highly effective treatment for depression but is infrequently used owing to stigma, uncertainty about indications, adverse effects, and perceived high cost. Objective: To assess the cost-effectiveness of ECT compared with pharmacotherapy/psychotherapy for treatment-resistant major depressive disorder in the United States. Design, Setting, and Participants: A decision analytic model integrating data on clinical efficacy, costs, and quality-of-life effects of ECT compared with pharmacotherapy/psychotherapy was used to simulate depression treatment during a 4-year horizon from a US health care sector perspective. Model input data were drawn from multiple meta-analyses, randomized trials, and observational studies of patients with depression. Where possible, data sources were restricted to US-based studies of nonpsychotic major depression. Data were analyzed between June 2017 and January 2018. Interventions: Six alternative strategies for incorporating ECT into depression treatment (after failure of 0-5 lines of pharmacotherapy/psychotherapy) compared with no ECT. Main Outcomes and Measures: Remission, response, and nonresponse of depression; quality-adjusted life-years; costs in 2013 US dollars; and incremental cost-effectiveness ratios. Strategies with incremental cost-effectiveness ratios of $100 000 per quality-adjusted life-year or less were designated cost-effective. Results: Based on the Sequenced Treatment Alternatives to Relieve Depression trial, we simulated a population with a mean (SD) age of 40.7 (13.2) years, and 62.2% women. Over 4 years, ECT was projected to reduce time with uncontrolled depression from 50% of life-years to 33% to 37% of life-years, with greater improvements when ECT is offered earlier. Mean health care costs were increased by $7300 to $12 000, with greater incremental costs when ECT was offered earlier. In the base case, third-line ECT was cost-effective, with an ICER of $54 000 per quality-adjusted life-year. Third-line ECT remained cost-effective in a range of univariate, scenario, and probabilistic sensitivity analyses. Incorporating all input data uncertainty, we estimate a 74% to 78% likelihood that at least 1 of the ECT strategies is cost-effective and a 56% to 58% likelihood that third-line ECT is the optimal strategy. Conclusions and Relevance: For US patients with treatment-resistant depression, ECT may be an effective and cost-effective treatment option. Although many factors influence the decision to proceed with ECT, these data suggest that, from a health-economic standpoint, ECT should be considered after failure of 2 or more lines of pharmacotherapy/psychotherapy.

In-depth analysis of cost structure for electroconvulsive therapy in a performance-based hospital budget.

OBJECTIVE: New medical guideline recommendations for the treatment of major depressive disorders and regulative changes in the payment system of the German mental health care system warrant a revision of the framework in which electroconvulsive therapies (ECT) are offered. METHODS: A cost structure analysis of the clinical resources essential for the ECT procedure was conducted and economically validated, exemplified at a German inpatient ECT treatment center. RESULTS: The identification of directly attributable costs to the ECT intervention presupposes an accurate assessment of personnel engagement time and material consumption as well as an inclusion of overhead costs for the operational readiness of the hospital. CONCLUSION: The increasing importance of ECT in the clinical portfolio of therapy options demands an adequate refunding to support the expansion of this highly effective treatment. For the calculation of an appropriate reimbursement for ECT and ascertaining an acceptable contribution, a detailed knowledge of personnel costs and infrastructure settings of the respective hospitals is required.

Cost-Effectiveness Modeling of Repetitive Transcranial Magnetic Stimulation Compared to Electroconvulsive Therapy for Treatment-Resistant Depression in Singapore.

BACKGROUND: Compared to electroconvulsive therapy (ECT), the cost-effectiveness of repetitive transcranial magnetic stimulation (rTMS) in the management of treatment-resistant depression (TRD) remains unclear. OBJECTIVE/HYPOTHESIS: This study evaluated the cost-effectiveness of rTMS vs. ECT for TRD from Singapore societal perspective. METHODS: We constructed a Markov model to project the cost and benefit of rTMS compared with ECT over one year in patients with TRD. The relative treatment effects between rTMS and ECT were obtained from meta-analyses of published trials. The effectiveness and quality of life data for patients using ECT, resource use for TRD and their associated costs were derived from the national tertiary mental institution in Singapore. RESULTS: At one year, rTMS was cost-effective relative to ECT. The incremental cost-effectiveness ratio (ICER) associated with ECT was Singapore dollars (SGD) 311,024 per quality-adjusted life-year (QALY) gained. This exceeded the willingness-to-pay threshold of SGD 70,000 per QALY gained. A similar trend was observed for ICER per remission achieved (i.e., SGD 143,811 per remission achieved with ECT). In the subgroup analysis, rTMS was found to be less costly and more effective than ECT in nonpsychotic depressive patients. In the scenario analysis, ECT employed as an ambulatory service yielded a much smaller ICER (i.e., SGD 78,819 per QALY gained) compared to the standard inpatient setting. CONCLUSIONS: rTMS was a cost-effective treatment compared to ECT in TRD over one year. The cost-effectiveness of rTMS was attenuated when ECT was used in the outpatient setting.

Effectivity and Cost-effectivity of the Maintenance Electroconvulsive Therapy: A mirror naturalistic analysis.

INTRODUCTION: Maintenance Electroconvulsive Therapy (mECT) is a biological long-term treatment in which patients receive ECT on periods from 2 to 4 weeks, during a variable period of time, usually for more than 6 months. Recent studies showed the efficacy of mECT in prevention of relapse and recurrences. Our study wants to demostrate the effectivity and cost-effectivity of this therapy in the naturalistic conditions of our area. DESIGN: Retrospective longitudinal study, with mirror analysis in naturalistic conditions. SUBJECTS: Patients attended at the Corporació Sanitària Parc Taulí (Sabadell, Catalonia), and included in the mECT program during more than six months. We performed diagnostic following DSM-IV criteria, subdividing the sample in three groups: patients affected of Recurrent Major Depression, Bipolar Disorder and Schizophrenia and Related Disorders. MEASURES: Number and duration of hospitalizations for the previous three years before the beginning of mECT, compared with the same data for the next three years following the beginning of mECT. Comparative analysis of direct hospitalization costs, costs of the mECT and pharmacologic costs. Statistic: Descriptive and non- parametric tests. RESULTS: Sample of 35 patients (1997-2008). There is a significative reduction the number of hospitalizations and days of hospitalization in the total sample and also in each of the three subgroups. The direct total cost decreased but it was only significant in the Bipolar Disorder subgroup, due to the increased pharmacological costs. CONCLUSIONS: mECT in our area is an effective and costeffective treatment with a great impact on the reduction of clinical decline and hospitalizations.

Factors Associated With Global Variability in Electroconvulsive Therapy Utilization.

OBJECTIVES: The aims of this study were to investigate the social and economic factors that contribute to global variability in electroconvulsive therapy (ECT) utilization and to contrast these to the factors associated with antidepressant medication rates. METHODS: Rates of ECT and antidepressant utilization across nations and data on health, social, and economic indices were obtained from multiple international organizations including the World Health Organization and the Organization for Economic Co-operation and Development, as well as from the published literature. To assess whether relationships exist between selected indices and each of the outcome measures, a correlational analysis was conducted using Pearson correlation coefficients. Those that were significant at a level of P < 0.05 in the correlation analysis were selected for entry into the multivariate analyses. Selected predictor variables were entered into a stepwise multiple regression models for ECT and antidepressant utilization rates separately. RESULTS: A stepwise multiple regression analysis indicated that government expenditure on mental health was the only significant contributor to the model, explaining 34.2% of global variation in ECT use worldwide. Human Development Index was the only variable found to be significantly correlated with global antidepressant utilization, accounting for 71% of the variation in global antidepressant utilization. CONCLUSIONS: These findings suggest that across the globe ECT but not antidepressant medication utilization is associated with the degree to which a nation financially invests in mental health care for its citizens.

Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression: An Economic Analysis.

BACKGROUND: Major depressive disorder (MDD, 10% over a person's lifetime) is common and costly to the health system. Unfortunately, many MDD cases are resistant to treatment with antidepressant drugs and require other treatment to reduce or eliminate depression. Electroconvulsive therapy (ECT) has long been used to treat persons with treatment-resistant depression (TRD). Despite its effectiveness, ECT has side effects that make patients intolerant to the treatment, or they refuse to use it. Repetitive transcranial magnetic stimulation (rTMS), which has fewer side effects than ECT and might be an alternative for TRD patients who are ineligible for or unwilling to undergo ECT, has been developed to treat TRD. OBJECTIVES: This analysis evaluates the cost-effectiveness of rTMS for patients with TRD compared with ECT or sham rTMS and estimates the potential budgetary impact of various levels of implementation of rTMS in Ontario. REVIEW METHODS: A cost-utility analysis compared the costs and health outcomes of two treatments for persons with TRD in Ontario: rTMS alone compared with ECT alone and rTMS alone compared with sham rTMS. We calculated the six-month incremental costs and quality-adjusted life-years (QALYs) for these treatments. One-way and probabilistic sensitivity analyses were performed to test the robustness of the model's results. A 1-year budget impact analysis estimated the costs of providing funding for rTMS. The base-case analysis examined the additional costs for funding six centres, where rTMS infrastructure is in place. Sensitivity and scenario analyses explored the impact of increasing diffusion of rTMS to centres with existing ECT infrastructure. All analyses were conducted from the Ontario health care payer perspective. RESULTS: ECT was cost effective compared to rTMS when the willingness to pay is greater than $37,640.66 per QALY. In the base-case analysis, which had a six-month time horizon, the cost and effectiveness for rTMS was $5,272 and 0.31 quality-adjusted life-years (QALYs). The cost and effectiveness for ECT were $5,960 and 0.32 QALYs. This translates in an incremental cost-effectiveness ratio of $37,640.66 per QALY gained for ECT compared to rTMS. When rTMS is compared with sham rTMS, an additional $2,154.33 would be spent to gain 0.02 QALY. This translates to an ICER of $98,242.37 per QALY gained. Probabilistic sensitivity analysis showed that the probability of rTMS being cost-effective compared to sham rTMS was 2% and 45% at the thresholds of $50,000 and $100,000 per QALY gained, respectively. CONCLUSIONS: Repetitive transcranial magnetic stimulation may be cost-effective compared to sham treatment in patients with treatment-resistant depression, depending on the willingness-to-pay threshold.

Routine Cross-Sectional Head Imaging Before Electroconvulsive Therapy: A Tertiary Center Experience.

PURPOSE: Electroconvulsive therapy (ECT) is generally contraindicated in patients with intracranial mass lesions or in the presence of increased intracranial pressure. The purpose of this study was to determine the prevalence of incidental abnormalities on routine cross-sectional head imaging, including CT and MRI, that would preclude subsequent ECT. METHODS: This retrospective study involved a review of the electronic medical records of 105 patients (totaling 108 imaging studies) between April 27, 2007, and March 20, 2015, referred for cranial CT or MRI with the primary indication of pre-ECT evaluation. The probability of occurrence of imaging findings that would preclude ECT was computed. A cost analysis was also performed on the practice of routine pre-ECT imaging. RESULTS: Of the 105 patients who presented with the primary indication of ECT clearance (totaling 108 scans), 1 scan (0.93%) revealed findings that precluded ECT. None of the studies demonstrated findings that indicated increased intracranial pressure. A cost analysis revealed that at least $18,662.70 and 521.97 relative value units must be expended to identify one patient with intracranial pathology precluding ECT. CONCLUSIONS: The findings of this study demonstrate an extremely low prevalence of findings that preclude ECT on routine cross-sectional head imaging. The costs incurred in identifying a potential contraindication are high. The authors suggest that the performance of pre-ECT neuroimaging be driven by the clinical examination.

The real world cost and health resource utilization associated to manic episodes: The MANACOR study.

INTRODUCTION: Bipolar disorder is a relapsing-remitting condition affecting approximately 1-2% of the population. Even when the treatments available are effective, relapses are still very frequent. Therefore, the burden and cost associated to every new episode of the disorder have relevant implications in public health. The main objective of this study was to estimate the associated health resource consumption and direct costs of manic episodes in a real world clinical setting, taking into consideration clinical variables. METHODS: Bipolar I disorder patients who recently presented an acute manic episode based on DSM-IV criteria were consecutively included. Sociodemographic variables were retrospectively collected and during the 6 following months clinical variables were prospectively assessed (YMRS,HDRS-17,FAST and CGI-BP-M). The health resource consumption and associate cost were estimated based on hospitalization days, pharmacological treatment, emergency department and outpatient consultations. RESULTS: One hundred sixty-nine patients patients from 4 different university hospitals in Catalonia (Spain) were included. The mean direct cost of the manic episodes was €4,771. The 77% (€3,651) was attributable to hospitalization costs while 14% (€684) was related to pharmacological treatment, 8% (€386) to outpatient visits and only 1% (€50) to emergency room visits. The hospitalization days were the main cost driver. An initial FAST score>41 significantly predicted a higher direct cost. CONCLUSIONS: Our results show the high cost and burden associated with BD and the need to design more cost-efficient strategies in the prevention and management of manic relapses in order to avoid hospital admissions. Poor baseline functioning predicted high costs, indicating the importance of functional assessment in bipolar disorder.

Clinical usefulness and economic implications of continuation/maintenance electroconvulsive therapy in a Spanish National Health System public hospital: A case series.

INTRODUCTION: Continuation/maintenance electroconvulsive therapy has been shown to be effective for prevention of relapse in affective and psychotic disorders. However, there is a limited nubber of studies that investigate clinical management, associated costs, and perceived quality variables. MATERIAL AND METHODS: A series of 8 cases included during the first 18 months of the Continuation/Maintenance Electroconvulsive Therapy Program of the Psychiatry Department at 12 de Octubre University Hospital is presented. Clinical variables (Clinical Global Impression-Improvement Scale, length of hospitalization, number of Emergency Department visits, number of urgent admissions) before and after inclusion in the continuation/maintenance electroconvulsive therapy program were compared for each patient, as well as associated costs and perceived quality. RESULTS: After inclusion in the program, 50.0% of patients reported feeling « much better ¼ and 37.5% « moderately better ¼ in the Clinical Global Impression-Improvement Scale. In addition, after inclusion in the continuation/maintenance electroconvulsive therapy program, patients were hospitalized for a total of 349 days, visited the Emergency Department on 3 occasions, and had 2 urgent admissions, compared to 690 days of hospitalization (P = .012), 26 Emergency Department visits (P = .011) and 22 urgent admissions (P = .010) during the same period before inclusion in the program. Associated direct costs per day of admission were reduced to 50.6% of the previous costs, and costs associated with Emergency Department visits were reduced to 11.5% of the previous costs. As regards perceived quality, 87.5% of patients assessed the care and treatment received as being « very satisfactory ¼, and 12.5% as « satisfactory ¼. CONCLUSIONS: This continuation/maintenance electroconvulsive therapy program has shown to be clinically useful and to have a favourable economic impact, as well as high perceived quality.

Cost-effectiveness of electroconvulsive therapy compared to repetitive transcranial magnetic stimulation for treatment-resistant severe depression: a decision model.

BACKGROUND: Electroconvulsive therapy (ECT) is widely applied to treat severe depression resistant to standard treatment. Results from previous studies comparing the cost-effectiveness of this technique with treatment alternatives such as repetitive transcranial magnetic stimulation (rTMS) are conflicting. METHOD: We conducted a cost-effectiveness analysis comparing ECT alone, rTMS alone and rTMS followed by ECT when rTMS fails under the perspective of the Spanish National Health Service. The analysis is based on a Markov model which simulates the costs and health outcomes of individuals treated under these alternatives over a 12-month period. Data to populate this model were extracted and synthesized from a series of randomized controlled trials and other studies that have compared these techniques on the patient group of interest. We measure effectiveness using quality-adjusted life years (QALYs) and characterize the uncertainty using probabilistic sensitivity analyses. RESULTS: ECT alone was found to be less costly and more effective than rTMS alone, while the strategy of providing rTMS followed by ECT when rTMS fails is the most expensive and effective option. The incremental cost per QALY gained of this latter strategy was found to be above the reference willingness-to-pay threshold used in these types of studies in Spain and other countries. The probability that ECT alone is the most cost-effective alternative was estimated to be around 70%. CONCLUSIONS: ECT is likely to be the most cost-effective option in the treatment of resistant severe depression for a willingness to pay of €30,000 per QALY.

Evaluating the evidence on comparative effectiveness and value of management options for treatment-resistant depression.

Treatment-resistant depression (TRD) is a debilitating patient condition with significant clinical and economic impact. The introduction of a new treatment approach, repetitive transcranial magnetic stimulation (rTMS), created the opportunity for a multi-stakeholder initiative to examine the comparative clinical effectiveness and comparative value of the different approaches to managing patients with TRD. The New England Comparative Effectiveness Public Advisory Council (CEPAC) convened in December 2011 to discuss the evidence on management options for patients with TRD. The Council voted that rTMS was as good or better than usual care and represented a reasonable value compared with usual care. The votes and deliberation of CEPAC led to first-in-the-nation payer coverage policies allowing patients access to this new treatment option. Regional groups that examine and deliberate on the comparative effectiveness evidence for existing and emerging treatments can have a direct influence on medical policy that accelerates access to innovative treatments.

Socioeconomic status of patients receiving electroconvulsive therapy.

This study describes the relationship between socioeconomic deprivation and electroconvulsive therapy (ECT) prescription and outcomes. Two research questions are addressed in this study: (1) Does the rate of ECT prescription increase with deprivation? and (2) Does deprivation influence ECT outcomes? Electroconvulsive therapy outcomes, of consecutive patients from Aberdeen, were compared across socioeconomic groups determined by the Scottish Index of Multiple Deprivation (SIMD) quintiles. A primary care sample, invited to complete the Hospital Anxiety and Depression Scale (HADS), was used for comparison. The proportion of patients in the most affluent quintile (32%) was greater than that in the least affluent (9%): this reflects the distribution of the local population, unlike the prevalence of depressive disorder, as demonstrated in our primary care group. Severity of depressive symptoms in patients receiving ECT was no different across the socioeconomic groups: before ECT (χ = 8.056; df = 4; P = 0.09), after ECT (χ = 6.035; df = 4; P = 0.197); nor was the total change in score (χ = 4.367; df = 4; P = 0.359). There were no differences among the SIMD quintiles for the number of ECT treatments administered (χ = 6.076; df = 4; P = 0.194) or the number of courses of ECT each patient had during contact with the service (χ = 6.505; df = 4; P = 0.164).Socioeconomic deprivation has no effect on the rate of ECT prescription or treatment outcomes despite a higher proportion of patients with severe depressive symptoms in the least affluent groups in a local community sample.

Benefits of Returning to Work After ECT.

BACKGROUND: Severe unipolar or bipolar depression is often not helped by pharmacotherapy and/or psychotherapeutic treatment alone, whereas more than 80% of these patients remit after sessions of electroconvulsive treatment (ECT). Getting patients back to work after a severe depression may be important for maintaining the effect of ECT. METHODS: Twenty consecutive patients remitted to an acute psychiatric hospital for depression underwent ECT. None of the patients had been working before the inpatient stay. Four patients were living on a permanent sickness allowance from the State (invalidity pension) before ECT, and thus were not expected to start work thereafter. RESULTS: Ten of the patients returned to work. Hospital treatment in Norway (including ECT) is provided free of charge with no copayments from the patient. The mean length of sick leave before ECT was 14.7 months. The 10 patients who returned to work had accrued public costs before their inpatient stays totalling NOK (Norwegian krone) 2,994,635 or a mean of NOK 299,463 per patient (&OV0556;1 = 9 NOK or $1 = 6 NOK ). The total public cost of their inpatient stays was NOK 1,680,000. During the first year after ECT, these 10 patients received NOK 2,680,000 in wages (NOK 3,238,300 during the mean number of months they were observed). CONCLUSION: Most of the patients (10 of 16) receiving ECT returned to work and within 2 years had earned more than the total cost both of their sick leave before admittance to hospital and the public cost of their 4 weeks' inpatient treatment. It is a pity that many countries, including Norway, only allow ECT as a treatment of last resort after failed psychotherapy or pharmacotherapy. Higher public spending is an inadvertent result of such a policy toward ECT.