Research report
Electroconvulsive therapy for major depression within the Veterans Health Administration

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Abstract

Objectives

Electroconvulsive therapy (ECT) is the most effective treatment for severe or treatment resistant depression; however, the lack of widely accepted methods for determining when ECT is indicated may contribute to disparities and variation in use. We examined receipt of ECT among depressed patients in the largest coordinated health system in the US, the Veterans Health Administration.

Methods

Using administrative data, we conducted a multivariable logistic regression to identify individual clinical and sociodemographic predictors of receiving ECT, including variables of geographic accessibility to ECT, among patients diagnosed with major depressive disorder between 1999 and 2004.

Results

307 (0.16%) of 187,811 patients diagnosed with major depression received ECT during the study period. Black patients were less likely to receive ECT than whites (odds ratio 0.33; 95% confidence interval: 0.20, 0.55), and patients living in the South (OR: 0.71; 95% CI: 0.53, 0.95) or West (OR: 0.59; 95% CI: 0.42, 0.82) were less likely to receive ECT than patients living in the central US. Patients whose closest VA facility provided ECT had a higher likelihood of receiving ECT (OR: 3.02; 95% CI: 2.22, 4.10). Depressed patients with no major medical comorbidities were also more likely to receive ECT (OR: 2.42; 95% CI: 1.65, 3.55).

Limitations

Findings are not adjusted for depression severity.

Conclusions

ECT use for major depression was relatively uncommon. Race, US region, geographic accessibility, and general medical health were all associated with whether or not patients received ECT. Clinicians and health systems should work to provide equitable access and more consistent use of this safe and effective treatment.

Introduction

Electroconvulsive therapy (ECT) is the most effective treatment option for severe depression (Carney et al., 2003). Response rates with ECT are also 50–70% among patients who have not responded to prior antidepressant treatment (Prudic et al., 1990). There are few contraindications to ECT, and the mortality rate from the procedure is comparable to receiving general anesthesia alone (Lisanby, 2007, Roy and Overdyk, 1997, Sartorius and Hewer, 2007).

Although the efficacy and safety of ECT have a well-established evidence base, there has been substantial variation in its availability and use. In the US, the most recent nationwide data regarding ECT use are from a 1988–1989 survey of psychiatrists that estimated the rate of ECT use at 4.9 patients per 10,000 people (0.05%) with 36.3% of metropolitan areas reporting no ECT use (Hermann et al., 1995). When areas that provided ECT were ranked by rate of ECT use, there was a four-fold difference in the rates between the 25th and 75th percentile areas, which is a greater variation than for most other medical procedures. The variability in ECT use was not explained by the prevalence of depression; rather, the number of psychiatrists and primary care physicians and state regulations were the strongest predictors of ECT use.

Reducing disparities in access to and quality of healthcare is a stated goal of the US Department of Health and Human Services (US Department of Health and Human Services, 2001). The VA health system, the largest national health system in the US, prioritizes the use of evidence-based treatments and has established a minimum degree of uniformity in services provided across all of its medical centers (Kizer, 1996). Examining the use of ECT within the VA health system provides an opportunity to determine the degree to which disparities exist within a large coordinated US health system and may provide guidance in achieving more equitable and effective treatment of depression, both within the VA and other health systems. Using VA administrative and clinical data, we determined the overall prevalence of ECT use among depressed veterans and the degree to which use varied by proximity to a VA medical center that provided ECT, by demographic and clinical factors, and by region within the US.

Section snippets

Study population

We used data on patient clinical and demographic characteristics from the VA National Registry for Depression (NARDEP), which was created and maintained by the VA's Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC) in Ann Arbor, Michigan (Blow et al., 2003). Patients were included if they were diagnosed with major depressive disorder and had at least one other visit with any depression diagnosis or were treated with an antidepressant medication during the period between

Study population

187,811 VA patients with major depression were included in the study, of which 90% were male, 72% white, 15% black, and 6% Hispanic, and the mean age was 54 years old. 307 (0.16%) of these patients received ECT during the 5 1/2 year study period.

Availability and regional variation of ECT

Out of 128 VA Medical Centers, 60 (47%) performed ECT. Depressed patients who received ECT were more likely to have the procedure available at their nearest VA facility than depressed patients who did not receive ECT (84% vs. 64%), and ECT recipients

Discussion

Within the VA health system, approximately 1 in 613 patients with major depression received ECT. It is difficult to contextualize this finding with prior work in the VA and general US population, which has relied on survey methods and assessed populations other than those with major depression (Hermann et al., 1995, Srinivasaraghavan and Weiner, 1997). However, as treatment algorithms for chronic depression recommend ECT after 3 or 4 failed psychotropic medication trials, as many as 1 in 3

Conclusions

Treatment with ECT is relatively uncommon within the VA health system but is more likely among patients with local access to the service; with fewer than half of the VA Medical Centers providing ECT, the VA should consider further increasing access to this highly effective treatment. Other health systems should consider parallel efforts to monitor and improve access to ECT. Racial disparities also exist and subsequent research should address the contribution of patient and provider attitudes

Role of funding source

This study was funded in part by the Department of Veterans Affairs, Health Services Research and Development Service, IIR 04-211-1 (MV), CD2 07-206-1 (KZ), the National Institute of Mental Health, R01-MH078698-01 (MV), the National Institute of Nursing Research, R21-NR010856 (KJH), and by the Depression Health Services Research Evaluation and Management (DREAM) program in the Comprehensive Depression Center at the University of Michigan. Funding sources had no further role in study design; in

Conflict of interest

All authors declare that they have no conflicts of interest.

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