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In 1990, the American Psychiatric Association (APA) published the first edition of The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging, a comprehensive set of recommendations for the practice of electroconvulsive therapy (ECT). This work was well received and influenced clinical practice in a number of meaningful ways, including the encouragement of guideline development by other groups within the U.S. (Fink et al. 1996) and elsewhere (Royal Australian & New Zealand College of Psychiatrists 1992; Royal College of Psychiatrists 1993; Gangadhar 1995). In the ensuing decade, the field of ECT has continued to advance, with a substantial amount of new scientific and clinical information forthcoming. Each year, hundreds of relevant publications have appeared, as interest in this treatment modality continues to expand.
Because of this growing knowledge base, APA gave the Task Force on ECT a mandate to undertake an update of this report. This revision has been an extensive process. A review of the available clinical literature included a search of all clinical citations related to ECT published between 1989 and 1998 that had been entered into the Medline database by December 1998. Supplementing, this literature review were suggestions received at a Task Force workshop at the 1996 APA Annual Meeting, and after subsequent presentations at Annual Meetings of the Association for Convulsive Therapy (ACT), as well as via informal input from experts and other interested parties. The Task Force's efforts were made known to the APA membership on an ongoing basis through published summaries of component activities and by notification of the APA Assembly.
To help ensure that these recommendations would be clinically useful, as well as scientifically, ethically, and legally sound, the Task Force sought input from a large number of professional organizations (covering the fields of psychiatry, anesthesiology, nursing, nurse anesthesia, and psychology), individual experts in related areas (including child, adult, and geriatric psychiatry, neurology, psychology, anesthesiology, cardiology, obstetrics, medical ethics, and law), regulatory bodies (Joint Commission on Accreditation of Healthcare Organizations [JCAHO] and the Food and Drug Administration [FDA]), and major lay mental health organizations (see Appendix A). As the initial draft of the revised document neared completion, an article was published in Psychiatric News (the APA newspaper) soliciting the names of additional members with an interest in reviewing the draft. This request ensured that rank and file practitioners would also have the opportunity to have input. Finally, the APA's own internal review process ensured that drafts were examined from a wide variety of perspectives. Input from these diverse sources was taken into account in the determination of the final product.
This revised volume offers a set of recommendations to assist practitioners and facilities in the safe and effective use of ECT. We have once more attempted to make the scope of the recommendations as comprehensive as possible, including coverage of the important issues of education, training, and privileging. In each section, recommendations are preceded by applicable background information, including pertinent literature citations(with a particular focus on recent work). This format differs from that of the original report, in which background information was placed in a separate Rationale section that was preceded by an overall Recommendations section. The goal of this change in format was an improved integration of the recommendations with their justification. As before, a Bibliography and Appendices provide additional source material of use to practitioners. Due to the growing importance of defined policy and procedure statements in clinical practice, an example of such a document is provided in Appendix E [not present in this Draft] and is designed to be in conformance with these recommendations. While it is not possible to highlight all the changes from the original volume, Appendix F [not present in this Draft] contains a list of major substantive differences between the present recommendations and those made in the 1990 volume.
Over the past 60 years, the practice of ECT has evolved into a complex procedure about which much has been learned, but many questions remain. In providing a comprehensive set of recommendations, it was necessary to include material based up on empirical findings as well as clinical consensus for those situations where well controlled clinical trials are either unavailable or not applicable. It was also apparent that in some cases reasonable alternative courses of action to those presented in these recommendations exist, and attempts have been made to describe a number of such alternative, where applicable. For these reasons, these recommendations should be viewed as suggestions rather than requirements.
In writing recommendations for a complex procedure such as ECT, it is impossible to cover all situations or deal with all possible exceptions. Accordingly, there will be times when overriding factors will lead a reasonable and prudent practitioner to alter practice from that recommended here. In addition, new clinically relevant information is continually appearing, and should be readily incorporated into clinical practice whenever it is shown to either maximize efficacy or minimize adverse effects.
To aid the practitioner in weighing the importance of individual recommendations, we have distinguished between recommendations that we believe are critical to the delivery of safe and effective treatment from those that we believe to be of lesser importance. The categorical term "should" is used to designate crucial recommendations, whereas other recommendations are described in more equivocal terms such as "encouraged," "suggested," "recommended," or "considered".
As a final caveat, the practitioner should be aware that legal regulations exist regarding ECT, particularly concerning informed consent procedures (see Chapter 8). These regulations vary considerably among jurisdictions and over time. Consequently, these recommendations may not always be compatible with all requirements of present or future statutes. Accordingly, practitioners should seek out information on applicable regulations before beginning practice of ECT and should be aware of substantive statutory changes as they unfold.
We encourage practitioners and trainees in psychiatry as well as those in related disciplines to read this document and to integrate its recommendations into their clinical practice. It is designed to offer a comprehensive yet practical overview of the safe and effective use of ECT, with recommendations that should be applicable across a wide spectrum of clinical settings.
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