Electroconvulsive Therapy in the Treatment of Depression: The Impact on Length of Stay Keith G. Wilson, Neil J. Kraitberg, James H. Brown, and James N. Bergman It has been reported that one advantage to administering electroconvulsive therapy (ECT) for the treatment of depression is that it results in shorter hospitalizations than alternative treatments. The generality of this finding was assessed in the present study, which comprised a retrospective review of 192 admissions for depression. It was found that the prompt initial decision to administer ECT did not reduce the overall length of hospital stays. In fact, patients who were discharged after an initial medication trial actually had shorter admissions than patients treated promptly with ECT. Nevertheless, one subgroup of patients-those who were started on medications, but who were later switched to ECT-had very long admissions. Whether the prompt initiation of ECT will reduce the average length of stay at any individual institution may depend on the numbers of patients who fall into this latter category. This number, in turn, appears to vary widely across institutions. Copyright 0 1991 by W.B. Saunders Company
A
LTHOUGH electroconvulsive therapy (ECT) for the treatment of depression is widely regarded as being both efficacious and safe, it still tends to be held back as a treatment of last resort. However, it has been suggested recently that psychiatrists should consider the use of ECT more readily. This suggestion has been supported by several converging lines of research. First, some studies that have compared ECT with other common inpatient treatments for depression have found that ECT results in better clinical outcomes.‘-4 As Rifkin’ has noted, the controlled research in this area suffers from a range of methodological problems that undermine the general strength of this conclusion. Nevertheless, based on a meta-analysis of the available evidence, Janicak et aI6 have concluded that ECT produces better clinical results than antidepressant medications. Second, there is a growing body of literature addressed to the specific problem of side effects-especially memory impairments-which indicates that complications are relatively uncommon.7*8 Because the prospect of irreversible cognitive impairment represents one of the primary objections of the general public to the use of ECT, this body of research is relevant to considerations of the social acceptability of the treatment. Finally, it has been reported that ECT reduces the overall length of hospitalization for depression.299-” Markowitz et al.” found that patients who were treated promptly with ECT stayed an average of 13 fewer hospital days relative to patients who were started on a course of tricyclic antidepressants. This finding is particularly important for two reasons. Not only does it indicate that ECT relieves the patient’s suffering more quickly, thus promoting an early return to family and community, it also suggests that ECT will considerably reduce the costs of
From the Department of Psychiatry University of Manitoba, Health Sciences Centre, Winnipeg; and Grace Hospital, Uknipeg, Canada. Address reprint requests to Keith G. Wilson, Ph.D., Department of Psychology, The Rehabilitation Centre, 505 Smyth Rd, Ottawa, Ontario, Canada, KIH 8M2. Copyright 0 1991 by W.B. Saunders Company 0010-440X/91/3204-0010$03.00/0 Comprehensive
Psychiatry, Vol. 32, No. 4 (July/August),
1991: pp 345354
345
346
WILSON
ET AL
hospitalization for episodes of depression. In the study by Markowitz et al., the reduction amounted to over $6,400 (US) per patient. Unfortunately, the finding that ECT is associated with reduced length of hospital stays is by no means a universal one, and the relevant literature contains both confirming and conflicting results. Confirming findings have been reported by the British Medical Research Council’ and by Avery and Winokur.” The latter investigators reviewed the charts of 609 psychiatric inpatients who had been admitted to the University of Iowa Psychopathic Hospital from 1959 to 1969. They concluded that “it is well documented that ECT significantly shortens the duration of hospitalization of depressed patients compared to conservative treatment” (p. 520). Black et a1.,12on the other hand, reviewed 1,495 charts from the same locale for the period 1970 to 1982, and found longer hospital stays for patients treated with ECT-a finding that has also been reported by other investigators.‘3.14 In summary, then, the impact of ECT on the duration of hospital admissions remains unclear. The issue is a significant one, because if considerations regarding efficacy and safety are generally comparable across treatment modalities, then cost-effectiveness becomes an increasingly appropriate factor on which to base clinical decisions. However, the available studies that address this issue show wide discrepancies, which may be due to a combination of methodological inconsistencies and specific institutional factors that govern local admission and discharge policies. The present study represents an attempt to clarify these discrepancies. Specifically, the study comprises a retrospective chart review, which examines the impact on length of stay of the clinical decision to treat depressed patients with either ECT or antidepressant medications. In particular, the study attempts to identify those factors that should be considered at any individual institution before assuming that ECT will necessarily shorten the duration of hospitalizations. METHOD Setting The study was conducted using patient records from the Department of Psychiatry of the Health Sciences Centre (HSC), Winnipeg. The HSC is an l,lOO-bed teaching hospital, and it is the major tertiary care facility in the province of Manitoba. The hospital is situated physically in the city’s core area, and the patient population comes largely from the lower socioeconomic classes. The province provides universal medical care at no direct cost to the patient, including coverage for hospital stays. Although there is no fixed maximum length of stay, the duration of hospitalization tends to be monitored closely in the interest of cost-containment. The basic philosophy of care emphasizes symptomatic stabilization on the inpatient units, with discharge to outpatient treatment as soon as possible. For 1987 (the most recent year in the study period), the average length of stay across all patients was 33.4 days. Most individuals return to their residences, although discharge to personal-care homes or supervised transitional-living programs is undertaken when necessary. Transfer to a longer-stay psychiatric institution occurs rarely, and not at all among the group of patients who were selected for the present study.
Subjects A computerized file containing demographic, diagnostic, and treatment information is kept routinely on each patient who is admitted. For the present purpose, the computer archives were scanned to identify all patient discharges occurring between December 1, 1982 and January 31, 1988.
ECT AND LENGTH OF STAY
347
During this time, diagnostic information was obtained for all patients according to criteria outlined in DSM-III of the American Psychiatric Association.” All records for adult inpatients that indicated a primary diagnosis of major depressive episode (DSM-III codes 296.2.296.3) were selected for further review. This initial listing included 338 patients. The hospital chart of each individual was then reviewed in detail in order to exclude patients with very short admissions (< 1 week, cf. Markowitz et al.“‘); patients discharged against medical advice; patients whose hospitalizations were extended because of placement problems; and those whose treatments were complicated by coexisting medical disorders. Of the remaining patients, only 13 were found to have received neither ECT nor any specific antidepressant medication. In the interest of maintaining a homogeneous sample, these patients were also excluded from further analyses. The final study group consisted of 192 patients (74 men, 118 women), ranging in age from 18 to 78 years (mean. 43.2).
Procedure Because some individuals had multiple hospitalizations during the study period, the following criteria were used to select an index admission: (1) if a patient had only a single admission, then that admission was used; (2) if a patient had more than one admission, each involving ECT, then the first admission was used; (3) if a patient had more than one admission, none of which involved ECT, then the first admission was used; (4) if a patient had more than one admission, any of which involved ECT, then the first admission during which the patient received ECT was used. This latter criterion was adopted because there were fewer ECT than non-ECT admissions, and thus it served to maximize the sample size for the ECT group. The chart notes and discharge summaries for each eligible admission were then reviewed to obtain the following information: demographic characteristics, symptom profiles, treatment information. outcome, and length of stay. Wherever possible, scoring pertained to direct objective referents in the charts. For example, in order for symptom ratings to be coded as “definitely present,” it was required that a symptom be mentioned explicitly in the notes. The presence/absence of (1) concern regarding physical health, (2) pronounced weight loss, (3) delusions, (4) hallucinations, (5) psychomotor agitation, (6) psychomotor retardation, and (7) overt suicidal comments or actions, were all coded separately. Clinical outcomes were judged by one of two raters, based on reviews of discharge summaries and physicians’ and nurses’ progress notes for the last week of treatment. Outcomes were scored according to criteria reported by Black et aLI2Specifically, treatment outcome for each patient was assessed using the following scale: 1, unimproved or worse; 2, partially improved (mildly or modestly improved, but still exhibiting one or more depressive symptoms at discharge); 3. improved (reported as having good, moderate, or fair response, or judged to have been globally improved with no persistent signs of depression); 4. marked improvement (patient is entirely well, recovered, or “back to usual self,” or the notes indicate that no depressive symptoms remain at any time). Each rater reviewed a randomly selected series of charts. They overlapped in their reviews of a sample of 50 cases. For these patients, the interrater reliability for the outcome scores was r = .82.
Data Analysis The data were analyzed in two ways. For the first analysis, each patient was assigned to one of two groups-medication therapy or ECT-based on the initial treatment approach that had been used with that patient. The decision to treat an individual with either drugs or ECT was the responsibility of the attending psychiatrist. Although there was undoubtedly some variability in treatment preferences across different psychiatrists, the general emphasis of the inpatient service is on the application of somatic therapies. ECT is well accepted in this context. However, regardless of the primary focus of treatment, individual counseling and occupational therapy are offered routinely to most patients, and marital and family therapy are introduced as needed. The psychiatrist’s initial treatment decision was viewed as a binary one involving either the prompt administration of ECT (after an appropriate assessment and work-up) or the initiation/continuation of a course of antidepressant medications. In fact, substantial proportions of the patients in both groups were already in active treatment with antidepressant medications at the time of their index admissions (47.7% and 66.9% for the ECT and medication groups, respectively). However, patients who were already in treatment at the time of admission did not differ from those who were not in treatment in
348
WILSON
ET AL
either length of stay or clinical outcomes. Hence, treatment status before admission was not considered further. For the second analysis, the group of patients who were started initially on antidepressants was divided into two subgroups. One subgroup comprised those patients who eventually received a change of treatment and were switched to ECT. The other subgroup consisted of those patients who remained on antidepressant medications throughout the course of their hospitalizations.
RESULTS Initial Treatment Decision: ECT Versus Antidepressant Medications
Forty-four patients (22.9%) received ECT as their primary initial treatment. Of these, 29 (65.9%) received unilateral ECT treatments, five (11.4%) received bilateral, and 10 (22.7%) received a mixed series. Sine-wave stimulation was used in each case. Typically, the treatments were adminstered by psychiatric residents who had been trained under the supervision of staff psychiatrists. Most treatments were initiated after a short work-up period (6.2 days, on average). The average number of ECT administrations was 9.1 (range, 2 to 22). They were usually given three times a week, although this was variable on the basis of individual tolerance. On occasion, treatments were interrupted in order to monitor the stability of a patient’s recovery, with a subsequent resumption of ECT if indicated. One hundred forty-eight patients (77.1%) were started initially on a trial of antidepressants. A variety of specific medications were prescribed. The most frequently administered antidepressant was amitryptiline, which was given to 39 patients. This was followed by imipramine (30 patients), desipramine (22 patients), doxepin (17 patients), clomipramine (13 patients), trazodone (nine patients), ludiomil (seven patients), trimipramine and amoxapine (three patients each), phenelzine and tranylcypromine (two patients each), and nomifensine (one patient). It should be noted that few of the patients were treated “cleanly,” in the sense of receiving only ECT or a specific antidepressant drug. In fact, a majority of the patients receiving ECT (25/44, or 56.8%) were also given an antidepressant. Similarly, benzodiazepines and neuroleptics were commonly prescribed for both groups. Minor tranquilizers were administered occasionally with 63.6% and 55.4% of the ECT and medication groups, respectively. These proportions were not significantly different (x’(1) < 1). However, more patients in the ECT group (31/44, or 70.5%) than in the medications group (76/148, or 51.4%) were given neuroleptics (x’ (1) = 4.3; P = .04). The two groups were also compared on demographic characteristics, symptoms, and clinical findings. The 44 patients who were given ECT as their primary treatment and the 148 patients who were given antidepressants did not differ significantly in age or sex. However, the patients who received primary ECT were more likely to have undergone treatment with ECT in the past (x’ (1) = 8.2; P = .004). They also had a greater number of previous hospitalizations, on average (mean, 2.5 and 1.5 for ECT and medications groups, respectively; t(190) = 2.15; P = .03). The two groups differed reliably on only one of seven individual symptoms that were scored from the charts. More patients who were given medication treatment were noted to have been overtly suicidal (x’(l) = 4.4; P = .04).
ECT AND LENGTH OF STAY
349
The major dependent variables of interest were clinical outcomes and length of stay. It was found that patients who received prompt treatment with ECT received significantly higher outcome ratings (mean, 2.98) than patients who were started on medication therapy (mean, 2.66; t(190) = 2.34; P = .02). Thirty (68.2%) of the patients who received a prompt course of ECT were rated as being either “improved” or “markedly improved,” as compared with 80 (54.1%) patients who were started on antidepressants. However, the two groups did not differ in length of stay (mean, 42.0 and 37.9 days for the ECT and medication groups, respectively; t(190) < 1). Effects of Changing Patients From Medication to ECT The first analysis indicates that the psychiatrists’ initial binary treatment decision-to intervene with ECT or medications-is not in itself associated with systematic differences in the length of hospitalizations. However, it should be noted that the initial treatment decision is not necessarily the final treatment decision. In fact, many patients who are started on antidepressants ultimately require a switch to ECT because of a lack of improvement, or because of other clinical considerations. In the present sample, 28 of 148 patients (18.9%) fell into this category. For the second set of analyses, then, comparisons were made between three groups of patients: (1) those who received prompt ECT (N = 44); (2) those who received only medications throughout the course of their admissions (N = 120); and (3) those who received ECT after a trial of antidepressants (N = 28). Summaries of the demographic, clinical, and outcome data for each of the three groups are presented in Table 1. One-way analyses of variance Table 1. Demographic,
Clinical, and Outcome Characteristics ECT as Primary Initial Treatment (N = 44)
Age (mean in years)
45.8” (15.6) Male (%) 29.5 Female (%) 70.5 Symptoms (% of patients with symptom present) Concern about physical status 52.3 Starvation/pronounced weight loss 15.9 Delusions 34.1 Hallucinations 22.7 Psychomotor agitation 20.5 Psychomotor retardation 25.0 Overtly suicidal 40.9 Total no. of symptoms 2.11 (1.37) Length of stay (mean in days) 42.0 (24.2) Outcome (mean) 2.98” (0.85)
of Three Patient Groups
Medications Only (N = 120)
ECT After Medications (N = 28)
40.3 (14.8) 43.3 56.7
51.7” (17.2) 32.1 67.9
41.7
60.7
22.5 21.7 14.2 16.7 20.0 60.8 1.97 (1.04) 29.1” (19.6) 2.60b (0.80)
NOTE. Table entries that have different superscripts are significantly Standard deviations, where applicable, are presented in parentheses.
46.4” 32.1 14.3 32.1 32.1 50.0 2.68” (1.16) 75.4b (65.5) (Z;” different at P < .05.
350
WILSON
ET AL
(ANOVA) were used to compare the groups on continuous variables, using the Newman-Keuls procedure for post-hoc pairwise contrasts. As shown in Table 1, patients who were switched to ECT after an initial medication trial were significantly older than patients who only received medications throughout the course of their admissions (F (2,189) = 7.15, P < .OOl), although they were comparable in age to patients who received an early course of ECT. They also had a greater number of symptoms than patients in either of the other two groups (F (2,189) = 4.33, P < .Ol). However, only one of the individual symptoms-pronounced starvation or weight loss-was found to be significantly more prevalent (x2 (2) = 9.30, P < .Ol). As in the first set of analyses, there was a significant difference between the groups on the outcome ratings (F(2,189) = 4.28; P = .02). In post-hoc comparisons, patients who received prompt ECT received higher outcome ratings (indicative of b etter outcomes) than patients who were treated with medications only. Those patients who received ECT after an initial trial of antidepressants occupied an intermediate position, and were not significantly different than patients in either of the other two groups. In contrast to the two-group comparison, the ANOVA comparing length of stay among the three groups was highly significant (F(2,189) = 24.86; P < .OOl), with all three groups differing from one another. Patients receiving only medications had the shortest hospitalizations, followed by those who received a prompt initial course of ECT. Patients who required ECT after a trial of antidepressants clearly had very long hospital stays, which amounted numerically to summing the separate average durations for admissions involving medication only and prompt ECT. Psychotic and Nonpsychotic Patients
The foregoing anaIyses provide no support for the hypothesis that the prompt initiation of ECT will reduce the duration of hospitalizations for depression. However, it should be noted that the diagnosis of depression that was used for these analyses was based on global DSM-III criteria, without regard to particular clinical features. In fact, the ECT-treated patients had histories of more frequent psychiatric admissions, and they were more likely to receive concurrent treatment with neuroleptics. Hence, the initial decision to administer ECT may have been influenced by the overall severity of the depressive syndrome, or by the presence of psychotic features. These factors, in turn, may have affected treatment durations and length of stay. In order to examine this potential confound, a series of reanalyses was undertaken in which patients were divided into subgroups based on the presence or absence of psychotic features. Patients who were noted to have experienced delusions or hallucinations (64/192, or 33.3%) were classified as suffering from psychotic depressions, while the remainder were classified as having nonpsychotic depressions. The data for outcome and length of stay were then reanalyzed as 2 X 2 (psychotic v nonpsychotic x prompt ECT v medications) ANOVAs. The mean values are presented in Table 2. The most salient feature of the reanalysis was the extent to which the original findings were replicable for both psychotic and nonpsychotic patients. When the
351
ECT AND LENGTH OF STAY
Table 2. Mean Outcome Ratings and Length of Stay for Patients With Psychotic or Nonpsychotic Depressions
ECT as Primary Initial Treatment Psychotic No. of patients Outcome Length of stay (d) Nonpsychotic No. of patients Outcome Length of stay (d)
Medications as Primary Initial Treatment
Medications Only
ECT After Medications
19 3.11 (0.74) 41.0 (29.0)
45 2.76 (0.83) 33.9 (20.9)
36 2.75 (0.87) 27.4 (13.7)
9 2.78 (0.67) 59.8 (25.1)
25 2.88 (0.93) 42.7 (20.5)
103 2.61 (0.77) 39.6 (43.2)
84 2.54 (0.77) 29.8 (21.6)
19 2.94 (0.71) 82.7 (77.4)
NOTE. The “medications-only” group comprises that subset of patients receiving medications as a primary initial treatment who were discharged after the antidepressant trial (i.e., they did not go on to receive ECT). Standard deviations are presented in parentheses.
initial treatment decision was examined, the outcome data showed only a significant main effect of treatment type (F(1,188) = 4.70, P = .03). This confirmed that patients treated promptly with ECT were discharged at a better level of improvement, regardless of their diagnostic subtype. Length of stay, on the other hand, did not differ as a function of either diagnostic status or method of initial intervention (P > .lO). As before, however, the medication-treated group included patients who were eventually switched to ECT at a later point in their admissions. When these individuals were removed from the analysis (because only nine psychotic patients were switched to ECT after a medication trial, they were not included as a separate subgroup in the statistical comparisons), the administration of ECT still resulted in better outcomes at the point of discharge (F(1,160) = 5.81, P = .02). However, it was also evident that ECT resulted in admissions that were significantly longer than those of medication-treated patients (F(1,160) = 12.40, P = .OOl). These findings were consistent for both psychotic and nonpsychotic patients; no main effects or interactions involving diagnostic group status approached statistical significance (all Pvalues > .lO). DISCUSSION
In the present study, the use of ECT as the primary initial treatment for depression was not associated with a shorter length of hospitalization, even for patients who presented with psychotic features. This finding represents a failure to confirm the results presented by Markowitz et al.” However, close examination of the relevant data from the two studies shows an interesting pattern of similarities and differences. As is evident in Table 3, the average length of hospitalization for the groups who received ECT as a primary treatment and those who received ECT after a trial of antidepressants are similar across both studies. Hence, while it can be argued that shorter ECT admissions might be achieved with
352
WILSON
ET AL
Table 3. Mean Length of Hospital Stays (Days) Group ECT as primary initial treatment Medications as primary initial treatment Medications only ECT after medications
Markowitz et al.
Present Study
41.4 (N = 19) 54.6 (N = 55) 37.5 (N = 27) 71.0 (N = 28)
42.0 (N = 44) 37.9 (N = 148) 29.1 (N = 120) 75.4 (N = 28)
NOTE. Patients in the “medications only” and “ECT after medications” groups are subsets of the larger group, “medications as primary initial treatment.”
faster work-ups, alternative modes of administration (i.e., brief-pulse rather than sine-wave stimulation), and a shorter period of monitoring following treatment, it is unlikely that the present findings reflect unusually long hospitalizations for ECT at our institution. On the other hand, there are two areas in which the studies diverge. The first is in the duration of hospitalization for patients who are given antidepressants only, which is shorter by about 8 days at our hospital. The second area of divergence lies in the proportions of patients who were treated with medications initially, but who eventually received ECT at a later time in their admissions. These patients have very long hospital stays. Markowitz et al. found that 50.9% their medicationtreated patients fell into this category, compared with only 18.9% of the patients in the present sample. Thus, whether the initial decision to treat with medications results in longer admissions overall depends to a large extent on the number of patients falling into this subgroup with long hospitalizations-a number that clearly varies considerably across settings. This analysis also helps to explain some of the apparent discrepancies across other studies that have examined the impact of ECT on length of stay. Specifically, most studies that have found ECT to be associated with long hospitalizations have failed to distinguish patients who received ECT after a medication trial from patients who received ECT early in the course of their admissions (i.e., combining all patients who received ECT at any time into one group for comparison purposes; cf references 12-14). Studies that have reported short admissions with ECT, on the other hand, have examined the effects of a promptly-administered course of treatment (cf. references 2,9,10,11). However, even with prompt ECT, the present results indicate that shorter hospitalizations are not an inevitable outcome. These findings show limitations in the use of length of stay in cross-center comparisons. To a large extent, length of stay will be influenced by specific institutional policies regarding admission and discharge decisions. Whereas some centers may be able to keep patients in hospital until their depressions have largely remitted, other institutions tend, because of bed shortages and other local pressures, to discharge patients to outpatient care as soon as it is safe to do so. At the HSC, patients who begin to respond to antidepressant medications are likely to be discharged for follow-up when they have only partially improved. Patients
ECT AND LENGTH OF STAY
353
who are given ECT, on the other hand, will be kept in hospital until the course of treatment is regarded as completed. Hence, the present study demonstrates that the more frequent and prompt use of ECT will not necessarily reduce the cost of hospitalization at any given institution. This will depend on (1) the average length of stay for the comparison group-patients who are treated with medications, and (2) the proportion of patients who are switched to ECT after a medication trial. These factors are best examined at the level of the individual hospital. Had ECI been administered promptly to every patient in the present series, it would actually have cost an extra $1,988 per admission (assuming the $485per diem used by Markowitz et al. in their own calculations). Despite the fact that ECT did not reduce the length of hospitalizations, it was associated with better outcomes at the time of discharge. Although this could be seen as supporting the suggestion that psychiatrists should consider this treatment modality more routinely, the limitations of the present study must be emphasized in this context. The study was a retrospective design in a naturalistic setting. The lack of random assignment to treatments, the finding of clinical and demographic differences between ECT and non-ECT patients, and the use of adjunct medications among both groups, are all important factors that preclude the present work being offered as evidence of the superiority of one treatment over the other. In fact, the rationale for early discharge of many medication-treated patients is that they will continue to improve on an outpatient basis. Nevertheless, the presumption of such continuing recovery remains to be demonstrated in prospective research using postdischarge follow-ups. In the future, investigations of that type may indeed demonstrate that ECT should be considered more routinely as a treatment of first choice, on the grounds that a better level of clinical response might be achieved. However, in the meanwhile, economic considerations supporting the use of ECT should be viewed critically, because they are neither straightforward nor directly comparable across settings. REFERENCES 1. Greenblatt M, Grosser GH, Wechsler H: Differential response of hospitalized depressed patients to somatic therapy. Am J Psychiatry 120:935-943, 1964 2. Medical Research Council Clinical Psychiatry Committee: Clinical trial of the treatment of depressive illness. Br Med J 1881~886.1965 3. Robin AA, Harris JA: A controlled comparison of imipramine, electroconvulsive therapy and placebo in the treatment of depression. J Ment Sci 108:217-219,1962 4. Wilson IC, Vernon JT, Guin T, et al: A controlled study of treatments of depression. J Neuropsychiatry 4:331-338, 1963 5. Rifkin A: ECT versus tricyclic antidepressants in depression: A review of the evidence. J Clin Psychiatry 49~3-7, 1988 6. Janicak PG, Davis JM, Gibbons RD, et al: Efficacy of ECT: A meta-analysis. Am J Psychiatry 142:297-302, 1985 7. Abrams R: Electroconvulsive Therapy. New York, NY, Oxford University, 1988 8. Coffey CE, Weiner RC: Electroconvulsive therapy: An update. Hosp Community Psychiatry 41:515-521,199O 9. Bratfos 0, Haug JO: Electroconvulsive therapy and antidepressant drugs in manic-depressive disease. Acta Psychiatr Stand 41:588-596, 1965 10. Markowitz J, Brown R, Sweeney J, et al: Reduced length and cost of hospital stay for major depression in patients treated with ECT. Am J Psychiatry 144:1025-1029,1987
354
WILSON
ET AL
11. Avery D, Winokur G: The efficacy of electroconvulsive therapy and antidepressants in depression. Biol Psychiatry 12:507-522,1977 12. Black DW, Winokur G, Nasrallah A: The treatment of depression: Electroconvulsive therapy vs. antidepressants: A naturalistic evaluation of 1,495 patients. Compr Psychiatry 28:169-182, 1987 13. Babigian HM, Guttmacher LB: Epidemiologic considerations in electroconvulsive therapy. Arch Gen Psychiatry 41:246-253,1984 14. Bailine SH, Rau JH: The decision to use ECT: A retrospective study. Compr Psychiatry 22:274-281, 1982 15. American Psychiatric Association: Diagnostic and Statistical Manual (ed 3). Washington, DC, APA, 1980
A
LTHOUGH electroconvulsive therapy (ECT) for the treatment of depression is widely regarded as being both efficacious and safe, it still tends to be held back as a treatment of last resort. However, it has been suggested recently that psychiatrists should consider the use of ECT more readily. This suggestion has been supported by several converging lines of research. First, some studies that have compared ECT with other common inpatient treatments for depression have found that ECT results in better clinical outcomes.‘-4 As Rifkin’ has noted, the controlled research in this area suffers from a range of methodological problems that undermine the general strength of this conclusion. Nevertheless, based on a meta-analysis of the available evidence, Janicak et aI6 have concluded that ECT produces better clinical results than antidepressant medications. Second, there is a growing body of literature addressed to the specific problem of side effects-especially memory impairments-which indicates that complications are relatively uncommon.7*8 Because the prospect of irreversible cognitive impairment represents one of the primary objections of the general public to the use of ECT, this body of research is relevant to considerations of the social acceptability of the treatment. Finally, it has been reported that ECT reduces the overall length of hospitalization for depression.299-” Markowitz et al.” found that patients who were treated promptly with ECT stayed an average of 13 fewer hospital days relative to patients who were started on a course of tricyclic antidepressants. This finding is particularly important for two reasons. Not only does it indicate that ECT relieves the patient’s suffering more quickly, thus promoting an early return to family and community, it also suggests that ECT will considerably reduce the costs of
From the Department of Psychiatry University of Manitoba, Health Sciences Centre, Winnipeg; and Grace Hospital, Uknipeg, Canada. Address reprint requests to Keith G. Wilson, Ph.D., Department of Psychology, The Rehabilitation Centre, 505 Smyth Rd, Ottawa, Ontario, Canada, KIH 8M2. Copyright 0 1991 by W.B. Saunders Company 0010-440X/91/3204-0010$03.00/0 Comprehensive
Psychiatry, Vol. 32, No. 4 (July/August),
1991: pp 345354
345
346
WILSON
ET AL
hospitalization for episodes of depression. In the study by Markowitz et al., the reduction amounted to over $6,400 (US) per patient. Unfortunately, the finding that ECT is associated with reduced length of hospital stays is by no means a universal one, and the relevant literature contains both confirming and conflicting results. Confirming findings have been reported by the British Medical Research Council’ and by Avery and Winokur.” The latter investigators reviewed the charts of 609 psychiatric inpatients who had been admitted to the University of Iowa Psychopathic Hospital from 1959 to 1969. They concluded that “it is well documented that ECT significantly shortens the duration of hospitalization of depressed patients compared to conservative treatment” (p. 520). Black et a1.,12on the other hand, reviewed 1,495 charts from the same locale for the period 1970 to 1982, and found longer hospital stays for patients treated with ECT-a finding that has also been reported by other investigators.‘3.14 In summary, then, the impact of ECT on the duration of hospital admissions remains unclear. The issue is a significant one, because if considerations regarding efficacy and safety are generally comparable across treatment modalities, then cost-effectiveness becomes an increasingly appropriate factor on which to base clinical decisions. However, the available studies that address this issue show wide discrepancies, which may be due to a combination of methodological inconsistencies and specific institutional factors that govern local admission and discharge policies. The present study represents an attempt to clarify these discrepancies. Specifically, the study comprises a retrospective chart review, which examines the impact on length of stay of the clinical decision to treat depressed patients with either ECT or antidepressant medications. In particular, the study attempts to identify those factors that should be considered at any individual institution before assuming that ECT will necessarily shorten the duration of hospitalizations. METHOD Setting The study was conducted using patient records from the Department of Psychiatry of the Health Sciences Centre (HSC), Winnipeg. The HSC is an l,lOO-bed teaching hospital, and it is the major tertiary care facility in the province of Manitoba. The hospital is situated physically in the city’s core area, and the patient population comes largely from the lower socioeconomic classes. The province provides universal medical care at no direct cost to the patient, including coverage for hospital stays. Although there is no fixed maximum length of stay, the duration of hospitalization tends to be monitored closely in the interest of cost-containment. The basic philosophy of care emphasizes symptomatic stabilization on the inpatient units, with discharge to outpatient treatment as soon as possible. For 1987 (the most recent year in the study period), the average length of stay across all patients was 33.4 days. Most individuals return to their residences, although discharge to personal-care homes or supervised transitional-living programs is undertaken when necessary. Transfer to a longer-stay psychiatric institution occurs rarely, and not at all among the group of patients who were selected for the present study.
Subjects A computerized file containing demographic, diagnostic, and treatment information is kept routinely on each patient who is admitted. For the present purpose, the computer archives were scanned to identify all patient discharges occurring between December 1, 1982 and January 31, 1988.
ECT AND LENGTH OF STAY
347
During this time, diagnostic information was obtained for all patients according to criteria outlined in DSM-III of the American Psychiatric Association.” All records for adult inpatients that indicated a primary diagnosis of major depressive episode (DSM-III codes 296.2.296.3) were selected for further review. This initial listing included 338 patients. The hospital chart of each individual was then reviewed in detail in order to exclude patients with very short admissions (< 1 week, cf. Markowitz et al.“‘); patients discharged against medical advice; patients whose hospitalizations were extended because of placement problems; and those whose treatments were complicated by coexisting medical disorders. Of the remaining patients, only 13 were found to have received neither ECT nor any specific antidepressant medication. In the interest of maintaining a homogeneous sample, these patients were also excluded from further analyses. The final study group consisted of 192 patients (74 men, 118 women), ranging in age from 18 to 78 years (mean. 43.2).
Procedure Because some individuals had multiple hospitalizations during the study period, the following criteria were used to select an index admission: (1) if a patient had only a single admission, then that admission was used; (2) if a patient had more than one admission, each involving ECT, then the first admission was used; (3) if a patient had more than one admission, none of which involved ECT, then the first admission was used; (4) if a patient had more than one admission, any of which involved ECT, then the first admission during which the patient received ECT was used. This latter criterion was adopted because there were fewer ECT than non-ECT admissions, and thus it served to maximize the sample size for the ECT group. The chart notes and discharge summaries for each eligible admission were then reviewed to obtain the following information: demographic characteristics, symptom profiles, treatment information. outcome, and length of stay. Wherever possible, scoring pertained to direct objective referents in the charts. For example, in order for symptom ratings to be coded as “definitely present,” it was required that a symptom be mentioned explicitly in the notes. The presence/absence of (1) concern regarding physical health, (2) pronounced weight loss, (3) delusions, (4) hallucinations, (5) psychomotor agitation, (6) psychomotor retardation, and (7) overt suicidal comments or actions, were all coded separately. Clinical outcomes were judged by one of two raters, based on reviews of discharge summaries and physicians’ and nurses’ progress notes for the last week of treatment. Outcomes were scored according to criteria reported by Black et aLI2Specifically, treatment outcome for each patient was assessed using the following scale: 1, unimproved or worse; 2, partially improved (mildly or modestly improved, but still exhibiting one or more depressive symptoms at discharge); 3. improved (reported as having good, moderate, or fair response, or judged to have been globally improved with no persistent signs of depression); 4. marked improvement (patient is entirely well, recovered, or “back to usual self,” or the notes indicate that no depressive symptoms remain at any time). Each rater reviewed a randomly selected series of charts. They overlapped in their reviews of a sample of 50 cases. For these patients, the interrater reliability for the outcome scores was r = .82.
Data Analysis The data were analyzed in two ways. For the first analysis, each patient was assigned to one of two groups-medication therapy or ECT-based on the initial treatment approach that had been used with that patient. The decision to treat an individual with either drugs or ECT was the responsibility of the attending psychiatrist. Although there was undoubtedly some variability in treatment preferences across different psychiatrists, the general emphasis of the inpatient service is on the application of somatic therapies. ECT is well accepted in this context. However, regardless of the primary focus of treatment, individual counseling and occupational therapy are offered routinely to most patients, and marital and family therapy are introduced as needed. The psychiatrist’s initial treatment decision was viewed as a binary one involving either the prompt administration of ECT (after an appropriate assessment and work-up) or the initiation/continuation of a course of antidepressant medications. In fact, substantial proportions of the patients in both groups were already in active treatment with antidepressant medications at the time of their index admissions (47.7% and 66.9% for the ECT and medication groups, respectively). However, patients who were already in treatment at the time of admission did not differ from those who were not in treatment in
348
WILSON
ET AL
either length of stay or clinical outcomes. Hence, treatment status before admission was not considered further. For the second analysis, the group of patients who were started initially on antidepressants was divided into two subgroups. One subgroup comprised those patients who eventually received a change of treatment and were switched to ECT. The other subgroup consisted of those patients who remained on antidepressant medications throughout the course of their hospitalizations.
RESULTS Initial Treatment Decision: ECT Versus Antidepressant Medications
Forty-four patients (22.9%) received ECT as their primary initial treatment. Of these, 29 (65.9%) received unilateral ECT treatments, five (11.4%) received bilateral, and 10 (22.7%) received a mixed series. Sine-wave stimulation was used in each case. Typically, the treatments were adminstered by psychiatric residents who had been trained under the supervision of staff psychiatrists. Most treatments were initiated after a short work-up period (6.2 days, on average). The average number of ECT administrations was 9.1 (range, 2 to 22). They were usually given three times a week, although this was variable on the basis of individual tolerance. On occasion, treatments were interrupted in order to monitor the stability of a patient’s recovery, with a subsequent resumption of ECT if indicated. One hundred forty-eight patients (77.1%) were started initially on a trial of antidepressants. A variety of specific medications were prescribed. The most frequently administered antidepressant was amitryptiline, which was given to 39 patients. This was followed by imipramine (30 patients), desipramine (22 patients), doxepin (17 patients), clomipramine (13 patients), trazodone (nine patients), ludiomil (seven patients), trimipramine and amoxapine (three patients each), phenelzine and tranylcypromine (two patients each), and nomifensine (one patient). It should be noted that few of the patients were treated “cleanly,” in the sense of receiving only ECT or a specific antidepressant drug. In fact, a majority of the patients receiving ECT (25/44, or 56.8%) were also given an antidepressant. Similarly, benzodiazepines and neuroleptics were commonly prescribed for both groups. Minor tranquilizers were administered occasionally with 63.6% and 55.4% of the ECT and medication groups, respectively. These proportions were not significantly different (x’(1) < 1). However, more patients in the ECT group (31/44, or 70.5%) than in the medications group (76/148, or 51.4%) were given neuroleptics (x’ (1) = 4.3; P = .04). The two groups were also compared on demographic characteristics, symptoms, and clinical findings. The 44 patients who were given ECT as their primary treatment and the 148 patients who were given antidepressants did not differ significantly in age or sex. However, the patients who received primary ECT were more likely to have undergone treatment with ECT in the past (x’ (1) = 8.2; P = .004). They also had a greater number of previous hospitalizations, on average (mean, 2.5 and 1.5 for ECT and medications groups, respectively; t(190) = 2.15; P = .03). The two groups differed reliably on only one of seven individual symptoms that were scored from the charts. More patients who were given medication treatment were noted to have been overtly suicidal (x’(l) = 4.4; P = .04).
ECT AND LENGTH OF STAY
349
The major dependent variables of interest were clinical outcomes and length of stay. It was found that patients who received prompt treatment with ECT received significantly higher outcome ratings (mean, 2.98) than patients who were started on medication therapy (mean, 2.66; t(190) = 2.34; P = .02). Thirty (68.2%) of the patients who received a prompt course of ECT were rated as being either “improved” or “markedly improved,” as compared with 80 (54.1%) patients who were started on antidepressants. However, the two groups did not differ in length of stay (mean, 42.0 and 37.9 days for the ECT and medication groups, respectively; t(190) < 1). Effects of Changing Patients From Medication to ECT The first analysis indicates that the psychiatrists’ initial binary treatment decision-to intervene with ECT or medications-is not in itself associated with systematic differences in the length of hospitalizations. However, it should be noted that the initial treatment decision is not necessarily the final treatment decision. In fact, many patients who are started on antidepressants ultimately require a switch to ECT because of a lack of improvement, or because of other clinical considerations. In the present sample, 28 of 148 patients (18.9%) fell into this category. For the second set of analyses, then, comparisons were made between three groups of patients: (1) those who received prompt ECT (N = 44); (2) those who received only medications throughout the course of their admissions (N = 120); and (3) those who received ECT after a trial of antidepressants (N = 28). Summaries of the demographic, clinical, and outcome data for each of the three groups are presented in Table 1. One-way analyses of variance Table 1. Demographic,
Clinical, and Outcome Characteristics ECT as Primary Initial Treatment (N = 44)
Age (mean in years)
45.8” (15.6) Male (%) 29.5 Female (%) 70.5 Symptoms (% of patients with symptom present) Concern about physical status 52.3 Starvation/pronounced weight loss 15.9 Delusions 34.1 Hallucinations 22.7 Psychomotor agitation 20.5 Psychomotor retardation 25.0 Overtly suicidal 40.9 Total no. of symptoms 2.11 (1.37) Length of stay (mean in days) 42.0 (24.2) Outcome (mean) 2.98” (0.85)
of Three Patient Groups
Medications Only (N = 120)
ECT After Medications (N = 28)
40.3 (14.8) 43.3 56.7
51.7” (17.2) 32.1 67.9
41.7
60.7
22.5 21.7 14.2 16.7 20.0 60.8 1.97 (1.04) 29.1” (19.6) 2.60b (0.80)
NOTE. Table entries that have different superscripts are significantly Standard deviations, where applicable, are presented in parentheses.
46.4” 32.1 14.3 32.1 32.1 50.0 2.68” (1.16) 75.4b (65.5) (Z;” different at P < .05.
350
WILSON
ET AL
(ANOVA) were used to compare the groups on continuous variables, using the Newman-Keuls procedure for post-hoc pairwise contrasts. As shown in Table 1, patients who were switched to ECT after an initial medication trial were significantly older than patients who only received medications throughout the course of their admissions (F (2,189) = 7.15, P < .OOl), although they were comparable in age to patients who received an early course of ECT. They also had a greater number of symptoms than patients in either of the other two groups (F (2,189) = 4.33, P < .Ol). However, only one of the individual symptoms-pronounced starvation or weight loss-was found to be significantly more prevalent (x2 (2) = 9.30, P < .Ol). As in the first set of analyses, there was a significant difference between the groups on the outcome ratings (F(2,189) = 4.28; P = .02). In post-hoc comparisons, patients who received prompt ECT received higher outcome ratings (indicative of b etter outcomes) than patients who were treated with medications only. Those patients who received ECT after an initial trial of antidepressants occupied an intermediate position, and were not significantly different than patients in either of the other two groups. In contrast to the two-group comparison, the ANOVA comparing length of stay among the three groups was highly significant (F(2,189) = 24.86; P < .OOl), with all three groups differing from one another. Patients receiving only medications had the shortest hospitalizations, followed by those who received a prompt initial course of ECT. Patients who required ECT after a trial of antidepressants clearly had very long hospital stays, which amounted numerically to summing the separate average durations for admissions involving medication only and prompt ECT. Psychotic and Nonpsychotic Patients
The foregoing anaIyses provide no support for the hypothesis that the prompt initiation of ECT will reduce the duration of hospitalizations for depression. However, it should be noted that the diagnosis of depression that was used for these analyses was based on global DSM-III criteria, without regard to particular clinical features. In fact, the ECT-treated patients had histories of more frequent psychiatric admissions, and they were more likely to receive concurrent treatment with neuroleptics. Hence, the initial decision to administer ECT may have been influenced by the overall severity of the depressive syndrome, or by the presence of psychotic features. These factors, in turn, may have affected treatment durations and length of stay. In order to examine this potential confound, a series of reanalyses was undertaken in which patients were divided into subgroups based on the presence or absence of psychotic features. Patients who were noted to have experienced delusions or hallucinations (64/192, or 33.3%) were classified as suffering from psychotic depressions, while the remainder were classified as having nonpsychotic depressions. The data for outcome and length of stay were then reanalyzed as 2 X 2 (psychotic v nonpsychotic x prompt ECT v medications) ANOVAs. The mean values are presented in Table 2. The most salient feature of the reanalysis was the extent to which the original findings were replicable for both psychotic and nonpsychotic patients. When the
351
ECT AND LENGTH OF STAY
Table 2. Mean Outcome Ratings and Length of Stay for Patients With Psychotic or Nonpsychotic Depressions
ECT as Primary Initial Treatment Psychotic No. of patients Outcome Length of stay (d) Nonpsychotic No. of patients Outcome Length of stay (d)
Medications as Primary Initial Treatment
Medications Only
ECT After Medications
19 3.11 (0.74) 41.0 (29.0)
45 2.76 (0.83) 33.9 (20.9)
36 2.75 (0.87) 27.4 (13.7)
9 2.78 (0.67) 59.8 (25.1)
25 2.88 (0.93) 42.7 (20.5)
103 2.61 (0.77) 39.6 (43.2)
84 2.54 (0.77) 29.8 (21.6)
19 2.94 (0.71) 82.7 (77.4)
NOTE. The “medications-only” group comprises that subset of patients receiving medications as a primary initial treatment who were discharged after the antidepressant trial (i.e., they did not go on to receive ECT). Standard deviations are presented in parentheses.
initial treatment decision was examined, the outcome data showed only a significant main effect of treatment type (F(1,188) = 4.70, P = .03). This confirmed that patients treated promptly with ECT were discharged at a better level of improvement, regardless of their diagnostic subtype. Length of stay, on the other hand, did not differ as a function of either diagnostic status or method of initial intervention (P > .lO). As before, however, the medication-treated group included patients who were eventually switched to ECT at a later point in their admissions. When these individuals were removed from the analysis (because only nine psychotic patients were switched to ECT after a medication trial, they were not included as a separate subgroup in the statistical comparisons), the administration of ECT still resulted in better outcomes at the point of discharge (F(1,160) = 5.81, P = .02). However, it was also evident that ECT resulted in admissions that were significantly longer than those of medication-treated patients (F(1,160) = 12.40, P = .OOl). These findings were consistent for both psychotic and nonpsychotic patients; no main effects or interactions involving diagnostic group status approached statistical significance (all Pvalues > .lO). DISCUSSION
In the present study, the use of ECT as the primary initial treatment for depression was not associated with a shorter length of hospitalization, even for patients who presented with psychotic features. This finding represents a failure to confirm the results presented by Markowitz et al.” However, close examination of the relevant data from the two studies shows an interesting pattern of similarities and differences. As is evident in Table 3, the average length of hospitalization for the groups who received ECT as a primary treatment and those who received ECT after a trial of antidepressants are similar across both studies. Hence, while it can be argued that shorter ECT admissions might be achieved with
352
WILSON
ET AL
Table 3. Mean Length of Hospital Stays (Days) Group ECT as primary initial treatment Medications as primary initial treatment Medications only ECT after medications
Markowitz et al.
Present Study
41.4 (N = 19) 54.6 (N = 55) 37.5 (N = 27) 71.0 (N = 28)
42.0 (N = 44) 37.9 (N = 148) 29.1 (N = 120) 75.4 (N = 28)
NOTE. Patients in the “medications only” and “ECT after medications” groups are subsets of the larger group, “medications as primary initial treatment.”
faster work-ups, alternative modes of administration (i.e., brief-pulse rather than sine-wave stimulation), and a shorter period of monitoring following treatment, it is unlikely that the present findings reflect unusually long hospitalizations for ECT at our institution. On the other hand, there are two areas in which the studies diverge. The first is in the duration of hospitalization for patients who are given antidepressants only, which is shorter by about 8 days at our hospital. The second area of divergence lies in the proportions of patients who were treated with medications initially, but who eventually received ECT at a later time in their admissions. These patients have very long hospital stays. Markowitz et al. found that 50.9% their medicationtreated patients fell into this category, compared with only 18.9% of the patients in the present sample. Thus, whether the initial decision to treat with medications results in longer admissions overall depends to a large extent on the number of patients falling into this subgroup with long hospitalizations-a number that clearly varies considerably across settings. This analysis also helps to explain some of the apparent discrepancies across other studies that have examined the impact of ECT on length of stay. Specifically, most studies that have found ECT to be associated with long hospitalizations have failed to distinguish patients who received ECT after a medication trial from patients who received ECT early in the course of their admissions (i.e., combining all patients who received ECT at any time into one group for comparison purposes; cf references 12-14). Studies that have reported short admissions with ECT, on the other hand, have examined the effects of a promptly-administered course of treatment (cf. references 2,9,10,11). However, even with prompt ECT, the present results indicate that shorter hospitalizations are not an inevitable outcome. These findings show limitations in the use of length of stay in cross-center comparisons. To a large extent, length of stay will be influenced by specific institutional policies regarding admission and discharge decisions. Whereas some centers may be able to keep patients in hospital until their depressions have largely remitted, other institutions tend, because of bed shortages and other local pressures, to discharge patients to outpatient care as soon as it is safe to do so. At the HSC, patients who begin to respond to antidepressant medications are likely to be discharged for follow-up when they have only partially improved. Patients
ECT AND LENGTH OF STAY
353
who are given ECT, on the other hand, will be kept in hospital until the course of treatment is regarded as completed. Hence, the present study demonstrates that the more frequent and prompt use of ECT will not necessarily reduce the cost of hospitalization at any given institution. This will depend on (1) the average length of stay for the comparison group-patients who are treated with medications, and (2) the proportion of patients who are switched to ECT after a medication trial. These factors are best examined at the level of the individual hospital. Had ECI been administered promptly to every patient in the present series, it would actually have cost an extra $1,988 per admission (assuming the $485per diem used by Markowitz et al. in their own calculations). Despite the fact that ECT did not reduce the length of hospitalizations, it was associated with better outcomes at the time of discharge. Although this could be seen as supporting the suggestion that psychiatrists should consider this treatment modality more routinely, the limitations of the present study must be emphasized in this context. The study was a retrospective design in a naturalistic setting. The lack of random assignment to treatments, the finding of clinical and demographic differences between ECT and non-ECT patients, and the use of adjunct medications among both groups, are all important factors that preclude the present work being offered as evidence of the superiority of one treatment over the other. In fact, the rationale for early discharge of many medication-treated patients is that they will continue to improve on an outpatient basis. Nevertheless, the presumption of such continuing recovery remains to be demonstrated in prospective research using postdischarge follow-ups. In the future, investigations of that type may indeed demonstrate that ECT should be considered more routinely as a treatment of first choice, on the grounds that a better level of clinical response might be achieved. However, in the meanwhile, economic considerations supporting the use of ECT should be viewed critically, because they are neither straightforward nor directly comparable across settings. REFERENCES 1. Greenblatt M, Grosser GH, Wechsler H: Differential response of hospitalized depressed patients to somatic therapy. Am J Psychiatry 120:935-943, 1964 2. Medical Research Council Clinical Psychiatry Committee: Clinical trial of the treatment of depressive illness. Br Med J 1881~886.1965 3. Robin AA, Harris JA: A controlled comparison of imipramine, electroconvulsive therapy and placebo in the treatment of depression. J Ment Sci 108:217-219,1962 4. Wilson IC, Vernon JT, Guin T, et al: A controlled study of treatments of depression. J Neuropsychiatry 4:331-338, 1963 5. Rifkin A: ECT versus tricyclic antidepressants in depression: A review of the evidence. J Clin Psychiatry 49~3-7, 1988 6. Janicak PG, Davis JM, Gibbons RD, et al: Efficacy of ECT: A meta-analysis. Am J Psychiatry 142:297-302, 1985 7. Abrams R: Electroconvulsive Therapy. New York, NY, Oxford University, 1988 8. Coffey CE, Weiner RC: Electroconvulsive therapy: An update. Hosp Community Psychiatry 41:515-521,199O 9. Bratfos 0, Haug JO: Electroconvulsive therapy and antidepressant drugs in manic-depressive disease. Acta Psychiatr Stand 41:588-596, 1965 10. Markowitz J, Brown R, Sweeney J, et al: Reduced length and cost of hospital stay for major depression in patients treated with ECT. Am J Psychiatry 144:1025-1029,1987
354
WILSON
ET AL
11. Avery D, Winokur G: The efficacy of electroconvulsive therapy and antidepressants in depression. Biol Psychiatry 12:507-522,1977 12. Black DW, Winokur G, Nasrallah A: The treatment of depression: Electroconvulsive therapy vs. antidepressants: A naturalistic evaluation of 1,495 patients. Compr Psychiatry 28:169-182, 1987 13. Babigian HM, Guttmacher LB: Epidemiologic considerations in electroconvulsive therapy. Arch Gen Psychiatry 41:246-253,1984 14. Bailine SH, Rau JH: The decision to use ECT: A retrospective study. Compr Psychiatry 22:274-281, 1982 15. American Psychiatric Association: Diagnostic and Statistical Manual (ed 3). Washington, DC, APA, 1980
![[Electroconvulsive therapy for the treatment of major depression].](/assets/img/hold.png)
