Due to the evolution of COVID-19, some countries may be forced to impose new confinements or restrictions to prevent the spread of the virus (Looi, 2020). These circumstances are accompanied by an overload on the health system, and pose a challenge in terms of management and organization (Moros et al., 2020). In this context, the dilemma of whether to suspend the treatment of seriously ill patients such as those treated in Electroconvulsive Therapy units (ECT-U) may arise again.
On March 14, 2020, Spain declared a state of alarm with people told to confine at home (Boletín Oficial del Estado, 2020). From that date until the publication of the first official recommendations in mid-May (Gil-Badenes et al., 2020), most of the ECT-U suspended or drastically reduced their activity (Daniel and Begoña, 2020). Our hospital Unit decided to maintain its activity, adapting it to the limitations at that time. The objective of this study is to present the experience of our ECT-U during the first two months of lockdown in Spain. Specifically, we intend to describe the changes made in our unit and describe the results after analysing the clinical, electrical and management variables in both maintenance ECT (m-ECT) and admitted ECT (i-ECT) patients.
We analysed all the ECTs performed from March 16, 2020 to May 16, 2020: a total of 31 patients (17 m-ECT and 14 i-ECT). Patient demographic, clinical and electrical variables were analysed: age, sex, diagnosis according to DSM-5 criteria (American Psychiatric Association, 2013), medication using standardized equivalents of psychotropics (Procyshyn et al., 2019), and ECT application parameters using the Thymatron® System IV with bi-temporal electrode placement. The following variables were included: duration of clinical seizure, duration of electroencephalographic (EEG) seizure and EEG quality indices.
The study was conducted in accordance with the latest version of the Declaration of Helsinki (World Medical Association, 2013). We followed the guidelines of the Drug Research Ethics Committee (Arnau de Vilanova University Hospital) for retrospective observational studies.
-
a)
ECT-U Management
Our ECT-U is usually located in the Post-Anesthesia Care Unit (PACU) where ECTs are performed every day for both inpatients and outpatients. During the first wave of COVID-19, due to the conversion of the PACU into an intensive care unit for COVID-19 patients, the ECT-U was transferred to a psychiatric emergency cubicle. To reduce the risk of contagion, it was decided to perform the i-ECT and m-ECT on different days. Both preventive and protective measures were taken according to the availability of resources at that time (shortage of PPE and diagnostic tests).
All patients admitted who had ECT prescribed underwent the technique, reducing the usual frequency from 3 to 2 weekly sessions. In some outpatients, treatment was discontinued, a decision made by the psychiatrists at the ECT-U in coordination with those at the Mental Health Centre, using the following criteria: 1) clinical stability during the previous 6 months, 2) no autolytic thoughts, 3) on stable medication, 4) good family support involving family members with a psychoeducation in early detection of relapses. Those who continued ECT received weekly face-to-face follow-ups prior to the procedure, and those whose inter ECT period was suspended or extended received weekly telephone follow-ups.
-
b)
Maintenance ECT (m-ECT)
We analysed the time between sessions, and clinical, pharmacological and electrical data records in maintenance ECT (m-ECT) patients and compared them to their own data records in the two-month period prior to COVID-19.
Data were collected from the 17 patients in the m-ECT program. We delayed ECT in 8 patients (47.1%) due to clinical stability, 1 patient (5.8%) had been hospitalized prior to the COVID-19 period, and 8 patients (47.1%) continued with inter-session time adjustment.
Of the patients who had their ECT suspended 87.5% were women with an average age of 66.27 years (±11.50). Diagnosis distribution according to DSM-5 criteria was: 62.5% major depressive disorder, 12.5% schizoaffective disorder, 12.5% schizophrenia. No patients with a bipolar disorder had their ECT suspended. None of the 8 patients whose m-ECT was discontinued presented a clinical relapse at 2 months.
We analysed the data of the 8 outpatients whose m-ECT was continued. They were all women with a mean age of 59.88 (±9.98) years. The distribution of diagnoses according to DSM-5 criteria were: 37.5% major depressive disorder, 25% schizoaffective disorder, 25% schizophrenia, and 12.5% bipolar disorder. We found a significant increase in inter-session time (p=0.022) with no modifications in the electrical parameters or seizure quality. There were no differences in the pharmacological treatment of the patients or in the doses of drugs administered during anaesthesia between the two periods (Table 1 ).
Table 1.
Comparison between different variables in the m-ECT and i-ECT programs before and during the first two months of the COVID-19 lockdown.
| MAINTENANCE ECT (n=8) | |||
|---|---|---|---|
| Pre COVID-19 | During COVID-19 | p-value | |
| Time between sessions (days) | 11.50 (±3.29) | 19.87 (±7.45) | p=0.022* |
| Anesthesia medication | |||
| - Propofol (ml) | 65 (±8) | 65 (±8) | p=1.000 |
| - Etomidate (ml) | 6 (±2) | 6 (±2) | p=1.000 |
| - Succinylcholine (ml) | 37 (±5) | 37 (±5) | p=1.000 |
| - Atropine (ml) | 0.6 (±0.1) | 0.6 (±0.1) | p=1.000 |
| Electrical parameters | |||
| - EEG seizure (s) | 37.12 (±5.46) | 35.37 (±13.25) | p=0.270 |
| - Motor seizure (s) | 23.75 (±6.86) | 26.87 (±13.71) | p=0.502 |
| - Charge (mC) | 430.12 (±235.75) | 466.62 (±282.78) | p=0.150 |
| Seizure quality parameters | |||
| - PSI (%) | 61.02 (±12.60) | 64.75 (±10.05) | p=0.325 |
| - COH (%) | 71.01 (±8.86) | 77.50 (±14.62) | p=0.310 |
| INPATIENT ECT (n= 14) | |||
|---|---|---|---|
| Pre COVID-19 | During COVID-19 | p-value | |
| Length of admission (days) | 27.8 (±11.9) | 49.9 (±13.1) | p=0.006* |
| Pharmacological treatment1 | |||
| - Haloperidol (mg/d) | 9.12(±10.05) | 26.87(±10.68) | p=0.098 |
| - Diazepam (mg/d) | 20.53(±4.22) | 32.90(±24.70) | p= 0.371 |
| - Fluoxetine (mg/d) | 48.67(±45.71) | 51.72(±41.22) | p= 0.472 |
| - Lithium (mg/d) | 800 (± 200) | 1000 (±300) | p= 0.514 |
| Anesthesia medication | |||
| - Propofol (ml) | 75 (±25) | 65 (±8) | p=0.011* |
| - Etomidate (ml) | 7 (±2) | 6 (±1) | p=0.944 |
| - Succinylcholine (ml) | 37 (±6) | 36 (±5) | p=0.955 |
| - Atropine (ml) | 0.6 (±0.1) | 0.6 (±0.1) | p=1.000 |
| Electrical parameters | |||
| - EEG seizure (s) | 36.55 (±8.62) | 28.60 (±8.92) | p=0.037* |
| - Motor seizure (s) | 28.53 (±8.79) | 22.82 (±7.71) | p=0.084 |
| - Charge (mC) | 250.64 (±143.84) | 332.18 (±109.35) | p=0.027* |
| Seizure quality parameters | |||
| - PSI (%) | 70.29 (±5.54) | 74.11 (±10.90) | p=0.169 |
| - COH (%) | 73.39 (±12.46) | 75.97 (±14.09) | p=0.799 |
Abbreviations: s, seconds; mC, millicoulombs; PSI, postictal suppression index; COH, maximum sustained coherence; MSEI, mean seizure energy index; MSP, maximum sustained power; microV2, micro Volts; TTP, time to maximum sustained power; TTC, time to maximum sustained coherence; * indicates statistical significance.
doses of pharmacological treatment using standardized equivalents of neuroleptics, benzodiazepines and antidepressants (Procyshyn et al., 2019).
During our study, with correct patient selection and weekly follow-up, there were no relapses in m-ECT despite stopping treatment or increasing the time between sessions.
-
c)
Inpatient ECT (i-ECT)
We analysed admission duration, as well as clinical, pharmacological and electrical records in inpatients (i-ETC) and compared them to patients of the entire pre COVID-19 year paired by age, sex and diagnosis.
During the COVID-19 period, we performed i-ECT on 14 newly admitted patients. Eighty percent of patients were female, with a mean age of 60.30 (±15.56) years. The distribution of diagnoses according to DSM 5 criteria was: 70% major depressive disorder, 20% schizoaffective disorder and 10% schizophrenia.
When comparing the data, we found a significant increase in the length of inpatient stay (p=0.006) and the charge administered (p=0.027) along with a decrease of propofol doses (p=0.011) and EEG seizures (p=0.037). We did not find significant differences in the psychopharmacological treatment administered nor in the rest of the anaesthetic medication, ECT electrical parameters or seizure quality parameters (Table 1).
Statistical significance in changes in load, propofol dose, and EEG seizure lacks clinical relevance and could be explained by multiple variables. The increase in the mean stay can be related to the decrease in weekly sessions.
There was no contagion among patients or the staff within the Unit.
These results support the feasibility of adapting the operation of the ECT-U to the restrictions of the lockdown periods, and thus preserving the ECT as an essential medical procedure (Sienaert et al., 2020) for critically ill patients as recommended by some authors (Espinoza et al., 2020).
Author statement
Contributors
VL, IB, MA, EB and AT conducted patient acquisition, data processing, analyses and wrote the manuscript. JP helped interpreting the data and co-revised the writing of the manuscript and decision to submit the article for publication.
Financial support
This research has not received specific support from public sector agencies, the commercial sector or non-profit organisations.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
We are grateful for the hard work and effort of all the Psychiatry Resident Interns who have helped during this period. We also wish to thank all the members of the Anaesthesiology and Resuscitation Service and the members of the Psychiatric Emergency Service of the University Hospital of Santa Maria, Lleida for their professionalism and collaboration. Finally, we would like to thank the patients for their generosity in the anonymized transfer of their medical history data.
References
- American Psychiatric Association . 5th Edition: DSM-5. American Psychiatric Association Publishing; Arlington, VA: 2013. Diagnostic and Statistical Manual of Mental Disorders. [Google Scholar]
- Boletín Oficial del Estado . 2020. Real Decreto 463/2020, de 14 de marzo, por el que se declara el estado de alarma para la gestión de la situación de crisis sanitaria ocasionada por el COVID-19. [Google Scholar]
- Daniel H.H., Begoña A.S.E. Access barriers to electroconvulsive therapy during COVID-19 pandemic. Psychiatry Res. 2020 doi: 10.1016/j.psychres.2020.113057. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Espinoza R.T., Kellner C.H., McCall W.V. Electroconvulsive Therapy During COVID-19. J ECT. 2020;36:78–79. doi: 10.1097/YCT.0000000000000689. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Gil-Badenes J., Valero R., Valentí M., Macau E., Bertran M.J., Claver G., Bioque M., Baeza I., Bastidas Salvadó A., Lombraña Mencia M., Pacchiarotti I., Bernardo M., Vieta E. Electroconvulsive therapy protocol adaptation during the COVID-19 pandemic. J. Affect. Disord. 2020;276:241–248. doi: 10.1016/j.jad.2020.06.051. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Looi M.K. Covid-19: Is a second wave hitting Europe? BMJ. 2020 doi: 10.1136/bmj.m4113. [DOI] [PubMed] [Google Scholar]
- Moros M.J.S., Monge S., Rodríguez B.S., Miguel L.G.S., Soria F.S. COVID-19 in Spain: view from the eye of the storm. Lancet Public Heal. 2020 doi: 10.1016/S2468-2667(20)30286-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Procyshyn R., Bezchlibnyk-Butler K., Jeffries J. 23rd ed. Hogrefe; Toronto: 2019. Clinical Handbook of Psychotropic Drugs. [Google Scholar]
- Sienaert P., Lambrichts S., Popleu L., Van Gerven E., Buggenhout S., Bouckaert F. Electroconvulsive Therapy During COVID-19-Times: Our Patients Cannot Wait. Am. J. Geriatr. Psychiatry. 2020 doi: 10.1016/j.jagp.2020.04.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- World Medical Association World Medical Association declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA. 2013 doi: 10.1001/jama.2013.281053. [DOI] [PubMed] [Google Scholar]