ELECTROCONVULSIVE

THERAPY
GUIDELINES

ECT Guidelines
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INTRODUCTION:
Electroconvulsive therapy (ECT) is a safe procedure, which involves the induction of
seizures for therapeutic purposes by the administration of a low frequency electrical
stimulus via electrode(s) applied to the scalp.

A.

Clinical Indications for Electroconvulsion Therapy (ECT) use:

1. Depression
- Severe depressive disorder immediate risk of suicide,
Depressive stupor that may also endanger physical
health.
- depression with psychotic symptoms.
- depression with poor response to adequate dose of antidepressant.
2. Bipolar Disorder
- mania (do not respond to drug treatment or requiring high doses of antipsychotic)
- affective psychosis following childbirth (puerperal psychosis)
3. Schizophrenia and other functional psychosis
a. Schizophrenia with acute exacerbation in the following situations:
(i) Catatonia
(ii) When affective symptomatology is prominent
(iii) When there is a past history of favorable response to ECT
b. Related psychotic disorders
- Schizoaffective disorder

B.

Situations in which ECT may be used for rapid response:

1. Need for rapid, definitive response exists on either medical or psychiatric grounds e.g.
severely depressed elderly.
2. Risk of other treatments outweigh the risks of ECT, e.g. past history of neuroleptic
malignant syndrome; history of Parkinsons disease with psychosis.
3. History of poor drug response and/or good ECT response exists for previous episodes
of the illness.

C.

Special indications for ECT:

should be based on at least one of the following:

1.

Treatment failure - After adequate treatment (dose and duration).

2.

Adverse effects which are unavoidable/undesirable.

3.

Deterioration of the patient's condition such that there is a need for rapid, definitive
response on either medical or psychiatric grounds

D.

Contraindications and situations associated with substantial risk

There are no absolute contraindications to electroconvulsive therapy.

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However in situations associated with substantial risk or anesthetic risk referral to the
appropriate discipline should be done.
1. Situations associated with substantial risk
a. Space-occupying cerebral lesion.
b. Recent myocardial infarction with unstable cardiac function.
c. Recent intracerebral hemorrhage/infarct.
d. Bleeding or otherwise unstable vascular aneurysm or malformation
e. Retinal detachment.
2. Anesthetic risk factors
Medical illnesses that increase the risk of anesthetic procedure
e.g. -Respiratory infections, serious pyrexial illness, recent coronary thrombosis
-cerebral or aortic aneurysm, raised intracranial pressure.
-diabetic patients who take insulin extra care
-patients taking lithium increase cognitive impairment

E.

Use of ECT in special populations

1. The elderly
a. May be used with the elderly.
b. Efficacy does not diminish with advancing age.
c. May be less risky than pharmacotherapy.
d. Dosages of anticholinergic, anesthetic and relaxant agents may need
modification on the basis of physiologic changes associated with aging.
e. The stimulus intensity should be selected with the awareness that seizure
threshold generally increases with age.
f.

Decisions regarding ECT technique should be guided by possibility that

ECT-included cognitive dysfunction may be greater in the elderly.

2. Children and adolescents

ECT reserved for instances in which other treatments have not been
effective or cannot be safely administered
3. Pregnancy
a. May be used in all three trimesters of pregnancy.
b. Obstetrical consultation prior to ECT and ready access to means of managing
fetal emergencies

F.

Informed consent for ECT

Informed consent should to be taken from patient or immediate relative or

guardian. In situations where there is no consent from the above, consent must be
obtained from two psychiatrists, one of whom shall be the attending psychiatrist.
The consent document should provide:
1. A description of ECT procedures and a brief overview of the ECT technique.
2. A statement of why ECT is being recommended and by whom, including a
consideration of reasonable treatment alternatives.
3. A statement as to the likelihood and severity of risks related to anesthesia,
muscular relaxation and seizure induction, including mortality, cardiac
dysfunction, confusion, acute memory impairment, headaches and muscle
pain.
4. An acknowledgment that consent is voluntary and can be revoked at any time
before or during the treatment course.
5. ECT should be commenced within 2 weeks of the date of consent.

G.

Appendix 1a Patients consent form for ECT

Appendix 1b Relatives consent form for ECT
Appendix 1c Consent by two psychiatrists

Appendix 2 fact sheet for ECT

Pre-ECT evaluation

1.

The decision to initiate ECT should be done by a psychiatrist.

2.

Psychiatric history and examination to determine the indication

for ECT. Mental status, including baseline information pertinent to later
determinations of therapeutic outcome, orientation and memory function.

3.

A medical evaluation to define risk factors - including medical

history, physical examination, hydration status, vital signs, hematocrit and/or
hemoglobin, serum electrolytes and electrocardiogram. (Appendix 3 - Section I ECT treatment record form)

4.

Anesthetic evaluation, addressing the nature and extent of

anesthetic risk and advising of the need for modification in ongoing medications
and/or anesthetic technique. Some medications may increase or reduce seizure
threshold or duration during the ECT procedure (Appendix 4)

5.

In special situations such as in psychiatric institutions, medical

officers trained in anesthesia should do anesthetic evaluation.

6.

Signed consent and statement covering other elements of

consent.

i.

OUT-PATIENT ECT
ECT can be given as an outpatient procedure. For this purpose, the patient needs
special preparation as given below:

You must not have anything to eat or drink after midnight on the day before your
treatment

If you are taking medication in the morning, dont take them on the morning of your
treatment

You must be accompanied by a friend or relative to hospital on the day of ECT.

You must not drive a car on the day on which you have a treatment.

Follow the doctors advice.

ii.

ECT PROCEDURE

i. During ECT.
(Appendix 3 - Section II)
a. Place patient in supine position. Make sure bed is adequately insulated.
b. Check blood pressure.
c. Prepare and place EEG (if available) and ECG electrodes.
d. Clean skin with alcohol at sites of electrode placement. Apply electrolytic cream
or saline solution to stimulus electrodes.
e. Administer anesthetic agent.
f.

Ventilate patient with 100% oxygen.

g. Administer muscle relaxant.

h. When optimal paralysis is achieved, insert rubber bite block and apply upward
pressure to the patient's jaw, extending the neck until stimulus ceases.
i.

Apply electrodes, either bilateral (usually bitemporal) or unilateral, nondominat

j. Flexibility is needed to define a stimulus dosing policy for use in ECT in different
hospitals. The factors to consider are:
o
the medication routinely usedd
o
the model of ECT machine and the electrode placement
o
local anaesthetic practice
Patients will require restimulation if the initial stimulus dose has failed to induce
an adequate seizure. If the patient need to be restimulated the dose should be
increased by at least 50% for bilateral ECT and by at least 100% for unilateral
ECT.

k. Seizure duration & monitoring

i.

The duration of cerebral seizure activity may exceed that of the peripheral
manifestations of the seizure (muscle twitching) by 10-15 seconds.
ii. An 'adequate' seizure is a generalised (bilateral) tonic/clonic seizure
lasting 15 seconds or more peripherally, and/or 25 seconds or more on an
EEG recording.
iii. Prolonged seizures (i.e. lasting longer than 2 minutes) should be
terminated by means of a further bolus of general anesthetic or diazepam.
l. Continue to oxygenate the patient during seizure and until the patient begins to
breathe spontaneously. It is not necessary to hyperventilate.
m. When the seizure is complete and the patient is stable. He can be returned to
the unit and observed for the next 30 minutes to 1 hour with vital signs and
temperature taken periodically, until the patient is fully alert and the vital signs
are stable. (Appendix 3 Section III)

ii.

Between ECT treatment sessions

a.

Mental state examination by doctor, prior to each treatment

b.

Notes to include assessment of therapeutic outcome and adverse effects

iii.

Following completion of an ECT course

a.

A summary of overall therapeutic outcome and adverse effects as a result of

ECT.

b.

J.

A plan for post-ECT clinical management and any plans for follow-up of
adverse effects

Number of treatments

1.

A set number of treatments should not be prescribed. The total number should be a
function of the patient's response and the severity of adverse effects (patient
assessed after each treatment).

2.

The psychiatrist should review patient receiving ECT after each treatment.

3.

For responders, ECT should be ended as soon as it is clear that maximum response
has been reached (changes in target symptoms).

K.

Evaluation of outcome

1. Therapeutic response
a. Each treatment plan should indicate specific criteria for remission.
b. Clinical assessment should be performed by the doctor in-charge and
documented prior to ECT and after every treatment, preferably on the day
following the treatment.
2. Adverse effects
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Unwanted effects after ECT

- brief retrograde amnesia, loss of memory for up to 30min after the seizure
- brief disorientation
- headache
- confusion, nausea, vertigo for a few hours after treatment
- muscular pain
- in rare instances sporadic seizures in months after ECT.
(However other causes of seizures should be excluded.)
- injury to teeth, tongue, or lips problems in positioning the gag or airway
- small electrical burns
- crush fracture of the vertebrae ECT given without muscle relaxants
Other complications --- in patients suffering from physical illness:
-

Arrhythmia

Pulmonary embolism

Aspiration pneumonia

CVA

Prolonged apnea muscle relaxants

Status epilepticus predisposed subjects, or taking medication that prolongs

seizure duration.

L.

There is no evidence of brain damage in-patients who under gone ECT.

Equipment in the ECT treatment room:

(a)

Electroconvulsive machine

(b)

An oxygen cylinder, mask and bag and at least one full spare cylinder.

(c)

A fully equipped emergency drugs tray / trolley.

(d)

An ECG monitor.

(e)

A defibrillator.

(f)

A suction machine.

(g)

A blood pressure stand and cuff.

(h)

A pulse oximeter .

M.

ECT machines
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Several ECT machines models are available worldwide and purchasing one
requires a general understanding of the merits and limitations of available
equipment. In Malaysia the ECT machines currently used are the following:- Ectron Series 5 Ectonus machines (stimulus output 150-400 mC)
- Ectron Series 5A Ectonus machines (stimulus output 50-700 mC)
- Thymatron-DGx

N.

Maintenance and checking of ECT machines and resuscitation

equipment
This should include:
(a) The output and electrical safety of the ECT machine should be checked and
recorded as recommended by manufacturer.

O.

(b)

The ECT electrodes should be visually checked weekly for integrity of their
insulation and wiring.

(c)

Emergency resuscitation equipment should be tested and checked weekly.

(d)

The emergency drug tray should be checked at regular intervals.

(e)

There should be an agreement as to who is responsible for the above checks.

Training and supervision of staff giving ECT

All junior staff should receive training in the administration of ECT and the staff
should be adequately supervised. (Appendix 5 Privileging and credentialing)

CONCLUSION
ECT is a safe and effective procedure, which should be administered by trained personals
in a designated area within a psychiatric department. All documentation related to the ECT
procedure should be properly maintained to ensure quality of care in psychiatry practice.
Regular maintenance of equipment used for delivering ECT should be done.

REFERENCES
1.

Abrams R: Electroconvulsive Therapy. New York, Oxford

University Press, 1997
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2.

The ECT Handbook. The second report of the Royal College

of Psychiatrists Special Committee on ECT. Council Report: CR39). Edited by C.P.
Freeman (1995).

3.

Krystal, Andrew D et al. Ect Stimulus Intensity: Are present

ECT devices too limited. The American Journal of Psychiatry 2000; 157(6): 963-967.

4.

Treatment Protocol Project (1997). Management of Mental

Disorders (Second edition). Sydney: World Health Organisation Collaborating
Centre for Mental Health and Substance Abuse.

5.

Coffeey CE, Weiner RD. Electronvulsive Therapy: An Update.

Hospital and Community Psychiatry 1990, 41,5,515-521

6.

Mayur PM, Gangadhar N, Janakiramaiah N, Subbakrishna DK.

Motor seizure monitoring during electroconvulsive therapy The British Journal of
Psychiatry,1999, 174, 270-272.

7.

Trezisek K . Changes in practice of ECT: a follow-on study.

Psychiatric Bulletin , 1998, 22, 687-690.

8.

Trezisek K, Conlon B. Effect of changes in practice of

electroconvulsive therapy over a 2 year period. Psychiatric Bulletin. 1997, 21, 10-12

9.

Sobin C, Sackeim HA, Prudic J, Devenand DP, Moody BJ,

Mchlhiney MC. Predictors of retrograde amnesia following ECT. American Journal of
Psychiatry. 1995, 152, 995-1001.

10.

Jhaak, Stein GS, Fenwick F. Negative Interaction between

Lithium and Electroconvulsive Therapy - A Case-Control Study. The British Journal of
Psychiatry. 1996, 168, 214-243.

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