Ethical Considerations in Providing Electroconvulsive Therapy during the COVID-19 Pandemic

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.

The Impact of COVID-19 on Brain Stimulation Therapy

Among the far-reaching effects of the COVID-19 pandemic has been restricted access to safe and effective forms of psychiatric treatment. Focusing on electroconvulsive therapy and transcranial magnetic stimulation, we review the pandemic's impact on brain stimulation therapy by asking 3 fundamental questions-Where have we been? How are we doing? And where are we going?