Rates and Patient Characteristics of Electroconvulsive Therapy in China and Comparisons With the United States

Factors associated with electroconvulsive therapy treatment for adults with serious psychiatric conditions in Australia

OBJECTIVE

To identify factors associated with receiving electroconvulsive therapy (ECT) for serious psychiatric conditions.

METHODS

Retrospective observational study using hospital administrative data linked with death registrations and outpatient mental health data in New South Wales (NSW), Australia. The cohort included patients admitted with a primary psychiatric diagnosis between 2013 and 2022. The outcome measure was receipt of ECT.

RESULTS

Of 94,950 patients, 3465 (3.6%) received ECT. The likelihood of receiving ECT was higher in older (hazard ratio [HR] = 1.03), female (HR = 1.24) patients. Compared to depression, patients with schizophrenia/schizoaffective disorder (HR = 0.79), schizophrenia-related disorders (HR = 0.37), mania (HR = 0.64) and other mood disorders (HR = 0.45) had lower odds of receiving ECT. Patients with depression and one other serious psychiatric condition had higher odds of receiving ECT than depression alone. Bipolar disorder likelihood of ECT did not differ from depression. A higher number of mental health outpatient visits in the prior year and an involuntary index admission with depression were also associated with receiving ECT. Likelihood of receiving ECT increased with year of admission (HR = 1.32), private patient status (HR = 2.06), higher socioeconomic status (HR = 1.09) and being married (HR = 1.25).

CONCLUSIONS

ECT use for depression and bipolar disorder in NSW aligns with clinical national guidelines. Patients with schizophrenia/schizoaffective, schizophrenia-related disorders, mania and other mood disorders had lower likelihood of ECT than depression, despite ECT being recommended by clinical guidelines for these diagnoses. Variations in ECT were strongly associated with healthcare access, with private patients twice as likely to receive ECT than their public counterparts, suggesting a need to explore ECT accessibility.

Electroconvulsive therapy in a tertiary Australian mental health facility between 2009 and 2020

BACKGROUND

Despite electroconvulsive therapy being one of the most effective treatments in psychiatry, few studies report trends in the provision of electroconvulsive therapy over time. This study aims to investigate the use of electroconvulsive therapy between 2009 and 2020 in an Australian public tertiary mental health facility, and to describe the electroconvulsive therapy patient population and change in courses of treatment.

METHODS

Routinely collected data for 677 patients who received 1669 electroconvulsive therapy courses of treatment at an Australian public tertiary mental health facility between 2009 and 2020 were examined.

RESULTS

The provision of acute electroconvulsive therapy was stable across the study period; however, the number of maintenance electroconvulsive therapy courses commenced declined over the study. Schizophrenia was the most common indication for index treatment (37.4%). The majority of patients (85.7%) received acute electroconvulsive therapy only. Voluntary provision of electroconvulsive therapy declined over the study period, reducing from 44.9% in 2009 to 16.3% in 2020.

CONCLUSION

Over the study period, there was a significant reduction in the number of maintenance electroconvulsive therapy courses commenced, and a large increase in involuntary treatment. The provision of electroconvulsive therapy was more likely to occur in males with a diagnosis of schizophrenia. Further studies are needed to generate a greater understanding of the factors influencing the provision of electroconvulsive therapy within differing geographical, social and healthcare landscapes.

Electroconvulsive therapy or clozapine for adolescents with treatment-resistant schizophrenia: an explorative analysis on symptom dimensions

OBJECTIVE

This study sought to compare pre-intervention patient characteristics and post-intervention outcomes in a naturalistic sample of adolescent inpatients with treatment-resistant psychotic symptoms who received either electroconvulsive therapy (ECT) or clozapine.

METHODS

Data of adolescents with schizophrenia/schizoaffective disorder receiving ECT or clozapine were retrospectively collected from two tertiary-care psychiatry-teaching university hospitals. Subscale scores of the Positive and Negative Symptom Scale (PANSS) factors were calculated according to the five-factor solution. Baseline demographics, illness characteristics, and post-intervention outcomes were compared.

RESULTS

There was no significant difference between patients receiving ECT (n = 13) and clozapine (n = 66) in terms of age, sex, and the duration of hospital stay. The ECT group more commonly had higher overall illness and aggression severity. Smoking was less frequent in the clozapine group. Baseline resistance/excitement symptom severity was significantly higher in the ECT group, while positive, negative, affect, disorganisation, and total symptom scores were not. Both interventions provided a significant reduction in PANSS scores with large effect sizes.

CONCLUSION

Both ECT and clozapine yielded high effectiveness rates in adolescents with treatment-resistant schizophrenia/schizoaffective disorder. Youth receiving ECT were generally more activated than those who received clozapine.

Factors Associated With Utilization of Electroconvulsive Therapy During Psychiatric Hospitalization Among Children and Adolescents in China

PURPOSE

Based on a nationally representative sample in China, we examined the demographic and clinical correlates of utilization of electroconvulsive therapy (ECT) in child and adolescent (C/A) patients younger than 18 years during psychiatric hospitalization.

METHODS

As part of a national survey, 41 provincial tertiary psychiatric hospitals in mainland China were selected. Data from 196 C/A patients who were discharged from these psychiatric hospitals from March 19 to 31, 2019, were retrieved and analyzed.

RESULTS

(1) The overall rate of ECT among C/A patients during psychiatric hospitalization was 15.6% (n = 30). (2) Between ECT and non-ECT groups, significant differences were found in sex, age, length of stay, Global Assessment of Functioning at admission, treatment outcome, and self-injurious behavior during hospitalization, and the ratio of marked improvement on discharge. (3) Multiple logistic regression analysis revealed that ECT use was independently and positively associated with an older age, male sex, lower Global Assessment of Functioning, and self-injurious behavior during hospitalization.

CONCLUSIONS

The frequency of ECT use was relatively frequent in C/A patients during psychiatric hospitalization in our nationally representative sample in China. Developing more specific and operational criteria for the use of ECT for C/A patients is needed to provide guidance for the optimal use of ECT in this patient population.

Cross-cultural Comparison of Perceptions and Knowledge About Electroconvulsive Therapy Among Adults Who Screened Positive for Depression in the United States, India, and China

OBJECTIVE

Despite the established efficacy of electroconvulsive therapy (ECT), negative perceptions and inaccurate knowledge about ECT in the United States and other countries persist. This study examined ECT perceptions and knowledge in the 3 most populous countries in the world.

METHODS

We recruited participants who screened positive for depression on the Patient Health Questionnaire 9 (PHQ-9) in the United States (n = 1643), India (n = 1469), and China (n = 328) and compared responses on the ECT-Perception and Knowledge Scale.

RESULTS

Although the US sample had significantly higher PHQ-9 scores than the India and China samples, the US sample was less likely to have been offered ECT or to have ever received ECT. Moreover, the US sample scored lower on the ECT Perception and Knowledge subscales than the other samples indicating more negative perceptions and inaccurate knowledge about ECT. Across samples, there were moderate fears about ECT being painful or causing brain damage, and misconceptions about ECT being outdated and adverse effects of induced seizures. Higher PHQ-9 scores were correlated with more negative perceptions.

CONCLUSIONS

Greater public education is needed about ECT, particularly in the United States. Misperceptions and lack of knowledge may hinder utilization of ECT in India, China, and the United States.

Differential Effects of Electroconvulsive Therapy in the Treatment of Major Depressive Disorder

BACKGROUND/AIMS/METHODS

Electroconvulsive therapy (ECT) is still one of the most potent treatments in the acute phase of major depressive disorder (MDD) and particularly applied in patients considered treatment resistant. However, despite the frequent and widespread use of ECT for >70 years, the exact neurobiological mechanisms underlying its efficacy remain unclear. The present review aims to describe differential antidepressant and cognitive effects of ECT as well as effects on markers of neural activity and connectivity, neurochemistry, and inflammation that might underlie the treatment response and remission.

RESULTS

Region- specific changes in brain function and volume along with changes in concentrations of neurotransmitters and neuroinflammatory cytokines might serve as potential biomarkers for ECT outcomes.

CONCLUSIONS

However, as current data is not consistent, future longitudinal investigations should combine modalities such as MRI, MR spectroscopy, and peripheral physiological measures to gain a deeper insight into interconnected time- and modality-specific changes in response to ECT.

Efficacy and safety of electroconvulsive therapy plus medication versus medication alone in acute mania: A meta-analysis of randomized controlled trials

Although some studies have reported the potential efficacy of electroconvulsive therapy (ECT) in the treatment of acute mania, there is no consensus on the matter. Therefore, we performed a meta-analysis to determine the efficacy and safety of ECT combination with medication (ECT-combo) vs. medication alone (Med-alone) in the treatment of acute mania. Randomized controlled trials (RCTs) of ECT-combo versus Med-alone in acute mania were searched in Chinese databases and English databases from their inceptions up to February 2020. Twelve RCTs (including 863 patients, n=863) met our criteria and were included into meta-analysis. The pooled results found that ECT-combo outperformed Med-alone in reducing manic symptoms from baseline to endpoint with a standardized mean difference of -3.50 (95% CI: -4.57, -2.44, p<0.00001). The significant difference occurred after 3-5 treatments or after a 1-week treatment. ECT-combo had significantly increased memory impairment compared to Med-alone. Apart from increased memory impairment in ECT-combo group (SMD=8.33; 95% CI: 2.73 to 25.45, p= 0.0002), no other statistically significant differences in side effects or drop-out rates were found between groups. The results of this meta-analysis suggest that ECT-combo was significantly superior to Med-alone in efficacy and well-tolerated as Med-alone in the acute treatment of mania. However, larger studies with randomized, double-blind design, and standardized treatment regimens are still warranted due to the high heterogeneity of studies included in the present meta-analysis.

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.

Electroconvulsive therapy is associated with lower readmission rates in patients with schizophrenia

BACKGROUND

Electroconvulsive therapy is an important somatic treatment for severe mental disorders with established efficacy and safety. However, data on the relationship between ECT and the readmission rate of patients with schizophrenia are scarce. This study will explore the association between the administration of ECT and readmission rates using a machine learning method.

METHODS

Inpatient medical records from the year of 2016 in one large psychiatric hospital in Beijing, China, were analyzed using a machine learning algorithm to determine the most important variables affecting readmission of patients with schizophrenia.

RESULTS

The medical records of 2131 inpatients with schizophrenia were reviewed. 1099 patients were followed up within 3 months of their index admission (642 ECT cases and 457 non-ECT cases) and 1032 patients were followed up within 6 months (596 ECT cases and 436 non-ECT cases) after discharge. The 3- and 6-month readmission rates in the ECT group (11.37% and 17.94%, respectively) were significantly lower than that of the patients who did not receive ECT (18.79% and 29.36%, respectively, both p < 0.001). The risk of readmission was significantly associated with male sex, older age, being married, having a lower income, a shorter inpatient length of stay, and receiving specific antipsychotic medications including olanzapine, paliperidone, clozapine, and haloperidol during the index admission. In the ECT group, patients who received 9 or more treatments were significantly less likely to be readmitted.

CONCLUSION

Receiving ECT may be associated with a lower risk of readmission in patients with schizophrenia.

Effectiveness of electroconvulsive therapy in patients with "less treatment-resistant" depression by the Maudsley Staging Model

INTRODUCTION

Electroconvulsive therapy (ECT) is an effective treatment for patients with mood disorders and is most often used for treatment-resistant cases. This study aimed to examine the effectiveness of ECT in a real-world treatment sample in a Chinese psychiatric hospital which included both treatment-resistant and nontreatment-resistant patients.

METHODS

An observational study of symptom outcomes from admission to the time of discharge was conducted with 37 inpatients diagnosed with unipolar or bipolar depression treated with ECT. Symptom severity was assessed with the 17-item Hamilton Rating Scales for Depression (HRSD-17) and treatment-resistance with the Maudsley Staging Model (MSM). Stratifying at the MSM median admission characteristics and symptom change was compared between patients who were treatment-resistant (n = 18) and who were not (n = 19). The outcome difference between groups was compared using analyses of covariance adjusted for baseline characteristics including symptom severity, followed by linear regression to identify factors associated symptom improvement in the entire sample.

RESULTS

The sample (n = 37) showed moderate treatment-resistance (MSM = 7.30 ± 1.13) at admission and both groups received 8.3 ± 2 ECT sessions. The treatment-resistant group had a smaller proportion of bipolar patients and more severe symptoms, but showed no significant difference from the nontreatment-resistant group in HDRS-17 scores at the time of discharge (adjusted means = 6.23 ± 1.00 vs. 5.94 ± 0.97, Partial η²  = 0.001, p = .845). Baseline symptom severity was the strongest correlate of reduction in HDRS-17 scores (β = 0.891, p < .001).

CONCLUSIONS

Symptom change with ECT in depression did not differ by level of treatment-resistance but was greatest among those with more severe baseline symptoms. Correlates of ECT effectiveness should be further evaluated in stratified randomized trials.

Factors associated with 30-day and 1-year readmission among psychiatric inpatients in Beijing China: a retrospective, medical record-based analysis

BACKGROUND

Psychiatric readmissions negatively impact patients and their families while increasing healthcare costs. This study aimed at investigating factors associated with psychiatric readmissions within 30 days and 1 year of the index admissions and exploring the possibilities of monitoring and improving psychiatric care quality in China.

METHODS

Data on index admission, subsequent admission(s), clinical and hospital-related factors were extracted in the inpatient medical record database covering 10 secondary and tertiary psychiatric hospitals in Beijing, China. Logistic regressions were used to examine the associations between 30-day and 1-year readmissions plus frequent readmissions (≥3 times/year), and clinical variables as well as hospital characteristics.

RESULTS

The 30-day and 1-year psychiatric readmission rates were 16.69% (1289/7724) and 33.79% (2492/7374) respectively. 746/2492 patients (29.34%) were readmitted 3 times or more within a year (frequent readmissions). Factors significantly associated with the risk of both 30-day and 1-year readmission were residing in an urban area, having medical comorbidities, previous psychiatric admission(s), length of stay > 60 days in the index admission and being treated in tertiary hospitals (p < 0.001). Male patients were more likely to have frequent readmissions (OR 1.30, 95%CI 1.04-1.64). Receiving electroconvulsive therapy (ECT) was significantly associated with a lower risk of 30-day readmission (OR 0.72, 95%CI 0.56-0.91) and frequent readmissions (OR 0.60, 95%CI 0.40-0.91).

CONCLUSION

More than 30% of the psychiatric inpatients were readmitted within 1 year. Urban residents, those with medical comorbidities and previous psychiatric admission(s) or a longer length of stay were more likely to be readmitted, and men are more likely to be frequently readmitted. ECT treatment may reduce the likelihood of 30-day readmission and frequent admissions. Targeted interventions should be designed and piloted to effectively monitor and reduce psychiatric readmissions.

Electroconvulsive Therapy for Patients with Catatonia: Current Perspectives

Catatonia is a serious, common syndrome of motoric and behavioral dysfunction, which carries high morbidity and mortality. Electroconvulsive therapy (ECT) is the definitive treatment for catatonia, but access to ECT for the treatment of catatonia remains inappropriately limited. Catatonia is observable, detectable, and relevant to various medical specialties, but underdiagnosis impedes the delivery of appropriate treatment and heightens risk of serious complications including iatrogenesis. Current understanding of catatonia's pathophysiology links it to the current understanding of ECT's mechanism of action. Definitive catatonia care requires recognition of the syndrome, workup to identify and treat the underlying cause, and effective management including appropriate referral for ECT. Even when all of these conditions are met, and despite well-established data on the safety and efficacy of ECT, stigma surrounding ECT and legal restrictions for its use in catatonia are additional critical barriers. Addressing the underdiagnosis of catatonia and barriers to its treatment with ECT is vital to improving outcomes for patients. While no standardized protocols for treatment of catatonia with ECT exist, a large body of research guides evidence-based care and reveals where additional research is warranted. The authors conducted a review of the literature on ECT as a treatment for catatonia. Based on the review, the authors offer strategies and future directions for improving access to ECT for patients with catatonia, and propose an algorithm for the treatment of catatonia with ECT.