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Electroconvulsive therapy during the COVID-19 pandemic

Grover, Sandeep; Sinha, Preeti1; Sahoo, Swapnajeet; Arumugham, Shyamsundar1; Baliga, Sachin2; Chakrabarti, Subho; Thirthalli, Jagadisha1,

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doi: 10.4103/psychiatry.IndianJPsychiatry_335_20
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Abstract

COVID-19 pandemic and the ensuing lockdown have impacted mental healthcare services across many countries in various ways. This holds true for India as well. Most hospitals have actively discharged relatively stable patients, shut down outpatient services, and limited themselves to providing only emergency services. This has resulted in inability to access nonemergency clinical consultation, maintenance medications, psychotherapy, and other nonpharmacological interventions. During the pandemic, lockdowns and the resultant economic difficulties have caused additional stress to many individuals. In this background, there is high likelihood of patients relapsing or worsening with severe symptoms, which may necessitate electroconvulsive therapy (ECT).

ECT services, however, have also been impacted. As the procedure itself has high chances of spreading the COVID-19 virus to healthcare personnel and other patients, it has either been stopped entirely or reduced drastically. Some patients were already in the middle of their ECT course, some were on maintenance ECT, while others were still under evaluation for the commencement of ECT; their treatment has become uncertain. It is critical to have directions for appropriate ECT practices. The International Society for ECT and Neurostimulation has provided guidelines for its members in this regard.[1] In addition, groups from Singapore[2] and Ireland[3] also recently published the process followed at their respective places. Any position with respect to ECT would depend on factors listed below; these factors may change rapidly in the current scenario and decision regarding ECT may change accordingly: (1) phase of spread of the virus worldwide, in our country and in the region; (2) availability of resources, particularly of personal protective equipment (PPE), in the given healthcare setting; (3) ECT-related recommendations for COVID-19 pandemic available from other sources; (4) clinical condition of COVID-19 in given patients and safety of anesthesia and ECT in them.

The following factors make ECT riskier than routine clinical care in terms of spread of the COVID-19 virus to healthcare professionals and other patients: (a) the virus has been shown to be present in aerosols;[4] (b) bag and mask ventilation and suctioning of secretions, as a part of ECT procedure, are known to produce aerosols;[5] (c) asymptomatic carriers are known to shed the virus,[6] which makes clinical screening dubious, but at the same time, laboratory tests for COVID-19 infection may not be conducted for such patients. However, ECT can be vital and inevitable for patients with marked suicidal behavior, catatonia, agitation, and refusal to feeds and medications, with the risk of deterioration of general health, particularly in the elderly. On a balance, it is essential that efforts should be made to administer ECT when it is life-saving and other modes of treatment are unhelpful. ECTs may also be indicated if there is a risk of violation of social distancing due to severe mental illness (i.e., patients' inability to keep the recommended distance from others to avoid the spread of COVID-19 virus due to severe agitation despite attempts for chemical restraints). Following steps may be considered in this regard:

  1. Avoid ECTs for elective indications even if patients are not suspected cases of COVID-19 and when patients are medically unstable
  2. The benefits of administering ECT should clearly outweigh the risks of transmission of COVID-19 infection, during the procedure. Hence, it is preferred that the decision of administering ECT may be taken independently by two psychiatrists
  3. Screening questionnaire to assess the risk of COVID-19 infection to be applied. Each center may develop screening tools to assess the risks according to its local realities regarding the COVID-19 pandemic and may modify them according to the changes in the pandemic situation
  4. All these steps to be followed before each ECT session for each patient
  5. While obtaining the consent for the ECT, the possible risk of COVID-19 infection to the patient should be informed to the patient and his/her family.

We recommend following steps to be followed ideally to avoid any possibility of COVID-19 transmission. This becomes particularly important in situations where a patient who has tested positive on COVID-19 test has to be administered ECT. In such cases, all following measures would have to be taken in designated wards away from the usual ECT setup, and the staff would then have to be in isolation as per the prescribed standards.

  1. Complete PPE, consisting of shoe covers, outer and inner gloves, gown, N-95 mask, surgical cap, goggles, and face shield, should be donned by all medical personnel involved in ECT procedure. As the status of PPE will differ for each establishment, each can have a different threshold for consideration of ECT. Places where adequate precautions cannot be taken could refer such cases to other establishments
  2. General safety precautions for COVID-19 have to be taken at all times while conducting ECT procedure. It has to be ensured that social distancing is practiced in the waiting area as well as in the ECT administration and recovery area
  3. Minimum number of professionals (such as 1 anesthetist, 1 psychiatrist, and 1–2 nursing staffs) to be involved at a given time. Staff could be specially designated for ECT who could work for 2–3 weeks in a rotating schedule
  4. All necessary anesthesia equipment such as bag, mask with tubing, and suction cannula with catheter, the pulse oximeter probe, and the blood pressure cuff with tubing attached to the vital signs monitor along with ECT machine and its electrodes should be soon discarded/disinfected with hypochlorite solution or 70% alcohol disinfectant. This process should be repeated after every patient to avoid transmission of infection to the next patient
  5. There should be designated places for donning and doffing PPE separately. The disposal of PPE of all persons should be done together appropriately as per the ICMR guidelines[7]
  6. Specially designed aerosol box shields can also be used to better contain the spread of aerosols from the patient during the procedure
  7. In consultation with an anesthesiologist, disposable high-efficiency particulate air filters can be used during bag and mask ventilation to prevent potential viral contamination of the anesthesia breathing circuit and thus reduce the risk of cross-infections.

We also suggest following steps in the ECT procedure so that patient gets maximum effectiveness in minimum number of sessions. This may be appropriate even at the cost of cognitive deficits.

  1. Brief-pulse ECT with bilateral (bifrontal or bitemporal) ECTs may be preferred to unilateral and ultra-brief-pulse ECT
  2. To avoid the possibility of a failed seizure, particularly during the first session, ECT psychiatrists may consider administering a higher stimulus charge; for example: 120 mC in relatively younger patients; 180–240 mC in those aged >45 years
  3. If patients are on antiepileptic medications, the charge may be adjusted keeping in mind possible higher threshold
  4. It is also advisable to discuss with the anesthetist about the routine use anticholinergics to reduce secretion formation and aerosolization, unless contraindicated

At present, there is inconclusive information with respect to utility of testing during the early quarantine period for detecting asymptomatic COVID-19 patients. Till additional information is available, testing each patient for COVID-19 before ECT may not be feasible. We believe that all these measures will help in ensuring a safe ECT practice and hopefully encourage more use of ECT during the ongoing pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

1. ISEN Executive Committee. COVID-19 and ECT. Pers Commun 2020.
2. Tor PC, Phu AH, Koh DS, Mok YM. ECT in a time of COVID-19 J ECT. 2020;36:80–5 doi: https://doi.org/10.1097/YCT.0000000000000690
3. Colbert SA, McCarron S, Ryan G, McLoughlin DM. Images in clinical ECT: Immediate impact of COVID-19 on ECT Practice J ECT. 2020;36:86–7 doi: https://doi.org/10.1097/YCT.0000000000000688
4. van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 N Engl J Med. 2020;382:1564–7
5. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review PLoS One. 2012;7:e35797
6. Cai J, Sun W, Huang J, Gamber M, Wu J, He G. Indirect virus transmission in cluster of COVID-19 cases, Wenzhou, China, 2020 Emerg Infect Dis. 2020;26:1343–5
7. . Guidelines for Handling, Treatment, and Disposal of Waste Generated during Treatment/Diagnosis/Quarantine of COVID-19 Patients. Rev. 1Last accessed on 2020 Apr 12 Available from: https://www.mohfw.gov.in/pdf/63948609501585568987wastesguidelines.pdf
Keywords:

COVID-19; electroconvulsive therapy; pandemic

© 2020 Indian Journal of Psychiatry | Published by Wolters Kluwer – Medknow