5.3 Risks and side-effects of E.C.T.

1. Guidance very strongly advises against giving E.C.T. to patients who have had a recent myocardial infarction (heart attack), a recent cerebrovascular accident (stroke) or an intracranial mass or lesion (brain injury or tumour).

2 .Relative contraindications for E.C.T. are: angina, congestive heart failure, severe pulmonary disease, severe osteoporosis, major bone fractures, glaucoma, retinal detachment, thrombophlebitis and pregnancy. Heart disease in particular produces much greater risks for patients having E.C.T. There are many other side effects reported by survivors.

3. The greatest risks of E.C.T. are probably those associated with the regularly repeated general anaesthesia which is given.

4. There are divided opinions on whether E.C.T. causes brain damage.

5. The research into the relationship between E.C.T. and deaths caused by it tends only to concentrate on very short-term time scales. The risk of death from E.C.T. ranges from 0.002% to 0.0045%, although it is argued that many deaths are not reported or not linked to the administration of E.C.T. The risk of death is higher in older people than younger ones.

6. The immediate side effects of E.C.T. commonly include: amnesia, drowsiness, confusion, disorientation, apathy, physical weakness, headaches, nausea and dizziness. For older people, there are particular risks of heart problems, falls and strokes.

7. Memory loss or impairment is the most commonly reported side effect of E.C.T. Most survivors experience some short-term memory impairment, while a significant proportion report longer-term or permanent memory loss. Many survivors report that clinical staff tend to be rather dismissive of these complaints.

8. The level of memory impairment varies, at least in part, according to E.C.T. technique, with bilateral E.C.T. appearing to cause more severe memory loss than unilateral E.C.T., although the latter may cause more severe damage to the patient's brain.

9. Sine wave E.C.T. appears to cause more damage to patients than brief-pulse E.C.T.

10. The emotional and psychological effects of E.C.T. are often underestimated or ignored.

11. The Royal College of Nursing's E.C.T. - Guidance for Nurses identifies a range of measures that can reduce the anxiety of patients before E.C.T. and the level of memory impairment afterwards, including: management of anxiety; management of cognitive side-effects of E.C.T.; the type of information more likely to retained; and care planning.

5.4 E.C.T. and alternative treatments.

1. E.C.T. is not always used as a treatment of last resort before all other alternatives have been tried. This is, at least in part, due to the extreme severity of the condition of some patients.

2. In most cases, most psychiatrists see the prescription of drugs as the only real alternative to E.C.T. Relatively few patients (especially older people) are offered other (non-drug) therapies and many are offered no alternative at all.

3. There is little good research or evidence to demonstrate the relative effectiveness of E.C.T. and alternative treatments.

5.5 Rules, guidance and criteria for E.C.T.

1. The most widely accepted guidance for E.C.T. is The E.C.T. Handbook (including "checklists for good practice in E.C.T.") produced by the Royal College of Psychiatrists (61).

2. There is guidance for nurses in the Royal College of Nursing's E.C.T. Guidance for Nurses (137).

3. Guidance is also available in Electroconvulsive Therapy (E.C.T.). A Good Practice Statement and the accompanying summary for purchasers, produced by the Working Group on Mental Illness of the Clinical Resource and Audit Group at the Department of Health in The Scottish Office 26 27.

4. There are no accurate or accepted criteria to determine a person's threshold for the current involved in E.C.T.

5. The post-treatment care and observation of outpatients, but especially inpatients, has generally been given insufficient consideration.

6. There is no national specification for E.C.T. machines.

5.6 Quality of care and practice of E.C.T.

1. There are extremely wide variations in the use of E.C.T. between psychiatrists, hospitals and regions, without any apparently logical reasons for this.

2. Audits by the Royal College of Psychiatrists showed that one-third of units examined failed to deliver adequate care in 1981, and 21% in 1995. Despite some improvements in practice, only 30% of E.C.T. clinics were rated as good or exemplary in 1995.

3. The anaesthetic standards of care and practice used for E.C.T. are substantially inferior to those for other patients (such as those receiving day surgery) and commonly fall short of accepted national guidelines.

4. Despite several initiatives and audits by the Royal College of Psychiatrists since 1980, E.C.T. is still often being delivered by inadequately trained staff.

5.7 Training and supervision of clinical staff.

1. The Royal College of Psychiatrists recommends that each individual E.C.T. service should have a named consultant responsible for its supervision and for ensuring that it meets the standards set.

2. E.C.T. clinics that are genuinely consultant-led tend to achieve higher standards than others, but are the exception in Britain.

3. In Britain, most E.C.T. is administered by junior doctors on rotation. Many have had little or no training in E.C.T. and often administer it without consultant supervision. The training that is given is of variable quality.

4. The traditional British system of delegating responsibility to junior staff for the administration of E.C.T. effectively prevents accreditation and the assurance of high quality training and supervision.

5. There are no training or competency standards for nurses practising in E.C.T. clinics.