ECT Trust Wide Medical Protocol UPDATE

ELECTROCONVULSIVE THERAPY
Protocol for the preparation and

administration of ECT
Version: 8
Policy Number: 7762
Policy Lead/Author & Dr R.Tobiansky,Consultant
position: Psychiatrist
Ward / Department: ECT Department
Replacing Document: Previous version
Approving Committee / ECT Department
Group:
14th March 2011
Date Approved/Ratified:
Ratified by: Governance and Risk
Management Committee
Previous Reviewed November 2010
Dates:
Date of Current January 2011
Review:
Date of Next Review: August 2011
Relevant NHSLA ECTAS; NICE Guidance; Trust
Standard(s): policies
Target Audience All clinical staff involved in the
preparation and treatment of
patients who may be offered
ECT
Version Control Summary
Version Date Section Author Comments

8 14/03/2011 DrTobiansky Update
Electroconvulsive Therapy Protocol Version 8 Page 2

Contents:
1. Introduction
2. List of key Personnel
3. Transportation of patients
4. Indications for ECT
5. Contraindications
6. Medical Workup
7. Fasting before ECT
8. Consent
9. Prescription & Monitoring
10. Using the Thymatron system 4
11. Seizure Threshold
12. Selecting the Dose (Stimulus Dosing Regimen)
13. Administering ECT
13(i)- The Anaesthetist's Role
13(ii)- Preparing the Patient
13(iii)- Impedance Measurement
13 (iv)- Administering the Treatment Stimulus
14. Seizure Monitoring
15. Missed Seizures
16. Prolonged Seizures
17. Treatment Record
18. Number of treatments in a course
19. Maintenance & Continuation ECT
20. Outpatient ECT
21. Vulnerable patient groups
22. Training
23. Quality Assurance
24. List of Other ECT related Documents
Appendices:
1. Care Pathway / Checklist for patients having ECT
2. Extract from NICE guidance on ECT
3. Summary of operating instructions for Thymatron system 4
4. Table of dose stimulus parameters
5. Consent form (including form 4 for incapacitated informal patients)
6a. ECT Referral form 6b. Pre- ECT Anaesthesia assessment
7. Pre ECT Anaesthesia assessment guidelines
8. Patient information document
9. Outpatient ECT patient leaflet and pre-discharge checklist
10. Responsibilities of Nursing staff
11. Medication Strategies for Treatment Resistant Depression
12. ECT Treatment record for case notes
13. Montgomery-Asberg Depression Rating Scale
14. ECT competencies
15. Blood results chart
16. ECT & Driving RCPsych. Advice
17. Guidelines on Dental Management in ECT patients
18. ECT Treatment Record

1. INTRODUCTION
Since February 2005, all ECT treatment within the Trust has been
provided at the ECT suite in the Mental Health Unit at Chase Farm
Hospital (The Chase Building). The service was officially accredited
by ECTAS (a rigorous accreditation system administered by the
Royal College of Psychiatrists) in 2006. Following completion of a
second audit cycle the clinic was peer reviewed in March 2009 and
received accreditation with excellence.
The aim of this document is to inform clinical staff about how ECT is
given in this unit. The contents reflect the guidance in the Royal
College of Psychiatrists' " ECT Handbook, 2nd edition" (CR128, 2005)
and the guidance from the National Institute of Clinical Excellence
(NICE-April 2003), updated by CG90, the clinical guidelines on
Depression (NICE Oct 2009). Documents relating to the practice of
other professionals involved in providing ECT are listed at the end of
this paper. This document is not intended to be a sole reference for
theoretical and clinical knowledge about ECT. Readers wishing to
consult a definitive textbook on ECT are referred to Richard Abram’s
“Electroconvulsive Therapy”, 4th edition.
The ECT service will provide high standards of treatment with ECT,
complying with the requirements of the Royal Colleges of
Psychiatrists and Anaesthetists, the UKCC, the Care Quality
Commission and taking cognizance of NICE guidance.
The process of providing ECT should be as safe, acceptable and

effective as possible for the patient. The role of the patient's
prescribing Consultant, ward team and care-coordinator is central to
meeting this aim, specifically in identifying whether or not ECT is
indicated, ensuring that lawful consent is obtained and monitoring the
patient closely before, during and after the course of ECT.
With a single-site, Trust-wide ECT service it is necessary to ensure
the safe transportation of patients from Barnet and Haringey to and
from the ECT unit at CFH. In order to facilitate the smooth running of
the ECT clinic, it is essential that all patients are properly prepared,
that documentation is complete and that nurse escorts are available.
The safe and effective running of the service will depend on a clinical
partnership between the patient’s prescribing Consultant and ward
team and the ECT department. There will therefore be shared
responsibility for ensuring that ECT is given to the best possible
standards.
The care pathway for patients undergoing ECT is intended to serve

as an “aide memoir” and checklist for clinical staff that prescribe ECT
and prepare patients for treatment. ECT staff reserve the right to
cancel treatments in the interests of patient safety if patients are not
properly prepared and if the care pathway is not followed.
ECT is most commonly prescribed for inpatients, but it may also be

given on an outpatient or day-patient basis. This document applies to
ECT in all settings

2. KEY PERSONNEL IN THE ECT DEPARTMENT
It is advisable that ECT referrals are made at least a day before

ECT sessions, which are held on Tuesdays & Fridays. To make
a referral contact Miss Tina Keeling, ECT Secretary, DIRECT
LINE- 020 8375 1519 or 0845111 4000 ext 3389. If unavailable
contact Karl Sunkersing.
The ECT service manager and coordinator at CFH is Karl

Sunkersing, who can be contacted at CFH on 08451114000 bleep
number 3886 or on 02083752102
The telephone number of the ECT suite is 02083751542
ECT Consultants
The Trust-wide Lead Consultant Psychiatrist for ECT is Dr Robert
Tobiansky office tel 02089377117, mobile tel 07976839787 or long
range pager tel. 08448222888, pager number 867137. Dr
Tobiansky attends the clinic on Fridays.
Dr. Ioana Popescu is the other ECT Consultant and attends the ECT
clinic on Tuesdays mobile tel. 07710728816
Anaesthetists
There are two Consultant Anaesthetists with responsibility for ECT,
Dr Thillai tel 07770954052 attends on a Tuesday and Dr. Haemeed
on 07946293366 attends on a Friday. An anaesthetic opinion can be
requested by contacting either of the anaesthetists or by contacting
the dept. of anaesthesia at Chase Farm Hospital x 1411 or
02083751040 for Enfield & Haringey patients or Barnet Hospital
02082165283 for Barnet patients. When in doubt it is advisable to
speak to one of the anaesthetists before sending the patient for ECT.
3.Transportation of patients from Barnet or Haringey to CFH
All patients travelling from either Barnet or Haringey must have an

appropriately qualified nurse escort. It is the responsibility of the ward
manager (or in the case of outpatients, the care coordinator) to
ensure that this is provided. Problems encountered in the provision of
escorts will be resolved in consultation between the ward manager /
care coordinator and the lead nurse and / or Service Director.
The contract for transportation of patients is now provided by London
Ambulance Service. The service specification requires flexibility,
reliability and safety.
In very exceptional circumstances, the team prescribing ECT may

judge that it is clinically unsafe for patients to travel from Barnet or
Haringey. In this situation discussions will need to take place at
Service Director level, as to the feasibility of transferring that patient
to the Mental Health Unit at CFH for the duration of the ECT course.

4.INDICATIONS FOR ECT
Depression is the condition for which ECT is most often prescribed,

but it can be an effective treatment for mania, as well as catatonia
and puerperal psychosis. It can also be effective in treating acute
paranoid/psychotic states and schizoaffective disorder. NICE
guidance (HTA 2003) initially restricted the indications for ECT to
severe depression, catatonia and severe or treatment resistant
mania (see appendix). This guidance has now been updated (CG90)
to include Depression which is of moderate severity but which has
been resistant to other treatments. The Royal College of
Psychiatrists (RCPsch.) and the Scottish ECT Audit network (SEAN)
had challenged the original NICE guidance in this and other respects.
Nevertheless, it is advisable to seek a second opinion in situations
where ECT has been prescribed for indications other than those
described in NICE guidance.
ECT is a fast and reliable form of treatment, which can make it the
treatment of choice when any of the above conditions is severe, and
giving rise to significant short-term risks, such as severe depression
leading to dangerous self neglect or suicidal behaviour. NICE
guidance urges that ECT should only be prescribed after a
documented assessment of risks and benefits has been made and
fully discussed with the patient.
ECT is also used when drug treatments have failed, or is relatively

contraindicated (e.g. by severe side effects), or where a known
individual's psychiatric history tells us ECT is the best choice of
treatment for them. Medication is usually given concurrently with
ECT, to prevent later relapse.
The following guidance on indications for ECT is extracted from Scott

et al, Advances in Psychiatric Treatment 2005 as well as NICE CG90
RCPsych. guidance on ECT in the treatment of depressive illness
• ECT may be the treatment of choice for severe depressive illness when the illness is
associated with:
• attempted suicide
• strong suicidal ideas or plans
• life-threatening illness because of refusal of food or fluids
• ECT may be considered for the treatment of severe depressive illness associated with:
• stupor
• marked psychomotor retardation
• depressive delusions and/or hallucinations
• In the absence of the above, ECT may be considered as a second- or third-line treatment

of depressive illness that has not been adequately treated by antidepressant drug
treatment and where social recovery has not been achieved
• The selection of ECT may be affected by:
• patient preference
• previous experience of ineffective and/or intolerable medical treatment
• previous recovery with ECT
NICE guidance on ECT in the treatment of depressive illness (CG90)
• Consider ECT for acute treatment of severe depression that is life threatening and when a
rapid response is required or when other treatments have failed.
• ECT should not be used routinely for moderate depression but should be considered if
there has not been a response to multiple drug treatments and psychological treatment
Although the 2003 HTA explicitly stated that maintenance ECT was not recommended, there is
recognition in the updated guidance that maintenance ECT may be necessary in some
circumstances.
Suggestions for accommodating prescription practices to the discrepancy between

College and NICE guidance in depressive illness
• Divergence would occur only if ECT were used:

• if the episode was not potentially life-threatening or severe
• if the episode was not demonstrably treatment resistant
• as continuation or maintenance treatment
• Health professionals should make decisions appropriate to the individual patient, in
consultation with the patient and/or guardian or carer
• The NICE guidance in itself does not have legal jurisdiction over clinical practice
• Any deviation from the NICE guidelines would require a documented assessment of
potential risks and benefits and the patient’s true valid informed consent
• An informal second opinion may be helpful in controversial indications
• Prescribers ought to exercise particular circumspection in depressed patients who have
never before been treated with ECT (they have no personal experience to enable them to
weigh the benefits and costs of ECT)
• The balance between immediate benefit and longer term-risk of distressing retrograde
amnesia can be moved in favour of benefit by considering the use of unilateral ECT
• Valid and documented patient preference may support divergence from the guidance
Treatment failure in depressive illness

• Initial treatment failure may be defined as a lack of recovery after a course of an
antidepressant drug given at a proven effective dose for at least 6 weeks
• Elderly patients may take longer to respond to antidepressant drug treatment
• A switch to an antidepressant drug with a different mode of action is the preferred second-
line treatment where there is no urgent need for treatment. If the depressive illness
persists with antidepressant treatment, several options are available (see appendix):
• add an augmenting agent such as lithium carbonate
• adjunctive cognitive–behavioural therapy or similar
• ECT

The place of ECT in the treatment of mania:
• The treatment of choice for mania is a mood-stabilising drug plus an antipsychotic drug
• ECT may be considered for severe mania associated with:
• life-threatening physical exhaustion
• treatment resistance, that is, mania that has not responded to the treatment of
choice
• The selection of ECT may be affected by:
• patient choice
• previous experience of ineffective and/or intolerable medical treatment
• previous recovery with ECT
The place of ECT in the treatment of acute schizophrenia:
• The treatment of choice for acute schizophrenia is antipsychotic drug treatment

• ECT may be considered as a fourth-line option, that is, an option for treatment-
resistant schizophrenia after treatment with two different antipsychotic drugs and then
with clozapine has already proven ineffective or intolerable
The place of ECT in neuropsychiatric conditions:
Parkinson’s disease: ECT is a safe adjunctive treatment for both motor and affective
symptoms in people with severe disability despite medical treatment
Catatonia: The treatment of choice is a benzodiazepine drug; most experience is with
lorazepam. ECT may be indicated when treatment with lorazepam has been ineffective.
ECT remains an experimental treatment for disorders such as neuroleptic malignant
syndrome, Huntington’s disease and treatment- resistant epilepsy
5.CONTRAINDICATIONS TO ECT
Given that psychiatric disorders can be life threatening, most

practitioners only consider relative contraindications, with a balance
of risks and benefits of all the options being necessary. The opinion
of the anaesthetist should be sought as far in advance of treatment
as possible. Where the risk of physical health complications is high,
the ECT may be carried out in main operating theatres in Barnet or
CFH, to be nearer appropriate resuscitation facilities.
Examples of conditions where high anaesthetic risk exists are:

Myocardial Infarction in the last 3 months
Cerebrovascular Accident in the last 3 months
Cardiac failure
Valvular heart disease
Aneurysm or other vascular malformation
Unstable cervical spine
Any medical condition which limits physical activity (ASA grade 3 and
above see below)
6. MEDICAL WORKUP & PREPARATION FOR ECT
Please also refer to the section on “Giving ECT”.

The “pre-ECT anaesthesia questionnaire” form (see appendix 6)
must be completed for all patients referred for ECT and an ASA
grade assigned. Detailed pre-anaesthesia assessment guidelines are
also provided as an appendix to this document.
A physical examination must be completed and documented in the
notes. Where the patient is physically fit (ASA grade 1), the
anaesthetist does not require a referral prior to the first treatment
session but will meet the patient on the morning of treatment.
It is the responsibility of the patient's psychiatric team to decide

whether referral to the anaesthetist for assessment is necessary
before ECT is started. The anaesthetist should be informed at least
24 hrs in advance of the first treatment, and earlier if possible. The
referral should be made to the department of anaesthesia (see the
section on Key personnel). Where urgent anaesthetic review is
necessary the anaesthetics department can direct you to the
appropriate doctor.
The referring psychiatric team should allocate an ASA Grade to a

patient prior to ECT. This is as follows:
1. Fit and well, a healthy patient.

2. Minor medical problems, not affecting lifestyle.
3. A patient with severe systemic disease that
limits activity but is not incapacitating
4. A patient with an incapacitating systemic disease
that is a constant threat to life
5. A moribund patient not expected to survive 24
Hours, with or without operation.
For ASA grade three or more then it is essential that the patient’s
case is discussed with the anaesthetist prior to the patient attending
the ECT suite (see below).
Attention should be paid, in the history and physical examination of

the patient, to the cardiovascular, respiratory, and neurological
systems, with an enquiry into oesophageal reflux. The state of
dentition (missing or loose teeth, dentures, implants, crowns etc),
and previous anaesthetic history should be known and documented.
All current medication and known drug sensitivity must be recorded.
Results of recent Haemoglobin and U&Es should be recorded in the

notes and written on the blood results sheet (see appendix), with
other blood investigations and referrals to specialists carried out as
indicated. Potassium levels must be within normal range before an
anaesthetic is given. For patients on anticoagulants the results of the
most recent INR must be available. For diabetic patients on insulin
the blood glucose level on the morning of ECT must be available.
Patients with hiatus hernia or reflux should be prescribed ranitidine
300mg or omeprazole 40mg
A chest X-ray should be done if indicated. An ECG is indicated in any

patient on vasoactive drugs, diabetics over 40, men over 40, women
over 55 and any patient with known ischaemic heart disease.
To summarise the procedure for Pre- ECT Preparation:
1. Routine laboratory investigations should be carried out and results

written on the results sheet (see appendix).
2. Ordering of additional tests should be guided by the presence
and severity of medical risk factors.
3. Refer to the pre-assessment guidelines for help. When in doubt
consult the anaesthetist.
4. Occasionally, if the patient has a severe needle phobia or is
refusing to have blood tests these may be carried out when the
patient is under anaesthesia.
5. Regular medications should usually be continued during a course
of ECT, especially antihypertensives, which should be given on the
morning of ECT but omit diabetic medication on the morning of
treatment.
6. Complete the ECT referral form and anaesthetic proforma
(appendix 6a and 6b)
Patients with ASA grade 3 and above:
An anaesthetic consultation/evaluation should be requested

before the first ECT, or during a course of ECT if there is a
significant change in the patients medical status or medications.
After assessing the patient, the anaesthetist may order further
investigations and may advise referral to other specialists (eg
Cardiac / Respiratory) before proceeding. Having identified the
peri-ECT risk, the anaesthetist will than decide to carry out the
treatment in the main hospital theatre suite .
Very stable ASA3 with low risk can have the treatment in the
ECT suite itself.
The ECT coordinator MUST be informed when the patient

needs to have the treatment in the main hospital - in order to
make the necessary arrangements.
The medical case notes must be available at the ECT clinic; results
of recent investigations should be properly filed in the notes and
written in the notes or on Rio. The referring team must make
available the completed anaesthesia proforma, the consent form or
copies of the relevant MHA papers, all relevant details from history,
including previous ECT treatment and a list of current medication. At
each treatment session ECT staff will document details of the
treatment given. This is done on a proforma “sticky label” which will
be placed in the case notes (see appendix 12). A similar entry will
also be made on Rio. Following each ECT treatment, it is essential
that requests for investigations and other feedback from ECT staff
made in the case notes are acted upon by the ward team.
Various factors affect seizure threshold (see later section) and

consideration should be given to the effect of changing treatments.
The following factors are known to influence seizure threshold:
INCREASE THRESHOLD REDUCE THRESHOLD
Older Age Caffeine

Anticonvulsants (incl. benzodiazepines) Hypocapnoea
Baldness Theophylline
Bones (thickened, any cause) SSRIs
Dehydration antipsychotics
Recent ECT
Male gender
MAOIs
Propofol / other anaesthetic induction agents
Poor electrode contact (due to hair, oil, etc.)
7. FASTING before ECT
All food, solids, alcohol and drinks with milk should be excluded in
the six hours prior to ECT. Other drinks: clear fluids, non-particulate
fruit juices [i.e. no bits in them] can be taken up to two hours prior to
ECT. In the final two hours before ECT no fluids should be given at
all.
Chewing gum should be avoided in the two hours prior to ECT as it
produces large amounts of saliva, which builds up in the stomach.
The anaesthetist usually advises that patients on regular anti-

hypertensive medication should take this medication with a small
amount of water on the morning of ECT.
8. CONSENT, CAPACITY, THE MENTAL HEALTH ACT

2003 (as amended 2007) & MENTAL CAPACITY ACT 2005
CONSENT To ECT, including a discussion of potential

benefits and adverse effects of ECT, must be obtained by
the Responsible Consultant or prescribing doctor
The indications for, likely risks and benefits of as well as the actual
process of ECT should be explained to the patient (and their carer -
relative, next of kin, significant other or advocate– where
appropriate). Potential risks and benefits of the treatment, and those
of all alternatives, should be discussed. The patient information
document may be used to help in this process, where it is thought
appropriate, with a chance to discuss it with a professional (e.g.
primary nurse). This is not an alternative to a full discussion between
doctor and patient when assessing capacity and seeking consent.
The efficacy and safety of ECT is well-established (see Geddes et al

Lancet 2003 for review). The evidence indicates that in the short-
term, ECT is a highly effective treatment for Depression, with either
partial or complete remission of symptoms seen in approximately
85% of appropriately selected patients. Bilateral ECT frequently
leads to short-term impairment of memory although it remains
unclear for how long this persists. This is less likely with unilateral
ECT. Some patients who have had bilateral ECT may complain of
gaps in autobiographical memory for periods of up to several years
before the treatment. While bilateral ECT is commonly associated
with retrograde and anterograde amnesia for the period around the
treatment course, there is no evidence of any persistent impairment
of actual memory function (“working memory”) due to ECT. There is
no evidence of structural brain damage from ECT.
Different doses and modes of application of ECT appear to show

differences in efficacy and adverse acute effects. Where there are
specific concerns about memory disruption, unilateral ECT may be
preferred. The commonest adverse effects following bilateral ECT
are headache, myalgia and memory disruption. Transient nausea,
drowsiness and weakness may also be experienced. Transient
arrhythmias, hyper- and hypotension, post-ictal delirium, and
spontaneous or prolonged seizures may occur. There is also a need
to be aware of damage to dental work and a fractured tooth and cut
lip can occur. Other rare but more serious adverse effects include,
aspiration, fractures, ruptured viscus, myocardial infarction, CVA,
ruptured aneurysm etc. The overall mortality rate associated with
ECT is estimated at around 1 in 50 000, which is roughly the same
rate associated with brief anaesthetic procedures. (see patient
information leaflet and section on risks and benefits).
NICE CG90 makes specific reference to the consent process:
12.2.7.4 When considering ECT as a treatment choice, ensure that the

person with depression is fully informed of the risks associated with ECT,
and with the risks and benefits specific to them. Document the assessment
and consider:
• the risks associated with a general anaesthetic
• current medical comorbidities
• potential adverse events, notably cognitive impairment

• the risks associated with not receiving ECT.
12.2.7.5 A decision to use ECT should be made jointly with the person with
depression as far as possible, taking into account, where applicable, the
requirements of the Mental Health Act 2007. Also be aware that:
• valid informed consent should be obtained (if the person has the capacity
to grant or refuse consent) without the pressure or coercion that might
occur as a result of the circumstances and clinical setting
• the person should be reminded of their right to withdraw consent at any

time
• there should be strict adherence to recognised guidelines about consent,

and advocates or carers should be involved to facilitate informed
discussions
• if informed consent is not possible, ECT should only be given if it does not
conflict with a valid advance decision and the person’s advocate or carer
should be consulted.
12.2.7.6 The choice of electrode placement and stimulus dose related to

seizure threshold should balance efficacy against the risk of cognitive
impairment. Take into account that:
• bilateral ECT is more effective than unilateral ECT but may cause more
cognitive impairment
CONSENT & CAPACITY:
There are several potential scenarios with regard to consent and

capacity:
• A detained patient with capacity who gives or withholds

consent
• A detained patient without capacity
• An informal patient with capacity who gives or withholds
consent
• An informal patient without capacity
The Detained Patient who Consents to ECT:

Where an adult detained patient consents to ECT and the AC in
charge of administering the ECT or a SOAD considers that the
patient is capable of understanding the nature, purpose and likely
effect of the treatment, the consent form is completed, and the AC or
SOAD completes Form T4 (in accordance with section 58A(3)(c)),
stating the number of treatments to be given. Further consent (and a
new Form T4) is sought if the number of treatments is to be
exceeded. Further consent (and a new Form T4) will also be required
if it was completed by an AC and that AC ceases to be the AC in
charge of the treatment.

The Detained Patient who does not Consent to ECT:
Under the Mental Health Act 1983 (as amended), a detained patient
with capacity, who withholds consent, cannot be treated with ECT
(see below), except when it is judged necessary to be given in an
emergency under section 62.
The Detained Patient without capacity to consent:

When there is no consent from a detained patient through lack of
capacity, a Second Opinion Appointed Doctor (SOAD) appointed by
the Care Quality Commission is requested to assess the suitability of
the ECT treatment plan. If they comply with section 58A(5) by signing
Form T6, treatment can continue without the patient's consent, up to
the number of treatments specified by the SOAD.
Emergency ECT for Detained Patients:

Patients who are liable to detention may be given emergency ECT
under section 62 if it is immediately necessary to save the patient’s
life or immediately necessary to prevent a serious deterioration of the
patient’s condition (and is not irreversible, i.e. does not have
unfavourable irreversible physical or psychological consequences).
This applies to patients with or without capacity. Although custom
dictates that a maximum of two treatments should be given under
section 62, there is no statutory limit on the number of treatments
under section 62.
Informal patients:
Informal Patients with Capacity to Consent:

If the patient is informal, and has capacity to give consent, they can
sign the consent form. The prescribing doctor who has explained it
also signs, and should record the interview discussion concerning
risks, benefits, alternatives, likely outcomes and capacity in the
patient's case-notes. NICE guidance emphasises that consent should
be an ongoing process and may be withdrawn at any time. The ward
team should ensure that, where informed consent is required for a
patient's treatment, such consent is ongoing and that this is noted
before each treatment. The ECT staff will repeat this procedure prior
to administering the ECT.
Informal Patients without capacity to consent:

In the situation where an informal patient cannot consent through
lack of capacity, it was previously possible for ECT to be given under
the common law doctrine of necessity. This situation has now
changed, with the Mental Capacity Act 2005. If an informal patient
who requires ECT lacks capacity then we must consider use of the
MHA if:
• They are dissenting in any way

• It is not possible to give the ECT without depriving them of
their liberty
• They may need to be restrained in a way that is not allowed
under the MCA
• It is not possible to assess or treat them safely or effectively
without treatment being compulsory
If it is decided that it is not appropriate/necessary to use the MHA, we

can give them ECT in the absence of consent if it is in their best
interests, under section 5 of the Mental Capacity Act. However, in
keeping with the Mental Capacity Act 2005, the “best interests”
check-list should be followed and carefully documented, other people
(carers, relatives, attorney under LPA etc) should be consulted. If
there is no one who is appropriate to consult with then an
Independent Mental Capacity Advocate (IMCA) should be involved
(Contact VoiceAbility on 0845 0175 198 or imca@voiceability.org).
If time allows, a non-statutory second opinion from a Consultant
colleague should be sought.
If there is a valid and applicable advance decision made by the

patient not to receive the treatment or the treatment would conflict
with a decision made by a health and welfare deputy or donee of a
Lasting Power of Attorney, or there is an order from the court of
protection against treatment, then ECT cannot be given.
Further points on THE MENTAL HEALTH ACT (as amended)
Under age 18 with consent

Whether detained or informal, a SOAD will need to certify the
consent and that the treatment is appropriate (using Form T5), i.e.
section 58A(4) applies.
If a patient is under 18 and lacks capacity then the same provisions

as for adults who lack capacity apply (as set out above).
Detained patient without capacity to consent:

The SOAD needs to certify that the patient is not capable of
understanding the nature, purpose and likely effects of the treatment,
that it is appropriate for the patient to receive the treatment and there
is no conflicting advance decision or decision by a donee under a
Lasting Power of Attorney, health and welfare deputy or the Court of
Protection.
The SOAD is also under a duty to consult with a nurse concerned

with the patient’s medical treatment and one other who is
professionally concerned but who is not a doctor or a nurse. Neither
can be the RC or the AC in charge of the ECT.
Regarding the detained patient who does not have capacity at the
time ECT is prescribed, and it is subsequently given following a
second opinion and the completion of form T6: It is possible /
probable that at some point during the course of treatment, the
patient will regain capacity to consent and consequently it will not
be lawful to continue treatment in the absence of consent. In these
circumstances, all detained patients who are deemed not to have
capacity to consent must be made subject to a capacity test as close
in time as practicable to each planned administration of ECT, thus
ensuring that the treatment is administered lawfully (or not
administered at all). Assuming the patient now has capacity and does
consent, the appropriate form must be signed (T4).
9. PRESCRIPTION of ECT by the Responsible Consultant &

Monitoring the Effects of ECT during and after a course
The decision to prescribe ECT, including due consideration of the

likely risks and benefits should be carefully documented by the
prescribing psychiatrist. The ECT referral form and anaesthetic
proforma (appendix 6a & b) should be completed and sent to the
ECT department. The ECT treatment record (see appendix 18) will
now be kept in the ECT department. A pro-forma, printed on a sticky
label, will be completed by the ECT team and affixed in the patients
case notes for the purposes of communicating clinical details on the

patient, and for recording treatments. There is also a section on the
pro-forma for the Consultant to sign when further ECT is prescribed.
Details of the ECT treatment will also be recorded on Rio under the
progress notes.
The prescription of ECT is the responsibility of the patient’s

Consultant or senior responsible clinician, who retains overall clinical
responsibility for the patient. The Responsible Clinician / Consultant
must sign the patient agreement (consent form) in the appropriate
section. The decision as to whether to prescribe unilateral or bilateral
ECT or whether to use fixed dose or dose-titrated ECT is that of the
prescribing consultant. Where there is any doubt about the most
appropriate modality, this should be discussed with one of the ECT
Consultants. There is some debate on methods of determining
stimulus dose and on laterality (bilateral vs. unilateral ECT). If the
prescribing consultant does not stipulate either bilateral or high dose
unilateral ECT or the method of dose selection, the “default” position
has been to give dose-titrated bilateral ECT, although this policy will
be kept under regular review.
Patients having ECT should be reviewed at an appropriate time after

each treatment, with a record of the mental state examination being
made in the notes. It is good practice to use a standardised rating
scale for changes in mood in order to attempt to document change
in response to ECT in a valid and reliable way. The Montgomery–
Asberg Scale (see appendix) is a suitable instrument and could be
completed prior to ECT and after every 2 or 3 treatments.
The prescribing consultant should sign the ECT treatment proforma

(sticky label, see appendix 12) prior to the next two treatment
sessions as a minimum, or preferably prior to each treatment. It is
good practice to ensure that the patient has given on-going consent
to further ECT treatment and to document this discussion in the
case-notes. The same would apply to patients having maintenance
ECT.
Patients should be reviewed by their clinical team after each

treatment and specifically asked about side-effects, particularly with
regard to memory. It is also good practice to record baseline
cognitive function eg with the MMSE and to repeat this
approximately weekly, in order to monitor for significant cognitive
side-effects related to ECT. If there are concerns about significant
cognitive side-effects this should be discussed with the ECT team.
ECTAS standards recommend that the patient’s cognitive side
effects/memory are assessed using the MMSE and subjective
questioning in a clinical interview by the referring psychiatrist 3 or 4
days after the end of the treatment course, and at 1 or 2 months
follow up.
The latest ECTAS standards also require that the patient's clinical
status/symptomatic response is assessed and recorded at baseline,
between each treatment session, and following the course of ECT
using the Clinical Global Impression (CGI) scale.
The standards further recommend that the patient's clinical status /

symptomatic response is recorded 3 and 6 months after treatment
and the patient’s memory and cognitive functioning is recorded 3
and 6 months after a treatment course is finished
NICE CG 90 October 2009 stipulates the following:
12.2.7.7 Assess clinical status after each ECT treatment using a formal
valid outcome measure, and stop treatment when remission has been
achieved, or sooner if side effects outweigh the potential benefits.
12.2.7.8 Assess cognitive function before the first ECT treatment and
monitor at least every three to four treatments, and at the end of a course
of treatment.
12.2.7.9 Assessment of cognitive function should include:
• orientation and time to reorientation after each treatment
• measures of new learning, retrograde amnesia and subjective memory

impairment carried out at least 24 hours after a treatment.
If there is evidence of significant cognitive impairment at any stage

consider, in discussion with the person with depression, changing from
bilateral to unilateral electrode placement, reducing the stimulus dose or
stopping treatment depending on the balance of risks and benefits.
12.2.7.10 If a person’s depression has responded to a course of ECT,

antidepressant medication should be started or continued to prevent
relapse. Consider lithium augmentation of antidepressants.
10. USING THE THYMATRON SYSTEM 4 (see summary in

appendix)
The current ECT apparatus is the Thymatron system 4. This allows a

record of EEG activity which is a useful indicator of seizure length
and generalization. The apparatus can deliver a charge of up to
1000mC if required.
The Thymatron has two dials, one of which, the “percent energy” dial
determines the stimulus dose (as percent energy and charge in
millicoulombs) and the other, the Flexdial, which determines the
properties of the treatment stimulus such as frequency and pulse
width. These parameters can be adjusted to promote a seizure
without increasing the dose of electric charge. For a given dose, if
either of these parameters is varied, the treatment stimulus time will
vary. This is the function of the settings on the flexdial. It can be used
to manipulate the characteristics of the electrical impulse. The
maximum stimulus duration is fixed at 8 seconds. The decision to
adjust the flexdial in this way should be made by the ECT consultant.
The central “percent energy” dial is used to set the dose of electrical
charge delivered during treatment. It is marked 0 - 100%. The 100%
position represents a dose of 504 millicoulombs (mC). For a higher
dose it can be set to X2 output, so that 120% equates to 600mC etc,
increasing to a maximum dose of 200% or 1000 mC.
Rotation of the dial displays the percent energy settings for each
stimulus dose, followed by a 1-second display of the corresponding
stimulus charge in mC.
11. SEIZURE THRESHOLD
The purpose of ECT is to stimulate the brain electrically in order to

produce clinical improvement. Effective stimulation always induces a
generalised bilateral seizure. Seizure Threshold (ST) is taken to be
the lowest stimulus dose that induces a generalized convulsion.
However, it is known that the mere induction of a seizure is not
sufficient to be therapeutically effective. To be clinically effective the
stimulus needs to be at a dose sufficiently above ST. In the case of
bilateral ECT, the therapeutic stimulus needs to be approximately 2 x
ST. In the case of unilateral ECT the therapeutic stimulus needs to
be approximately 4 - 6 x ST. (Abrams. Stimulus titration and ECT
Dosing. Journal of ECT 18(1) 13-9. 2002)
Seizure threshold varies. Biological variation accounts for the

greatest part of this. Remember that poor technique will contribute to
variation in response. Electrodes need to be applied firmly, rotated
to and fro and then kept still.
Various other factors affect ST as described previously, but ECT
itself raises the seizure threshold. This is noticeable over a course of
treatment (up to 100% increase, but usually around 30-40%).
12.SELECTING THE STIMULUS DOSE FOR ECT
The stimulus dose can be determined in a number of ways, 3 of

which will be mentioned here. For patients who begin a new course
of treatment, we would usually determine the seizure threshold by a
stimulus dosing regime (see below), unless the prescribing
consultant requests otherwise.
a. The “age-based” formula for determining stimulus dose:

For bilateral ECT the dial labeled percent energy should be set to
approximately one-half the patients age (eg 25% for a 50 year-old). If
there is no seizure, the percent energy setting should be set to
double the initial dose (eg 50% for a 50year old) and the patient re-
stimulated within 30 – 60 seconds to maximise the likelihood of
obtaining a therapeutically satisfactory seizure during the first
treatment session.
For unilateral ECT the percent energy dial should be set to the
patient’s age in years eg 75% for a 72 year-old patient.
b. The “benchmark” method for setting and adjusting the ECT

stimulus dose;
Since neither seizure duration nor seizure threshold are
systematically related to the clinical efficacy of an ECT treatment,
another approach is to regulate the stimulus dose according to a
physiological measurement that has been reported to correlate with
treatment response i.e. a “target measure”. One possible target
measure is the postictal EEG suppression index (PSI), which the
Thymatron will calculate as the ratio of the peak amplitude of EEG
activity relative to the flattened trace observed following cessation of
such activity. In this method, a stimulus dose is given which is high
enough to induce vigorous and effective seizure activity in the
majority of patients. The value of the target measurement (such as
PSI) is then used as a goal for all subsequent treatments. Selection
of the initial stimulus dose can be made by the fixed-dose method or
an age based method. A fixed dose of 75 – 90% energy should be
high enough for the vast majority of patients, regardless of treatment
electrode placement. Alternatively the percent energy dial can be set
to the patients age for unilateral ECT or for 50 – 75 % of patients age
for bilateral ECT. Dosage should be adjusted for subsequent
treatments to maintain the PSI at same value as the benchmark,
keeping in mind that seizure threshold will rise across a course of
treatment.
c. Stimulus Dosing Regimen
Seizure threshold (ST) varies widely. In order to avoid giving a dose

that far exceeds the necessary therapeutic stimulus, (which may
induce unnecessary cognitive side-effects), an attempt is made to
estimate the ST. At the first session more than one stimulus may be
used, starting from a low dose, and increasing until a seizure is
induced. This is taken as the ST. This is the procedure for titration of
the dose of electrical charge given against the resulting seizure. This
stimulus dosing regimen can be used to establish the starting dose at
a patient's first session, then how to vary the dose at subsequent
sessions. It does not need to be repeated for patients whose starting
dose is known from a previous course of ECT, unless circumstances
affecting seizure threshold have changed.
When this protocol requires two or three treatments in one session,

the psychiatrist will check with the anaesthetist that there is enough
time. 30 - 40 seconds should be left between treatments, during
which time the anaesthetist is asked to hyperventilate the patient
again. Hyperoxygenating [20 breaths of oxygen] produces better
seizure duration (by lowering CO2).

Starting point at first Session & Percent Millicoulombs
subsequent step numbers energy ( % )
(at 2xsetting)
Male / Female Bilateral 1 10 50
Female / Male Unilateral 2 20 100

3 30 150
4 40 200
5 50 251
6 60 300
7 70 353
8 80 404
9 100 500
….etc 200 1008
To re-iterate: the aim of stimulus dosing is to find the seizure

threshold. Seizure threshold (ST) is that dose (measured in
millicoulombs, the units of charge), needed to produce a generalized
seizure on the EEG. Having determined the ST one must then
increase the output to the therapeutic stimulus. For bilateral ECT the
therapeutic stimulus is taken as 2 x ST. For unilateral ECT the
therapeutic stimulus is 4-6 x ST.
For example, if a woman is to have bilateral ECT then on the first

session she should be given a stimulus dose of 10% (50mC). If this
produces a generalized seizure of at least 10 – 15 second duration
with reasonable postictal suppression, then this is taken as ST. No
further stimulus would usually be given on that session, unless the
patient is so severely ill (for example refusing to eat or drink or
actively suicidal), in which case the patient is given a further stimulus
at the therapeutic dose at this session. The threshold is recorded as
10% (50mC) and the subsequent sessions should be given at 2 x ST
for bilateral ECT [ 4 - 6x ST for unilateral ECT]. In this example the
woman would have 20% (100mC) given to her on the second
session of ECT. If on the first session the initial setting did not
produce a 10 second, generalized seizure on the EEG then the
anaesthetist would be asked to reoxygenate the patient and the
woman would be stimulated again at the next level up on the scale
[in this case 20% (100mC)]. No more than three stimuli would be
given in each session and if the threshold is not reached in the first
session the process should continue in the second session.
On average, seizure thresholds increase by 5 - 10% with each
treatment given. Thus it is common to slightly increase the stimulus
dose given throughout the course.

The RCPsych. recommendations are that stimulus dosing should
start at one level higher than indicated above if the anaesthetic agent
being used is propofol, or the individual is over 65 years, or if they
are on benzodiazepines or anticonvulsant mood stabilisers.
13. Administering ECT
ECT is given in the treatment suite in the Chase Building at CFH,

twice a week, on Tuesdays and Friday mornings, starting at 09:00.
The junior doctor and care coordinator looking after the patient on the
ward or in the community have a duty to ensure continuity of care,
reassurance for the patient, and regular communication with the ECT
team. The doctor should let the ECT team know about:
• changes in medication;
• changes in the patients general medical condition
• changes in factors influencing seizure threshold;
• changes in legal status;
• changes in mental state and therapeutic response;
• side-effects of ECT (which should be monitored by the ward
team)
• any concerns the patient has about the treatment.
13 (i)THE ROLE OF THE ANAESTHETIST
At the ECT treatment session, the anaesthetist will proceed if it is

safe to administer a general anaesthetic to the patient. Information
from previous examinations and investigations is essential in
informing this decision.
ECG electrodes, pulse oximeter and blood pressure cuff are applied
and an intravenous cannula is inserted into a vein. After pre-
oxygenation the patient is anaesthetised. An induction agent, (usually
propofol 1.5-2.5mg/kg or occasionally a short- acting barbiturate such
as thiopentone, c.1mg/kg) and the muscle relaxant succinylcholine is
used (approx. 0.5 mg/kg). This will modify the convulsion in order to
minimize the risk of physical injury. The depolarizing muscle relaxant
has worked when fasciculation is observed.
The anaesthetist will hyperventilate the patient for about 20

respirations prior to treatment to promote oxygenation, to reduce the
chances of hypoxia during the seizure - a time of markedly raised
cerebral oxygen consumption. The ventilation will also reduce carbon
dioxide levels, which reduces the seizure threshold.
After the ECT, when the patient is breathing spontaneously, they are
moved to the recovery room, where the recovery nurse and the
escorting nurse remains with them and keeps the recovery record.
Recovery is supervised by the anaesthetist, who will remain in the
suite until all the patients have recovered post-anaesthesia.
Anaesthetists have guidelines for ECT produced by the Royal

College of Anaesthetists. Through ECTAS, joint accreditation visits

are conducted when ECT departments are inspected in order to
ensure standards are being met.
13 (ii)PREPARING THE PATIENT IMMEDIATELY BEFORE ECT
The patient will have fasted and should have been to the toilet to
empty their bowels and bladder prior to ECT. In the treatment room
any jewellery, spectacles, dentures etc., are removed and tight
clothing loosened.
The ECT nurse uses a nursing checklist for completeness.
The patient is invited to lie on the treatment trolley. An intravenous

cannula is inserted. The electrode leads from the EEG recording
Channels are attached bilaterally to the fronto-mastoid positions.
A pulse oximeter, and ECG monitor are also attached. The patient is
given oxygen through a face mask and the anaesthesia is
administered.
To prepare the temples for optimal electrical contact, oil (and make-
up) is best removed by rubbing firmly with an alcohol swab. The
psychiatrist carries out this part of the preparation.
When the patient is anaesthetized, the electrodes, with a conducting

gel are then applied, pressing firmly on each temple. The point at
which the electrode is placed on the temple lies 4cm above the
midpoint of an imaginary line from the lateral angle of the orbit to the
external auditory meatus. For unilateral ECT a specially adapted
concave electrode is placed on the vertex and the other electrode
placed on the temple over the non-dominant hemisphere.
13 (iii) IMPEDANCE MEASUREMENT
When the patient is fully anaesthetised, muscle relaxant given and

the dental guard inserted, the electrodes are applied to the
appropriate positions, either bilateral or unilateral. The electrodes are
slightly rotated in a clockwise and then counterclockwise fashion and
then firmly applied. The electrodes must be kept immobile from now
on, maintaining firm pressure.
The ECT nurse or Consultant will depress the impedance
measurement button. A reading is displayed on the Thymatron ECT
apparatus. It should read between 100 and 2500 ohms. A lower
reading is suggestive of a short circuit between the electrodes, such
as excess fluid, in which case the current will take that route, and not
induce a seizure. The cause of the short-circuit should quickly be
identified, and removed.
Excessively high impedance (>3000 ohms) will result in insufficient

current to induce a seizure. The cause should be sought - ensure
clean skin, minimize the hair between skin and electrode, and apply
firm pressure when the electrodes are replaced. Test the impedance
again. Treatment should not take place until the impedance is within
the correct range.
13 (iv) ADMINISTERING THE TREATMENT STIMULUS
The electrodes are kept still, with constant firm pressure maintained,
until the end of the treat impulse. The attending Consultant or the
ECT nurse presses the "treat" button, for the duration of the
treatment impulse. The Thymatron gives a one second warning
sound, then the treatment button is illuminated and the machine
gives an audible signal for the duration of the impulse ( 4 to 8
seconds), only at the end of which should the electrodes be
removed.
The EEG paper record starts printing automatically at the end of the
treatment impulse, and will continue until the "start/stop" button is
pressed when the record shows seizure activity has finished. It prints
a summary of the dose and stimulus parameters as well as seizure
duration and the Post-Ictal Suppression Index (PSI). The print-out is
then torn off, the patient's name and the date are written on it and it
is filed in the ECT records.
14. SEIZURE MONITORING
The seizure is "bilateral and generalised" if a generalised motor

convulsion is observed affecting all limbs.
The convulsion should be "modified" in that the muscle relaxant and
anaesthetic substantially reduce the motor component of the
convulsion. The pattern of motor activity is an initial tonic contraction
during the electrical stimulus, followed by a brief delay, then clonic
contractions which usually entails rhythmic twitching of fingers, toes
and periorbital and perioral muscles.
On the EEG recording strip the seizure begins with polyspike activity
(high frequency spike waves), followed by slower spike and wave
complexes at a frequency of three cycles per second (3Hz). After the
seizure the recording shows "postictal suppression", where the
recording is flattened.
The duration of the seizure can be measured in three ways:

1. The observed fit (clonus) is timed from the end of the treatment
stimulus to the end of the last observable motor activity from the
seizure. The "cuff method" was used in the past where there was
uncertainty whether a patient was having seizures during treatment.
2. The EEG seizure is recorded on a paper print-out and the duration
of seizure activity can be determined from this. The end of three
hertz spike and wave activity is taken as the end of the seizure,
ideally followed by post-ictal suppression. The EEG seizure is often
longer than the observed one. New college recommendations are
that a seizure should not be longer than 120-180 seconds on EEG.
Since the EEG seizure is often longer than the duration of clonus, it
should be looked at closely.
3. Electromyography can also be used to measure seizure length
although this is not usually necessary.
15.MISSED SEIZURES
The aim of ECT is to induce a generalized cerebral seizure

manifested by tonic –clonic motor movements and EEG activity as
described above. Seizures of less than 25 seconds duration were
previously regarded as being of short duration, although this is
arbitrary and it is established that length of cerebral seizures is not
related to clinical efficacy.
On occasions there may be no observable clonic convulsions at all
and no evidence of seizure activity on EEG. These are regarded as
missed seizures. If this occurs during dose-titration we would follow
the titration procedure described. If this occurs during an established
course of treatment, this is regarded as a “missed seizure” and the
patient should be re-stimulated when the machine indicates ”ready”.
The dose should be increased by at least 20% (100mC).
16.PROLONGED SEIZURES
In the event of a prolonged seizure (120 seconds or more) the

seizure will be terminated. The anaesthetist will use the induction
agent propofol or may use diazepam to do this, having prepared to
do so when the seizure length exceeds 90 seconds.
17.TREATMENT RECORD
An entry will be made on the ECT treatment sheet which is kept in

the ECT department). A similar entry will also be made on a pro-
forma “sticky label” placed (usually on green paper) in the paper case
notes. An additional entry will also be made in the “progress notes”
section of Rio. The specific Rio ECT subfolder is not functional at
present but may be used in the next version of Rio. The triplicated
record will include details of the stimulus dose, a description of the
nature of the seizure (i.e. whether generalized), its modification, and
the duration of both the observed clonic movements and seizure
duration according to the EEG print-out.
If the treatment has gone well, then the entry for outcome of
treatment may read: "Bilateral, well modified seizure, observed
clonus 20s, EEG 25s, PSI 80%". The record will also include a plan
for the ECT stimulus dose at the next treatment session and may
have comments from the anaesthetist eg advising if further
investigations are needed.

18.NUMBER OF TREATMENTS IN A COURSE OF ECT and
when to stop treatment
There is no absolute upper or lower limit to the number of ECT

treatments that may be given in a course of ECT. The number given
depends on the clinical response to treatment and whether or not
unacceptable side-effects or adverse effects have occurred. If the
latter do occur, consideration should be given to early
discontinuation, weighing the risks and potential benefits of further
treatment. If the risks of treatment, including adverse response to the
general anaesthetic, are judged to be substantial, ECT may be
withheld by the ECT treatment team.
For patients who do respond well to treatment, the decision as to

when to stop should be made with the patient and the clinical team,
based on an assessment of whether the patient has improved to their
pre-morbid mental state and level of function and the acceptability of
any side-effects which may have occurred.
The typical “modal” number in a “course” of ECT may be between 6

to 8 treatments but many patients may need more or less than this. If
there has been no response by the 12th treatment it would be
unusual to persevere and it would be advisable to review the patients
history, physical and mental state as well as carefully documenting
any side effects of ECT before proceeding with further treatment.
When ECT is given under The Mental Health Act the maximum
number will be stipulated by the SOAD and limited to a maximum of
12 treatments (sometimes 6).
19. CONTINUATION (CECT) & MAINTENANCE ECT (MECT)
"Continuation ECT" describes the situation where, following a course

of ECT, the treatment is continued at a frequency of less than twice a
week, for up to six months, in order to prevent relapse. "Maintenance
ECT" refers to such preventative ECT given beyond six months
(although the terms are used synonymously). MECT would usually
only be prescribed when other attempts at preventing relapse and
recurrence have failed. Original NICE guidance recommends that
MECT should not be used. The RCPsych and SEAN have contested
this. It is advisable for Consultants prescribing MECT to obtain an
informal second opinion and to ensure that consent specifically for
MECT has been obtained and documented. This should be repeated,
ideally after every 6 MECT treatments.
CECT & MECT may be considered for patients with relapse /

recurrence of symptoms despite taking medication, or those who
cannot tolerate medication or those patients who specifically request
it. Before considering CECT the case should be carefully reviewed,
including medication history in order to ensure that any possible
alternatives have been explored. A detailed discussion with the
patient (and preferably family / carer) should cover the likely risks
and benefits and consent should be obtained and fully documented.
This should include a description of the proposed treatment plan,
describing the frequency of treatment, proposed upper limit,
frequency and arrangements for review, monitoring of response and
side effects, practical arrangements etc. The prescribing consultant
should discuss the case with the ECT Consultant and anaesthetist
and should make arrangements for a second opinion to be obtained.
Medical screening, blood tests, CXR and ECG should be repeated at
intervals in discussion with the anaesthetist. A standardised
assessment of mood state, using eg the MADRS should be recorded
at base line and at regular intervals and a record of side –effects and
adverse effects should be carefully documented. This should include
a standardized assessment of cognitive function such as the MMSE,
again recorded at base line and at regular intervals.
Once a patient has completed and responded to an acute course of

ECT and the decision and arrangements to proceed with CECT have
been made, the following reducing frequency of administration may
be followed as a guide, clinical judgement will need to be exercised,
based on regular monitoring, to aid the decision as to when to reduce
the frequency of treatments: once a week, at 10 days, 2 weeks, 3
weeks, monthly, 6 weekly, 8 weekly, then consider discontinuation if
patient remains well. The patient should be reviewed regularly and
before each change in treatment frequency, with information
obtained from family and carers. In some situations the frequency
may need to be increased again, if the patient shows signs of
relapse.
Clinicians considering recommending MECT for a patient may find it

helpful to review the “pharmacological strategies for Treatment
Resistant Depression” given in appendix 10 of this document. These
strategies may also be helpful for patients referred to ECT for
recurrent episodes of depression.
20.OUTPATIENT ECT
Some patients, particularly those who have benefited from previous
treatment with ECT, may prefer to have the treatment performed on
an outpatient basis (as a “day case”). In deciding whether or not this
is suitable for a given patient, consideration will need to be given to
factors such as the patient’s general medical health and likelihood of
any adverse reaction to anaesthesia, previous response to ECT and
ECT related side-effects, level of social support which they may have
at home etc. Special arrangements will need to be made to ensure
that the usual pre-ECT work-up (consent, investigations etc) has
been carried out, that the patient is appropriately escorted to and
from the ECT department and that they can be monitored for a
suitable time after ECT. The patient’s GP should be informed in
advance of treatment commencing and agreement reached on the
appropriate course of action if the patient needs to contact a health
professional out of hours. It is often advisable for the patient to attend
a day hospital or ward for several hours after leaving the ECT
department. The patient should be reviewed to ensure that he/ she is
fit to leave the unit and this assessment must be documented. A
leaflet providing key information must be given to the patient and / or

a responsible adult following treatment. A template is provided in the
appendices.
21. ECT IN VULNERABLE PATIENT GROUPS
Children and Adolescents
The use of ECT in children and adolescents is controversial. The

RCPsych. Handbook recommends the following:
• ECT should be used with caution in young people because of
the lack of evidence from RCTs
• First line use of ECT in young people should be very rare
• For a person under 16years, two independent opinions should
be available from child & adolescent psychiatrists.
• Stimulus dosing should take into account the lower seizure
threshold which young people are likely to have and lower
doses would usually be used
• Parents and child should be involved in the consent process.
Where it is not possible to obtain consent, ECT should only be
given when the patients life is at risk from suicide or physical
debilitation because of depressive illness.
• Whether detained or informal, a SOAD will need to certify the
consent and that the treatment is appropriate (using Form
T5), i.e. section 58A(4) applies.
• If a patient is under 18 and lacks capacity then the same
provisions as for adults who lack capacity apply
• Provision would be made to treat younger patients separately
from sessions involving adults
Learning Disability (LD)
There have been no RCTs on ECT in this patient group, evidence is

based on case series or case-reports. ECT should only be used if the
psychiatric illness is refractory to treatment or medication cannot be
tolerated or the patient’s condition has deteriorated severely. There
are no absolute contra-indications to ECT in patients with LD. The
high prevalence of epilepsy in this patient group is not a contra-
indication but use of anticonvulsant drugs has implications for seizure
threshold.
Older People
Older people are as likely as younger patients to respond to ECT.

People should not be denied access to treatment solely on the
grounds of age. Co-existing medical conditions should be carefully
assessed prior to ECT and should be treated before referral if at all
possible. Monitoring of older people should include careful attention
to changes in general physical state and cognitive function. Older
people may have higher seizure thresholds. ECT technique may
need to be modified in order to attempt to minimize cognitive side-
effects.

For a discussion on ECT in patients who lack capacity to consent see
the section on Consent to treatment.
22.TRAINING
Training of doctors, nurses, and anaesthetists involved in ECT is the

responsibility of the ECT consultant, the ECT manager, and the ECT
anaesthetist, respectively.
These guidelines will be provided for all new doctors to the service.
As part of the six monthly induction programmes for new trainees in
psychiatry, the ECT consultants will provide a teaching session on
theory and practice of ECT.
Dedicated one-to-one practical training in ECT administration is

available for all trainee doctors on either Tuesday or Friday
mornings. Doctors and nurses wishing to attend must make prior
arrangements with Karl Sunkersing. There is now a heavy demand
for training in ECT and new trainees should make arrangements for
this early in their placement as we now have to operate a “waiting
list” for training.
The Royal College of Psychiatrists has now published competencies

in ECT for doctors from foundation year level through to Consultant
Psychiatrist. Trainees will be assessed against these competencies
and those judged to have met the required standards will be receive
a certificate.
At times a Specialist Registrar (ST 4-6) may have a special interest

session in ECT. They will be educated and supervised in this by the
ECT Consultants.
The ECT Consultants will attend the Royal College of Psychiatrists'

Practitioners update on ECT, and will do so every 3 years at a
minimum.
23.ECT QUALITY ASSURANCE
The ECT consultants, ECT manager, ECT nurse specialists and ECT
anaesthetists are responsible for ensuring appropriate audit of their
service to patients having ECT.
The ECT service is registered with and formally accredited (with

excellence) by ECTAS, the ECT accreditation scheme of the Royal
College of Psychiatrists. This involves a rigorous audit of clinical
practice, personnel, clinical facilities and equipment and includes self
audit as well as external validation of standards.
The ECT service is also compliant with CQC requirements and Trust
policies and procedure eg Infection control.

24.LIST OF OTHER ECT - RELATED DOCUMENTS
These documents should be available on all wards across the Trust.

Copies are also available from Karl Sunkersing (some are attached
as appendices).
-Information for Patients and Carers

-ECT Treatment Sheet
-ECT Medical Audit Checklist
-Consent Form
-Anaesthesia questionnaire for ECT
-Nursing Checklist
-Recovery Record
-ECT nurse protocol
-ECT information for outpatients (“day cases”)
-National Institute for Clinical Excellence: Guidance on the use of
ECT. April 2003
- National Institute for Clinical Excellence CG90 Clinical guidelines on
Depression Oct 2009

Appendix 1.
PRE ECT CHECK LIST & CARE PATHWAY FOR PATIENTS
RECEIVING ECT:
(Responsibility: RC= responsible consultant; JD = Junior Doctor; WM = ward

manager / senior duty nurse; NE = Nurse Escort)
Before treatment
1. ECT clinically indicated and reasons documented
2. Consultant / prescribing doctor discusses risks / benefits with
patient (also advocate/carer if appropriate). Discussion
recorded in case notes RC
3. Patient information document given to patient WM
4. Consent form signed by Consultant / prescribing doctor and
patient RC
5. If ECT given under section MHA (Non-consenting patient or
patient lacking capacity): complete section 3 MHA, the SOAD
to complete form T6. Ensure copies of all MHA documentation
are present in the case notes, including signed section 17
leave form for patients travelling from other hospitals, RC
6. ECT referral form completed including anaesthesia proforma
(appendix 6a )JD
7. Medical work-up to ensure patient is fit for ECT: Physical
examination carried out by SHO (also physician if indicated)
and documented. Relevant investigations carried out and
results recorded and filed in notes: bloods, CXR, ECG
documented JD
8. Anaesthetic proforma completed appendix 6b (& consultation
with anaesthetist if indicated) JD
9. ECT nurse co-ordinator informed and appointment made for
treatment to commence –book transport, giving at least 24hrs
notice WM
On day of treatment
1. Patient has been fasting for 6 hours prior to treatment. If
essential medication (eg antihypertensives) required this
should be taken with 20mls of water. Remember to omit
hypoglycaemics until after ECT given on the day JD & WM
2. Nurse escort accompanies patient to and from the ECT suite
at CFH and remains with patient throughout WM
3. Patient and qualified nurse escort to be ready to leave at 8.30
a.m. WM
4. Before departure check that patient is physically well e.g. have
they just developed a cold or chest infection? If in doubt phone
Chase Farm ECT Clinic JD and WM
5. Case notes, medicine chart, ECT treatment pack, consent
form, all relevant investigation results and Mental Health Act
documentation available and ready to travel with the patient.
NE

6. Ensure Patient wearing loose clothing. Dentures present.
Jewelry in safe-keeping NE
7. Ensure a meal will be available on patient’s return WM
8. Patient given support and reassurance as needed NE
Appendix 2: EXTRACT FROM NICE GUIDANCE (HTA) ON ECT:
Guidance on indications for ECT points 1.1 to 1.10
NICE: Guidance on the use of ECT. April 2003
• Use only to achieve short term and rapid

improvement in: severe depressive illness,
catatonia, prolonged or severe mania
• Decision to prescribe is based on a documented
assessment of risks and potential benefits
• Consent must be on-going, based on informed
discussion, involving carer/ relatives/ advocate
• Clinical status must be assessed after each
treatment and treatment stopped when a
response achieved or sooner if adverse effects
• Maintenance ECT is not recommended (but see
CG 90)
• Use in schizophrenia not recommended
Also refer to extracts from NICE CG 90 in text above.

Appendix 3:
OPERATING THE THYMATRON SYSTEM 4: A SUMMARY
1. Plug EEG and Electrode cables into machine
2. Switch on Power
3. Wait for “SELFTEST” to complete – message will show “NO

BASE”
4. Decide on stimulus dose and set dose with the percent energy
dial
5. Clean skin thoroughly with saline solution
6. Attach EEG electrodes
7. Impedance test for baseline EEG, press until “3000” flashes, then
release
8. Wait for “READY”
9. Press start for EEG baseline and stop after 5 – 10 seconds
10. Give anaesthetic and hyperoxygenate
11. Place paddles with conducting gel in either bilateral or unilateral

position
12. Press impedance test, hold until gives reading (between 100 –
2500 OHM)
13. Wait for “READY”
14. Press “TREAT” button and HOLD until light goes off
15. Printer will come on automatically
16. If re-stimulating, increase stimulus dose to required setting
17. Press impedance test, wait for “ready”
18. Place paddles with more gel on head
19. Impedance test, wait for reading between 100 – 2500 OHM
20. Wait for “ready”

21. Press “TREAT” button and HOLD until light goes off
22. If 3rd (and final) stimulus is to be given repeat steps 16 – 21
Appendix 4:
Standard Dose Stimulus parameters: stimulus duration (sec), charge (mC)
and Joules (at 220 ohms impedance) at every percent energy dial setting for:
FREQUENCY = 50 Hz and Pulse Width = 0.5 ms
DIAL DURATION mC JOULES
5% 0.56 25.2 5.0

10 % 1.12 50.4 10.0
15 % 1.68 75.6 15.0
20 % 2.24 100.8 20.0
25 % 2.80 126 24.9
30 % 3.36 151.2 29.9
35 % 3.92 176.4 34.9
40 % 4.48 201.6 39.9
45 % 5.04 226.8 44.9
50 % 5.60 252 49.9
55 % 6.16 277.2 54.9
60 % 6.72 302.4 59.9
65 % 7.28 327.6 64.9
70 % 7.84 352.8 69.9
FREQUENCY = 70 Pulse Width= 0.5

DIAL DURATION mC JOULES
5% 0.40 25.2 5.0
10 % 0.80 50.4 10.0
15 % 1.20 75.6 15.0
20 % 1.60 100.8 20.0
25 % 2.00 126 24.9
30 % 2.40 151.2 29.9
35 % 2.80 176.4 34.9
40 % 3.20 201.6 39.9
45 % 3.60 226.8 44.9
50 % 4.00 252 49.9
55 % 4.40 277.2 54.9
60 % 4.80 302.4 59.9
65 % 5.20 327.6 64.9
70 % 5.60 352.8 69.9
75 % 6.00 378 74.8
80 % 6.40 403.2 79.8
85 % 6.80 428.4 84.8
90 % 7.20 453.6 89.8
95 % 7.60 478.8 94.8
100 % 8.00 504 99.8

Appendix 5:
Patient agreement to Electroconvulsive

Therapy (ECT)
Patient details (or pre-printed label)

Patient’s surname/family name..………………………….
Patient’s first names .……………………………………….
Date of birth ………………………………………………….
Consultant Psychiatrist………...……………………………
NHS number (or other identifier)……………………………..
Male Female
Special requirements ………………………………………

(eg other language/other communication method)
To be retained in patient’s notes

Patient name……………………………………
A course of Bilateral/Unilateral Electroconvulsive Therapy up to

a maximum of …………….. treatments.
(This section must be completed. If a number is not stated then treatment will
not be given).
Statement of health professional (to be filled in by consultant)

I have explained the procedure to the patient. In particular, I have explained:
The intended benefits … - improvement of depression

- Other (specify) ……………..
Serious/ frequently occurring risks Transient side-effects

- memory loss (possibly permanent) - headache
- post-treatment confusion - muscle aches
- nausea
- ‘muzzyheadedness’
- fatigue
I have also discussed what the procedure is likely to involve, the benefits and risks of any
available alternative treatments (including no treatment) and any particular concerns of this
patient.
The following leaflet has been provided - ECT Information Booklet
This procedure will involve:

general anaesthesia muscle relaxation
Signed:…….…………………………………… Date .. …………………….……….

Name (PRINT) ………………………. ……… Job title …….. ………………….…
Contact details (if patient wishes to discuss options later) …………..…. …………………via
secretary
Statement of interpreter (where appropriate)

I have interpreted the information above to the patient to the best of my ability and in a way in
which I believe s/he can understand.
Signed ………………………….……………………. Date ………………..…………….

Name (PRINT) …………………..………………………………………………………………
Top copy accepted by patient: yes/no (please ring)
Statement of patient Patient
identifier/label

Please read this form carefully. You should already have your own copy of page 2 and an
information booklet that describes the intended benefits and frequently occurring risks of ECT. If
not, you will be offered a copy now. If you have any further questions, do ask – we are here to
help you. You have the right to change your mind at any time, including after you have signed
this form.
I agree to the procedure and course of treatment described on this form.
I understand that you cannot give me a guarantee that a particular person will perform the
procedure. The person will, however, have appropriate experience.
I understand that I will have the opportunity to discuss the details of anaesthesia
with an anaesthetist before the procedure, unless the urgency of my situation
prevents this.
I understand that any procedure in addition to those described on this form will
only be carried out if it is necessary to save my life or to prevent serious harm to
my health.
I have been told about additional procedures which may become necessary during my
treatment. I have listed below any procedures which I do not wish to be carried out without
further discussion. …………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………..
Patient’s signature ………………………………………….. Date…………………………..
Name (PRINT) ………………………………………………………………………………………
A witness should sign below if the patient is unable to sign but has indicated his
or her consent.
Signature …………………………………………… Date ……………………..….………
Name (PRINT) ………………………………………………………………………………….…
Important notes: (tick if applicable)
See also advance directive/living will (eg Jehovah’s Witness form)

Patient name……………………………………
Confirmation or withdrawal of consent (to be completed by a health

professional each time the patient attends for the procedure, if the patient
has signed the form in advance).
On behalf of the team treating the patient, I have confirmed with the patient that s/he has no
further questions and wishes the procedure to go ahead. I have explained that the patient may
withdraw consent at any time.
Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Signed:…….…………………………………… Date .. …………………….……….

Name (PRINT) ………………………. ……… Job title ……..
………………….…
Patient has withdrawn consent (ask patient to sign /date here)……………………..

If consent withdrawn date of last treatment …. ……………………………………

Guidance to health professionals (to be read in conjunction with consent
policy)
What a consent form is for:

This form documents the patient’s agreement to go ahead with the investigation or
treatment you have proposed. It is not a legal waiver – if patients, for example, do not
receive enough information on which to base their decision, then the consent may not be
valid, even though the form has been signed. Patients are also entitled to change their
mind after signing the form, if they retain capacity to do so. The form should act as an
aide-memoire to health professionals and patients, by providing a check-list of the kind of
information patients should be offered, and by enabling the patient to have a written
record of the main points discussed. In no way, however, should the written information
provided for the patient be regarded as a substitute for face-to-face discussions with the
patient.
The law on consent:

See the Department of Health’s Reference guide to consent for examination or treatment
for a comprehensive summary of the law on consent (also available at
www.doh.gov.uk/consent).
Who can give consent

Everyone aged 16 or more is presumed to be competent to give consent for themselves,
unless the opposite is demonstrated. If a child under the age of 16 has “sufficient
understanding and intelligence to enable him or her to understand fully what is
proposed”, then he or she will be competent to give consent for himself or herself. Young
people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign this
form for themselves, but may like a parent to countersign as well. If the child is not able
to give consent for himself or herself, some-one with parental responsibility may do so on
their behalf and a separate form is available for this purpose. Even where a child is able
to give consent for himself or herself, you should always involve those with parental
responsibility in the child’s care, unless the child specifically asks you not to do so. If a
patient is mentally competent to give consent but is physically unable to sign a form, you
should complete this form as usual, and ask an independent witness to confirm that the
patient has given consent orally or non-verbally.
When NOT to use this form

If the patient is 18 or over and is not legally competent to give consent, you should use
form 4 (form for adults who are unable to consent to investigation or treatment) instead
of this form. A patient will not be legally competent to give consent if:
• they are unable to comprehend and retain information material to the decision
and/or
• they are unable to weigh and use this information in coming to a decision.
You should always take all reasonable steps (for example involving more specialist
colleagues) to support a patient in making their own decision, before concluding that
they are unable to do so.
Relatives cannot be asked to sign this form on behalf of an adult who is not legally
competent to consent for himself or herself.

Information
Information about what the treatment will involve, its benefits and risks (including side-
effects and complications) and the alternatives to the particular procedure proposed, is
crucial for patients when making up their minds. The courts have stated that patients
should be told about ‘significant risks which would affect the judgement of a reasonable
patient’. ‘Significant’ has not been legally defined, but the GMC requires doctors to tell
patients about ‘serious or frequently occurring’ risks. In addition if patients make clear
they have particular concerns about certain kinds of risk, you should make sure they are
informed about these risks, even if they are very small or rare. You should always
answer questions honestly. Sometimes, patients may make it clear that they do not want
to have any information about the options, but want you to decide on their behalf. In such
circumstances, you should do your best to ensure that the patient receives at least very
basic information about what is proposed. Where information is refused, you should
document this on page 2 of the form or in the patient’s notes.
Barnet, Enfield & Haringey NHS Mental Health Trust

Form 4: Form for adults who lack the capacity to consent to investigation,
treatment, personal care or assessment
Patient details (or pre-printed label):
Surname/family name..………………………….
First names .……………………………………….
Date of birth ………………………………………………….
Responsible professional.……………………………
Job title ……………………………………………………….
NHS number (or other identifier)……………………………..
Male / Female (circle)
Special requirements ………………………………………
(eg other language/other communication method) Copy to be retained in patient’s notes
All sections to be completed by professional proposing the procedure
Details of procedure or course of treatment proposed:

………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………..
Assessment of patient’s capacity:

I confirm that the patient lacks capacity to give or withhold consent to this
procedure or course of treatment because of an impairment of the mind or brain
or disturbance affecting the way their mind or brain works (for example, a
disability, condition of trauma, or the effect of drugs or alcohol) and they cannot
do one or more of the following:
Understand the information about the procedure or course of treatment.
Retain that information in their mind.
Use or weigh that information as part of the decision- making process.
Communicate their decision (by talking, using sign language or any other
means).
Further details: for example how above judgements were reached; which colleagues
Were consulted; what attempts made to assist the patient make his or her own
decision and why these were not successful
l.…………………………………………………………………………………………....
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………
Assessment of patient’s best interests:

I am satisfied that the patient has not refused this procedure in a valid
advance decision. As far as is reasonably possible, I have considered the
person’s past and present wishes and feelings (in particular if they have been
written down) any beliefs and values that would be likely to influence the decision
in question. As far as possible, I have consulted with other people (those

involved in caring for the patient, interested in their welfare or the patient has said should
be consulted) as appropriate. I have considered the patient’s best interests in
accordance with the requirements of the Mental Capacity Act and believe the procedure
to be in their best interests because:
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………….…………
……………………………………………………………………………………………
(Where incapacity is likely to be temporary, for example if patient is unconscious, or
where patient has fluctuating capacity) The treatment cannot wait until the patient
recovers capacity because:
………………………………………………………………………………………………
………………………………………………………………………………………………
……………………………………………………………………………………
Involvement of the patient’s family and others close to the patient:
The final responsibility for determining whether a procedure is in an incapacitated
patient’s best interests lies with the professional performing the procedure.
However, it is good practice to consult with those close to the patient (e.g.
spouse/partner, family and friends, carer, supporter or advocate) unless you
have good reason to believe that the patient would not have wished
particular individuals to be consulted, or unless the urgency of their situation
prevents this. “Best interests” go far wider than “best medical interests”, and
include factors such as the patient’s wishes and beliefs when competent,
their current wishes, their general well-being and their spiritual and religious
welfare. (to be signed by a person or persons close to the patient, if they wish)
Independent Mental Capacity Advocate (IMCA)

Where there is no one appropriate to consult other than staff, has an Independent
Mental Capacity Advocate (IMCA) been instructed?
Yes / No (circle)
Details:……………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………
Signature …………………………………………..
Date………………………………………………….
Name (print) ………………………………………
I/We have been involved in a discussion with the relevant professionals over the
treatment of………………………(patient’s name). I/We understand that he/she is unable
to give his/her own consent, based on the criteria set out in this form. I/We also
understand that treatment can lawfully be provided if it is in his/her best interests to
receive it.
Name………………………………………………
Relationship to patient……………………………………….
Address……………………………………………………………………………………
Any other comments (including any concerns about decision)
Name………………………………………………
Relationship to patient……………………………………….

Address……………………………………………………………………………………
………………………………………………………………………………………………
…………………………………………………………………………………..
If a person close to the patient was not available in person, has this matter been
discussed in any other way (e.g. over the telephone?)
Yes / No (circle)
Details:
Signature of professional proposing treatment:
The above procedure is, in my professional judgment, in the best interests of the
patient, who lacks capacity to consent for him or herself. Where possible and
appropriate I have discussed the patient’s condition with those close to him or her, and
taken their knowledge of the patient’s views and beliefs into account in determining his
or her best interests.
I have/have not sought a second opinion.

Signature……………………………………
Date………………………………………………………….
Name (Print)………………………………………..
Job Title………………………………………………………
Where second opinion sought, s/he should sign below to confirm agreement:
Signature……………………………………………..
Date………………………………………………………….
Name(Print)………………………………………..
Job Title………………………………………………………
If the patient has an Attorney or Deputy:

Where the patient has authorised an attorney to make decisions about the
procedure in question under a Lasting Power of Attorney or a Court Appointed
Deputy has been authorised to make decisions about the procedure in question,
the attorney or deputy will have final responsibility for determining whether a
procedure is in a patient’s best interests.
Signature of attorney or deputy
I have been authorised to make decisions about the procedure in question under
a Lasting Power of Attorney/ as a Court Appointed Deputy (delete as appropriate). I
have considered the relevant circumstances relating to the decision in question and
believe the procedure to be in the persons best interests.
Any other comments (including the circumstances considered in assessing the

Patient’s best interests)
Signature: …………………………………………….
Date …………
Barnet, Enfield & Haringey NHS Mental health Trust

Appendix 6a: ECT Referral Form
This form must be fully completed by the referring medical team prior to the first ECT treatment
and will be retained in the ECT department. This form is to be used in conjunction with the ECT
protocol, available on the Trust intranet. The referring medical team must refer to the ECT
protocol when completing this form to ensure the individual patient is adequately prepared for
ECT to ensure the safe administration of ECT. In particular the Anaesthesia proforma (appendix
6b) and blood results forms must be completed. Please do not simply enter “see Rio” - if
information is available on Rio it should be “cut and pasted” into an electronic version of this form,
a hard copy should then be printed off and be available when the patient presents for their first
ECT treatment.
Name: Patient’s sticky label:

Date of Birth:
Ethnicity:
Mental Health Act Status:
Please record assessment of benefits and risks of ECT treatment for this
patient, including no treatment:
Reason for ECT:
Mental State Examination:
Medical history:

Current medication:
Physical examination (no more than 7 days prior to 1st ECT treatment,
include cardiovascular, respiratory, neurological systems, temp and BP):
Investigations:

Blood tests done y/ n with results on attached pre-anaesthesia form
Recent ECG carried out and filed in notes yes n/a (circle)
Recent chest x-ray carried out and filed in notes yes n/a (circle)
Any other investigations and results required for individual patient: (see ECT
protocol anaesthesia guidelines for specific requirements for individual patients)
Cognitive testing
Clinical history of subjective experience of memory loss:
MMSE completed on:

MMSE score:
Any other cognitive assessment done:
Also to be completed prior to 1st treatment:
Initial prescription by referring Psychiatrist

Name: ……………………………………….
Signature: …………………………………..
Date:…………………………………………
Pre ECT Medical assessment for Anaesthesia Appendix 6b

Documentation in the notes of the consent process, including a written
record of the assessment of capacity
Consent form (include on this the maximum number of treatments the patient is
consenting to and whether unilateral or bilateral ECT )
For patients having ECT under the MHA please provide copies of appropriate
documentation eg T4 or T6 or section 62.
Name of Doctor completing this form:………………………………………………

Signature & Date:……………………………………………………………………….
Contact number:………………………………………………………………………...
Appendix 6b: Ward Doctors’s PRE-ECT Medical ASSESSMENT

ASA Grade (1-5)_____
Patient Name :
Hospital number :
Dob :
Age : Weight :
Current / Recent Illness :
Previous Medical Illness & Surgery :
Previous Anaesthetic History :

Yes No
Problems after receiving an anaesthetic ?
Patient :
Family Member :
If Yes , please give details :
(e.g Malignant hyperthermia , suxamethonium apnoea or anaphylaxis

- refer to anaesthetist )
Medications :
Allergies (medication and food eg eggs) :
Dental : Loose teeth / Crowns / Dentures / Implants ( please inform anaesthetist of

any loose teeth or Crowns )
Cardiovascular :
Suffer with angina? Yes / No ( If Yes , ECG )

Angina at rest Yes / No ( If Yes, refer Cardiologist )
Frequency of angina: ( Refer If > 2 episodes per week)
M. I. In the last 3 months: Yes / No ( If Yes, ECG & refer )
Palpitations: Yes / No (If yes , ECG )
Palpitations associated with Yes /No (If yes , ECG & refer )
Syncope:
Breathless when lying flat Yes /No ( If yes , refer )
Breathless when walking

On flat ground: Yes / No ( If yes , refer )
Needs to pause when going

Up 10 –14 stairs to catch breath ? Yes /No ( If yes , refer )
Have a pacemaker ? Yes /No (If yes , ECG & details )
Check patient pacemaker record card for details :

Date inserted :
Type :
Last check :
Reason for insertion of pacemaker :
Any heart valve problems : Yes/ No ( If yes, ECG & Echo )
Has the patient had an echo ? Yes/No ( If yes , details of report )
Has the patient had angioplasty ? Yes / No ( If yes, ECG & refer )
Has the patient got high BP ? Yes/ No (If yes, ECG & CXR )
Respiratory
Does the patient have breathing problems ? Yes / No ( If yes - details & CXR see
protocol )
Admitted to hospital /ITU with breathing Yes /No ( If yes, refer & details )
Problems in the last year ?
Productive cough ? Yes /No ( If yes with green sputum

refer )
Does the patient use an inhaler ? Yes / No
Extra puffs throughout the day ? Yes /No ( If yes, details ,CXR & refer
)
Does the patient smoke ? Yes /No ( If yes , how many per day ?
)

Metabolic
Diabetic Yes/No ( If yes specify - Insulin dependent (IDDM )
Non Insulin dependent (NIDDM )
Diet controlled
(All diabetics should have blood sugar, U&E and ECG done and a BM result should be
available in the notes on the morning of ECT )
Liver disease or problems Yes /No ( If yes , details , liver functions tests ,
U&Es )
Thyroid disease or problems Yes / No ( If yes , details, ECG & thyroid function
tests )
Regular heartburn or
Acid reflux : Yes /No ( If yes , follow Lanzoprazole policy )
Renal
Kidney disease or problems : Yes / No ( If yes , details , FBC & U&E )
Renal failure Yes / No ( If yes, details, FBC, U&E , refer )
Neurological
Any neurological problems ? Yes /No ( If yes, details )
CVA / TIA Yes /No ( If yes, & less than 6 months refer )
Fainting /blackouts : Yes /No ( If yes, details - frequency & precipitating

factors
& refer )
Muscular & Skeletal

Any Muscular disease or disorder ? Yes /No ( If Yes, details and refer )
(i.e. muscular dystrophy )
Any skeletal disease ? Yes/No ( If yes, details & refer )

(i.e. ankylosing spondylitis )
Anaesthetists :
Patients requiring an anaesthetic referral can be referred to :
Dr. Thillai : tel 07770954052 on Tuesdays

Dr. Haemeed : tel 07946293366 on Fridays
Where urgent anaesthetic review / ECT is required out of hours -contact on call
anaesthetic registrar or consultant

CONTRAINDICATIONS (ABSOLUTE /RELATIVE ) TO ECT
Recent MI (< 6 months )

Recent CVA (< 6 months )
Coronary stenting < 6 months
Cardiac failure
Severe valvular heart disease
Aneurysm
Space Occupying lesions
Unstable cervical spine
The anaesthetist should be informed at least 24 hours in advance of the first

ECT treatment of all patients.
However patients with medical problems may require early referral for assessment &
further workup before ECT is commenced.
ANAESTHETIC REFERRAL
Refer the following patients to the anaesthetist for Assessment & further workup as
indicated.
Previous Anaesthetic reactions or problems

Patients with moderate to severe heart disease or poor exercise tolerance
Recent heart surgery on warfarin
Recent MI (< 6 months)
Recent coronary angioplasty with stenting ( < 6 months)
Patients with pacemaker
Poorly controlled hypertensive
Recent CVA (less than 6 months)
Patients with palpitations , dizziness and syncope
Patients with muscular , skeletal and neurological disorders ( myotonia, spondylosis,
Myasthenia gravis, etc )
Renal failure on dialysis
Severe liver disease.
Chronic or severe respiratory disease or patients requiring oxygen supplements
.
Investigations : (Please ensure ECG & CXR report / film is attached or available on day of ECT)
1. ECG - Men over 40 , women over 45

All patients with heart disease
All patients with hypertension
All diabetics
All patients with palpitations , history of syncope or dizzy spells
All patients with thyroid disease
2. CXR - All patients with chronic , moderate – severe lung disease

All patients with recent onset breathlessness
Patients on Home oxygen supplementation
Patients with chest infections
Chronic cough (lasting > a month )
All patients with heart disease and hypertension

3. ECHO - All patients with valvular heart disease.
Patients with heart disease associated with reduced or poor exercise
tolerance.
Patients with heart rhythm , other than sinus, i.e atrial fibrillation.
4. BLOOD - FBC & Blood glucose for all (Diabetics will require blood sugar levels done
on the morning of ECT )
U&E - All patients (mandatory if on diuretics, lithium, if heart disease & high BP
and any of renal, liver and metabolic disorders)
Clotting Screen : - All patients on anticoagulants ( i.e.warfarin )

- All patients with severe renal & liver disease.
Thyroid function tests : All patients with thyroid disease
Liver function tests : All patients with liver disease

Chronic alcoholics
PLEASE WRITE RESULTS IN HERE: (HB, WCC, Glucose; U+E, creatinine etc)
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PREOPERATIVE
1. Fasted - 6 hours
2. All regular medications that the patient is on should be administered with the
exception of ACE –INHIBITORS & DIABETIC medications (see below)
3. All diabetics (IDDM & NIDDM ) - Should not receive their diabetic medications
before treatment but can have their diabetic medications following breakfast after
ECT .
4. All patients who suffer from heartburn or acid reflux should receive 30mg
Lanzoprazole 2 hours before the anaesthetic . ( This will not be necessary if the
patient is already on regular antacid, i.e ranitidine or omeprazole )

Appendix 7: PRE- ECT MEDICAL ASSESSMENT GUIDELINES
These guidelines have been written in conjunction with the medical pre-
assessment documentation (Medical Assessment Forms). They are to be
used together and as a guide for the benefit of the assessing doctor. The
guidelines contain questions that need to be answered with regard to
common medical problems. These questions must be asked and the
answers recorded in the assessment form. It may be necessary to check
patients previous notes for all significant medical, surgical and anaesthetic
history.
Please bear in mind that patients with significant medical problems are at
higher risk from complications related to anaesthesia and ECT. Hence
these group of patients should be referred to the anaesthetist as soon as
possible, to avoid any delays in the treatment.
Allergies
1. It is important to list not only drug allergies, but other types of

Allergies, particularly important are nuts and eggs. Patients with
allergies to banana, kiwi or avocado may be at risk of latex allergy.
2. Note what type of reaction occurs.
3. Inform the anaesthetist if there is known allergy to any anaesthetic drug.
4. Latex/rubber allergy - please highlight on assessment form and
inform the ANAESTHETIST and ECT COORDINATOR.
Previous General Anaesthetic (GA)
1. List the year of last GA.

2. Refer to anaesthetist if Previous Anaesthetic Problems, ie
- Cardiac Arrest
- Respiratory Arrest
- Severe bronchospasm
- unexpected post-op in ITU
- History of difficult airway/intubation
3. Note and inform anaesthetist of suxamethonium (scoline) apnoea.
4. Note any post-operative nausea and vomiting.
5. Blood relatives with problems - refer if malignant hyperthermia
Social History
Smoking/ drinking / illicit drugs

1. Heavy Smokers (20 -40 a day) need to be asked breathlessness
questions
2. Heavy drinkers (over 40 units per week) need U&Es and LFT
3. For drug abusers, note and highlight use. Advise to stop prior to

admission . Inform anaesthetist if on crack/cocaine
Surgical History
Note all relevant history and the year performed
Medical History
Note all relevant history and the year occuring.
Medications
1. List all current medications and dosage taken.
2. Ensure that medication list is consistent with answers to health
questions.
Section 1 : Cardiovascular
All patients with cardiovascular concerns must have ECG and U &E’s
All patients with worsening cardiovascular symptoms must be referred.
Exercise Tolerance :
All patients who answer yes to any question in section 1 must be asked
the following exercise tolerance question:
1. Can you walk up a flight of stairs without stopping to catch your

breath? If yes, accept, if no refer but continue with questions
2. How far can you walk on a flat surface and at what pace?
500 meters accept, slow pace and less than 500meters refer.
3. Do you get breathless when just sitting or laying flat?
(How many pillows used at night?). If yes refer.
4. Do you get breathless dressing / undressing? If yes, refer.
Observe patients for obvious signs of breathlessness. They may be so used

to their breathlessness state that they don’t think it is abnormal.
Hypertension
Known hypertensive patients must have had an ECG & U &E’s within 3
months. Ask the following:
1. How long have you been on medication?

2. Does someone regularly check your BP?
3. Is your hypertension controlled?
4. Have you changed your medication in the last 3 months ?
5. Any recent readings with the GP?
Accept diagnosed hypertension that is treated and stable (DBP below

100mmHg, SBP below 170 mmHg ).
Undiagnosed Hypertension will need further work-up and treatment prior to
receiving treatment. However if ECT is required urgently then refer to the
Anaesthetist.

Angina /Chest Pain
Further questions to be asked:
1. How frequently do you get chest pain?

2. What brings on your chest pain?
3. Do you use GTN spray or tablets to control it?
4. How often do you use GTN?
5. How long does it take for the pain to resolve?
6. How far can you walk and at what pace before getting chest pain?
7. Have your symptoms worsened in the last 6-12months?
8. Has your GP investigated you for this and what was the outcome?
Refer Patients if :
1. Their angina is more frequent than 2 -3 times per week.
2. Their angina occurs with limited or no exertion.
3. They can walk less than 500 meters at a slow pace before stopping.
4. Their symptoms have worsened in the last 6 -12 months.
5. If their chest pain is undiagnosed.
Recent Myocardial Infarction (MI)
All patients with MI within 12 months must be referred to the

anaesthetist.
If MI is recent , less than 6 months then cancel. But if ECT is absolutely
necessary than refer to anaesthetist for evaluation and discuss. (see notes
on anaesthetic referral).
All patients who have been stented post MI must be referred if they are
taking clopidogrel/ warfarin or if the stent was done less than 6 months ago.
Palpitations /Irregular Heart Beat
Undiagnosed, symptomatic palpitations must have ECG and then referred.

Young fit patients on antipsychotic medications can have palpitations from
their medications . They must be referred and may require further investigation.
All patients with AF should be asked about angina & exercise tolerance. Patients
on warfarin should have their average INR listed. All previously undiagnosed AF
should have TFT, Echo and be referred
Heart Murmur
Further enquiry:
1. When was the murmur diagnosed?
2. Who diagnosed it?
3. Have you had any investigations - Echo, etc?

Patients with symptomatic murmur which has not been investigated, should
be referred. All other asymptomatic murmur can be treated but inform
anaesthetist.
Rheumatic Fever
Patients who receive antibiotic prophylaxis at the dentist may have underlying
valvular lesions and will require further questioning. Trace any previous echo
report.
Pacemaker
Questions to be asked :
1. When was the pacemaker inserted?
2. What was the indication for the pacemaker?
3. Ensure the last check was done within last 12 months.
4. What is the pacing mode?
5. Does the patient have an implanted automatic defibrillator (ICD)?
If unsure, contact the pacemaker clinic for information.
All patients with cardiac pacemaker and ICD should be referred to the
anaesthetist prior to ECT
Bilateral Pitting Oedema

Refer if associated with breathlessness or worsening symptoms.
Section 2 : Respiratory :
Asthma / Bronchitis / COPD

Questions to be asked:
1. Do you use inhalers?
2. How often do you use inhalers? (especially ventolin)
3. What degree of exercise makes you use ventolin?
4. Have you taken oral steriods, and when last taken?
5. How many pillows do you sleep on at night?
6. Have you ever been admitted into hospital with breathing
problems?
7. Have you ever been in ITU after an operation?
8. Do you have productive cough?
Patients who have had hospital admissions for breathing problems should
be referred. Any patients admitted to ITU post GA must be referred.
Patients should have peak flow performed. If less than 300, refer.
Any previously undiagnosed breathing problems should be referred.
Sleep Apnoea: ALL patients with sleep apnoea should be referred

Questions to be asked:
1. When was sleep apnoea diagnosed?
2. How was it diagnosed?
3. Do you use CPAP /BiPAP?

4. Are you sleepy during the day?
Be vigilant for BMI > 35 and short thick neck (collar size > 17)
Section 3 : Neurological
Any undiagnosed fits/blackout or those under investigation must be referred.

Those with a proven neurological /muscle disease may not be suitable for day
case and should be referred. Stable MS is acceptable.
Epilepsy
Well controlled epilepsy can be done as day case and rarely complicates
ECT (e.g prologed seizures). Epileptics tend to have a higher seizure threshold
(anticonvulsant medication).
Uncontrolled epilepsy may be unsuitable for day treatment.
Myasthenia Gravis and Myopathies
Must all be referred to the Anaesthetist for evaluation.
CVA /TIA :
Refer all patients with history of CVA or TIA within 6 months

All patients with recurrent CVA should be referred.
Section 4: Endocrine
IDDM and NIDDM
All patients can be done as day case.

Patients must have been diagnosed for at least 3 months
Patients must have been on the same medication for at least 3 months. Normal
morning BM (before breakfast) should be less than 10mmol.
All patients falling outside these criteria must be discussed with the anaesthetist
All diabetics should omit their diabetic medication before ECT and have a
BM done every 2 hours until after treatment when they can than have
their breakfast and resume their normal diabetic regime
All patients should have U&E’s and ECG done.
Other Endocrine Diseases
Thyrotoxicosis, Phaeochromocytoma, etc. Should be referred to the anaesthetist.

Section 5: Haematology
Sickle Cell Anaemia
All afro-carribean patients should be tested for sickle cells.

Refer all patients to the anaesthetist.
Section 6: Other Diseases
Liver and Kidney Diseases

All patients with moderate to severe liver or renal disease must be referred
to the anaesthetist.
All patients with hepatic or renal failure should also be referred.
Arthritis
Neck involvement or moderate to severe joint involvement, inform the
anaesthetist.
Acid Reflux /Hiatus Hernia.

Should have H2 BLOCKER (Ranitidine) or proton pump inhibitor (eg
omeprazole) prior to ECT.
Anxiety/depression/psychotic illness:
Patients on medication for psychiatric disorders may have side-effects or
drug interactions and may require close monitoring (nb lithium levels).

Appendix 8:
Barnet, Enfield & Haringey Mental Health NHS Trust
Electroconvulsive Therapy (ECT) :

information for patients and their families
CONTENTS
1. Introduction
2. What is ECT?
3. Why has ECT been recommended for me?
4. Is ECT used for other conditions?
5. How is ECT given in Barnet, Enfield & Haringey Mental Health Trust?
6. What investigations will I need if I have ECT?
7. What happens on the day of ECT?
8. How will I feel immediately after ECT ?
9. How well does ECT work?
10. How many treatments are usually necessary?
11. What ECT can't do
12. What are the risks and side effects of ECT?
13. What else is known about Memory Impairment and ECT?
14. Does ECT cause Brain Damage?
15. Are there other serious risks from the treatment?
16. What other treatments could I have?
17. Will I have to give consent?
18. What Safeguards Are There?
19. Can I refuse to have ECT?
20. Can Relatives Give Consent To ECT?
21. Are there any risks in not having ECT as recommended?
22. Can ECT be given as an Emergency?
23. Why has ECT been controversial?
24. Advocacy services
25. Summary
26. Further information

1. Introduction
This leaflet has been produced in order to try to answer some of the questions
you may have about ECT. You will probably want to know what it is, why it is
used and what it is like to have ECT. You will also want to know about the
possible risks and benefits of ECT. The leaflet has been written by clinicians from
the ECT department in this Trust but is based on a similar leaflet produced by the
Royal College of Psychiatrists and the Scottish ECT audit network (SEAN).
When you are depressed, it is often quite difficult to concentrate. Don't be

concerned if you can't read through all of this leaflet - just pick out the sections
that seem important at the time and come back to it later. You may wish to use it
to help you ask questions of staff, relatives or other patients who have had ECT.
2. What is ECT?
ECT is a physical treatment for severe depressive illness. During ECT a small
amount of electric current is passed across the brain for usually 3 to 6 seconds.
This produces a brief seizure (like an epileptic fit) which affects the entire brain,
including the parts which control thinking, mood, appetite and sleep. Repeated
treatments alter some of the chemical messengers in the brain and bring them
back to normal. This helps you to recover from your illness.
ECT is only given under a general anaesthetic and with drugs to relax the body's
muscles. This means that unlike a person experiencing a natural epileptic fit, you
will be asleep before it starts. Your arms and legs will not thrash around, usually
there will just be a flickering of the eyelids. You should have no memory of the
treatment itself.
A special machine is used to precisely control the amount of electricity used to
make sure that you are given as little as possible.
For most people ECT acts more quickly than medication and in some cases this
can be life-saving. The improvements produced by ECT will usually need to be
maintained with anti-depressant medication.
As with any form of treatment, there are possible side effects. The most common
ones are headache for a short time immediately after each ECT treatment and
memory loss for periods around the treatment. This is discussed in more detail
later on.
3. Why has ECT been recommended for me?

ECT is given for several reasons, most commonly it is given for severe
depression. If you are not sure why you are being given ECT, don't be afraid to
ask. It's sometimes difficult to remember things when you are depressed, so you
may need to ask several times. Your consultant may recommend that you be
treated with ECT if:
• You have had a severe depressive illness for some time and a number of
different drug treatments have been tried without success.
• You have tried several different anti-depressants but have had to stop
them because of side-effects.
• You have responded well to ECT in the past.
• Your life is in danger because you are not eating or drinking enough
• Your life is in danger because you feel so bad you want to kill yourself.
• If your depression is so bad that you may die, ECT can literally be life-
saving.
4. Is ECT used for other conditions?
Occasionally ECT may be used to treat mania and catatonia and rarely for
schizophrenia.
5. How is ECT given in Barnet, Enfield & Haringey Mental Health Trust?
The ECT service at Chase Farm Hospital has been accredited with excellence by
ECTAS, a department of the Royal College of Psychiatrists responsible for setting and
maintaining high standards of care in accredited clinics. The ECT service is based at
Chase Farm Hospital in a purpose built unit and ECT is given twice a week, on Tuesday
and Friday mornings. If you are an inpatient in Barnet or Haringey, arrangements will be
made for you to travel to and from Chase Farm hospital with a nurse escort. Some
people who have had it before may have ECT given as an outpatient, in which case
arrangements will be made for you to be escorted to and from the unit.
6. What medical investigations will I need if I have ECT?
Once you and your doctors have agreed that you will receive a course of ECT,
they will need to do some tests to make sure that it is safe for you to have a
general anaesthetic. They will also ask about your medical history and if you
have had any previous operations or general anaesthetics. Do not worry if you
cannot remember exact times and dates. The doctors will take a blood test – this
is to make sure that your blood chemistry is normal. They will also take a tracing
of your heart, (an ECG), and sometimes a chest X-ray to make sure that you
have no problems with your heart or lungs.
7. What exactly happens on the day of ECT?

You will be asked to have nothing to eat or drink from midnight on the night
before treatment because you will be having a general anaesthetic. The only
exception is if you take essential medication for conditions like high blood
pressure, which should be taken as usual if prescribed in the mornings, with a
small sip of water. You will be able to wear your own day-clothes, which should
be loose fitting and comfortable. You should also remove any earrings, necklaces
and watches and leave them on the ward for safekeeping. You may keep your
wedding ring on. Your ward nurse will have removed any nail polish.
You will have an allocated ward nurse who will attend the treatment with you and
help you to get ready. Your nurse will remain with you throughout the procedure.
Don’t be afraid to ask about anything you are unsure of as they will be there to
support you. Before each treatment your nurse will check your blood pressure,
pulse and temperature. If you have diabetes the nurse will also measure your
blood sugar level.
When you get to the ECT suite you will be shown into a waiting room. The
treatment takes place in a separate room with special equipment. Other patients
will not be able to see you having the treatment.
You will then be asked into the treatment room. You may find this unusual and
possibly frightening at first as the room contains lots of equipment and some
members of staff whom you may not have met before. All of these staff are there
to ensure that you have a safe and uneventful treatment session. They will try to
make you feel as comfortable as possible. The staff will include a psychiatrist
who is responsible for giving you the ECT treatment, an anaesthetist and an
anaesthetic assistant who will be giving you a general anaesthetic and an ECT
nurse, who will assist the psychiatrist and anaesthetist, and who has overall
responsibility for the smooth running of the clinic.
From time to time student doctors and nurses may attend the ECT clinic for
training purposes. You will be asked in advance if this is acceptable to you. If you
do not want students to attend your treatment session please inform the ECT
nurse. It is your choice and will not affect your treatment session whatsoever.
The ECT staff will introduce themselves to you, but if you are unsure about who
they are, or you have forgotten, please do not be afraid to ask.
You will be asked to lie down on a treatment trolley. Your pulse and blood
pressure will be checked again.
Some small electrode pads will be attached to the front of the chest to allow us to
measure the heart rate and similar pads are placed on the forehead, which
allows us to record the duration of the seizure when you have the actual
treatment. You will not feel any pain from this. The anaesthetist will ask you to
hold out your hand so you can be given an anaesthetic injection into a vein on

the back of your hand. Inserting the small needle should be the only part of the
treatment which may be slightly painful. The anaesthetic will make you go to
sleep and cause your muscles to relax completely. You will be given some
oxygen to breathe as you go off to sleep. Once you are fast asleep a small,
carefully calculated electric current is passed across your head and this causes a
fit (seizure) in the brain. Unlike normal epileptic fits, there is little movement of
your body because of the relaxant injection that the anaesthetist gives, there will
usually only be slight twitching of the muscles around the eyes, fingers and toes.
This usually lasts for around 30 seconds. Note that there is no incision or surgical
operation.
After about 15 to 20 minutes you will start to wake up and you will be in a
separate room called the “recovery” area, where a specially trained nurse will be
with you at all times. When you are ready to leave this area you will be able to
have a drink and snack before leaving the unit with your escorting nurse.
When you return to the ward you will have breakfast, a drink and your normal
medication. You may still feel sleepy and want to rest on your bed for a while,
but you should soon be able to take part in your usual activities.
If you have any worries or concerns following your treatment please speak to
your ward doctor or the nursing staff who are there to help you.
8.How will I feel immediately after ECT ?
Most people will feel “woozy” or “muzzy-headed” for up to an hour after the
treatment, don’t worry about this as it will clear. The nurse will be there to help
you through any problems.
9. How well does ECT work?
Research evidence shows that 8 out of 10 patients with severe depression

respond well to ECT, either showing full recovery from depression or a
substantial improvement. In fact, ECT is the most effective treatment for very
severe depression. People who have responded to ECT report that it makes
them feel "like themselves again" or "as if life was worth living again". Severely
depressed patients will become more optimistic and less suicidal. Most patients
recover their ability to work and lead a productive life after their depression has
been treated with a course of ECT.

10. How many treatments are usually necessary?
ECT is given twice a week. It is not possible to say exactly how many treatments
you may need. Some people get better with as few as 2 or 3 sessions, others
may need as many as 12 and very occasionally more.
11. What ECT can't do
The effects of ECT will relieve the symptoms of your depression but will not help
all your problems. An episode of depression may be due to problems with
relationships or problems at home or at work. It may also cause such problems.
These may still be present after your treatment and you may need further help
with these. Hopefully, because the symptoms of your depression are better you
will be able to deal with these other problems more effectively. You may then find
that you are able to make good use of counselling or psychotherapy.
12. What are the side effects of ECT?
Some patients may be confused just after they wake from the treatment and this
generally clears up within an hour or so. The commonest side effect is transient
headache. If this persists then your nurse will arrange for you to have a pain-killer
(analgesic) for this. Some people also experience minor muscle discomfort and
nausea.
Your memory of recent events may be upset and dates, names of friends, public
events, addresses and telephone numbers may be temporarily forgotten. In most
cases this memory loss goes away within a few hours or days although
sometimes patients continue to experience memory problems for several weeks
or months. There may be gaps in your memory for events before and after the
ECT for this period of time and in some cases events around the time of ECT
may be permanently forgotten.
13. What else is known about Memory Impairment and ECT?

Memory impairment can be associated with severe depression and can be
marked even when patients have not had ECT.
Memory impairment for events occurring around the course of ECT and the few
weeks afterwards is very common (60-70% of patients). Past memories can also
be affected. It is difficult to know how much of this is caused by ECT and how
much by severe depression. Memory impairment due to ECT tends to recover
gradually over the six months following treatment, though some patients only
very slowly recover past memories and some may have permanent gaps in their
memory for some past events.
Despite these concerns it is important to note that the research evidence
indicates that the ability to use our memory (working memory) may actually

improve after ECT, as depression lifts. To the best of our knowledge and after
nearly 70 years of experience with ECT, we can say that ECT does not appear to
have any long- term effects on the ability to use memory in the future, once your
depression has improved, nor should there be any harmful effects on overall
intelligence or other brain functions. The side effects on memory are more likely
with bilateral ECT than unilateral ECT, although unilateral ECT may take longer
to work. Your doctor will explain the difference between the two and will discuss
the advantages and disadvantages of these 2 forms of ECT with you.
14. Does ECT cause Brain Damage?
The straightforward answer is ‘NO’.
Brain damage can be of two types:
1. Shrinkage of the brain or loss of particular groups of cells. There are many
studies using modern brain scans which have shown that ECT does not
cause such damage.
2. Impairment of function
o This might not show up on brain scans.
o It might be detected by tests of memory, concentration or ability to
plan.
o Most studies show that these abilities improve in patients who have
had ECT. This is because ECT reverses depression not because of
a direct positive effect on brain function.
o This emphasises that depression itself has profound effects on
memory, concentration and other mental tasks.
Could there be a small number of people who do have permanent memory
changes after ECT?
• Yes, there are certainly patients who have lost memories from their past
which have not returned even after many years.
• Detecting these gaps in individual memories has proved very difficult in
large research studies.
• Even in this very small number of patients the ability to learn new facts
remains intact.

15. Are there other serious risks from the treatment?
ECT is amongst the safest medical treatments given under general
anaesthesia. The risk of death or serious injury with ECT is rare and occurs in
about one in 50,000 treatments. For example this is much lower than reported
for childbirth. Very rarely deaths do occur and these are usually because of
heart problems. Patients with a pre-existing medical condition are at
increased risk of experiencing cardiac or respiratory problems following
treatment. For this reason pre-treatment medical assessments to identify and
minimise any risk are carried out. If you do have heart disease it may still be
possible for you to have ECT safely as long as the doctors take special
precautions, such as heart monitoring. Your doctor will ask another specialist
to advise if there are grounds for concern.
In some cases severely depressed people treated with ECT may develop a
swing in mood and become manic, the risk of a swing into manic mood is the
same as for treatment with antidepressant drugs.
Not having ECT also has risks. Studies have shown that depressive illness
increases mortality rate. There is evidence that suicide rate in severe
depression is decreased in patients who are treated with ECT in comparison
with those who are not.
16. What other treatments could I have?
Anti-depressant and other drugs may be available to treat your particular

condition and it is possible that some of them may work as well as ECT. You may
also be offered psychotherapy. The advantage and disadvantages of other
treatments should be discussed with you by your doctor.
17. Will I have to give consent?
If you have the “capacity” to make a decision, which means that you are able to
understand the likely risks and benefits of ECT, can remember the information for
long enough to make a decision and can communicate your decision, then ECT
can only be given with your agreement. At some stage before the treatment you
will be asked, by your doctor to sign a consent form for ECT. If you sign the form
you are agreeing to have up to a certain number of treatments, although you can
withdraw your consent at any time. Before you sign the form your doctor should
explain what the treatment involves and why you are having it, and should be
available to answer any questions you may have about the treatment.

18. What Safeguards Are There?
Usually ECT does not have to be given urgently. There should be plenty of time
to discuss the treatment. It’s always important to talk to someone, a doctor, your
GP, a nurse, close friend or trusted family member or an advocate. Try to talk to
other patients who have had ECT. If there is no one close to you that you can
confide in, ask the ward staff for advice as there is an advocacy service available
to you. If you are unsure don’t be afraid to ask your doctor to arrange a second
opinion. Make sure that the alternatives to ECT have been explained to you.
19. Can I refuse to have ECT?
You can refuse to have ECT and you may withdraw your consent at any time
even before the first treatment has been given. The consent form is not a legal
document and does not commit you to having the treatment. It is a record that an
explanation has been given to you and that you understand to your satisfaction
what is going to happen to you. Withdrawal of your consent to ECT will not in any
way alter your right to continue treatment with the best alternative methods
available. No one should be put under undue pressure to have ECT. If there are
doubts independent advice should be sought.
In some cases a person may become particularly seriously ill with depression.
They may be suicidal, convinced that they are too wicked to be treated, or eat
and drink too little to stay alive for much longer. In these circumstances ECT may
be given to patients without their consent. For this to happen, two doctors and a
social worker must agree that the person is so unwell that they need to be kept in
hospital under a section of the Mental Health Act. Then another independent
Psychiatrist, sent by the Care Quality Commission (Previously called the Mental
Health Act Commission), must agree that the treatment is necessary. If you are
detained in hospital under a section of the Mental Health Act and are uncertain
about your rights, ask to speak to the Mental Health Act administrator for the
hospital.
20. Can Relatives Give Consent To ECT?

A relative cannot give consent to treatment on behalf of another. The only
exceptions to this would be in the case of a minor or where a Lasting Power of
attorney for Health and welfare is in place. It is good practice to always inform
and then involve relatives in arriving at a decision.

21. Are there any risks in not having ECT as recommended?
If you choose not to accept your doctors' recommendation to have ECT you may
experience a longer and more severe period of illness and disability than might
otherwise have been the case. The alternative is treatment with anti-depressant
and other types of drugs and psychotherapy if you are able to use it. Medication
also has risks and complications and may not be any safer than ECT
22. Can ECT be given as an Emergency?

In very urgent situations this can happen. If a consultant believes that a patient’s
life is in danger because of severe depression then ECT can be given as an
emergency. This usually only applies to the first one or two treatments. The
Mental Health Act Commission must be contacted as soon as possible.
23. Why has ECT been controversial?
In the 1930s it was noticed that people who had both epilepsy and mental health
problems often became brighter or indeed, happier, after an epileptic seizure.
ECT was introduced as a result of this and was first given in 1938.
In the past, ECT was used for a wide variety of problems, without anaesthetic
and very long courses were given. THIS IS NO LONGER THE CASE. However,
ECT remains controversial. Some people want it banned, others have claimed it
saved their lives.
A great deal is known about how it works. We know more about how ECT and
drug treatments work than we do about how psychotherapy works.
It is viewed in the medical profession as safe, effective and painless, with a low
risk of unacceptable side effects. Furthermore, psychiatrists believe it can save
lives.
However, this view has not always been shared by the public; this is perfectly
understandable. Much of what people believe about ECT comes from the way it
is portrayed in films, television drama and documentary, where the purpose is
often to entertain or to be controversial. In addition, there is a lot of
misinformation about ECT. ECT has become an important target for anti-
psychiatry groups. Several such groups want ECT to be banned. Claims are
made that ECT causes brain damage, irreversibly changes personality or even
causes breast cancer. The majority of ECT web sites on the internet are strongly
anti-ECT. The most extreme ones state that ECT never does any good, if
patients appear to get better it is because they are stunned, shocked or brain
damaged. There is no scientific evidence to back these claims.

A common claim is that ECT works because it impairs memory, in other words it
makes you forget why you were depressed. This is not true, getting better with
ECT does not depend on memory impairment
Other frequently expressed concerns are that ECT is ineffective and always
causes unacceptable side effects. There is no scientific evidence to back up
these concerns. The results of an important national audit carried out from
February 1996 to August 1999, covering all ECT sites in Scotland, show these
fears to be without foundation.
Remember that people can say almost anything on the internet, and it is
important to be selective about what you read. If you feel overwhelmed by
negative views, speak to other patients, to staff or ask to speak to an advocate.
Don’t be embarrassed about doing so. Discuss any information you have with
members of the team treating you. If you are not happy ask for a second opinion.
24. Advocacy Services
Advocacy services are available to you and can provide a sympathetic,

supportive and helpful role by listening to your views and questions which you
may not feel able to ask of the clinical team. Advocates will act as intermediaries
for you and can be very helpful particularly if you either have no immediate family
member available to do so or you would prefer not to involve your family. In some
situations, where a person may lack capacity, an Independent Mental Capacity
Advocate (IMCA) will be involved. For people detained under the Mental Health
Act, an Independent Mental Health Advocate (IMHA) may be involved. Please
ask your care coordinator or ward nurse for details of local advocacy services.
Their contact numbers are as follows:
Barnet: 0208732 6540
Enfield: 0208884 5000
Haringey: 0208340 2474
25. In Summary
ECT is a very effective treatment for certain conditions such as severe
depression. The degree and rate of improvement is better than would be
expected for either medication or talking treatments.
ECT is not effective for everyone, but for patients with the most severe forms of
depression the majority are likely to show some improvement.
Many of the public perceptions and fears about ECT are not corroborated by
research evidence and audit.

26. Further information
The National Institute for Clinical Excellence (NICE) provides guidance for both
the NHS and patients on the use of medicines, medical equipment, diagnostic
tests and medical and surgical procedures and under what circumstances they
should be used. NICE was asked to look at the available evidence on ECT and
to provide guidance on ECT practice. These guidelines have been recognised
and incorporated into the ECT service provided by this NHS Trust.
An information booklet on the use of ECT has been produced by NICE for
service users, advocates, carers and the public. There is a copy of the booklet
on each of the wards. Please ask your doctor or nurse if you would like to read
it. Alternatively, you can order a copy from the NHS Response Line by phoning
0870 1555 455 and quote reference NO205.
Please let your Doctor or Nurse know if you would like to discuss any aspect of
ECT treatment with the ECT team before you decide about the treatment.

APPENDIX 9:
OUT-PATIENT ECT INFORMATION (to be kept by patient)

Name:
Date:
Unit number:
Consultant:
Key worker:
Doctor:
Out-of-hours telephone number:
Today you received electroconvulsive therapy. This involved a general anaesthetic;

therefore you should not do any of the following for at least the next 24 hours:
• Operate machinery or electrical appliances

• Consume alcohol
• Sign any legal documents
You should not drive if you have a severe depression and would usually be advised not to
drive throughout the course of ECT and thereafter only if assessed as competent to drive.
You should discuss this with your Consultant.
You should have another responsible adult to remain with you for the first 24 hours after
treatment. You should have a responsible escort home and continuous responsible adult
supervision at home for 24 hours after treatment and access to a telephone,
If you suffer any serious side-effects, then contact your own general practitioner in the
first instance and pass on the information on this sheet.
If you have any concerns relating to your treatment or develop a cold or physical illness,
then contact the ward or team that organised your ECT treatment. The information will be
passed on to your hospital doctor.
The evening before your next treatment, please remember not to eat any food after
midnight, and take the tablets or medicines only as agreed with your hospital doctor.

Out Patient Post ECT Agreement (To be signed by patient and
retained in notes)
Today you will be receiving electroconvulsive therapy. This involves

a general anaesthetic; therefore you should not do any of the
following for 24hours:
1) operate machinery
2) consume alcohol
3) sign any legal documents.
You should not drive if you have a severe depression and would
usually be advised not to drive throughout the course of ECT and
thereafter only if assessed as competent to drive. You should discuss
this with your Consultant.
A responsible adult must accompany you when you leave the

department and this person should stay with you for 24 hours after
treatment.
I am in agreement with the above advice.
Name:__________________________________________________
Signed:_________________________________________________
Date:______________________
Out Patient Post ECT pre-discharge checklist for ECT Staff

Prior to discharge confirm that patient has: YES NO N/A
Blood pressure & pulse stable, within normal range
Is fully awake & orientated
Minimal nausea & no vomiting

i.v. cannula removed
mobile without feeling faint
taken fluids
passing urine as normal where relevant
has their post operative instructions

knows follow-up arrangements
has someone to take them home
has someone to stay with them overnight
aware not to drive during an acute course of ECT

and thereafter only if assessed as competent to
drive (nb see appendix on driving & ECT)
aware not to have alcohol for 24 hours
aware not to sign legal documents for 24 hours
signed: ________________ practitioner (name & grade)__________
signed: _________________ patient / carer__________________
date / time/ discharged to the care of _______________________

Appendix 10: ECT Protocol – the responsibilities of nursing staff in
ensuring appropriate standards of care for patients receiving
Electro-convulsive Therapy
Policy statement: This policy has been written in order to assist in ensuring that
the statutory requirements for the administration of ECT are met, in addition to
ensuring that the highest standards of clinical care is provided for patients,
including attention to their dignity and comfort.
Preparing a patient for ECT
1. The ECT information document is to be given to the patient and his/her

relatives.
2. The ward manager/named nurse/care coordinator should contact the ECT

coordinator, Karl Sunkersing, on 0845 111 4000 bleep number 3886, once
it has been decided that the patient will be offered ECT.
3. Transport (Metropolitan and London, tel: 020 8442 6000, transport office)
should be informed of the details of commencement date for ECT, the
ward from which the patient will be departing, the number of escorting
staff and any special requirements in order to ensure the safe transport of
the patient.
Procedure before ECT treatment (treatment day)
1. The named nurse/care-coordinator reminds the patient, in understandable

terms, what the procedure will entail.
2. Nursing staff will ensure that the patient has fasted for a period of six
hours before ECT is administered.
3. Nursing staff to ensure that patients are wearing loose-fitting, comfortable

day clothes before presenting to the ECT department.
4. Make-up and nail varnish is to be removed.
5. Jewellery and valuables are to be retained on the ward for safekeeping.
6. The patient’s vital signs (temperature, pulse rate, respiratory rate, blood
pressure) should be recorded prior to the patient departing for ECT
treatment.

Documentation checklist
The ward manager/care coordinator should ensure the following:
1. The patient’s health records are in good order and are available on the
day the patient departs for ECT.
2. Legal documentation, specifically Mental Health Act forms, when

applicable, including form 39 authorizing treatment under the Mental
Health Act, is available in the case notes.
3. Patient agreement (consent form) signed by the prescribing consultant

and the patient (when applicable), is available.
4. Results of recent blood investigations (and X-rays, scan reports if

applicable), ECG and anaesthesia pro-forma (this must be completed by
the ward doctor) is available in the notes.
5. Current prescription sheet/sheets available and conveyed to the ECT

department.
6. Any other relevant documentation.
7. To receive the patient back on the ward after returning from treatment,
ensuring that he/ she is offered support, encouragement, re-orientation
and resumption of their ward-based programmed activities as appropriate.
8. Ensure that lunch will be available for the patient upon their return to the
ward.
Responsibilities/duties of the escorting nurse (first level nurse)
1. The escorting nurse should be known to the patient and would ideally be
the patient’s named nurse
2. The escorting nurse should always be a qualified nurse.
3. The escorting nurse should have up-to-date training in basic life support.
4. The escorting nurse should be familiar with emergency equipment.
5. The escorting nurse should identify and introduce the patient to the ECT
clinic staff.

6. The escorting nurse should offer reassurance before and after ECT
treatment to the patient.
7. The escorting nurse should ensure the safety and dignity of the patient is
maintained at all times.
8. Ensure that the patient is encouraged to drink and to eat a light snack
after leaving the recovery room and prior to leaving the department.
8. Ensure that all necessary notes and documents are returned to the ward.
The role of the recovery nurse
1. A trained nurse is to assume overall responsibility of the recovery room.
2. At any given time, there should be two trained nurses in the recovery
room.
3. Recovery nurses will be familiar with the operation of emergency

equipment.
4. The recovery nurse will be competent in airway management.
5. The recovery nurse will be capable of understanding instructions from the

anaesthetists in relation to oxygen therapy, administration of intravenous
fluids and other procedures relative to the recovery process.
6. The recovery nurse will ensure a safe environment is maintained.
7. The recovery nurse will address any concerns raised by the escorting
nurse.
8. The recovery nurse will assume responsibility for communicating to the

anaesthetist any known adverse events which have occurred during prior
treatment with ECT.
9. The recovery nurse will participate in re-orientating the patient.
10. The recovery nurse will ensure that the patient has fully recovered (ie, vital
signs are stable, breathing spontaneously, has normal colour, is
responding verbally and is re-orientated before leaving the recovery room.
If there are any concerns, the recovery nurse will seek the advice of the
anaesthetist prior to the patient departing from the ECT unit.
11. The recovery nurse will ensure that day- or outpatients are escorted home
by a responsible adult.

12. The recovery nurse will ensure that day- or outpatients are provided with
the appropriate patient information document advising them against
driving or operating any machinery/equipment for the rest of the day, after
treatment.
Role of the ECT coordinator
1. To ensure the safe and efficient running of the ECT department.
2. To ensure that ECT equipment is maintained in good working order.
3. To assist the anaesthetists and operating department practitioner to safely

administer anaesthetic agents and supervise the recovery of patients post-
administration of anaesthesia.
4. To ensure that drugs used in the ECT department are within date and
available when required.
5. To ensure that ECT apparatus is in good working order and regularly

maintained.
This policy is to be read in conjunction with the following Trust documents
1. Clinical Risk Assessment and Management Policy
2. Consent to Treatment for Patients Detained Under the Mental Health Act,
1983
3. Making equipment safe prior to repair of medical devices
4. Refusal of Treatment
5. Resuscitation
6. Use of a “Living Will”
7. Mental Health Act, 1983
8. Mental Capacity Act, 2005
9. Mental Health Act, 1983 – Code of Practice
10. Mental Capacity Act, 2005 – Code of Practice
11. ECT Handbook, The Royal College of Psychiatrists, 2005

APPENDIX 11: TREATMENT RESISTANT DEPRESSION:
PHARMACOLOGICAL STRATEGIES TO CONSIDER
Extracted from the Report on the Dundee AI/NMD service – January 2006
The following extract has been included in this protocol as a guide to additional pharmacological
maintenance treatment options for patients who have completed a course of ECT in order to
attempt to avoid frequent recurrences of severe depressive episodes. In general patients should
not be treated with the same antidepressant medication regime on which they became unwell
originally as this is unlikely to be effective in the prophylaxis of further episodes.
Treatment Resistant Depression (TRD)

Physical Treatment Methods
As a guiding principle, all of the physical treatments that have been shown to be effective in
‘treatment-resistant-depression’ (preferably in randomised, controlled trials) must have been tried
in adequate dosage for an adequate period of time. In general terms, this will reflect the
prescription of antidepressant drugs within, or above, the dose range recommended by the British
National Formulary (BNF) for a period of at least six weeks.
It is important to note that a proportion of individuals with chronic, refractory depression will have
unrecognised or ‘undeclared’ Bipolar Disorder. Therefore, the following also considers the
application of “bipolar depression” treatment strategies as part of the framework for treatment
‘adequacy’ prior to ablative NMD.
At present, the use of plasma drug concentration monitoring (where possible) is not included as a
mandatory requirement, but this is sometimes desirable, particularly where ‘rapid metaboliser’
status is suspected.
N.B. For some of the following treatments, particularly those where drug doses exceed those
listed in the British National Formulary and where drug treatments are combined, regular
physiological monitoring (e.g. blood pressure, ECG) is required to facilitate safe and continuing
review of the relative risks and benefits of treatment.
Most patients referred for assessment will have already have been exposed to many different
treatment trials. The following represent those deemed ‘essential’ before proceeding to ablative
surgery.
The minimum inclusion criteria are:
a) at least two ‘adequate’ courses of treatment with a tricyclic
antidepressant drug. One of these trials must be with either clomipramine,
imipramine or amitriptyline.
b) at least two ‘adequate’ courses of treatment with a selective serotonin
re-uptake inhibitor (SSRI).
c) at least one ‘adequate’ course of treatment with a ‘classical’ monoamine
oxidase inhibitor (i.e. not moclobemide).
d) at least one of the above (TCA, SSRI or MAOI) plus lithium carbonate
augmentation for a period of 4-6 weeks with a 12 hr post-medication plasma
lithium level of 0.5-0.8 mmol/l.
e) at least one ‘adequate’ course of treatment with a tricyclic
antidepressant drug as defined above plus thyroid hormone augmentation
for a period of 6 weeks. This involves the administration of liothyronine
sodium / T3 hormone (not T4) [at a maximally tolerated dose up to 20 μg
t.d.s.]. Failure to respond within 6 weeks ought to lead to termination of T3
administration. Where the patient is known to suffer from hypothyroidism and
is taking replacement T4 (biochemically euthyroid), this strategy of T3
augmentation is still advised.
f) at least two ‘adequate’ courses of treatment with an antidepressant drug as

defined above, plus the prescription of two atypical antipsychotic drugs for
a period of six weeks at a dose within the BNF recommended range. There is
probably greatest evidence to support the selection of olanzapine and
risperidone, although others (quetiapine, amisulpride, aripiprazole) may
be worth considering. Where psychotic symptoms are prominent in the clinical
presentation, trials of both typical and atypical antipsychotic drugs should be
considered.
g) at least two ‘adequate’ trials of electroconvulsive therapy (ECT), spaced
6 months apart. Adequacy in this context is defined as a minimum of 12 bilateral applications of
ECT with recorded evidence of seizure duration exceeding 15 s per treatment. Failure to respond
is defined as either no clinical response, minimal clinical response or a brief response with
relapse
within a period of four weeks, despite antidepressant drug maintenance treatment. Where
available, and considered more acceptable/appropriate for the patient, a trial of high dose
unilateral ECT (5X seizure threshold) can substitute for bilateral ECT.
h) at least one ‘adequate’ course of treatment with an antidepressant drug as defined above
plus the essential fatty acid ethyl-eicosapentaenoate (EPA) at a dose of 1g per day.
i) at least one ‘adequate’ course of treatment with an SSRI as defined above plus the addition of
bupropion (SR) at a dose of 150-300mg/day.
j) at least one trial of an anticonvulsant drug shown to have some evidence for efficacy in bipolar
depression. This includes lamotrigine at a dose of up to 400mg day, divalproex sodium
(Depakote) at a dose of up to 2.5g per day and carbamazepine at a dose of 800-1200mg per
day.
k) at least one trial of an antipsychotic drug shown to have efficacy in bipolar depression. This
includes olanzapine (5-20mg/day) and quetiapine (300- 600mg /day). NB: There is also some
preliminary evidence for increased response rates in the treatment of Bipolar I depression where
olanzapine (6- 12mg/day) is combined with fluoxetine (25-50mg/day).
l) at least one of the following:
1. combination therapy with clomipramine, lithium carbonate and Ltryptophan.
The clomipramine to be administered at a maximally tolerated dose (150-300 mg / day), with a 12
hr post-medication plasma lithium level of 0.5-0.8 mmol/l. This ought to be administered for a
minimum period of 6 weeks.
2. combination therapy with phenelzine, lithium carbonate and Ltryptophan.
The phenelzine to be administered at the maximally tolerated dose (45-90 mg / day), with a 12 hr
post-medication plasma lithium level of 0.5-0.8 mmol/l. This ought to be administered for a
minimum period of 6 weeks.
Alternative Recommended Pharmacological Treatment Strategies
(Desirable but not essential prior to ablative NMD.
Either: an absence of unequivocal evidence of efficacy in TRD, or, only suitable for selected
patients on the basis of increased risk to physical health)
1. Prescription of an antidepressant drug beyond BNF recommended maximum daily dose.
For example, gradual escalation to highest tolerated dose of venlafaxine (>500 mg / day).
Beyond 375 mg / day, weekly ECG recordings are advisable, with regular BP monitoring required
beyond 200 mg / day. Alternatively, gradual escalation to highest tolerated dose of imipramine
(>300 mg / day). Similar close physiological monitoring is required. Measurement of plasma
levels may be indicated, with a target concentration of 200-250 ng/ml. This ought to be continued
for 6 weeks.
2. Combination of venlafaxine (375mg/day or maximally tolerated dose) with mirtazapine (30-
45mg/day) with appropriate physiological monitoring (BP measurements and ECG recordings).
3, Psychostimulant Drug Treatment.
Prescription of a maximally tolerated dose of a tricyclic drug (preferably
imipramine), to which methylphenidate (Ritalin) is added, initially as a single 10 mg test dose,
gradually increasing to 30 mg t.d.s. This ought to be continued for 6 weeks.

Appendix 12:
ECT Treatment record: sticky label to be affixed in patient’s case notes following
each treatment by the ECT staff
ECT TREATMENT Session No: ________________ Date: _____________
Patient: _________________________________ Procedure Explained: Yes/No
Consent: Yes / S62 / S58 / MCA

Comment:_______________________
Stimulus: Bilateral/Unilateral Dose: % / mc ______________________
Visible seizure duration _______________ EEG ____________PSI_________
ECT Consultant: _____________________Anaesthetist: __________________
Administered by: ______________________Sign: _______________________
Comments: _______________________________________________________
__________________________________________________________________
__________________________________________
*Consultant Prescription for 2 further treatments:________________________

Appendix 13:
Montgomery-Åsberg Depression Rating Scale
(MADRS)
1. Apparent sadness
Representing despondency, gloom and despair (more than just ordinary

transient low spirits), reflected in speech, facial expression, and posture.
Rate by depth and inability to brighten up.
0. = No sadness.
□
2. = Looks dispirited but does brighten up without
□
difficulty.
4. = Appears sad and unhappy most of the time.

□
6. = Looks miserable all the time. Extremely despondent.

□
2. Reported sadness
Representing reports of depressed mood, regardless of whether it is

reflected in appearance or not.
Includes low spirits, despondency or the feeling of being beyond help and
without hope.
0. = Occasional sadness in keeping with the circumstances.
□
2. = Sad or low but brightens up without difficulty.
□
4. = Pervasive feelings of sadness or gloominess. The mood is

□
still influenced by external circumstances.
6. = Continuous or unvarying sadness, misery or

□
despondency.

3. Inner tension
Representing feelings or ill-defined discomfort, edginess, inner turmoil,

mental tension mounting to either panic, dread or anguish. Rate according
to intensity, frequency, duration and the extent of reassurance called for.
0. = Placid. Only fleeting inner tension.

□
2. = Occasional feelings of edginess and ill-defined

□
discomfort.
4. = Continuous feelings of inner tension or intermittent

□
panic which the patient can only master with some difficulty.
6. = Unrelenting dread or anguish. Overwhelming panic.

□
4. Reduced sleep
Representing the experience of reduced duration or depth of sleep

compared to the subject’s own normal pattern when well.
0. = Sleeps as usual.
□
2. = Slight difficulty dropping off to sleep or slightly reduced,

□
light or fitful sleep.
4. = Sleep reduced or broken by at least 2 hours.

□
6. = Less than 2 or 3 hours sleep.

□

5. Reduced appetite
Representing the feeling of a loss of appetite compared with when well.

Rate by loss of desire for food or the need to force oneself to eat.
0. = Normal or increased appetite.

□
2. = Slightly reduced appetite.

□
4. = No appetite. Food is tasteless.

□
6. = Needs persuasion to eat at all.

□
6. Concentration difficulties
Representing difficulties in collecting one’s thoughts mounting to an

incapacitating lack of concentration. Rate according to intensity, frequency,
and degree of incapacity produced.
0. = No difficulties in concentrating.
□
2. = Occasional difficulties in collecting one’s thoughts.

□
4. = Difficulties in concentrating and sustaining thought

□
which reduces ability to read or hold a conversation.
6. = Unable to read or converse without great difficulty.

□

7. Lassitude
Representing difficulty in getting started or slowness in initiating and

performing everyday activities.
0. = Hardly any difficulty in getting started. No sluggishness.

□
2. = Difficulties in starting activities.

□
4 = Difficulties in starting simple routine activities, which are

□
carried out with effort.
6. = Complete lassitude. Unable to do anything without help.

□
8. Inability to feel
Representing the subjective experience of reduced interest in the

surroundings, or activities that normally give pleasure. The ability to react
with adequate emotion to circumstances or people is reduced.
0. = Normal interest in the surroundings and in other people.

□
2. = Reduced ability to enjoy usual interests.

□
4. = Loss of interest in the surroundings. Loss of feelings for

□
friends and acquaintances.
6. = The experience of being emotionally paralysed, inability

□
to feel anger, grief or pleasure and a complete or even painful failure
to feel for close relatives and friends.

9. Pessimistic thoughts
Representing thoughts of guilt, inferiority, self-reproach, sinfulness,

remorse and ruin.
0. = No pessimistic thoughts.
□
2. = Fluctuating ideas of failure, self-reproach or self-

□
depreciation.
4. = Persistent self-accusation, or definite but still rational

□
ideas of guilt or sin. Increasingly pessimistic about the future.
6. = Delusions of ruin, remorse or irredeemable sin. Self-

□
accusations, which are absurd and unshakable.
10. Suicidal thoughts
Representing the feeling that life is not worth living, that a natural death
would be welcome, suicidal thoughts, and preparations for suicide. Suicide
attempts should not in themselves influence the rating.
0. = Enjoys life or takes it as it comes.

□
2. = Weary of life. Only fleeting suicidal thoughts.

□
4. = Probably better off dead. Suicidal thoughts are common,

□
and suicide is considered as a possible solution, but without specific
plans or intension.
6. = Explicit plans for suicide when there is an opportunity.

□
Active preparations for suicide.

APPENDIX 14
Royal College of Psychiatrists ECT Competencies:
The trainee by year 3 ought to be able to administer ECT without direct supervision,
prepare patients for ECT, explain to patients and relatives about ECT, its indications and
broad place within psychiatric treatment. Trainees ought to be able to monitor a patient’s
mental state and cognitive functioning during a course of ECT.
Consultants and trainees by the end of year 6 ought to have a good understanding of
the place of ECT in modern clinical practice sufficient to obtain informed consent from
patients to reach level 1 competency. Only consultants responsible for the ECT clinic or
trainees (ST4-6) with a special interest in the administration of ECT would be expected
to have level 1 competency in the practical aspects of the administration of ECT
(sufficient to run an ECT clinic).
Name:……………………….
1 = fully conversant (FC)

2 = working knowledge (WK)
3 = awareness (A)
Verbally assessed
1 FC = Is able to explain accurately all the important features to a standard that
shows sufficient understanding that would allow them to competently and
independently apply the knowledge
2 WK = Is able to explain the key features to a standard that shows sufficient
understanding that would allow them to apply the knowledge in common
situations and access further information if necessary
3 A = Is aware of the topic and knows where to get further information but not to a
level that provides a WK
2
Observed
1 FC = Is able to carry out the procedure to a standard that shows sufficient skill
and understanding that would allow them to competently and independently carry
it out.
2 WK = Is able to carry out the procedure to a standard that shows sufficient skill
and understanding that would allow them to carry it out in usual situations but to
know their limitations and access further help if necessary
3 A = Is aware of the topic and knows where to get further information but not to a
level that provides a WK

1. Theory and background
Competency How evidenced Level Date Signature

1. Demonstrate a knowledge of NICE Guidelines. Verbally
2 Demonstrate an awareness of Royal College and Verbally

ECTAS Guidelines.
3. Demonstrate a knowledge of local policies and Verbally

procedures, including
a. emergency ECT
b. outpatient ECT
c. high risk patient
4. Demonstrate a knowledge of the Consent to treatment Verbally

requirements, including Common Law and MHA
documentation/ requirements 0(p. 20 NICE)
5. Knowledge of the indications for ECT with special Verbally

reference to NICE
6. Able to describe the contra-indications to ECT. Verbally
7. Able to describe the possible side effects, risks and Verbally

benefits of ECT.
8. Able to describe the pre-treatment preparations Verbally

required to be undertaken by referring doctor.
9. Able to describe the procedure for the administration of Verbally

ECT.
10 Able to describe the procedure for the referral of an Verbally

outpatient for ECT

11 Demonstrate a knowledge of: Verbally
NICE Guidance on
a. Continuance ECT.
b. When ECT should be discontinued.
Unilateral or bilateral treatment.
12 Knowledge of current theories of mechanism of action Verbally

of ECT
13 Knowledge of physiological effects of ECT verbally
2. Practical Aspects of ECT

1. Attaching EEG leads Observed
2. Set correct stimulus Observed
3. Apply Electrodes bilateral Observed
4. Apply Electrodes unilateral Observed
5. Impedance testing Observed
6. Observe motor seizure and EEG monitoring Observed
7. Understand clinic dosing protocol Verbally
8. Understand when to restimulate verbally
9. Understand procedure for prolonged seizure verbally
10 Understand how to interpret EEG verbally
11 Correct recording of treatment in patient record Observed
12 Knowledge of anaesthetics and muscle relaxants Verbally

used in ECT
13 Basic resuscitation training* Written
14 ILS training Written

3. Other aspects of ECT practice
a)
Competency How evidenced Date Signature
1. Attended Induction to ECT
2. Observed clinical application of Observed
ECT
3. Supervised clinical application 1 Observed
6. Additional clinical application 1 Observed
10 Additional clinical application 5 Observed
11 Additional clinical application 6 Observed

b)
1. Participation in audit of ECT
2. Participation in one day of CPD relating to ECT each year
3. Able to advise consultant colleagues on relative merits of bilateral/

unilateral treatment
4. Able to advise colleagues on suitability of patient for ECT
5. Involved in regular review of policies and procedures in ECT clinic
6. Evidence of training and supervising doctors in training in ECT

practice
7. Able to advise colleagues on drug treatments during ECT
8. Able to advise colleagues on the management of side effects

during ECT

Required competencies:
Foundation doctors
Theory & background awareness 1-13
Practical aspects of ECT not required
Other aspects of ECT practice a not required
Other aspects of ECT practice b not required
ST1-3
Theory & background working knowledge 1, 3-13
Awareness 2
Practical aspects of ECT fully conversant 1-11, 13
Working knowledge 12
Other aspects of ECT practice a 1-5 to be achieved
ST4-6 & Prescribing Consultants

Theory & background fully conversant 1-13
Practical aspects of ECT working knowledge 1-13
ECT consultants
Theory & background fully conversant 1-13
Practical aspects of ECT fully conversant 1-12,14
Other aspects of ECT practice b 1-8 to be achieved
* for resuscitation training:
• Fully conversant = training in last year
• Working knowledge= last 5 years
90
Appendix 15: Blood results chart
Barnet , Enfield and Haringey Mental Health NHS Trust

AFFIX PATIENT LABEL HERE
Laboratory Results Flow Chart Surname:
ECT Care Pathway First Names:
Hospital Number:
DOB: Age:
DATE
TIME Normal ref.
HB 11.0 – 18.0
WCC 4.0 – 11.0
Neutrophills 1.5 – 7.50
Platelets 130 - 450
PCV ..370 - .540
INR 0.8 – 1.2
APTT 27- 38 sec
Fibrinogen 1.5 – 4.5
D-Dimer 0 - 300
APTT Ratio 0.8 – 1.2
Sodium 136 -145
Potassium 3.5 –5.1
Creatinine 60 - 120
Urea 3.0 – 7.5
Glucose 3.0 –6.0
Osmolality 280 -300
Creat Clearence 60- 120
CRP 0 -5
ESR 1 - 10
Bilirubin 0 - 17
Alk Phosphatase 35 - 115
ALT 10 - 60
Gamma-GT 5 - 60
Total Protien 60 - 83
Albumin 32 - 53
Globulin 16 - 36
Magnesium 0.85 – 1.15
Phosphate 0.74 – 1.52
Calcium 2.1 – 2.7
CPK 40 - 360
Troponin I <0.01
Amylase 25 -125
Lithium level
TSH
T3
T4
91
Appendix 16: RCPsych. advice on Driving and ECT:
Depression, ECT and fitness to drive

The DVLA changed its guidance on driving and severe mental illness in March
2009. Given that most, if not all, patients having ECT would qualify as severely
mentally ill, it is timely to review the College guidance in advance of the next ECT
Handbook. DVLA guidance is updated twice a year in March and September:
there were no new changes relating to psychiatric conditions in September 2009
What does DVLA Guidance say?

The current guidance is dated September 2009 and psychiatric disorders are in
chapter 4 pages 32-34.
1. Anxiety or depression without significant memory or concentration
problems, agitation, behavioural disturbance or suicidal thoughts
does not need to be notified to the DVLA
2. More severe depression with any of the above features requires that driving
ceases pending the outcome of a medical enquiry. Patients who have a group 2
(Heavy Goods Vehicle licence) must be well and stable for 6 months before they
can drive again. Holders of group 1licence require “a period of stability”.
3. Acute psychotic disorders of any type. For group one drivers driving must
cease and relicensing will be considered when all of four
conditions are met. These include remaining well and stable for 3
months. For group 2 drivers driving must cease pending a medical
enquiry and it is normally a requirement that the person is well and
stable for 3 years.
What is a medical review?

This is carried out by a DVLA medical advisor and is not simply a review by the
responsible clinician. The DVLA warns that this can be a relatively lengthy
process. It is clear that the guidance remains more concerned with the risk of
suicide and the potential risk to others from a suicidal driver than it is with any
cognitive impairment from depression and /or ECT. It does make the helpful
comment that it is the “illness rather than the medication which is of prime
importance” stressing that it is the underlying depressive disorder, rather than
treatment, which matters most when making a judgement.
There are a number of areas to consider in making a clinical judgement about

driving after ECT:
1. The 24 hour rule following anaesthetic. This is the least important and is
trumped by all other factors. It is important that a false impression of being fit to
drive after 24 hours is not given by simply stating that the patient should not drive
or operate machinery for “at least 24 hours after each treatment.” Day case
information sheets may need to be amended to avoid this.
2. The cognitive impairment caused by severe depression. This can be
marked, and can involve all cognitive abilities, including slowing of reaction time.
92
This is an issue for all those treating depressed patients whatever treatment they
are getting.
3. The added effect of ECT. ECT both impairs cognitive function and improves it
if it successfully treats the underlying depression. Despite the marked subjective
complaints from patients, what evidence we have is that cognitive function is
worse or at least no better than pre ECT levels for approximately two weeks after
a course and after that patient are functioning better than they were pre ECT.
That of course does not mean they are not impaired.
4. Suicidal risk. This should be assessed separately from cognitive
Function
5. Confidentiality. The guidance quotes the GMC confidentiality
handbook “when a patient has a condition which makes driving
unsafe and the patient is either unable to appreciate this or refuses to
cease driving, the GMC advise breaking confidentiality and informing
the DVLA”.
Conclusions and Recommendations

1. We are concerned that little attention appears to have been paid to this
issue and that many information sheets include advice about not driving
for 24 hours post ECT. This advice is misleading and should be removed.
Day case information sheets should be amended and the 24 hour clause
removed or qualified.
2. Patients should be advised not to drive during a course of ECT:
this includes not driving when on pass/ on leave from a ward
between treatments.
3. Most patients who are depressed enough to have ECT should be
advised not to drive for 3 months after recovery because this is the
law. They may be advised that this is because of the nature of
their depression, not because of ECT. Given that ECT may bring
about a more rapid remission, they may be driving again more
quickly if they have ECT than if they don’t.
4. How long after a course of ECT a patient is considered unfit to
drive is a matter of clinical judgement and there may be occasions
when a moderately depressed patient has had ECT, improved and
is considered fit to drive before 3 months.
5. Depressed patients referred for ECT should routinely be given
advice on driving related to their level of depression by their RMO.
6. Patients should be advised to inform the DVLA about their
circumstances.
7. If there is evidence that patients are driving during or shortly after
ECT against clear advice the RMO and/ or the lead ECT
Consultant should consider, if it is appropriate, breaching
confidentiality and should inform the DVLA directly.
8. Remember the much more stringent rules that apply to group 2
licence holders.
93
Special situations
1. Maintenance ECT: Patients receiving maintenance ECT may not be
depressed or have only mild symptoms. Maintenance ECT given
once every two weeks or less frequently does not produce cumulative
cognitive deficits. Unfortunately there are no studies which can help
with guidance in this area as to when a patient is fit to drive. The
decision when, after each maintenance treatment, a patient is fit to
drive has to remain a matter of clinical judgement.
2. Patients under section of Mental Health Act can drive if they meet
requirements set out above.
Chris Freeman October 2009
94
APPENDIX 17: Guidelines on Dental Management for ECT
(Adapted from Beli & Bentham, Psychiatric Bulletin 1998)
For referring teams:

1. Patients should be asked about relevant dental information, including the
frequency of visits to the dentist, presence of dental restorations and prostheses,
symptoms such as toothache, temperomandibular joint pain, loose teeth and
bleeding gums.
2. Patients should undergo a brief oral examination with the aim of identifying:
(a) loose, broken, decayed or missing teeth, gross dental tartar, failed
restorations and abnormal occlusions: (b) removable dental prostheses (dentures
and partial dentures): (c) non-removable dental prostheses (cemented crowns,
bridges and dental implants); (d) soft tissue lesions and swellings: (e) mandibular
deformities: (f) temporomandibular joint dysfunction (popping, clicking, crepitus
and locking).
3. Patients with significant dental symptoms or abnormalities on examination
(other than simply being edentulous) should be referred for an opinion from a
dentist with knowledge and experience of the effects of ECT on oral structures.
4. Consideration should be given to dental risks during the consent procedure.
5. Information on the patients dental state should be made available to the ECT
treatment team.
For the ECT team:

6. A mouthguard should be used for all patients including the fully dentate and
edentulous.
7. The mouthguard should be constructed of a material that is partly
compressible, and extend sufficiently far back into the mouth to separate the first
and second molar teeth. The guard should displace the tongue and buccal
mucosa from opposing teeth or ridges and avoid overloading anterior dental
structures. More than one size should be available.
8. The decision to retain partial dentures is dependent on the position,
composition and stability of the prosthesis, the aim being to evenly distribute the
load through structures with the ability to cope.
9. The jaws should be firmly held together by hand pressure on the mandible
throughout the seizure in order to prevent the mouthguard from becoming
displaced.
10. Attention should be paid to any abnormal sound coming from the mouth
during the seizure. The mouthguard must be carefully removed and the oral
cavity inspected for evidence of bleeding or loose and missing teeth. In recovery
the patients should be asked about oral pain and difficulty in opening and closing
the mouth. If significant abnormalities are identified these should be documented
and the patient referred for a post-ECT dental evaluation.
95
Appendix 18: ECT Treatment record
96
Barnet, Enfield & Haringey Mental Health NHS Trust ECT Treatment Record Form ……. of………
Patient Details (affix sticky label if available) Medications: DIAGNOSIS – psychiatric:
Legal status: informal / formal
Surname: …………………………………………. (please circle) ……………………………………… ……………………………………
Forenames: ………………………………………. MHA ……………………………………… …………………………………….

Treatment given under s.62
RiO number: ……………………………………… (please circle) ………………………………………. Physical health problems:
Treatment given under s.58
DoB: ………………………………………………. (please circle) ………………………………………. ……………………………………..
MCA
Address: ………………………………………….. Section 5 of MCA s.5 ……………………………………….. ……………………………………..
(please circle)
……………………………………………………… ……………………………………….. ……………………………………..
……………………………………………………… Ward: ………………………………… KNOWN DRUG SENSITIVITIES/ ASA GRADE (circle)

Prescribing ALLERGIES:
……………………………………………………… Consultant: ………………………….. 1 2 3 4 5
……………………………………….. ……………………………………..
Previous ECT course/s: ………………………. Laterality: Unilateral / Bilateral
…………………………………………….. (please circle) ……………………………………….. ……………………………………..
Treatment number: …………………. Date: ………………….. ASA Grade: 1 2 3 4 5

(please circle)
Anaesthetic Agents: Monitoring: Recovery, Discharge &Comments: Anaesthetist name
ECG (HR): (print) & signature:
FiO2:
SPO2:
ETCO2:
NIBP:
ECT stimulus no. Dose mC / % Unilateral / bilateral Seizure length PSI Comments: Administered by
Clonus / EEG + signature:
1
3
97
(please circle)
Anaesthetic Agents: Monitoring: Recovery, Discharge &Comments: Anaesthetist name
(print) & signature:
ECG (HR):
FiO2:
SPO2:
ETCO2:
NIBP:
ECT stimulus no. Dose mC / % Unilateral / bilateral Seizure length PSI Comments: Administered by
Clonus / EEG + signature:
1

(please circle)
Anaesthetic Agents Monitoring: Recovery, Discharge &Comments: Anaesthetist name
(print) & signature:
ECG (HR):
FiO2:
SPO2:
ETCO2:
NIBP:
ECT stimulus no. Dose mC / % Unilateral / bilateral Seizure length PSI Comments Administered by
Clonus / EEG + signature
1
98

ECT Trust Wide Medical Protocol UPDATE

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ELECTROCONVULSIVE THERAPY

Protocol for the preparation and

Version Date Section Author Comments

Electroconvulsive Therapy Protocol Version 8 Page 2

Electroconvulsive Therapy Protocol Version 8 Page 3

The process of providing ECT should be as safe, acceptable and

The care pathway for patients undergoing ECT is intended to serve

ECT is most commonly prescribed for inpatients, but it may also be

Electroconvulsive Therapy Protocol Version 8 Page 4

It is advisable that ECT referrals are made at least a day before

The ECT service manager and coordinator at CFH is Karl

3.Transportation of patients from Barnet or Haringey to CFH

All patients travelling from either Barnet or Haringey must have an

In very exceptional circumstances, the team prescribing ECT may

Electroconvulsive Therapy Protocol Version 8 Page 5

Depression is the condition for which ECT is most often prescribed,

ECT is also used when drug treatments have failed, or is relatively

The following guidance on indications for ECT is extracted from Scott

RCPsych. guidance on ECT in the treatment of depressive illness

Electroconvulsive Therapy Protocol Version 8 Page 6

NICE guidance on ECT in the treatment of depressive illness (CG90)

Suggestions for accommodating prescription practices to the discrepancy between

• Divergence would occur only if ECT were used:

Treatment failure in depressive illness

Electroconvulsive Therapy Protocol Version 8 Page 7

The place of ECT in the treatment of acute schizophrenia:

• The treatment of choice for acute schizophrenia is antipsychotic drug treatment

The place of ECT in neuropsychiatric conditions:

Given that psychiatric disorders can be life threatening, most

Examples of conditions where high anaesthetic risk exists are:

6. MEDICAL WORKUP & PREPARATION FOR ECT

Please also refer to the section on “Giving ECT”.

It is the responsibility of the patient's psychiatric team to decide

The referring psychiatric team should allocate an ASA Grade to a

1. Fit and well, a healthy patient.

Attention should be paid, in the history and physical examination of

Results of recent Haemoglobin and U&Es should be recorded in the

A chest X-ray should be done if indicated. An ECG is indicated in any

To summarise the procedure for Pre- ECT Preparation:

1. Routine laboratory investigations should be carried out and results

Patients with ASA grade 3 and above:

An anaesthetic consultation/evaluation should be requested

The ECT coordinator MUST be informed when the patient

Various factors affect seizure threshold (see later section) and

INCREASE THRESHOLD REDUCE THRESHOLD

Older Age Caffeine

7. FASTING before ECT

The anaesthetist usually advises that patients on regular anti-

8. CONSENT, CAPACITY, THE MENTAL HEALTH ACT

CONSENT To ECT, including a discussion of potential

The efficacy and safety of ECT is well-established (see Geddes et al

Different doses and modes of application of ECT appear to show

NICE CG90 makes specific reference to the consent process:

12.2.7.4 When considering ECT as a treatment choice, ensure that the

• the risks associated with a general anaesthetic

• current medical comorbidities

• potential adverse events, notably cognitive impairment

Electroconvulsive Therapy Protocol Version 8 Page 12

• the person should be reminded of their right to withdraw consent at any

• there should be strict adherence to recognised guidelines about consent,

12.2.7.6 The choice of electrode placement and stimulus dose related to

CONSENT & CAPACITY:

There are several potential scenarios with regard to consent and