BackgroundChina confirmed person to person transmission of a novel coronavirus (now named SARS-CoV-2) on 21 st Jan 2020 1 with more than 200 cases and 4 deaths. The World Health Organization (WHO) declared the COVID-19 outbreak as one of international concern on 30 th Jan 2020 2 . By 11 th Mar 2020 the WHO Director-General declared the COVID-19 outbreak a pandemic with 118,00 cases in 114 countries and 4291 deaths 3 . COVID-19 is currently understood as a droplet spread illness with a reproduction number of approximately 2.2 4 , transmitted via respiratory droplets, contact, fomites and fecal-oral routes 5,6 and with high lethality (3.4%) 7 . Many more patients with COVID-19 than SARS (Severe Acute Respiratory Syndrome) 8 have mild symptoms that contribute to spread as these patients are not picked up by current screening mechanisms 9 . The current outbreak is expected to last at least till the end of 2020 10 with the possibility of a second deadlier wave several months after the current outbreak like the 1918 Spanish Flu 11 . There is no known specific treatment or vaccine. Challenges Facing ECT during COVID-19This situation poses significant challenges for ECT services around the world. ECT is an essential psychiatric service that provides lifesaving treatment for severe mental illnesses like depression and catatonia if given in a timely fashion 12,13 and for which there is no viable alternative. However, ECT service is often not prioritized in hospitals 14 and may be stopped if anaesthesia resources are limited. This occurred at the beginning of the COVID-19 situation in a general hospital in Singapore, resulting in an acute ECT course stopping halfway for a patient

The profiles of frequent ED users in Singapore resembled those reported in other large urban centers. The opinions of service providers and their reactions to difficult situations were similar to those of providers in nonpsychiatric settings. The service providers' perspectives highlight how societal pressures influence the way in which individuals with mental illnesses use services.

Our study findings affirmed our hypothesis and supported the utility of the observation unit in monitoring the overall clinical status of patients, which was linked with subsequent inpatient admissions. Better management of these patients at the outpatient level can potentially decrease unnecessary hospitalization and reduce health care cost as well as illness burden on patients and caregivers.

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