Discontinuation of Continuation or Maintenance Electroconvulsive Therapy Caused by the COVID-19 Pandemic

Abstract

Background: Continuation or maintenance electroconvulsive therapy (C/M-ECT) is recommended to reduce relapse rates of patients with major depressive disorder. During the ongoing COVID-19 pandemic, ECT services have come under pressure or needed to close because of redirected resources and safety reasons. We investigated the impact of C/M-ECT discontinuation on relapse in patients with unipolar depressive disorder in Flanders, Belgium.Methods: Between March 30 and June 18, 2020, all patients receiving C/M-ECT in 2 ECT centers were included. Continuation or maintenance electroconvulsive therapy was discontinued in 33 patients and continued in 4 patients. Relapse was defined as the need to restart ECT or the need for hospitalization. Depressive symptoms were assessed every 3 weeks using the Patient Health Questionnaire, the Clinical Global Impression Scale, and 2 additional patient-rated questions.Results: Relapse in the discontinuation group was 60.6%. All 4 patients who continued ECT remained remitted. Kaplan-Meier survival analysis showed significantly shorter relapse rates for patients receiving bitemporal and/or frequent C/M-ECT (1-to 2-week intervals). Patients older than 60 years showed longer survival rates. Conclusions:Our results confirm earlier prospective and retrospective data regarding the efficacy and importance of C/M-ECT as relapse prevention. After treatment discontinuation, close monitoring of early warning signs for relapse is crucial, especially in the first few months. With the COVID-19 pandemic continuing, our data provide an indication of the necessity to ensure adequate care and access to ECT not only for the acutely ill but also for the vulnerable patients who are depending on C/M-ECT.

Provision of Electroconvulsive Therapy During the COVID-19 Pandemic

“…In an observational study of 37 patients receiving maintenance ECT from 2 ECT centers in Belgium, maintenance treatment was discontinued for 33 patients during the COVID-19 pandemic, whereas it remained unchanged for the remaining 4 patients. While the discontinuation group showed a relapse rate of 60.2%, none of the patients with unchanged maintenance ECT relapsed 23 . Another study from Belgium following up on 81 patients whose maintenance ECT was abruptly discontinued because of the COVID-19 pandemic reported a 44.4% relapse rate in the 6 months after the discontinuation of ECT 20 .…”

“…While the discontinuation group showed a relapse rate of 60.2%, none of the patients with unchanged maintenance ECT relapsed. 23 Another study from Belgium following up on 81 patients whose maintenance ECT was abruptly discontinued because of the COVID-19 pandemic reported a 44.4% relapse rate in the 6 months after the discontinuation of ECT. 20 In a German university hospital, maintenance ECT was reduced in frequency or stopped in 86.8% of patients and remained unmodified in 13.2% of patients, based on factors like the persistence of marked residual symptoms, a lack of treatment alternatives, or at the patients' explicit request.…”

“…Many ECT services were forced to operate at reduced capacity or suspend service altogether during the early stages of the pandemic. [18][19][20][21][22][23] However, most studies have not provided reasons for the reduction of ECT services. For example, survey data from ECT clinics in England, Wales, Northern Ireland, and the Republic of Ireland mention the unavailability of anesthesiologists, increased requirements for personal protective equipment (PPE), required infection control procedures, staff sickness, or staff redeployment as reasons for the reduction of ECT services.…”

“…Indeed, some studies have reported high rates of relapse when maintenance ECT was abruptly discontinued. 20 , 22 , 23 In cases where the most severely ill patients were able to stay on maintenance ECT, relapse rates were higher in the less severely ill patients whose maintenance ECT was suspended. 22 …”

Impact on Electroconvulsive Therapy Services, Including Patient Relapse and Death, During the COVID-19 Pandemic

“…Large studies from Europe report that, among patients whose ECT was completely discontinued, between 44.1% and 60.6% relapsed. [18][19][20] It must be acknowledged that definitions of "relapse" differ, ranging from a worsening of symptoms to the need for involuntary hospital admission 6 ; nevertheless, relapse due to lack of ECT access is a considerable problem. Indeed, one multisite study found that more ECT clinicians were concerned about patients relapsing due to lack of ECT access during the pandemic than they were about patients completing suicide (36.0% vs 18.0%).…”