Barriers to ECT: Survey Results From the USA

 Out on PubMed, from Sam Wilkinson and colleagues, in Psychiatric Services, is this article:

Barriers to the Implementation of Electroconvulsive Therapy (ECT): Results From a Nationwide Survey of ECT Practitioners.

Wilkinson ST, Kitay BM, Harper A, Rhee TG, Sint K, Ghosh A, Lopez MO, Saenz S, Tsai J.Psychiatr Serv. 2021 May 11:appips202000387. doi: 10.1176/appi.ps.202000387. Online ahead of print.PMID: 33971727

The abstract is copied below:

Objective: Electroconvulsive therapy (ECT) is an effective treatment for major depressive disorder; yet, its use is confined to <1% of individuals with this disorder. The authors aimed to examine barriers to ECT from the perspective of the provider.

Methods: Qualitative interviews were conducted with U.S.-based ECT providers to identify potential barriers. A quantitative survey was created asking providers to rank-order barriers to starting a new ECT service or expanding existing services.

Results: Survey responses were received from 192 physicians. Respondents were representative of all ECT providers found in the Medicare Provider Utilization and Payment Database with respect to gender and geographic distribution. Approximately one-third (N=58, 30%) of survey respondents graduated from one of 12 residency programs. Programs with dedicated hospital space were more likely to have larger services than those borrowing surgical recovery space (χ2=25.87, df=1, p<0.001). The most prominent provider-reported barriers to expanding an existing ECT service were lack of physical space, stigma on the part of patients, and transportation difficulties. The most prominent barriers to initiating a new service were lack of well-trained colleagues and ECT practitioners, lack of a champion within the institution, and lack of physical space. Wide geographic variation was found in the availability of ECT, with the highest concentration of ECT providers per 1 million individuals found in New England (6.4), and the lowest found in the West South Central (1.1).

Conclusions: Coordinated efforts to overcome identified barriers may allow ECT to be more broadly implemented. Investments in education may increase the number of competent practitioners.

Keywords: Depression; ECT; Health Services.

And from the text:

Qualitative Results 

Analysis of the qualitative component of the study showed that within hospitals, providers face barriers with hospital administration, including bureaucracy, stigma, and lack of understanding of the treatment and finances. In some cases, providers reported that hospital administrators do not value ECT compared with other procedural-based diagnostics or therapies (i.e., colonoscopy) because of relatively low reimbursement rates. Subsequent lack of administrative support leads to low resource allocation, including physical procedure space, support staff, and inadequate marketing of the treatment, resulting in invisibility both internal and external to the hospital. Barriers are also faced among support staff: collaboration of anesthesiologists is critical, but they often have competing interests and duties such that attending to the ECT service receives low priority; nursing staff often harbor negative perceptions of the treatment (similar to the general public) or are not adequately trained to provide ECT-related care; and even fellow psychiatric staff can have antiquated perceptions of the treatment. More successful programs have the support of a champion (one who is fully invested and committed to expanding access to the treatment) (16) within the administration and a commitment to accurate communication and education about ECT to hospital staff. When adequate space and staffing are provided, the service functions well, and the reputation and visibility of the service also improve among hospital staff and community providers.

DISCUSSION To our knowledge, this study is the first attempt to quantitatively compare provider-perceived barriers with ECT service expansion or initiation and the first nationwide survey of ECT providers. Qualitative data showed at least 22 barriers to initiating or expanding an ECT service. With respect to expanding an existing service, the most prominent provider-reported barriers were lack of physical space, stigma on the part of patients, and transportation issues. With respect to initiating a new service, the most prominent provider-reported barriers were lack of well-trained colleagues and ECT practitioners, lack of a champion, and lack of physical space. We also found great geographical variation in the availability of ECT providers. and visibility of the service also improve among hospital staff and community providers.

This excellent article is an important contribution to the ECT literature. It documents the current state of affairs regarding the obstacles faced by ECT practitioners in the USA, but many of the issues are likely generalizable to other countries.
The great opening paragraph is a particularly good summary of the efficacy of ECT.
With 690 ECT providers in the Medicare database, I think it is reasonable to estimate that are ~1000 overall in the USA.
The geographic disparities and the poor access to care, particularly for minority groups, are striking.
The authors also point out the major financial obstacle to more widespread prescription of ECT: the CMS reimbursement requirement that ECT be performed in a "hospital" setting, not in ambulatory care settings.
This paper is a must-read for all ECT providers, ~20 minutes.