1. Equal Access to ECT Hampered by Income and Attitudes Patricia Bradley RN PhD Jhansi Raj MD

2. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Patricia J. Bradley Retiree Research Grant Awarded by Texas Christian University for the purpose of presenting this research.

3. Social Justice Mandates Equal Access to Mental Health Services But Access to ECT is Hampered by Income, Attitudes and Availability

4. The Efficacy of ECT Most effective treatment for bipolar depression and major depression, especially if medications ineffective. Most effective treatment for bipolar depression and major depression, especially if medications ineffective. Meta-analysis revealed ECT is 4 times as likely to produce a response over anti-depressants (Pagnin, de Queiroz, Peni, & Cassano, 2004). Meta-analysis revealed ECT is 4 times as likely to produce a response over anti-depressants (Pagnin, de Queiroz, Peni, & Cassano, 2004). Treatment of bipolar mania Treatment of bipolar mania Among 11 randomized clinical trials the response rate to ECT ranged from 33.33% to 100% (Pagnin, de Queiroz, Peni, & Cassano, 2004). Among 11 randomized clinical trials the response rate to ECT ranged from 33.33% to 100% (Pagnin, de Queiroz, Peni, & Cassano, 2004). The cost is less than rehospitalization The cost is less than rehospitalization

5. Availability of ECT Only 21 treatment centers in Texas Only 21 treatment centers in Texas 6 in the Metroplex 6 in the Metroplex 1 in Fort Worth 1 in Fort Worth Reimbursement for ECT is very low so many psychiatrists do not use ECT Reimbursement for ECT is very low so many psychiatrists do not use ECT Outpatient ECT is not reimbursed by Medicaid Outpatient ECT is not reimbursed by Medicaid Less than 8% of psychiatrists nation-wide use ECT (Koran, 1996) Less than 8% of psychiatrists nation-wide use ECT (Koran, 1996)

6. How is ECT Performed? Initially several times weekly, then weekly for a Initially several times weekly, then weekly for a total of 6-14 times If maintenance is needed done every 4-12 weeks If maintenance is needed done every 4-12 weeks Pretreatment procedures Pretreatment procedures Complete History and Physical Complete History and Physical EKG, EEG, lab tests EKG, EEG, lab tests Hold anti-seizure meds Hold anti-seizure meds Atropine 0.6 mg IM Atropine 0.6 mg IM Start IV Start IV The treatment itself The treatment itself Baseline EEG, EKG Baseline EEG, EKG BP, P and oxygen saturation monitored BP, P and oxygen saturation monitored Bite block inserted, !00% Oxygen Bite block inserted, !00% Oxygen IV anesthesia IV anesthesia Paddle placement either unilateral or bilateral Paddle placement either unilateral or bilateral Grand-mal seizure induced Grand-mal seizure induced Post treatment monitoring Post treatment monitoring

7. Possible Side Effects from ECT Headaches Headaches Muscle Soreness Muscle Soreness Memory Loss Memory Loss Less with Unilateral ECT than Bilateral ECT (Fraser, O’Carroll & Ebmeier, 2008) Less with Unilateral ECT than Bilateral ECT (Fraser, O’Carroll & Ebmeier, 2008)

8. ECT – A Miracle for Me Diagnosed 12 years ago as Bipolar Diagnosed 12 years ago as Bipolar Medication management effective for 8 years Medication management effective for 8 years Then depression set in on recurrent basis Then depression set in on recurrent basis Final depressive episode Final depressive episode The MIRACLE after 3 ECT treatments The MIRACLE after 3 ECT treatments

9. In the 6 DFW ECT treatment centers, 450 people received ECT in 2008: Received ECT ECT delivered in DFW ECT delivered in DFW Based on Race Fort Worth Demographics White95.1%63% African American 3.0%18% Hispanic1.8%33.8%

10. Utilization Rates No ECT available 115 of 317 metropolitan areas No ECT available 115 of 317 metropolitan areas Variation in ECT ranges from 0.4 - 81.2 per 10,000 population. Variation in ECT ranges from 0.4 - 81.2 per 10,000 population. Strongest predictors of ECT use were number of psychiatrists, number of primary care physicians, number of private hospital beds per capita and stringency of state regulations for ECT. (Hermann, Dorwart, Hoover & Brody, 1995) Strongest predictors of ECT use were number of psychiatrists, number of primary care physicians, number of private hospital beds per capita and stringency of state regulations for ECT. (Hermann, Dorwart, Hoover & Brody, 1995)

11. Why ECT Is Not More Widely Used Cost Cost Attitudes towards ECT Attitudes towards ECT Held by the public Held by the public Held by professionals Held by professionals Portrayed in Media Portrayed in Media Poor referral rate from Poor referral rate from psychiatrists psychiatrists

12. The benefit outweighs the cost The lifetime suicide rate for: The lifetime suicide rate for: Bipolar patients = 20% Bipolar patients = 20% Major depression patients = 9% (America’s Mental Health Channel, 2010) Major depression patients = 9% (America’s Mental Health Channel, 2010) Depression is leading cause of disability (Mark, Shern, Bagalman & Cao, 2007) 2007 ) Depression is leading cause of disability (Mark, Shern, Bagalman & Cao, 2007) 2007 ) ECT offers opportunity to: ECT offers opportunity to: Improve quality of life Improve quality of life Decrease suicide ideation Decrease suicide ideation Decrease need for many medications Decrease need for many medications Increase ability to maintain employment Increase ability to maintain employment Avoid rehospitalization and its costs Avoid rehospitalization and its costs

13. How can access to ECT be promoted? Changes in education for nurses, physicians, and counselors Changes in education for nurses, physicians, and counselors Changes in attitude towards ECT Changes in attitude towards ECT Promotion of adequate Medicaid reimbursement for psychiatrists Promotion of adequate Medicaid reimbursement for psychiatrists Higher reimbursement rates from all insurers for psychiatrists performing ECT Higher reimbursement rates from all insurers for psychiatrists performing ECT Increased publicity about ECT Increased publicity about ECT Patients and Psychiatrists Patients and Psychiatrists must stand up and share must stand up and share their experiences!!!

14. Lives Will Be Saved If ECT Can Be Made Accessable

16. References Fraser, L. M., O’Carroll, R. E.,& Ebmeier, K. P., (2008), The effect of electroconvulsive therapy on autobiographical memory: A systematic review. Journal of ECT, 24:1, 10- 17. Hermann, R. C., Darwart, R.A. Hoover, C. W. & Brody, J. (1995). Variation in ECT use in the United Stares. American Journal of Psychiatry, 152:6, 869-875. Koran, L.M. (1996). Electroconvulsive therapy. Psychiatric Services, 7 (1), 23. Mark, Tll L.,, Shern, D.L., Bagalman, J. E. & Cao, Z. (2007), Ranking America’s mental health: An analysis of depression across the states. Mental Health America, p. 1-50. Pagnin, D, de Queiroz, V., Peni, S., & Cassano, G. B. (2004). Efficacy of ECT in depression: A meta-analytic review. Journal of ECT, 20 (1), 13-20. depression: A meta-analytic review. Journal of ECT, 20 (1), 13-20. US DHEW Medical Practice Project (1979). A State of the Service Report for the Office of the Assistant Secretary for the US Dept of Health, Education and Welfare. In: Policy Research, Author. Retrieved from http://www.mentalhealth.com/rx2/bp-Can1.html#Head_1 http://www.mentalhealth.com/rx2/bp-