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Summary electroconvulsive therapy in psychiatry
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electroconvulsive therapy in psychiatry
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Chapter 21Electroconvulsive Therapy
162
, Chapter 21: Electroconvulsive Therapy
Introduction
• During electroconvulsive therapy (ECT), electrodes are placed on the patient’s head. An electric current is
passed briefly though the electrodes to the brain, which causes a tonic clonic seizure.
• ECT is given under a general anaesthetic. A muscle relaxant is also given to prevent body spasms.
• Usually ECT is given twice a week for 3-6 weeks (i.e. 6-12 sessions of ECT in total).
• Sometimes ECT is given once every two weeks or once a month to prevent the symptoms returning (this
is called maintenance ECT).
• The decision whether ECT is clinically indicated should be based on a documented assessment of the risks and
potential benefits to the individual, including:
o The risks associated with the anaesthetic.
o Current co-morbidities.
o Anticipated adverse events, particularly cognitive impairment.
o The risks of not having the treatment.
• ECT is rarely used and only when other treatments have failed or when life-saving treatment is needed.
• In Ireland, about 450 people each year are given ECT.
• ECT is a safe and effective treatment.
• The majority of people who receive ECT in Ireland are voluntary patients.
• In Ireland, ECT can only be given to a voluntary patient if they provide consent in writing.
• An involuntary patient should also be asked for their written consent to have ECT. If such patient does not or
cannot consent, their consultant psychiatrist can ask a second consultant psychiatrist to assess the patient. If
they both think that ECT is the best treatment option for the patient, ECT can be given to the patient without their
consent.
Note: Version 3 of the Rules Governing the Use of Electro-Convulsive Therapy was published by the Mental Health
Commission in February 2016. Following implementation of the Mental Health (Amendment) Act 2015, ECT can only
be administered to an involuntary patient without consent where it has been determined that the patient is unable to
consent to the treatment. All references to the administration of treatment, where a patient is ‘unwilling’ to consent,
have been removed from the Rules Governing the Use of ECT. The Rules have been updated to align with best
international practice.
• Elderly - ECT is as effective in the elderly as any other age group. ECT is well tolerated even in the very old.
Older people are more susceptible to side effects that younger individuals.
Indications
• It is recommended that ECT is used only to achieve rapid and short-term improvement of severe symptoms
after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to
be potentially life-threatening in individuals with severe depression, catatonia or treatment resistant mania.
Note: a patient with severe depression who is intent on suicide and/or is not eating or drinking might not be able to
wait three weeks for an antidepressant to take effect. This patient may be a good candidate for ECT because it
works more rapidly than an antidepressant. ECT can therefore be a life-saving treatment.
Note: in Ireland, the majority of people who have ECT have a diagnosis of severe depression.
• ECT has also been advocated as a treatment for neuroleptic malignant syndrome, intractable seizure
disorders (ECT acts to raise the seizure threshold), psychotic conditions (e.g. postnatal psychosis, Cotard’s
syndrome and schizoaffective disorder).
• The effectiveness of ECT has not been demonstrated for dysthymia, anxiety disorders (e.g. neurotic, stress-
related and somatoform disorders), substance misuse, eating disorders, personality disorders.
Note: neurotic personality traits are associated with a poor response to ECT.
Contraindications
• There are no absolute contraindications to ECT (e.g. pregnancy, not eating/taking fluids, individuals taking any
particular medication, those with pacemakers or patients suffering from any other condition).
• Relative contraindications to ECT: raised intracranial pressure, myocardial infarction in the last three months,
cardiac arrhythmias, intracerebral haemorrhage or cerebral aneurysm, brain tumour, acute/impending retinal
detachment, phaeochromocytoma, high anaesthetic risk, unstable vascular aneurysm or malformation.
Improvement rate
• Approximately 70-80% of people with severe depression recover or are much improved.
• Mood usually begins to improve within 1-2 weeks.
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