(183) Community at Bedside: Navigating Old Order Amish Cultural Values in a Patient Undergoing Electroconvulsive Therapy

Background/Significance: We present a case in which appreciation of the patient’s cultural background and collaboration with community leaders allowed for creative implementation of psychiatric treatment, specifically Electroconvulsive Therapy (ECT).   

Case: PL is a 71-year-old Older Order Amish male with a past psychiatric history of depression and anxiety, transferred from an outside hospital following suicide attempt via autoamputation of his left hand using a saw. When Consultation-Liaison psychiatry saw the patient on hospital day two, he was profoundly dysphoric and had several features of parkinsonism. He endorsed a 15-year history of depression, worsening in the past month following the self-tapering of psychiatric medications due to fear of side effects, and he expressed continuous intense suicidal ideation and anxious distress. The patient had multiple family members present continuously at the bedside who expressed a strong desire to remain physically with him throughout treatment. This posed a significant barrier to their acceptance of standard inpatient psychiatry admission. In considering treatment options, the family noted that medical expenses were arranged through community-based funds overseen by the community spiritual leader, the Deacon. The Deacon and the patient’s family expressed interest in ECT, a treatment based in electrical machinery. Given family and patient preferences and parkinsonian features, an agreement was made for the community to fund admission to the hospital medical floor for ECT. The patient underwent nine ECT sessions with dramatic improvement in affect and mood. He was discharged home with continued outpatient ECT and follow-up at an Intensive Outpatient Program.  

Discussion: Stigma regarding mental health conditions exists in some Amish communities (Cate, 2011). Thus, it is crucial to provide culturally competent care within a biopsychosocial framework and avoid stereotyping, as it may increase willingness to engage in mental health treatment. Instead of commercial insurance, Old Order Amish communities often utilize a health insurance program called Amish Hospital Aid, which in our case allowed for the unique treatment setting (Rohrer and Dundes, 2016). Additionally, studies have shown that ECT significantly improves motor manifestations of Parkinsonism, in addition to improving depression and psychosis (Takamiya, et al 2021). In our case, the patient had rapid improvement in his suicidal ideation. 

Conclusion/Implications: Our case highlights the impact of considering both cultural and patient-specific characteristics in creating treatment plans for medically admitted patients. This case is unique because we treated a patient with ECT while admitted to the medical floors and avoided any acute inpatient psychiatric admission per patient and family request.   

References:  

Cates, J. A. (2011). Of Course It’s Confidential—Only the Community Knows: Mental Health Services With the Old Order Amish. In Ethical Conundrums, Quandaries and Predicaments in Mental Health Practice: A Casebook from the Files of Experts (pp. 309–316). online edn, Oxford Academic. Retrieved March 3, 2024,.  

Rohrer, K., & Dundes, L. (2016). Sharing the Load: Amish Healthcare Financing. Healthcare (Basel, Switzerland), 4(4), 92. https://doi.org/10.3390/healthcare4040092 

Takamiya, A., Seki, M., Kudo, S., Yoshizaki, T., Nakahara, J., Mimura, M., & Kishimoto, T. (2020). Electroconvulsive therapy for parkinson’s disease: A systematic review and meta‐analysis. Movement Disorders, 36(1), 50–58. https://doi.org/10.1002/mds.28335 


Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: Respect and humility for diverse cultural, religious, and spiritual identities is imperative to establishing health equity and inclusion. We approached care for a patient from the Old Order Amish community by gathering information from family members and community leaders and advocating for a unique care plan through the lens of his culture. Due to cultural differences, patients from this community have distinct vulnerabilities in healthcare. We reflect on how we can serve as fervent advocates by building a multidisciplinary and inter-spiritual coalition, involving community leaders, and aligning values and goals with patients to promote cultural sensitivity and equitable outcomes.