ORIGINAL STUDY
Electroconvulsive Therapy and Its Association With Demographic and Clinical Characteristics in Chinese Psychiatric Patients Zhi-Min Wang, MD,* Hui Zhu, MD,* Yan-Li Pan, MD,* Helen F. K. Chiu, FRCPsych,† Christoph U. Correll, MD,‡ Gabor S. Ungvari, MD,§k Kelly Y. C. Lai, MRCPsych,† Xiao-Lan Cao, MD,† Yan Li, MD,† Bao-Liang Zhong, MD,† Xiang-Yang Zhang, MD, PhD,¶ and Yu-Tao Xiang, MD, PhD# Purpose: Little is known about the frequency of electroconvulsive therapy (ECT) use in China. This study examined the frequency of ECT and its relationship with demographic and clinical characteristics in a large psychiatric institution in China. Methods: This was a retrospective chart review of all the 19,982 inpatients aged 18 to 59 years treated during the period of 8 years (2007–2013) in a tertiary psychiatric institution in Beijing. Sociodemographic and clinical data were collected from the electronic chart management system for discharged patients. Results: The frequency of ECT use was 57.7% in the whole sample, 68.4% in bipolar disorders, 66.3% in major depression, 55.2% in schizophrenia, and 28.6% in other psychiatric disorders. Patients who received ECT (ECT group) had shorter length of hospitalization compared with the non-ECT group. In multiple logistic regression analysis, ECT use was independently associated with age younger than 30 years; higher risk for suicide and aggression at time of admission; mood disorders; lower risk for falls; more treatment with antipsychotics, mood stabilizers, and antidepressants; less health insurance coverage and major medical conditions; as well as non–local residency status. Compared with 2007 (35.5%), ECT use significantly increased in the period of 2008 (49.1%) to 2013 (61.9%). All these significant correlates combined explained 20% of the variance of ECT use (P < 0.001). Conclusions: In a major psychiatric center in China, the use of ECT was much more common than the figures reported from most countries around the world. Reasons for this difference and variances in outcomes between settings with higher and lower ECT use should be studied. From the *Beijing Anding Hospital, Capital Medical University, Beijing, China; †Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Special Administrative Regions of the People’s Republic of China; ‡Division of Psychiatry Research, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, NY; §The University of Notre Dame Australia/ Marian Centre, Perth, Australia; ∥School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia; ¶Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; and #Faculty of Health Sciences, University of Macau, Macau, Special Administrative Regions of the People’s Republic of China. Received for publication May 27, 2014; accepted July 29, 2014. Reprints: Yu-Tao Xiang, MD, PhD, Department of Psychiatry, Building E-12, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macau, Special Administrative Regions of the People’s Republic of China (e‐mail: [email protected]). Conflicts of Interest and Source of Funding: Dr Correll has been a consultant and/or advisor to or has received honoraria from Bristol-Myers Squibb, Eli Lilly, Genentech, Gerson Lehrman Group, Intra-Cellular Therapies, Janssen/Johnson & Johnson, Lundbeck, MedAvante, Medscape, Otsuka, Pfizer, ProPhase, Roche, Sunovion, Supernus, and Takeda. He has received grant support from Bristol-Myers Squibb, Novo Nordisk A/S, and Otsuka. This work was supported by the Key Projects in the National Science and Technology Pillar Program during the 12th Five-Year Plan Period (no. 2012BAK16B00) and the National Natural Science Foundation of China (30800368, 81071107). The remaining authors have no conflicts of interest or financial disclosures to report. Authors Zhi-Min Wang, Hui Zhu, and Yan-Li Pan contributed equally to this article. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000181
114
www.ectjournal.com
Key Words: electroconvulsive therapy, inpatients, China, correlates (J ECT 2015;31: 114–118)
U
se of electroconvulsive therapy (ECT) for treating severe mental illness, such as depression, bipolar disorder, and schizophrenia, has been controversial. Some researchers have insisted that ECT use is associated with better symptom relief, lower treatment costs, and shorter hospital stay compared with non-ECT treatments.1,2 Others argued that, because of the risk for significant cognitive impairments, use of ECT should be strictly controlled.3 The frequency of ECT use varies widely across countries. For example, ECT use in psychiatric inpatients ranged from 0.01% in Thailand4 to 1.3% to 1.8% in Hong Kong,3 1.6% in Hungary,5 and 13.4% in India.6 Common correlates of ECT use are the diagnosis of mood disorders, severity of psychopathology, younger age (in Asia), female sex, suicide risk, and aggression.3,5,7,8 Examining the pattern of ECT use and its correlates can help one better understand its place in the therapeutic armamentarium in a given psychiatric service, region, or country. Considering that ECT use is influenced by a host of legal, social, and cultural factors,5,7 findings obtained in 1 particular sociocultural context may not be applicable to other ethnically and socioculturally distinct regions. China has a large patient population receiving ECT, but there have been very few reports about the correlates and outcomes justifying this practice. An et al9 reported that 0.5% of inpatients with schizophrenia received ECT in 1999 and that 5.6% of patients received ECT in 2008 in 1 psychiatric hospital in China. In 1999, ECT was still administered unmodified, that is, without anesthesia and muscle relaxation. It is estimated that approximately 150,000 ECT sessions are performed in China annually.10 The aim of this study was to retrospectively examine the frequency of ECT and its demographic and clinical correlates in a major psychiatric hospital in China during the period between January 2007 and October 2013.
METHODS Setting and Subjects The study was conducted in Beijing Anding Hospital, a university-affiliated teaching hospital in China. This hospital has 800 beds, receives 1100 outpatient visits daily, and serves approximately 20 million people. Patients from other parts of China also seek treatment at this hospital. An electronic chart management system (ECMS) for discharged patients aged 18 to 59 years has been available since January 2007, providing data on the patients’ basic demographic and clinical characteristics as well as drug prescriptions. In this hospital, patients aged 18 to 59 years were under the care of the Journal of ECT • Volume 31, Number 2, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 31, Number 2, June 2015
ECT in China
The more severe diagnosis was used if the patient had more than 1 diagnosis. The study protocol was approved by the Human Research and Ethics Committee of Beijing Anding Hospital, which waived the need for consent for this chart review study.
adult psychiatric service. A form designed by the Nursing Department of this hospital was used by nurses to evaluate high risk for suicide, aggression, and falls at time of admission for all inpatients, with the data being stored in the ECMS. An extensive chart review was carried out, collecting data on the basic sociodemographic characteristics and treatment modalities, including ECT and all types of psychotropic medications given during hospitalization between January 1, 2007, and October 31, 2013. The principal author (Z.M.W.) and a technician responsible for the ECMS collected the data and established a database for analyses. The International Statistical Classification of Diseases, 10th Revision diagnoses at discharge were collapsed into 4 hierarchical groups: schizophrenia or other psychotic disorders (SZ), bipolar disorders (BD), major depressive disorder (MDD), and all others.
Statistical Analysis The data were analyzed using Statistical Package for the Social Sciences 20.0 for Windows. Basic sociodemographic and clinical characteristics and the use of psychotropic medications were compared between the ECT and the non-ECT groups using independent sample t test and Mann-Whitney U test as appropriate. Length of current hospitalization between the 2 groups was compared after controlling for potentially confounding effects of variables
TABLE 1. Basic Demographic and Clinical Characteristics of the Study Sample From Beijing Anding Hospital The Whole Sample (N = 19,982)
Male Local resident Employed Married/cohabitating High risk for suicide High risk for aggression High risk for fall On SGA On FGA On benzodiazepine On mood stabilizer On antidepressant Having health insurance Primary psychiatric diagnosis Schizophrenia-spectrum disorders Bipolar disorder Major depression Others Age, y 18–29 30–44 45–59 Major medical conditions Year 2007 2008 2009 2010 2011 2012 2013 No. hospitalizations Length of current hospitalization, wk
Non-ECT Group (n = 8456)
ECT Group (n = 11,526)
Statistics
n
%
n
%
n
%
χ
df
P
9633 9614 7321 7891 2295 11,198 663 17,073 14,352 11,362 10,032 5497 9865
48.2 48.1 36.6 39.5 11.5 56.0 3.3 85.4 71.8 56.9 50.2 27.5 49.4
4138 4480 3115 3306 732 4104 450 6714 6053 4082 3568 2221 4753
48.9 53.0 36.8 39.1 8.7 48.5 5.3 79.4 71.6 48.3 42.2 26.3 56.2
5495 5134 4206 4585 1563 7094 213 10,359 8299 7280 6464 3276 5112
47.7 44.5 36.5 39.8 13.6 61.5 1.8 89.9 72.0 63.2 56.1 28.4 44.4
3.1 139.0 0.2 0.9 115.3 335.3 183.4 430.3 0.4 440.7 376.2 11.3 274.3 1145.5
1 1 1 1 1 1 1 1 1 1 1 1 1 3
0.08
Electroconvulsive Therapy and Its Association With Demographic and Clinical Characteristics in Chinese Psychiatric Patients Zhi-Min Wang, MD,* Hui Zhu, MD,* Yan-Li Pan, MD,* Helen F. K. Chiu, FRCPsych,† Christoph U. Correll, MD,‡ Gabor S. Ungvari, MD,§k Kelly Y. C. Lai, MRCPsych,† Xiao-Lan Cao, MD,† Yan Li, MD,† Bao-Liang Zhong, MD,† Xiang-Yang Zhang, MD, PhD,¶ and Yu-Tao Xiang, MD, PhD# Purpose: Little is known about the frequency of electroconvulsive therapy (ECT) use in China. This study examined the frequency of ECT and its relationship with demographic and clinical characteristics in a large psychiatric institution in China. Methods: This was a retrospective chart review of all the 19,982 inpatients aged 18 to 59 years treated during the period of 8 years (2007–2013) in a tertiary psychiatric institution in Beijing. Sociodemographic and clinical data were collected from the electronic chart management system for discharged patients. Results: The frequency of ECT use was 57.7% in the whole sample, 68.4% in bipolar disorders, 66.3% in major depression, 55.2% in schizophrenia, and 28.6% in other psychiatric disorders. Patients who received ECT (ECT group) had shorter length of hospitalization compared with the non-ECT group. In multiple logistic regression analysis, ECT use was independently associated with age younger than 30 years; higher risk for suicide and aggression at time of admission; mood disorders; lower risk for falls; more treatment with antipsychotics, mood stabilizers, and antidepressants; less health insurance coverage and major medical conditions; as well as non–local residency status. Compared with 2007 (35.5%), ECT use significantly increased in the period of 2008 (49.1%) to 2013 (61.9%). All these significant correlates combined explained 20% of the variance of ECT use (P < 0.001). Conclusions: In a major psychiatric center in China, the use of ECT was much more common than the figures reported from most countries around the world. Reasons for this difference and variances in outcomes between settings with higher and lower ECT use should be studied. From the *Beijing Anding Hospital, Capital Medical University, Beijing, China; †Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, Special Administrative Regions of the People’s Republic of China; ‡Division of Psychiatry Research, The Zucker Hillside Hospital, North Shore-Long Island Jewish Health System, Glen Oaks, NY; §The University of Notre Dame Australia/ Marian Centre, Perth, Australia; ∥School of Psychiatry and Clinical Neurosciences, University of Western Australia, Perth, Australia; ¶Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX; and #Faculty of Health Sciences, University of Macau, Macau, Special Administrative Regions of the People’s Republic of China. Received for publication May 27, 2014; accepted July 29, 2014. Reprints: Yu-Tao Xiang, MD, PhD, Department of Psychiatry, Building E-12, Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, Macau, Special Administrative Regions of the People’s Republic of China (e‐mail: [email protected]). Conflicts of Interest and Source of Funding: Dr Correll has been a consultant and/or advisor to or has received honoraria from Bristol-Myers Squibb, Eli Lilly, Genentech, Gerson Lehrman Group, Intra-Cellular Therapies, Janssen/Johnson & Johnson, Lundbeck, MedAvante, Medscape, Otsuka, Pfizer, ProPhase, Roche, Sunovion, Supernus, and Takeda. He has received grant support from Bristol-Myers Squibb, Novo Nordisk A/S, and Otsuka. This work was supported by the Key Projects in the National Science and Technology Pillar Program during the 12th Five-Year Plan Period (no. 2012BAK16B00) and the National Natural Science Foundation of China (30800368, 81071107). The remaining authors have no conflicts of interest or financial disclosures to report. Authors Zhi-Min Wang, Hui Zhu, and Yan-Li Pan contributed equally to this article. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/YCT.0000000000000181
114
www.ectjournal.com
Key Words: electroconvulsive therapy, inpatients, China, correlates (J ECT 2015;31: 114–118)
U
se of electroconvulsive therapy (ECT) for treating severe mental illness, such as depression, bipolar disorder, and schizophrenia, has been controversial. Some researchers have insisted that ECT use is associated with better symptom relief, lower treatment costs, and shorter hospital stay compared with non-ECT treatments.1,2 Others argued that, because of the risk for significant cognitive impairments, use of ECT should be strictly controlled.3 The frequency of ECT use varies widely across countries. For example, ECT use in psychiatric inpatients ranged from 0.01% in Thailand4 to 1.3% to 1.8% in Hong Kong,3 1.6% in Hungary,5 and 13.4% in India.6 Common correlates of ECT use are the diagnosis of mood disorders, severity of psychopathology, younger age (in Asia), female sex, suicide risk, and aggression.3,5,7,8 Examining the pattern of ECT use and its correlates can help one better understand its place in the therapeutic armamentarium in a given psychiatric service, region, or country. Considering that ECT use is influenced by a host of legal, social, and cultural factors,5,7 findings obtained in 1 particular sociocultural context may not be applicable to other ethnically and socioculturally distinct regions. China has a large patient population receiving ECT, but there have been very few reports about the correlates and outcomes justifying this practice. An et al9 reported that 0.5% of inpatients with schizophrenia received ECT in 1999 and that 5.6% of patients received ECT in 2008 in 1 psychiatric hospital in China. In 1999, ECT was still administered unmodified, that is, without anesthesia and muscle relaxation. It is estimated that approximately 150,000 ECT sessions are performed in China annually.10 The aim of this study was to retrospectively examine the frequency of ECT and its demographic and clinical correlates in a major psychiatric hospital in China during the period between January 2007 and October 2013.
METHODS Setting and Subjects The study was conducted in Beijing Anding Hospital, a university-affiliated teaching hospital in China. This hospital has 800 beds, receives 1100 outpatient visits daily, and serves approximately 20 million people. Patients from other parts of China also seek treatment at this hospital. An electronic chart management system (ECMS) for discharged patients aged 18 to 59 years has been available since January 2007, providing data on the patients’ basic demographic and clinical characteristics as well as drug prescriptions. In this hospital, patients aged 18 to 59 years were under the care of the Journal of ECT • Volume 31, Number 2, June 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Journal of ECT • Volume 31, Number 2, June 2015
ECT in China
The more severe diagnosis was used if the patient had more than 1 diagnosis. The study protocol was approved by the Human Research and Ethics Committee of Beijing Anding Hospital, which waived the need for consent for this chart review study.
adult psychiatric service. A form designed by the Nursing Department of this hospital was used by nurses to evaluate high risk for suicide, aggression, and falls at time of admission for all inpatients, with the data being stored in the ECMS. An extensive chart review was carried out, collecting data on the basic sociodemographic characteristics and treatment modalities, including ECT and all types of psychotropic medications given during hospitalization between January 1, 2007, and October 31, 2013. The principal author (Z.M.W.) and a technician responsible for the ECMS collected the data and established a database for analyses. The International Statistical Classification of Diseases, 10th Revision diagnoses at discharge were collapsed into 4 hierarchical groups: schizophrenia or other psychotic disorders (SZ), bipolar disorders (BD), major depressive disorder (MDD), and all others.
Statistical Analysis The data were analyzed using Statistical Package for the Social Sciences 20.0 for Windows. Basic sociodemographic and clinical characteristics and the use of psychotropic medications were compared between the ECT and the non-ECT groups using independent sample t test and Mann-Whitney U test as appropriate. Length of current hospitalization between the 2 groups was compared after controlling for potentially confounding effects of variables
TABLE 1. Basic Demographic and Clinical Characteristics of the Study Sample From Beijing Anding Hospital The Whole Sample (N = 19,982)
Male Local resident Employed Married/cohabitating High risk for suicide High risk for aggression High risk for fall On SGA On FGA On benzodiazepine On mood stabilizer On antidepressant Having health insurance Primary psychiatric diagnosis Schizophrenia-spectrum disorders Bipolar disorder Major depression Others Age, y 18–29 30–44 45–59 Major medical conditions Year 2007 2008 2009 2010 2011 2012 2013 No. hospitalizations Length of current hospitalization, wk
Non-ECT Group (n = 8456)
ECT Group (n = 11,526)
Statistics
n
%
n
%
n
%
χ
df
P
9633 9614 7321 7891 2295 11,198 663 17,073 14,352 11,362 10,032 5497 9865
48.2 48.1 36.6 39.5 11.5 56.0 3.3 85.4 71.8 56.9 50.2 27.5 49.4
4138 4480 3115 3306 732 4104 450 6714 6053 4082 3568 2221 4753
48.9 53.0 36.8 39.1 8.7 48.5 5.3 79.4 71.6 48.3 42.2 26.3 56.2
5495 5134 4206 4585 1563 7094 213 10,359 8299 7280 6464 3276 5112
47.7 44.5 36.5 39.8 13.6 61.5 1.8 89.9 72.0 63.2 56.1 28.4 44.4
3.1 139.0 0.2 0.9 115.3 335.3 183.4 430.3 0.4 440.7 376.2 11.3 274.3 1145.5
1 1 1 1 1 1 1 1 1 1 1 1 1 3
0.08
