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Electroconvulsive Therapy (ECT)

March 2014

Position statement 74


Summary

Electroconvulsive therapy (ECT) is a highly effective treatment with a strong evidence base, particularly for the treatment of severe depressive disorders.

Introduction

Electroconvulsive therapy (ECT) is a therapeutic medical procedure for the treatment of severe psychiatric disorders. It has efficacy in treating clinical depression, mania and psychosis, and it is occasionally used to treat other neuropsychiatric conditions. Its primary purpose is to quickly and significantly alleviate psychiatric symptoms.

What is ECT?

ECT involves the delivery of an electrical current to induce a seizure for therapeutic purposes. The treatment is always delivered by a medical practitioner. Before the treatment another medical practitioner ensures the patient is anaesthetized. A medication which causes muscle relaxation (i.e. prevents muscles from contracting) is administered with the anaesthetic so there is minimal physical movement during the seizure. The patient is anaesthetized during the procedure and awakes several minutes after the procedure is completed. There should be careful evaluation of each patient before, during and after ECT. ECT treatments are usually given one to three times a week. The length of a course of ECT is highly variable, but the average number of sessions used to treat depression ranges from eight to twelve sessions.

Some patients may require treatment with continuation or maintenance ECT because other treatments have not been effective in preventing illness relapse. Continuation/maintenance ECT consists of further treatments given after the end of the acute treatment course, to prevent relapse. It typically ranges from an ECT treatment given every week to every few weeks.

There have been substantial developments which have improved the practice of ECT in recent years.1 There are several valid treatment approaches and there is no single “protocol” for administering ECT. The treatment approach needs to be individualized to the patient, his/her disorder and response to ECT. The practice of ECT is supported by active research aimed at improving efficacy and minimizing side effects.

New Zealand and several states in Australia have ECT guidelines and information for practitioners, and/or patients and their families and caregivers. ECT must be performed within legislative requirements.

Clinical indications

  • ECT is a highly effective treatment with a strong evidence base, particularly for the treatment of severe depressive disorders.
  • ECT has therapeutic benefit for patients with other psychiatric disorders such as mania, psychosis, treatment of catatonia and severe melancholic depression with psychotic features, where-ECT can be life saving. It should be considered a therapeutic option alongside other treatments. Such considerations must be done on an individual basis, after detailed specialist psychiatric assessment.

Patient selection and consent

  • The screening and selection of appropriate patients is essential and should be conducted by a specialist psychiatrist with appropriate training and expertise in ECT.
  • Informed consent is essential for patients considering ECT. Enough information should be provided for patients to make an informed decision. It is recommended that families and caregivers are involved in this process where possible. Adequate time should be made available for patients and their families and caregivers to discuss any concerns.
  • There appear to be no differences in the effectiveness and safety of ECT in adolescents, compared to adults. It is exceptionally rare for ECT to be used in children in the preadolescent age group. In all cases in which ECT is considered for a child or adolescent, the opinion of a child and adolescent psychiatrist should be sought.
  • During the consent process, patients should be given information on the potential side effects of ECT, particularly the possible loss of short term and recent memories around the time of ECT, and occasionally, past memories. The practitioner should take into account the patient’s mental state in deciding on the level of detail given. Family and carers may also be involved in this process.
  • For patients unable to consent to ECT and involuntary patients, there should be legal processes to ensure that patients receive timely and potentially lifesaving treatments such as ECT. The state, territory and national legislation governing the use of ECT in these circumstances should be observed.

ECT administration

  • ECT should be available in private and public medical settings and should be accessible and, where appropriate, offered as a potential therapeutic option.
  • ECT should be administered by a medical practitioner (usually a psychiatrist) who has received specialized training in ECT treatment techniques, and is of an adequate standard to have received clinical privileges to perform the procedure.
  • Patients should be monitored closely during a course of ECT including their progress and side effects. Infection control and safety are paramount for the patient.
  • Administration of ECT should be conducted in a respectful manner and practitioners should ensure privacy is maintained throughout the procedure
  • Where more than one patient is having ECT, delivery and recovery should not occur concurrently in the same room. It is not appropriate for a patient to be receiving ECT when another patient is recovering or waiting for treatment in the same room.
  • The use of evidence based pharmacotherapy and other strategies to prevent relapse after improvement from ECT is essential for obtaining a lasting improvement.

Credentialing and training

  • The College endorses ongoing mandatory training of psychiatry registrars in ECT, and credentialing of psychiatrists who give ECT.
  • Ongoing education is essential and all psychiatrists involved in the delivery and prescription of ECT should be familiar with recent advances in ECT treatment approaches, including the effects of varying electrode placement, dosing and stimulus parameters, and the interaction of these factors.

Future directions

  • The College encourages ongoing research into ECT.
  • Although other brain stimulation treatments are being developed in psychiatry, none have been shown to be a replacement for ECT. ECT remains a useful and essential treatment option that should be available to all patients in whom its use is clinically indicated.

1 For further details, please refer to the reading list at the end of the position statement.

Dunne RA, McLoughlin DM. Systematic review and meta-analysis of bifrontal electroconvulsive therapy versus bilateral and unilateral electroconvulsive therapy in depression. World Journal of Biological Psychiatry 2012, 13: 248-258.

Kellner CH, Knapp RG, Petrides G, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multi-site study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry 2006, 63: 1337–44.

Lisanby SH. Electroconvulsive therapy for depression. NEJM 2007, 357: 1939-45.

Loo CK, Katalinic N, Martin D, Schweitzer I. A review of ultrabrief pulse width electroconvulsive therapy. Therapeutic Advances in Chronic Disease 2012, 3: 69-85.

Mankad MV, Beyer JL, Weiner RD and Krystal A. Clinical Manual of Electroconvulsive Therapy. Washington DC: American Psychiatric Publishing, 2010.

Ministry of Health. Electroconvulsive Therapy (ECT) in New Zealand: What you and your family and whānau need to know. Wellington: Ministry of Health, 2009.

Navarro V, Gasto C, Torres X et al. Continuation/maintenance treatment with nortriptyline versus combined nortriptyline and ECT in late-life psychotic depression: a two year randomized study. American Journal of Geriatric Psychiatry 2008, 16: 498-505.

New South Wales Department of Health. ECT Minimum Standards of Practice in NSW. Sydney: NSW Department of Health, 2010. www.health.nsw.gov.au/policies/pd/2011/pdf/PD2011_003.pdf Accessed 4 June 2012.

Ottosson J-O, Fink M. Ethics in Electroconvulsive Therapy. New York: Brunner-Routledge, 2004.

Semkovska M, McLoughlin DM. Objective cognitive performance associated with electroconvulsive therapy for depression: a systematic review and meta-analysis. Biological Psychiatry 2010, 68:568–577.

State of Victoria. Electroconvulsive Therapy Manual. Licensing, legal requirements and clinical guidelines. Melbourne: Victorian Department of Human Services, 2009. www.health.vic.gov.au/mentalhealth/ect/ect.pdf Accessed 4 June 2012.

Tess AV, Smetana GW. Medical evaluation of patients undergoing electroconvulsive therapy. N Engl J Med 2009, 360: 1437-44.

UK ECT Review Group. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003, 361: 799–808.

Western Australia Chief Psychiatrist. Practice Standards for the Administration of Electroconvulsive Therapy 2011.


Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.