Indicators for Electroconvulsive Therapy among Patients Hospitalized for Depression

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1 Indicators for Electroconvulsive Therapy among Patients Hospitalized for Depression Muhammad A. K. Suri, MD; Mariam Suri; Malik M. Adil, MD; Mushtaq H. Qureshi, MD; Ahmed A. Malik, MD; M. Fareed K. Suri, MD; and Adnan I. Qureshi, MD Muhammad A. K. Suri, MD, is as Psychiatrist, North Memorial Hospital. Mariam Suri, is a Graduate Student in Biological Sciences, University of Minnesota. Malik M. Adil, MD, is a Clinical Research Fellow, Zeenat Qureshi Stroke Institute. Mushtaq H. Qureshi, MD, is a Clinical Research Fellow, Zeenat Qureshi Stroke Institute. Ahmed A. Malik, MD, is a Clinical Research Fellow, Zeenat Qureshi Stroke Institute. M. Fareed K. Suri, MD, is an Interventional Cardiologist, Centracare Health System. Adnan I. Qureshi, MD, is an Interventional Neurologist, Zeenat Qureshi Stroke Institute. Address correspondence to Ahmed A. Malik, MD, Zeenat Qureshi Stroke Institute, 519 2nd Street N, St. Cloud, MN 56303; AhmedMalik1@yahoo.com. Adnan I. Qureshi has received funding from the American Heart Association Established Investigator Award N, the National Institute of Health U01-NS A2 (medication provided by Cornerstone Therapeutics), and the Minnesota Medical Foundation. Disclosure: The authors have no relevant financial relationships to disclose. doi: / ABSTRACT This article compares various characteristics, including demographics, comorbid conditions, hospital status, and outcomes, in patients with major depression who received electroconvulsive therapy (ECT) versus those who did not. It seeks to determine if dyslipidemia is an indicator for ECT among patients hospitalized for depression. Data from all patients admitted to US hospitals between 2009 and 2010 with a primary discharge diagnosis of depression were included. We compared patients with depression who received ECT with those who did not. A logistic regression analysis was used to identify the association between patient and hospital characteristics and odds of receiving ECT. All variables that were significant in the univariate analysis were added as predictor variables to the stepwise logistic regression model. A total of 925,060 patients with depression were included. Of these, 20,251 (2.2%) underwent ECT. In the stepwise logistic regression, female gender (odds ratio [OR] 1.3, 95% confidence interval [CI] ), white ethnicity (OR 1.8, 95% CI ), and dyslipidemia (OR 1.3, 95% CI ) were associated with receiving ECT among the patients with major depression. Large-sized hospitals (OR 1.9, 95% CI ) and teaching hospitals (OR 3.2, 95% CI ) were more likely to use ECT. [Psychiatr Ann. 2015;45(3): ] Shutterstock 140 Copyright SLACK Incorporated

2 Depression is a common psychiatric illness, with an incidence of about 6% in the United States. 1 Approximately 30% of depression cases are classified as severe depression, and approximately 3% of severely depressed patients commit suicide. Many of the severely depressed patients are admitted to hospitals for inpatient treatment. Treatment for depression varies from psychotherapy to medication management. In many depressed patients, electroconvulsive therapy (ECT) is used as a mode of treatment, and it is usually administered to severely depressed patients in an inpatient hospital setting. Many of the characteristics of the patient population who receive ECT are unknown. ECT has been used for more than 70 years, but, with the growing concerns of memory impairment and the availability of new psychopharmacologic medications, greater effort is being placed on the identification of factors that are indicators for use of ECT. Such identification may have the potential to prevent the eventual need for unnecessary use of ECT practice. METHODS We analyzed data from the National Inpatient Sample (NIS) from 2009 to The NIS is the largest all-payer database in United States. It derives data on patients demographic and clinical characteristics, in-hospital procedures, hospital characteristics, and discharge outcomes from 20% of nonfederal hospitals. (A comprehensive synopsis on NIS data is available at ahrq.gov. 2 ) We used the International Classification of Diseases, 9th revision, clinical modification 3 (ICD-9-CM) primary diagnosis codes 296.2, 296.3, and 311 to identify the patients admitted with depression. We used ICD-9-CM procedure code to identify patients who underwent ECT. We compared patients with major depression who underwent ECT to patients with Treatment for depression varies from psychotherapy to medication management. major depression who did not. Study variables include patient s age, gender, race/ethnicity, and comorbidities. Comorbidities obtained from the Agency for Healthcare Research and Quality comorbidity data files included congestive heart failure, diabetes mellitus, hypertension, dyslipidemia, alcohol abuse, renal failure, and chronic lung disease. We used ICD-9-CM secondary diagnostic codes to identify comorbid atrial fibrillation ( and ), ischemic stroke ( ), schizophrenia (295), chronic pain (307.8 and 338.4), and nicotine dependence (305.1). Discharge status was categorized into home routine, home with home health care, short-term hospital, and other facility including intermediate care and skilled nursing home, or death. We defined none to minimal disability as discharged home and any other discharge status as moderate to severe disability as previously described. We used ICD-9-CM diagnosis codes to identify the incidence of status epilepticus (345), intracranial hemorrhage (ICH) ( ), and subarachnoid hemorrhage (SAH) (430). Statistical Analysis The Statistical Analysis System 9.3 software (SAS Institute, Cary, NC) was used for all analysis. We used weighted counts to generate national estimates according to the Healthcare Cost and Utilization Project recommendations. 2 We performed univariate analysis, chisquare for categorical, and t-test for continuous variables to compare patients with major depression who received ECT to those who did not. A logistic regression analysis was performed that included variables that were significant in univariate analysis to identify independent predictors in hospitalized patients with depression who underwent ECT. We also performed an exploratory analysis to compare length of stay, hospitalization charges, and rates of status epilepticus, ICH, and SAH in patients who did or did not receive ECT. RESULTS A total of 925,060 patients were hospitalized with a primary diagnosis of depression between 2009 and Of these, 20,251 (2.2%) patients underwent ECT. The patients who received ECT were comparatively younger, with a mean age ± standard deviation (SD) of 41 ± 18 years versus 57 ± 16 years (P <.0001). The proportions of women patients and white patients were significantly higher in those who received ECT. The proportion of patients with hypertension, diabetes mellitus, atrial fibrillation, dyslipidemia, and ischemic stroke were higher in those who received ECT compared with those who did not (Table 1). The proportion of patients with chronic pain was not significantly different between the two groups (2.4% vs 1.7%, P = 0.2). The proportion of patients admitted to teaching hospitals was higher among those who received ECT (66.3%, P <.0001). None of the patients who received ECT had ICH or status epilepticus, whereas.01% had ICH and.01% had status epilepticus in patients who did not receive ECT. In the backward stepwise logistic regression, women (odds ratio [OR] 1.3, 95% confidence interval [CI] ), white ethnicity (OR 1.8, 95% CI ), schizophrenia (OR 1.6, 95% CI ), and presence of dyslipidemia (OR 1.3, 95% CI ) were significant predictors among the patients with depression who underwent ECT. Patients admitted to large PSYCHIATRIC ANNALS Vol. 45, No. 3,

3 TABLE 1. Patients Demographic and Clinical Characteristics, In-Hospital Procedures, Hospital Characteristics, and Discharge Outcomes in Patients with Severe Depression Variable Patients Receiving ECT (%) Patients Not Receiving ECT (%) P value Overall number (%) 20, ,809 Age mean, year (SD) 41 ± ± 16 Women 13,298 (65.1) 50,6041 (56.1) Race/ethnicity White 14,896 (89.1) 53,6667 (72.2) Black 676 (4.0) 105,646 (14.2) Hispanic 91 (2.7) 63,426 (8.5) Other 701 (4.2) 37,567 (5.0) Comorbid conditions Hypertension 9,580 (47.3) 251,417 (27.8) Diabetes mellitus 2,910 (14.4) 88,340 (9.8) Atrial fibrillation 766 (3.8) 11,836 (1.3) Dyslipidemia 1,670 (8.2) 34,874 (3.8) Congestive heart failure 3,885 (1.9) 14,794 (1.6).29 Chronic lung disease 3,024 (15.0) 130,111 (14.4).51 Renal failure 738 (3.6) 14,394 (1.6) Ischemic stroke 270 (1.3) 6,191 (.7).03 Nicotine dependence 3,228 (16.0) 199,231(22.0) Alcohol abuse 2,043 (10.1) 219,283 (24.2) Schizophrenia 487 (2.4) 13,384 (1.5).01 Chronic pain 493 (2.4) 15,883 (1.7).2 Teaching status Non-teaching 6,673 (33.7) 482,490 (54.0) Teaching 13,102 (66.3) 410,784 (46.0) Insurance status Medicare/Medicaid 11,995 (59.2) 419,564 (46.3) Private HMO 7,441 (36.7) 313,414 (34.6) No insurance 785 (3.8) 167,025 (18.4) Hospital bed size Small 1,687 (8.5) 81,464 (9.1) Medium 3,474 (17.5) 214,266 (30.0) Large 14,614 (74.0) 597,544 (67.0) Length of stay, mean days (SD) 17 ± 14 6 ± 6 Hospital charges, mean (SD) ($) 44,787 ± 40,855 13,345 ± 16,314 Discharge disposition None to minimal disability 18,272 (91.4) 808,843 (89.3).27 Moderate to severe disability 1,954 (9.6) 94,875 (10.4).26 In-hospital mortality 0 (.0) 276 (.03) Adverse events Status epilepticus 0 (.0) 67 (.01) ICH 0 (.0) 122 (.01) ICH/SAH 5 (.02) 140 (.01).66 Abbreviations: ECT, electroconvulsive therapy; HMO, health maintenance organization; ICH, intracranial hemorrhage; SAH, subarachnoid hemorrhage; SD, standard deviation Copyright SLACK Incorporated

4 hospitals (OR 1.9, 95% CI ) and teaching hospitals (OR 3.2, 95% CI ) were more likely to receive ECT. Patients with private health maintenance organization (HMO) insurance (OR 1.5, 95% CI ) were more likely to receive ECT as well (Table 2). In the exploratory analysis, the length of stay was longer in patients who received ECT compared with those who did not (17 ± 14 days versus 6 ± 6 days, P <.0001). The hospital charges were significantly higher in the patients who had received ECT ($44,787 ± 40,855 vs $13,345 ± 16,314, P <.0001). DISCUSSION ECT has been traditionally considered as one option in the treatment of major depression. Although various studies have found ECT to be effective in the treatment of severe and treatmentresistant depression, 4-9 there are many adverse effects that are associated with ECT, such as long-term cognitive deficits; 10 retrograde amnesia, semantic and lexical memory loss; 11 and prolonged seizures 12 or status epilepticus. 13 Although we know that patients with depression who cannot tolerate pharmacotherapy, 5 those who are resistant to drug therapy, 5 or those who have severe depression 6 are good candidates to receive ECT, no study, to our knowledge, has elucidated the independent predictors of the eventual need for ECT. In our study, we identified independent predictors of ECT among patients with depression admitted to the hospital. We found that women 14 and white ethnicity 14 are predictors of ECT. In the backward stepwise logistic regression, women, white ethnicity (OR 1.8, 95% CI ), and presence of dyslipidemia (OR 1.3, 95% CI ) were significant predictors of ECT. The disparity in race as a predictor of ECT may be due to the fact that black patients with depression are less likely to receive care than white patients. 15 When black patients with depression do receive outpatient treatment, it is typically less intensive, of lower quality, and less commonly provided by a specialist. 16 Likewise, with few exceptions, the prevalence, incidence, and morbidity risk of depressive disorders are higher in women than in men, beginning at mid-puberty and persisting through adult life. 17 There appeared to be a higher frequency of cardiovascular risk factors in patients who underwent ECT. It remains to be seen whether vascular depression, an entity prominent in patients with cardiovascular diseases, may lead to a greater need of ECT. The relationship was particularly prominent with dyslipidemia. The finding of dyslipidemia can be of significance in the understanding of metabolic derangements in patients who are depressed. There are few studies, however, that address the association between plasma concentration of cholesterol and high-density lipoprotein cholesterol with depression. 18,19 It is possible that dyslipidemia is associated with severe depression, and thus with higher odds of undergoing ECT. Further research needs to be done to clarify this issue. ECT use decreased in the United States from the late 1970s to 1980s, 20 TABLE 2. Effect of Patients Demographic and Clinical Characteristics and Hospital Characteristics on ECT Requirement by Multivariate Analysis Unadjusted Adjusted Characteristics Odds ratio (95% CI) P value Odds ratio (95% CI) P value Women 1.5 ( ) 1.3 ( ) White ethnicity 1.9 ( ) ( ).001 Dyslipidemia 2.2 ( ) 1.3 ( ).008 Schizophrenia 1.6 ( ) ( ).008 Teaching hospitals 2.2 ( ) 3.2 ( ) Private HMO 1.1 ( ) ( ) No insurance.2 ( ).3 ( ) Large-sized hospitals 1.3 ( ) ( ).002 Abbreviations: CI, confidence interval; ECT, electroconvulsive therapy; HMO, health maintenance organization. with some stabilization of the rate in the 1990s, only to have a slight resurgence of use in the 2000s. 21 ECT use varies across different metropolitan areas in the US based on the number of psychiatrists, number of private hospital beds per capita, and stringency of state regulation pertaining to ECT. 22 ECT is administered in hospitals all across the US, 23 but the results in our study show that most of the ECTs were administered in large teaching hospitals. 24 General public hospitals in some studies perform more ECTs than private hospitals, 25 depending on state regulations. 20 ECTs are performed at a higher rate in Northeastern states compared to Western states. 26 White patients, as compared to those of other races, and women, in comparison to men, in affluent metropolitan areas are more likely to receive this treatment. 14,26,27 Patients with an HMO were more likely to receive ECT in our study. Although some adverse effects of ECT are known, more studies are needed to identify complications such as ICH 28 and stroke 29,30 after ECT administration. Although there is insufficient data, we were able to find two case reports. The first, described PSYCHIATRIC ANNALS Vol. 45, No. 3,

5 by Weisberg et al., 31 was a patient in whom a parieto-occipital hemorrhage was observed after ECT treatment. The other was a case report of a 44-year-old woman who presented with an acute embolic right middle cerebral artery stroke immediately after ECT. 29 Our retrospective study analysis was limited because we used ICD-9-CM codes for diagnoses that were not adjudicated. In a previous study, the ICD- 9-CM codes (94.26 and 94.27) for ECT were validated and found to have a sensitivity of 0.96 (95% CI ) and a specificity of (95% CI ). 26 Another study, conducted by Butt et al., 32 reported that the sensitivity and specificity of ICD-9-CM codes for major depression were 44.8% and 90.0%, respectively. 32 The strength of our study was its large size and its sample representation of US hospital admissions of individuals with depression. CONCLUSION Our study identifies factors, such as dyslipidemia, that are predictors of ECT treatment in a national cohort of patients hospitalized with primary diagnosis of depression. Larger retrospective studies of cohorts need to be conducted to further identify patients who are likely to receive ECT. Identification of the at-risk population among hospitalized patients with depression may result in the development of novel preventive strategies, thereby concurrently reducing the side effects and complications that can result from ECT. REFERENCES 1. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23): Healthcare Cost and Utilization Project. Overview of the National (Nationwide) Inpatient Sample (NIS). ahrq.gov/nisoverview.jsp. Accessed February 10, Centers for Disease Control and Prevention. 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