Characterization of the Quality of Electroconvulsive Therapy Among Older Medicare Beneficiaries


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How many older adults receive electroconvulsive therapy (ECT) for treatment-resistant depression? Among those who receive ECT, how many finish the course? What factors might predict patients’ continuation of ECT? Explore these topics in this journal CME activity.


Background: Electroconvulsive therapy (ECT) is an important therapy for treatment-resistant depression and is especially effective for elderly individuals with depression. This is the first US nationally representative description of ECT in the elderly.

Methods: Using 2014–2015 Medicare claims data, we compared elderly individuals with major depressive disorder (using ICD-9 and ICD-10 codes) who received ECT with those who did not on demographic and clinical measures. We characterized treatment patterns by setting and the proportion of individuals receiving index and continuation/maintenance courses, subtherapeutic courses of ECT, and post-ECT follow-up care.

Results: Of all Medicare beneficiaries aged 65 years and older diagnosed with depression in 2014–2015, 7,817 (0.41%) received 1 or more ECT sessions. Compared to the general population of elderly Medicare beneficiaries with depression, recipients of ECT were slightly younger and more likely to be male, non-Hispanic, and white and live in a zip code with a higher median income. Among those who received any ECT, 33.7% received < 5 total treatments. Of those who received an index ECT treatment, 33.7% received a continuation/maintenance course of ECT, while 60.9% received some form of post-ECT follow-up treatment (additional ECT or new psychotropic medication). Receipt of psychotherapy was the strongest predictor of those who received ≥ 5 ECT treatments (adjusted odds ratio = 1.43; 95% CI, 1.22 to 1.67).

Conclusions: Despite substantial evidence of efficacy, ECT use remains rare among elderly patients with depression. Findings suggest a potential need for efforts to increase the proportion of patients receiving adequate courses of ECT and evidence-based post-ECT follow-up care.

To cite: Rhee TG, Olfson M, Kyaw Sint, et al. Characterization of the quality of electroconvulsive therapy among older Medicare beneficiaries. J Clin Psychiatry. 2020;81(4):19m13186.

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Characterization of the Quality of Electroconvulsive Therapy Among Older Medicare Beneficiaries

© Copyright 2020 Physicians Postgraduate Press, Inc.

Target Audience


Learning Objectives

Consider a therapeutic course of electroconvulsive therapy for older patients with treatment-resistant depression

Activity summary
Available credit: 
  • 1.00 AMA PRA Category 1 Credit™
  • 1.00 Participation
Activity opens: 
Activity expires: 

CME Background

Articles are selected for credit designation based on an assessment of the educational needs of CME participants, with the purpose of providing readers with a curriculum of CME articles on a variety of topics throughout each volume. Activities are planned using a process that links identified needs with desired results.

To obtain credit, read the article, correctly answer the questions in the Posttest, and complete the Evaluation. A $10 processing fee will apply.

CME Objective

After studying this article, you should be able to:

  • Consider a therapeutic course of electroconvulsive therapy for older patients with treatment-resistant depression

Statement of Need and Purpose

Despite the efficacy of ECT in older patients with MDD, it is often not provided or is provided in subtherapeutic doses. Clinicians need education about the latest evidence on treatment strategies for MDD in older patients and how treatments such as ECT might improve the remission rate.

Release, Expiration, and Review Dates

This educational activity was published in July 2020 and is eligible for AMA PRA Category 1 Credit™ through August 31, 2022. The latest review of this material was June 2020.

Disclosure of off-label usage

The authors have determined that, to the best of their knowledge, no investigational information about pharmaceutical agents or device therapies that is outside US Food and Drug Administration–approved labeling has been presented in this article.


This work was supported by a young investigator grant from the American Foundation for Suicide Prevention (Dr Wilkinson) and from the National Institute of Mental Health (R21MH117438). Dr Wilkinson also acknowledges support from the Agency for Healthcare Research and Quality (K12HS023000), the Brain and Behavior Research Foundation (formerly NARSAD), and the Robert E. Leet and Clara Guthrie Patterson Trust Mentored Research Award.

Role of the sponsor

Other than providing financial support, the funding agencies had no role in the conduct or publication of this study.

Additional information

The Medicare and National Death Index data used in this project reside on secure servers at Yale University. They are subject to Data Use Agreement #52334 between Yale University and the Research Data Assistance Center and are thus not available to the public. Queries can be directed to Dr Wilkinson.

Faculty Affiliation

Taeho Greg Rhee, PhD
Department of Community Medicine and Health Care, School of Medicine, University of Connecticut, Farmington, and Yale Depression Research Program, Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut

Mark Olfson, MD, MPH
Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York

Kyaw Sint, PhD
Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut

Samuel T. Wilkinson, MD*
Yale Depression Research Program, Department of Psychiatry, Yale School of Medicine, and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut

*Corresponding author: Samuel T. Wilkinson, MD, Yale Depression Research Program, Yale School of Medicine, 100 York St, STE 2J, New Haven, CT 06511 (

Financial Disclosure

All individuals in a position to influence the content of this activity were asked to complete a statement regarding all relevant personal financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute has resolved any conflicts of interest that were identified. In the past year, Marlene P. Freeman, MD, Editor in Chief of The Journal of Clinical Psychiatry,  has received research funding from JayMac and Sage; has been a member of the advisory boards for Otsuka, Alkermes, and Sunovion; has been a member of the Independent Data Safety and Monitoring Committee for Janssen; has been a member of the Steering Committee for Educational Activities for Medscape; and, as a Massachusetts General Hospital (MGH) employee, works with the MGH National Pregnancy Registry, which is sponsored by Teva, Alkermes, Otsuka, Actavis, and Sunovion, and works with the MGH Clinical Trials Network and Institute, which receives research funding from multiple pharmaceutical companies and the National Institute of Mental Health. No member of the CME Institute staff reported any relevant personal financial relationships.

Dr Wilkinson has received contract funding from Janssen and Sage Therapeutics for the conduct of clinical trials administered through Yale University; anticipates receiving contract funding from LivaNova and Oui Therapeutics for conducting clinical trials; and has received consulting fees from Janssen, Oui Therapeutics, and Biohaven Pharmaceuticals. Drs RheeSint, and Olfson have no personal affiliations or financial relationships with any commercial interest to disclose relative to the article.

Accreditation Statement

The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation

The CME Institute of Physicians Postgraduate Press, Inc., designates this journal-based CME activity for a maximum of 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note: The American Nurses Credentialing Center (ANCC) and the American Academy of Physician Assistants (AAPA) accept certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by the ACCME.

Available Credit

  • 1.00 AMA PRA Category 1 Credit™
  • 1.00 Participation


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