From Scottish ECT Audit Network.

Main: GuidelinesForHealthcare

Royal College of Psychiatrists

Guidelines for Healthcare Commissioners for an ECT Service

1. Why commission an ECT service?

ECT is the most effective and rapidly-acting treatment for severe depressive disorders. It is usually reserved for patients who have failed to respond to drug or other therapies, but it can be a first line treatment. It is particularly indicated for severely depressed patients who are at risk of suicide or at risk of death because of their refusal to eat or drink. There is a firm evidence base for the effectiveness of ECT. It also has a place in the treatment of other disorders such as schizophrenia, mania, catatonia and neuroleptic malignant syndrome. Its role in these conditions is usually when drug therapy has proved ineffective or for some reason is inadvisable.

No comprehensive mental health care service should be without easy and regular access to a high quality ECT treatment facility.

2. What is ECT?

The treatment consists of passing a small amount of carefully controlled electric current across the brain. This is delivered for three to five seconds. During the treatment the patient is briefly anaesthetised and also given a muscle relaxant. The electric current induces seizure activity in the brain which is necessary for the effectiveness of the treatment. The whole procedure takes between five and ten minutes. ECT is usually given in the mornings in a separate ECT department and a course involving two or three treatments a week is required. The average number of treatments in a course is six, but sometimes longer courses are required. ECT may be given on an in or out-patient basis, depending on the patient�s clinical condition.

3. How does ECT work?

A number of elements are required to make ECT effective:

• The passage of an electrical current
• The triggering of a generalised seizure
• A series of treatments spaced out over two to three weeks

These elements induce changes in several neurotransmitter systems in the brain which are known to be disordered in major depression. ECT works on the same neurotransmitter systems as antidepressant drugs.

4. What adverse effects does ECT cause?

There is a very small, unavoidable mortality rate associated with ECT, comparable to the mortality of other minor procedures involving a general anaesthetic. Two studies on severely depressed patients have shown that mortality from suicide is less when ECT is used as a treatment than when it is not.

Commissioning Standards for ECT

Clinical guidance, treatment protocols and treatment standards have been set in a number of documents including the ECT Handbook of the Royal College of Psychiatrists 1995, the Scottish Office Good Practice Statement 'Electroconvulsive Therapy', the Royal College of Nursing 'Guidelines for Nurses' and the UKCC Nursing Guidelines (for references, see the end of this document).

Commissioning standards can be divided into four areas:

1. Accommodation and Plant

• The ECT suite should be purpose built or appropriately converted and contain areas for reception and preparation, ECT treatment and recovery. It should comply with the guidelines set out in the ECT handbook.
• Anaesthetic equipment should be provided in accordance with the equipment list in the ECT handbook. There should be a protocol for its maintenance and servicing. There should also be rapid access to anaesthetic backup equipment.
• An ECT machine recommended by the ECT Handbook should be used. No obsolete equipment should be used either for the main or backup machines. There should be a protocol for the maintenance and servicing of the machines.

2. Staffing

• The ECT clinic should be headed by a consultant psychiatrist who should have overall responsibility for ECT. This individual must have at least one dedicated session per week.
• The ECT clinic should be staffed by an appropriately trained psychiatrist and anaesthetist.
• The staff mix of other personnel involved will depend on local circumstances. The following are the minimum requirements: There should be a psychiatrist properly trained and properly supervised at each treatment session. There should be two trained personnel, one of whom should have resuscitation qualifications. These personnel may be one registered nurse and an assistant or one registered nurse and an operating department assistant (ODA) or equivalent.
• Particular local circumstances such as a very low rate of ECT may make it reasonable to have special staffing arrangements for such clinics.
• There should be a system in place to ensure that: one trained nurse is constantly with each unconscious patient, that assistants are there to care for fully conscious patients, and that there is easy access to backup for restless patients. There should be a system where each patient is accompanied by a nurse, preferably known to the patient, from their ward down to the ECT department. This nurse should stay with them throughout the treatment.

3. Protocols

There should be protocols for the following areas. They should be in accordance with the ECT Handbook 1995, but may be modified to suit local circumstances. They should be printed, readily available to all staff and regularly updated. These protocols should include:

• A full pre-treatment clinical workup
• Pre-treatment anaesthetic safeguards
• Cover for all aspects of consent to treatment
• The conduct of treatment itself
• Management of failed seizures
• Estimating the delivery of an appropriate electrical stimulus
• Stimulus dosing
• Outpatient ECT
• Policy and protocol for younger people
• Policies and protocol for training and supervision for psychiatric, anaesthetic, nursing and ODA staff
• Protocol for the transfer of information between ECT staff and clinical staff from wards and/or outpatient department.

4. Audit

There should be an active audit programme in each department such that each clinic is routinely auditing its standard of practice.

Audit cycles should examine how protocols are adhered to and protocols amended with successive audit cycles.

5. Further information

For further information and reading, please refer to the following documents:

The ECT Handbook (Second report of the Royal College of Psychiatrists - Special Committee) Council Report CR39. Royal College of Psychiatrists January 1995.

Electroconvulsive Therapy (ECT) A Good Practice Statement. CRAG Working group on Mental Illness. The Scottish Office, February 1997.

These guidelines were produced by the Special Committee on ECT, under the chairmanship of Dr Chris Freeman, and have been endorsed by Council. 11.6.98. They will be reviewed with the ECT Handbook review in 2000.