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Commentary

Electroconvulsive Therapy and Triaging During Reduced Access and the COVID-19 Pandemic

A Personal Perspective

Demas, Michael L. MD, FRCP

Author Information
doi: 10.1097/YCT.0000000000000713

Electroconvulsive therapy (ECT) is both a lifesaving and a life-sustaining treatment.1 Electroconvulsive therapy is an essential medical procedure2 similar to hemodialysis. Electroconvulsive therapy should “be readily available as a treatment option for mental disorders.”3 Electroconvulsive therapy results in “rapid reductions in suicide drive.”4 Suicide is rare in persons receiving ECT.5 Suicide, suicide attempts, and acute mental health deteriorations due to reductions in or withdrawal of essential treatments increase the burden on acute care health systems and associated resources such as police services, ambulance, fire, and other first responders. “Disasters disproportionately affect poor and vulnerable populations, and patients with serious mental illness may be among the hardest hit.”2

The author has been involved for more than 2 decades at his primary clinical site with triaging ECT. Despite a busy clinical service providing 15 treatments a day Mondays to Fridays, there have been many times where need for ECT has been far greater than the access to available ECT treatments. Over the past year, the service has also experienced 2 sudden, unexpected, dramatic reductions in ECT availability, one because of a sudden unexpected shortage of anesthesiologists without any available locum coverage, and one because of the worldwide succinylcholine shortage.

During shortages of access to ECT, there are often difficult decisions to be made. Maintenance ECT intervals are often lengthened, number of treatments per week decreased, inpatients and outpatients are put on waitlists to start ECT, and persons who would otherwise have been referred for ECT are not referred or are not seen and assessed for possible ECT on an outpatient basis. Often in such times, the only way someone will start ECT is because of an admission to hospital through an emergency department. During such shortages, there are often reports of increased hospitalizations of persons who had not been hospitalized for some time, rapid rehospitalization of persons recently released from hospital, and death, all increasing pressures on acute care health settings.6,7 Persons with psychiatric conditions under ideal circumstances are routinely subject to systemic micro inequities in health care and “often get second class treatment during normal times in healthcare systems, perhaps largely due to stigma and the lingering belief that psychiatric illness is somehow not as ‘real’ or serious as other types of medical illness.”8

Many psychiatrists work in centers where access to ECT is not a typical issue, but for many who work in centers where access to ECT can be limited, triaging ECT is a common issue not just during this or any other pandemic. The COVID-19 pandemic emphasizes that there is a need to begin to consider our methods of triaging ECT and to develop and have validated instruments that assist in triaging ECT in times of limited access to the treatment. Our ECT team was not aware of evidence-based methods to triage ECT as there was a paucity of evidence-based methods to triage ECT. Reflection on how ECT triaging was occurring, the lack of consistent methods of rating need for ECT, and reduced access to ECT on several occasions necessitated the development of a clinical, structured approach to ECT triage to ensure the best use of available ECT treatments and reduce patient risk and distress. Over the years of the author's psychiatric practice, the ECT team, administration, ECT triaging nurses, attending psychiatrists, and others at the author's ECT site have tried various methods of clinically triaging ECT. This culminated in the development and clinical use of the Edmonton Triage Scale (ETS) for the past several years (Appendix 1, Supplemental Digital Content 1, http://links.lww.com/JECT/A108). After experience, including the 2 recent shortage periods, the ECT team and attending psychiatrists have found the ETS useful in clinically triaging patients for ECT in these circumstances while recognizing the lack of evidence-based research with the instrument. Evidence-based methods of triaging ECT are needed. Thus far, attending psychiatrists, hospital administration, and patients have generally reported feeling that there is a measure of fairness and have expressed satisfaction with the use of ETS as a clinically based structured triage instrument.

Experts in triaging in medicine, ethics, and law may be able to provide additional discussion on utilization of available ECT and triaging when access to ECT is overwhelmed either because of reduced availability or increased need for the treatment. What principles are best used to withdraw or reduce ECT treatment for 1 patient to provide ECT for another patient? Similarly what other principles are best for considering triage of ECT during times of limited access to the treatment?

The COVID-19 pandemic has resulted in many challenges in triaging care in acute care medicine.9–11 During the COVID-19 pandemic, many jurisdictions have set in place or mandated guidelines including arm-length panels, public health officers, and others, to triage initial access to, or continued access to, ventilators and related care.12,13 Putting in place a similar mechanism for ECT is a discussion that should occur in our field. This should include input and discussion from experts in triaging in medicine, ethics, and law. There should be thorough, vigorous public engagement and discussion from patients and their loved ones. Principles of triaging ECT should be thoroughly vetted and should be able to apply at all times of limited access to ECT.

There are potential disadvantages to arm-length panels for ECT such as limited methods of quantifying need, lack of validated ECT triaging instruments, and lack of adequate knowledge about each individual patient situation. Most likely, there would be a requirement for increased time from attending psychiatrists and other physicians, nurses, and mental health workers to advise, update, and lobby the panel patient-by-patient during a time when there would likely inherently already be increased demand on the time of these healthcare workers. Having some validated measurements of need for ECT would be wise. Other areas of medicine, particularly, in intensive care, recommend that “triage systems might be more likely to apply medical decision making consistently across large groups of patients… (and that) triage teams… (should) make decisions independently from, and in communication with, frontline clinical staff.”10,14,15 “Public health ethics differ from clinical ethics by giving priority to promoting the common good over protecting individual autonomy.”15 Entire populations are experiencing this principle by shelter-in-place, isolation, and other public health orders during the COVID-19 pandemic. Triaging teams for ECT need improved methods and materials for managing triaging of ECT.

The ETS was developed for use during short-term reductions of access to ECT (ie, weeks) where a clear end to the shortage was expected and where staffing and supplies were always more than adequate. There is an increased and urgent need for ECT triaging during the COVID-19 pandemic to reduce impacts on health and associated systems such as minimizing suicide, suicide attempts, inpatient admissions, and other significant patient deteriorations. There is a clear need to ensure that first responders and essential healthcare staff stabilized by ECT do not deteriorate and drop out of the workforce during a crisis. There is a need to balance risk of exposure to the virus versus individual's treatments needs. There is a need to optimize use of limited supplies of personal protective equipment and medications used in ECT as well as a need to optimally use ECT treatment areas. There is a need to reduce risks of emergency department presentations with their associated risks of increased exposure to the virus and increased pressure on already taxed emergency departments. There is the need to optimize use of anesthesiology time. There is the need to reduce impacts on police, ambulance, and other first responders who respond to outpatients when they significantly deteriorate. Consequently, in mid-March 2020, the ETS was modified as the ETS – Pandemic Version (ETS-PV; Appendix 2, Supplemental Digital Content 2, http://links.lww.com/JECT/A109). The criteria match those recommended by the International Society for Electroconvulsive Therapy and Neurostimulation's 2 April 2020 letter to the profession.6

During the COVID-19 pandemic, patient access to ECT at the author's primary clinical site was reduced by 33%. The local health region with a population of approximately 1.5 million persons saw a 43% to 46% peak reduction in ECT access during the COVID-19 pandemic. During the pandemic, some hospitals consolidated ECT programs to one location. Some patients were transferred to other programs that had more access to ECT. In one case, an entire inpatient unit of an academic university hospital was moved to a local provincial mental hospital.

After long periods with reductions in access to the treatment, ECT programs and ECT psychiatrists usually have a significant “backlog” of need. This includes opening up again for and longer current waitlists for initial ECT consultations, waitlists for further medical workup before starting ECT, and scheduling ECT for each patient at their usual level of need for the treatment. In some cases, there is a need for repatriation of patients moved during times of reduced access to ECT programs with available capacity back to their preferred site of ECT. The COVID-19 pandemic has impacted the workflow and logistics around ECT delivery and has increased time per person per treatment because of the need to change out more PPE than prepandemic and other factors. Changes back to more “normal” prepandemic ECT operations will most likely be tentative as further “waves” of illness are often expected. Need for triaging ECT will continue as ECT programs resume pre-COVID-19 pandemic workloads.

Using the ETS early in the current COVID-19 pandemic and then the ETS-PV assisted the ECT program at the author's primary clinical site and at other sites, to make difficult choices in a more systematic and rational fashion. Often, the physicians and nurses involved in ECT triaging at the author's primary clinical site do not see or assess the patients outside of the ECT program, particularly the in patients admitted to the hospital. This makes evaluating each person and then triaging them very difficult. It is also time consuming for the triaging team to try to call unit managers, currently assigned primary nurses, and psychiatrists to obtain further information about the current status of each person needing ECT. Triaging during the COVID-19 pandemic has been a day-to-day process.

The emotional burden on the ECT triaging team has been significant and visible. They have spoken often, usually daily, about the struggle to triage during the COVID-19 pandemic and in the past during times of reduced access to ECT before the introduction use of the ETS or the ETS-PV. One ECT triaging nurse said that using the ETS in the past and using the ETS-PV during the COVID-19 pandemic make triaging ECT “less of a burden” in time, effort, and emotionally. The triaging team often directly hears complaints about reduced access to ECT from patients, families, other nurses, and mental health workers on units and in the community, and the attending psychiatrists. They have told the author that use of the ETS and ETS-PV help the triaging team know which patients can have reductions in treatment during an active course of ECT (eg, from 3 times per week to 2 times per week), has reduced the personal emotional burden on the triaging team, and has helped in actually making decisions about delays and reductions in treatment.

There are further challenges for physicians involved in the triaging process with ECT. Particularly for physicians acting as the attending psychiatrist for persons needing ECT and also for physicians involved in directing ECT programs and in triaging ECT. It is more challenging when there are multiple roles for the physician. The author helps direct the ECT program at his primary clinical site and triage ECT. There is a natural conflict when acting in this capacity and assisting the ECT triaging team with triaging and being an attending physician of persons needing ECT who are being triaged. Physicians have an obligation to put their own patients' interests first. How then can one resolve the conflict between both attending physician and ECT program director responsibilities when one's own patient comes up for triaging? This can be assisted by the use of some form of consistent rating of the current needs of all persons seeking ECT. On a personal level for the author, this conflict has been reduced by using the ETS-PV during the COVID-19 pandemic and the ETS during other times of limited access to ECT.

SUMMARY

The author is aware of many ECT services experiencing drastic reductions in ECT due to the COVID-19 pandemic.7 The ETS was developed and intended for brief crisis periods (2 or 3 weeks) of reduced ECT access. The COVID-19 pandemic necessitated a modification of the ETS to assist us in clinically triaging ECT during disaster psychiatry times. The scales have not been used or validated in clinical trials, but they nonetheless maybe helpful for clinicians during this pandemic and future crises. Ideally, evidence-based methods of triaging ECT during periods of limited access and during crises will be developed before the next crisis using sound, thoroughly vetted, ethical principles. Readers are encouraged to use and adapt the scales for their practice without further permission.

ACKNOWLEDGMENTS

The author wishes to thank the many colleagues in nursing, psychiatry, unit clerks, and administration who helped in the development, testing, and implementation of the ETS and ETS-PV and the reviewers for their excellent comments and recommendations for this article.

REFERENCES

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6. International Society of Electroconvulsive Therapy and Neurostimulation Executive Committee, Letter to the Profession RE: COVID-19 and ECT 2 April 2020. https://www.isen-ect.org//sites/default/files/ISEN.COVID19.letter.pdf.
7. ISENLISTSERVE reports.
8. Druss BG. Addressing the COVID-19 pandemic in populations with serious mental illness. JAMA Psychiatry. 2020;77:891–892.
9. Truog RD, Mitchell C, Daley GQ. The toughest triage - allocating ventilators in a pandemic. N Engl J Med. 2020;382:1973–1975.
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12. Crisis Standards of Care Planning Guidance for the COVID-19 Pandemic April 7, 2020, The Commonwealth of Massachusetts Department of Public Health.
13. Minnesota Crisis Standards of Care Framework Ethical Guidance 01/10/2020.
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Keywords:

electroconvulsive therapy; ECT; triage; shortage; pandemic; scale

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