Adapting electroconvulsive therapy service delivery: Insights from providers’ experiences during the COVID-19 pandemic in Australia and beyond

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic, one of the most significant global public health crises in generations, profoundly impacted population health and healthcare delivery worldwide.^[1] Its high virulence and mortality rate before mass vaccination placed a significant strain on health systems, leading to resource shortages, delays in elective procedures, and disruptions in the diagnosis and treatment of non-communicable diseases such as cancer.^[2,3] The disruption to mental health service delivery was especially concerning as COVID-19 drove a global increase in demand for mental health services.^[4] From June to August 2020, 93% of 130 countries across the World Health Organization regions reported disruptions to mental health, neurological, and substance use care.^[5] Organization for Economic Co-operation and Development – a group of largely developed countries data also showed increased depression and anxiety rates in early 2020, correlating with higher mortality and stricter public health mandates.^[6]

Electroconvulsive therapy (ECT), a lifesaving treatment for severe mood and psychotic disorders,^[7,8] also faced significant disruptions. Despite the urgency of ECT and patient vulnerability,^[9] services were reduced across North America, Europe, Australia, and Canada.^[8,10-12] Adaptations included screening protocols, personal protective equipment (PPE) use, and modifications to ECT suites, dosing, and anesthetic techniques.^[8]

Past studies have examined challenges, ethical issues, and barriers to ECT during the pandemic.^[9,13] Two studies explored clinicians’ experiences and offered recommendations for mitigating negative impacts on ECT services.^[10,12] One multicentric retrospective study was conducted across ECT networks in Australia and Singapore, which revealed no significant difference between observed and predicted numbers of ECT treatments delivered in the first 3 months of 2020.^[14] The pandemic continued to evolve and produced far more consequences, for instance, an increased number of deaths and extended lockdowns and restrictions in Australia, until mid-late 2022.^[15]

The location of this study – the city of Melbourne in Australia, was among the towns with the longest lockdown periods in the world, including a 111-day lockdown in 2020, the second-longest globally that year.^[16] Over 2020 and 2021, lockdowns totaled 262 days, the longest cumulative duration worldwide.^[16,17] Not only were Melbourne lockdowns prolonged, but they also entailed austere restrictions such as nightly curfews, limited reasons allowing people to leave their homes, mandatory mask wearing, no visitors to homes, and a travel limit of 5 km beyond one’s home.^[17] This context is important for interpreting the study’s results, as longitudinal data indicate a greater decline in mental health among Victorian residents in 2020 due to prolonged, stringent lockdowns compared to the rest of Australia.^[18] This study aims to examine the impact of COVID-19 on ECT delivery and service adaptations, focusing on the changes, challenges, and responses. It does so by analyzing quantitative data on ECT delivery over the past 5 years and exploring the perspectives of ECT service providers.

MATERIALS AND METHODS

Between November 2023 and January 2024, 100 surveys were sent via email through REDCap to psychiatrists (including registrars), anesthetists, and other staff involved in ECT at Western Health, a major metropolitan public hospital in Melbourne, Australia, during the pandemic. Reminder emails were sent biweekly to those who had not completed the survey. We collected demographic information (age and gender) and experience in ECT delivery, as well as their opinions on changes in demand, protocols, patient attitudes, support, and challenges during the pandemic. We also gathered their safety concerns and suggestions for future pandemics. Additionally, data on ECT sessions delivered from 2017 to 2022 and patient profiles were obtained from the hospital’s database.

The ECT guideline implemented during the pandemic at Western Health is illustrated in Figure 1.

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Figure 1:

Electroconvulsive therapy guideline in Western Health. DCS: Director of clinical services, ECT: Electroconvulsive therapy, PCR: Polymerase chain reaction, PPE: Personal protective equipment, RAT: Rapid antigen test

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RESULTS

Of the 100 online survey invitations distributed, 38 surveys were initiated. Of these, 19 surveys were completed and included in the analysis. Table 1 summarizes the demographic and professional characteristics of survey respondents and their experiences with ECT delivery during the COVID-19 pandemic. Participants ranged in age from 27 to 57 years, with a median age of 38 years (standard error [SE] = 2.43). Among the 19 respondents, 47% identified as male and 53% as female. Most were psychiatrists (68%), followed by psychiatric nurses, case managers, or theatre nurses (26%), and one anesthetist (5%). Respondents had between 1 and 25 years of ECT experience, with a median of 5 years (SE = 2.01). The number of ECT sessions delivered in the past year varied widely, ranging from 0 to 1092, with a median of 25 (SE = 74.87).

During the pandemic, 47% of respondents reported changes in ECT demand, 79% noted adjustments to delivery protocols, and 74% experienced challenges in providing ECT. Changes in patient attitudes toward ECT were observed by 32% of respondents. Notably, 89% reported receiving adequate organizational support for ECT delivery during this period.

The respondents were asked the following questions, and their answers were grouped based on recurring keywords or themes.

1. How has the pandemic affected the delivery of ECT services?

   • PPE and infection control: 9 mentions (47%)

   • COVID-19 testing and screening: 6 mentions (32%)

   • Delays and reduction in sessions: 4 mentions (21%).

2. What are the changes in demand for ECT you have experienced?

   • Reduced: 4 mentions (21%)

   • Increased: 2 mentions (11%)

   • Higher thresholds of prescribing: 3 mentions (16%).

3. What changes were made during the pandemic?

   • PPE and infection control: 9 mentions (47%)

   • COVID-19 testing and screening procedures: 6 mentions (32%).

4. What challenges have you experienced?

   • Operational and logistical challenges: 6 mentions (32%)

   • COVID-19 testing and screening procedures: 4 mentions (21%)

   • Staff and patient concerns/anxiety: 4 mentions (21%)

   • PPE and infection control: 3 mentions (16%).

5. In your opinion, what were the risks and safety concerns of delivering ECT during the pandemic for both you and the patient?

   • Risk of COVID transmission: 14 mentions (74%)

   • Deterioration due to delay in receiving ECT: 4 mentions (21%).

6. What are the changes in the attitude of patients toward ECT?

   • Hesitance due to procedures and precautions: 4 mentions (21%).

7. What advice would you give to other service providers who are delivering ECT services during a pandemic?

   • Precaution and safety measures: 8 mentions (42%)

   • Guideline-based management: 4 mentions (21%).

Table 2 the number of ECT sessions delivered at Western Health from 2017 to 2022. The number of sessions increased for three consecutive years, with an average annual growth of 9.4%. However, since the onset of the pandemic in 2020, the total sessions dropped by 5.7% compared to 2019. In 2021, the number surged by 24% to a record high of 1,312, before declining by 12% to 1,157 in 2022. We also note that the number of elderly ECT patients dropped by a greater proportion (12.7% vs. 1.7%) than the other adult population from 2019 to 2020, which could be secondary to extra precaution emphasized among the elderly at the time.

DISCUSSION

This study highlights the significant impact of the COVID-19 pandemic on ECT delivery, drawing on survey data from 19 clinicians and session trends at Western Health. While 89% of respondents reported adequate organizational support, 79% noted protocol adjustments (e.g., PPE mandates and COVID-19 screening) and 74% experienced challenges such as operational delays and staff shortages. These disruptions contributed to a 5.7% decline in ECT sessions in 2020 compared to pre-pandemic growth rates (9.4% annually from 2017 to 2019). A rebound in 2021 (24% surge) likely reflected eased restrictions and improved safety protocols, though subsequent declines in 2022 suggest ongoing volatility.

CONCLUSION

The COVID-19 pandemic has significantly impacted healthcare, including ECT delivery. Despite early disruptions, many institutions deemed ECT essential and developed protocols to ensure its continuity. This study at a major Melbourne hospital highlighted challenges such as PPE use, screening, and infection risks, but emphasized the necessity of precautions taken for patients’ and staff safety. Clinicians also raised concerns about delays in urgent cases. Services should evaluate pandemic protocols from patient and staff perspectives to inform updated guidelines for future use.