Electroconvulsive therapy (ECT)

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed this position statement to support the use of electroconvulsive therapy (ECT) as a safe and effective clinical psychiatric treatment. 

Key messages

• ECT is a treatment for a number of psychiatric disorders. It is used to treat severe depression, mania and psychosis, and occasionally other conditions.
• ECT is an effective treatment with a strong evidence base, particularly for the treatment of severe depressive disorders. There have been substantial developments which have improved the safety and practice of ECT in recent years.
• ECT should be available where clinically indicated and not limited by cost, service availability, age or other medical conditions, or overly restrictive legislation.
• Psychiatrists prescribing and administering ECT must be appropriately trained and should engage in ongoing education to promote and share best practice information with colleagues.
• Psychiatrists should continue to challenge the stigma and discrimination associated with ECT, and promote access to ECT treatment where clinically indicated.

Definition

ECT is a medical treatment that rapidly relieves symptoms of severe psychiatric disorders. ECT involves the delivery of a small, pulsed electrical current to the brain sufficient to induce a seizure for therapeutic purposes. ECT is performed whilst the person undergoing treatment is under general anaesthesia. Current evidence suggests that ECT may correct abnormalities in brain functioning associated with depression and other mental illnesses.  

Background

ECT was developed in Italy in 1938 as a treatment for catatonia and depression. Since 1938, the clinical practice of ECT has undergone substantial developments and improvements based on findings from clinical research. These have included the use of general anaesthesia, introduction of new forms of ECT that have high efficacy but minimise memory loss and other side effects, and strategies to prevent relapse after improvement from an acute course of ECT (Mills and Elwood, 2017). The efficacy of ECT, particularly in severe depression, has been demonstrated in clinical trials (Sackeim, 2017) although risks of memory impairment and other side effects still remain. 

With modern safeguards, ECT is a safe and evidence-based treatment although ECT remains a somewhat stigmatised treatment in the eyes of the public, owing to inaccurate and misleading depictions of ECT in the public arena including film and television. The RANZCP acknowledges that ECT treatments may have been used inappropriately in the past and is committed to learning from these past practices in order to provide the most effective care now and in the future 
(RANZCP, 2016).  

When is ECT used?

ECT can be recommended when other treatments such as talking therapies or medication don’t provide adequate benefit. It can also be effective when a person has a severe illness and  when any delay in improvement or recovery could be life threatening or damaging, as ECT generally works more rapidly than medications and other therapies. 

ECT is administered for an illness where there is adequate evidence of effectiveness and an appropriate clinical indication as assessed by a psychiatrist. Its primary use is for people with major depressive disorders, mania and schizophrenia (Malhi et al., 2015; Galletly et al., 2016). 

All people recommended for ECT undergo an appropriate selection process by a psychiatrist and are carefully monitored throughout treatment. In all cases the risks are carefully weighed up against those of other treatments, or no treatment. Particular consideration is given in the case of children and adolescents and people with medical comorbidies, such as older people and pregnant women. Ongoing research in the use of ECT in children and adolescents identifies it as an appropriate treatment for some young people (Ghaziuddin and Walter, 2013) when given in consultation with a psychiatrist with expertise in child and adolscent psychiatry and ECT. Current evidence indicates that ECT is an effective treatment during pregnancy and that the risks to mother and foetus are relatively low (Sinha et al., 2017; Leiknes et al., 2015; Anderson and Reti, 2009; Miller, 1994) when provided using available guidelines (Lakshmana et al., 2014; Austin and Highet, 2017). 

The ability to consent is essential for people considering ECT and is sought in accordance with principle 5 of the RANZCP Code of Ethics. Information is provided for individuals to make an informed decision, including about any potential side effects. For people who are unable to consent to ECT and/or those who require treatment on an involuntary basis under the relevant state law, psychiatrists comply with local and national legislation in relation to ECT consent. Family/whānau¹ and/or carers involvement in decisions is encouraged (RANZCP, 2014).  

Administration of ECT 

ECT is delivered in a hospital, either on an inpatient or outpatient basis. There are a wide range of variables which can be modified in the delivery of ECT (e.g. electrode placement, frequency of treatment sessions). These are determined by the treating psychiatrist following established protocols.  

On average 8-12 sessions of ECT are given in a treatment course, with ECT given 2-3 times per week during an acute course. Each session is performed under general anaesthesia, with the procedure taking around 10-20 minutes. Maintenance or continuation ECT (where further treatments are given after the acute course) is also important in some cases to maintain improvement and prevent relapse after an acute course of ECT (Kellner et al., 2006).  

It is important for the ECT service to have a process in place in every case to ensure that there is adequate monitoring during a course of treatment including ongoing assessment of progress, any side effects, as well as ensuring adequate medication review to maintain recovery. 

ECT is prescribed and administered by a psychiatrist with appropriate expertise. Each organisation that conducts ECT has a process for ensuring that the psychiatrist who administers it is properly and thoroughly trained in the theory, technique and safe operation of ECT.  

For further details for the administration of ECT in clinical practice, refer to the Electroconvulsive Therapy (ECT) Professional Practice Guideline.

Benefits and side effects of ECT 

In general, ECT is one of the best-tolerated biological therapies with low risk for severe complications, and is considered to be one of the safest medical procedures under anesthesia (Baghai and Moller, 2008). There is clearly documented evidence for the effectiveness of ECT in relieving psychiatric disorder with studies showing that ECT is effective 70-90% of the time (Baghai and Moller, 2008; Fink and Taylor, 2007; Kellner, 2010) with an especially high success rate when used to treat severe depression. Response to ECT may be predicted by a number of clinical variables including the type of psychiatric disorder (Petrides et al., 2001).   

Relapse after a successful ECT course can be a limitation of the therapy, with relapse rates within six months in some studies of more than 50% despite maintenance pharmacotherapy (Kellner et al., 2006; Prudic et al., 2004; Tew et al., 2007). However, the risk of relapse can be reduced by using evidence-based, optimised pharmacological management and, in some cases, continuation or maintenance ECT (Brown et al., 2014).  

The most frequent immediate side effects of ECT can include headache, which may be eased with pain relief medications such as paracetamol, and nausea occurring after anesthesia. Other potential complications of ECT are cardiovascular or respiratory events emerging from anesthesia. All individuals are closely monitored to ensure best outcomes.  

Memory impairment is often the side effect of ECT of most concern to individuals, their families and to the public. Anterograde memory changes (the change in ability to create new memories and to recall recent events after the ECT) generally return to normal or may be improved compared to pre-ECT levels within 2-4 weeks (Semkovska and McLoughlin, 2010). Retrograde memory changes (where autobiographical memories created prior to the ECT are lost) can persist for weeks to months after ECT (Sackeim et al., 2007). It is also possible that autobiographical memory impairment may persist permanently, the risk of this varying with the type of ECT treatment approach (Sackeim et al, 2007). Prior to undergoing ECT, individuals are advised that some people have significant cognitive side effects after a course of ECT. This should be taken into account in terms of any plans to make major life decisions, particularly in the first month after ECT. 

Improving outcomes

ECT practice is constantly evolving in response to advances in technique and administration, providing greater balance between the therapeutic benefits of treatment and undesired side effects. This includes developments in dosing, electrode placement, pulse width, session frequency, concomitant medication, cognitive monitoring tools, and anaesthetic approach.   

To enable best practice ECT, including practice development and improvement, there is a need for standardised recording of treatment outcomes and side effects, and regular review of these outcomes by clinical services. Comparison of treatment approaches and outcomes across multiple services is useful and ECT units are encouraged to participate in networks established for this purpose (e.g. Australian Clinical Alliance and Research in ECT (CARE) Network) (Martin et al., 2018; Clarke, 2018).  

It is also important that psychiatrists prescribing and administering ECT are appropriately trained and engage in ongoing education to promote and share best practice information with colleagues. 

Legislation and access to ECT

Legislation governing ECT use varies widely between different states, territories and New Zealand (RANZCP, 2017a; RANZCP, 2017b, RANZCP 2017c). Legislative restrictions of ECT can reduce access to this treatment for some of the most severely ill and disabled people (Clarke, 2018). In particular by strictly limiting the number of times that ECT can be applied within a given period, and requiring tribunal approval for each course of ECT, mental health acts can compromise clinical care (RANZCP, 2017c). ECT should be available where clinically indicated and should not be limited by cost, service availability, age or other medical conditions, or overly restrictive legislation.  

There are frequently difficulties reported in providing ECT for people with co-morbid mental and physical health conditions. These people often require access to other tertiary services, such as cardiac care, when undergoing ECT for severe depression. Unless these services are available concurrently it may require day transfers to and from such a hospital.  A further challenge can be trying to find an available bed in an adult public mental health facility where bed availability can delay access to timely care. It is not appropriate to try to provide treatment in a secondary hospital site where there is no capacity for a review by other medical specialties prior to or during a course of ECT. 

There is a need to ensure that there are an adequate number of hospitals that provide for cross-specialty care to prevent long waiting times at the few hospitals that may provide such services, or prevent people from getting ECT at all. This includes access to obstetric support for women from 20 weeks gestation.  

It is recognised that people in rural areas receive ECT later in their acute illness due to signifciant delays in being admitted to hospital (Johnston, 2015). Access to ECT needs to be improved as part of broader initiatives to improve access to psychiatry services in rural areas.  

Stigma reduction

Despite scientific evidence to support its efficacy and safety, there is misinformation in the public arena partly owing to the historic depictions of ECT in film and television, which do not accurately reflect contemporary ECT treatment, and partly owing to inaccurate and misleading accounts of ECT on the internet, as documented in various literature (Sadowsky, 2016). Common misconceptions include the person undergoing ECT is painfully ‘shocked’ out of their depressed state or ‘forgets’ that they are suffering from depression. 

The life-saving benefits of ECT in people with psychotic depression who are not eating or drinking and at risk to themselves or others, can mean that they are treated involuntarily under appropriate legislative requirements. This can put a further unwarranted negative perspective on ECT.  

The stigma surrounding ECT can unfortunately impede the acceptance of the treatment by both people who may benefit from ECT and practitioners, resulting in the failure of some people to access effective treatment. This is despite surveys of people who have received ECT consistently showing a large improvement in quality of life after ECT treatment (Brown et al., 2018). 

Whilst progress is being made, psychiatrists can contribute to challenging the stigma and discrimination associated with ECT by following an appropriate medical framework (evidence based and clinical experience), social framework (respond to society expectations and fears) and legal framework (comply with the law). Accurate depiction of ECT treatment in the media is also an important factor.  

Recommendations

• ECT should be available to all people for whom it is clinically indicated and that all jurisdictions should implement mental health legislation that does not restrict access to ECT by virtue of age or other medical conditions.
• Balanced and nationally consistent legislation should be introduced in Australia and New Zealand, including review of the oversight requirements of mental health tribunals in relation to the details of clinical administration of ECT.
• All jurisdictions should ensure that general or tertiary sites are available to provide ECT for pregnant women and/or for any people with significant physical health co-morbid issues. Services should seek to address the barriers to access for ECT to ensure equitable access to all.
• ECT units should participate in networks for standardised recording of treatment outcomes and side effects, and regular review of these outcomes by clinical services.
• All psychiatrists prescribing and administering ECT should have appropriate training and expertise.
• Ongoing mandatory training of psychiatry registrars in ECT, and credentialing of psychiatrists who provide ECT, should continue.
• Services that deliver ECT should detail credentialing requirements.
• Further options for training and ongoing education in ECT should be investigated to ensure that psychiatrists who administer ECT have appropriate higher specialist knowledge, including the potential development of RANZCP advanced certification in ECT and neurostimulation.
• Psychiatrists should continue to challenge the stigma and discrimination associated with ECT through following an appropriate medical, social and legal framework.
• Accurate depiction of ECT within the media should be promoted.

Resources

Weiss, Hussain, Ng et al. (2019). Royal Australian and New Zealand College of Psychiatrists
professional practice guidelines for the administration of electroconvulsive therapy. Australian and
New Zealand Journal of Psychiatry 53: 609-623.

¹ Whānau’ (pronunciation: fa:naᵾ) is a Māori word used to describe an extended family group spanning three
to four generations. The whānau continues to form the basic unit of Māori society

Responsible committee: Practice and Partnerships Committee 

References

Anderson E and Reti I. (2009) ECT in Pregnancy: A Review of the Literature From 1941 to 2007. Psychosomatic Medicine 71: 235-242.

Austin M and Highet N. (2017) Effective Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline. Centre of Perinatal Excellence. Melbourne.

Baghai TC and Moller HJ. (2008) Electroconvulsive therapy and its different indications. Dialogues Clin Neurosci 10.

Brown ED, Lee H, Scott D, et al. (2014) Efficacy of continuation/maintenance electroconvulsive therapy for the prevention of recurrence of a major depressive episode in adults with unipolar depression: a systematic review. J ect 30: 195-202.

Brown S, Nowlin R, Sartorelli R, et al. (2018) Patient Experience of Electroconvulsive Therapy: A Retrospective Review of Clinical Outcomes and Satisfaction. Journal of ECT 34: 240-246.

Clarke P. (2018) Hip Hip Hooray, ECT turns 80! Australasian Psychiatry 0: 1039856218815753.

Fink M and Taylor MA. (2007) Electroconvulsive therapy: evidence and challenges. JAMA 298: 330-332.

Galletly C, Castle D, Dark F, et al. (2016) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders. Australian & New Zealand Journal of Psychiatry 50: 410-472.

Ghaziuddin N and Walter G. (2013) Electroconvulsive Therapy in Children and Adolescents Oxford University Press.

Johnston NE. (2015) Delays in accessing electroconvulsive therapy: a comparison between two urban and two rural populations in Australia. Australasian Psychiatry 23: 566-570.

Kellner C, Knapp R and Petrides G. (2006) Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: A multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Archives of General Psychiatry 63: 1337-1344.

Kellner CH. (2010) ECT Today: The Good It Can Do. Psychiatric Times.

Lakshmana R, Hiscock R, Galbally M, et al. (2014) Electroconvulsive Therapy in Pregnancy. In: Galbally M, Snellen M and Lewis A (eds) Psychopharmacology and Pregnancy: Treatment Efficacy, Risks, and Guidelines. Berlin, Heidelberg: Springer Berlin Heidelberg, 209-223.

Leiknes K, Cooke M, von-Schweder L, et al. (2015) Electroconvulsive therapy during pregnancy: a systematic review of case studies. Archives of Womens Mental Health 18: 1-39.

Malhi GS, Bassett D, Boyce P, et al. (2015) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Australian & New Zealand Journal of Psychiatry 49: 1087-1206.

Martin DM, Gálvez V, Lauf S, et al. (2018) The Clinical Alliance and Research in Electroconvulsive Therapy Network: an Australian initiative for improving service delivery of electroconvulsive therapy. J ect 34: 7-13.

Miller L. (1994) Use of Electroconvulsive Therapy During Pregnancy. Hospital and Community Psychiatry 45: 445-450.

Mills J and Elwood P. (2017) Electroconvulsive therapy. InnovAiT 10: 667-670.

Petrides G, Fink M and Hussain MM. (2001) ECT remission rates in psychotic versus non psychotic depressed patients: a report from CORE. J ect 17.

Prudic J, Olfson M, Marcus SC, et al. (2004) Effectiveness of electroconvulsive therapy in community settings. Biological Psychiatry 55: 301-312.

RANZCP. (2014) Royal Australian and New Zealand College of Psychiatrists. Position Statement 62: Consumer, family/whānau and carer engagement. Accessed October 2019:
https://www.ranzcp.org/news-policy/policy-and-advocacy/positionstatements/consumer,family-whanau-and-carer-engagement

RANZCP. (2016) Royal Australian and New Zealand College of Psychiatrists. Position Statement 84: Acknowledging and learning from past mental health practices. Accessed October 2019: https://www.ranzcp.org/news-policy/policy-and-advocacy/positionstatements/acknowledging-and-learning-from-past-mental-health

RANZCP. (2017a) Royal Australian and New Zealand College of Psychiatrists. Comparison table: Regulation of ECT in Australian and New Zealand Mental Health Acts. Accessed October  2019: https://www.ranzcp.org/files/resources/college_statements/mental-health-legislationtables/3-regulation-of-electroconvulsive-treatment-compar.aspx

RANZCP. (2017b) Royal Australian and New Zealand College of Psychiatrists. Special provisions governing informed consent for ECT. Accessed October 2019: https://www.ranzcp.org/files/resources/college_statements/mental-health-legislationtables/4-informed-consent-to-electroconvulsive-treatment.aspx

RANZCP. (2017c) Royal Australian and New Zealand College of Psychiatrists. Position Statement 92. Mental health legislation and psychiatrists: putting the principles into practice. Accessed October 2019.

Sackeim H, Prudic J and al RFe. (2007) The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology 32: 244-254.

Sackeim HA. (2017) Modern electroconvulsive therapy: Vastly improved yet greatly underused. JAMA psychiatry 74: 779-780.

Sadowsky J. (2016) Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy: Routledge.

Semkovska M and McLoughlin D. (2010) Objective cognitive performance associated with electroconvulsive therapy for depression. A systematic review and meta-analysis. Biological Psychiatry 68: 568-577.

Sinha P, Goyal P and Andrade C. (2017) A Meta-review of the Safety of Electroconvulsive Therapy in Pregnancy. Journal of ECT 33: 81-88.

Tew JD, Mulsant BH, Haskett RF, et al. (2007) Relapse during continuation pharmacotherapy after acute response to ECT: a comparison of usual care versus protocolized treatment. Annals of Clinical Psychiatry 19: 1-4.

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.