7.1.1
Use ratesSeveral publications present data on the number of patients receiving ECT or on the number of ECT treatment sessions, without providing data on the population served. In this respect, 1,781 patients of the Toronto Clarke Institute in Toronto received a total of 22,647 ECT treatment sessions between 1967 and 1982 [Martin et al., 1984]. Taking into account the fact that this institution is a tertiary centre, the authors noted that it was impossible to define the population pool served by that establish-ment. To perform a comparative analysis of ECT use
rates, it would be necessary to have data on the populations concerned.
The use rates taking into account the popula-tion served are reported in two different forms, either the number of patients per 10,000 of the population or the number of ECT treatment sessions per 1,000 of the population. To compare these two rates, the number of ECT treatment sessions per course of treatment must be known or estimated. Table 4 indicates the differences that exist in the average number of treatment sessions per patient in various jurisdictions. It therefore appears impossible to directly compare the use rates expressed in terms of the number of patients with those expressed in terms of the number of ECT treatment sessions.
7
Table 4
Average number of treatment sessions per patient in various jurisdictions
Region/Country Year Average number of Reference
treatment sessions per patient
Massachusetts, USA 1974 to 1980 10 [Mills et al., 1984]
New York State, USA 1972 8.7 [Morrissey et al., 1981]
1977 7.5
New York Region, USA 1997 5 to 14.5 (in 59 hospitals) [Prudic et al., 2001]
with an average of 7 for all patients
California, USA 1977 to 1983 5.3 [Kramer, 1985]
1984 to 1994 5.7 [Kramer, 1999]
Region of Vienna, Austria 1995 8.9 [Tauscher et al., 1997]
Denmark 1973 6.5 [Hedemand and
1979 8.4 Christensen, 1982]
Vermont, USA 2000-2001 10.3 Letter from Dr. William
McMains, Medical Director, Department of Developmental and Mental Health Services, January 8, 2002.
40
Figure 2 represents a comparison of the use rates expressed in terms of patients treated with ECT per 10,000 of the general population, and Figure 3 compares the use rates expressed in ECT treatment sessions per 1,000 of the general population (the study details are found in Appendix 1) [Ernst, 1982;
Finch et al., 1999; Gassy and Rey, 1990; Glen and Scott, 1999; Hedemand and Christensen, 1982;
Kramer, 1985; Pippard, 1992; Pippard et al., 1981;
Sauer et al., 1987; Tauscher et al., 1997]. We have not included Westphal’s data for Louisiana [Westphal et al., 1997] and Rosenbach’s data for the United States as a whole, as these data apply to specific populations, Medicare programme beneficiaries, namely persons 65 years of age and older, and not to the general population [Rosenbach et al., 1997]. No publication indicates that the differences illustrated in
figures 2 and 3 may be explained by differences in mental-illness prevalence rates. They seem to stem from variations in medical practices.
According to a survey on the use of ECT in New York State, the rate decreases observed between 1961 and 1975 continued until 1977, with a 49%
decrease in the total number of treatments between 1972 and 1977 [Morrissey et al., 1979]. However, the results of this survey cannot be extrapolated to the various populations. In England, the decrease in the number of ECT treatment sessions was estimated to be 50% between 1972 and 1979 [Pippard et al., 1981]. Between 1987 and 1992, the ECT patient-treatment rate under the Medicare programme in the United States increased from 4.2 to 5.1 per 10,000 of the population [Rosenbach et al., 1997].
Figure 2
ECT use in various countries (patient rates)
8 7 6 5 4
Patients treated by ECT per 10,000 in the general population (crude rates) 3
1963 1966 1969 1972 1975
1978 1981
1984 1987
1990 1993 1996 1999 2002
Interestingly, Figure 3 illustrates that the treat-ment session rates per 1,000 of the population in Great Britain evolved separately in different regions.
Between 1979 and 1989, these rates decreased from 3.28 to 1.47 in the North East Thames District and increased from 3.07 to 3.7 in the East Anglian District [Pippard, 1992]. This rate of evolution in Great Britain must be considered in the context of highly developed control mechanisms [Duffett and Lelliott, 1998; Royal College of Psychiatrists et al., 1995], which will be dealt with in the section concerning professional regulation.
Theoretically, it would be possible to define an appropriate ECT use level for each indication.
Hence, according to our ECT efficacy analysis, treat-ment-resistant depression should constitute one of the
principal indications for this treatment. On the basis of epidemiological data on the prevalence of the vari-ous degrees of resistance, it would be possible to define a desirable and appropriate level of use for this type of depression. However, in the absence of such epidemiological data, it is impossible to make such a calculation. Nonetheless, it appears that ECT may be under-utilized in certain populations. For example, one study showed that ECT was used in only 4% of 277 Finnish patients receiving disability pensions for depression [Isometsa et al., 2000]. In this group of patients, the average duration of the episode of depression was 16.6 months. The low ECT use level could indicate that, in certain populations, ECT is not used as frequently as prescribed by the sequential-treatment protocols for depression.
Treatment sessions per 1,000 of the general population (crude rates) 2.5
ECT use in various countries (treatment session rates)
42
7.1.2
Geographic variationsAccording to the data obtained in a survey conducted on the practice profiles of psychiatrists in the United States in 1988-1989, no ECT use was reported in 115 of the 317 Metropolitan statistical areas.In the others, the use rates varied between 0.4 and 81.2 patients per 10,000 of the population [Hermann et al., 1995]. This strong variation was also observed in England, where, in 1990, the rates varied between 0.68 and 6.50 treatment sessions (as opposed to patients treated) per 1,000 of the population, in London and the county of Suffolk, respectively [Pippard, 1992].
In Switzerland, 13 of the 42 hospitals that responded to a survey did not use ECT between 1979 and 1981. Among the 29 hospitals that used ECT, two treated 48% of all patients. This study did not report use rates per population [Ernst, 1982].
In an analysis of data on ECT use in Louisiana hospitals from 1993 to 1994, Westphal et al.used the systemic component of variance method based on a binomial distribution (SCV: systemic component of variance = d2x 10-3). With an SCV of 1,340, ECT practice displays one of the highest levels of practice variation of all medical interventions and practices. In comparison, tonsillectomy and hysterec-tomy, which are classic examples of interventions with very strong practice variations, generally have SCVs of approximately 200 and 60, respectively [Wennberg, 1990]16.
The variations in the use of medical tech-nologies often result from uncertainties in the deci-sion-making process. Once informed of practice variations, the physicians concerned significantly
reduced such variations for several different inter-ventions. In many cases, clinical practice guidelines were increasingly developed at the same time [Wennberg, 1990].
According to a German study, the wide regional variability in the use of ECT is more a result of regulatory mechanisms, particularly at the institu-tional level, and sociocultural and political contexts, than a divergence in medical opinion concerning the indications for this therapy [Muller et al., 1998].
No evaluative research seems to have measured the impact of the introduction of clini-cal guidelines and quality control programs on the geographic variation in ECT use. The quality con-trol program in Louisiana had very significant impacts on compliance with the American Psychiatric Association practice guidelines [Westphal et al., 1999]. However, its impact on geographic variation was not measured17.