Psychiatric Readmissions Lower Among Patients Receiving ECT

A broader availability of electroconvulsive therapy (ECT) could lead to fewer hospital readmissions of psychiatric patients with severe affective disorders.

This reduced rate of psychiatric readmission carries a potential public health benefit that may be overlooked in U.S. hospitals’ current decision making regarding the use of ECT, according to a large-scale study published June 28 in JAMA Psychiatry.

The study found that the rate of inpatient readmissions within 30 days of discharge among this group of patients was 46 percent lower than those not receiving ECT.

“The importance of our result—lower readmission rates—shows that ECT is an effective treatment and a better value than we thought,” said lead author Eric Slade, Ph.D., an associate professor and director of Psychiatric Services Research at the University of Maryland School of Medicine.

Hospitals should take notice of this finding, especially because many of them now bear financial risk for inpatient readmissions under value-based payment arrangements, he said. (Value-based payment mandates better care at lower cost with less inefficiency and duplication of services.)

Among the study’s 162,691 inpatients with a principal diagnosis of major depressive disorder (MDD), bipolar disorder, or schizoaffective disorder included in the analysis, only 2,486 (1.5 percent) underwent ECT during their index admission.

“The strikingly low number of hospital patients in this study who received ECT, only 1.5 percent, shows ECT is being underutilized,” said geriatric psychiatrist Charles Kellner, M.D., chief of ECT at New York Community Hospital and an adjunct professor of psychiatry at the Icahn School of Medicine at Mount Sinai, New York City. “It’s very likely that three to five times more mentally ill people should be getting ECT. If ECT were appropriately prescribed in the United States, it would have a major public health impact.”

Increasing the use of ECT makes good financial and clinical sense, especially because “ECT is our most effective and rapid treatment for severe depression,” and “hospitals are incentivized [by some payers] to provide patient-centered care and produce good outcomes,” said Sarah Lisanby, M.D., director of the National Institute of Mental Health’s Division of Translational Research and an expert on ECT.

The study’s researchers speculated that a range of barriers have curbed ECT’s availability, including stringent regulatory restrictions on its use, limited graduate medical training, persistent concerns about ECT’s safety and adverse-effects profile, stigma, reluctance among medical professionals to recommend ECT, and cost considerations.

The first-line treatment for most patients with affective disorders is antidepressants, and if this treatment fails, ECT may be considered. However, patients who are urgently ill may get ECT as a first-line treatment, said Kellner.

While the Slade study found the use of ECT declining among hospital inpatients, Kellner said the practice of ECT has switched to becoming more of an outpatient procedure.

“Over half of patients are treated in outpatient facilities that are affiliated with hospitals. Some patients are mentally ill enough that they need hospitalization for the entire treatment—they may be suicidal, extremely depressed, and malnourished,” he said. “Overall, the use of ECT is increasing because nothing else has approached its efficacy and safety. This is a very powerful, serious treatment.”

According to the study, patients who received ECT were older and more likely to be female and non-Hispanic white, to have MDD rather than either bipolar disorder or schizoaffective disorder, to have private or Medicare insurance coverage, and to receive the treatment in urban small hospitals and nonurban hospitals, the researchers wrote.

The researchers found unexpectedly that ECT was administered more often to patients who had diagnoses indicating comorbid medical illnesses that may increase the relative health risks of ECT, possibly reflecting greater medical comorbidity in the group with ECT treatment or more frequent documentation of medical comorbidity among inpatients who are medically screened prior to ECT, according to the researchers.

For the study, Slade and colleagues relied on information contained in the Health Care Utilization Project’s State Inpatient Databases (SID) from general hospitals in the following nine states: Arizona, Arkansas, California, Florida, Nevada, New York, North Carolina, Utah, and Washington. While SIDs are available for most states, only the nine states included in the study had complete data on patient readmissions.

Administration of ECT was associated with a reduced 30-day readmission risk among patients with severe affective disorders from an estimated 12.3 percent among individuals not administered ECT to 6.6 percent among individuals administered ECT (risk ratio=0.54).

“The effect of ECT on 30-day readmission risk did not differ significantly by age or race/ethnicity, but was relatively larger among men than women and among individuals with bipolar disorder and schizoaffective disorder than among those with MDD,” according to the study.

“The findings of Slade et al. should be interpreted in the context of a large and diverse body of evidence regarding ECT efficacy,” Harold Sackeim, Ph.D., a professor of psychiatry at Columbia University, wrote in a related editorial. “The evidence indicating that ECT is effective in the treatment of mood disorders is diverse, long-standing, and incontrovertible. In both the short term and long term, it appears to exert greater benefit than pharmacological alternatives.”

ECT is used more frequently in private facilities compared with municipal, county, state, or federal health psychiatric hospitals. ECT recipients are older, more often white, more likely to have private insurance, and more likely to live in affluent areas, he wrote. “Contrary to its portrayal as a treatment inflicted on the poor or destitute, ECT is disproportionately administered to those more well off,” Sackeim concluded. ■