Utilization of Electroconvulsive Therapy for Older Homeless Adults Covered by Medicare

This study sought to examine the association between homelessness and receipt of electroconvulsive therapy (ECT) among older Medicare beneficiaries with homelessness. Among individuals with major depressive disorder who were older (age 65+) Medicare beneficiaries (2014-2015 data), we compared clinical and sociodemographic characteristics among those who were homeless and received ECT, those who were not homeless and received ECT, those who were homeless and did not receive ECT, and those who were domiciled and did not receive ECT. The unadjusted rate of ECT use among older homeless individuals with depression (1.46%) was higher than the rate of ECT use among older non-homeless individuals with depression (0.41%). Among all individuals receiving ECT, homeless individuals started as inpatients at a greater rate (94.0% v. 72.6%) and transitioned to outpatient ECT at a lower rate (23.8% v. 44.5%) compared to their domiciled counterparts. The individuals in the ECT/homeless group had more psychiatric comorbidities compared to all other groups. After adjusting for significant covariates, homelessness was associated with a lower odds ratio (0.74, 95% CI 0.55-0.99) of receiving ECT. Our data suggest that ECT can be provided to homeless individuals at rates comparable to domiciled individuals. The psychosocial support typically required for an ECT course may prove difficult for homeless patients in the outpatient setting, which may be an area for further development.