Electroconvulsive therapy services during COVID-19 pandemic

Trends in Electroconvulsive Therapy Utilization in South Korea: Health Insurance Review Data From 2008 to 2018

OBJECTIVE

The study aimed to analyze and clinically correlate 10-year trends in the demographic characteristics of patients receiving electroconvulsive therapy (ECT) to provide an overview of ECT utilization in South Korea.

METHODS

Using health insurance claims data from 2008 to 2018 retrieved from Health Insurance Review and Assessment Service database in South Korea, we identified individuals undergoing ECT based on procedural codes. Descriptive analysis evaluated baseline clinical characteristics, and trend analysis used a linear regression model.

RESULTS

The prevalence of ECT increased by 240.49% (0.405/105 inhabitants in 2008 to 0.974/105 inhabitants in 2018). The increasing trend was more pronounced in younger and older patients. The proportion of women consistently exceeded that of men. A rise in the proportion of patients with affective disorders, and a decrease in the proportion of psychotic disorders was observed. More antidepressants and atypical antipsychotics were prescribed to patients undergoing ECT. The proportion of ECT sessions conducted in large hospital inpatient settings also decreased during the observation period. Despite increasing global trends, ECT prevalence in South Korea remains significantly lower than worldwide rates.

CONCLUSION

This study demonstrated an increasing trend of ECT across a wide range of population demographics and in more accessible settings. The comparatively low prevalence of ECT in Korea compared to other countries might be attributed to insufficient mental health literacy and the stigma associated with ECT. Given the elevated suicide rates in Korea, more extensive adoption of ECT appears imperative.

Etomidate versus propofol for electroconvulsive therapy: An intraindividual comparative study during the COVID-19 pandemic

OBJECTIVES

The Coronavirus disease 2019 (COVID-19) pandemic markedly influenced mental health care practices, notably regarding electroconvulsive therapy (ECT). This was due to the redistribution of anesthetic agents used during ECT such as propofol, for intensive care units. Because in our center propofol was switched to etomidate to avoid ECT activity discontinuation, we undertook this study in order to compare Propofol and Etomidate regarding electroencephalographic seizure duration and stimulus intensity.

METHODS

We performed a retrospective and comparative study, each patient being its own control. We included patients with at least two courses of ECT on propofol and two others with etomidate over the period from September 2019 to April 2021, regardless of the psychiatric diagnosis. Our data collection process notably targeted stimulus intensity, seizure duration recorded using electroencephalography, and medication used for anesthetic induction.

RESULTS

Overall, we included 18 patients with a male: female ratio of 1:2.6 and a mean (and standard deviation) age of 62.7±13.4 years. We found that the mean intensity of stimulation was significantly lower with etomidate when compared to propofol (425.3±250.0 vs. 658.9±280.2 mC, P=0.001). The mean duration of electroencephalographic seizure was significantly higher with etomidate in comparison to propofol (53.5±16.6 vs. 35.0±12.2seconds, P<0.001).

CONCLUSION

By using each patient as its own control, our study found that etomidate, while compared to propofol, was related to a lower level of stimulatory intensity and a longer electroencephalographic seizure duration.

Impact on Electroconvulsive Therapy Services, Including Patient Relapse and Death, During the COVID-19 Pandemic: Quantitative Results From a Multinational Survey

OBJECTIVES

Electroconvulsive therapy (ECT) is important in the management of major, life-threatening, and treatment-resistant psychiatric illness. The COVID-19 pandemic has significantly disrupted ECT services. The need for new infection control measures, staff redeployment and shortages, and the perception that ECT is as an "elective" procedure have caused changes to, and reductions in, ECT delivery. The aim of this study was to explore the impact of COVID-19 on ECT services, staff, and patients globally.

METHODS

Data were collected using an electronic, mixed-methods, cross-sectional survey. The survey was open from March to November 2021. Clinical directors in ECT services, their delegates, and anesthetists were asked to participate. Quantitative findings are reported.

RESULTS

One hundred and twelve participants worldwide completed the survey. The study identified significant impacts on services, staff, and patients. Importantly, most participants (57.8%; n = 63) reported their services made at least 1 change to ECT delivery. More than three-quarters (81.0%; n = 73) reported that their service had identified at least 1 patient who could not access ECT. More than two-thirds (71.4%; n = 67) reported that their service identified patients who experienced a relapse in their psychiatric illness due to lack of ECT access. Six participants (7.6%) reported that their service had identified at least 1 patient who died, by suicide or other means, due to lack of ECT access.

CONCLUSIONS

All ECT practices surveyed were impacted by COVID-19 with decreases in capacity, staffing, changes in workflow, and personal protective equipment requirements with relatively little change to ECT technique. Lack of access to ECT resulted in significant morbidity and mortality, including suicide, internationally. This is the first multisite, international survey to explore the impacts of COVID-19 on ECT services, staff, and patients.

Impact of COVID-19 on electroconvulsive therapy practice across Canadian provinces during the first wave of the pandemic

BACKGROUND

Electroconvulsive therapy (ECT) is a procedural treatment that is potentially life-saving for some patients with severe psychiatric illness. At the start of the global coronavirus disease 2019 (COVID-19) pandemic, ECT practice was remarkably disrupted, putting vulnerable individuals at increased risk of symptom exacerbation and death by suicide. This study aimed to capture the self-reported experiences of psychiatrists based at healthcare facilities across Canadian provinces who were delivering ECT treatments during the first phase of the COVID-19 pandemic (i.e., from mid-March 2020 to mid-May 2020).

METHODS

A multidisciplinary team of experts developed a survey focusing on five domains: ECT unit operations, decision-making, hospital resources, ECT procedure, and mitigating patient impact. Responses were collected from psychiatrists providing ECT at 67 ECT centres in Canada, grouped by four geographical regions (Ontario, Quebec, Atlantic Canada, and Western Canada).

RESULTS

Clinical operations of ECT programs were disrupted across all four regions - however, centres in Atlantic Canada were able to best preserve outpatient and maintenance care, while centres in Western Canada were able to best preserve inpatient and acute care. Similarly, Atlantic and Western Canada demonstrated the best decision-making practices of involving the ECT team and clinical ethicists in the development of pandemic-related guidelines. Across all four regions, ECT practice was affected by the redeployment of professionals, the shortage of personal protective equipment, and the need to enforce social distancing. Attempts to introduce modifications to the ECT delivery room and minimize bag-valve-mask ventilation were consistently reported. All four regions developed a new patient prioritization framework, and Western Canada, notably, aimed to provide ECT to only the most severe cases.

CONCLUSIONS

The results suggest that ECT provision was disproportionately affected across different parts of Canada. Possible factors that could explain these interregional differences include population, distribution of urban vs. rural areas, pre-pandemic barriers in access to ECT, number of cases, ability to control the spread of infection, and the general reduction in physicians' activities across different areas of health care. Studying these factors in the future will inform how medical centres should respond to public health emergencies and pandemic-related circumstances in the context of procedural treatments.

Management for A Depressive Patient with Femoral Neck Fracture by Electroconvulsive Therapy during COVID-19 Pandemic: A Case Report and Literature Review

Electroconvulsive therapy (ECT) is an effective treatment for refractory major depressive disorder with suicidal ideation. The most common adverse medical events are transient retrograde amnesia, falls and pneumonia. Hip fractures, associated with high-energy trauma by convulsions, were occasionally reported in western countries, in the period before the COVID-19 pandemic. Strict COVID-19 regulations influenced the course and further investigation of the treatment of post-ECT complications. A 33-year-old man, previously diagnosed with major depressive disorder, had a history of nine successful sessions of ECT treatment for depression five years ago. He was hospitalized again for 12 sessions of ECT for recurrent depression. Unfortunately, an ECT-induced right hip-neck fracture was noted after the ninth session of ECT, in March 2021. After receiving close reduction and internal fixation of the right femoral neck fracture, with three screws, his original daily function was restored. His treatment was regularly followed up at the outpatient clinic for 20 months; he achieved partial remission with three combined antidepressants. This case of ECT-induced right hip-neck fracture informed psychiatric staff to be aware of this rare adverse complication and ensure its appropriate management, especially during the COVID-19 pandemic.

Strategies from A Multi-National Sample of Electroconvulsive Therapy (ECT) Services: Managing Anesthesia for ECT during the COVID-19 Pandemic

Electroconvulsive therapy (ECT) is important in the management of severe, treatment-resistant, and life-threatening psychiatric illness. Anesthesia supports the clinical efficacy and tolerability of ECT. The COVID-19 pandemic has significantly disrupted ECT services, including anesthesia. This study documents strategies for managing ECT anesthesia during the pandemic. Data were collected between March and November 2021, using a mixed-methods, cross-sectional, electronic survey. Clinical directors in ECT services, their delegates, and anesthetists worldwide participated. One hundred and twelve participants provided quantitative responses to the survey. Of these, 23.4% were anesthetists, and the remainder were ECT clinical directors. Most participants were from Australia, New Zealand, North America, and Europe. Most were located in a public hospital, in a metropolitan region, and in a ‘medium/high-risk’ COVID-19 hotspot. Half of the participants reported their services made changes to ECT anesthetic technique during the pandemic. Services introduced strategies associated with anesthetic induction, ventilation, use of laryngeal mask airways, staffing, medications, plastic barriers to separate staff from patients, and the location of extubation and recovery. This is the first multi-national, mixed-methods study to investigate ECT anesthesia practices during the COVID-19 pandemic. The results are vital to inform practice during the next waves of COVID-19 infection, ensuring patients continue to receive ECT.

Concurrent catatonia and COVID-19 infection - An experiential account of challenges and management of cases from a tertiary care psychiatric hospital in India

Catatonia has been reported as one among many neuropsychiatric manifestations associated with COVID-19 infection. Catatonia and COVID-19 co-occurrence remain clinical concerns, often posing challenges pertaining to diagnosis, and especially management. Limited information is available regarding the appropriate approaches to the management of catatonia in COVID-19 infection, particularly with reference to the safety and efficacy of benzodiazepines and Electro-convulsive therapy (ECT). We present our experience of five patients with catatonia consequent to heterogeneous underlying causes and concurrent COVID-19 infection, who received care at the psychiatric COVID unit of our tertiary care psychiatric hospital. An interesting observation included varying underlying causes for catatonia and the potential role that COVID-19 infection may have played in the manifestation of catatonia. In our experience, new-onset catatonia with or without pre-existing psychiatric illness and concurrent COVID-19 can be safely and effectively managed with lorazepam and/or ECTs. However, critical to the same is the need to implement modified protocols that integrate pre-emptive evaluation for COVID-19 disease and proactive monitoring of its relevant clinical parameters, thereby permitting judicious and timely implementation of catatonia-specific treatment options.

"ECT should never stop": Exploring the experiences and recommendations of ECT clinical directors and anesthetists about ECT during the COVID-19 pandemic

Electroconvulsive therapy (ECT) is an effective treatment option for severe, treatment-resistant, and life-threating psychiatric illness. The COVID-19 pandemic has significantly disrupted ECT services. Services across North America, Europe, and Australia have reported decreased ECT delivery, and changes in the ways ECT is delivered. This study aimed to identify the impacts of COVID-19 on ECT services globally by exploring clinicians' experiences about ECT during the pandemic, and their recommendations for reducing the negative impacts of the pandemic. Data were collected using an electronic, cross-sectional survey, which included elicitation of free-text responses. The survey was open from March to November 2021. Clinical directors in ECT services, their delegates, and anesthetists were invited to participate. This paper reports the qualitative analysis of responses provided. Fifty-two participants provided qualitative response/s; 74.5% were clinical directors or their delegates, and 25.5% were anesthetists. Greater than one-third of participants were from Australia/New Zealand, and there was also representation from North America, Europe, and the UK. Participants' responses were detailed, averaging 43 words. Three themes were identified: (1) Service provision, about the importance of ECT services continuing during the pandemic, (2) Preparedness, through guidelines and environmental design, and (3) Personal protection, about strategies to increase staff safety. This is the first multi-site, international study to document the experiences and recommendations of ECT clinical directors and anesthetists about the effect of COVID-19 on ECT practice. The findings inform evidence-based practice, and ensure people with major psychiatric illnesses continue to receive ECT during the pandemic.

Perinatal Mental Health Care for Women With Severe Mental Illness During the COVID-19 Pandemic in India-Challenges and Potential Solutions Based on Two Case Reports

The ongoing COVID-19 pandemic in India has created several challenges in the care of women with perinatal mental illness. Access to healthcare has been disrupted by lockdowns, travel restrictions, and the unavailability of outpatient services. This report aims to discuss the challenges faced by women with severe mental illnesses during the perinatal period with the help of two case reports. Accordingly, we have highlighted the role of COVID-19 infection as a traumatic event during childbirth and its role in triggering a psychotic episode in women with vulnerabilities; difficulties faced by women with postpartum psychosis in accessing perinatal psychiatry services; and the challenges of admission into an inpatient Mother-Baby Unit (MBU). Further, we have discussed potential solutions from the perspectives of Lower and Middle-income (LAMI) countries that need to be extended beyond the pandemic. They include offering video consultations, reviewing hospital policies, and evolving strategies to mitigate traumatic experiences for pregnant and postpartum women with severe mental illnesses in both obstetric and psychiatric care.