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      Why keep an ECT unit open during a COVID-19 lockdown period

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          Abstract

          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 (Bezchlibnyk-Butler and Jeffries, 2004), 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-anaesthetic Resuscitation Unit (REA) where ECTs are performed every day for both inpatients and outpatients. During the first wave of COVID-19, due to the conversion of the REA 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. a 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. Table 1 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 treatment 1 - 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 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 1 doses of pharmacological treatment using standardized equivalents of neuroleptics, benzodiazepines and antidepressants (Bezchlibnyk-Butler and Jeffries, 2004). 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. a 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 Each author listed below substantially contributed to the article: V Llorca-Bofí conducted patient acquisition, data processing, analyses, and wrote the manuscript. I Batalla conducted patient acquisition, data processing, analyses, and wrote the manuscript. M Adrados-Pérez conducted patient acquisition, data processing, analyses, and wrote the manuscript. E Buil-Reiné conducted patient acquisition, data processing, analyses, and wrote the manuscript. J Pifarré helped interpreting the data and co-revised the writing of the manuscript and decision to submit the article for publication. A Torrent conducted patient acquisition, data processing, analyses, and wrote the manuscript. 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.

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          World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.

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            Covid-19: Is a second wave hitting Europe?

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              Electroconvulsive Therapy During COVID-19-Times: Our Patients Cannot Wait

              Now is a crucial time for us to stand up for our patients’ right to continued access to ECT Randall T. Espinoza, Charles H. Kellner, & William V. McCall, 2020 The rapidly evolving pandemic of coronavirus disease 2019 (COVID-19) is a major challenge for health services and drastic measures have been taken to contain this global crisis. Anticipating a shortage of health-care providers, in particular anesthesiologists, hospitals around the world did not hesitate to close down their electroconvulsive therapy (ECT)-units. In Flanders, a region in Belgium with 6,596,000 inhabitants, 70% of the ECT-units stopped treatments from the start of the pandemic. The remaining have put treatments for older patients residing in nursing homes on hold. Reasons cited are unavailability of anesthesiologists rescheduled to work in intensive care units, shortage of muscle relaxants needed for mechanical ventilation of COVID-patients, and fear of virus transmission through bag-mask-ventilation during the ECT-procedure. Another reason for closing down the ECT-service is that ECT is considered an elective intervention, and that, moreover, ”psychiatry can wait.” It is not unusual for patients with a psychiatric disorder to experience poor access to health care compared with people without a psychiatric disorder. 1 But, as eloquently argued by Espinoza et al., 2 in this COVID-era, "ECT is a lifesaving gem,” an often essential medical procedure that should not be discarded as an elective intervention. OUR PATIENTS CANNOT WAIT In this challenging time, the need to deliver care for older adults experiencing serious mental illness is higher than ever. ECT not only yields high remission rates in older patients, 3 it is often life-saving in patients refusing food and fluid intake, or those with psychotic depression, catatonia, and suicidality. 4 In considering the implications of COVID-19 for ECT, it is important for psychiatrists to carefully review the treatment needs in consultation with patients and their families. If ECT is stopped, the 6-month relapse rate with continuation pharmacotherapy will mount up to 37%. 5 Relapse rates after discontinuing an ongoing maintenance-ECT (M-ECT) are similar. 6 , 7 Moreover, it is of note that, apart from the burden caused by a depressive relapse, in this particular pandemic context, a depressive relapse might make older patients more vulnerable to infectious diseases. It is known that depression is associated with immunological impairments, especially in older adults, 8 and that in stressful situations, mortality from viral respiratory infections is higher. 9 Therefore, when M-ECT is withheld, or the intertreatment interval is lengthened, a close follow-up is of utmost importance. A protocol of using rescue ECT-sessions based on monitoring of psychiatric symptoms through televisits, 10 using validated rating scales, and providing ECT only in case of early signs of relapse, 11 should be considered standard clinical care in these exceptional times. This practice was shown to be feasible in a large trial on flexible M-ECT in older patients. 12 In an attempt to contain the epidemic, the Belgian government issued on April 3th 2020 all day hospitalizations for persons over 65 years of age to be closed temporarily. As a consequence, M-ECT for outpatients was kept to a strict minimum. More specifically, older patients residing in nursing homes could not be treated on an outpatient basis, in order to protect their fellow-patients from infection. On a weekly basis, assessments were performed via telephone consultations with patients and/or care-providers. If possible, a standardized rating scale was used. Furthermore, cases were discussed on a weekly (video) ECT-team meeting. If signs of relapse were emerging, or in case of increasing suicidality, patients were readmitted to apply rescue ECT starting with ECT twice a week. Readmission was organized in a 7-day quarantine-regime, with close follow-up of clinical signs and screening for COVID through polymerase chain reaction (PCR) testing. PROTECTING PATIENTS AND STAFF To safely administer ECT, protecting staff and patients from exposure to respiratory droplets, our unit, situated in a tertiary psychiatric hospital, adopted a number of additional safety measures. A nasopharyngeal swab for PCR-testing was performed the day before ECT. Hospitalized patients were monitored daily for symptoms of fever, coughing and dyspnea; PCR-testing was repeated once a week. Outpatients had PCR-testing the day before a treatment-session. Patients with a positive PCR-test were treated at the end of the program to prevent contamination of the treatment room and to enable rigorous cleaning afterwards. The treatment room was adequately ventilated ensuring ventilation with air flow of 5 air changes per hour, 13 and all medical devices and high touch surfaces were disinfected with a chlorine solution after every treatment. After treating a patient with a positive PCR-test the entire treatment room, including the floor, was cleaned with a chlorine solution. The number of persons present in the treatment room was kept to the absolute minimum required for the patient's care (ECT-nurse, ECT-psychiatrist, anesthesiologist and assistant-anesthesiologist). Appropriate personal protective equipment was used, including a standard "filtering face piece” 2-respirator, eye protection, a fluid-resistant long-sleeved gown and gloves, as prescribed by the World Health Organization 13 (Fig. 1 ). Filtering face piece 2-respirators were worn for a whole treatment day. Gloves were changed according to the 5 WHO indications for hand hygiene. Gowns were changed every treatment day, after a treatment of a COVID-positive patient, or in case of accidental contamination. FIGURE 1 ECT-team wearing personal protective equipment, including FFP2-respirator, eye protection shield, fluid-resistant long-sleeved gown and gloves. FIGURE 1: Glycopyrrolate was used routinely 14 to prevent salivation, thus reducing the risk of producing aerosol. It is suggested that glycopyrrolate also prevents cerebral deoxygenation during ECT. 15 A minor drawback of its use is the fact that patients may experience dry mouth upon recovery. ECT-anesthesia typically involves manual ventilation through a tight mask connected with an open Bain circuit. Manual ventilation is an aerosol-generating procedure, shown to pose an increased risk of coronavirus transmission to healthcare workers. 16 Oxygen-therapy, however, does not increase droplet count. 17 On the other hand, it is suggested that hyperventilation, using a bag-mask, might increase seizure length and improve seizure adequacy. 18 Nevertheless, in our unit, bag-mask-ventilation was avoided and patients were pre-oxygenated using a simple oxygen-mask (5 L/min). Re-organizing ECT-care necessitates a re-allocation of resources. Trained practitioners are needed to perform telephone or video-assessments. Weekly supervision is necessary to assess the need of readmission and rescue ECT. Practitioners and policy makers of nearby regional ECT-units should combine forces to centralize ECT-care and continue treatments in a limited number of centers. Although this approach may cause inconvenience for some patients, it will increase expertise and limit the amount of personnel and resources needed to enable continued access to ECT. In these exceptional times, in which we must all arm ourselves against the coronavirus-pandemic, treating the most vulnerable of our patients is of major importance. Within the limits imposed on us during this pandemic, ECT should be seen as an essential medical procedure and made available in order to prevent long-term mental health consequences in older adults already experiencing serious mental illness. The caveats and measures described here, can guide ECT-practitioners in the context of this viral pandemic. Author Contribution Pascal Sienaert: Conceptualization, Investigation, Writing —review & editing. Simon Lambrichts: Writing—review & editing. Leen Popleu: Review & editing. Satya Buggenhout: Review & editing. Elke Van Gerven: Review & editing. Filip Bouckaert: Writing— review & editing.
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                Author and article information

                Journal
                J Affect Disord
                J Affect Disord
                Journal of Affective Disorders
                Elsevier B.V.
                0165-0327
                1573-2517
                11 February 2021
                11 February 2021
                Affiliations
                [a ]Psychiatry Department. GSS-Hospital Universitari de Santa María, Lleida, Spain
                [b ]Institut de Recerca Biomèdica de Lleida (IRBLleida), Lleida, Spain
                [c ]Medicine Department, Universitat de Lleida (UdL), Lleida, Spain
                [d ]Sant Joan de Déu Terres de Lleida, Lleida, Spain
                Author notes
                [* ]Corresponding author: Iolanda Batalla MD, PhD, Psychiatry Department. GSS-Hospital Universitari de Santa María de Lleida, Institut de Recerca Biomèdica de Lleida (IRBLleida), Medicine Department. Universitat de Lleida (UdL), Rovira Roure, 44. 25198 Lleida, Spain
                Article
                S0165-0327(21)00145-2
                10.1016/j.jad.2021.02.029
                7875709
                7e26ce50-6395-4718-9b3c-0f0f2bf0358e
                © 2021 Elsevier B.V. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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