2. Electro-Convulsive Therapy
and Its Use.

E.C.T. involves passing an electric current through a person's brain while they are under a general anaesthetic and have been given a muscle relaxant. This produces a convulsion (muscular contractions) modified by the anaesthetic.

There is evidence that seizures were used since the Nineteenth Century to treat schizophrenia (starting in 1834 in Hungary). These seizures were induced via various means such as with insulin and other so-called pharmacological means.

Electro-convulsive therapy (E.C.T.) was first used as a treatment for mental illness in 1938 by Cerletti and Bini (50), and then developed as a mainstream treatment. E.C.T. was used before the development of modern anaesthetics and muscle relaxants. It also predated drug treatments for depression. As such, it has had a significant historical role in influencing the perceptions of people towards mental illness and the potential of different treatments.

In the 1950s and 1960s antipsychotic, antidepressant, and anti-manic drugs were discovered (169). Although E.C.T. was partially replaced by drug treatments with reduced side effects, it continued to be used on a large number of people, the level of which tended to stabilize in the early 1980s.

Internationally, E.C.T. is banned in Italy, while its use is limited in Canada and the Netherlands. E.C.T. is used much less in other European countries than in Great Britain. For example, in West Germany in 1986, E.C.T. was used in 26% of state psychiatric hospitals, 40% of psychiatric departments of general hospitals and in 78% of university hospitals. A total of 500 people had E.C.T. in 1986, (compared with some 22 000 in England) (93). The use of E.C.T. is rare and discouraged by the authorities in Austria, China and Japan.

E.C.T. is perhaps the most controversial treatment currently used by the medical profession. While some survivors report it as helpful or life-saving to them, others find it much less helpful, and many view it as a damaging and threatening tool of psychiatric oppression. Especially controversial are:

• what conditions it is used to treat
• who is given E.C.T.
• its administration
• training of clinical staff
• variations in use and practice
• precisely how it works
• its effectiveness
• its risks and side-effects
• consent to treatment

E.C.T. is principally used to treat depressive disorders, but is also used for mania, schizophrenia and various neuropsychiatric conditions. It has, however, been pointed out that many patients given E.C.T. have more than one diagnosis (125). One national survey of survivors found that E.C.T. had also been used for post-natal depression, anxiety, hypomania, post-traumatic stress disorder and puerperal psychosis (163).

2.2.1 E.C.T. and depressive disorders.

Although there are considerable variations between psychiatrists, E.C.T. is usually used as a treatment for depression when:

• other treatments (such as antidepressants) have not worked; or
• a patient is considered unable to tolerate or reliably take antidepressant medication; or
• E.C.T. is believed to be the safer option (for example, due to the side effects of antidepressants); and/or
• a rapid result is required when a person is very severely ill (for example, if they are acutely and actively suicidal, extremely distressed and/or refusing to eat and drink).

In one survey of old-age psychiatrists, depressive psychosis was identified as the condition for which E.C.T. was felt most often to be useful (10).

2.2.2 E.C.T. and mania.

E.C.T. is also used to treat a number of people with mania. It should not, however, be used as a first-line treatment for mania unless the illness is genuinely life-threatening (79), as drugs such as haloperidol, phenothiazine and lithium are the mainstay of treatment for manic illness.

2.2.3 E.C.T. and schizophrenia.

It is argued that E.C.T. can be effective in schizophrenia, but mainly for those people with the positive symptoms of type 1 (acute) schizophrenia, and not for those with type 2 (chronic) schizophrenia unless there is co-existing depression (76). It is, however, important to note the arguments attacking the whole concept of schizophrenia as a concept developed by psychiatrists (156).

On average over the three years, 69.6% of all patients who were given E.C.T. were female and only 30.4% male. This gender difference varied only slightly between the over-65 and under-65 groups.

According to responses to a survey in September 1997 by Psychology Politics Resistance as part of its North West Right to Refuse Electroshock Campaign, the use of E.C.T. by gender within the Mental Health Services of Salford N.H.S. Trust compares with other N.H.S. trusts in Greater Manchester as follows:

3.5.2 E.C.T. and age.

The Project Team was informed by consultants that the major indication for E.C.T. is depression and that this develops with age. Dr. Moss said that this accounted for the fact that older people are more likely to receive E.C.T.

The Trust reported that "it would be difficult and inordinately time consuming to break the patients down into age bands as this information is not one of the items that is kept in the E.C.T. recording book. It seems . . . sensible to arrange for this for the future."

By age, E.C.T. was given to patients within the Trust as follows:

On average over the three years, 60.2% of all patients who were given E.C.T. were over 65 years and 39.8% under 65. This age difference varied only slightly between male and female patients.

According to responses to a survey in September 1997 by Psychology Politics Resistance as part of its North West Right to Refuse Electroshock Campaign, the use of E.C.T. by age within the Mental Health Services of Salford N.H.S. Trust compares with other N.H.S. trusts in Greater Manchester as follows:

3.3.1 Historical use:

The following figures show the historical use of E.C.T. within the Mental Health Services of Salford. It should be noted that Meadowbrook only came into being in 1991 (Glendale several years later). E.C.T. was previously given at The Lancastrian Unit at Hope Hospital.

There are no clear reasons for the variations over time in E.C.T. use. The Trust, however, reported that "in the past, the figures for E.C.T. were artificially inflated by individuals on the long stay wards being reviewed and diagnosed as having long-standing untreated affective disorders. Many of them required prolonged treatment with E.C.T. to relieve their long-standing illnesses. It was then possible to discharge a number of these patients from hospital. These changes in the number of patients being treated are a response to increasingly active earlier treatment for patients leading to a steady reduction in the number of patients receiving inpatient treatment from Salford. Many patients, particularly in the older age groups, now benefit from prophylaxis with lithium and/or carbamazepine which is closely monitored by a Domiciliary Drug Treatment Clinic. Theoretically this should reduce the relapse rate and consequently the need for E.C.T." (Hyde, 1997: 6).

The Project Team was informed by consultants that in the Trust:

Many fewer patients now get E.C.T. because depression tends to be picked up earlier and more patients can tolerate the new antidepressants. The Elderly Service has expanded over the past 15 years from one consultant to three. This allows a better quality of maintenance of patients.

The declining or more appropriate use of E.C.T. is also due to the better training of psychiatrists. "The present generation of psychiatrists working in Salford have received excellent training compared to the last generation of 'asylum psychiatrists' and may well have a more realistic case load with consequent ability to spend more time with individual patients. " (Hyde, 1997: 7).

According to responses to a survey in September 1997 by Psychology Politics Resistance as part of its North West Right to Refuse Electroshock Campaign, the use of E.C.T. within the Mental Health Services of Salford N.H.S. Trust compares with other N.H.S. trusts in Greater Manchester as follows:

3.4 What conditions is E.C.T. used to treat?

The Project Team was informed by consultants that, in the Trust:

E.C.T. is used according to diagnosis, mainly for depression and rarely for conditions such as catatonic schizophrenia. It is used not necessarily always as a last resort, but when depression is very severe or that other treatments have produced negative results in the past for individual patients. In addition, some patients cannot tolerate antidepressants (although this is now less so with new drugs).

Most patients do not get E.C.T. because they respond themselves or with alternative treatments.

3.5 Who is given E.C.T.?

3.5.1 E.C.T. and gender.

The Project Team was informed by consultants in the Trust that the major indication for E.C.T. is depression and that this is more common in women than men. Dr. Moss said that this (together with the fact that women tend to live longer) accounted for the fact that women are more likely to receive E.C.T.

By gender, E.C.T. was given to patients within the Trust as follows:

3.5.3 E.C.T. and people under 18 years old.

There was no evidence or report of E.C.T. being given to a young person under 18 years of age in Salford in the recent past.

3.5.4 Use by home district:

In regard to the home district of patients, assuming that some patients getting E.C.T. in the Mental Health Services of Salford come from outside the City, and that a few Salford people may be getting E.C.T. elsewhere, the figures from the Trust suggest a rate of use of approximately 250 - 280 treatments per 100 000 population. This is in the mid-range for reported rates of use across England and Wales.

During the visit to the E.C.T. Suite at Meadowbrook on 27 October, 1997, it was reported that of the patients then being given E.C.T., the vast majority were Salford residents

3.5.5 E.C.T. and ethnicity.

The Trust replied: "the recording of the use of E.C.T. by ethnicity and home district is again something that is not recorded. It would be possible to back track home districts to each patient by name by looking at their notes, but this would be an extremely time consuming exercise. As you are aware, ethnicity has only been recorded in the N.H.S. since April 1995 and again is something which is not recorded currently for E.C.T. I will arrange for this to be recorded in the future."

Later, however, the Trust reported that "the Afro-Caribbean and Asian population within Salford at present is very small and the ethnic groups who are represented in significant numbers, for example, the large Jewish community in Higher Broughton, are not regarded as ethnic groups at all within the official N.H.S. categories. At present, information collected is appropriate for the tasks of the Trust. Other information is of course available in the patient's notes. " (Hyde, 1997: 7).

Reliable information on the ethnicity of the population of Salford is, in fact, limited. Its accuracy is also questionable due to under-reporting, especially among black and minority ethnic communities (for example, the Census form was produced in English only).

The 1991 Census and a later 1993 profile by Salford Community Health Council, Salford Family Health Services Authority and Salford Health Authority 144 reported the ethnic group of the Salford's residents as:

Clearly, these figures do not reflect "white minorities", such as people of Irish, Jewish and East European descent. They make up a significant proportion of the total population.

According to responses to a survey in September 1997 by Psychology Politics Resistance as part of its North West Right to Refuse Electroshock Campaign, the use of E.C.T. by ethnicity within the Mental Health Services of Salford N.H.S. Trust compares with other N.H.S. trusts in Greater Manchester as follows:

3.6.1 Good practice and guidelines.

The C.H.C. requested the clinical and non-clinical criteria and guidelines used within the Trust for E.C.T. The response from the Trust was that "it is difficult to give clinical and non-clinical guidelines for the use of E.C.T., as E.C.T. is given as a medical treatment on the clinical judgment of the prescriber and it is therefore a clinical decision in each case."

It was also reported by the Trust that "there are no specifications on standards of guidelines about E.C.T. contained in contracts held by the Trust with purchasers." Thus, it can be concluded that no guidelines are in operation for the use of E.C.T., with judgments left to individual clinicians.

There are written guidelines from the Anesthetics Department." The anesthetic guidelines of January 1990 were updated in November 1996, during the course of the Project. Both versions are attached at Appendix One. The Project Team was told that these were still the only guidelines for E.C.T.

This response made no reference to the procedure for E.C.T. developed by the Mental Health Unit of Salford Health Authority (which became the Mental Health Services of Salford N.H.S. Trust) in 1993, nor its updated version, Procedure: Electro-Convulsive Therapy (E.C.T.) (July 1996 - review date July 2000) (see Appendix Three).

It was not until the Project Team specifically asked about this documents it was either provided or referred to. While the procedure had been updated (albeit significantly later than the review date set on the original versions), the lack of reference to it in any of the discussions or correspondence with the Trust raises a question about staff awareness and implementation of it.

3.6.2 Equipment.

Dr. Moss stated that the E.C.T. machines within the Trust are "obsolete and unsatisfactory" and that it does not have any "modern" machines.

The Trust informed the C.H.C. that the following E.C.T. machines were in use at Prestwich Hospital as at February 1997, and were to be moved to Meadowbrook when the E.C.T. facilities transferred there later in 1997:

Ectonus Series 5-regular machine

Ectron CCX-reserve

Duopulse (2c/
-used only if both other machines fail.

Ectonus (2c/

It should be noted that the Ectonus Series 5 machine had been superseded by the Ectonus Series 5A. The Duopulse E.C.T. machine has long been superseded by a more modern device.

During the visit to the Prestwich E.C.T. Suite on 22 November, 1996, the Project Team were told that staff wanted a new E.C.T. machine that could also measure E.E.G. This may be significant, as E.E.G.-based seizure times are estimated to be 10 - 40 % longer than seizure times by observation of muscle activity (using the Cuff Technique to control for the muscle relaxant) (59) (98).

When the C.H.C. visited the E.C.T. Suite at Meadowbrook on 27 October, 1997, the Ectonus Series 5 E.C.T. machine was still in use. Staff involved in the administration of E.C.T. considered that a new machine capable of providing E.C.G. monitoring was required. The short list included a Mecta SR1, a Mecta SR2 or a Thymatron DGX, although on 29 October, 1997, the Vickers Company stopped sales of the Mecta machines and terminated their contracts with the makers, as they were found to be possibly dangerous (48). Following demonstrations and using guidance from the Royal College of Psychiatrists, a new machine had been identified and ordered which would do brain traces and allow the voltage used to be age-related.

The servicing of E.C.T. machines is also a concern of many. According to responses to a survey in September 1997 by Psychology Politics Resistance as part of its North West Right to Refuse Electroshock Campaign, the servicing of E.C.T. machines within the Mental Health Services of Salford N.H.S. Trust compares with other N.H.S. trusts in Greater Manchester as follows:

3.6.3 Frequency and number of treatments.

The Project Team was told by consultants that in the Trust, although fewer patients now get E.C.T., those that do probably receive a similar number of treatments and for similar lengths of time to patients in past years.

While no direct information was provided by the Trust, use of the figures provided produces the following average number of treatments per patient:

Allowance may have to be made for the small number of patients who received more than one course of treatment during any year. It is, however, unclear whether this distinction is made when data is collected and whether such information is readily available.

3.6.4 Anaesthesia.

The C.H.C. requested the clinical and non-clinical criteria and guidelines used within the Trust for E.C.T. The response from the Trust was that "it is difficult to give clinical and non-clinical guidelines for the use of E.C.T., as E.C.T. is given as a medical treatment on the clinical judgment of the prescriber and it is therefore a clinical decision in each case."

There are written guidelines from the Anesthetics Department." The anesthetic guidelines of January 1990 were updated in November 1996, during the course of the Project. Both versions are attached at Appendix One. The Project Team was told that these were still the only guidelines for E.C.T.

The guidelines for anaesthesia for E.C.T. in the Mental Health Services of Salford N.H.S. Trust varied significantly from those used for day surgery in the Salford Royal Hospitals N.H.S. Trust, even though the anaesthetists in both cases are employed by the Salford Royal Hospitals. [See Appendix One].

Only post-fellowship or consultant anesthetists were allowed to be involved in E.C.T.

Anesthesia varies according to the patient's condition.

3.7 Training of Clinical Staff.

3.7.1 Training of staff:

Discussions with clinical staff in the Trust highlighted that:

At the time of the C.H.C.'s first review, doctors (except anaesthetists) got no specific or formal training in E.C.T. This situation began to change after the relocation of the service from Prestwich to Meadowbrook.

While the E.C.T. service was at Prestwich (1996-1997), E.C.T. was administered almost entirely by Dr. Rosenberg with assistance from trainees in Old Age Psychiatry who were all experienced in the administration of E.C.T. Specific training was not provided to junior doctors as they were not required to administer E.C.T." (Hyde, 1997: 7).

From April 1997, "trainee psychiatrists based at Meadowbrook [had] been involved in the administration of E.C.T. and were all offered individual training in the use of the E.C.T. box. They were experienced trainees having worked in other hospitals and had been trained in administering E.C.T., and none have taken up this invitation." (Hyde, 1997: 7-8).

From 1 August, 1997, all junior doctors on the rotation were required to complete a log book defining the experience they had, as well as to develop a learning contract within the first month of their attachment with the Trust. Both of these documents should be reviewed by the Postgraduate Dean's Department in reviewing their training. These were intended to act as checks to ensure that doctors administering E.C.T. received the appropriate training 79.

On the C.H.C.'s visit to Meadowbrook on 27 October, 1997, it was reported that were still junior doctors applying E.C.T. who had not been trained in its use, although assurances were given that all doctors would be trained on the use of the new machine when it was obtained and that this training would be repeated by a consultant psychiatrist every six months when new junior doctors arrived.

There were two regular nursing staff at the Prestwich E.C.T. Suite, both of whom were registered mental nurses (R.M.N.s).

3.8 Variations in use and practice.

The use of E.C.T. by consultant was as follows:

These figures make interesting reading, not least in the variations both for individual consultants year-on-year, but also between consultants. The reasons for these variations are unclear and warrant further investigation.

Discussions with consultants within the Trust highlighted that:

There is no information held by the Trust on the variations in use of E.C.T. between consultants and hospitals, although some of this may be due to differing clinical judgments.

There was no work known by them in England and Wales to allow comparison of E.C.T. provision in different N.H.S. trusts, or any work similar to that being undertaken in Scotland.

3.9 Effectiveness of E.C.T.

3.9.1 Clinical Audit and Research.

Within the Trust, clinical audit had been undertaken in regard to E.C.T., but this was only a single audit in 1992 about its administration rather than outcomes. The Project Team was told by consultants in the Trust that:

the recent reorganization of the Elderly Service had left things somewhat disorganized, but it was felt that a suggestion should be put to Salford and Trafford Health Authority to seek an audit of E.C.T.

Although the Salford Case Register records information on research and audit, this appears irrelevant in the case of E.C.T., as so little research and audit has actually been undertaken.

3.9.2 Duration of Effect.

The Project Team was told by consultants in the Trust that:

Psychiatrists would look for a quick difference as a result of E.C.T. - an effect after two weeks. It would be difficult to check the effectiveness for patients having E.C.T. against those who do not.

The relapse rate of patients is fairly high, perhaps 60% within two years. E.C.T. should therefore always be followed up with maintenance treatment.

The Project Team was informed that "Psychiatrists in Salford do not prescribe E.C.T. expecting that this will reduce the rate of relapse. Psychiatrists in Salford do not prescribe E.C.T. to prevent long-term relapse. The Royal College of Psychiatrists' Committee on E.C.T. emphasize that it is essential that maintenance of the treatment with medication should be instituted after a course of E.C.T. to reduce the risk of relapse. This may be with antidepressants, lithium, carbamazepine or a combination." (Hyde, 1997: 5).

3.9.3 Survivors' Views.

No work had ever previously been done in Salford to assess patients', survivors' or relatives' views about E.C.T. and its use.

3.9.4 Who does E.C.T. work for?

On criteria to determine the effectiveness of E.C.T., the Project Team was told by consultants in the Trust that a major factor they used to decide how effective E.C.T. is likely to be for any patient is the presence of delusion and also biological symptoms. Both can, of course, be seen as matters of judgment rather than objective fact.

A depressive delusion involves a person believing that they are worthless, unlovable and not deserving of care or attention. In such a psychological state, there is no logical reason to continue to live, and the person will believe that everyone is better of without them. A delusion is a belief that cannot be questioned.

Biological symptoms are those which suggest a depressive illness that is not a response to grief, a lack of self-confidence or a lack of coping skills, but one that is related to biochemical and pathological changes in the brain and body.

3.9.5 E.C.T. and Alternatives.

The Project Team was informed by consultants that in the Trust the alternatives to E.C.T. used are mainly antidepressants. There was no mention of psychological services, "talking treatments" or other alternatives. This was despite the presence in the Mental Health Services of Salford of both a Psychotherapy Department and also a large, highly-trained Psychology Department that offers cognitive therapy and various other treatments that can be used to treat depression, either with or without physical treatments.

It was, however, reported that "In considering alternative treatments to E.C.T., it should be noted that patients treated with E.C.T. are normally too ill to be accessible to psychological treatments. These are available and will be considered where appropriate either when someone who has been severely depressed has improved or for an individual with a less severe depressive illness for whom E.C.T. would not be considered. Many individuals with depressive illnesses have a biologically determined illness and are not necessarily in need of psychological treatment." (Hyde, 1997: 8).

The C.H.C. was later informed that "When contemplating E.C.T. in Salford, we consider not only alternative pharmacological treatments but the availability of both eclectic psychological treatments, and specific psychological treatments of cognitive behavioral therapy and psychodynamic therapy. The majority of people receiving E.C.T. are not amenable at that time to psychological treatments." (Hyde, 1997: 5).

3.10 Risks and Side Effects of E.C.T.

3.10.1 Risk assessment for E.C.T.

The Project Team was told by consultants in the Trust:

On a patient's first referral, an anesthetist makes an assessment, including investigations. E.C.T. is only allowed if the anesthetist is satisfied it is safe to do so. The final decision on whether a patient can be given E.C.T. is that of the anaesthetist, who takes into account the consultant's view.

Older people are at a higher risk, especially if they have heart disease. If a patient's physical health is borderline, the anesthetist will check with the consultant psychiatrist about the decision to give E.C.T. (although this does not happen often). Problems with heart conditions, falls and strokes (even in older people) are few.

There is no evidence that E.C.T. has ever been given in a coronary care unit or intensive care unit in Salford 79.

3.10.2 Side Effects of E.C.T.

The Project Team was told by consultants that in the Trust, there was currently no mechanism in place for monitoring the side effects of E.C.T., including memory loss. Dr. Moss felt that differences were individual to patients. This should be an important area for further research to be undertaken.

3.10.3 Anesthesia.

The anesthetists used by the Mental Health Services of Salford N.H.S. Trust are employed by the Salford Royal Hospitals N.H.S. Trust. The service involves four E.C.T. consultant anesthetist sessions. During the period of the project, the source funding for these was an unresolved issue, with sessions being cancelled and discharges being delayed. A service level agreement was drafted to improve the situation, although this had extra funding implications.

The Project Team was told by consultants that:

No day case surgery in undertaken on patients over 75 years in the Salford Royal Hospitals N.H.S. Trust, but E.C.T. is undertaken on patients older than this in the Mental Health Trust. Greater monitoring of E.C.T. patients may be required.

Repeated anesthesia has no cumulative effect, as only has a short-term effect. Repeated anesthesia does, however, increase the level of risk.

3.10.4 E.C.T. and Death.

The Project Team was told by consultants that death and serious injury due to E.C.T. are very rare. There had been no instances in the Trust in at least the previous 18 months. In the past there had been two or three deaths, but these were of people who would probably have died any way.

3.11 Consent to Treatment.

3.11.1 Rules and Guidance.

The local guidance on consent within the Mental Health Services of Salford N.H.S. Trust in force at the time of the Project was:

Procedure: Consent to Treatment (March 1995) - review date October 1999: see Appendix Two; and

Quality Statement: Consent to Treatment (Mental Health Act 1983) (February 1994) - review date February 1999: see Appendix Four.

It was not until the Project Team specifically asked about these documents that they referred to by the Trust. While the procedure and quality statement had been updated (albeit significantly later than the review dates set on the original versions), the lack of reference to them in any of the discussions or correspondence with the Trust raises a question about staff awareness and implementation of them.

On the question of consent, the Mental Health Act 1983 and the Mental Health Act Code of Practice provides the essential framework. Many statements from these are reproduced in the Trust's procedure guidance and quality statement.

If a patient is able and willing to give consent to E.C.T. and anesthesia, they are then asked to sign a standard N.H.S. consent form, which is countersigned by the R.M.O. The Trust actually provided the C.H.C. with a consent form specific for E.C.T. [Appendix Three]. This identifies that the E.C.T. treatment has been explained. The form should be checked by the medical staff giving the E.C.T. and anesthetic and by the nursing staff. Treatment should not be given without a valid consent form being provided.

The treatment course is reviewed weekly by the R.M.O. and the multi-disciplinary team. Competence to give or refuse consent is not formally assessed prior to each individual session. Consent is, however, reaffirmed by the patient at each treatment by his/her confirmation to the named nurse or nurse in charge prior to each treatment that they will be attending for that treatment and not by mere assent or being there.

While some patients' capacity to consent may vary over time, their right to refuse treatment should always be observed. Any attempts at persuasion should involve only discussion and reason without undue pressure. If a patient does refuse E.C.T., alternative treatments should be continued, along with an explanation of the associated benefits and risks.

If a patient refuses to give consent or their consent is clinically judged to be not valid, the R.M.O. has to make a clinical judgment as to whether to carry on with the treatment under the Mental Health Act, in line with the Code of Practice. In the case of patients who are given E.C.T. without their consent, the authority of a Second Opinion Appointed Doctor (S.O.A.D.) from the Mental Health Act Commission to do this must be recorded on a Form 39. This should accompany the patient. Without it, the patient should not be given any treatment. E.C.T. staff also have a responsibility to check the number of treatments the patient is given against the specified number authorized by the S.O.A.D.

During Mental Health Act training, staff are taught about the withdrawal of consent. This can be done not only by a patients saying that they do not want the treatment, but also by action, such as refusing to get on a trolley or not putting their arm out for the anesthetic. To give treatment in these circumstances (unless the Mental Health Act is fulfilled) would be illegal.

3.11.2 Information and Explanations.

In 1996, the Trust reported that "there is no written information given to patients regarding E.C.T. E.C.T. is individually discussed with each client by the doctor prescribing it. It is also backed up with discussions by nursing staff and also by E.C.T. staff when then patient first comes for treatment."

Clinical staff also told the Project Team that information for patients and the obtaining of consent to treatment was not standardized within the Trust.

During discussions with clinical staff in the Trust, the Project Team was told that no written information is given to patients about E.C.T. At present, the only explanation for E.C.T. was verbal. All information is given verbally, and is thus dependent on staff, their communication skills and the way in which the information is presented. A new form and set of criteria were required. It was noted that the Royal College of Psychiatrists had produced videos illustrating "ideal interviews".

At the time of the visit to the E.C.T. Suite at Meadowbrook on 27 October, 1997, the C.H.C. team was told that patients should be given the Royal College of Psychiatrists' leaflet by ward staff, although this was probably more likely to be on request than automatic.

This situation was in contrast to that when Salford C.H.C. enquired about this in 1994, when it was provided with a copy of the Royal College of Psychiatrists E.C.T. (Electroconvulsive Therapy) A Factsheet for You and Your Family dated 12 July, 1993, and marked for the Meadowbrook Department of Psychiatry of the Mental Health Services of Salford.

The Trust indicated that the information as suggested by Mind "would be very useful for patients or their relatives to ask about E.C.T. These reports of survivors and the comments about validity of consent make disturbing reading and should be read by doctors prescribing E.C.T. . . . We will explore with the staff administering E.C.T. the development of a small pamphlet addressing these questions and providing some written information." (Hyde, 1997: 6).

3.11.3 Validity of Consent.

The process of obtaining valid consent from a patient is based on the clinical judgment of their responsible medical officer (R.M.O.). If they and the clinical team consider that a course of E.C.T. treatments would be beneficial, this should be discussed with the patient and, where appropriate, their relatives. Under the Patient's Charter, patients should be given a full explanation, including about the benefits, risks and alternatives. Nursing staff can have an important role in this process. The Trust is expected by the local Health Authority to audit and report on performance against this standard.

The Trust includes obtaining valid consent as an integral part of its Mental Health Act training updates.

The Project Team was informed by Trust staff that there is no independent advocacy available to patients who are offered or given E.C.T.

3.11.4 E.C.T. Without Consent.

The Project Team was told by Trust staff that treatment without consent is monitored by the Mental Health Act Commission, including against the Mental Health Act Code of Practice.

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