OVERVIEW

•Electroconvulsive therapy (ECT) is not commonly used to treat mental illness and can be considered as rather controversial. Its use has significantly decreased in recent years and it is used far less than medication and talking therapies.
•ECT involves an electrical current being passed through the brain, causing a fit/seizure. This is done under a general anaesthetic and the use of muscle relaxants.
•Some people may prefer the option of a short course of ECT to taking medication long term.
•It should only be used for certain conditions – severe depression, catatonia (lack of, or excessive movement) or mania. It should not be used for the general treatment of schizophrenia.
•It is recommended only in severe cases when other treatments have been ineffective or the condition is potentially life threatening.
•ECT can have side effects, particularly memory loss. This is usually short-term, but people can experience memory loss for longer periods.
•ECT should not be given to you without consent and you should not feel pressured into giving consent. This also applies if you are ‘sectioned’ under the Mental Health Act.
•If you are too unwell to make a decision about ECT (known as lacking capacity), then it can only be given to you without consent with the approval of a Second Opinion Appointed Doctor (SOAD).
•You can make an advance statement on future decisions about treatment. If you have an advance statement refusing ECT, this cannot be overridden unless it is an emergency.
•ECT can be given in an emergency without consent after SOAD approval if it there is a risk to life, or to prevent a serious deterioration of your condition.

WHAT IS ECT

During ECT, an electrical current is passed through your brain, usually by electrodes attached onto your head (electrodes can be on just one side, or on both sides of your head). The electrical current travels through the brain causing a fit (seizure). ECT is not done whilst you are awake – it is given under a general anaesthetic and with muscle relaxants (to prevent body spasms).

It has never been fully understood how or why ECT works. A common belief is that ECT changes the way ‘chemical messengers’ behave in the central nervous system. This will change the way the brain functions.

ECT treatment is most often given in short courses, twice a week for 3-6 weeks (so usually involving 6-12 sessions in total). You may have further fortnightly or monthly sessions to keep you stable.

Why is ECT used?

ECT is used mainly within NHS hospitals (although some private hospitals may use the procedure) for people who are not responding to conventional treatments. It is used for:
•Severe depression
•Catatonia (associated with schizophrenia and mood disorders – usually total lack of, or excessive movement)
•Prolonged or severe manic episode.

Medications and ‘talking treatments’ are the first options for treating people with mental illnesses. The National Institute of Health and Clinical Excellence (NICE) recommends that ECT is only used when:
•ECT would provide fast or short-term improvement of symptoms in severe cases after all other treatment options have not worked

and / or
•Where the current illness situation is seen as potentially life-threatening.

NICE also recommends that ECT should not be used for the general management of schizophrenia or depression.

If you are very unwell, and ECT has been tried in the past and failed to work, ECT should only be used again if all other options have been considered. The risks and benefits of further ECT treatment would have to be weighed up. This should always be discussed with you and, where appropriate, your carer/advocate.

What are the side effects of ECT?

NICE recommends that you and your doctor should carry out an assessment of risks and benefits when ECT is being considered.

Many people report that they have a headache and aching muscles after ECT. Some people may also feel sick. The most common side effect of ECT is memory loss, which can be short- or long-term and affects about one in three people. Memory loss is usually short-term (affecting memories of the time just before and after the treatment), but longer term memories can be affected too. Memory loss may last days or weeks after the final treatment, and has lasted several months in rare cases.

ECT can affect heart rhythm and blood pressure. Some patients may be at increased risk of heart-related complications with ECT. NICE recommends that doctors should be especially cautious when considering ECT for pregnant women and older or younger people because the risk of complications can be higher for people in these groups.

Other rare, immediate complications include:
•Persistent seizure
•Laryngospasm – closing up of muscles which makes breathing difficult
•Peripheral nerve palsy – nerve damage which affects movement of muscles

The risk of death is the same as that of general anaesthetic. Patients should be told the health risks associated with the general anaesthetic during ECT.

You and your doctor should also think about the potential risks of not having ECT, such as the risk of detention under the Mental Health Act 1983, suicide, or being a danger to others. ECT is a way of treating severe symptoms more quickly than other types of treatment such as antidepressants, which may take several weeks to reach maximum effect.

You should be assessed for signs of side effects before each new session of ECT. This should include checking whether you have signs of memory loss, for example. If there are any signs of adverse effects from ECT, the treatment should be stopped immediately.

ECT CONSENT

ECT must not be imposed on you without your consent except in very limited circumstances. Doctors should not put pressure on you to consent to ECT, and you can stop ECT at any time by withdrawing your consent to treatment.

If you need to be treated in an emergency

If you are detained under the Mental Health Act 1983 (MHA), section 62 of the Act allows ECT to be used without your consent if:
•there is a real risk to life or
•to prevent serious deterioration of the condition

If you lack the capacity to consent

If you are detained under the MHA and you lack the capacity to consent to ECT, it can be given without your consent if a Second Opinion Appointed Doctor (SOAD) approves it. However, this is not the case if you have an advance directive refusing ECT, or if someone has the power to make treatment decisions for you and has refused it on your behalf.

The SOAD would need to sign a ‘Part 4A Certificate’ stating that ECT is appropriate for you. The SOAD must interview you, discuss your treatment with the doctor in charge of your care and consult two other professionals who are involved with your medical treatment. You should then normally be given written reasons for the treatment, unless this would cause mental or physical harm to you or anyone else.

If you are under 18

All people under 18 years old must be seen by a SOAD, who must agree that ECT is appropriate in order for it to be used. This is the case whether or not the patient is detained under the Mental Health Act 1983.

Advance directives

If you do not want to receive ECT in the future, you can make this clear in an ‘advance directive’. An advance directive is a written statement of the specific treatments that you do not want to have in the future. People write these statements in case they lose the capacity to make these decisions for themselves when treatment is needed. If you make a valid advance directive refusing ECT then it could only be used in emergencies under section 62 of the MHA (see above).