Recommendations for Treatment, Training, and Privileging

A Task Force Report of the American Psychiatric Association

The APA Task Force on Electroconvulsive Therapy:

Richard D. Weiner, M.D., Ph.D. (Chairperson)
Max Fink, M.D.
Donald W. Hammersley, M.D.
Iver F. Small, M.D.
Louis A. Moench, M.D.
Harold Sackeim, Ph.D. (Consultant)

APA Staff

Harold Alan Pincus, M.D.
Sandy Ferris

Published by the American Psychiatric Association
1400 K Street, N.W.
Washington, DC 20005

11.4.3. Electrical Safety Considerations

a) The device's electrical grounding should not be bypassed. ECT devices should be connected to the same electrical supply circuit as all other electrical devices in contact with the patient, including monitoring equipment (see Section 11.7).

b) Grounding of the patient through the bed or other devices should be avoided, except where required for physiological monitoring (see Section 11.7).

11.5. Stimulus Electrode Placement

11.5.1. Characteristics of Stimulus Electrodes

Stimulus electrode properties should be in conformance with any applicable national device standards.

11.5.2. Maintenance of Adequate Electrode Contact

a) Adequate contact between stimulus electrodes and the scalp should be assured. Scalp areas in contact with stimulus electrodes should be cleansed and gently abraded.

b) The contact area of the stimulus electrodes should be coated with a conducting gel, paste, or solution prior to each use.

c) When stimulus electrodes are placed over an area covered by hair, a conducting medium, such as a saline solution, should be applied; alternatively, the underlying hair may be clipped. Hair beneath the electrodes should be parted prior to application of the stimulus electrodes.

d) Stimulus electrodes should be applied with sufficient pressure to assure good contact during stimulus delivery.

e) Conducting gel or solution should be confined to the area under the stimulus electrodes, and should not spread across the hair or scalp between stimulus electrodes.

f) A means of assuring the electrical continuity of the stimulus path is encouraged (see Section 11.4.1.(g)).

11.5.3. Anatomic Location of Stimulus Electrodes

a) Treating psychiatrists should be familiar with the use of both unilateral and bilateral stimulus electrode placement.

b) The choice of unilateral versus bilateral technique should be made on the basis of an ongoing analysis of applicable risks and benefits. This decision should be made by the treating psychiatrist in consultation with the consentor and the attending physician. Unilateral ECT (at least when involving the right hemisphere) is associated with significantly less verbal memory impairment than is bilateral ECT, but some data suggest that unilateral ECT may not always be as effective. Unilateral ECT is most strongly indicated in cases where it is particularly important to minimize the severity of ECT-related cognitive impairment. On the other hand, some practitioners prefer bilateral ECT in cases where a high degree of urgency is present and/or for patients who have not responded to unilateral ECT.

c) With bilateral ECT, electrodes should be placed on both sides of the head, with the midpoint of each electrode approximately one inch above the midpoint of a line extending from the tragus of the ear to the external canthus of the eye.

d) Unilateral ECT should be applied over a single cerebral hemisphere. Most practitioners using unilateral electrode placement routinely place both electrodes over the right hemisphere, since it is usually nondominant with respect to language even for the majority of left-handed individuals. Stimulus electrodes should be placed far enough apart so that the amount of current shunted across the scalp is minimized. A typical configuration involves one electrode in the standard frontotemporal position used with bilateral ECT, and the midpoint of the second electrode one inch ipsilateral to the vertex of the scalp (d'Elia placement).

e) Care should be taken to avoid stimulating over or adjacent to a skull defect.