The Other Victims of COVID-19

Dear Sir,

The COVID-19 pandemic has prompted dramatic adjustments to the practice of medicine. Regarding electroconvulsive therapy (ECT), its availability has been limited because of a variety of factors, including (a) the implementation of more time-consuming protocols because of the aerosol-generating nature of the procedure, (b) risk of patient infection because of exposure to a health care setting, and (c) reassignment of health care professionals to other higher-priority positions during the pandemic. Consequently, many patients have seen their ECT schedules altered, either in terms of frequency reduction or in terms of discontinuation of the therapy.^1–3

In our hospital, as of the third Monday of June 2020, 4 of our 29 acutely hospitalized psychiatric patients had relapsed coinciding with changes in their ECT schedule due to the COVID-19 crisis. Three were receiving care at our acute psychiatric ward, and the fourth was home hospitalized. None of them had suspected or confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, but the reduction in availability of ECT during the pandemic forced a decrease in frequency or complete interruption of their ECT schedules. We describe their cases hereinafter.

CASE 1

A 39-year-old woman with resistant, multiepisodic schizophrenia relapsed while being hospitalized in a subacute psychiatric facility after discontinuation of weekly ECT maintenance therapy. Medication adjustments and daily psychiatric supervision were insufficient for stabilization, and the patient was finally admitted to our acute inpatient unit, where ECT is available, as opposed to the subacute facility. We implemented triweekly ECT sessions, and the patient recovered slowly, being then readmitted to the subacute unit with continuation of weekly ECT sessions.

CASE 2

The second case was a 51-year-old woman with rapid cycling bipolar disorder type I whose twice-a-month maintenance ECT was paused temporarily, and afterward, she refused to restart the treatment. She soon presented with a severe mixed episode that required acute hospitalization. Because the patient kept rejecting ECT, we intensified psychopharmacological therapy, which eventually controlled the symptoms and the patient could be discharged home.

CASE 3

The third case was a 72-year-old woman with resistant, multiepisodic schizophrenia who was receiving treatment with clozapine and long-term weekly maintenance ECT whose schedule was reduced to every 2 weeks. A month afterward, she developed catatonia, being admitted to our acute inpatient unit for ECT intensification. After 3 weeks of twice-a-week ECT, the patient was back to normal, and we discharged her home with weekly ECT sessions.

CASE 4

A 72-year-old man with recurrent major depressive disorder relapsed—with a depressive episode with psychotic symptoms—after his once-monthly ECT schedule was discontinued. He was admitted to home hospitalization, and ECT was restarted, initially twice a week for 2 weeks and then weekly, achieving a rapid improvement, which allowed us to discharge him within 5 weeks. We maintained weekly ECT afterward to ensure full remission.

DISCUSSION

We report 4 simultaneous cases in which ECT schedule adjustments due to the COVID-19 pandemic coincided with—and probably favored—psychiatric relapse, which was severe enough to require hospitalization. From March 14, 2020, to May 1, 2020, our hospital reduced its ECT activity up to 75% (from 40 weekly sessions to 10) because of anesthetists' relocation, shortage of materials, and time-demanding proper implementation of the SaRS-CoV-2 safety protocol. Also, since then, all patients have been required to have a negative nasopharyngeal swab for SARS-CoV-2 performed 24 to 48 hours before each session. As of the end of June 2020, we are progressively increasing our activity, having reached up to 60% of the usual number of ECT sessions. For this quantitative readjustment, we established the following prioritization criteria of patients: catatonia or severe persistent agitation unresponsive to medication, and maintenance ECT with a history of either relapse when discontinued or severe clinical features, including catatonia, suicidal attempts, or other violence. Concurrently, we have intensified the communication between patients, families, and therapists to maximize the early detection of relapse. Cases 1, 2, and 4 were not prioritized because they had no history of the mentioned severe clinical features, and besides, they were on their first maintenance ECT course; case 3 did meet these features and was considered intermediate priority, so we proceeded to a frequency adjustment but not a discontinuation.

Electroconvulsive therapy is a safe, effective therapy for severe mental illness. In many patients, acute ECT requires continuation and/or maintenance therapy for sustained benefit, consistently with the chronic, episodic nature of the conditions it is prescribed for. Decisions on ECT frequency reduction or termination are necessarily individualized and, often, empirically modulated.⁴ The COVID-19 pandemic has required forced adjustments on ECT schedules, leading to nonclinical, availability-related changes on the patients' frequency or maintenance of the procedure. In any case, prioritization of individuals has undoubtedly been kept under strict clinical reasoning.¹ Nonetheless, these adjustments may have led to a worsening of preexisting psychiatric illness, which is probably the case of the 4 patients we report. None of them had neither been subjected to recent major psychopharmacological changes nor suffered from significant stressful life events apart from the lockdown situation, of which we cannot discard a contribution to their clinical worsening. In fact, one of them (case 1) was actually hospitalized in a subacute unit when she relapsed, which guaranteed she was adherent to medication—that is to say, including unsuccessful adjustments—and under strict professional supervision.

As a matter of fact, our patients are “collateral victims” of SARS-CoV-2. None of them acquired the infection, but all suffered indirect health consequences serious enough for requiring hospitalization. Unfortunately, these collateral victims of the COVID-19 pandemic emerge not only from the deterioration of standard health care, which has affected—and is still affecting—millions of people worldwide. The impact of lockdown, the traumatic experiences of those close to COVID-19 cases, and the consequences of the emergent social and economic crisis, among others, will inexorably leave behind countless other victims.⁵

This case series highlights the value of ECT as an effective, timely critical therapy for severe mental disorders. Thorough benefit-risk assessment is always needed when deciding about frequency changes or discontinuation of ECT; things as they are, it seems to be no different in these overwhelmingly transformed times of COVID-19.

Maria Sagué-Vilavella, MD, MPH
Joaquín Gil-Badenes, MD
Núria Baldaquí Baeza, MD
Santiago Madero Gómez, MD
Isabella Pacchiarotti, MD, PhD
Maria Teresa Pons Cabrera, MD
Marc Valentí Ribas, MD, PhD
Miquel Bioque, MD, PhD
Department of Psychiatry and Psychology Institute of Neuroscience Hospital Clínic de Barcelona Barcelona, Catalonia, Spain msague@clinic.cat