ORIGINAL PAPER EARLY READMISSION IN PATIENTS AFTER ELECTROCONVULSIVE THERAPY IN A UNIVERSITY HOSPITAL SETTING - A RETROSPECTIVE STUDY Ng CG*, Amer Siddiq AN*, Salina M*, Koh OH*, Zuraida NZ* *Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur Abstract Electroconvulsive therapy (ECT) is an effective treatment for major mental illnesses. It is used to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options have proven ineffective. Relapse rates following ECT are high and leading to early readmission. Objective: To study the early readmission rate in patients had received ECT and its relation with age, gender, race and clinical diagnosis. Methods: This is a retrospective descriptive study of patients who had received ECT in 1-year period. Subjects were identified from the ECT record book. Case notes of these patients were then traced and reviewed. Clinical diagnosis and demographic data were collected. Patients readmitted within 6 months after being discharged were identified. The data was compared for the readmitted and not readmitted group. Result: A total of 156 subjects who had received ECT were included in this study. Mean age was 40 years old, 51% were female and the main diagnosis was bipolar affective disorder (42.9%). Early readmission rate was 30.1%. Mean time to relapse was 5.3 months. Chi Square analysis indicated that younger age was significantly associated with early readmission among ECT patients. Conclusion: ECT patients had high early readmission rate. Adequate post ECT psychosocial intervention and pharmacotherapy may help to reduce the readmission rate. Keywords: electroconvulsive therapy, early readmission, mental illness Introduction Electroconvulsive therapy (ECT) is a treatment for mental illness, which involves the application of electrodes to the head to induce a generalized seizure. It was introduced in the 1930s as another treatment for psychiatric illnesses when psychotherapy fails. Its introduction was rife with controversy but its conception has helped psychiatrists then and today in treating some refractory psychiatric illnesses. 1 In the past, 1
this treatment was often administered to the most severely disturbed patients residing in the large mental institutions. 2 In the mid 1950s, the use of ECT began to decline due to the discoveries of various psychotropic drugs and the stigma attached on ECT1. However, of late, the use of ECT has increased due to improved delivery method and safety. This modest resurgence was also due to the acceptance by psychiatrists that despite psychotropic medications, some illnesses remained drug refractory 3. Furthermore, the speed of action of ECT with respect to alternative treatments has become of increasing interest in the present era of managed care and the ever increasing lengths of stay in hospital 4. Electroconvulsive therapy (ECT) is highly effective for treatment of major depression, however, without active treatment, virtually all remitted patients relapse within 6 months of stopping ECT with a relapse rate of 84% 5. The Royal College of Psychiatrists fact sheet states that more than 8 out of 10 depressive patients who receive ECT responded well. 6 Similarly, for mania, ECT is associated with remission or marked clinical improvement in 80% of manic patients and it is an effective treatment for patients who responded poorly to pharmacotherapy 7. ECT has been suggested to be use in patients with severe risk of suicide 8,9. The National Institute for Clinical Excellence (NICE) 10 recommended that electroconvulsive therapy (ECT) is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially lifethreatening, in individuals with severe depressive illness, catatonia and a prolonged or severe manic episode. ECT combined with treatment with antipsychotic drugs may be considered an option for people with schizophrenia, particularly when rapid global improvement and reduction of symptoms is desired as well as for those with schizophrenia who show limited response to medication alone. 11 Financial constraints on health care and the increasing number of psychiatric patients in the last decade causes the hospitals struggle to reduce inpatients length of stay. Electroconvulsive therapy (ECT) has been widely acknowledged as an effective and appropriate acute treatment for psychiatric illnesses which fail to respond to conventional treatment 12. The prompt effectiveness of ECT shortened the duration of stay of the patients in the hospital 12. One of the major drawbacks, however, is the high relapse rate in the use of ECT5. Reported relapse rates range widely, exceeding 50% in 6 to 12 months in (acute) ECT up to 95% 13. Using adequate pharmacotherapy after index ECT relapse rates between 20% and 68% have also been reported 14. Readmission is commonly used as an outcome and quality indicator for inpatient services. 15,16 Hospital readmission, particularly when it occurs within a relatively short time after previous discharge, is often seen as a failure of the earlier hospital admission. 17 In Malaysia, early readmission (within 6 months) is used 2
as one of the two National Indicators in Psychiatry (NIP-2). 18 The main objective of this study was to determine the rate of early readmission in patients who had received ECT in psychiatric ward in University Malaya Medical Centre (UMMC) Kuala Lumpur. We also aimed to study the relation of clinical diagnosis and certain demographic factors with early readmission. Method Sample The study was conducted at the psychiatric ward of UMMC. UMMC is a teaching hospital situated in Kuala Lumpur. Its patient catchment area includes those living in Kuala Lumpur and also Petaling Jaya, Selangor. Most of these patients are urbanized, young and affluent. UMMC psychiatry department is also one of the oldest in the country and the pioneer of psychiatrist training for Malaysia. It has close to 15 consultant and specialist psychiatrists and 25 medical officers, all whom are in the postgraduate training program in psychiatry. UMMC on the average, has close to 25000 outpatient visits and 1275 inpatients a year. 19 Study..design patients who received ECT in UMMC from 1st January 2007 till 31st December 2007. ECT is conducted 3 times per week in UMMC. Decision to provide ECT treatment is made by a team of psychiatrists after discussion in the management rounds. Subjects were identified from the ECT record book. Case notes of these patients were then traced and reviewed. All patients receiving ECT during the study period were included. Subjects were then determined whether they were readmitted within 6 month after being discharged. Those who were readmitted for clinical drug trial, for maintenance electroconvulsive therapy (ECT) and forensic case were excluded. The relevant demographic and clinical data including age, race, sex and diagnosis were collected. Analysis Data were analyzed using Statistical Package for Social Sciences (SPSS) version 13.0. To test the statistical significance of difference, Chi Square test was used for categorical variables. All test of significance were two-tailed, with an alpha level of 0.10. Results A total of one hundred and fifty six cases were identified and included in the study. This is a retrospective descriptive study of 3
Sample Description Table 1: Descriptive characteristics of the subjects Characteristic (N = 156) Mean (SD) Age 40.0 (13.8) Sex n (%) Male Female 77 (49.4) 79 (50.6) Race Malay Chinese Indian Others 36 (23.1) 86 (55.1) 30 (19.2) 4 (2.6) Diagnosis Schizophrenia Bipolar Disorder Major Depressive Disorder 51 (32.7) 67 (42.9) 38 (24.4) SD = standard deviation Table 1 shows the descriptive characteristics of the 156 subjects. The average age was 40 years (range =13-78). The study group was predominantly Chinese. 49% were males and 51% of them were females. Most of the patients were admitted with a primary diagnosis of bipolar disorder. They were discharged well from the ward after completed a course of ECT. Early Readmission A total of 47 (30.1%) cases readmitted within 6 months after being discharged. Result also showed the mean duration until readmission was 5.3 months (SD = 5.7, range = 0.43 21.37). 4
Table 2 Relationship between the descriptive variables and early readmission Readmission Yes No p Descriptive Variables Age n (%) n (%) OR 95% CI value Less than 40 years 40 years and above Sex Male Female Race Malay Non Malay Diagnosis Schizophrenia Mood Disorder OR = odds ratio * p < 0.1 30 (36.6) 17 (23.0) 26 (33.8) 21 (26.6) 14 (38.9) 33 (27.5) 32 (30.5) 15 (29.4) 52 (63.4) 57 (77.0) 1.93 0.96-3.91 0.06* 51 (66.2) 59 (73.4) 1.41 0.71-2.80 0.33 22 (61.1) 87 (72.5) 1.68 0.77-3.66 0.19 74 (69.5) 36 (70.6) 1.05 0.50-2.19 0.89 Table 2 shows the Chi Square analysis of the relationship between the descriptive variables and early readmission. Younger age was the only factor significantly associated with early readmission (p < 0.1). Discussion The characteristics of the sample of current study were comparable with the previous retrospective study done in the same centre 20. The mean age of the patients in the psychiatric ward, UMMC was about 40 years old. Majority of the patients were found to be Chinese descent. This study revealed that there was not much difference between male and female subjects needing ECT who were admitted in UMMC. In contrast, study done by Bloch et al (2005), suggested that a possible gender difference in the implement of ECT treatment. Result of the study illustrated that hospitalized women were referred earlier to ECT. 21 5
Those subjects who received ECT in UMMC in this study were noted to be diagnosed mostly with bipolar mood affective disorder, followed by schizophrenia and major depressive disorder at 42.9%, 32.7% and 24.4%, respectively. When mood disorder diagnosis were summed up as a single entity i.e. both bipolar mood affective disorder and major depressive disorder, it made up 67.3% of those receiving ECT. Volpe et al (2004) suggested that manic episode usually yield severe psychological, moral and economic consequences. It causes more disruption to marital relationship and higher divorce rate. It might explain the higher rate of ECT use in bipolar patients. 22 Besides, in the same study conducted by the authors previously, UMMC has an annual admission of 1275 for which 47.6% of them were patients with mood disorders and 37.5% of them were psychosis related disorder mainly schizophrenia type. 19 The evidence for the use of ECT in mood related disorders were plenty 23,24 with even some calling for more aggressive management i.e. earlier intervention as opposed to most guideline recommendations. The evidence for the use of schizophrenia was however not as convincing. 12 The result of the current study shows that the early readmission rate in ECT patients within 6 months was 30%. It was two times higher than the readmission rate of 16% in the previous study conducted by the same authors. 20 In the previous study, the authors studied the early readmission rate of all psychiatric patients after discharged from UMMC. The higher readmission rate in ECT patients was reported in other studies. 22,23 Volpe et al (2004) found that if readmission occurred after ECT, it took place 6 months after the index episode. 22 Devanand et al (1991) reported that relapse rate following ECT are high and clustered in the first 4 months following clinical response. 23 An explanation for the higher relapse rate is related to the severity of illness in those patients underwent ECT. They usually are the more unmanageable ones with more chronic and severe illnesses. 12 For those with psychosis it may usually mean treatment refractory type. Often this group of patients did not do well with oral medication even after the ECT 5. Therefore this results them to relapse earlier. The result of current study illustrated that younger age was associated with higher early readmission. The similar finding was found in other study. 25 It might relate with higher risk of co-morbid substance abuse in younger age-group. Another possible explanation was that the levels of treatment adherence or insight had not been modified in the early stage of illness. 26 The current study found that gender, race and clinical diagnosis had no significant effect on early readmission in ECT patients. This was similar to the finding of the authors previous study. 20 Dixon et al (1997) and Lyons et al (1997) also reported that there was no significant association between socio-demographic predictors with readmission. 17,27 Limitation This is a retrospective study with small sample size. There was lack of information 6
on the psycho-social intervention and patients psychopathology during discharge. In addition, the author surmises the final finding of significant predicting variable (young age) at the p < 0.1 in Chi Square analysis represent a fairly debatable conclusion. Conclusion This study showed that 30% of patients underwent electro-convulsive therapy will be readmitted within 6 months after discharged from a psychiatric ward in UMMC. Younger age was significantly associated with higher early readmission in ECT patients. It also illustrated that gender, race and clinical diagnosis did not have significant effect on the early readmission rate. Adequate post ECT psychosocial intervention and pharmacotherapy may help to reduce the readmission rate. Acknowledgement We would like to take this opportunity to thank sister Jamilah Suleiman who was involved in data collection for the study. Reference: 1. Babigian HM, Guttmacher LB (1984). Epidemiologic considerations in electroconvulsive therapy. Archives of General Psychiatry. 41: 246-253. 2. Lalitanatpong D (2005) The use of electroconvulsive therapy and the length of stay of psychiatric inpatients a King Chulalongkorn Memorial Hospital, Thai Red Cross Society. J Med Assoc Thai 88 (Suppl 4): S142-8. 3. Thompson JW, Weiner RD, Myers CP (1994). Use of ECT in the United States in 1975, 1980, and 1986. American Journal of Psychiatry. 151: 1657-1661. 4. Beyer JL, Weiner RD, Glenn MD (1998). Electroconvulsive therapy: A programmed text. Washington: American Psychiatric Press. 5. Sackeim HA. Haskett RF. Mulsant BH. Thase ME. Mann JJ. Pettinati HM. Greenberg RM. Crowe RR. Cooper TB. Prudic J (2001) Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy: a randomized controlled trial, JAMA, 285(10):1299-307. 6. Royal College of Psychiatrists (1995) Fact sheet on ECT. London: RCP. 7. Mukherjee S. Sackeim HA. Schnur DB (1994). Electroconvulsive therapy of acute manic episodes: a review of 50 years' experience. American Journal of Psychiatry, 151(2):169-76. 8. Maris RW (2002). Suicide. Lancet, 360:319-26. 9. Tharyan P, Adams CE (2005). Electroconvulsive therapy for schizophrenia (Cochrane Review). In: The Cochrane Library, Issue 2. Oxford: Update Software. 10. National Institute for Clinical Excellence (NICE) (2005). Guidance on the use of electroconvulsive therapy. 11. Taylor MA, Fink M (2006). Melancholia: The Diagnosis, Pathophysiology, and Treatment of 7
Depressive Disorders. Cambridge, England: Cambridge University Press. 12. American Psychiatric Association (2001) Committee on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy. Recommendations for Treatment, Training and Privileging: A task force Report of The American Psychiatric Association, 2nd edition. 13. Bourgon LN, Kellner CH (2000) Relapse of depression after ECT: A review. Journal of ECT. 16(1):19-31 14. Petrides G, Dhossche D, Fink M, Francis A (1994) Continuation ECT: relapse prevention in affective disorders. Convuls Ther 10(3):189-94. 15. Jenkins R (1991) Towards a system of outcome indicators for mental health care. Jenkins R, Griffiths (eds) Indicators for mental health in the population. Department of Health, London 16. Craig TJ, Kline NS (1982) Factors associated with recividism: Implications for a community support system. Community Support Serv J 2 : 1-4 17. Lyons JS, O Mahoney MT, Miller SI, Neme J, Kabat J, Miller F (1997) Predicting readmission to the psychiatric hospital in a managed care environment: Implications for quality indicators. Am J Psychiatry 154 : 337-340 18. Malaysia National Indicator in Psychiatry (NIP-2) 19. Aida SA, Ng CG, Amer Siddiq AN (2007) Patterns of Admission in Psychiatric Ward, University Malaya Medical Centre. Presented in Young Research Award Competition at the Post Graduate Conference, Sept 2007. 20. Amer Siddiq AN, Ng C G, Aida SA, Zainal NZ, Abdul Kadir (2008) Factors Affecting Readmission in A Teaching Hospital in Malaysia. R. Australian And New Zealand Journal Of Psychiatry (2007) 41 (Suppl. 2). Malaysian Journal of Psychiatry, 2008. 21. Bloch Y, Ratzoni G, Sobol D, Mendlovic S, Gal G, Levkovitz Y (2005) Gender differences in electroconvulsive therapy: a retrospective chart review. Journal of Affective Disorders 84:99-102. 22. Volpe FM, Tavares A (2004) Manic patients receiving ECT in a Brazilian sample. Journal of Affectiv Disorders 79: 201-8. 23. Danavand DP, Sackeim HA, Prudic J (1991) Electroconvulsive therapy in the treatment resistant patient. Psychiatr Clin North Am 14(4):905-923. 24. Rose D, Fleischmann P, Wykes T, Leese M, Blindman J (2003) patients perspectives on electroconvulsive therapy: systematic review. BMJ 326:1363. 25. Sanguineti VR, Samuel SE, Schwartz SL, Robeson MR (1996) Retrospective Study of 2,200 involuntary psychiatric admissions and readmissions. Am J Psychiatry 153 : 392-396 26. Cougnard A, Parrot M, Grolleau S, Kalmi E, Desage A, Misdrahi D, Brun- Rosseau H, Verdoux H (2006) Pattern of 8
health service utilization and predictors of readmission after a first admission for psychosis: a 2 year follow up study. Acta Psychiatr Scand: 113; 340-9. 27. Dixon M, Robertson E, George M, Oyebode F (1997) Risk factors for acute psychiatric readmission. Psychiatr Bull 21 : 600-603 Correspondence: Dr Ng Chong Guan, Department of Psychological Medicine,Faculty of Medicine,University of Malaya, 50603, Kuala Lumpur. 9