The arrival of the global pandemic in March 2020 meant that most elective medical procedures were cancelled or put on indefinite hold. It also meant that medical providers needed to decide which procedures were actually elective— and which were potentially life-saving.
At Allina Health, mental health providers were forced to make an important decision: Should could electroconvulsive therapy (ECT) — a medical treatment used in patients with severe depression involving brief electrical stimulation to the brain — be considered a non-elective procedure? And if ECT were given that designation, how could Abbott Northwestern, United and Unity — the three Allina hospitals that offered the therapy to patients — continue to perform it safely?
For James Van Doren, lead physician for inpatient psychiatry at Unity Hospital in Fridley, those early days of the pandemic were shrouded in a heavy layer of stress.
“It was a blur,” he said. “When I think back about it now, it felt like things were being updated every day. There were constant changes for several weeks. None of us was sure what was going to happen.”
Bennett Poss, a general adult psychiatrist at Abbott Northwestern Hospital in Minneapolis, said that as news about COVID and its transmissibility spread, he and his staff began to worry that they may not be able to continue to provide ECT for their patients.
“There wasn’t any sort of clear guidelines at the beginning,” he said. “It pretty quickly went from treating people as usual to thinking, ‘Maybe we should do something extra to protect our staff like provide masks or something.’” Hospital staff, Poss explained, were just figuring things out as they went along, hoping against hope that they would be able to continue to offer the procedure for their patients: “The important thing we did know was that ECT is very different from other mental health services because it can’t be done remotely. It needs to be delivered in person.”
Ryan Coon, a general adult psychiatrist at United Hospital in St. Paul, had other concerns. Because patients are briefly under anesthesia during ECT, and need medical assistance to breathe, there is an increased risk of aerosol transmission of the virus. He recalled that he and other providers worried that the limited supply of personal protective equipment (PPE) for healthcare workers might mean that hospitals would decide that they had no choice but to cancel ECT appointments. “There were a lot of questions coming up about what was truly an essential procedure,” Coon said.
Coon and his colleagues argued that ECT, a procedure that is often used to pull patients out of severe depressive states or even catatonia, is actually essential and lifesaving in many cases. Their higher-ups at Allina agreed, adding ECT to the list of procedures that the health system would continue to provide during the pandemic.
“Early on in the process our medical director announced to us that they were going to allow us to continue doing ECT,” Van Doren said. Though a lot of outpatient procedures had been put on hold because of the pandemic, he continued, “It was determined that ECT was a life-saving intervention and we shouldn’t defer it if at all possible. For us and our patients, this was good news.”
While the news that Allina would keep ECT services going during the pandemic was good news, it came with a puzzle: To ensure that the procedure was being conducted in the safest way possible, all ECT services had to be moved to one facility. This required coordination, planning and shifting of everything from provider schedules to inpatient rooms.
A relatively simple procedure, ECT treatments in non-pandemic times often take place in regular hospital rooms. This was the case at United and Abbott Northwestern, Poss explained.
“We didn’t use a surgery center or an operating room with sterile conditions,” he said. “Usually that isn’t required during ECT. We don’t do any cutting or anything where it would be an infection risk. The facilities that we used before were perfectly safe — if there wasn’t a rampant respiratory virus.” When COVID hit, Poss added, changes needed to happen quickly. “We knew right away that would be a huge challenge.”
COVID-era enhanced safety precautions required that ECT be performed in a regular operating room — something that was in short supply at Abbott Northwestern and United.
“We couldn’t retrofit Abbott or United for that,” Poss said. “We couldn’t find an air purifier or an empty operating room. The biggest challenge was that we needed to have a place to do ECT in a predictable and reliable manner.”
Though they all worked on the same mental health team at Allina, before the pandemic, Coon, Poss and Van Doren generally did their work independently at their own individual hospitals. As it became clear that this new situation would require coordination, they scheduled a series of meetings focused on figuring out how they could safely continue to provide ECT to their patients.
While Abbott and United didn’t have spare operating space, Unity did. During the meetings, the three psychiatrists and their support teams discussed what it would take to consolidate their services in one location.
“We ran through all those scenarios,” Poss said. “It required us to be very flexible. We had a lot of harried meetings about, ‘Can we do this?’ ‘Where can we get these people treated?’ ‘How quickly can we do it?’”
Consolidating all ECT services at Unity had the benefit of limiting the use of PPE and provider time, Coon explained. “Because we were going to be at one location, we would only be using one provider, using one mask and one anesthesiologist during those ECT days. Typically we have ECT running at three of our hospitals.”
Though the consolidation reduced the need for PPE, it did put extra strain on physicians and other providers, Van Doren said.
“It was a stressful time. It was busy. There were long days doing ECTs. We were doubling the number of procedures we were doing every day at Unity.” On busy days, as many as 24 patients received ECT treatments at Unity Hospital: “That’s double what we usually do.” In an attempt to take the strain off Unity providers, the other psychiatrists each took shifts providing ECT at Unity, he added: “We came up with a rotation where Dr. Poss and Dr. Coon would come over to do the procedures on some days.”
At the beginning of the pandemic, there was no reliable way to determine if a patient had COVID, Van Doren said. “We didn’t have the ability to screen patients ahead of time. We didn’t have any way to know who had an infection or not.”
This made the need for PPE particularly acute, but then science presented a way to determine if patients had the virus. “We got to a point where we were able to get pretty rapid test results,” Van Doren said. “They’d be tested prior to ECT, then they’d be tested weekly as long as they were undergoing ECT.”
Thanks to this advancement, providers were able to continue to offer ECT safely, with little or no virus transmission as a result of the procedure.
“We’ve had some patients that were not able to have treatment because they did end up testing positive for COVID before treatment and they had to wait until they cleared,” Van Doren said. “To my knowledge, we didn’t have any infections that were transmitted during treatment.”
Bad reputation, high success
For many people, ECT sounds like a last resort, a brutal treatment like the one depicted in the film, “One Flew Over the Cuckoo’s Nest.” Even “shock therapy,” the popular name for the procedure, gives it a frightening reputation. But Coon, Poss, Van Doren and other mental health providers say that ECT is a safe and effective procedure, one that has helped countless patients struggling with severe depression or bipolar disorder.
Coon, for one, said many of his patients have a similar reaction when he proposes the idea of ECT. “When I bring it up in my clinical practice, I often get comments from patients like, ‘You really think I’m that bad?’ I’ll say, ‘You’re struggling with depression. I think this can help you.’”
While ECT’s reputation is that of a last resort, Poss said that the procedure is actually safer and more effective than traditional antidepressant medication.
ECT, Poss said, “is the most effective thing we know of in treating depression. It has the highest success rates. It is a very safe procedure. It has low complication risks. It is something that is well tolerated in terms of side effects when compared to medications.”
Coon added that ECT treatment’s impact is felt more quickly than antidepressants’.
“An antidepressant typically takes effect in six to eight weeks, whereas with ECT the typical treatment course would be somewhere between 6-12 sessions, typically doing those three times a week,” Coon said. “So you will have completed a course of ECT within four weeks. The outcomes or rates of getting better are much higher with ECT.”
It is important, however, to understand that ECT is a medical procedure that requires more commitment than taking a daily pill.
“It’s not just one treatment and you’re done,” Coon said. “You have to go to a day-surgery center and have an IV placed. It is done under general anesthesia. We ask that you not drive during the acute series of ECT. Patients might experience headache, body ache, loss of short- term memory. You can have difficulties with nausea and fatigue on treatment days. There is a time investment and a risk of side effects associated with ECT.”
Van Doren said that he has seen ECT save lives.
“If you took a random ECT case, the treatment might not be life-saving for that one individual,” he said. “But there are many patients that without ECT might end up committing suicide. Or another more common scenario is patients that become catatonic from their depression and stop eating and drinking and start to deteriorate physically. ECT can reverse the effects of catatonia and help a person come alive again.”
Coon said that despite the time commitment and potential side effects, he feels that ECT treatments have the power to change the lives of people with serious depression.
“For major depressive disorder, the response rate from ECT is upwards of 75 to 80 percent,” he said. “Most patients will have at least some very meaningful improvement, and up to 50 percent of individuals with major depression can have a full remission with ECT. Compare that to an antidepressant trial, where the response rate might be 35 percent and the remission rate 15 percent. This is an important treatment option that needs to be available for patients.”
Benefits of collaboration
With the darkest, most confusing days of the pandemic now in the past, Allina has moved ECT services back to all three hospitals, creating COVID-safe spaces for the procedures at Abbott Northwestern and United so that Unity’s caseload can go back down to normal.
While they’re happy to be back in their home hospitals, Coon, Poss and Van Doren all feel that the experience of working together during crisis improved the way they provide their services.
“It was nice to get to work with the other providers,” Van Doren said. “It was a good opportunity for us to get on the same page in terms of our practices.” Before the pandemic hit, he explained, “The providers at the different sites were siloed and isolated from each other. We all had our own culture in terms of practice standards and preferences. There are more updated practices that we weren’t up to speed on, and when the docs from the different sites came together we all began learning from each other.”
Coon said that the collaborative learning has helped to expand the way he and his colleagues practice medicine. He predicts that this approach will continue long after the pandemic has faded from memory: “One nice thing is that the providers at all three hospitals were getting to know each other. We’ve been able to maintain that collaboration and help develop best-practice approaches for ECT that are consistent across our organization.”
This collaboration could’ve gone poorly if the individual providers resisted working together, Poss said, “but I think the spirit of collaboration came from as high up as you want to go at Allina. From the CEO to the director of our service line in mental health, everyone was supportive of what we were doing and recognized that this was an unprecedented challenge. We all understood that the only way to navigate it was through timely communication and collaboration.”
In the end, he added, “It made me feel more connected with my co-workers and made me feel a lot more confident in our ability to work around huge challenges. We had to do the hard work of figuring out what’s best for our patients and our staff and our safety, too, and it really paid off.”