Electroconvulsive therapy, also known as ECT or shock therapy, may serve as a cost-effective treatment for depression after two other interventions have failed, according to a University of Michigan study published May 9 this year.

ECT is a 15- to 20-minute procedure in which the patient is placed under light anesthesia and an electric stimulus is delivered to electrodes attached to the patient’s scalp. Common diagnoses treated by ECT include depression, bipolar disorder, psychosis, schizophrenia, catatonia and epilepsy. Michigan Medicine opened a new facility dedicated to ECT in 2016, which now treats about 150 to 200 patients a year, totaling about 3,000 ECT procedures annually, said Daniel Maixner, a psychiatry associate professor and co-author of the study.

Maixner administers ECT to patients ranging from their teens to nearly 100 years old. He said ECT often yields positive results in severely depressed patients because, simply put, the procedure “resets” neural pathways by causing between 20 and 60 seconds of hyperactivity in the brain.

“It’s not really rewiring, but it could be calming circuits that are stuck on,” Maixner said. “There’s some evidence that the circuitry gets stuck with depression, and patients describe it that way too.”

Psychiatry associate professor Neera Ghaziuddin, who also administers ECT, said electrical stimulation can alter many of the different physiological pathways associated with depression. The procedure normalizes the hypothalamic pituitary adrenal access, which controls stress response, and regulates the release of neurotransmitters. In addition, ECT thickens the linings of blood cells, increases blood infusion to the brain, ups the production of proteins that affect neurons and controls the transcription of genes involved in depression. According to Ghaziuddin, ECT treats depression through more mechanisms than antidepressant medication.

Physicians recommend ECT to depressed patients based on two main factors, resistance to treatment and severity of illness, where severity generally takes precedence. Maixner said like any treatment, ECT becomes less effective the longer a patient has been suffering. In the study published May 9, Maixner and his colleagues investigated when in the course of a patient’s illness ECT should be considered. The team used an analytic model to perform a cost-benefit analysis of ECT, considering the quality-adjusted life-years, or relatively happy and healthy years, that patients gain from the procedure.

The algorithm, called a deterministic state transition model, used data sourced from medical literature to simulate treatment outcomes for a theoretical group of patients with depression. The researchers were able to change when ECT was administered to the patients and compared the costs of different outcomes. In the simulation, patients received eight ECT sessions during the first month and 16 sessions over each subsequent year. ECT cost $586 per session.

According to the results of the study, ECT costs about $54,000 per quality-adjusted life-year gained when used as a third-line treatment, meaning after two other treatments have failed. The researchers accepted any amount equal to or less than $100,000 per quality-adjusted life-year as cost-effective.

Kara Zivin, an associate professor in the School of Public Health and another co-author of the study, defined cost-effectiveness as a ratio between cost and benefit. She said “cost-effective” is always a relative term used to compare treatments. Though generic antidepressants can be very inexpensive, for instance, they may not be as successful as ECT, which might cost more.

“There are a lot of interventions that we have that may not necessarily be that expensive, but they provide very little benefit, so it actually makes their cost-effectiveness ratios look bad,” Zivin said.

Though Maixner was pleased ECT qualified as a cost-effective third-line treatment, he said the results don’t mean every patient who has two antidepressant failures should automatically get ECT. Depression ranges in severity and each patient has different needs, so Maixner said ECT should always be considered on a case-by-case basis.

“We’re not saying that, 'Hey, everybody should get treatment after two med failures,'" Maixner said. “If the patient’s very sick, they’ve failed a few meds and they’re not getting better, or they’re dangerously ill, all these things – then in the right patient, earlier might be a better choice, especially if you’re thinking about cost.”

Zivin said the results raise interesting clinical questions as to how frequently ECT should be prescribed. There are side effects patients need to consider, but on the other hand, Zivin said, ECT often has very positive results for seriously depressed patients.

“It’s not without some very substantial risks or concerns,” Zivin said. “The impact on memory is something that people are concerned about, and there’s no guarantee how anyone’s going to respond. There are also some people who suffer for very long periods of time quite severely, where it seems that nothing is going to work, and this really can be a life-saver for them.”

According to the authors of the study, ECT has some issues with its public image. Maixner said he and other psychiatrists have to deal with a persisting stigma surrounding ECT. Not only is the treatment often called “shock therapy,” a name Maixner said might seem alarming, but movies like “One Flew Over the Cuckoo's Nest” portray ECT as a dangerous, easily abused tool.

“Hollywood loves to play up the role of ECT as a harsh treatment, something to control somebody,” Maixner said. “In general, people don’t understand it, and I think the whole term is still scary.”

Ghaziuddin thinks distrust of ECT makes some of her first-time patients more worried about the effects of the procedure. She said negative portrayals of ECT began about two decades after its invention in 1938 for several different reasons.

“When ECT first came into existence, I would say for the first 20 years or so there was very little stigma, and then due to a variety of reasons that stigma became more pronounced,” Ghaziuddin said. “There was the anti-psychiatry movement in the ’60s and ’70s. There was (sic) rights of patients – that somehow rights of patients are being violated, because a lot of people who receive ECT may not be able to give permission or consent. There was the issue of anesthesia not being as good as it is today.”

In the procedure’s early years, from its first use in 1938 until the 1960s, machines were less advanced and the anesthesia and muscle relaxants now administered to ECT patients were not as available. Maixner said many medical treatments, like surgery and chemotherapy, were also uglier in the past, but psychiatric treatments often pick up the most stigma and fear. ECT has been well-established since the 1960s, he added, and should be thought of as a refined treatment.

The largest issue both Maixner and Ghaziuddin identify is a lack of familiarity, among patients and doctors alike, with what ECT actually entails.

“Once they are exposed to ECT, once they see the procedure and learn more about it, the stigma goes away,” Ghaziuddin said. “It’s a very well-regulated procedure, there’s nothing dramatic about it. People who have never seen ECT, they have some fantasy that it’s a very big deal.”

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