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The recent increase in suicides highlights the urgent need for better treatment of severe depression. ECT is an intervention proven to reduce suicidality, yet it is underused because of the associated stigma.
The recent increase in suicides, including those of Kate Spade and Anthony Bourdain, highlights the urgent need for better treatment of severe depression. Recent data from the CDC document an alarming trend: suicide is up by nearly 30% since 1999.1 It is now the 10th leading cause of death, with 45,000 suicides in 2016. While the antecedents of suicide are multifactorial, at least half of the people who attempt/complete suicide have a psychiatric illness, mostly a mood or psychotic disorder.
In a piece in the New York Times, Richard A. Friedman, a psychiatrist, noted, “last year, the National Institutes of Health spent more money researching dietary supplements than it did suicide and suicide prevention. Any other disease that comes close to killing as many Americans as suicide does, like HIV and heart disease, gets marquee recognition as a public health menace and major federal research funding . . . the simple reason suicide has been neglected for so long is stigma.”2 Benedict Carey, in a New York Times article about the same CDC suicide data, wrote, “one of the few proven interventions [to reduce suicides] is unpalatable to wide swaths of the American public: reduced access to guns.”3 We believe that another intervention proven to reduce suicidality, ECT, is underused because it is similarly stigmatized and considered “unpalatable.”4,5
A recent series of articles and editorials documents the current state of ECT use (actually underuse) in the US. Herein, we review the new data and make suggestions about “right sizing” ECT in contemporary American psychiatric practice.
Efficacy and cost savings
In the August 2017 issue of JAMA Psychiatry, Harold Sackeim, PhD,6 wrote an editorial, which accompanied an important study that demonstrated that inpatients with mood disorders who received ECT had half the rate of hospital re-admission in 30 days than those who were treated with medications.7 More recent findings indicate that only 0.25% of patients with mood disorders in a large health care database received ECT.8 Similarly, in a cohort of over 11,000 veterans with psychiatric illness, only 50 received ECT (0.45%).9
Because of its speed and effectiveness, ECT may actually be a cost-saving intervention; this benefit is in addition to its ability to relieve suffering and save lives. The cost-effectiveness of ECT was investigated in a major health economics study.10 Six alternative strategies for incorporating ECT into depression treatment were modeled based on data drawn from multiple meta-analyses, randomized trials, and observational studies of patients with depression. The researchers concluded that an optimal cost-effective strategy is to offer ECT after two failed pharmacotherapy trials, not relegating it to a “last resort” position after innumerable trials. Furthermore, they found, “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.”
Utilization of ECT
How much is the right amount of ECT for optimum mental health outcomes? If ECT were used more often, would some suicides be prevented? Let’s start by addressing what we know about how much ECT is now done in the US. Unfortunately, in contrast with many European countries where national health databases provide accurate epidemiological data about the utilization of most medical procedures, including ECT, the US lacks such data.
ECT utilization rates have been shown to vary widely, both between regions in the US and between countries around the world.11 In a review, Leiknes and colleagues12 collected data about ECT utilization worldwide. They reported that, despite wide variability, the average ECT treated person rate (TPR) approximates 2.2 per 10,000 resident population per year. (In selected countries, where ECT may be less stigmatized, the rate is higher. For example, the TPR in Belgium is ~4.5 per 10,000 residents.) In the US, a TPR of 3 would equate to approximately 90,000 ECT patients per year. This accords well with an estimate derived from one of the best sources of population data in the US, the Medicare database.13 A similar extrapolation from this database is that approximately 450,000 to 500,000 ECT procedures are done annually in the US.
There are 49,000 psychiatrists in the US, but only 1216 were found in the 2016 Medicare database as having performed ECT.14 The International Society for ECT and Neurostimulation (ISEN), has about 300 members.15 There is a gender gap among ECT practitioners, with only 19% being female, despite the fact that psychiatry residency classes for the past decade have been more than 50% female. Only 14% of ECT procedures performed in the US are done by women psychiatrists.13
The ambivalence with which ECT is regarded derives from multiple sources, but the media, with its sensationalized and anachronistic portrayals, has been the major influencer. Unfortunately, ambivalence also comes from within the psychiatric profession, where residency experience in ECT is woefully lacking, leading to practitioners who are uncomfortable prescribing it.16
Modern ECT has been refined to the point that its morbidity and mortality are remarkably low. A recent systematic review and meta-analysis found a mortality rate of 2.1/100,000 procedures, making it among the safest treatments performed under general anesthesia.17 The technical advancement of ultrabrief pulse right unilateral ECT allows many seriously ill patients to recover with very few cognitive effects.18 ECT practice and research are advancing in the US and abroad. PubMed contains over 15,000 citations for ECT. And, ECT research continues around the world as we mark the 80th anniversary of the invention of ECT.19
Despite the enthusiasm with which newer brain stimulation techniques have been embraced, ECT remains alone; no other modality can come close to ECT for antidepressant/antipsychotic efficacy, speed of response, and clinical track record of utility. We do a disservice to our seriously ill patients when we conflate ECT with other “neurostimulation” techniques.
Taken together, the above data suggest that ECT is, in fact, vastly improved, but still underutilized. We believe that greater, and earlier, prescription of ECT in appropriately selected patients would lead to better mental health outcomes, including fewer suicides. While an exact right-sized figure is hard to come by, we speculate that closer to 250,000 ECT patients per year (resulting in about 1.5 million ECT procedures) in the US is a more appropriate number for optimal mental health outcomes and reduced suicides. Currently, it is easier to get a gun than a prescription for ECT in the US. Fortunately, this may now be changing. ECT-marginalized for decades-is regaining its rightful place in the treatment armamentarium of contemporary psychiatric medicine.
Dr Kellner is Chief of Electroconvulsive Therapy (ECT), New York Community Hospital, Brooklyn, NY and Adjunct Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, NY. Ms Patel is an undergraduate at Emory University. Dr Kellner reports that he has received research support from the NIMH, honoraria from UpToDate, Psychiatric Times, and Northwell Health, and royalties from Cambridge University Press. Ms Patel reports no conflicts of interest concerning the subject matter of this article.
1. Stone DM, Simon TR, Fowler KA, et al. Vital signs: trends in state suicide rates: United States, 1999-2016; and circumstances contributing to suicide: 27 states, 2015. MMWR Morb Mortal Wkly Rep. 2018;67:617-624.
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3. Carey B. How suicide quietly morphed into a public health crisis. NY Times. June 8, 2018.
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14. Medicaire National HCPCS Aggregate Summary Table CY2017. https://data.cms.gov/Medicare-Physician-Supplier/Medicare-National-HCPCS-Aggregate-Summary-Table-CY/jtra-d83c/data. Accessed July 5, 2018.
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18. Kellner CH, Husain MM, Knapp RG, et al. Right unilateral ultrabrief pulse ECT in geriatric depression: phase 1 of the PRIDE study. Am J Psychiatry. 2016;173:1101-1109.
19. EFFECT. http://www.theeffect.eu/category/meeting. Accessed July 5, 2018.