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.

Recruiting for a randomized clinical trial for late-life depression during COVID-19: outcomes of provider referrals vs. Facebook self-referrals

Objective To evaluate the effectiveness of online recruitment for a clinical trial of pharmacotherapy for late-life depression during COVID-19. Methods We calculated the yield, defined as recruitment leading to randomization (enrollment), from provider referrals versus Facebook self-referrals;compared characteristics and drop-out rates of participants from each source;and analyzed correlations between stringency of public health restrictions and referrals from each source over time. Results Provider referrals had a significantly higher yield (10 of 33 referrals;30.3%) versus Facebook self-referrals (14 of 323;4.3%) (p<0.00001). Participants self-referred from Facebook had significantly more education;otherwise, both groups had similar characteristics and drop-out rates. While public health stringency was negatively correlated with provider referrals (ρ=–0.32) and positively correlated with Facebook self-referrals (ρ=0.39), neither association reached statistical significance. Conclusions Online recruitment may improve access to clinical research for older depressed adults. Future studies should evaluate cost-effectiveness and potential barriers such as computer literacy.

Recruiting for a Randomized Clinical Trial for Late-Life Depression During COVID-19: Outcomes of Provider Referrals Versus Facebook Self-Referrals.

OBJECTIVE: To evaluate the effectiveness of online recruitment for a clinical trial of pharmacotherapy for late-life depression during COVID-19. METHODS: The authors calculated the yield, defined as recruitment leading to randomization (enrollment), from provider referrals versus Facebook self-referrals; compared characteristics and drop-out rates of participants from each source; and analyzed correlations between stringency of public health restrictions and referrals from each source over time. RESULTS: Provider referrals had a significantly higher yield (10 of 33 referrals; 30.3%) versus Facebook self-referrals (14 of 323; 4.3%) (p <0.00001). Participants self-referred from Facebook had significantly more education; otherwise, both groups had similar characteristics and drop-out rates. While public health stringency was negatively correlated with provider referrals (ρ = -0.32) and positively correlated with Facebook self-referrals (ρ = 0.39), neither association reached statistical significance. CONCLUSION: Online recruitment may improve access to clinical research for older depressed adults. Future studies should evaluate cost-effectiveness and potential barriers such as computer literacy.

Brief App-Based Cognitive Behavioral Therapy for Anxiety Symptoms in Psychiatric Inpatients: Feasibility Randomized Controlled Trial.

BACKGROUND: Psychiatric inpatients often have limited access to psychotherapeutic education or skills for managing anxiety, a common transdiagnostic concern in severe and acute mental illness. COVID-19-related restrictions further limited access to therapy groups on inpatient psychiatric units. App-based interventions may improve access, but evidence supporting the feasibility of their use, acceptability, and effectiveness in psychiatric inpatient settings is limited. MindShift CBT is a free app based on cognitive behavioral therapy principles with evidence for alleviating anxiety symptoms in the outpatient setting. OBJECTIVE: We aimed to recruit 24 participants from an acute general psychiatric inpatient ward to a 1-month randomized control study assessing the feasibility and acceptability of providing patients with severe and acute mental illness access to the MindShift CBT app for help with managing anxiety symptoms. METHODS: Recruitment, data collection, analysis, and interpretation were completed collaboratively by clinician and peer researchers. Inpatients were randomized to two conditions: treatment as usual (TAU) versus TAU plus use of the MindShift CBT app over 6 days. We collected demographic and quantitative data on acceptability and usability of the intervention. Symptoms of depression, anxiety, and psychological distress were measured in pre- and poststudy surveys for preliminary signals of efficacy. We conducted individual semistructured interviews with participants in the MindShift CBT app group at the end of their trial period, which were interpreted using a standardized protocol for thematic analysis. RESULTS: Over 4 weeks, 33 inpatients were referred to the study, 24 consented to participate, 20 were randomized, and 11 completed the study. Of the 9 randomized participants who did not complete the study, 7 were withdrawn because they were discharged or transferred prior to study completion, with a similar distribution among both conditions. Among the enrolled patients, 65% (13/20) were admitted for a psychotic disorder and no patient was admitted primarily for an anxiety disorder. The average length of stay was 20 days (SD 4.4; range 3-21) and 35% (7/20) of patients were involuntarily admitted to hospital. Small sample sizes limited accurate interpretation of the efficacy data. Themes emerging from qualitative interviews included acceptability and usability of the app, and patient agency associated with voluntary participation in research while admitted to hospital. CONCLUSIONS: Our study benefitted from collaboration between peer and clinician researchers. Due to rapid patient turnover in the acute inpatient setting, additional flexibility in recruitment and enrollment is needed to determine the efficacy of using app-based psychotherapy on an acute psychiatric ward. Despite the limited sample size, our study suggests that similar interventions may be feasible and acceptable for acutely unwell inpatients. Further study is needed to compare the efficacy of psychotherapeutic apps with existing standards of care in this setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT04841603; https://clinicaltrials.gov/ct2/show/NCT04841603.

PAS-MCI: Design and Rationale for a Randomized Controlled Trial to Enhance Prefrontal Cortical Plasticity and Working Memory in Individuals with Amnestic Mild Cognitive Impairment

Introduction Amnestic Mild Cognitive Impairment (aMCI) is a prodromal stage to Alzheimer's disease dementia (AD). Improving prefrontal cortical function in individuals with MCI could prevent progression from aMCI to AD. A key mechanism that has been linked to memory formation and thus may underlie this progression is cortical plasticity. Paired Associative Stimulation (PAS) is an intervention that uses transcranial magnetic stimulation (TMS) to enhance cortical plasticity. When delivered to the prefrontal cortex in individuals with AD, it has shown promise to improve prefrontal cortical plasticity and working memory. PAS-MCI is a randomized controlled trial (RCT) that aims to assess: (1) dorsolateral prefrontal cortex (DLPFC) plasticity in individuals with aMCI and compare it to cognitively unimpaired control participants, (2) the efficacy of PAS delivered for 10 days bilaterally to the DLPFC of individuals with aMCI in enhancing their DLPFC plasticity, working memory, and executive function, and (3) whether changes in DLPFC plasticity mediate changes in working memory and executive function. Methods 100 aMCI and 50 cognitively unimpaired (CU) control participants will be assessed clinically and cognitively, and then undergo a baseline PAS combined with electroencephalography (PAS-EEG) to characterize left DLPFC plasticity. The aMCI participants are randomized (1:1) to receive 10 daily sessions of either active or sham PAS delivered to the left and right DLPFC. On Day 0, 7, and 28 following the 10-day PAS course, participants undergo repeat cognitive testing and PAS-EEG to assess changes in working memory, executive function, and left DLPFC plasticity. Results Recruitment started on October 12, 2020 and as of October 16, 2021, we have already consented 9 aMCI and 7 CU participants. Of the 16 participants, 4 MCI and 4 CU participants were enrolled and 3 MCI and 4 CU completed the study (1 MCI participant is still active). Among the 5 participants who did not enroll, 3 were excluded because of: a contraindication for TMS (n = 1), having dementia and not MCI (n = 1), and having non-amnestic MCI (n = 1);1 withdrew before enrolment due to fatigue;and 1 is still undergoing eligibility assessments. Among the 3 CU participants who did not enroll, 2 were excluded because of low cognitive scores and 1 is still undergoing eligibility assessments. Conclusions Despite the COVID-19 pandemic, we were able to initiate recruitment over the past year. If successful, this RCT will establish the short-term efficacy of PAS, a new TMS approach to enhance prefrontal cortical function in individuals with aMCI. A follow-up longer-term trial will be then needed to assess whether PAS could prevent cognitive decline and progression to AD. This research was funded by Canadian Institutes of Health Research (CIHR) Project Grant # 201809 (PI: Rajji)

The Effect of Repetitive Transcranial Magnetic Stimulation on Suicidal Ideation in Treatment-Resistant Depression: A Meta-Analysis.

Objective: To quantitatively synthesize the literature on the effects of repetitive transcranial magnetic stimulation (rTMS) on suicidal ideation (SI) in patients with treatment-resistant depression.Data Sources: A literature search was conducted using PubMed, SCOPUS, Ovid, MEDLINE, Embase, and Web of Science from inception to January 11, 2021, for the keywords repetitive transcranial magnetic stimulation, suicidal ideation, suicidality, treatment-resistant depression, refractory depression, transcranial magnetic stimulation, and brain stimulation.Study Selection: A total of 16 publications were eligible for inclusion. Studies were included that investigated the effects of rTMS in adolescents and/or adults 16 years or older diagnosed with unipolar or bipolar depression with suicidal ideation data before and after rTMS intervention.Data Extraction: Data were extracted and managed using Covidence. Extracted data included authors, publication year, country of origin, study design, patient demographics, primary diagnosis, comorbidities, mean age, outcome assessment instruments, detailed stimulation parameters, sham control procedures, and any serious adverse events related to SI.Results: A quantitative analysis of effect size using Hedges g was calculated for both randomized controlled trials and all other uncontrolled trials. We found a decrease in SI scores in randomized controlled trials (g = 0.158, 95% confidence interval [CI] = -0.078 to 0.393, P = .191), although the effect was not significant. There was a significant decrease in suicidal ideation scores for uncontrolled trials (g = 0.692, 95% CI = 0.463 to 0.922, P < .001).Conclusions: Our findings suggest that rTMS may be an effective treatment for SI in individuals with treatment-resistant depression, although further investigation is warranted.

Electroconvulsive Therapy in Canada During the First Wave of COVID-19: Results of the "What Happened" National Survey.

OBJECTIVES: The COVID-19 pandemic has disrupted the provision of essential and potentially life-saving procedural treatments such as electroconvulsive therapy (ECT). We surveyed ECT providers across Canada to understand how the first wave of the pandemic affected ECT delivery between mid-March 2020 and mid-May 2020. METHODS: The survey was administered to ECT team members and decision makers at 107 Canadian health care centers with a focus on 5 domains: operations, decision-making, hospital resources, ECT procedure, and patient impact. Responses were obtained from 72 institutions, and collected answers were used to derive representative responses reflecting the situation at each ECT center. For specific domains, responses were split into 2 databases representing the perspective of psychiatrists (n = 67 centers) and anesthesiologists (n = 24 centers). RESULTS: Provision of ECT decreased in 64% centers and was completely suspended in 27% of centers after the onset of the pandemic. Outpatient and maintenance ECT were more affected than inpatient and acute ECT. Programs reported a high level of collaboration between psychiatry and hospital leadership (59%) but a limited input from clinical ethicists (18%). Decisions were mostly made ad hoc leading to variability across institutions in adopted resource allocation, physical location of ECT delivery, and triaging frameworks. The majority of centers considered ECT to be aerosol-generating and incorporated changes to airway management. CONCLUSIONS: Electroconvulsive therapy services in Canada were markedly disrupted by the COVID-19 pandemic. The variability in decision-making across centers warrants the development of a rational approach toward offering ECT in pandemic contexts.

Accelerated intermittent theta burst stimulation in late-life depression: A possible option for older depressed adults in need of ECT during the COVID-19 pandemic

Objective: Electroconvulsive therapy (ECT) is an essential psychiatric service with an important role in treating older adults with severe or treatment-resistant depression. During the COVID-19 pandemic, ECT services have be constrained by infection control measures. We report a case of a 66-year-old female patient with a severe major depressive episode who had previously responded to right unilateral ECT and was treated with two modified accelerated intermittent theta-burst stimulation (aiTBS) protocols. Methods: The two aiTBS courses consisted of eight daily sessions over five consecutive days, followed by gradual tapering, using 1,800 pulses per session pre-COVID-19 (first course), and 600 pulses per session during the pandemic (second course). Results: Moderate to severe baseline depressive symptoms reached remission levels after both courses. Conclusion: The 600-pulses aiTBS treatment protocol reported here warrants further study and evaluation, but may be a potential option in cases where older adults with severe depressive symptoms cannot access ECT during the COVID-19 pandemic. (PsycInfo Database Record (c) 2021 APA, all rights reserved)