The ECT Handbook, 3rd Edition

This edition of The ECT Handbook is the fourth report of the Special Committee on Electroconvulsive Therapy (ECT) and Related Treatments. Compared with its third report published in 2006, the latest edition is significantly revised in light of newer research findings and updates from latest treatment guidelines. Several of its chapters have been updated and chapters on the following new topics have been added: (1) Mechanism of action of ECT; (2) Cognitive adverse effects of ECT; (3) Dental issues related to ECT; (4) Other brain stimulation treatments; and (5) Patients’ and carers’ perspectives on ECT. This edition also provides summaries and highlights on several important developments in ECT that have evolved over the past few years.

Depression remains the most frequent disorder for which ECT is used. Published clinical guidelines on depression (CG90) in 2009 by NICE (National Institute for Health and Care Excellence) include recommendations on the use of ECT in the treatment of depression. In this edition, there are no longer substantial differences between the Royal College’s views and those of NICE in this respect. Both recommend that ECT be considered for severe depression that is life-threatening, where a rapid response is deemed necessary or where other treatments have failed.

This edition also summarises recent amendments to mental health legislation and the relevant issues of consent and capacity pertaining to ECT. Electroconvulsive therapy is no different to other therapeutic interventions for which consent from patient should be obtained. However, ECT has a particular status both within psychiatry and within the law that makes its discussion necessary. The fact that the person receiving treatment has a psychiatric disorder of sufficient severity that ECT is being considered raises questions concerning their capacity. Therefore, an assessment of capacity is an important part of obtaining a valid consent for ECT and any form of coercion would be unethical and unacceptable. It is a recommended practice to seek every patient’s written consent using a standard consent form, but it is also important to verbally check the continuation of consent before each treatment session. At the same time, different countries have made amendments concerning this subject. For example, in Britain, the 2007 amendments to the Mental Health Act 1983 and the Mental Health Act (Scotland) 2003 have changed the legal framework for patients who do not or cannot consent to ECT. Therefore, practitioners should be familiar with the legal requirements of the country in which they are working and always keep up with the most up-to-date recommendations.

This edition also discusses the latest evidence on the pros and cons of unilateral versus bilateral electrode placement. Notably, several studies have pointed out that ECT can cause dysfunction in a wide variety of cognitive skills. Some indicate that a subject’s autobiographical memory can be affected for up to 6 months thereafter. The choice of electrode placement and stimulus dose should therefore balance efficacy against the risk of cognitive impairment. In previous editions, both the Special Committee on ECT and Related Treatments as well as NICE recommended routine adoption of unilateral electrode placement as a means of reducing potential adverse cognitive effects. However, over the past few years new evidence has been emerging regarding the relative efficacy and adverse cognitive effects of unilateral versus bilateral electrode placement. A NICE review in 2010 summarised findings from a few studies reported between 2002 and 2009 and concluded that there were few differences in efficacy or adverse cognitive effects between high-dose right unilateral ECT (i.e. treatment given at 4 or more times the seizure threshold) and bitemporal ECT. Another review published by Semkovska et al (2011) also concluded that significant benefits for unilateral electrode placements are limited to the first 3 days after the end of treatment. Based on the latest available evidence, the Special Committee now feels that most patients receiving ECT in Britain should start with bitemporal electrode placement.

This handbook is not just an important source of information about the latest evidence on ECT, but also a useful clinical guide on the prescription and administration of ECT. With the availability of all these new updates and research evidence, this latest edition of The ECT Handbook can serve as an essential guide for all psychiatrists, anaesthetists, and other medical professionals working in the area of ECT.

Candy Ching-Yi Wong, MBChB (email: wcy454@ha.org.hk)
Department of Psychiatry
Pamela Youde Nethersole Eastern Hospital
Chai Wan
Hong Kong SAR, China

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