The University of Michigan Medical Center received a patient last year − we’ll call him Sam − with such severe depression he could barely move, too low-energy to even enjoy playing video games. Sam’s doctor suggested electroconvulsive therapy, or ECT, commonly known as shock therapy. The treatment creates a seizure (CLICK), which essentially “resets” the brain through different biological pathways.
At first, Sam and his parents weren’t sure. Sam’s mother expressed her concern that the treatment might not be safe. This is a pretty common worry − think of One Flew Over the Cuckoo’s Nest (CLICK) and the other scary portrayals we’ve seen of ECT.
But after Sam received ECT, which is a well-established, straightforward, and fully anesthetized procedure, he started to feel different. Sam still struggles with depression, but in an interview with Michigan Medicine (CLICK), Sam said ECT gave him enough willpower to benefit from other therapies.
There are a lot of patients like Sam. Michigan Medicine alone treats 150 to 200 patients a year, totaling to about 3,000 procedures annually. Unfortunately, experts say ECT still has a negative public image, thanks to popular culture and the antipsychiatry movement, and many people don’t even realize it’s an option.
(CLICK) I’m actually an economist at the University of Michigan, so I didn’t know much about depression treatment until I got involved with a research project on ECT. Along with collaborators from the Medical School and School of Public Health, I helped produce a study that came out last May. As I learned more about ECT, I became interested in spreading the truth about ECT − that it’s a safe, effective therapy − to more people. That’s why I’m here to tell you about my work.
Now, we didn’t look at this from a medical perspective because we already know ECT is effective (CLICK). Take a look at this figure − as you can see, it’s been proven that ECT works.
So, we actually studied the cost-effectiveness of ECT. (CLICK) That is, we tried to identify at what point in a depressed patient’s treatment path ECT becomes a financially smart option. If a patient isn’t responding to other, more conventional treatments, like meds or talk therapy, when should their doctor suggest ECT? The problem is, ECT equipment is expensive. Based on our paper, the average cost of one ECT session is $586, and patients generally receive about 8 ECT treatments in one month plus around 16 maintenance sessions per year.
To answer this question of cost versus benefit, we used a statistical model to simulate depression treatment for a group of patients. In the model, ECT could be introduced in 6 different ways, or after 0-5 failed attempts to use medication or therapy. Here’s a diagram of our model (CLICK). It looks complicated, but we’re pretty much running each patient through different treatments, introducing ECT at different points, and each treatment can either work or not work based on actual statistics.
(CLICK) We ran this model over and over, simulating treatment over 4 years, and looked at the cost of introducing ECT at different times. We said a treatment is cost-effective if it costs less than or equal to $100,000 per quality-adjusted life-year. I know that sounds like a lot, but that’s actually a standard measure used by researchers. A “quality-adjusted life year” is basically the cost to have a “good” year − it’s a ratio between cost and benefit.
We were pretty surprised by our results. It turns out ECT starts being cost-effective as a third-line treatment, so after 2 other treatments have failed, costing $54,000 per quality-adjusted life year. Overall, ECT reduced the time with uncontrolled depression by about ¼ over the 4-year span. As you can see in this table (CLICK), it’s most likely that ECT as a third-line treatment is the optimal strategy.
So why are these results so surprising? Well, patients with uncontrolled depression don’t usually seek out electroconvulsive therapy after two meds fail, or after they try one antidepressant and some therapy but aren’t feeling better. ECT is usually considered much further down the line, but these results suggest maybe we should be considering it earlier to keep people from suffering unnecessarily. Personally, I’m pretty excited about our findings because ECT has such a negative public perception (CLICK); the survey results in this table show that ECT is seen as extreme, and sometimes even barbaric. Actually, though, it’s a safe, effective treatment, and now we know it can be cost-effective.
(CLICK) Of course, we do need to figure out if this is something we actually want to recommend − does it really make sense to get ECT right after two other treatments? Whether ECT should be considered definitely works on a case-by-case basis.
This study also raises some practical questions. Most insurance plans cover ECT at least partially, but according to Kara Zivin, one of my collaborators, coverage is pretty variable (CLICK). The full course of treatment costs thousands of dollars, and even with full insurance coverage for the procedure, you’d have to pay for hospital stay, which in 2017 cost about $4,000 per day. Our study shows that maybe, insurance providers should be covering ECT more completely and earlier in a patient’s course of treatment. If this is something that bothers you as much as it bothers me, check out my website, where you can sign a petition I’ve started to expand major insurance providers’ definitions of who qualifies for ECT.
(CLICK) We have a lot to consider going forward, but overall, I do think these results are exciting. I hope you see how our study supports a growing body of evidence that ECT is an effective treatment for severe depression. It’s a treatment that could really help the many patients who are suffering.
(CLICK) In the same interview with Michigan Medicine, Sam said ECT basically saved his life. Clearly, we should be giving ECT a second chance. I encourage you to start a conversation, put this on your friends’ radar screens. If we can get a dialogue going around ECT, maybe people won’t be so afraid.