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 Electroconvulsive therapy is frequently used to treat severe depression. Earlier studies examining trends in ECT prevalence over 10 or more years revealed a decline in use before the 1990s (1–3). The efficacy of ECT in older adults is well established for the treatment of severe major depression, particularly where there are concerns about severe anorexia or suicidality or where other treatments have failed; moreover, the treatment is generally safe and well tolerated (4). Older adults are generally overrepresented in use of ECT (2,5,6). Concerns about cognitive worsening in older patients following ECT or in those with dementia and depression have been unfounded, with several studies showing improved cognition associated with the mood improvement from ECT (4). The 1990s brought forth newer antidepressant agents, which were purportedly better tolerated and safer for older adults, leading to a rapid increase in antidepressant prescribing (7). Trends in ECT prevalence in the 1990s and early 2000s, however, are unknown. The present study examined temporal trends in ECT among all 12 million Ontario residents from January 1992 to December 2004 and compared the trends in older adults with those in younger adults. MethodsWe examined annual trends in ECT prevalence between January 1992 and December 2004, using linked provincial datasets. ECT prevalence was coded by examining the numbers of residents per year for whom OHIP claims for ECT were submitted. In Ontario, ECT must be performed by a physician. The OHIP database includes codes for doctors’ billings for both inpatient and outpatient procedures, including ECT. We therefore used it as the index of ECT use. Statistics Canada census data provided the number of residents in Ontario on July 1 of each year. For older subjects, we obtained data on antidepressant prevalence (numbers of older adults who received a prescription for an antidepressant per year) from the ODB database. The ODB database is used by the Ontario government to pay pharmacy claims for older adults and has very little missing information (8). The ODB database did not provide data on antidepressant prevalence among younger adults. We reported statistics descriptively and presented them graphically. The numerators of interest were the numbers of residents who had OHIP claims for ECT or ODB claims for antidepressants. Individuals who had more than one claim for ECT were counted only once. The denominators were the numbers of Ontario residents. For ECT, we converted the ratio to prevalence per 100 000 individuals; for antidepressants, we converted ratios to prevalence per 100 population. Data for ECT were presented for the population as a whole. Subsequently, trends were presented separately by age groups. We arbitrarily divided the age group of the population for each year into younger (the entire population up to age 65 years) and older (aged 65 years and older). We also examined the female-to-male subjects prevalence ratio. We used data for antidepressant prevalence in older adults over the same period as a comparator for ECT trends. ResultsOverall, rates of ECT were stable through the time period (see Figure 1). A modest increase in the use of ECT in the mid-1990s, was followed by slightly reduced ECT use by the early 2000s: Annual population rates of individuals receiving ECT increased by about 27% from 12.3 per 100 000 population in 1992 to 15.6 per 100 000 in 1997 and then decreased again to 12.5 per 100 000 by 2004. The net effect was a 1.1% overall increase over 12 years. Female subjects were more likely to be treated with ECT than were male subjects throughout the study period, with only minor fluctuations in the female-to-male ratio, ranging from 1.6:1 to 2.1:1.
The population rates of ECT were about threefold higher among older adults relative to the younger population, ranging from 9.4 to 12.7 individuals per 100 000 among those younger than age 65 years and ranging from 28.4 to 37.2 among those aged 65 years and older. In the older population, ECT dropped slightly, by 6.4% (from 34.0 to 31.8 per 100 000) over the time span, whereas ECT in younger adults increased in prevalence by 2.0% (from 9.4 to 9.6 per 100 000). Over the same time period, antidepressant use among older adults increased in prevalence by 90.1% (from 8.8 per 100 to 16.8 per 100) (see Figure 2).
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DiscussionIn Ontario, the overall prevalence of ECT since the early 1990s has been stable, with only minor variability over time. Overall rates of ECT per 100 000 population were lower from 1992 to 2004, compared with previous reports from the 1960s to the 1980s in both the Uniter States and Canada (1–3,5). However, the previous studies are not directly comparable because they employed different populations and ECT reporting methods. Despite a small overall reduction in ECT in older adults (6.4%), a minimal increase in younger adults (2.1%) and in the population as a whole (1.6%), and year-to-year variation, the prevalence and sex profile overall remained relatively stable throughout the study period. Older adults in this sample were about 3 times more likely to have ECT than were younger adults, which is consistent with some (2,5,6), but not all (1,9), earlier epidemiologic reports. The soaring prevalence of antidepressant use among older adults since the introduction of newer antidepressant agents in the 1990s is consistent with prior reports (7). ECT remains a prescribed treatment for patients, mostly for those with severe mood disorders, particularly in old age. Factors that possibly contributed to the modest reduction in ECT prevalence in older adults, as well as to the minor overall variability, include changes in the number of adult and geriatric psychiatry inpatient beds, the availability of physicians and services offering ECT, and bed closures and hospital amalgamations in the 1990s. Throughout the study period, ECT prevalence was robustly higher among older adults. The medical frailty of the population, the inability to tolerate antidepressants, the ineffectiveness of antidepressants for severe or psychotic depression, an increased willingness to agree to physician-recommended treatment, and previous effective exposure to ECT during younger adulthood may play a role in clinical decision making regarding ECT. Limitations of the present study include the absence of information about diagnosis, region, inpatient–outpatient status, and duration of ECT, as well as the lack of antidepressant prescription data for younger adults. Further, the descriptive nature of the data precludes analysis of reasons for the higher rates in older adults and the modest variability over time. Although the present study has not captured ECT performed outside OHIP-funded settings (for example, in provincial psychiatric hospitals), there is no theoretical reason to suspect that the trends in ECT prevalence in the community would differ from trends in provincial psychiatric hospital settings. Despite dramatic changes in the pharmacotherapy of depression in the 1990s, with the introduction of antidepressants that are purportedly safer and better tolerated, the overall prevalence of ECT has remained constant, with rates being much higher in the elderly. ECT clearly continues to be an essential treatment for major depression, especially for older adults. References1. Babigian HM, Guttmacher LB. Epidemiologic considerations in electroconvulsive therapy. Arch Gen Psychiatry 1984;41:246–53. 2. Thompson JW, Weiner RD, Myers CP. Use of ECT in the United States in 1975, 1980, and 1986. Am J Psychiatry 1994;151:1657–61. 3. Smith WE, Richman A. Electroconvulsive therapy: a Canadian perspective. Can J Psychiatry 1984;29:693–9. 4. van der Wurff FB, Stek ML, Hoogendijk WJ, Beekman AT. The efficacy and safety of ECT in depressed older adults: a literature review. Int J Geriatr Psychiatry 2003;18:894–904. 5. Thompson JW, Blaine JD. Use of ECT in the United States in 1975 and 1980. Am J Psychiatry 1987;144:557–62. 6. Kramer BA. Use of ECT in California, revisited: 1984–1994. J ECT 1999;15:245–51. 7. Mamdani MM, Parikh SV, Austin PC, Upshur RE. Use of antidepressants among elderly subjects: trends and contributing factors. Am J Psychiatry 2000;157:360–7. 8. Williams JI, Young W. A summary of studies on the quality of health care administrative databases in Canada. In: Naylor C, editor. Patterns of health care in Ontario. The ICES practice atlas. Ottawa (ON): Canadian Medical Association; 1996. p 339–345. 9. Rosenbach ML, Hermann RC, Dorwart RA. Use of electroconvulsive therapy in the Medicare population between 1987 and 1992. Psychiatr Serv 1997;48:1537–42. AuthorsManuscript received December 2005, revised, and accepted March 2006. 1. Staff Psychiatrist, Sunnybrook Health Sciences Centre, Toronto, Ontario; Assistant Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario. 2. Associate Professor, Faculty of Pharmacy and Medicine, University of Toronto, Toronto, Ontario; Scientist, Institute for Clinical Evaluative Sciences, Toronto, Ontario. 3. Staff Psychiatrist, Sunnybrook Health Sciences Centre, Toronto, Ontario; Professor, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario. Address for correspondence: Dr MJ Rapoport, FG37-2075 Bayview Avenue, Toronto, ON, M4N 3M5 e-mail: mark.rapoport@sunnybrook.ca
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