RESEARCH WEEKLY: Barriers to ECT Access for Major Depressive Disorder

By Elizabeth Sinclair Hancq

Electroconvulsive therapy (ECT) is a safe and effective treatment for individuals with severe psychiatric disorders. In fact, ECT has been shown to produce remission rates in individuals with major depressive disorder at rates of 80-90% if used as a first-line treatment. For individuals with treatment-resistant depression, ECT has been shown to produce remission rates in 50-60% of cases, compared to less than 15% when using oral anti-depressive medications. Additionally, ECT has been shown to be effective in individuals with schizophrenia who are treatment-resistant to clozapine, the only antipsychotic medication shown to be effective for treatment-resistant individuals, indicating the effectiveness of the procedure when so many other treatments fail for these individuals.  

Despite these promising outcomes, ECT is extremely underutilized. One study conducted in 2015 estimated that just 0.25% of individuals in the United States with major depressive disorder received one or more sessions of ECT. New research published this month in Psychiatric Services from researchers from the Yale Depression Research Program aimed to study barriers to implementation of ECT in order to understand why so few providers offer ECT services.  

Implementation barriers to ECT according to practitioners 

The study authors first conducted semi-structured qualitative interviews of ECT practitioners to understand key themes around barriers to expanding an existing ECT service or starting a new one. The results from the qualitative interviews informed the creation of a quantitative survey, to which 192 ECT practitioners responded. Medicare data was then used to examine regional variability in ECT services:  
Top three states in availability of ECT providers per population:  
  1. Maine  
  2. Vermont  
  3. New Hampshire 
Bottom three states in availability of ECT providers per population:  
  1. Nevada  
  2. Idaho  
  3. Alaska  
ECT practitioners rated different prominence of implementation barriers depending on if they were related to expanding an existing ECT service or to starting a new one:  
Top three barriers to expanding an existing ECT service:  
  1. Lack of physical space 
  2. Stigma on part of patients 
  3. Transportation 
Top three barriers to initiating a new ECT service:  
  1. Lack of well-trained colleagues and ECT practitioners 
  2. Lack of a champion 
  3. Lack of physical space
Based on the results, lack of a physical space was a prominent barrier to both expanding an existing ECT service and initiating a new one. The study authors suggest this is in part due to low reimbursement rates of ECT compared to other procedure-based therapies and diagnostics, like colonoscopies. The authors suggest that enhancing the reimbursement rate for ECT services, either locally with private insurers or federally with Medicaid and Medicare, would help to promote increased availability of ECT services. 

Of the more than 200 psychiatry residency programs in the United States, most survey respondents came from 12 residency programs, indicating that investment into ECT education and training could increase the number of trained ECT providers. Current education guidelines only require didactic lectures on ECT, so most graduating psychiatry residents will have never even seen an ECT procedure.  

Stigma surrounding ECT  

Stigma surrounding ECT was another prominent barrier to expanding ECT services, according to the results. The authors suggest this stigma is the result of negative or inaccurate portrayal of ECT in the media. “Data have shown that the majority of media representations of ECT are negative or inaccurate,” the authors write. “In American media, most movies or TV shows depict ECT being performed without anesthesia or done for the purposes of behavioral control or torture (neither of which are accurate in contemporary psychiatric practice).” 

ECT is an important treatment option for individuals with serious mental illness, including those with major depression or individuals with schizophrenia whom are treatment-resistant to clozapine. Combatting barriers to implementation of ECT services are vital in order to make ECT available to individuals who may need it.  

References:  
Elizabeth Sinclair Hancq is the director of research at the Treatment Advocacy Center.

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