The Practice of Electroconvulsive Therapy - Practice of Electroconvulsive Therapy

Written by Juli Lawrence

The description of the ECT procedure should include the times when treatments are given (e.g., Monday, Wednesday, Friday mornings), general location of treatment (i.e., where treatments will take place), and typical range for number of treatments to be administered. In the absence of precise quantitative data, the likelihood of specific adverse effects is generally described in terms such as "extremely rare," "rare," "uncommon," and "common" (see Section 4). Because of ongoing concern regarding cognitive dysfunction with ECT, an estimate of the potential severity and persistence of such effects should be given (see Section 4). In light of the available evidence, "brain damage" need not be included as a potential risk.

Capacity and Voluntariness to Provide Consent

Informed consent is defined as voluntary. In the absence of consensus as to what constitutes "voluntary," it is defined here as the consentor's ability to reach a decision free from coercion or duress.

Since the treatment team, family members, and friends all may have opinions concerning whether or not ECT should be administered, it is reasonable that these opinions and their basis be expressed to the consentor. In practice, the line between "advocacy" and "coercion" may be difficult to establish. Consentors who are either highly ambivalent or are unwilling or unable to take full responsibility for the decision (neither of which are rare occurrences with patients referred for ECT) are particularly susceptible to undue influence. Staff members involved in clinical case management should keep these issues in mind.

Threats of involuntary hospitalization or precipitous discharge from the hospital due to ECT refusal clearly represent a violation of the informed consent process. However, consentors do have the right to be informed of the anticipated effects of their actions on the patient's clinical course and the overall treatment plan. Similarly, since physicians are not expected to follow treatment plans which they believe are ineffective and/or unsafe, an anticipated need to transfer the patient to another attending physician should be discussed in advance with the consentor.

It is important to understand the issues involved in a consentor's decision to refuse or withdraw consent. Such decisions may sometimes be based upon misinformation or may reflect unrelated matters, e.g., anger towards self or others or a need to manifest autonomy. In addition, a patient's mental disorder can itself severely limit the ability to cooperate meaningfully in the informed consent process, even in the absence of psychotic ideation. Patients who are involuntarily hospitalized represent a special case. A number of suggestions have been offered to help guarantee the right of such individuals to accept or refuse specific components of the treatment plan, including ECT. Examples of such recommendations include the use of psychiatric consultants not otherwise involved in the case, appointed lay representatives formal institutional review committees, and legal or judicial determination. While some degree of protection is indicated in such cases, overregulation will serve to limit the patient's right to receive treatment.

Informed consent requires a patient who is capable of understanding and acting intelligently upon information provided to him/her. For the purpose of these recommendations, the term the chronic dysthymia or whether dysthymic symptomatology also improves. However, some practitioners believe that dysthymic symptoms do improve and that focusing treatment termination on resolution of the major depressive episode alone may result in incomplete treatment, with possible heightened risk of relapse. In contrast, some patients with schizoaffective disorder present with relatively chronic forms of thought disorder (e.g., delusions), upon which is superimposed prominent episodic affective symptomatology. In a number of these patients, ECT may ameliorate the affective component without influencing the chronic thought disorder. Prolonging the ECT course to attempt such resolution may result in unnecessary treatment.

After the start of ECT, clinical assessments should be performed by the attending physician or designee after every one or two treatments. These assessments should preferably be conducted on the day following a treatment to allow for clearing of acute cognitive effects and should be documented. The assessments should include attention to changes in the episode of mental disorder for which ECT has been referred, both in terms of improvement in signs and symptoms present initially and the manifestation of new ones. During the course of ECT, switches from depression to mania may occur on an uncommon basis. In this context, it is important to distinguish between an organic euphoric state and mania (Devanand et al. 1988b) (see also Section 11.9). Formal assessment of changes in cognitive functioning may help in making this differential diagnosis.

In patients treated for prominent catatonic symptomatology, the nature of other symptoms may have been difficult to discern at pretreatment due to mutism or negativism. With introduction of ECT and the clearing of catatonia, other aspects of psychopathology may become evident and should be assessed and documented. Some patients may have experienced delusions or hallucinations prior to or during the ECT course, but, due to patient guardedness or other factors, these symptoms may have been difficult to verify With clinical improvement, the clinician may ascertain their presence, a determination which may impinge on discharge planning and future treatment.

12.2. Adverse Effects

Cognitive changes. The impact of ECT on mental status, particularly regarding orientation and memory functioning, should be assessed both in terms of objective findings and patient report during the ECT course (see Section 4). This assessment should be conducted prior to the start of ECT in order to establish a baseline level of functioning and repeated at least weekly throughout the ECT course. It is suggested that cognitive assessment, like assessment of therapeutic change, be conducted at least 24 hours following an ECT treatment to avoid contamination by acute postictal effects.