No abstract

Objective Continuation and maintenance ECT (c‐/m‐ECT) are effective in the prevention of relapse and recurrence of both affective and psychotic disorders. However, data are scarce concerning the trajectories of severe mental disorders after the end of c‐/m‐ECT. This prospective study investigates the clinical outcome of patients with versus without modifications of their c‐/m‐ECT schedules. Methods In the context of the COVID‐19 pandemic, ECT capacities were restricted at many clinics in early 2020. All patients receiving c‐/m‐ECT in March and April 2020 at our department ( n = 53, unipolar depression, bipolar disorder, schizophrenia) were followed up for six months to investigate the impact of treatment modifications imposed by the pandemic. Based on individual decisions, c‐/m‐ECT was either (a) continued without modification, (b) continued with reduced frequency, or (c) discontinued. Results Both reduced frequency and discontinuation of c‐/m‐ECT were associated with significant clinical deterioration as measured by CGI‐I (Clinical Global Impression Scale ‐ Global Improvement) during the six‐month follow‐up when compared to the subgroup of patients without any treatment modification ( p = 0.005, p = 0.011). Furthermore, patients with discontinued or reduced c‐/m‐ECT showed significantly higher rates of rehospitalizations ( p = 0.028) and new acute courses of ECT ( p = 0.018). Conclusion Despite the limitations of a heterogeneous and relatively small sample, our study strongly corroborates the effectiveness of c‐/m‐ECT in a real‐world population. Especially, patients with shorter time since index ECT seem to be at high risk for severe clinical deterioration in the case of treatment discontinuation or reduction.

This case series suggests that ECT may (and sometimes should) be administered to severely ill, non-consenting patients against their will with good effectiveness. Potential and mostly moderate and transient side effects have to be weighed up against the potentially life-saving character of ECT in patients with, e.g., suicidality and food refusal. Most importantly, the patients' retrospective appraisal also justifies the administration of ECT in situations of severe mental illness and legal incapacity.

Objectives Severe psychiatric disorders may be accompanied by life-threatening conditions, lack of insight, and treatment refusal. Involuntary treatment may be indicated in patients who lack capacity to consent and refuse treatment. In this context, there is a lack of systematic data regarding the use of electroconvulsive therapy (ECT) in Germany. Methods A questionnaire with 25 items comprising quantitative and qualitative data was sent to all psychiatric hospitals in Germany that perform ECT. Cases of ECT treatment in incapable patients refusing therapy were identified retrospectively in a 12-month period. Results Fifty-three hospitals completed the questionnaire, and 15 cases of ECT in incapable and refusing patients were reported. A marked clinical response was observed in 14 patients. Capacity to consent was restored in 11 patients. In contrast to this particularly good effectiveness, psychiatrists' attitudes revealed a widespread lack of experience as well as reservations and uncertainties regarding the use of ECT against the patient's wishes. Conclusions In line with other recent publications, our data suggest a very good benefit-to-risk ratio for ECT in incapable patients refusing the treatment, while at the same time the provision of ECT in such patients is rare in Germany. In light of the scarcity of treatment alternatives and the possible consequences of a refusal to perform ECT in life-threatening conditions, a general rejection of involuntary ECT does not seem ethically appropriate.