INTERNATIONAL J O U R N A L OF GERIATRIC PSYCHIATRY. VOL 11: 473-476 (1996)

FACTORS AFFECTING COMPLIANCE WITH MAINTENANCE ELECTROCONVULSIVE

THERAPY: A PRELIMINARY STUDY EDWARD KIM. MARC H ZISSELMAN A N D RODNEY PELCHAT

Assistant Professor, Department of’ Psychiatry and Hurnari Bt~havior, Jcferson Medical College of Thomas Jefferson University, and Attending Geriatric PsychiatriJt, Wills Eye Hospital, Philadelphia, USA

SUMMARY Maintenance electroconvulsive therapy (ECT) has been shown to be an effective treatment modality in preventing relapse in major depression following acute treatment. Nevertheless, clinical experience suggests that are obstacles to pursuing this form of long-term treatment. A retrospective chart review was conducted on 17 patients recommended for maintenance ECT following inpatient ECT for major depression over a 2-year period. Eleven (64.7%) accepted the recommendation and six (35.3%) refused. The two groups did not differ with respect to age, race, gender or number of medical codiagnoses. Patients who agreed to undergo maintenance ECT tended to live at home while all but one who refused lived in institutional settings ( p < 0.01). The type of social support available approached statistical significance ( p < 0.12), as did MMSE score ( p < 0.1 1). Patients with family support or MMSE scores lower than 27 tended to accept outpatient ECT (relative risk 7.00, 95% CI (0.69, 70.78)). These findings suggest that patients living in the community and with significant Family involvement are more likely to comply with outpatient ECT than those living in institutions and supported by professional personnel irrespective of cognitive status or other clinical or demographic factors

KEY WORDS-ECT; compliance; maintenance ECT

There has been increased recognition of the need for long-term management strategies for the treatment of major depression in the elderly. Recent reports have shown maintenance electro- convulsive therapy (ECT) to be an effective treatment modality in sustaining remission after treatment of the acute episode (Kramer, 1990; Thornton et a/., 1990; Petrides et al., 1994; Vanelle et al., 1994). In fact, there is evidence that patients who receive ECT for medication-refractory depression are more likely to relapse on continua- tion medication therapy (Sackheim et al., 1990). Literature reviews have found that most patients find ECT to be a beneficial treatment and would consent to have it again. However, other studies have described a proportion of patients who developed a ‘pathologic’ fear of ECT during the course of treatment, ultimately leading to refusal (Fox, 1993). Given the high rate of relapse after

Address for correspondence: Dr E. Kim, Department of Geriatric Psychiatry, Wills Eye Hospital, 900 Walnut Street, 8th Floor, Philadelphia, PA 19107, USA. Tel: 215-928-3033. Fax: 215-928-1317.

CCC 0885-6230/96/050473 -04 8 1996 by John Wiley & Sons, Ltd

successful ECT in elderly depressed patients and the efficacy of maintenance ECT (Stoudemire et al., 1994), i t is important to determine what factors lead to refusal of this effective treatment. In this pilot study we sought to examine barriers that preclude patients from entering into or continuing in physician-prescribed outpatient maintenance ECT treatment regimens.

METHODS

Setting

The Wills/Jefferson Geriatric Psychiatry Unit is a 26-bed facility specifically designed for an elderly disabled population. The unit treats elderly patients who suffer from chronic age-related psychiatric, medical and neurologic disorders such as depression, dementia, Parkinson’s disease and stroke. The multidisciplinary program involves the participation of psychiatry. neurology, internal medicine, occupational therapy and social work. There are approximately 20 new admissions per month, with an approximate length of stay of

Received 28 March 1995 Accepted 7 June 1995

474 E. KIM. M. H. ZISSELMAN A N D R. PELCHAT

25 days. The majority of patients suffer from depressive disorders (44%) and dementias (44%).

Study design

A retrospective chart review was conducted of all patients admitted to the unit who received ECT over a 2-year period ( N = 59). Of these, outpatient maintenance ECT was recommended to 15 patients (25.4%) due to either a rapid relapse of depression on prophylactic antidepressant medication follow- ing inpatient ECT treatment or intolerance of such medications. This was in accordance with the American Psychiatric Association Task Force on ECT (1990) guidelines for continuation and main- tenance ECT immediately following discharge and for long-term prophylaxis.

These 15 charts were reviewed by the author for specific data including demographics, Mini-Mental State Exam (MMSE) score on admission, the number of comorbid medical conditions and the number of inpatient treatments prior to recom- mendation of maintenance ECT. In addition, postdischarge living setting and social support were noted based on hospital social work assess- men t s .

Statistical analysis

The cohort of patients who complied with outpatient ECT were compared to those who refused with respect to the previously mentioned variables using chi-square tests. In cases where there was a trend towards significance using chi- square tests, the groups were also compared using odds ratios.

RESULTS

Table 1 describes our patient sample. Patients had a mean age of 78.9 and were predominantly female and white. The mean MMSE score was 26.5, and patients had an average of 3.3 medical diagnoses in addition to depression. They received a mean of 7.1 inpatient treatments during hospitalization before maintenance ECT was recommended. Table 2 describes the social support variables for our patient sample. Ten (58.8%) lived at home while seven (41.2%) lived in an institutional setting such as nursing home, personal care or retirement commu- nity. Six (35.3%) had a living spouse while 13 (76.5%) had involved family other than a spouse.

Results of our statistical analysis comparing patients who accepted maintenance ECT with those who refused appear in Table 3. A total of 15 patients received the recommendation to under- go outpatient maintenance ECT. Of these, eleven (64.7%) consented to undergo the treatment while six (35.3%) did not. These two groups demon- strated no significant differences in age, race, gender or number of medical codiagnoses. Patients who accepted the recommendation of outpatient ECT tended to live at home, while all but one of those who refused lived in institutional settings ( p < 0.01). The type of support, ie family versus professional, approached statistical significance ( p < 0.12), as did MMSE score ( p < 0.11). Patients with family support or MMSE scores lower than 27 tended to accept outpatient ECT (relative risk 7.00, 95% CI (0.69, 70.78)).

DISCUSSION

The safety and efficacy of electroconvulsive therapy for the acute treatment of depression and long-term prophylaxis against relapse of depression has been well documented (Kramer, 1990; Thornton et al., 1990). Nevertheless, fear of

Table 1. Demographic and clinical variables in patients recommended for maintenance ECT ( N = 17)

Age Sex

Male Female

White Black

Race

MMSE score Medical diagnoses Number of ECT inpatient treatments

78.9k7.2

3 (17.6%) 14 (82.4%)

16 (94.1 Yo) 1 (5.9%) 26.5 2. I 3.3 k 1.9 7.1 f 2.7

Table 2. Social support variables in patients recom- mended for maintenance ECT ( N = 17)

Disposition Home 10 (58.8%) Institution 7 (41.2%)

Living spouse 6 (35.3%) Involved family 13 (76.5%) Home services I (5.9%) Institutional personnel 7 (41.2%) Total number of social support types 1.6fO.6

MAINTENANCE ECT 475

the treatment continues to pose an obstacle to ECT. Some studies indicate that some of the patients who most vigorously object to ECT are those who have previously been treated and experienced a satisfactory response (Fox, 1993). Others indicate that a majority of patients who have received ECT felt that they had benefited from it and would consent to it again if they became depressed (Baxter ef a/., 1986; Hughes et al., 1981). In particular, prior education regarding the purpose, risks and benefits of the treatment involved in the consent process may be poorly recalled due to the amnestic effects of ECT (Freeman and Chesire, 1986). This may limit the influence of such education on future compliance.

A striking finding in our patient sample is that patients residing at home were more likely to comply with maintenance ECT than those living in institutions. The presence of an involved family member was not found to be statistically signifi- cant, but this may be due to our small sample size. The trend in our sample, however, suggests that family involvement exerted a positive influence on acceptance of outpatient ECT. One might expect that the problem of bringing a relative for ECT on a regular basis, and in our service quite early in the morning, would prove to be an insurmountable

Table 3. Comparison between patients who accepted and refused maintenance ECT

Accepted ( N = 1 1 )

Age 78.3 k 8.6 Sex

Male 3 (27.3%) Female 8 (72.7%)

Race White 10 (90.9%) Black 1 (9.1%)

MMSE score 25.6$-2.6 Medical diagnoses 3.5 2.2 Number of ECT 7.2+2.5

Disposition inpatient treatments

Home 9 (81.8%) Facility 2 (18.2%)

Total number of 1.8k0.6

Support type support types

Family 9 (81.8%) Professional 2 (18.2%)

Refused p-value for ( N = 6) chi-square* and

Fisher’s exact**

80.2 k 3.9 0.54*

0 (0%) 6 (lOOo/,) 0.51**

6 (100%) 0.65** 0 (0%) 0.65** 27.3 & 2.3 0.20* 3.021.3 0.5Y* 6.8 2 3.3 0.83*

1 (16.7%) 5 (83.3%) O.OOY** 1.320.5 0.11*

2 (33.3%) 4 (66.7%) 0.05**

inconvenience. This would lead to the prediction that patients who reside in institutional living situations such as personal care facilities, boarding homes and nursing homes would be more compliant with treatment in that transportation and scheduling could be more easily arranged through these facilities. Our findings do not support this prediction, and demonstrate the importance of involved familial caregivers in ensuring treatment compliance in the elderly. While we have not specifically studied the degree of caregiver distress in this study, we might surmise that the recommendation of maintenance ECT was in part accepted and supported by family members as well as patients due to the familial distress caused by the patient’s illness. It is known that the degree of anxiety and emotional distress in caregivers is a risk factor for relapse in major depression in general (Hinrichsen and Hernandez, 1993) This distress might motivate family members as well as patients to override their initial objections to the treatment and invest more effort in continued treatment.

The finding that lower admission MMSE scores correlated weakly with acceptance of maintenance ECT is somewhat paradoxical in that those who complied tended to live in the community. The fact that patients with generally intact cognitive functioning were living in institutional settings may be due to disability resulting from untreated or partially treated depression; patients with significant cognitive deficits may be able to function well in the community provided they have adequate social resources and their depres- sion is in remission. Further research comparing cognitive and functional deficits in depressed individuals living in the community and in institutions would help clarify this issue.

This study presents pilot data and is limited by the small sample size and the use of retrospective data acquisition. We did not investigate a number of factors that have been linked to the prognosis of late life depression. Individual factors such as smoking, alcohol use, lower socioeconomic status, decreased the satisfaction and feelings of lone- liness have been associated with poorer outcomes for individuals with depression (Stewart, 1991; Evans et ul., 1991; Burvill et a/. , 1991). Factors relating to a person’s medical and psychiatric status have also been implicated in the long-term outcome of late life depression (Harlow et al., 1991; Green et a/., 1992; Fawcett, 1995). We are unaware which if any of these factors may have

476 E. KIM. M. H . ZISSELMAN A N D R. PELCHAT

been present in our patient sample and what effect they may have had on the decision to accept o r reject physician-prescribed maintenance ECT. Likewise, we did not examine the physician- patient relationship and how it may have influenced the decision-making process. Further investigation of the degree of family involvement and family distress would be needed to better elaborate the factors which contribute to or interfere with compliance with maintenance ECT in a geriatric population. Such studies could lead to the development of interventions to decrease utilization of acute hospital care resulting from early relapse due to non-compliance with main- tenance ECT.

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American Psychiatric Association Task Force on Electroconvulsive Therapy (1990) The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. American Psychiatric Association, Washington.

Baxter, L. R., Roy-Byrne, P., Liston, E. H. and Fair- banks, L. (1986) The experience of electroconvulsive therapy in the 1980s: A prospective study of the knowledge, opinions, and experience of California electroconvulsive therapy patients in the Berkeley years. Convuls. Ther. 2, 179-189.

Burvill, P. W., Hall, W. D., Stampfer, H. G . and Emmerson, J. P. (1991) The prognosis of depression in old age. Brit. J . Psychiat. 158, 6471.

Evans, M. E., Copeland, J. R. M. and Dewey, M. E. (1991) Depression in the elderly in the community: Effect of physical illness and selected social factors. Int. J . Geriatr. Psychiat. 6, 787-795.

Fawcett, J. (1995) Compliance: Definitions and key terms. J . Clin. Psychiat. 56(Suppl.), 4-8.

Fox, H. A. (1993) Patients’ fear of and objection to electroconvulsive therapy. Hosp. Commun. Psychiat.

Freeman, C. P. L. and Chesire, K. E. (1986) Attitude 44, 357-360.

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