Introduction Electroconvulsive therapy (ECT) is a highly effective and essential treatment for patients suffering from severe mental illness, including treatment-resistant depression and catatonia. Delaying ECT treatment leads to worsening symptoms, which require more repeat ECT treatments for patients to recover, and increases wait times for others. During the COVID-19 pandemic, many ECT facilities significantly reduced or cancelled their ECT services. The overall clinical and economic effects of these delayed and cancelled ECT treatments are unknown. Methods We conducted a scoping review of studies assessing the clinical and economic effects of missed or cancelled ECT treatment during the COVID-19 pandemic among patients ≥18 years. We searched MEDLINE, Embase, and PsycINFO (inception to March 2024). Three independent reviewers performed screening and extracted data. Results were summarized narratively. Results Of 365 articles screened, a total of 11 articles met eligibility criteria for inclusion in this review. There was consistent evidence across all included studies to suggest that cancelling and reducing ECT treatment was associated with patient relapse, hospitalization, and need for new treatment. Only one of the included studies reported economic outcomes, with the findings suggesting that cancelled and reduced ECT led to significantly increased healthcare costs. Conclusion Our findings highlight that delaying access to critical services, such as ECT, can result in negative clinical outcomes and greater healthcare spending. ECT facilities should prioritize maintaining access to treatment, both presently and during future emergencies, especially for patients with the greatest need, such as those with treatment-resistant disorders or who require more frequent ECT treatments.
Introduction Schizoaffective disorder affects approximately 0.3% of the United States general population, [1] while antisocial personality disorder (ASPD) affects 2–5%. [2] Their co-occurrence is exceedingly rare, poorly characterized, and presents unique challenges in treatment. Most case reports focus on schizophrenia with ASPD in forensic settings; [3] schizoaffective disorder with ASPD in young adults presenting with acute violence risk remains virtually undocumented. ASPD traits, such as deceitfulness and manipulation, compromise reliable symptom reporting, while psychotic features may be dismissed as malingering. Violence risk assessment becomes complex when instrumental and reactive violence factors coexist. In patients with comorbid schizoaffective disorder and ASPD, improvement in psychotic disorganization may occur alongside more organized antisocial behaviors. Case History and Description An adopted Caucasian male in his early 20s with genetic predisposition for psychotic illness and early-onset conduct disorder presented to the emergency department following firearm acquisition and escalating violence. Developmental history revealed long-standing aggression toward others, rule violations, and deceitfulness. Recent functional decline included job loss, social withdrawal, animal cruelty, and acquiring firearms with suicidal and homicidal ideation. Case Assessment and Resolution Mental status examination revealed thought disorganization, paranoid ideation, depressive symptoms, and poor insight. Based on longitudinal history, the patient met diagnostic criteria for schizoaffective disorder and ASPD. The patient was treated with divalproex sodium and oral risperidone and was transitioned to paliperidone palmitate, a long-acting injectable antipsychotic (LAI), which improved psychotic symptoms and impulsivity. During hospitalization, the patient's organization and psychotic symptoms improved; however, his previous ASPD-related behaviors, particularly deceptive behavior and sophisticated manipulation, became more organized. In this case, we observed that as psychotic symptoms and thought disorganization improved, the patient's behavior became more coherent. As thought processes become more linear with antipsychotics, longstanding ASPD-related behaviors appeared more organized, including the capacity for planned deception. This observation suggests that improvement in psychotic symptoms may occur alongside more organized expression of antisocial behaviors in comorbid ASPD. This requires reconceptualizing clinical improvement beyond symptom reduction to include functional outcomes and ongoing risk assessment. Conclusions, Recommendations, and Implications This case highlights a clinical challenge in patients with comorbid schizoaffective disorder and ASPD. Management warrants use of LAIs, legal treatment mandates, intensive case management, comprehensive violence risk monitoring, and harm reduction goals. Traditional clinical improvement metrics are insufficient when severe personality pathology co-occurs with psychosis. This case highlights the need for specialized resources to address both conditions simultaneously and underscores the need for further research on this complex population.
