|Year : 2017 | Volume
| Issue : 2 | Page : 131-134
Trends in use of electroconvulsive therapy among geriatric patients over a period of 9 years at a tertiary care center in North India
Sandeep Grover, Devakshi Dua, Subho Chakrabarti, Ajit Avasthi
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||29-Dec-2017|
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
Background: Electroconvulsive therapy (ECT) is an important modality of treatment for various psychiatric disorders in all age groups. The trends of use of ECT in the elderly population have not been studied despite wide variation in the utilization of this treatment modality. Aim: This study aimed to evaluate the trends in use of ECT in geriatric patients at a tertiary care center over a period of 9 years. Methodology: Data were extracted from the departmental registry for the period of 2008–2016 to evaluate the total number of new patients attending the psychiatric services, total number of new elderly (i.e., ≥60 years) patients attending the psychiatric services, total number of inpatients, total number of elderly inpatients, total number of patients who received ECT, and total number of elderly patients who received ECT. Results: During the period of 2008–2016, elderly formed from 4.6% to 19.11% of the total number of patients who received ECT. There was an upward trend in the proportion of elderly patients receiving ECT, with a nearly 10-fold rise in absolute number and doubling of the percentage of elderly patients among those receiving ECT. Over the years, there was an increase in use of ECT among elderly inpatients and use of ECT as an outpatient treatment for elderly. Conclusion: Over the years, there has been increase in the absolute number as well as proportion of elderly patients receiving ECT. There is a significant increase in the use of ECT among elderly at the outpatient basis.
Keywords: Elderly, electroconvulsive therapy, trends
|How to cite this article:|
Grover S, Dua D, Chakrabarti S, Avasthi A. Trends in use of electroconvulsive therapy among geriatric patients over a period of 9 years at a tertiary care center in North India. J Geriatr Ment Health 2017;4:131-4
|How to cite this URL:|
Grover S, Dua D, Chakrabarti S, Avasthi A. Trends in use of electroconvulsive therapy among geriatric patients over a period of 9 years at a tertiary care center in North India. J Geriatr Ment Health [serial online] 2017 [cited 2019 Jun 16];4:131-4. Available from: http://www.jgmh.org/text.asp?2017/4/2/131/221900
| Introduction|| |
Electroconvulsive therapy (ECT) is one of the oldest treatments in psychiatric practice. Although the mode of administration has advanced significantly since its introduction in 1938 by Cerletti and Bini, to the current practice of modified ECT, it remains one of the most important somatic therapies for the management of severe mental disorders in patients across different age groups.,
Although in the beginning, ECT was recommended for use in patients with schizophrenia, gradually, the use of ECT has been limited to use in patients with affective disorders, especially depression.
Over the years, there has been a change in the practice of ECT in different countries. Data from the United States suggest that 48%–59% of patients who receive ECT are elderly (≥60 years).,, In fact, some of the authors described a typical patient from the United States to be receiving ECT, being an elderly female, who pay for the treatment from insurance or private funds., However, some of the data contradict this and suggest reduction in proportion of elderly, among those receiving ECT. A study from Texas, United States, showed that the utilization of ECT for patients above 65 years of age dropped significantly between the years 1993 (43.73% of total patients receiving ECT) and 2014 (18.05%). This was in contrast to the trends in the elderly population, which mostly remained constant. Similarly, another study reported that there was a falling trend in the use of ECT, more so in the elderly population, across the United States. A study from Canada reported that a higher proportion of elderly patients were receiving ECT as compared to their younger counterparts with depression, with only a slight fall in utilization of ECT in the elderly over a 13-year period. Studies from other parts of the world show a significant variation in proportion of patients receiving ECT being elderly. A study in South Africa reported that 10.6% of the patients receiving ECT belonged to the geriatric population. A survey of practice of ECT in various teaching institutions in India revealed that 14.7% of patients who receive ECT are aged ≥65 years. A similar survey of 977 psychiatric facilities in 45 Asian countries showed that only 4.4% of patients receiving ECT were aged ≥64 years. A study from a tertiary care in North India, which evaluated the ECT data over the period of 8 years, reported that patients ≥60 years of age constitute 15% of the total number of patients receiving ECT.
A systematic review which evaluated the use of ECT worldwide reported a differential utilization of ECT for the elderly patients depending on the region of study. It was seen that in countries like the USA, Australia, and Europe, a higher proportion of patients receiving ECT were older, whereas elderly formed a very small proportion of patients who received ECT in Asian, African, and South America countries, barring Japan and Hong Kong. However, most of the data which are available in terms of trends in use of ECT among elderly are cross sectional in nature. Studies which have reported trends have also compared the utilization of ECT between years and have drawn their conclusions about the trends.,, The trends over time have not been studied adequately.
Accordingly, the present study aimed to evaluate the trends in use of ECT among elderly patients in a tertiary care center. In addition, an attempt was made to evaluate whether the trends in the practice of use of ECT among elderly was influenced by the overall number of elderly patients attending the psychiatry services.
| Methodology|| |
This study followed a retrospective study design. The study was approved by the Institute Ethics Committee. As the study was based on evaluation of hospital statistics, consent was not required from the patients.
At our setup, bilateral modified ECT is administered on a thrice-weekly basis (Monday, Wednesday, and Saturday). ECT is administered to both, inpatients and outpatients. The decision to start ECT is made by the consultant in charge of the case, along with the other members of the treating team. For a few complicated cases, opinion of a second consultant is sought. All the patients undergo detailed physical evaluation before ECT to determine fitness for ECT. Only those cases, found to be fit to undergo general anesthesia, are considered for ECT. Before ECT, all the patients and their caregivers are provided adequate information about the procedure, side effects, efficacy/effectiveness, available alternative treatment options, etc., Only those patients are considered for ECT who themselves or their caregivers or both provide written informed consent.
The details of every patient receiving ECT are entered into a computer-based registry, which is checked for completeness from time to time. The registry includes information about the patients' age, gender, psychiatric diagnoses, comorbid physical illnesses, inpatient/outpatient status at the time of initiation of ECT, indications for ECT, history of use of ECT and response to the same, concomitant medications used, total number of ECTs given, anesthetic medications used, and side effects experienced.
For this study, the computer-based registry was used to identify the number of patients aged ≥60 years, who received ECT during the years 2008–2016. In addition, data of total number of patients who received ECT during each calendar year were also extracted.
The computer-based registry of the outpatient and inpatient services were also used to identify the total number of new patients attending the psychiatry services and admitted during each calendar year.
Data were analyzed using the Statistical Package for the Social Sciences (SPSS for Windows, Version 14.0, SPSS Inc., Chicago). Frequency and percentages were calculated.
| Results|| |
As it is evident from [Table 1], during the period under evaluation, elderly (i.e., ≥60 years) formed from 4.6% to 19.11% of the total number of patients who received ECT in each calendar year. In general, there was a downward trend from the years 2009–2011 and an upward trend during the period of 2012–2016 in terms of proportion of elderly patients among those receiving ECT, except for a dip in the year 2013. When the data of years 2008 and 2016 were compared, it was evident that proportion of elderly patients among those receiving ECT increased to more than double. However, in terms of absolute number, there was nearly a 10-fold increase in the number of elderly patients receiving ECT. This increase was in commensurate with the increase in proportion of total number of new patients of any age group and those in the elderly age group attending the outpatient services. In terms of trends, there was a secular trend in the increase of elderly patients attending the outpatient services, and similarly, there was a secular increasing trend in number of patients receiving ECT. However, as discussed earlier, the proportion of elderly patients who received ECT fluctuated to a certain extent.
When the proportion of elderly patients was compared with elderly patients attending the outpatient services, it is evident than during the years 2013–2016, there was only a marginal increase in the proportion of new elderly patients attending the outpatient services; however, the proportion of elderly patients receiving ECT has doubled.
As it is evident from [Table 2], over the years, there was a fluctuation in the number of elderly patients admitted to the inpatient unit. As it is evident from [Table 2], over the years, there was reduction in proportion of inpatients among those who were treated with ECT, which meant increase in the trend of use of ECT among elderly at the outpatient level. In terms of proportion, 28.57%–72% of elderly patients who were admitted received ECT. However, when the data of the years 2008 and 2016 were compared, higher proportion of elderly inpatients received ECT as outpatients. A review of data from [Table 2] suggests that although there is a decrease in the proportion of inpatients among those receiving ECT, there is an increase in the use of ECT among elderly inpatients.
|Table 2: Proportion of elderly inpatients, proportion of elderly inpatients receiving electroconvulsive therapy, and proportion of elderly inpatients among those receiving electroconvulsive therapy|
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| Discussion|| |
ECT is considered as an important treatment modality among elderly patients with depression. This is particularly so due to the greater risk of side effects and poor response to antidepressant medications in the elderly. It has also been shown that the elderly have a better response to ECT than their younger counterparts with depression though they may require a longer duration of treatment.,
Understanding the trends in use of ECT among elderly can help in understanding the utilization of this important treatment modality. The present study suggests that over the period of 2008–2016, there has been increase in absolute number (from 4 to 39) of elderly patients receiving ECT. Further, there is also increase in the proportion formed by elderly among those receiving ECT from 8.7% to 19.11%. When these trends were compared with trends in elderly patients attending the outpatient services, it is evident that during the years 2013–2016; there is a marginal increase in the proportion of new elderly patients attending the outpatient services; however, the proportion of elderly patients receiving ECT has doubled. Taking all these facts into consideration, it can be said that over the years, ECT is increasingly used among elderly.
As there is a lack of previous longitudinal studies evaluating the trends in utilization of ECT among elderly, it is not possible to compare the findings of the present study with existing literature.
However, findings of the present study are supported by previous study from India, in which elderly formed about 15% of patients receiving ECT  and the survey of different teaching institutions in India, which revealed that 14.7% of patients who receive ECT are aged ≥ 65 years. In the present study, out of the 9 years under evaluation, for 5 years, elderly formed 12.04%–19.11% of total patients receiving ECT. Majority of the studies from developed countries like the United States have reported a downward trend in use of ECT among patients of all age groups,, more so among elderly., When one compares the findings of the present study with these trends, it can be said that there is an increase in the trend of use of ECT among patients belonging to all age groups in the present study. This could be possibly due to more acceptance of ECT in Indian setting when compared to Western countries. Further, in developing countries like India, many a times, clinicians use ECT to have early response to treatment, whereas, in developed countries like the United States, ECT is often considered as a treatment of the last resort.
Another important finding of the present study was a significant increase in use of ECT among elderly at the outpatient setting. In contrast to the year 2008, when none of the elderly patients received ECT on the outpatient basis, in the year 2016, half of the ECTs among elderly were administered at the outpatient basis. This trend possibly reflects improvement in the practice of ECT. Over the study years, ECT services were upgraded in terms of anesthesia and intensive monitoring instruments along with introduction of electroencephalogram monitoring of seizure during the ECT procedure.
The present study has its limitations. The trends in utilization of ECT were evaluated only over the period of 9 years. Data were not available for number of follow-up elderly patients attending the services. This could have influenced the utilization of the ECT services. The present study was limited to a single center, and hence, these cannot be generalized to all the institutions in India.
| Conclusion|| |
The present study suggests that over the years, there has been increase in the absolute number of patients receiving ECT. The present study also suggests that there is also increase in the proportion of elderly among those receiving ECT, despite only marginal increase in the total number of new elderly patients attending the outpatient services. Further, the present study also suggests that there is a significant increase in use of ECT among elderly at the outpatient basis. However, although there is a decrease in proportion of inpatients among those receiving ECT, there is an increase in use of ECT among elderly inpatients.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Payne NA, Prudic J. Electroconvulsive therapy: Part I. A perspective on the evolution and current practice of ECT. J Psychiatr Pract 2009;15:346-68.
Van der Wurff FB, Stek ML, Hoogendijk WL, Beekman AT. Electroconvulsive therapy for the depressed elderly. Cochrane Database Syst Rev 2003;CD003593.
American Psychiatric Association. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging (A Task Force Report of the American Psychiatric Association). American Psychiatric Publication; 2008.
Reid WH, Keller S, Leatherman M, Mason M. ECT in Texas: 19 months of mandatory reporting. J Clin Psychiatry 1998;59:8-13.
Sylvester AP, Mulsant BH, Chengappa KN, Sandman AR, Haskett RF. Use of electroconvulsive therapy in a state hospital: A 10-year review. J Clin Psychiatry 2000;61:534-9.
Prudic J, Olfson M, Sackeim HA. Electro-convulsive therapy practices in the community. Psychol Med 2001;31:929-34.
Kramer BA. Use of ECT in California, revisited: 1984-1994. J ECT 1999;15:245-51.
Rosenbach ML, Hermann RC, Dorwart RA. Use of electroconvulsive therapy in the medicare population between 1987 and 1992. Psychiatr Serv 1997;48:1537-42.
Williams J, Chiu L, Livingston R. Electroconvulsive therapy (ECT) and race: A Report of ECT use and sociodemographic trends in Texas. J ECT 2017;33:111-6.
Case BG, Bertollo DN, Laska EM, Price LH, Siegel CE, Olfson M, et al.
Declining use of electroconvulsive therapy in United States general hospitals. Biol Psychiatry 2013;73:119-26.
Rapoport MJ, Mamdani M, Herrmann N. Electroconvulsive therapy in older adults: 13-year trends. Can J Psychiatry 2006;51:616-9.
Benson-Martin JJ, Milligan PD. A survey of the practice of electroconvulsive therapy in South Africa. J ECT 2015;31:253-7.
Chanpattana W, Kunigiri G, Kramer BA, Gangadhar BN. Survey of the practice of electroconvulsive therapy in teaching hospitals in India. J ECT 2005;21:100-4.
Chanpattana W, Kramer BA, Kunigiri G, Gangadhar BN, Kitphati R, Andrade C, et al.
A survey of the practice of electroconvulsive therapy in Asia. J ECT 2010;26:5-10.
Jain G, Kumar V, Chakrabarti S, Grover S. The use of electroconvulsive therapy in the elderly: A study from the psychiatric unit of a North Indian teaching hospital. J ECT 2008;24:122-7.
Leiknes KA, Jarosh-von Schweder L, Høie B. Contemporary use and practice of electroconvulsive therapy worldwide. Brain Behav 2012;2:283-344.
Kerner N, Prudic J. Current electroconvulsive therapy practice and research in the geriatric population. Neuropsychiatry (London) 2014;4:33-54.
Rapoport M, Mamdani M, Shulman KI, Herrmann N, Rochon PA. Antipsychotic use in the elderly: Shifting trends and increasing costs. Int J Geriatr Psychiatry 2005;20:749-53.
[Table 1], [Table 2]