Finally, Evidence for Continuation Electroconvulsive Therapy in Major Depressive Disorder.

Abstract

C olleagues in countries outside the United States may be surprised to discover that American psychiatrists must get permission (“authorization”) from commercial (ie, nongovernmental) health insurance companies if they want to be paid for their efforts providing electroconvulsive therapy (ECT) to patients covered by commercial health insurance. In my recent experience, successful authorization of ECT services is handed out in increments of 3 to 6 treatment sessions at a time. After that, additional authorization is required. The same process is followed for continuation ECT following successful acute ECT for major depressive disorder (MDD). The restrictions on payment can be even worse. In my last attempt to obtain authorization for outpatient continuation ECT, the insurance representative denied the request, saying the continuation ECTwas “not a covered service” within that particular patient’s health plan. He was not arguing about the merits or demerits of continuation ECT; hewas simply informing me that his company would not pay for this service. It is easy for the insurance company to deny payment, and difficult for the physician to appeal the denial, when hard evidence is lacking to support continuation ECT as superior to medications alone for MDD. This lack of empirical support for continuation ECTwas also cited as a weakness in the Food and Drug Administration expert panel review of ECT and was also cited by the United Kingdom’s NICE (National Institute for Health and Care Excellence) report on ECT, as summarized elsewhere. Thankfully, the data shortage has now been addressed by Kellner et al, the Prolonging Remission in Depressed Elderly (PRIDE) study. This study recruited 240 elderly MDD patients for an acute course of right unilateral ultrabrief ECT, combined with venlafaxine. Remission of MDD was achieved in 148 (61.7%) of these participants, and 120 of these subsequently consented and were randomized to pharmacotherapy (venlafaxine plus lithium) versus pharmacotherapy accompanied by weekly continuation ECT for 4 weeks with additional ECT after that as needed. The highlights of the randomized phase included the superiority of the continuation ECT arm over the 6 months of follow-up and that only 34.4% of the patients in the ECT group required additional ECT sessions beyond the initial required 4 weekly continuation ECT sessions. Furthermore, the ECT sessions were well tolerated by those assigned in the ECT group, with no meaningful change in Mini Mental State Exam scores. Clinically, the PRIDE study provides guidance for ECT providers and supports offering continuation ECTon a routine basis after successful acute ECT. Apart from the value of the PRIDE study in guiding clinical care, the PRIDE study provides important ammunition for continuation ECT in advocacy with regulatory authorities (ie, NICE) and with payers (ie, commercial insurers). American psychiatrists should have the PRIDE data on the tip of their tonguewhen preparing for a conversation with regulators, news media representatives, politicians, and payers. Those who see the glass as half empty will note that the PRIDE study did not include young adults or patients with bipolar disorder. While this is true, logic dictates that a basic finding, such as the superiority of continuation ECT in the elderly, ought to hold true for younger patients and for patients with bipolar depression.