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.

COVID-19 and catatonia: Prevalence, challenges, pathophysiology, and treatment.

BACKGROUND: Emerging literature supports the association between acute COVID-19 infection and neuropsychiatric complications. This article reviews the evidence for catatonia as a potential neuropsychiatric sequela of COVID-19 infection. METHODS: PubMed was searched using the terms catatonia, severe acute respiratory syndrome coronavirus 2, and COVID-19. Articles were limited to those published in the English language between 2020 and 2022. Forty-five articles that specifically studied catatonia associated with acute COVID-19 infection were screened. RESULTS: Overall, 30% of patients with severe COVID-19 infection developed psychiatric symptoms. We found 41 cases of COVID-19 and catatonia, with clinical presentations that varied in onset, duration, and severity. One death was reported in a case of catatonia. Cases were reported in patients with and without a known psychiatric history. Lorazepam was successfully used, along with electroconvulsive therapy, antipsychotics, and other treatments. CONCLUSIONS: Greater recognition and treatment of catatonia in individuals with COVID-19 infection is warranted. Clinicians should be familiar with recognizing catatonia as a potential outcome of COVID-19 infection. Early detection and appropriate treatment are likely to lead to better outcomes.

COVID-19 Pandemic and the Provision for Electroconvulsive Therapy and Other Non-Invasive Brain Stimulation in India: A Template for Future Pandemics.

The coronavirus disease (COVID-19) has emerged as a major public health concern worldwide. While containing the infection and caring for the ill has been a focus over the last 2 years, there has also been a burgeoning concern for mental health issues during this never-ending pandemic. The focus of health care machinery prioritized confronting and containing the pandemic that had majorly side-lined other aspects of public health. This also impacted persons with mental illness (PMI) requiring Electroconvulsive Therapy (ECT), an often essential and life-saving treatment and thus an essential procedure. ECT and other non-invasive brain stimulation (NIBS) services have seen a setback during this pandemic both in terms of its accessibility by the PMI and in effectively delivering its benefits by psychiatrists. In this article, we will be discussing the problems with provision and delivery of ECT services as well as other NIBS during this pandemic with a brief outline on the solutions for such with special focus on a developing country like India. This article will also endeavour in providing a roadmap in the delivery and provision of NIBS modalities of therapy for future pandemics, if any.

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.

Impact of COVID-19 on ECT Practice in Qatar.

There is paucity of Electroconvulsive therapy (ECT) utilization surveys from the Arabian Gulf region and none available from Qatar. There is no literature available on impact of Coronavirus Disease 2019 (COVID-19) pandemic on ECT provision. ECT is a lifesaving treatment in psychiatric practice requiring anesthetic support and there were concerns that redeployment of anesthetists due to COVID-19 pandemic might have comparatively bigger impact on the provision of ECT. These concerns stem from the fact that psychiatric patients often get discriminated against in health care systems; largely due to stigma and the belief among healthcare providers that psychiatric illness is somehow not as serious as other types of medical or surgical illness. In this brief report we present pre-COVID ECT utilization from Qatar. We also report findings on ECT utilization during COVID-19 and compare changes with other elective and non-elective surgeries. ECT provision was down by 40% during March to August 2020 in our setting. The decline in ECT provision was comparable to other elective and non-elective surgeries.

Catatonia After COVID-19: A Case Series.

ABSTRACT: Coronavirus disease 2019 (COVID-19) has affected more than a hundred million people worldwide. In addition to the devastating number of deaths caused by this disease, it can cause significant morbidity in some survivors. The understanding of the morbidity associated with COVID-19 is rapidly evolving. This report describes 3 cases of catatonia associated with COVID-19. Catatonia is easily confused with other forms of delirium but if recognized can be effectively treated. We hope that awareness gained from these cases would help clinicians better recognize and diagnose catatonia following COVID-19 infection.

Effectiveness of electroconvulsive therapy in acute management of delirious mania in COVID-19 positive woman in second trimester pregnancy.

Delirious mania has been described as a state of acute excitement, fluctuating sensorium, affective and catatonic symptoms. Electroconvulsive therapy (ECT) despite being an effective treatment modality in such cases, has been under-utilised during pregnancy, mainly due to safety concerns. Here, we report the effectiveness of ECT in acute management of delirious mania in a 24 weeks pregnant woman who also tested COVID-19 positive during hospitalisation. Patient presented with three weeks history of acute manic excitement with period of altered sensorium and catatonic symptoms with no response to trials of two antipsychotic agents. After organic causes ruled out, patient was planned for ECT while ongoing antipsychotic was continued. After the first ECT session, patient tested positive for COVID-19, though asymptomatic and had to be shifted to COVID-19 isolation facility. Complete resolution of psychiatric symptoms occurred after fifth ECT. All five ECT sessions, including those in COVID-19 isolation facility were carried out under supervision of a multidisciplinary team. None of the ECT sessions had any major adverse event. Symptom remission sustained even following ECT discontinuation. No neonatal or maternal adverse effects observed after an uneventful delivery at 35 weeks. Both mother and child continued to maintain well in follow-up period of one year on oral olanzapine. In this unusual concurrent presentation of mania, delirium and catatonic symptoms during second trimester pregnancy, we highlighted the effectiveness and safety of ECT as a viable treatment modality. Additionally, management challenges posed by patient testing COVID-19 positive and then, administering ECT in COVID-19 isolation facility using personal protective equipment by multidisciplinary team has been highlighted.

Provision of Electroconvulsive Therapy During the COVID-19 Pandemic: A Survey Among Clinics in Germany, Austria, and Switzerland.

ABSTRACT: The coronavirus disease 2019 (COVID-19) pandemic has had a marked impact on psychiatry. Capacity reductions also affected electroconvulsive therapy (ECT), even though ECT is an essential rather than an elective procedure. We sent a survey to all 197 clinics in Germany, Austria, and Switzerland with an ECT service between March and May 2021 to provide an overview of the changes made to ECT services in these countries during the acute phase of the COVID-19 pandemic. More than a quarter of the clinics (27.0%) reported a temporary suspension of all ECT treatments, and 28.2% of the clinics reported reductions of up to 75%. Maintenance ECT was suspended in 46.7% of the clinics and reduced by up to 75% in 30.6% of the clinics. At the time of the survey, 40.8% of the clinics still reported lower numbers of ECT treatments compared with the prepandemic situation. Reasons for the reduced number of ECT treatments included patient safety and testing measures, personnel shortages in the anesthesiology departments, and limited availability of rooms. The COVID-19 pandemic had and continues to have a marked negative impact on the provision of ECT in clinics in Germany, Austria, and Switzerland. To avoid negative consequences for patients, ECT clinics should urgently take steps to provide ECT services without disruptions.

The Use of ECT in the Elderly-Looking Beyond Depression.

PURPOSE OF REVIEW: We reviewed recent evidence on the use of electroconvulsive therapy (ECT) in the geriatric population. This review looked at the literature on depression, for which there is a breadth of data, as well as other conditions that have historically not been as well studied, as well as attempting to provide practical recommendations for ECT practitioners. This review also examined the impact of the COVID-19 pandemic on ECT in the elderly. RECENT FINDINGS: ECT shows robust efficacy across many psychiatric diseases, from depression and bipolar disorder to psychosis and catatonia. It has also shown positive results at improving behavioral symptoms of dementia, as well as improving motor symptoms seen in Parkinson's disease. It is routinely found to be a safe treatment as well, generally with only minimal transient side effects. ECT should not be considered a "last-resort" treatment for geriatric patients suffering from psychiatric disorders. It has historical and recent literature supporting its use in many psychiatric disorders and has been shown to be safe with minimal side effects when appropriate considerations are taken for the elderly population.

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.

Discontinuation of Continuation or Maintenance Electroconvulsive Therapy Caused by the COVID-19 Pandemic: A Naturalistic Study Investigating Relapse in Patients With Major Depressive Disorder.

BACKGROUND: Continuation or maintenance electroconvulsive therapy (C/M-ECT) is recommended to reduce relapse rates of patients with major depressive disorder. During the ongoing COVID-19 pandemic, ECT services have come under pressure or needed to close because of redirected resources and safety reasons. We investigated the impact of C/M-ECT discontinuation on relapse in patients with unipolar depressive disorder in Flanders, Belgium. METHODS: Between March 30 and June 18, 2020, all patients receiving C/M-ECT in 2 ECT centers were included. Continuation or maintenance electroconvulsive therapy was discontinued in 33 patients and continued in 4 patients. Relapse was defined as the need to restart ECT or the need for hospitalization. Depressive symptoms were assessed every 3 weeks using the Patient Health Questionnaire, the Clinical Global Impression Scale, and 2 additional patient-rated questions. RESULTS: Relapse in the discontinuation group was 60.6%. All 4 patients who continued ECT remained remitted. Kaplan-Meier survival analysis showed significantly shorter relapse rates for patients receiving bitemporal and/or frequent C/M-ECT (1- to 2-week intervals). Patients older than 60 years showed longer survival rates. CONCLUSIONS: Our results confirm earlier prospective and retrospective data regarding the efficacy and importance of C/M-ECT as relapse prevention. After treatment discontinuation, close monitoring of early warning signs for relapse is crucial, especially in the first few months. With the COVID-19 pandemic continuing, our data provide an indication of the necessity to ensure adequate care and access to ECT not only for the acutely ill but also for the vulnerable patients who are depending on C/M-ECT.

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?

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.