3 questions to… Coralie Gandré, Pierre Lecarpentier and Magali Coldefy following the publication of Issues in Health Economics n° 267, April 2022: "The Use of Electroconvulsive Therapy in France: Initial National Findings Underline Significant Disparities", in collaboration with Anis Ellini
Electroconvulsive therapy (ECT), which is one of the recommended treatments for severe psychiatric disorders that are resistant to standard treatments, is a procedure that consists of triggering an epileptic crisis under general anaesthesia. After having spread rapidly throughout the Western world at the end of the 1930s, ECT, rivalled by the arrival of psychotropic drugs, was widely criticised, due in particular to abusive practices during the Second World War. It was only in the decade 1970-80 that the treatment made a comeback, due, on the one hand, to the identification of the limitations of psychotropic drugs (side effects, drug resistance, etc.), and, on the other hand, the proven effectiveness of ECT in randomised clinical trials. Clinical guidelines were then published in many countries, including France.
Nevertheless, while many scientific studies concur on the benefits and innocuity of ECT for persons suffering from severe and drug-resistant psychiatric disorders, in comparison with the long-term administration of psychotropic medicines, ECT is still associated with negative représentations and there is an ongoing debate on these issues in the scientific literature. The lack of recent data about the use of ECT, which has been emphasized by many stakeholders, participates in maintaining fears about this practice, which remains little known. In this context, the availability of an additional record of ECT procedures in France in 2017, was the departure point for this study, which provided large-scale information based on data that was more exhaustive to assess the use of this treatment.
In accordance with national guidelines, ECT is a highly specialised treatment that concerned 3,705 individuals for 44,668 procedures and just over 1% of adults hospitalised for at least one whole day in psychiatric facilities in France in 2019. These individuals were older, most often female, had more severe and complex psychiatric disorders and were more likely to have severity markers than the other persons hospitalised under the same conditions. These clinical characteristics comply with national guidelines. Nevertheless, these guidelines are old and should be updated, incorporating the viewpoints of the individuals who have undergone ECT. Furthermore, significant variations in the rate of use of ECT have been observed between hospitals in charge of the psychiatric follow-up and these variations did not seem to be solely associated with patients’ characteristics, which raises questions.
Beyond the differences in the characteristics of the patients treated, our results underline that a significant part of the disparities in the use of ECT between facilities is associated with healthcare supply characteristics: in particular the type of facility in charge of the psychiatric follow-up and the distance to the closest facility providing ECT. This finding raises questions about the heterogeneity of treatments of severe drug-resistant psychiatric disorders, whereas French psychiatry was initially conceived in such a way as to provide similar psychiatric services throughout the country via a territorial organisation.
The lack of a stepped-care approach in mental health as well as the compartmentalisation of psychiatric and somatic care, resulting from the historical territorial organisation of mental health care, may partly explain the heterogeneity in the use of ECT, a treatment that is indicated in a limited number of clinical situations. Although this highly specialised treatment is not intended to be locally available, access to it must be facilitated by a better coordination of care, enabling better referrals, between hospitals in charge of regular psychiatric follow-up and those providing specialised care.