Today, very few depression patients receive the treatment once known as “shock therapy.”
But a new study suggests the approach — which today uses far milder electrical impulses than it did decades ago — should be more available to patients who have tried two other types of treatment, such as antidepressant medications and talk therapy, and are seeking a third option.
The study, published in JAMA Psychiatry by a team from the University of Michigan, looked at the cost-effectiveness of electroconvulsive therapy, or ECT. Its findings could inform depression care decisions by insurers and policy makers, as well as conversations between doctors and patients.
The researchers used data from recent, highly regarded clinical studies to create a simulation of patients’ potential journeys through many depression treatment strategies.
The model found that for patients getting depression treatment for the first time, medication, psychotherapy or a combination of the two is more cost-effective than ECT, which delivers brief, mild electrical impulses to the brain under short-term anesthesia. This also held true for patients whose first depression treatment choice didn’t help them.
But for patients whose depression symptoms didn’t ease after trying two different treatments — what psychiatrists call “treatment resistant” depression — ECT emerged as a cost-effective choice, the study found.
“Although choosing a depression treatment is a very personal choice that each patient must make with their physician based on their preferences and experience, our study suggests that ECT should be on the table as a realistic option as early as the third round of care,” says lead author Mr. Eric L. Ross, a University of Michigan fourth year Medical School student who will enter a psychiatry residency program this summer.
“ECT is often considered a last resort by patients and providers,” says senior author Dr. Daniel Maixner, “Unfortunately, research shows that with multiple medication failures and long duration of illness — sometimes many years — the chance that patients can achieve remission drops quickly to very low numbers.
“ECT is the best treatment to produce remission. So, in addition to the clinical idea that ECT should be used sooner, our study adds another perspective highlighting that ECT is also cost-effective earlier in the treatment course of depression.”
Dr. Maixner, an associate professor of psychiatry at U-M, directs the ECT program at Michigan Medicine, the University of Michigan’s academic medical center.
That ECT was a cost-effective third-line treatment was contrary to the team’s expectations — who hypothesized this to be true for ECT as a fifth- or sixth-line treatment. The findings suggest that if patients and physicians decide to try a third, fourth or fifth antidepressant or psychotherapy course, or combinations of medicine and therapy before they opt for ECT, the latter would will still be most cost-effective the sooner they decide to try it.
For the work, Mr. Ross and Dr. Maixner collaborated with Dr. Kara Zivin, an associate professor of health management and policy at the University of Michigan School of Public Health and associate professor of psychiatry. Dr. Zivin is also a member of the University of Michigan Institute for Healthcare Policy and Innovation and the Veterans Affairs (VA) Center for Clinical Management Research.
[Photo attached: Dr. Kara Zivin]
In 2011, Drs. Zivin, Maixner and their University of Michigan and VA colleagues showed that just 0.16 percent of VA patients nationwide who had depression received ECT. Their study also revealed wide variations in the use of ECT by region and by the race and medical health status of the patient. More recent studies have shown that patients receive ECT only after trying five to seven different antidepressants and other medications.
For the new study, the team created a model that used data from the gold-standard national STAR*D study of drug- and psychotherapy-based depression treatment and from randomized controlled studies and observational studies of ECT’s initial effects, long-term maintenance and risk of relapse.
The model also used data from ECT clinical trials. It took a conservative approach based on those findings that assumed that half of patients who try ECT would get immediate and full relief, also called remission, though one-third might relapse after a year. ECT treatment regimens start with multiple sessions in the first few weeks, followed often by a brief or longer-term maintenance schedule.
By comparison, the STAR*D study showed that 33 percent of patients experienced remission after trying their first antidepressant, and only 25 percent of those who went on to try a second antidepressant experienced remission. After that, STAR*D found diminishing returns: a third antidepressant-based treatment only helped about 15 percent of those who failed to get relief from the first two options they tried, and a fourth option only helped 7 to 10 percent of patients.
The University of Michigan team’s model suggests that instead of spending half the four years after diagnosis with active depression symptoms, patients could be symptom-free two-thirds of the time.
The study predicts ECT as a third-line treatment would have an incremental cost-effectiveness ratio of $54,000 per quality-adjusted life year. This ratio, which measures the value received for the dollars spent to restore patients’ quality of life, falls well below the $100,000 threshold usually considered worthwhile for health spending. The cost-effectiveness analysis focused on health care-related costs and did not take into account lost productivity by the individual because of depression, or time or travel costs for ECT or clinic appointments.
The new findings might help physicians make the case to insurers that ECT should be covered earlier in a treatment-resistant depression patient’s course, Dr. Zivin notes.
“Coverage for ECT varies widely, and it’s not clear why since it’s one of the most effective treatments we have,” she says. “We shouldn’t allow the stigma attached to the past incarnations of this approach to prevent its modern form from being seriously considered for appropriate patients. Increased coverage could also help address the widespread ECT service-area gaps that we’ve found in other research.”
The study was funded by Dr. Zivin’s grant from Veterans Affairs Health Services Research and Development Services.
Hear the researchers discuss their work at JAMANetwork.com, or on your favorite podcast platform.