From the Editor

It’s difficult not to be excited about Bell Let’s Talk. Last week’s event set a fundraising record. Pause for a moment and appreciate how far we have traveled: a major Canadian corporation is promoting mental health awareness, raising millions of dollars in the process, and gathering praise from many, including the Prime Minister. The decline of stigma is seen across the west, with talk of tackling the opioid epidemic in New Hampshire, US, and of bettering psychological interventions in Hampshire, UK.

But how accessible is evidence-based care?

In the first selection, we consider a paper just published on ECT in the United States. Drawing on a massive database, the authors of this Psychiatric Services paper find ECT is used rarely and unevenly. In this Reading, we compare the American data to Canada’s – and draw a similar conclusion.

flag_map_of_the_contiguous_united_states_1912-1959A large country with many people – but not much ECT

And speaking of Bell Canada, in our second selection, we consider a Globe article on CEO George Cope’s recent Canada Club speech. In it, Cope challenges other businesses to implement a mental health strategy. “For business leaders… here’s the call-out: The numbers are self-funding. There’s no reason not to adopt a program in your company.”



ECT and Treatment

“Identifying Recipients of Electroconvulsive Therapy: Data From Privately Insured Americans”

Samuel T. Wilkinson, Edeanya Agbese, Douglas L. Leslie, Robert A. Rosenheck

Psychiatric Services, 1 February 2018 Ahead of Print

Major depressive disorder is the leading cause of disability worldwide and is associated with significant morbidity and mortality. Electroconvulsive therapy (ECT) is an effective therapy for severe major depressive disorder and other mood disorders. Especially among adults with treatment-resistant depression, generally defined as depression that does not remit or respond to one or more standard antidepressant pharmacotherapies, ECT stands out in its effectiveness. Whereas standard antidepressant therapies achieve response with 16%–17% of patients with treatment-resistant depression, ECT achieves response rates of 50%–70% with such patients. Recent data show that among psychiatric inpatients, ECT is associated with a 46% lower risk of 30-day readmission compared with a matched group of patients with severe depression who did not receive ECT.

ECT is thought to be underutilized despite both its demonstrated effectiveness and the significant reductions in its associated cognitive side-effect profile in recent decades. Despite evidence that it is more effective than other treatments for the most common psychiatric disorder, recent data suggest that only approximately one in 10 hospitals that provide inpatient psychiatric care even have the capacity to provide ECT. The underutilization of ECT is thought to reflect a combination of factors, including stigma, risk of cognitive side effects, and restricted access because of limited availability. However, few published studies have examined rates and correlates of ECT use in U.S. samples. Case et al. reported that the total number of hospitals offering ECT has been declining. In international settings, ECT utilization varies widely across regions, with utilization estimates ranging from 1.1 ECT patients per 100,000 people in Poland to 41 ECT patients per 100,000 people in Sweden. The most recent utilization estimates for the procedure in the United States date to 1999 or earlier and vary widely by region, ranging from eight ECT patients per 100,000 people in California in 1995 to 42 ECT patients per 100,000 people in New England in the same year.

Samuel T. Wilkinson

So begins a new paper by Samuel T. Wilkinson et al.

Here’s what they did:

  • The authors drew data from MarketScan, a database of US private insurance claims, for the year 2014, covering 47 million people. They considered those who had ECT (based on a code).
  • They included people over 18.
  • They looked at those who had ECT and considered basic demographics, geographic distribution, diagnoses (both physical and mental health), service use, and medication use.
  • Various statistical analyses were done, including logical regression.

Here’s what they found:

  • “In 2014, there were 47,258,528 individuals in the MarketScan database, of whom 5,525,173 who were older than age 18 had any psychiatric diagnosis (11.7% of all patients). Of these, 2,628 (.05%) received at least one ECT treatment, yielding a rate of 5.56 ECT patients per 100,000 in the general population and .05% of those with psychiatric diagnoses.” Considering those with a mood disorder: “2,471 (.25%) received at least one ECT treatment, representing 94.0% of all patients who received ECT.”
  • Geographic distribution. “The proportion of patients with a diagnosis of mood disorder who received ECT in the West (.19%) was substantially lower than the proportion in the Northeast (.28%), North-Central (.27%), and South (.27%), which taken together had an ECT rate of .28%.” See table below.
  • “There were no substantial differences between groups on gender, age, or proportion living in urban areas… Compared with patients with mood disorders who did not receive ECT, those who underwent ECT had a higher prevalence of renal disease (2.71% versus 1.31%) and seizures (3.12% versus 1.32%).” “Compared with those who did not receive ECT, the ECT group had substantially higher rates of comorbid alcohol use disorder (9.71% versus 4.57%). Comorbid psychiatric diagnoses were also substantially higher in the ECT group…”
  • Service use. “Compared with those who did not receive ECT, those who did had substantially higher levels of service use on measures of inpatient mental health treatment (58.7% versus 9.3%) and total number of outpatient psychiatric visits (36.7 versus 10.8).”
  • Inpatient care. “Compared with those who did not receive ECT, those who did had substantially higher levels of service use on measures of inpatient mental health treatment (58.7% versus 9.3%) and total number of outpatient psychiatric visits (36.7 versus 10.8).”
  • “Total psychotropic medication prescription fills were also substantially higher among the ECT group compared with the non-ECT group (Cohen’s d=.77).”


The authors summarize their results:

In this study of privately insured patients, .25% of patients with a diagnosis of a mood disorder received ECT in 2014. The overall ECT utilization rate was 5.56 ECT patients per 100,000 in the population. ECT utilization was associated with older age, greater psychiatric and substance use comorbidity, and greater mental health service use, specifically psychotherapy visits and psychotropic prescription fills. ECT utilization rates were also higher among those living out- side the west region.

The authors comment on ECT use:

ECT utilization rates may have declined substantially in recent decades in the United States. Our general population– based utilization rate of 5.56 ECT patients per 100,000 is substantially lower than previous estimates of 42 per 100,000 from a sample in New England in 1995 and is even lower than a study reporting eight per 100,000 from California in the same year. This trend is consistent with conclusions from a previous study of inpatient ECT, which reported a marked decline from 1993 to 2009.

A few thoughts:

  1. This is good study, drawing on an impressive dataset.
  1. Careful here: not only is the dataset American but it’s for privately insured Americans. There is evidence that those with public coverage receive less care, including fewer ECT.
  1. Use of ECT north of the 49th parallel is also problematic. As noted in a previous Reading, the Lemasson et al. study found the rate to be 10 per 100,000 in Quebec – better than the American stats, but low. And they found that ECT use had declined by 33% over a 15-year period. You can find that Reading here:
  1. And, just a reminder, there is incredible evidence for ECT. In a recent Reading, we considered the JAMA Psychiatry paper showing that ECT reduced readmissions. You can find that Reading here:


Mental Health and Corporate Canada

“Bell CEO calls on corporate Canada to implement mental health programs”

Christine Dobby

The Globe and Mail, 29 January 2018

BCE Inc. chief executive officer George Cope is calling on corporate leaders to put mental health programs in place at their companies, pointing to the business benefit that comes from helping employees stay healthy.

Speaking to a lunchtime crowd at the Canadian Club in Toronto on Monday, Mr. Cope reflected on starting the Bell Let’s Talk corporate social responsibility program eight years ago. The broad aim was to help tackle the stigma around discussing mental illness, but it also forced Canada’s largest communications and media company to consider internal changes for its own large workforce (it employed 48,000 people as of the end of 2016).

There was no existing standard for how to deal with mental health issues from a workplace perspective, he said, so BCE Inc.-owned Bell Canada worked with community leaders such as the Centre for Addiction and Mental Health (CAMH) to put together a program. He urged those in the audience to press their own companies to adopt the Mental Health Commission of Canada’s national standard for psychological health and safety in the workplace, a voluntary program developed in part with funding from Bell and launched in 2013.

George Cope

The article discusses Bell Canada.

  • Cope on the changes: “We’re certainly not perfect, but we’ve made significant strides.”
  • And the impact of those changes: “[S]ince 2010, Bell has provided mental health training for 10,000 employees, recorded a 20-per-cent reduction in mental health-related short-term disability claims and seen a 50-per-cent decline in relapses and reoccurrence.”

A few thoughts:

  1. Wow.
  1. What a great example for other corporations.
  1. Caution here: there is much work to be done. A Conference Board of Canada report found just 39% of Canadian corporations have a mental health strategy.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.