Ever wondered what it's like to be a psychiatrist? This series explores a day in the life of psychiatrists who work in different areas of psychiatry.

In this article, we hear from Dr Shane Gill who is a psychiatrist who administers electroconvulsive therapy and neurostimulation.

Electroconvulsive therapy (ECT) and neurostimulation in psychiatry

An ECT psychiatrist is a conventional psychiatrist with an interest and some expertise in the use of ECT and other neurostimulation treatments for people with mental illness. This is contrary to the image perpetuated by media and some anti-psychiatry organisations. ECT is a mainstream, evidence-based intervention for some severe mental illnesses, for which it can be lifesaving.

ECT practitioners also prescribe the full range of other evidence-based interventions in their clinical practice, both biological and psychological. In fact, many psychiatrists with expertise in ECT also have expertise in psychotherapy, such as cognitive behaviour therapy (CBT). They might also use their expertise in several administrative, policy and leadership areas.

ECT can improve or clear depression in patients and has been proven to help with other conditions such as mania and schizophrenia. It can be a life-saving treatment for people who are at risk of suicide, or who are not eating or drinking because of their depression.

Transcranial magnetic stimulation (TMS) is an example of a neurostimulation therapy safe for treatment for major depression, with approximately half of patients noticing an improvement. Side effects are minimal, and usually resolve after a few treatment sessions.

Pre-ECT considerations

One of the roles of the credentialed ECT practitioner is to review patients newly referred by their treating psychiatrist for a course of ECT. Not all psychiatrists are automatically credentialed to provide ECT – additional training and experience is required for this. However, all psychiatrists are trained to prescribe ECT and to manage patients being treated with a course of ECT.

When I review a patient before ECT, the main things I consider are:

• The diagnosis (severe major depression is the main indication, but severe psychosis, mania and catatonia are some other possible indications).
• That the patient can consent and is willing to proceed. I must ensure the patient understands the procedure, why it is being given, what the risks or side effects might be, as well as answer any questions they or family might have.

I might also make a recommendation about what sort of placement and pulse width might be used – there is a balance between the need for an urgent response vs the need to minimise cognitive side effects.

An anaesthetist (+/- a physician) will also review the patient’s physical health and fitness for ECT and for the anaesthetic.

ECT administration

I work at The Adelaide Clinic, where ECT is delivered 3 times per week on Monday, Wednesday and Friday mornings. The list starts at 07.00 am, so I’m up at 06.00 when rostered on to give ECT (once per week).

Working alongside an anaesthetist and two nurses in the ECT suite, the patient is taken through a ‘time-out’ procedure to check their identity and that consent is valid before administering the ECT. After adjusting the device to the stimulus prescription (placement, pulse width and stimulus dose) and once the patient is asleep under the anaesthetic, the stimulus is initiated. The patient is then taken into recovery, where they will wake within a few minutes and remain for a further hour or two.

Each ECT treatment session takes about 10 minutes, so we can treat approximately 6 patients per hour. An average list covers 12-16 patients, so we might be there for 2½ hours. I will leave the hospital at 09.30 am and am ready to commence my usual day’s work at 10.00.

Neurostimulation therapy

It is not surprising that ECT practitioners have also developed an interest in the emerging neurostimulation techniques that have become increasingly available over the last 10-20 years. ECT is now considered one form of a range of neurostimulation treatments.

In particular, TMS has emerged as a neurostimulation therapy which is now more widely available. This involves the use of repeated pulses of a focal magnetic field to stimulate brain activity.

I have been involved in setting up and co-directing the TMS service at The Adelaide Clinic, which has been operating since 2009. The differences between TMS and ECT are that TMS only stimulates a very localised area of the brain, does not require an anaesthetic, can be done in an outpatient setting and has very few, if any, cognitive side effects.

On the downside, it does not work in as many people as ECT does, nor as quickly and not in as severe illness. It won’t replace the role of ECT, but it has proved to be an excellent option for people who don’t respond well to pharmacotherapy and psychotherapy.

Special interests in ECT and neurostimulation

Having a special interest in ECT and neurostimulation is rewarding, as the field is undergoing considerable research and development. ECT is probably the most stigmatised treatment in all of psychiatry, but it is also the most dramatically effective treatment we have and can result in extremely unwell people going into remission within a matter of 1-4 weeks. Contrary to the image portrayed in the media, if practiced according to modern standards, it is remarkably safe.

To learn more about ECT and TMS treatments, visit the RANZCP’s Your Health in Mind website, which provides mental health information for consumers.

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Read more A Day in the Life of a Psychiatrist articles to learn about other careers in psychiatry.

Disclaimer: Any patients mentioned in this article have been deidentified and created for the purposes of this article. This article may represent the views of the author and not necessarily the views of The Royal Australian and New Zealand College of Psychiatrists ('RANZCP'). By accessing the article you also agree to the RANZCP Website Terms of Use Agreement.