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Using nationwide 2023 administrative data from the German psychiatric prospective payment system (PEPP), we examined whether regional ECT utilization corresponded to regional diagnostic burden and assessed patient-, institutional-, and regional-level factors associated with receiving ECT. The analysis included 837,762 inpatient psychiatric discharges; in addition, descriptive information on day hospital ECT activity was obtained from publicly available aggregate data. Across inpatient and day hospital settings, 16,312 cases received ECT and 72,193 ECT procedures were documented. Regional ECT rates showed essentially no association with the regional frequency of ECT-relevant diagnoses. ECT provision was also strongly concentrated in larger institutions. In multilevel models, depression, catatonia, schizophrenia-spectrum disorders, bipolar disorder, female sex, older age, and annual psychiatric case volume were positively associated with ECT receipt. However, substantial residual heterogeneity remained at the institutional level (median odds ratio 23.6) after adjustment for case mix and contextual factors. These findings suggest that variation in ECT use in Germany is only weakly aligned with proxies of clinical need and is shaped to a considerable extent by institutional and structural conditions, indicating potential inequities in access to ECT across regions and providers.<\/jats:p>","DOI":"10.1007\/s00406-026-02305-y","type":"journal-article","created":{"date-parts":[[2026,6,26]],"date-time":"2026-06-26T16:38:50Z","timestamp":1782491930000},"page":"3459-3468","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Electroconvulsive therapy in Germany: a nationwide multilevel analysis of determinants, regional patterns, and institutional variation"],"prefix":"10.1007","volume":"276","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-6879-604X","authenticated-orcid":false,"given":"Marie","family":"Dreger","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Uphaus","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Zilles-Wegner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Sartorius","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Guhra","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefan","family":"Kreisel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,26]]},"reference":[{"issue":"7","key":"2305_CR1","doi-asserted-by":"publisher","first-page":"667","DOI":"10.1056\/NEJMra2034954","volume":"386","author":"RT Espinoza","year":"2022","unstructured":"Espinoza RT, Kellner CH (2022) Electroconvulsive therapy. 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