COVID-19: Providing Electroconvulsive Therapy (ECT)

This guidance is for ECT services and should be read in conjunction with official guidance for maintaining services within health and care settings.

Patients requiring electroconvulsive therapy (ECT) are usually among the most psychiatrically unwell and are likely to be severely affected by a delay or halt to treatment. Despite this, many care providers reduced their provision of ECT services in the spring of 2020, mainly because of the implementation of infection control procedures and the staffing difficulties imposed by the pandemic.

The administration of anaesthesia for ECT may be associated with events that are currently considered to be aerosol generating procedures (AGPs), including, but not restricted to:

  • bag-mask ventilation
  • coughing as a result of airway manipulation or use of airway adjuncts.
In January 2021, official guidance on maintaining healthcare services was jointly published by the Department of Health and Social Care, Public Health Wales, Public Health Agency Northern Ireland, Health Protection Scotland/National Services Scotland, Public Health England and NHS England. Consequently, mental health care providers across the UK should now all have safely resumed their ECT services.

The most recent update of this official guidance, published on 15 March 2022, recommends the screening, triaging and testing of patients to establish the likelihood of Covid-19 infection. This process depends upon effective provision of testing, focusing on "rapid or near-patient" testing.

Indeed, the Royal College has become aware of practical barriers to the provision of frequent SARS-CoV-2 polymerase chain reaction (PCR) tests for patients receiving ECT. Additionally, because a PCR test needs to be taken and sent to a laboratory well in advance of each treatment, the test result has become historical by the day of the planned treatment.

Having taken advice from the Medical Microbiology Committee of the Royal College of Pathologists and from the Royal College of Anaesthetists, the Royal College of Psychiatrists believes that any marginally lower sensitivity of lateral flow device (LFD) tests compared to PCR tests is offset by the ability of LFD tests to provide an up-to-date coronavirus status on the day of each planned treatment.

Consequently, the Royal College suggests that an LFD test, on the day of each planned treatment, is sufficient for routine testing for ECT purposes, as long as the test is performed in the presence of, or by, a member of healthcare staff. Our guidance is supported by the Royal College of Anaesthetists and is in keeping with its own guidance, which is based on official recommendations. 

The screening, triage and testing process effectively separates patients into two pathways of care, which are listed below alongside updated summary information relating to the delivery of ECT.

Using this process, it is believed that most inpatients and outpatients receiving ECT will be judged to be at lower risk of having Covid-19. This should enable providers to deliver a quality, efficient and sustainable ECT service to patients, close to levels prior to the pandemic, whilst avoiding unnecessary waste of resources.

Less commonly, patients may be considered to be at higher risk of having Covid-19, particularly if they are inpatients on wards where there have been recent Covid-19 cases, or if they have refused testing for Covid-19.

Confirmed Covid-19 infection is not an absolute contraindication to ECT.

Patients in this group should meet all the following criteria:

  • the patient has none of the following symptoms:
    • a high temperature or fever
    • a new, continuous cough
    • a loss or alteration to taste or smell.
  • neither the patient, nor any household/family member, nor any inpatient on the same ward:
    • has had a confirmed diagnosis of Covid-19 in the last 10 days
    • has been advised to isolate by any NHS organisation in the last 10 days
    • is awaiting a non-routine PCR test result.
  • the patient has had a negative, witnessed LFD test on the day of treatment.

For these patients:

  • support workers, trainees, students and others may be present during treatment
  • only a standard level of PPE need be worn by staff, comprising gloves (single-use) and a fluid-resistant surgical mask (extended use possible); additionally, an apron (single-use) and eye protection (single use or re-usable) can be considered in unusual cases where the spraying or splashing of bodily fluids, such as saliva, is anticipated
  • there is no requirement to dispose of all waste as infectious waste
  • there is no requirement for additional cleaning of the treatment room
  • patients can be recovered in a recovery room, even if an AGP has been performed
  • there is no additional requirement for ventilation or 'down time' prior to treating the next patient.

All patients who do not meet the lower risk criteria listed above should be considered at higher risk of having Covid-19.

The following precautions apply:

  • depending upon the degree of risk in individual cases, consideration should be given by clinical team leaders as to whether support workers, trainees, students and others may be present during treatment
  • patients should be treated last on the list
  • airborne PPE should be available to all staff present, comprising: gloves (single-use); gown (single-use or re-usable); FFP3 respirator mask (extended use possible) or hood (re-usable); and eye protection (single-use or re-usable).
  • all waste generated in the treatment and recovery rooms should be treated as infectious waste
  • all re-usable equipment, including the ECT equipment and monitoring equipment, and all surfaces in the treatment room, should be decontaminated after each patient using a chlorine-based product
  • patients should be recovered in the treatment room following an AGP, but may be transferred to a recovery room if no AGP has been performed or if the treatment room is a negative-pressure environment
  • following an AGP, 'down time' for required ventilation should be observed prior to the treatment room being cleaned.
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