Outcomes of patients receiving interventional psychiatric procedures in a large integrated healthcare system.

Patients receiving electroconvulsive therapy, transcranial magnetic stimulation, or ketamine intravenous treatments for treatment-resistant depression showed greater improvement on the PHQ-9 depression questionnaire at six weeks compared to those receiving standard medication management alone. Among 22,481 patients in a large integrated healthcare system, the adjusted improvement was 2.16 points greater for ECT, 2.02 points greater for ketamine, and 1.64 points greater for TMS. Certain patient characteristics were linked to worsening symptoms, including non-white race for ECT and medication management, anxiety disorder for TMS, and personality disorder for all groups. Conversely, psychotic disorder was associated with better response to ECT, and bipolar disorder with better response to ketamine. Continuation or maintenance ketamine treatment was associated with a 75% lower risk of psychiatric hospitalization within 12 months.

Study at a glance

Abstract

Interventional psychiatric procedures (IPPs) such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and ketamine intravenous treatments (KIT) are widely used for treatment resistant depression (TRD), but we lack studies of their real-world impact compared to standard outpatient medication management (MM). Longitudinal electronic health records of 22,481 patients in a large integrated healthcare system during 2018-2022 were examined to describe depression improvement via 9-item Patient Health Questionnaire (PHQ-9), changes in psychiatric admissions, and use of continuation/maintenance (C/M) treatments. Overall, each IPP group had significantly greater depression improvement at 6 weeks compared to MM: adjusted estimates TMS:1.64 (p < 0.001), KIT:2.02 (p < 0.001), and ECT:2.16 (p < 0.001). Patient characteristics were associated with symptom worsening within treatment groups, for example: (1) non-white race for ECT (2.33, p < 0.01) and MM (0.29, p < 0.001); (2) anxiety disorder for TMS (1.73, p < 0.001); and (3) personality disorder for all treatment groups, with significant coefficients found for KIT (3.27, p < 0.05) and MM (1.27, p < 0.001). Some examples of correlations with improved symptom response include: (1) psychotic disorder for ECT (-3.57, p < 0.01); and (2) bipolar disorder for KIT (-2.19; p < 0.05). For the KIT group, C/M treatment versus no C/M treatment was associated with lower risk for 12-month psychiatric hospitalization (adjusted relative risk: 0.25). This is the first study to show a protective association for maintenance ketamine on psychiatric hospitalization risk. Treatment-specific predictors of response should be confirmed in future comparative effectiveness studies.