Electroconvulsive therapy: practice guidelines for its administration

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Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of electroconvulsive therapy

Weiss A, Hussain S, Ng B, Sarma S, Tiller J, Waite S, Loo C
Aust N Z J Psychiatry 2019; 53: 609–623

Introduction

Electroconvulsive therapy (ECT) is a fast-acting treatment approach for severe psychiatric disorders that works by inducing seizures, under anaesthetic, via small electrical signals.  A rise in the number of different evidence-based ECT techniques, including differences in electrode placement, pulse width and dosing, has brought about large variations in practice.1,2  As a result, differences in treatment outcomes and rates of cognitive side effects have been noted.2  The Royal Australian and New Zealand College of Psychiatrists (RANZCP) Section for Electroconvulsive Therapy and Neurostimulation (SEN) aimed to provide up-to-date recommendations and advice for psychiatrists on ECT administration to address these variations in practice and clinical outcomes.

Methodology

Draft guidelines were developed by the SEN executive committee taking into account information from existing guidelines.  Feedback was sought from relevant RANZCP committees representing relevant patient groups.  An overview of important considerations for ECT treatment was included (Figure 1), facilitating best practice to maintain high efficacy of ECT while minimising side effects.

 

Figure 1

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Knowledge and experience from credentialled psychiatrists with current and appropriate ECT experience should be sought when considering ECT.

Specialist knowledge and individual treatment strategy recommendations

Knowledge and experience from credentialled psychiatrists with current and appropriate ECT experience should be sought when considering ECT. The approach towards ECT constantly varies, in terms of both the individual treatment strategy and optimised therapeutic effect, and, therefore, physicians who administer ECT should have ongoing education and training. Specialist knowledge is especially appropriate when determining the dose, electrode placement, pulse width, session frequency, concomitant medication and anaesthetic approach, all of which should be considered in relation to the needs of the individual patient and the characteristics of the illness episode.

Response to treatment should be regularly assessed before, during and after treatment to identify side effects and monitor a patient’s mental state.

Recommendations for preventing relapse

Response to treatment should be regularly assessed before, during and after treatment to identify side effects and monitor a patient’s mental state. Over 50% of patients relapse within 12 months of ECT, irrespective of maintenance pharmacotherapy or ECT.3  Tapering of an index course of ECT can be useful for many patients and some may require a dynamic ECT maintenance schedule if other approaches to preventing relapse have failed.  Continuation of ECT should particularly be considered for those patients with severe and recurrent illness.  For patients with schizophrenia, ECT should be continued together with antipsychotic medication.  Psychotropic medication use before ECT should be reviewed and a medication plan for during and after ECT should be developed with the aim of optimising the efficacy of ECT and reducing the risk of subsequent relapse.  Considerations include a balanced approach to the use of tricyclic antidepressants, combining antidepressants with lithium after the index ECT, ceasing benzodiazepines and anticonvulsants before ECT treatment, and the use of antipsychotics with ECT for psychosis.

There is a need to include patients, their family and their carers in the discussion surrounding ECT, which can help address many of their concerns.

Recommendations for patient involvement

Acquiring consent from patients for ECT is essential. Furthermore, there is a need to include patients, their family and their carers in the discussion surrounding ECT, which can help address many of their concerns.  Informing them about the administration of ECT, as well as the outcomes and associated risks, and providing them with relevant information is important.

References
  1. Sackeim HA et al.  Neuropsychopharmacology 2007; 32: 244–254.
  2. Gálvez V et al.  J Affect Disord 2016; 206: 268–272.
  3. Jelovac A et al.  Neuropsychopharmacology 2013; 38: 2467–2474.
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