key: cord-0936768-e25wrm0p authors: Daniel, Hernández-Huerta; Begoña, Alonso-Sánchez Elena title: Access barriers to electroconvulsive therapy during COVID-19 pandemic date: 2020-05-06 journal: Psychiatry Res DOI: 10.1016/j.psychres.2020.113057 sha: b23ca47f66e25be68d041cb204f4c51b517c3622 doc_id: 936768 cord_uid: e25wrm0p nan Coronavirus disease 2019 (COVID-19) is a clinical syndrome caused by the severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). The first cases of COVID-19 occurred in Wuhan (China) in December 2019. Since then, human-to-human transmission has eased its spread around the world causing more than a million infected people and more than a hundred thousand deaths. Because of this, World Health Organization characterized COVID-19 as a pandemic on 11 th March 2020. COVID-19 outbreak has dramatically and rapidly transformed hospitals. For example, in Madrid (Spain), one of the biggest focus of SARS-Cov-2 in the world, general hospitals have undergone major changes in less than two weeks. Psychiatric services have not been oblivious to this situation. The number of psychiatric beds has been drastically reduced. Other mental health services, such as day hospitals, rehabilitation units, and therapy groups units have all been closed. Moreover, almost all outpatient visits have been switched to telephone conferences liker other countries (Arango, 2020) . Psychiatric inpatient units have also been affected and many of them have been transferred to Psychiatric Hospitals at the beginning of the pandemic. In contrast, we have had to strengthen psychiatric liaison programs because an increasing in the consults because of the increasing number of assessments. The main causes for this high demand rely on severe drug interactions, as well as neuropsychiatric side effects induced by therapeutic agents used to treat COVID-19. Delirium and agitation also contribute to increase the demand for a psychiatric assessment, as SARS-Cov-2 has mainly affected older people with comorbidities, frequently hospitalized in the intensive care unit and prolonged length of hospital stay (Shalev and Shapiro, 2020) . Despite psychiatric hospital services have been reduced in many countries affected by the pandemic, it is important to note that mental illness patients could be more vulnerable to COVID-19 infection due to their disordered mental state, poor selfcontrol and self-care, as well as inadequate insight. They may be incapable of practicing infection control measures to protect themselves. In fact, there is evidence that mental health disorders can increase the risk of infections, including pneumonia (Xiang et al., 2020) . Of course, electroconvulsive therapy (ECT) has been affected by the COVID-19 outbreak. Usually, ECT is not prioritized in many hospitals and it has been evident in this scenario. One of the first access barriers have been the scarce medical resources. ECT is a droplet and aerosol-generating procedure and could easily transmit coronavirus infection. Patients may also require suctioning of airway fluids, creating further opportunity for droplet spread in the treatment room. For this reason, use of Personal Protective Equipment (EPP) is mandatory in all suspected or confirmed COVID-19 patients (Colbert et al., 2020) . Unfortunately, the availability of EPP in Madrid has been one of the greatest challenges we have had to face. Therefore, at the beginning of the pandemic there was not enough EPP and many ECT treatments had to be suspended. As I said previously, many psychiatric inpatient units from general hospitals in Madrid have been moved to Psychiatric Hospitals. This situation has created an overload of severely ill patients in one of the main psychiatric hospitals, but had not increased medical resources for anesthesists or ECT devices to deal with this situation. This has been another access barrier because many patients have been forced to stop or delay their ECT treatments. In the same way, patients who were receiving continuation and maintenance ECT have also been stopped. In this group, the risk of infection when reaching the hospital and the state of emergency announced by the government have also hindered their access to hospitals. Another access barrier is due to human resources. COVID-19 has infected many of the staff usually involved in the procedure. They have been replaced by other professionals but they do not have the same experience and may be afraid and less confident in using ECT. All the access barriers previously mentioned previously have worsened clinical evolution of the patients who would have been candidates to receive ECT in a non-pandemic situation. They have suffered slow recovery and prolonged hospital length of stay. At this point, it is necessary to remark that ECT, based on evidence, is an effective and efficient technique, more effective and efficient than many other therapeutic strategies in Psychiatry. Beyond that, there are a lot of pending challenges that ECT has to deal with in our country and, probably, in most parts of the world (Bernardo and Lessons learned from the coronavirus health crisis in Madrid, Spain: How COVID-19 has changed our lives in the last two weeks Dignifying Electroconvulsive Therapy based on evidence Images in Clinical ECT: Immediate impact of COVID-19 on ECT Practice Epidemic psychiatry: The opportunities and challenges of COVID-19 The COVID-19 outbreak and psychiatric hospitals in China: managing challenges through mental health service reform The authors declare that there are no competing conflicts of interest regarding this article.