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Introduction While the COVID-19 pandemic caused by the SARS-CoV2 virus has challenged healthcare systems across the country, inpatient psychiatric hospitals struggle with a unique challenge. Psychiatric patients participate in therapy groups and eat meals together on milieus. It is difficult to enforce mask use or self-isolation practices in the setting of psychosis or mania. Additionally, neuropsychiatric disorders such as new onset psychosis, delirium, and affective disorders have all been documented following a SARS-CoV2 infection. A surveillance study from the UK found that primary psychiatric diagnoses were most common in younger patients and encephalopathy was more common in older adults following a SARS-CoV2 infection. A multicenter cohort study looking specifically at older adults found that 226 (28%) of 817 geriatric patients with COVID-19 had delirium at ED presentation. Delirium was the sixth most common of all presenting symptoms of COVID-19. Of patients with delirium, 16% had delirium as a primary presenting complaint and 37% had no fever or shortness of breath. Our psychiatric hospital has a geriatric psychiatry service, which has generated further challenges during the pandemic. The hospital requires COVID-19 testing prior to admission, but false negatives are possible. We continue to adapt our procedures to best serve this vulnerable population as we learn more about COVID-19 and atypical presentations. We provide a case report of a geriatric psychiatry patient who presented with delirium secondary to COVID-19 and the subsequent consideration in our admission process. Methods A case report of a patient who was admitted to the geriatric psychiatry inpatient service and was found to have delirium as a presenting COVID-19 symptom. A review of neuropsychiatric manifestations of COVID-19 will be presented. Results Ms. A is an 80-year-old woman with history of major depressive disorder, recent non-ST-elevation myocardial infarction, aortic stenosis, ischemic cardiomyopathy, and hypertension. She was originally admitted to the inpatient psychiatry from the ED for suicidal ideation and worsening depression but was found to be inattentive and disoriented. She had multiple falls in the several days leading up to admission, but no respiratory symptoms or fever. The geriatric psychiatry service determined she was delirious and started medical work up for etiology. Her rapid COVID-19 test at an outside facility was negative. Her medical work up was remarkable for a leukocytosis of 11 ×109 per liter, and an acute kidney injury (AKI) with BUN 20 mg/dL and Creatinine 1.31 mg/dL increased acutely from baseline of 0.9. Urinalysis was negative for infection. She was transferred to the emergency room for encephalopathy and declining oral intake. There, she tested positive for COVID-19 by PCR and was admitted to medicine for delirium of likely multiple etiologies including COVID-19. Her EEG showed generalized slowing and her head CT was negative for hemorrhage or infarction. The consult liaison psychiatry service continued to follow Mrs. A during her three-week hospitalization, during which she required Olanzapine 2.5 mg as needed for agitation related to her hyperactive delirium. Her AKI resolved with intravenous fluids and avoidance of nephrotoxic agents. She was discharged into the care of family on psychiatric medications fluoxetine 40 mg and mirtazapine 45 mg after her delirium gradually resolved with supportive care including physical and occupational therapy. Conclusions The diverse clinical presentation, often multifactorial etiology and the waxing and waning course of delirium makes it difficult to diagnose in an emergency room setting even for experienced physicians. Delirium can present with depressive, cognitive, and psychotic symptoms. It is not uncommon for delirious geriatric patients to be admitted to our inpatient unit for agitation, psychosis or depression, as was the case with Ms. A. Delirium can be a presenting symptom of COVID-19. Given this and our unique circumstances on a psychiatric milieu, we need to take greater consideration when assessing for delirium and other possible neuropsychiatric symptoms of SARS-CoV2 infection prior to admission. Grossman et al. developed a modified confusion assessment method for the emergency department (mCAM-ED) that requires 3 to 5 minutes to complete the whole instrument. However, despite having this and other tools, formal assessment tools for delirium are rarely used in the ED. It is important that geriatric patients are triaged to the appropriate level of care so proper medical treatment can be initiated without delay, as prolonged encephalopathy can lead to permanent decline in cognitive function, worse outcomes, and increased mortality. This case reinforces the clinical importance of including delirium on checklists of presenting symptoms of COVID-19, specifically for geriatric patients, that guide standardized screening, evaluation, and treatment. Funding The authors received no financial support for the research, authorship, and/or publication of this article.

Introduction Electroconvulsive therapy (ECT) has long been a treatment modality of choice for treatment resistant depression. It remains one of the most effective treatments in psychiatry for a multitude of diseases. However, if patients fail ECT there is a lack of robust options for alternative treatments. This case describes a patient who was initially treated with ECT with no response after several treatments and subsequently transitioned to IV ketamine. Once started on ketamine patient showed a significnat improvement in his depressive symptoms and was able to be discharged from an inpatient psychiatric unit. Mr. X is a 70 year old male with a history of major depressive disorder and three prior suicide attempts. He had multiple recent life stressors, including a spouse diagnosed with cancer and being unable to work after back surgery which significantly contributed to his depression. He was admitted to the psychiatric hospital after an attempted overdose. He was started on escitalopram and buproprion XL, which were titrated to max doses throughout his hospitalization. Given his history of incomplete response with medication, his severe depression, and his high suicide risk, aggressive treatment was warranted. ECT was initiated and he underwent 5 treatments of right unilateral, 2 treatments of bifrontal, and 1 treatment of bitemporal. Throughout the course of ECT he had a lack of seizures despite flumazenil, hyperventilation, various induction agents (including ketamine) and pharmacology. During that time he was not getting out of bed, reporting consistently depressed mood, amotivated, and apathetic. He also began noticing some increased cognitive difficulties with the bifrontal and bitemporal ECT treatments. He ultimately was deemed an ECT failure after 8 treatments with no response. Given his continued depression and failure of ECT, it was decided to attempt IV ketamine infusions as the next intervention for his depression. Methods A literature review was conducted searching for Ketamine vs ECT treatment for depression and suicidality using MESH terms of "(Depression) AND (Suicidal behavior) AND (Electroconvulsive therapy OR Electroshock therapy OR Shock therapy OR Electroshock OR Shock treatment OR Convulsive therapy OR Electric shock therapy OR Electric Convulsive therapy OR ECT) AND Ketamine" and "(Depression) AND (Suicidality) AND (Electroconvulsive therapy OR Electroshock therapy OR Shock therapy OR Electroshock OR Shock treatment OR Convulsive therapy OR Electric shock therapy OR Electric Convulsive therapy OR ECT) AND Ketamine." Additional literature regarding Ketamine for treatment resistant depression was searched for using MESH terms of "(Ketamine OR CI-581 OR CI 581 OR CI581 OR Ketalar OR Ketaset OR Ketanest OR Calipsol OR Kalipsol OR Calypsol) AND (therapy OR medical plan OR treatment OR regimen) AND (treatment resistant depression OR therapy resistant depression OR TRD OR refractory depression)." Results After initiation of ketamine Mr. X noticed an immediate improvement. He was given 3 total treatments while inpatient with significant clinical improvment noted after each treatment. He was noted to be more engaged, had improved eye contact, and was reporting improvment in his mood. He was also more active, and was noted to be consistently out of bed ambulating with his walker. After the 3 treatments inpatient he was deemed psychiatrically stable for discharge with the plan to continue an acute course of treatment post discharge. He received 2 more treatments after discharge as an outpatient before ultimately being lost to follow up. Electroconvulsive Therapy continues to show a robust response rate of approximately 80%, with remission in about 75% of cases. Even with these response rates, there is a significant patient population that will not respond to ECT. Research has shown that ketamine can have an immediate response of up to or greater than 70% of patietns within the 24 hours post-infusion. Duration of response is varied, though has been found to be present in about 50–70% of patients. However, there has not been significant published research looking into response to ketamine post ECT failure. Conclusions Mr. X is a prime example of the ongoing difficulties in treating patients with treatment resistant depression who do not respond to ECT. This case shows that after ECT failure it is appropriate to attempt treatment with ketamine barring the patient having any contraindications for treatment. Given that there is little published data regarding the response of patients who have failed ECT but subsequently respond to ketamine infusions, this case is an attempt to add to the literature in that regard. Funding None

IntroductionCaregivers are essential in providing valuable patient information to medical providers. With limited available research investigating caregiver burden among those caring for patients receiving ECT and the new life challenges presented by the COVID-19 pandemic, it is more important now than ever to take a closer look at the caregivers’ experiences.MethodsEmory’s Wesley Woods Geriatric Hospital is one of the busiest ECT services in the country with around 2000 treatments completed every year. In this chart review, researchers are looking at caregivers’ responses to the Zarit Caregiver Burden Interview. This assessment includes 22 questions assessing the caregivers’ current emotional state in order to examine the impact of the patient’s condition oncaregiver wellbeing. The score ranges from 0 (no burden) to 88 (severe burden). Other objective assessments completed with ECT patients are BDI (Beck Depression Inventory), BDI Suicide, Sheehan Disability Scale, ECCA (Electrocompulsive Cognitive Assessment), GAD-7 (Generalized Anxiety Disorder Scale), and CGI (Clinical Global Impression). The purpose of this chart review is to investigate whether the higher severity of depression in patients correlates with higher levels of caregiver burden and whether the pandemic contributed to caregiver burden.ResultsThe Zarit Caregiver Burden Interview has been administered on twelve caregivers (n=12; 6 male and 6 female), all providing care for patients currently undergoing ECT for depressive symptoms. Out of the twelve caregivers, 66.6% reported little caregiver burden, 16.6% reported mild to moderate burden, and 16.6% reported moderate to severe burden. Additional patients are being interviewed in the ECT suite and further data collected will be presented at the 2021 IPA Virtual International Congress.ConclusionAs the world adjusts to life in the COVID-19 era, caregivers face new challenges in providing care for vulnerable, at-risk populations. Caregivers of patients receiving ECT facilitate frequent COVID testing and limited visitation policies while continuing to provide care and emotional support to patients with advanced age and a mental illness. Administrating the Zarit Caregiver Burden Interview can help providers look at the degree of burden in caregivers of patients receiving ECT for depressive symptoms and provide better caregiving strategies during and post pandemic.