Declining use of electroconvulsive therapy in United States general hospitals.

BACKGROUND: Falling duration of psychiatric inpatient stays over the past 2 decades and recent recommendations to tighten federal regulation of electroconvulsive therapy (ECT) devices have focused attention on trends in ECT use, but current national data have been unavailable. METHODS: We calculated the annual number of inpatient stays involving ECT and proportion of general hospitals conducting the procedure at least once in the calendar year with a national sample of discharges from 1993 to 2009. We estimated adjusted probabilities that inpatients with severe recurrent major depression (n = 465,646) were treated in a hospital that conducts ECT and, if so, received the procedure. RESULTS: The annual number of stays involving ECT fell from 12.6 to 7.2/100,000 adult US residents, driven by dramatic declines among elderly persons, whereas the percentage of hospitals conducting ECT decreased from 14.8% to 10.6%. The percentage of stays for severe recurrent major depression in hospitals that conducted ECT fell from 70.5% to 44.7%, whereas receipt of ECT where conducted declined from 12.9% to 10.5%. For depressed inpatients, the adjusted probability that the treating hospital conducts ECT fell 34%, whereas probability of receiving ECT was unchanged for patients treated in facilities that conducted the procedure. Adjusted declines were greatest for elderly persons. Throughout the period inpatients from poorer neighborhoods or who were publicly insured or uninsured were less likely to receive care from hospitals conducting ECT. CONCLUSIONS: Electroconvulsive therapy use for severely depressed inpatients has fallen markedly, driven exclusively by a decline in the probability that their hospital conducts ECT.

Racial differences in the availability and use of electroconvulsive therapy for recurrent major depression.

BACKGROUND: Black Americans with depression were less likely to receive electroconvulsive therapy (ECT) than whites during the 1970s and 80s. This pattern was commonly attributed to treatment of blacks in lower quality hospitals where ECT was unavailable. We investigated whether a racial difference in receiving ECT persists, and, if so, whether it arises from lesser ECT availability or from lesser ECT use within hospitals conducting the procedure. METHODS: Black or white inpatient stays for recurrent major depression from 1993 to 2007 (N=419,686) were drawn from an annual sample of US community hospital discharges. The marginal disparity ratio estimated adjusted racial differences in the probabilities of (1) admission to a hospital capable of conducting ECT (availability), and (2) ECT utilization if treated where ECT is conducted (use). RESULTS: Across all hospitals, the probability of receiving ECT for depressed white inpatients (7.0%) greatly exceeded that for blacks (2.0%). Probability of ECT availability was slightly greater for whites than blacks (62.0% versus 57.8%), while probability of use was markedly greater (11.8% versus 3.9%). The white versus black marginal disparity ratio for ECT availability was 1.07 (95% confidence interval 1.06-1.07) and stable over the period, while the ratio for use fell from 3.2 (3.1-3.4) to 2.5 (2.4-2.7). LIMITATIONS: Depressed persons treated in outpatient settings or receive no care are excluded from analyses. CONCLUSIONS: Depressed black inpatients continue to be far less likely than whites to receive ECT. The difference arises almost entirely from lesser use of ECT within hospitals where it is available.

Innovations: clinical computing: an audio computer-assisted self-interviewing system for research and screening in public mental health settings.

This column describes the nonproprietary software Talker, used to adapt screening instruments to audio computer-assisted self-interviewing (ACASI) systems for low-literacy populations and other populations. Talker supports ease of programming, multiple languages, on-site scoring, and the ability to update a central research database. Key features include highly readable text display, audio presentation of questions and audio prompting of answers, and optional touch screen input. The scripting language for adapting instruments is briefly described as well as two studies in which respondents provided positive feedback on its use.