ECT Trust Wide Medical Protocol UPDATE

ELECTROCONVULSIVE THERAPY

Protocol for the preparation and administration of ECT

Version: 8 Policy Number: 7762 Policy Lead/Author & position:

Dr R.Tobiansky,Consultant Psychiatrist

Ward / Department: ECT Department Replacing Document: Previous version Approving Committee / Group:

ECT Department

Date Approved/Ratified: 14th March 2011 Ratified by: Governance and Risk

Management Committee Previous Reviewed Dates:

November 2010

Date of Current Review:

January 2011

Date of Next Review: August 2011 Relevant NHSLA Standard(s):

ECTAS; NICE Guidance; Trust policies

Target Audience All clinical staff involved in the preparation and treatment of patients who may be offered ECT

Electroconvulsive Therapy Protocol Version 8

Version Control Summary Version Date Section Author Comments 8 14/03/2011 DrTobiansky Update


Contents: 1. Introduction 2. List of key Personnel 3. Transportation of patients 4. Indications for ECT 5. Contraindications 6. Medical Workup 7. Fasting before ECT 8. Consent 9. Prescription & Monitoring 10. Using the Thymatron system 4 11. Seizure Threshold

12. Selecting the Dose (Stimulus Dosing Regimen) 13. Administering ECT 13(i)- The Anaesthetist's Role 13(ii)- Preparing the Patient

13(iii)- Impedance Measurement 13 (iv)- Administering the Treatment Stimulus 14. Seizure Monitoring 15. Missed Seizures 16. Prolonged Seizures 17. Treatment Record 18. Number of treatments in a course 19. Maintenance & Continuation ECT 20. Outpatient ECT 21. Vulnerable patient groups 22. Training 23. Quality Assurance 24. List of Other ECT related Documents

Appendices: 1. Care Pathway / Checklist for patients having ECT 2. Extract from NICE guidance on ECT 3. Summary of operating instructions for Thymatron system 4 4. Table of dose stimulus parameters

5. Consent form (including form 4 for incapacitated informal patients) 6a. ECT Referral form 6b. Pre- ECT Anaesthesia assessment 7. Pre ECT Anaesthesia assessment guidelines 8. Patient information document 9. Outpatient ECT patient leaflet and pre-discharge checklist

10. Responsibilities of Nursing staff 11. Medication Strategies for Treatment Resistant Depression 12. ECT Treatment record for case notes 13. Montgomery-Asberg Depression Rating Scale 14. ECT competencies 15. Blood results chart 16. ECT & Driving RCPsych. Advice 17. Guidelines on Dental Management in ECT patients 18. ECT Treatment Record


1. INTRODUCTION Since February 2005, all ECT treatment within the Trust has been provided at the ECT suite in the Mental Health Unit at Chase Farm Hospital (The Chase Building). The service was officially accredited by ECTAS (a rigorous accreditation system administered by the Royal College of Psychiatrists) in 2006. Following completion of a second audit cycle the clinic was peer reviewed in March 2009 and received accreditation with excellence. The aim of this document is to inform clinical staff about how ECT is given in this unit. The contents reflect the guidance in the Royal College of Psychiatrists' " ECT Handbook, 2nd edition" (CR128, 2005) and the guidance from the National Institute of Clinical Excellence (NICE-April 2003), updated by CG90, the clinical guidelines on Depression (NICE Oct 2009). Documents relating to the practice of other professionals involved in providing ECT are listed at the end of this paper. This document is not intended to be a sole reference for theoretical and clinical knowledge about ECT. Readers wishing to consult a definitive textbook on ECT are referred to Richard Abram’s “Electroconvulsive Therapy”, 4th edition. The ECT service will provide high standards of treatment with ECT, complying with the requirements of the Royal Colleges of Psychiatrists and Anaesthetists, the UKCC, the Care Quality Commission and taking cognizance of NICE guidance. The process of providing ECT should be as safe, acceptable and effective as possible for the patient. The role of the patient's prescribing Consultant, ward team and care-coordinator is central to meeting this aim, specifically in identifying whether or not ECT is indicated, ensuring that lawful consent is obtained and monitoring the patient closely before, during and after the course of ECT. With a single-site, Trust-wide ECT service it is necessary to ensure the safe transportation of patients from Barnet and Haringey to and from the ECT unit at CFH. In order to facilitate the smooth running of the ECT clinic, it is essential that all patients are properly prepared, that documentation is complete and that nurse escorts are available. The safe and effective running of the service will depend on a clinical partnership between the patient’s prescribing Consultant and ward team and the ECT department. There will therefore be shared responsibility for ensuring that ECT is given to the best possible standards. The care pathway for patients undergoing ECT is intended to serve as an “aide memoir” and checklist for clinical staff that prescribe ECT and prepare patients for treatment. ECT staff reserve the right to cancel treatments in the interests of patient safety if patients are not properly prepared and if the care pathway is not followed. ECT is most commonly prescribed for inpatients, but it may also be given on an outpatient or day-patient basis. This document applies to ECT in all settings


2. KEY PERSONNEL IN THE ECT DEPARTMENT It is advisable that ECT referrals are made at least a day before ECT sessions, which are held on Tuesdays & Fridays. To make a referral contact Miss Tina Keeling, ECT Secretary, DIRECT LINE- 020 8375 1519 or 0845111 4000 ext 3389. If unavailable contact Karl Sunkersing. The ECT service manager and coordinator at CFH is Karl Sunkersing, who can be contacted at CFH on 08451114000 bleep number 3886 or on 02083752102 The telephone number of the ECT suite is 02083751542 ECT Consultants The Trust-wide Lead Consultant Psychiatrist for ECT is Dr Robert Tobiansky office tel 02089377117, mobile tel 07976839787 or long range pager tel. 08448222888, pager number 867137. Dr Tobiansky attends the clinic on Fridays. Dr. Ioana Popescu is the other ECT Consultant and attends the ECT clinic on Tuesdays mobile tel. 07710728816 Anaesthetists There are two Consultant Anaesthetists with responsibility for ECT, Dr Thillai tel 07770954052 attends on a Tuesday and Dr. Haemeed on 07946293366 attends on a Friday. An anaesthetic opinion can be requested by contacting either of the anaesthetists or by contacting the dept. of anaesthesia at Chase Farm Hospital x 1411 or 02083751040 for Enfield & Haringey patients or Barnet Hospital 02082165283 for Barnet patients. When in doubt it is advisable to speak to one of the anaesthetists before sending the patient for ECT. 3.Transportation of patients from Barnet or Haringey to CFH All patients travelling from either Barnet or Haringey must have an appropriately qualified nurse escort. It is the responsibility of the ward manager (or in the case of outpatients, the care coordinator) to ensure that this is provided. Problems encountered in the provision of escorts will be resolved in consultation between the ward manager / care coordinator and the lead nurse and / or Service Director. The contract for transportation of patients is now provided by London Ambulance Service. The service specification requires flexibility, reliability and safety. In very exceptional circumstances, the team prescribing ECT may judge that it is clinically unsafe for patients to travel from Barnet or Haringey. In this situation discussions will need to take place at Service Director level, as to the feasibility of transferring that patient to the Mental Health Unit at CFH for the duration of the ECT course.


4.INDICATIONS FOR ECT

Depression is the condition for which ECT is most often prescribed, but it can be an effective treatment for mania, as well as catatonia and puerperal psychosis. It can also be effective in treating acute paranoid/psychotic states and schizoaffective disorder. NICE guidance (HTA 2003) initially restricted the indications for ECT to severe depression, catatonia and severe or treatment resistant mania (see appendix). This guidance has now been updated (CG90) to include Depression which is of moderate severity but which has been resistant to other treatments. The Royal College of Psychiatrists (RCPsch.) and the Scottish ECT Audit network (SEAN) had challenged the original NICE guidance in this and other respects. Nevertheless, it is advisable to seek a second opinion in situations where ECT has been prescribed for indications other than those described in NICE guidance.

ECT is a fast and reliable form of treatment, which can make it the treatment of choice when any of the above conditions is severe, and giving rise to significant short-term risks, such as severe depression leading to dangerous self neglect or suicidal behaviour. NICE guidance urges that ECT should only be prescribed after a documented assessment of risks and benefits has been made and fully discussed with the patient.

ECT is also used when drug treatments have failed, or is relatively contraindicated (e.g. by severe side effects), or where a known individual's psychiatric history tells us ECT is the best choice of treatment for them. Medication is usually given concurrently with ECT, to prevent later relapse. The following guidance on indications for ECT is extracted from Scott et al, Advances in Psychiatric Treatment 2005 as well as NICE CG90

RCPsych. guidance on ECT in the treatment of depressive illness

• ECT may be the treatment of choice for severe depressive illness when the illness is associated with:

• attempted suicide • strong suicidal ideas or plans • life-threatening illness because of refusal of food or fluids

• ECT may be considered for the treatment of severe depressive illness associated with: • stupor • marked psychomotor retardation • depressive delusions and/or hallucinations

• In the absence of the above, ECT may be considered as a second- or third-line treatment


of depressive illness that has not been adequately treated by antidepressant drug treatment and where social recovery has not been achieved

• The selection of ECT may be affected by: • patient preference • previous experience of ineffective and/or intolerable medical treatment • previous recovery with ECT

NICE guidance on ECT in the treatment of depressive illness (CG90)

• Consider ECT for acute treatment of severe depression that is life threatening and when a rapid response is required or when other treatments have failed.

• ECT should not be used routinely for moderate depression but should be considered if there has not been a response to multiple drug treatments and psychological treatment

Although the 2003 HTA explicitly stated that maintenance ECT was not recommended, there is recognition in the updated guidance that maintenance ECT may be necessary in some circumstances. Suggestions for accommodating prescription practices to the discrepancy between College and NICE guidance in depressive illness

• Divergence would occur only if ECT were used: • if the episode was not potentially life-threatening or severe • if the episode was not demonstrably treatment resistant • as continuation or maintenance treatment

• Health professionals should make decisions appropriate to the individual patient, in consultation with the patient and/or guardian or carer

• The NICE guidance in itself does not have legal jurisdiction over clinical practice • Any deviation from the NICE guidelines would require a documented assessment of

potential risks and benefits and the patient’s true valid informed consent • An informal second opinion may be helpful in controversial indications • Prescribers ought to exercise particular circumspection in depressed patients who have

never before been treated with ECT (they have no personal experience to enable them to weigh the benefits and costs of ECT)

• The balance between immediate benefit and longer term-risk of distressing retrograde amnesia can be moved in favour of benefit by considering the use of unilateral ECT

• Valid and documented patient preference may support divergence from the guidance

Treatment failure in depressive illness

• Initial treatment failure may be defined as a lack of recovery after a course of an antidepressant drug given at a proven effective dose for at least 6 weeks

• Elderly patients may take longer to respond to antidepressant drug treatment • A switch to an antidepressant drug with a different mode of action is the preferred second-

line treatment where there is no urgent need for treatment. If the depressive illness persists with antidepressant treatment, several options are available (see appendix):

• add an augmenting agent such as lithium carbonate • adjunctive cognitive–behavioural therapy or similar • ECT


The place of ECT in the treatment of mania:

• The treatment of choice for mania is a mood-stabilising drug plus an antipsychotic drug • ECT may be considered for severe mania associated with:

• life-threatening physical exhaustion • treatment resistance, that is, mania that has not responded to the treatment of

choice • The selection of ECT may be affected by:

• patient choice • previous experience of ineffective and/or intolerable medical treatment • previous recovery with ECT

The place of ECT in the treatment of acute schizophrenia:

• The treatment of choice for acute schizophrenia is antipsychotic drug treatment • ECT may be considered as a fourth-line option, that is, an option for treatment-

resistant schizophrenia after treatment with two different antipsychotic drugs and then with clozapine has already proven ineffective or intolerable

The place of ECT in neuropsychiatric conditions: Parkinson’s disease: ECT is a safe adjunctive treatment for both motor and affective symptoms in people with severe disability despite medical treatment Catatonia: The treatment of choice is a benzodiazepine drug; most experience is with lorazepam. ECT may be indicated when treatment with lorazepam has been ineffective. ECT remains an experimental treatment for disorders such as neuroleptic malignant syndrome, Huntington’s disease and treatment- resistant epilepsy

5.CONTRAINDICATIONS TO ECT

Given that psychiatric disorders can be life threatening, most practitioners only consider relative contraindications, with a balance of risks and benefits of all the options being necessary. The opinion of the anaesthetist should be sought as far in advance of treatment as possible. Where the risk of physical health complications is high, the ECT may be carried out in main operating theatres in Barnet or CFH, to be nearer appropriate resuscitation facilities.

Examples of conditions where high anaesthetic risk exists are: Myocardial Infarction in the last 3 months


Cerebrovascular Accident in the last 3 months Cardiac failure Valvular heart disease Aneurysm or other vascular malformation Unstable cervical spine Any medical condition which limits physical activity (ASA grade 3 and above see below)

6. MEDICAL WORKUP & PREPARATION FOR ECT

Please also refer to the section on “Giving ECT”. The “pre-ECT anaesthesia questionnaire” form (see appendix 6) must be completed for all patients referred for ECT and an ASA grade assigned. Detailed pre-anaesthesia assessment guidelines are also provided as an appendix to this document. A physical examination must be completed and documented in the notes. Where the patient is physically fit (ASA grade 1), the anaesthetist does not require a referral prior to the first treatment session but will meet the patient on the morning of treatment.

It is the responsibility of the patient's psychiatric team to decide whether referral to the anaesthetist for assessment is necessary before ECT is started. The anaesthetist should be informed at least 24 hrs in advance of the first treatment, and earlier if possible. The referral should be made to the department of anaesthesia (see the section on Key personnel). Where urgent anaesthetic review is necessary the anaesthetics department can direct you to the appropriate doctor. The referring psychiatric team should allocate an ASA Grade to a patient prior to ECT. This is as follows:

1. Fit and well, a healthy patient. 2. Minor medical problems, not affecting lifestyle.

3. A patient with severe systemic disease that limits activity but is not incapacitating 4. A patient with an incapacitating systemic disease that is a constant threat to life 5. A moribund patient not expected to survive 24 Hours, with or without operation.

For ASA grade three or more then it is essential that the patient’s case is discussed with the anaesthetist prior to the patient attending the ECT suite (see below). Attention should be paid, in the history and physical examination of the patient, to the cardiovascular, respiratory, and neurological systems, with an enquiry into oesophageal reflux. The state of dentition (missing or loose teeth, dentures, implants, crowns etc), and previous anaesthetic history should be known and documented. All current medication and known drug sensitivity must be recorded.

Results of recent Haemoglobin and U&Es should be recorded in the notes and written on the blood results sheet (see appendix), with


other blood investigations and referrals to specialists carried out as indicated. Potassium levels must be within normal range before an anaesthetic is given. For patients on anticoagulants the results of the most recent INR must be available. For diabetic patients on insulin the blood glucose level on the morning of ECT must be available. Patients with hiatus hernia or reflux should be prescribed ranitidine 300mg or omeprazole 40mg A chest X-ray should be done if indicated. An ECG is indicated in any patient on vasoactive drugs, diabetics over 40, men over 40, women over 55 and any patient with known ischaemic heart disease. To summarise the procedure for Pre- ECT Preparation: 1. Routine laboratory investigations should be carried out and results written on the results sheet (see appendix). 2. Ordering of additional tests should be guided by the presence and severity of medical risk factors. 3. Refer to the pre-assessment guidelines for help. When in doubt consult the anaesthetist. 4. Occasionally, if the patient has a severe needle phobia or is refusing to have blood tests these may be carried out when the patient is under anaesthesia. 5. Regular medications should usually be continued during a course of ECT, especially antihypertensives, which should be given on the morning of ECT but omit diabetic medication on the morning of treatment. 6. Complete the ECT referral form and anaesthetic proforma (appendix 6a and 6b) Patients with ASA grade 3 and above: An anaesthetic consultation/evaluation should be requested before the first ECT, or during a course of ECT if there is a significant change in the patients medical status or medications. After assessing the patient, the anaesthetist may order further investigations and may advise referral to other specialists (eg Cardiac / Respiratory) before proceeding. Having identified the peri-ECT risk, the anaesthetist will than decide to carry out the treatment in the main hospital theatre suite . Very stable ASA3 with low risk can have the treatment in the ECT suite itself. The ECT coordinator MUST be informed when the patient needs to have the treatment in the main hospital - in order to make the necessary arrangements. The medical case notes must be available at the ECT clinic; results of recent investigations should be properly filed in the notes and written in the notes or on Rio. The referring team must make available the completed anaesthesia proforma, the consent form or copies of the relevant MHA papers, all relevant details from history, including previous ECT treatment and a list of current medication. At each treatment session ECT staff will document details of the treatment given. This is done on a proforma “sticky label” which will


be placed in the case notes (see appendix 12). A similar entry will also be made on Rio. Following each ECT treatment, it is essential that requests for investigations and other feedback from ECT staff made in the case notes are acted upon by the ward team.

Various factors affect seizure threshold (see later section) and consideration should be given to the effect of changing treatments. The following factors are known to influence seizure threshold:

INCREASE THRESHOLD REDUCE THRESHOLD

Older Age Caffeine Anticonvulsants (incl. benzodiazepines) Hypocapnoea Baldness Theophylline Bones (thickened, any cause) SSRIs Dehydration antipsychotics Recent ECT Male gender MAOIs Propofol / other anaesthetic induction agents Poor electrode contact (due to hair, oil, etc.)

7. FASTING before ECT

All food, solids, alcohol and drinks with milk should be excluded in the six hours prior to ECT. Other drinks: clear fluids, non-particulate fruit juices [i.e. no bits in them] can be taken up to two hours prior to ECT. In the final two hours before ECT no fluids should be given at all. Chewing gum should be avoided in the two hours prior to ECT as it produces large amounts of saliva, which builds up in the stomach. The anaesthetist usually advises that patients on regular anti-hypertensive medication should take this medication with a small amount of water on the morning of ECT.

8. CONSENT, CAPACITY, THE MENTAL HEALTH ACT 2003 (as amended 2007) & MENTAL CAPACITY ACT 2005 CONSENT To ECT, including a discussion of potential benefits and adverse effects of ECT, must be obtained by the Responsible Consultant or prescribing doctor

The indications for, likely risks and benefits of as well as the actual process of ECT should be explained to the patient (and their carer - relative, next of kin, significant other or advocate– where appropriate). Potential risks and benefits of the treatment, and those


of all alternatives, should be discussed. The patient information document may be used to help in this process, where it is thought appropriate, with a chance to discuss it with a professional (e.g. primary nurse). This is not an alternative to a full discussion between doctor and patient when assessing capacity and seeking consent.

The efficacy and safety of ECT is well-established (see Geddes et al Lancet 2003 for review). The evidence indicates that in the short-term, ECT is a highly effective treatment for Depression, with either partial or complete remission of symptoms seen in approximately 85% of appropriately selected patients. Bilateral ECT frequently leads to short-term impairment of memory although it remains unclear for how long this persists. This is less likely with unilateral ECT. Some patients who have had bilateral ECT may complain of gaps in autobiographical memory for periods of up to several years before the treatment. While bilateral ECT is commonly associated with retrograde and anterograde amnesia for the period around the treatment course, there is no evidence of any persistent impairment of actual memory function (“working memory”) due to ECT. There is no evidence of structural brain damage from ECT. Different doses and modes of application of ECT appear to show differences in efficacy and adverse acute effects. Where there are specific concerns about memory disruption, unilateral ECT may be preferred. The commonest adverse effects following bilateral ECT are headache, myalgia and memory disruption. Transient nausea, drowsiness and weakness may also be experienced. Transient arrhythmias, hyper- and hypotension, post-ictal delirium, and spontaneous or prolonged seizures may occur. There is also a need to be aware of damage to dental work and a fractured tooth and cut lip can occur. Other rare but more serious adverse effects include, aspiration, fractures, ruptured viscus, myocardial infarction, CVA, ruptured aneurysm etc. The overall mortality rate associated with ECT is estimated at around 1 in 50 000, which is roughly the same rate associated with brief anaesthetic procedures. (see patient information leaflet and section on risks and benefits).

NICE CG90 makes specific reference to the consent process: 12.2.7.4 When considering ECT as a treatment choice, ensure that the person with depression is fully informed of the risks associated with ECT, and with the risks and benefits specific to them. Document the assessment and consider: • the risks associated with a general anaesthetic • current medical comorbidities • potential adverse events, notably cognitive impairment


• the risks associated with not receiving ECT. 12.2.7.5 A decision to use ECT should be made jointly with the person with depression as far as possible, taking into account, where applicable, the requirements of the Mental Health Act 2007. Also be aware that: • valid informed consent should be obtained (if the person has the capacity to grant or refuse consent) without the pressure or coercion that might occur as a result of the circumstances and clinical setting • the person should be reminded of their right to withdraw consent at any time • there should be strict adherence to recognised guidelines about consent, and advocates or carers should be involved to facilitate informed discussions • if informed consent is not possible, ECT should only be given if it does not conflict with a valid advance decision and the person’s advocate or carer should be consulted. 12.2.7.6 The choice of electrode placement and stimulus dose related to seizure threshold should balance efficacy against the risk of cognitive impairment. Take into account that: • bilateral ECT is more effective than unilateral ECT but may cause more cognitive impairment CONSENT & CAPACITY: There are several potential scenarios with regard to consent and capacity:

• A detained patient with capacity who gives or withholds consent

• A detained patient without capacity • An informal patient with capacity who gives or withholds

consent • An informal patient without capacity

The Detained Patient who Consents to ECT: Where an adult detained patient consents to ECT and the AC in charge of administering the ECT or a SOAD considers that the patient is capable of understanding the nature, purpose and likely effect of the treatment, the consent form is completed, and the AC or SOAD completes Form T4 (in accordance with section 58A(3)(c)), stating the number of treatments to be given. Further consent (and a new Form T4) is sought if the number of treatments is to be exceeded. Further consent (and a new Form T4) will also be required if it was completed by an AC and that AC ceases to be the AC in charge of the treatment.


The Detained Patient who does not Consent to ECT: Under the Mental Health Act 1983 (as amended), a detained patient with capacity, who withholds consent, cannot be treated with ECT (see below), except when it is judged necessary to be given in an emergency under section 62. The Detained Patient without capacity to consent: When there is no consent from a detained patient through lack of capacity, a Second Opinion Appointed Doctor (SOAD) appointed by the Care Quality Commission is requested to assess the suitability of the ECT treatment plan. If they comply with section 58A(5) by signing Form T6, treatment can continue without the patient's consent, up to the number of treatments specified by the SOAD. Emergency ECT for Detained Patients: Patients who are liable to detention may be given emergency ECT under section 62 if it is immediately necessary to save the patient’s life or immediately necessary to prevent a serious deterioration of the patient’s condition (and is not irreversible, i.e. does not have unfavourable irreversible physical or psychological consequences). This applies to patients with or without capacity. Although custom dictates that a maximum of two treatments should be given under section 62, there is no statutory limit on the number of treatments under section 62. Informal patients: Informal Patients with Capacity to Consent: If the patient is informal, and has capacity to give consent, they can sign the consent form. The prescribing doctor who has explained it also signs, and should record the interview discussion concerning risks, benefits, alternatives, likely outcomes and capacity in the patient's case-notes. NICE guidance emphasises that consent should be an ongoing process and may be withdrawn at any time. The ward team should ensure that, where informed consent is required for a patient's treatment, such consent is ongoing and that this is noted before each treatment. The ECT staff will repeat this procedure prior to administering the ECT. Informal Patients without capacity to consent: In the situation where an informal patient cannot consent through lack of capacity, it was previously possible for ECT to be given under the common law doctrine of necessity. This situation has now changed, with the Mental Capacity Act 2005. If an informal patient who requires ECT lacks capacity then we must consider use of the MHA if:

• They are dissenting in any way • It is not possible to give the ECT without depriving them of

their liberty


• They may need to be restrained in a way that is not allowed under the MCA

• It is not possible to assess or treat them safely or effectively without treatment being compulsory

If it is decided that it is not appropriate/necessary to use the MHA, we can give them ECT in the absence of consent if it is in their best interests, under section 5 of the Mental Capacity Act. However, in keeping with the Mental Capacity Act 2005, the “best interests” check-list should be followed and carefully documented, other people (carers, relatives, attorney under LPA etc) should be consulted. If there is no one who is appropriate to consult with then an Independent Mental Capacity Advocate (IMCA) should be involved (Contact VoiceAbility on 0845 0175 198 or [email protected]). If time allows, a non-statutory second opinion from a Consultant colleague should be sought. If there is a valid and applicable advance decision made by the patient not to receive the treatment or the treatment would conflict with a decision made by a health and welfare deputy or donee of a Lasting Power of Attorney, or there is an order from the court of protection against treatment, then ECT cannot be given.

Further points on THE MENTAL HEALTH ACT (as amended) Under age 18 with consent Whether detained or informal, a SOAD will need to certify the consent and that the treatment is appropriate (using Form T5), i.e. section 58A(4) applies. If a patient is under 18 and lacks capacity then the same provisions as for adults who lack capacity apply (as set out above). Detained patient without capacity to consent: The SOAD needs to certify that the patient is not capable of understanding the nature, purpose and likely effects of the treatment, that it is appropriate for the patient to receive the treatment and there is no conflicting advance decision or decision by a donee under a Lasting Power of Attorney, health and welfare deputy or the Court of Protection. The SOAD is also under a duty to consult with a nurse concerned with the patient’s medical treatment and one other who is professionally concerned but who is not a doctor or a nurse. Neither can be the RC or the AC in charge of the ECT. Regarding the detained patient who does not have capacity at the time ECT is prescribed, and it is subsequently given following a second opinion and the completion of form T6: It is possible / probable that at some point during the course of treatment, the patient will regain capacity to consent and consequently it will not be lawful to continue treatment in the absence of consent. In these circumstances, all detained patients who are deemed not to have capacity to consent must be made subject to a capacity test as close


in time as practicable to each planned administration of ECT, thus ensuring that the treatment is administered lawfully (or not administered at all). Assuming the patient now has capacity and does consent, the appropriate form must be signed (T4). 9. PRESCRIPTION of ECT by the Responsible Consultant & Monitoring the Effects of ECT during and after a course The decision to prescribe ECT, including due consideration of the likely risks and benefits should be carefully documented by the prescribing psychiatrist. The ECT referral form and anaesthetic proforma (appendix 6a & b) should be completed and sent to the ECT department. The ECT treatment record (see appendix 18) will now be kept in the ECT department. A pro-forma, printed on a sticky label, will be completed by the ECT team and affixed in the patients case notes for the purposes of communicating clinical details on the


patient, and for recording treatments. There is also a section on the pro-forma for the Consultant to sign when further ECT is prescribed. Details of the ECT treatment will also be recorded on Rio under the progress notes.

The prescription of ECT is the responsibility of the patient’s Consultant or senior responsible clinician, who retains overall clinical responsibility for the patient. The Responsible Clinician / Consultant must sign the patient agreement (consent form) in the appropriate section. The decision as to whether to prescribe unilateral or bilateral ECT or whether to use fixed dose or dose-titrated ECT is that of the prescribing consultant. Where there is any doubt about the most appropriate modality, this should be discussed with one of the ECT Consultants. There is some debate on methods of determining stimulus dose and on laterality (bilateral vs. unilateral ECT). If the prescribing consultant does not stipulate either bilateral or high dose unilateral ECT or the method of dose selection, the “default” position has been to give dose-titrated bilateral ECT, although this policy will be kept under regular review.

Patients having ECT should be reviewed at an appropriate time after each treatment, with a record of the mental state examination being made in the notes. It is good practice to use a standardised rating scale for changes in mood in order to attempt to document change in response to ECT in a valid and reliable way. The Montgomery–Asberg Scale (see appendix) is a suitable instrument and could be completed prior to ECT and after every 2 or 3 treatments. The prescribing consultant should sign the ECT treatment proforma (sticky label, see appendix 12) prior to the next two treatment sessions as a minimum, or preferably prior to each treatment. It is good practice to ensure that the patient has given on-going consent to further ECT treatment and to document this discussion in the case-notes. The same would apply to patients having maintenance ECT. Patients should be reviewed by their clinical team after each treatment and specifically asked about side-effects, particularly with regard to memory. It is also good practice to record baseline cognitive function eg with the MMSE and to repeat this approximately weekly, in order to monitor for significant cognitive side-effects related to ECT. If there are concerns about significant cognitive side-effects this should be discussed with the ECT team. ECTAS standards recommend that the patient’s cognitive side effects/memory are assessed using the MMSE and subjective questioning in a clinical interview by the referring psychiatrist 3 or 4 days after the end of the treatment course, and at 1 or 2 months follow up.


The latest ECTAS standards also require that the patient's clinical status/symptomatic response is assessed and recorded at baseline, between each treatment session, and following the course of ECT using the Clinical Global Impression (CGI) scale. The standards further recommend that the patient's clinical status / symptomatic response is recorded 3 and 6 months after treatment and the patient’s memory and cognitive functioning is recorded 3 and 6 months after a treatment course is finished NICE CG 90 October 2009 stipulates the following: 12.2.7.7 Assess clinical status after each ECT treatment using a formal valid outcome measure, and stop treatment when remission has been achieved, or sooner if side effects outweigh the potential benefits. 12.2.7.8 Assess cognitive function before the first ECT treatment and monitor at least every three to four treatments, and at the end of a course of treatment. 12.2.7.9 Assessment of cognitive function should include: • orientation and time to reorientation after each treatment • measures of new learning, retrograde amnesia and subjective memory impairment carried out at least 24 hours after a treatment. If there is evidence of significant cognitive impairment at any stage consider, in discussion with the person with depression, changing from bilateral to unilateral electrode placement, reducing the stimulus dose or stopping treatment depending on the balance of risks and benefits. 12.2.7.10 If a person’s depression has responded to a course of ECT, antidepressant medication should be started or continued to prevent relapse. Consider lithium augmentation of antidepressants.

10. USING THE THYMATRON SYSTEM 4 (see summary in appendix)

The current ECT apparatus is the Thymatron system 4. This allows a record of EEG activity which is a useful indicator of seizure length and generalization. The apparatus can deliver a charge of up to 1000mC if required. The Thymatron has two dials, one of which, the “percent energy” dial determines the stimulus dose (as percent energy and charge in millicoulombs) and the other, the Flexdial, which determines the properties of the treatment stimulus such as frequency and pulse width. These parameters can be adjusted to promote a seizure


without increasing the dose of electric charge. For a given dose, if either of these parameters is varied, the treatment stimulus time will vary. This is the function of the settings on the flexdial. It can be used to manipulate the characteristics of the electrical impulse. The maximum stimulus duration is fixed at 8 seconds. The decision to adjust the flexdial in this way should be made by the ECT consultant. The central “percent energy” dial is used to set the dose of electrical charge delivered during treatment. It is marked 0 - 100%. The 100% position represents a dose of 504 millicoulombs (mC). For a higher dose it can be set to X2 output, so that 120% equates to 600mC etc, increasing to a maximum dose of 200% or 1000 mC. Rotation of the dial displays the percent energy settings for each stimulus dose, followed by a 1-second display of the corresponding stimulus charge in mC.

11. SEIZURE THRESHOLD

The purpose of ECT is to stimulate the brain electrically in order to produce clinical improvement. Effective stimulation always induces a generalised bilateral seizure. Seizure Threshold (ST) is taken to be the lowest stimulus dose that induces a generalized convulsion. However, it is known that the mere induction of a seizure is not sufficient to be therapeutically effective. To be clinically effective the stimulus needs to be at a dose sufficiently above ST. In the case of bilateral ECT, the therapeutic stimulus needs to be approximately 2 x ST. In the case of unilateral ECT the therapeutic stimulus needs to be approximately 4 - 6 x ST. (Abrams. Stimulus titration and ECT Dosing. Journal of ECT 18(1) 13-9. 2002) Seizure threshold varies. Biological variation accounts for the greatest part of this. Remember that poor technique will contribute to variation in response. Electrodes need to be applied firmly, rotated to and fro and then kept still. Various other factors affect ST as described previously, but ECT itself raises the seizure threshold. This is noticeable over a course of treatment (up to 100% increase, but usually around 30-40%).

12.SELECTING THE STIMULUS DOSE FOR ECT

The stimulus dose can be determined in a number of ways, 3 of which will be mentioned here. For patients who begin a new course of treatment, we would usually determine the seizure threshold by a stimulus dosing regime (see below), unless the prescribing consultant requests otherwise.

a. The “age-based” formula for determining stimulus dose: For bilateral ECT the dial labeled percent energy should be set to approximately one-half the patients age (eg 25% for a 50 year-old). If there is no seizure, the percent energy setting should be set to double the initial dose (eg 50% for a 50year old) and the patient re-


stimulated within 30 – 60 seconds to maximise the likelihood of obtaining a therapeutically satisfactory seizure during the first treatment session. For unilateral ECT the percent energy dial should be set to the patient’s age in years eg 75% for a 72 year-old patient.

b. The “benchmark” method for setting and adjusting the ECT stimulus dose;

Since neither seizure duration nor seizure threshold are systematically related to the clinical efficacy of an ECT treatment, another approach is to regulate the stimulus dose according to a physiological measurement that has been reported to correlate with treatment response i.e. a “target measure”. One possible target measure is the postictal EEG suppression index (PSI), which the Thymatron will calculate as the ratio of the peak amplitude of EEG activity relative to the flattened trace observed following cessation of such activity. In this method, a stimulus dose is given which is high enough to induce vigorous and effective seizure activity in the majority of patients. The value of the target measurement (such as PSI) is then used as a goal for all subsequent treatments. Selection of the initial stimulus dose can be made by the fixed-dose method or an age based method. A fixed dose of 75 – 90% energy should be high enough for the vast majority of patients, regardless of treatment electrode placement. Alternatively the percent energy dial can be set to the patients age for unilateral ECT or for 50 – 75 % of patients age for bilateral ECT. Dosage should be adjusted for subsequent treatments to maintain the PSI at same value as the benchmark, keeping in mind that seizure threshold will rise across a course of treatment.

c. Stimulus Dosing Regimen

Seizure threshold (ST) varies widely. In order to avoid giving a dose that far exceeds the necessary therapeutic stimulus, (which may induce unnecessary cognitive side-effects), an attempt is made to estimate the ST. At the first session more than one stimulus may be used, starting from a low dose, and increasing until a seizure is induced. This is taken as the ST. This is the procedure for titration of the dose of electrical charge given against the resulting seizure. This stimulus dosing regimen can be used to establish the starting dose at a patient's first session, then how to vary the dose at subsequent sessions. It does not need to be repeated for patients whose starting dose is known from a previous course of ECT, unless circumstances affecting seizure threshold have changed.

When this protocol requires two or three treatments in one session, the psychiatrist will check with the anaesthetist that there is enough time. 30 - 40 seconds should be left between treatments, during which time the anaesthetist is asked to hyperventilate the patient again. Hyperoxygenating [20 breaths of oxygen] produces better seizure duration (by lowering CO2).


Starting point at first Session & subsequent step numbers

Percent energy ( % ) (at 2xsetting)

Millicoulombs

Male / Female Bilateral 1

10

50

Female / Male Unilateral 2 20 100

3 30 150 4 40 200 5 50 251 6 60 300 7 70 353 8 80 404 9 100 500 ….etc 200 1008

To re-iterate: the aim of stimulus dosing is to find the seizure threshold. Seizure threshold (ST) is that dose (measured in millicoulombs, the units of charge), needed to produce a generalized seizure on the EEG. Having determined the ST one must then increase the output to the therapeutic stimulus. For bilateral ECT the therapeutic stimulus is taken as 2 x ST. For unilateral ECT the therapeutic stimulus is 4-6 x ST. For example, if a woman is to have bilateral ECT then on the first session she should be given a stimulus dose of 10% (50mC). If this produces a generalized seizure of at least 10 – 15 second duration with reasonable postictal suppression, then this is taken as ST. No further stimulus would usually be given on that session, unless the patient is so severely ill (for example refusing to eat or drink or actively suicidal), in which case the patient is given a further stimulus at the therapeutic dose at this session. The threshold is recorded as 10% (50mC) and the subsequent sessions should be given at 2 x ST for bilateral ECT [ 4 - 6x ST for unilateral ECT]. In this example the woman would have 20% (100mC) given to her on the second session of ECT. If on the first session the initial setting did not produce a 10 second, generalized seizure on the EEG then the anaesthetist would be asked to reoxygenate the patient and the woman would be stimulated again at the next level up on the scale [in this case 20% (100mC)]. No more than three stimuli would be given in each session and if the threshold is not reached in the first session the process should continue in the second session. On average, seizure thresholds increase by 5 - 10% with each treatment given. Thus it is common to slightly increase the stimulus dose given throughout the course.


The RCPsych. recommendations are that stimulus dosing should start at one level higher than indicated above if the anaesthetic agent being used is propofol, or the individual is over 65 years, or if they are on benzodiazepines or anticonvulsant mood stabilisers.

13. Administering ECT

ECT is given in the treatment suite in the Chase Building at CFH, twice a week, on Tuesdays and Friday mornings, starting at 09:00. The junior doctor and care coordinator looking after the patient on the ward or in the community have a duty to ensure continuity of care, reassurance for the patient, and regular communication with the ECT team. The doctor should let the ECT team know about:

• changes in medication; • changes in the patients general medical condition • changes in factors influencing seizure threshold; • changes in legal status; • changes in mental state and therapeutic response; • side-effects of ECT (which should be monitored by the ward

team) • any concerns the patient has about the treatment.

13 (i)THE ROLE OF THE ANAESTHETIST

At the ECT treatment session, the anaesthetist will proceed if it is safe to administer a general anaesthetic to the patient. Information from previous examinations and investigations is essential in informing this decision. ECG electrodes, pulse oximeter and blood pressure cuff are applied and an intravenous cannula is inserted into a vein. After pre-oxygenation the patient is anaesthetised. An induction agent, (usually propofol 1.5-2.5mg/kg or occasionally a short- acting barbiturate such as thiopentone, c.1mg/kg) and the muscle relaxant succinylcholine is used (approx. 0.5 mg/kg). This will modify the convulsion in order to minimize the risk of physical injury. The depolarizing muscle relaxant has worked when fasciculation is observed.

The anaesthetist will hyperventilate the patient for about 20 respirations prior to treatment to promote oxygenation, to reduce the chances of hypoxia during the seizure - a time of markedly raised cerebral oxygen consumption. The ventilation will also reduce carbon dioxide levels, which reduces the seizure threshold.

After the ECT, when the patient is breathing spontaneously, they are moved to the recovery room, where the recovery nurse and the escorting nurse remains with them and keeps the recovery record. Recovery is supervised by the anaesthetist, who will remain in the suite until all the patients have recovered post-anaesthesia.

Anaesthetists have guidelines for ECT produced by the Royal College of Anaesthetists. Through ECTAS, joint accreditation visits


are conducted when ECT departments are inspected in order to ensure standards are being met.

13 (ii)PREPARING THE PATIENT IMMEDIATELY BEFORE ECT The patient will have fasted and should have been to the toilet to empty their bowels and bladder prior to ECT. In the treatment room any jewellery, spectacles, dentures etc., are removed and tight clothing loosened. The ECT nurse uses a nursing checklist for completeness. The patient is invited to lie on the treatment trolley. An intravenous cannula is inserted. The electrode leads from the EEG recording Channels are attached bilaterally to the fronto-mastoid positions. A pulse oximeter, and ECG monitor are also attached. The patient is given oxygen through a face mask and the anaesthesia is administered. To prepare the temples for optimal electrical contact, oil (and make-up) is best removed by rubbing firmly with an alcohol swab. The psychiatrist carries out this part of the preparation. When the patient is anaesthetized, the electrodes, with a conducting gel are then applied, pressing firmly on each temple. The point at which the electrode is placed on the temple lies 4cm above the midpoint of an imaginary line from the lateral angle of the orbit to the external auditory meatus. For unilateral ECT a specially adapted concave electrode is placed on the vertex and the other electrode placed on the temple over the non-dominant hemisphere.

13 (iii) IMPEDANCE MEASUREMENT

When the patient is fully anaesthetised, muscle relaxant given and the dental guard inserted, the electrodes are applied to the appropriate positions, either bilateral or unilateral. The electrodes are slightly rotated in a clockwise and then counterclockwise fashion and then firmly applied. The electrodes must be kept immobile from now on, maintaining firm pressure. The ECT nurse or Consultant will depress the impedance measurement button. A reading is displayed on the Thymatron ECT apparatus. It should read between 100 and 2500 ohms. A lower reading is suggestive of a short circuit between the electrodes, such as excess fluid, in which case the current will take that route, and not induce a seizure. The cause of the short-circuit should quickly be identified, and removed.

Excessively high impedance (>3000 ohms) will result in insufficient current to induce a seizure. The cause should be sought - ensure clean skin, minimize the hair between skin and electrode, and apply firm pressure when the electrodes are replaced. Test the impedance again. Treatment should not take place until the impedance is within the correct range.


13 (iv) ADMINISTERING THE TREATMENT STIMULUS

The electrodes are kept still, with constant firm pressure maintained, until the end of the treat impulse. The attending Consultant or the ECT nurse presses the "treat" button, for the duration of the treatment impulse. The Thymatron gives a one second warning sound, then the treatment button is illuminated and the machine gives an audible signal for the duration of the impulse ( 4 to 8 seconds), only at the end of which should the electrodes be removed.

The EEG paper record starts printing automatically at the end of the treatment impulse, and will continue until the "start/stop" button is pressed when the record shows seizure activity has finished. It prints a summary of the dose and stimulus parameters as well as seizure duration and the Post-Ictal Suppression Index (PSI). The print-out is then torn off, the patient's name and the date are written on it and it is filed in the ECT records.

14. SEIZURE MONITORING

The seizure is "bilateral and generalised" if a generalised motor convulsion is observed affecting all limbs. The convulsion should be "modified" in that the muscle relaxant and anaesthetic substantially reduce the motor component of the convulsion. The pattern of motor activity is an initial tonic contraction during the electrical stimulus, followed by a brief delay, then clonic contractions which usually entails rhythmic twitching of fingers, toes and periorbital and perioral muscles. On the EEG recording strip the seizure begins with polyspike activity (high frequency spike waves), followed by slower spike and wave complexes at a frequency of three cycles per second (3Hz). After the seizure the recording shows "postictal suppression", where the recording is flattened.

The duration of the seizure can be measured in three ways: 1. The observed fit (clonus) is timed from the end of the treatment stimulus to the end of the last observable motor activity from the seizure. The "cuff method" was used in the past where there was uncertainty whether a patient was having seizures during treatment. 2. The EEG seizure is recorded on a paper print-out and the duration of seizure activity can be determined from this. The end of three hertz spike and wave activity is taken as the end of the seizure, ideally followed by post-ictal suppression. The EEG seizure is often longer than the observed one. New college recommendations are that a seizure should not be longer than 120-180 seconds on EEG. Since the EEG seizure is often longer than the duration of clonus, it should be looked at closely.


3. Electromyography can also be used to measure seizure length although this is not usually necessary.

15.MISSED SEIZURES The aim of ECT is to induce a generalized cerebral seizure manifested by tonic –clonic motor movements and EEG activity as described above. Seizures of less than 25 seconds duration were previously regarded as being of short duration, although this is arbitrary and it is established that length of cerebral seizures is not related to clinical efficacy. On occasions there may be no observable clonic convulsions at all and no evidence of seizure activity on EEG. These are regarded as missed seizures. If this occurs during dose-titration we would follow the titration procedure described. If this occurs during an established course of treatment, this is regarded as a “missed seizure” and the patient should be re-stimulated when the machine indicates ”ready”. The dose should be increased by at least 20% (100mC). 16.PROLONGED SEIZURES In the event of a prolonged seizure (120 seconds or more) the seizure will be terminated. The anaesthetist will use the induction agent propofol or may use diazepam to do this, having prepared to do so when the seizure length exceeds 90 seconds.

17.TREATMENT RECORD

An entry will be made on the ECT treatment sheet which is kept in the ECT department). A similar entry will also be made on a pro-forma “sticky label” placed (usually on green paper) in the paper case notes. An additional entry will also be made in the “progress notes” section of Rio. The specific Rio ECT subfolder is not functional at present but may be used in the next version of Rio. The triplicated record will include details of the stimulus dose, a description of the nature of the seizure (i.e. whether generalized), its modification, and the duration of both the observed clonic movements and seizure duration according to the EEG print-out.

If the treatment has gone well, then the entry for outcome of treatment may read: "Bilateral, well modified seizure, observed clonus 20s, EEG 25s, PSI 80%". The record will also include a plan for the ECT stimulus dose at the next treatment session and may have comments from the anaesthetist eg advising if further investigations are needed.


18.NUMBER OF TREATMENTS IN A COURSE OF ECT and when to stop treatment

There is no absolute upper or lower limit to the number of ECT treatments that may be given in a course of ECT. The number given depends on the clinical response to treatment and whether or not unacceptable side-effects or adverse effects have occurred. If the latter do occur, consideration should be given to early discontinuation, weighing the risks and potential benefits of further treatment. If the risks of treatment, including adverse response to the general anaesthetic, are judged to be substantial, ECT may be withheld by the ECT treatment team. For patients who do respond well to treatment, the decision as to when to stop should be made with the patient and the clinical team, based on an assessment of whether the patient has improved to their pre-morbid mental state and level of function and the acceptability of any side-effects which may have occurred. The typical “modal” number in a “course” of ECT may be between 6 to 8 treatments but many patients may need more or less than this. If there has been no response by the 12th treatment it would be unusual to persevere and it would be advisable to review the patients history, physical and mental state as well as carefully documenting any side effects of ECT before proceeding with further treatment. When ECT is given under The Mental Health Act the maximum number will be stipulated by the SOAD and limited to a maximum of 12 treatments (sometimes 6).

19. CONTINUATION (CECT) & MAINTENANCE ECT (MECT)

"Continuation ECT" describes the situation where, following a course of ECT, the treatment is continued at a frequency of less than twice a week, for up to six months, in order to prevent relapse. "Maintenance ECT" refers to such preventative ECT given beyond six months (although the terms are used synonymously). MECT would usually only be prescribed when other attempts at preventing relapse and recurrence have failed. Original NICE guidance recommends that MECT should not be used. The RCPsych and SEAN have contested this. It is advisable for Consultants prescribing MECT to obtain an informal second opinion and to ensure that consent specifically for MECT has been obtained and documented. This should be repeated, ideally after every 6 MECT treatments. CECT & MECT may be considered for patients with relapse / recurrence of symptoms despite taking medication, or those who cannot tolerate medication or those patients who specifically request it. Before considering CECT the case should be carefully reviewed, including medication history in order to ensure that any possible alternatives have been explored. A detailed discussion with the patient (and preferably family / carer) should cover the likely risks


and benefits and consent should be obtained and fully documented. This should include a description of the proposed treatment plan, describing the frequency of treatment, proposed upper limit, frequency and arrangements for review, monitoring of response and side effects, practical arrangements etc. The prescribing consultant should discuss the case with the ECT Consultant and anaesthetist and should make arrangements for a second opinion to be obtained. Medical screening, blood tests, CXR and ECG should be repeated at intervals in discussion with the anaesthetist. A standardised assessment of mood state, using eg the MADRS should be recorded at base line and at regular intervals and a record of side –effects and adverse effects should be carefully documented. This should include a standardized assessment of cognitive function such as the MMSE, again recorded at base line and at regular intervals. Once a patient has completed and responded to an acute course of ECT and the decision and arrangements to proceed with CECT have been made, the following reducing frequency of administration may be followed as a guide, clinical judgement will need to be exercised, based on regular monitoring, to aid the decision as to when to reduce the frequency of treatments: once a week, at 10 days, 2 weeks, 3 weeks, monthly, 6 weekly, 8 weekly, then consider discontinuation if patient remains well. The patient should be reviewed regularly and before each change in treatment frequency, with information obtained from family and carers. In some situations the frequency may need to be increased again, if the patient shows signs of relapse. Clinicians considering recommending MECT for a patient may find it helpful to review the “pharmacological strategies for Treatment Resistant Depression” given in appendix 10 of this document. These strategies may also be helpful for patients referred to ECT for recurrent episodes of depression. 20.OUTPATIENT ECT Some patients, particularly those who have benefited from previous treatment with ECT, may prefer to have the treatment performed on an outpatient basis (as a “day case”). In deciding whether or not this is suitable for a given patient, consideration will need to be given to factors such as the patient’s general medical health and likelihood of any adverse reaction to anaesthesia, previous response to ECT and ECT related side-effects, level of social support which they may have at home etc. Special arrangements will need to be made to ensure that the usual pre-ECT work-up (consent, investigations etc) has been carried out, that the patient is appropriately escorted to and from the ECT department and that they can be monitored for a suitable time after ECT. The patient’s GP should be informed in advance of treatment commencing and agreement reached on the appropriate course of action if the patient needs to contact a health professional out of hours. It is often advisable for the patient to attend a day hospital or ward for several hours after leaving the ECT department. The patient should be reviewed to ensure that he/ she is fit to leave the unit and this assessment must be documented. A leaflet providing key information must be given to the patient and / or


a responsible adult following treatment. A template is provided in the appendices. 21. ECT IN VULNERABLE PATIENT GROUPS Children and Adolescents The use of ECT in children and adolescents is controversial. The RCPsych. Handbook recommends the following:

• ECT should be used with caution in young people because of the lack of evidence from RCTs

• First line use of ECT in young people should be very rare • For a person under 16years, two independent opinions should

be available from child & adolescent psychiatrists. • Stimulus dosing should take into account the lower seizure

threshold which young people are likely to have and lower doses would usually be used

• Parents and child should be involved in the consent process. Where it is not possible to obtain consent, ECT should only be given when the patients life is at risk from suicide or physical debilitation because of depressive illness.

• Whether detained or informal, a SOAD will need to certify the consent and that the treatment is appropriate (using Form T5), i.e. section 58A(4) applies.

• If a patient is under 18 and lacks capacity then the same provisions as for adults who lack capacity apply

• Provision would be made to treat younger patients separately from sessions involving adults

Learning Disability (LD) There have been no RCTs on ECT in this patient group, evidence is based on case series or case-reports. ECT should only be used if the psychiatric illness is refractory to treatment or medication cannot be tolerated or the patient’s condition has deteriorated severely. There are no absolute contra-indications to ECT in patients with LD. The high prevalence of epilepsy in this patient group is not a contra-indication but use of anticonvulsant drugs has implications for seizure threshold. Older People Older people are as likely as younger patients to respond to ECT. People should not be denied access to treatment solely on the grounds of age. Co-existing medical conditions should be carefully assessed prior to ECT and should be treated before referral if at all possible. Monitoring of older people should include careful attention to changes in general physical state and cognitive function. Older people may have higher seizure thresholds. ECT technique may need to be modified in order to attempt to minimize cognitive side-effects.


For a discussion on ECT in patients who lack capacity to consent see the section on Consent to treatment.

22.TRAINING

Training of doctors, nurses, and anaesthetists involved in ECT is the responsibility of the ECT consultant, the ECT manager, and the ECT anaesthetist, respectively. These guidelines will be provided for all new doctors to the service. As part of the six monthly induction programmes for new trainees in psychiatry, the ECT consultants will provide a teaching session on theory and practice of ECT. Dedicated one-to-one practical training in ECT administration is available for all trainee doctors on either Tuesday or Friday mornings. Doctors and nurses wishing to attend must make prior arrangements with Karl Sunkersing. There is now a heavy demand for training in ECT and new trainees should make arrangements for this early in their placement as we now have to operate a “waiting list” for training. The Royal College of Psychiatrists has now published competencies in ECT for doctors from foundation year level through to Consultant Psychiatrist. Trainees will be assessed against these competencies and those judged to have met the required standards will be receive a certificate. At times a Specialist Registrar (ST 4-6) may have a special interest session in ECT. They will be educated and supervised in this by the ECT Consultants. The ECT Consultants will attend the Royal College of Psychiatrists' Practitioners update on ECT, and will do so every 3 years at a minimum.

23.ECT QUALITY ASSURANCE

The ECT consultants, ECT manager, ECT nurse specialists and ECT anaesthetists are responsible for ensuring appropriate audit of their service to patients having ECT. The ECT service is registered with and formally accredited (with excellence) by ECTAS, the ECT accreditation scheme of the Royal College of Psychiatrists. This involves a rigorous audit of clinical practice, personnel, clinical facilities and equipment and includes self audit as well as external validation of standards. The ECT service is also compliant with CQC requirements and Trust policies and procedure eg Infection control.


24.LIST OF OTHER ECT - RELATED DOCUMENTS

These documents should be available on all wards across the Trust. Copies are also available from Karl Sunkersing (some are attached as appendices). -Information for Patients and Carers -ECT Treatment Sheet -ECT Medical Audit Checklist -Consent Form -Anaesthesia questionnaire for ECT -Nursing Checklist -Recovery Record -ECT nurse protocol -ECT information for outpatients (“day cases”) -National Institute for Clinical Excellence: Guidance on the use of ECT. April 2003 - National Institute for Clinical Excellence CG90 Clinical guidelines on Depression Oct 2009


Appendix 1. PRE ECT CHECK LIST & CARE PATHWAY FOR PATIENTS RECEIVING ECT: (Responsibility: RC= responsible consultant; JD = Junior Doctor; WM = ward manager / senior duty nurse; NE = Nurse Escort) Before treatment

1. ECT clinically indicated and reasons documented 2. Consultant / prescribing doctor discusses risks / benefits with

patient (also advocate/carer if appropriate). Discussion recorded in case notes RC

3. Patient information document given to patient WM 4. Consent form signed by Consultant / prescribing doctor and

patient RC 5. If ECT given under section MHA (Non-consenting patient or

patient lacking capacity): complete section 3 MHA, the SOAD to complete form T6. Ensure copies of all MHA documentation are present in the case notes, including signed section 17 leave form for patients travelling from other hospitals, RC

6. ECT referral form completed including anaesthesia proforma (appendix 6a )JD

7. Medical work-up to ensure patient is fit for ECT: Physical examination carried out by SHO (also physician if indicated) and documented. Relevant investigations carried out and results recorded and filed in notes: bloods, CXR, ECG documented JD

8. Anaesthetic proforma completed appendix 6b (& consultation with anaesthetist if indicated) JD

9. ECT nurse co-ordinator informed and appointment made for treatment to commence –book transport, giving at least 24hrs notice WM

On day of treatment

1. Patient has been fasting for 6 hours prior to treatment. If essential medication (eg antihypertensives) required this should be taken with 20mls of water. Remember to omit hypoglycaemics until after ECT given on the day JD & WM

2. Nurse escort accompanies patient to and from the ECT suite at CFH and remains with patient throughout WM

3. Patient and qualified nurse escort to be ready to leave at 8.30 a.m. WM

4. Before departure check that patient is physically well e.g. have they just developed a cold or chest infection? If in doubt phone Chase Farm ECT Clinic JD and WM

5. Case notes, medicine chart, ECT treatment pack, consent form, all relevant investigation results and Mental Health Act documentation available and ready to travel with the patient. NE


6. Ensure Patient wearing loose clothing. Dentures present. Jewelry in safe-keeping NE

7. Ensure a meal will be available on patient’s return WM 8. Patient given support and reassurance as needed NE Appendix 2: EXTRACT FROM NICE GUIDANCE (HTA) ON ECT: Guidance on indications for ECT points 1.1 to 1.10

NICE: Guidance on the use of ECT. April 2003 • Use only to achieve short term and rapid

improvement in: severe depressive illness, catatonia, prolonged or severe mania

• Decision to prescribe is based on a documented assessment of risks and potential benefits

• Consent must be on-going, based on informed discussion, involving carer/ relatives/ advocate

• Clinical status must be assessed after each treatment and treatment stopped when a response achieved or sooner if adverse effects

• Maintenance ECT is not recommended (but see CG 90)

• Use in schizophrenia not recommended Also refer to extracts from NICE CG 90 in text above.


Appendix 3: OPERATING THE THYMATRON SYSTEM 4: A SUMMARY 1. Plug EEG and Electrode cables into machine 2. Switch on Power 3. Wait for “SELFTEST” to complete – message will show “NO

BASE” 4. Decide on stimulus dose and set dose with the percent energy

dial 5. Clean skin thoroughly with saline solution 6. Attach EEG electrodes 7. Impedance test for baseline EEG, press until “3000” flashes, then

release 8. Wait for “READY” 9. Press start for EEG baseline and stop after 5 – 10 seconds 10. Give anaesthetic and hyperoxygenate 11. Place paddles with conducting gel in either bilateral or unilateral

position 12. Press impedance test, hold until gives reading (between 100 –

2500 OHM) 13. Wait for “READY” 14. Press “TREAT” button and HOLD until light goes off 15. Printer will come on automatically 16. If re-stimulating, increase stimulus dose to required setting 17. Press impedance test, wait for “ready” 18. Place paddles with more gel on head 19. Impedance test, wait for reading between 100 – 2500 OHM 20. Wait for “ready”


21. Press “TREAT” button and HOLD until light goes off 22. If 3rd (and final) stimulus is to be given repeat steps 16 – 21 Appendix 4: Standard Dose Stimulus parameters: stimulus duration (sec), charge (mC) and Joules (at 220 ohms impedance) at every percent energy dial setting for: FREQUENCY = 50 Hz and Pulse Width = 0.5 ms DIAL DURATION mC JOULES

5 % 0.56 25.2 5.0 10 % 1.12 50.4 10.0 15 % 1.68 75.6 15.0

20 % 2.24 100.8 20.0 25 % 2.80 126 24.9

30 % 3.36 151.2 29.9 35 % 3.92 176.4 34.9 40 % 4.48 201.6 39.9 45 % 5.04 226.8 44.9 50 % 5.60 252 49.9 55 % 6.16 277.2 54.9 60 % 6.72 302.4 59.9 65 % 7.28 327.6 64.9 70 % 7.84 352.8 69.9

FREQUENCY = 70 Pulse Width= 0.5 DIAL DURATION mC JOULES

5 % 0.40 25.2 5.0 10 % 0.80 50.4 10.0 15 % 1.20 75.6 15.0 20 % 1.60 100.8 20.0 25 % 2.00 126 24.9 30 % 2.40 151.2 29.9 35 % 2.80 176.4 34.9 40 % 3.20 201.6 39.9 45 % 3.60 226.8 44.9 50 % 4.00 252 49.9 55 % 4.40 277.2 54.9 60 % 4.80 302.4 59.9 65 % 5.20 327.6 64.9 70 % 5.60 352.8 69.9 75 % 6.00 378 74.8 80 % 6.40 403.2 79.8 85 % 6.80 428.4 84.8 90 % 7.20 453.6 89.8 95 % 7.60 478.8 94.8 100 % 8.00 504 99.8


Appendix 5:

Patient agreement to Electroconvulsive Therapy (ECT)

Patient details (or pre-printed label)

Patient’s surname/family name..………………………….

Patient’s first names .……………………………………….

Date of birth ………………………………………………….

Consultant Psychiatrist………...…………………………… NHS number (or other identifier)……………………………..

Male Female Special requirements ……………………………………… (eg other language/other communication method)

To be retained in patient’s notes


Patient name…………………………………… A course of Bilateral/Unilateral Electroconvulsive Therapy up to a maximum of …………….. treatments. (This section must be completed. If a number is not stated then treatment will not be given). Statement of health professional (to be filled in by consultant)

I have explained the procedure to the patient. In particular, I have explained: The intended benefits … - improvement of depression

- Other (specify) …………….. Serious/ frequently occurring risks Transient side-effects - memory loss (possibly permanent) - headache - post-treatment confusion - muscle aches

- nausea - ‘muzzyheadedness’

- fatigue I have also discussed what the procedure is likely to involve, the benefits and risks of any available alternative treatments (including no treatment) and any particular concerns of this patient.

The following leaflet has been provided - ECT Information Booklet This procedure will involve:

general anaesthesia muscle relaxation Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Contact details (if patient wishes to discuss options later) …………..…. …………………via secretary Statement of interpreter (where appropriate) I have interpreted the information above to the patient to the best of my ability and in a way in which I believe s/he can understand. Signed ………………………….……………………. Date ………………..……………. Name (PRINT) …………………..………………………………………………………………

Top copy accepted by patient: yes/no (please ring)

Statement of patient Patient identifier/label


Please read this form carefully. You should already have your own copy of page 2 and an information booklet that describes the intended benefits and frequently occurring risks of ECT. If not, you will be offered a copy now. If you have any further questions, do ask – we are here to help you. You have the right to change your mind at any time, including after you have signed this form. I agree to the procedure and course of treatment described on this form. I understand that you cannot give me a guarantee that a particular person will perform the procedure. The person will, however, have appropriate experience. I understand that I will have the opportunity to discuss the details of anaesthesia with an anaesthetist before the procedure, unless the urgency of my situation prevents this. I understand that any procedure in addition to those described on this form will only be carried out if it is necessary to save my life or to prevent serious harm to my health. I have been told about additional procedures which may become necessary during my treatment. I have listed below any procedures which I do not wish to be carried out without further discussion. ………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….. Patient’s signature ………………………………………….. Date………………………….. Name (PRINT) ……………………………………………………………………………………… A witness should sign below if the patient is unable to sign but has indicated his or her consent. Signature …………………………………………… Date ……………………..….……… Name (PRINT) ………………………………………………………………………………….… Important notes: (tick if applicable)

See also advance directive/living will (eg Jehovah’s Witness form)


Patient name…………………………………… Confirmation or withdrawal of consent (to be completed by a health professional each time the patient attends for the procedure, if the patient has signed the form in advance). On behalf of the team treating the patient, I have confirmed with the patient that s/he has no further questions and wishes the procedure to go ahead. I have explained that the patient may withdraw consent at any time. Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Signed:…….…………………………………… Date .. …………………….………. Name (PRINT) ………………………. ……… Job title …….. ………………….… Patient has withdrawn consent (ask patient to sign /date here)…………………….. If consent withdrawn date of last treatment …. ……………………………………


Guidance to health professionals (to be read in conjunction with consent policy) What a consent form is for: This form documents the patient’s agreement to go ahead with the investigation or treatment you have proposed. It is not a legal waiver – if patients, for example, do not receive enough information on which to base their decision, then the consent may not be valid, even though the form has been signed. Patients are also entitled to change their mind after signing the form, if they retain capacity to do so. The form should act as an aide-memoire to health professionals and patients, by providing a check-list of the kind of information patients should be offered, and by enabling the patient to have a written record of the main points discussed. In no way, however, should the written information provided for the patient be regarded as a substitute for face-to-face discussions with the patient.

The law on consent: See the Department of Health’s Reference guide to consent for examination or treatment for a comprehensive summary of the law on consent (also available at www.doh.gov.uk/consent). Who can give consent Everyone aged 16 or more is presumed to be competent to give consent for themselves, unless the opposite is demonstrated. If a child under the age of 16 has “sufficient understanding and intelligence to enable him or her to understand fully what is proposed”, then he or she will be competent to give consent for himself or herself. Young people aged 16 and 17, and legally ‘competent’ younger children, may therefore sign this form for themselves, but may like a parent to countersign as well. If the child is not able to give consent for himself or herself, some-one with parental responsibility may do so on their behalf and a separate form is available for this purpose. Even where a child is able to give consent for himself or herself, you should always involve those with parental responsibility in the child’s care, unless the child specifically asks you not to do so. If a patient is mentally competent to give consent but is physically unable to sign a form, you should complete this form as usual, and ask an independent witness to confirm that the patient has given consent orally or non-verbally. When NOT to use this form If the patient is 18 or over and is not legally competent to give consent, you should use form 4 (form for adults who are unable to consent to investigation or treatment) instead of this form. A patient will not be legally competent to give consent if: • they are unable to comprehend and retain information material to the decision

and/or • they are unable to weigh and use this information in coming to a decision. You should always take all reasonable steps (for example involving more specialist colleagues) to support a patient in making their own decision, before concluding that they are unable to do so. Relatives cannot be asked to sign this form on behalf of an adult who is not legally competent to consent for himself or herself.


Information Information about what the treatment will involve, its benefits and risks (including side-effects and complications) and the alternatives to the particular procedure proposed, is crucial for patients when making up their minds. The courts have stated that patients should be told about ‘significant risks which would affect the judgement of a reasonable patient’. ‘Significant’ has not been legally defined, but the GMC requires doctors to tell patients about ‘serious or frequently occurring’ risks. In addition if patients make clear they have particular concerns about certain kinds of risk, you should make sure they are informed about these risks, even if they are very small or rare. You should always answer questions honestly. Sometimes, patients may make it clear that they do not want to have any information about the options, but want you to decide on their behalf. In such circumstances, you should do your best to ensure that the patient receives at least very basic information about what is proposed. Where information is refused, you should document this on page 2 of the form or in the patient’s notes. Barnet, Enfield & Haringey NHS Mental Health Trust


Form 4: Form for adults who lack the capacity to consent to investigation, treatment, personal care or assessment Patient details (or pre-printed label): Surname/family name..…………………………. First names .………………………………………. Date of birth …………………………………………………. Responsible professional.…………………………… Job title ………………………………………………………. NHS number (or other identifier)…………………………….. Male / Female (circle) Special requirements ……………………………………… (eg other language/other communication method) Copy to be retained in patient’s notes All sections to be completed by professional proposing the procedure Details of procedure or course of treatment proposed: ……………………………………………………………………………………………… ……………………………………………………………………………………………… …………………………….. Assessment of patient’s capacity: I confirm that the patient lacks capacity to give or withhold consent to this procedure or course of treatment because of an impairment of the mind or brain or disturbance affecting the way their mind or brain works (for example, a disability, condition of trauma, or the effect of drugs or alcohol) and they cannot do one or more of the following:

Understand the information about the procedure or course of treatment. Retain that information in their mind. Use or weigh that information as part of the decision- making process. Communicate their decision (by talking, using sign language or any other

means). Further details: for example how above judgements were reached; which colleagues Were consulted; what attempts made to assist the patient make his or her own decision and why these were not successful l.………………………………………………………………………………………….... ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… Assessment of patient’s best interests: I am satisfied that the patient has not refused this procedure in a valid advance decision. As far as is reasonably possible, I have considered the person’s past and present wishes and feelings (in particular if they have been written down) any beliefs and values that would be likely to influence the decision in question. As far as possible, I have consulted with other people (those


involved in caring for the patient, interested in their welfare or the patient has said should be consulted) as appropriate. I have considered the patient’s best interests in accordance with the requirements of the Mental Capacity Act and believe the procedure to be in their best interests because: ……………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………….………… …………………………………………………………………………………………… (Where incapacity is likely to be temporary, for example if patient is unconscious, or where patient has fluctuating capacity) The treatment cannot wait until the patient recovers capacity because: ……………………………………………………………………………………………… ……………………………………………………………………………………………… …………………………………………………………………………………… Involvement of the patient’s family and others close to the patient: The final responsibility for determining whether a procedure is in an incapacitated patient’s best interests lies with the professional performing the procedure. However, it is good practice to consult with those close to the patient (e.g. spouse/partner, family and friends, carer, supporter or advocate) unless you have good reason to believe that the patient would not have wished particular individuals to be consulted, or unless the urgency of their situation prevents this. “Best interests” go far wider than “best medical interests”, and include factors such as the patient’s wishes and beliefs when competent, their current wishes, their general well-being and their spiritual and religious welfare. (to be signed by a person or persons close to the patient, if they wish) Independent Mental Capacity Advocate (IMCA) Where there is no one appropriate to consult other than staff, has an Independent Mental Capacity Advocate (IMCA) been instructed? Yes / No (circle) Details:…………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………… Signature ………………………………………….. Date…………………………………………………. Name (print) ……………………………………… I/We have been involved in a discussion with the relevant professionals over the treatment of………………………(patient’s name). I/We understand that he/she is unable to give his/her own consent, based on the criteria set out in this form. I/We also understand that treatment can lawfully be provided if it is in his/her best interests to receive it. Name……………………………………………… Relationship to patient………………………………………. Address…………………………………………………………………………………… Any other comments (including any concerns about decision) Name……………………………………………… Relationship to patient……………………………………….


Address…………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………….. If a person close to the patient was not available in person, has this matter been discussed in any other way (e.g. over the telephone?) Yes / No (circle) Details: Signature of professional proposing treatment: The above procedure is, in my professional judgment, in the best interests of the patient, who lacks capacity to consent for him or herself. Where possible and appropriate I have discussed the patient’s condition with those close to him or her, and taken their knowledge of the patient’s views and beliefs into account in determining his or her best interests. I have/have not sought a second opinion. Signature…………………………………… Date…………………………………………………………. Name (Print)……………………………………….. Job Title……………………………………………………… Where second opinion sought, s/he should sign below to confirm agreement: Signature…………………………………………….. Date…………………………………………………………. Name(Print)……………………………………….. Job Title……………………………………………………… If the patient has an Attorney or Deputy: Where the patient has authorised an attorney to make decisions about the procedure in question under a Lasting Power of Attorney or a Court Appointed Deputy has been authorised to make decisions about the procedure in question, the attorney or deputy will have final responsibility for determining whether a procedure is in a patient’s best interests. Signature of attorney or deputy I have been authorised to make decisions about the procedure in question under a Lasting Power of Attorney/ as a Court Appointed Deputy (delete as appropriate). I have considered the relevant circumstances relating to the decision in question and believe the procedure to be in the persons best interests. Any other comments (including the circumstances considered in assessing the Patient’s best interests) Signature: ……………………………………………. Date ………… Barnet, Enfield & Haringey NHS Mental health Trust


Appendix 6a: ECT Referral Form This form must be fully completed by the referring medical team prior to the first ECT treatment and will be retained in the ECT department. This form is to be used in conjunction with the ECT protocol, available on the Trust intranet. The referring medical team must refer to the ECT protocol when completing this form to ensure the individual patient is adequately prepared for ECT to ensure the safe administration of ECT. In particular the Anaesthesia proforma (appendix 6b) and blood results forms must be completed. Please do not simply enter “see Rio” - if information is available on Rio it should be “cut and pasted” into an electronic version of this form, a hard copy should then be printed off and be available when the patient presents for their first ECT treatment. Name: Patient’s sticky label: Date of Birth: Ethnicity: Mental Health Act Status: Please record assessment of benefits and risks of ECT treatment for this patient, including no treatment: Reason for ECT: Mental State Examination: Medical history:


Current medication: Physical examination (no more than 7 days prior to 1st ECT treatment, include cardiovascular, respiratory, neurological systems, temp and BP): Investigations:


Blood tests done y/ n with results on attached pre-anaesthesia form Recent ECG carried out and filed in notes yes n/a (circle) Recent chest x-ray carried out and filed in notes yes n/a (circle) Any other investigations and results required for individual patient: (see ECT protocol anaesthesia guidelines for specific requirements for individual patients) Cognitive testing Clinical history of subjective experience of memory loss: MMSE completed on: MMSE score: Any other cognitive assessment done: Also to be completed prior to 1st treatment: Initial prescription by referring Psychiatrist Name: ………………………………………. Signature: ………………………………….. Date:………………………………………… Pre ECT Medical assessment for Anaesthesia Appendix 6b Documentation in the notes of the consent process, including a written record of the assessment of capacity Consent form (include on this the maximum number of treatments the patient is consenting to and whether unilateral or bilateral ECT ) For patients having ECT under the MHA please provide copies of appropriate documentation eg T4 or T6 or section 62. Name of Doctor completing this form:……………………………………………… Signature & Date:………………………………………………………………………. Contact number:………………………………………………………………………... Appendix 6b: Ward Doctors’s PRE-ECT Medical ASSESSMENT


ASA Grade (1-5)_____ Patient Name : Hospital number : Dob : Age : Weight : Current / Recent Illness : Previous Medical Illness & Surgery : Previous Anaesthetic History : Yes No Problems after receiving an anaesthetic ? Patient : Family Member : If Yes , please give details : (e.g Malignant hyperthermia , suxamethonium apnoea or anaphylaxis

- refer to anaesthetist )

Medications : Allergies (medication and food eg eggs) : Dental : Loose teeth / Crowns / Dentures / Implants ( please inform anaesthetist of any loose teeth or Crowns ) Cardiovascular : Suffer with angina? Yes / No ( If Yes , ECG )


Angina at rest Yes / No ( If Yes, refer Cardiologist ) Frequency of angina: ( Refer If > 2 episodes per week) M. I. In the last 3 months: Yes / No ( If Yes, ECG & refer ) Palpitations: Yes / No (If yes , ECG ) Palpitations associated with Yes /No (If yes , ECG & refer ) Syncope: Breathless when lying flat Yes /No ( If yes , refer ) Breathless when walking On flat ground: Yes / No ( If yes , refer ) Needs to pause when going Up 10 –14 stairs to catch breath ? Yes /No ( If yes , refer ) Have a pacemaker ? Yes /No (If yes , ECG & details ) Check patient pacemaker record card for details : Date inserted : Type : Last check : Reason for insertion of pacemaker : Any heart valve problems : Yes/ No ( If yes, ECG & Echo ) Has the patient had an echo ? Yes/No ( If yes , details of report ) Has the patient had angioplasty ? Yes / No ( If yes, ECG & refer ) Has the patient got high BP ? Yes/ No (If yes, ECG & CXR )

Respiratory Does the patient have breathing problems ? Yes / No ( If yes - details & CXR see protocol ) Admitted to hospital /ITU with breathing Yes /No ( If yes, refer & details ) Problems in the last year ? Productive cough ? Yes /No ( If yes with green sputum refer ) Does the patient use an inhaler ? Yes / No Extra puffs throughout the day ? Yes /No ( If yes, details ,CXR & refer ) Does the patient smoke ? Yes /No ( If yes , how many per day ? )


Metabolic Diabetic Yes/No ( If yes specify - Insulin dependent (IDDM ) Non Insulin dependent (NIDDM ) Diet controlled (All diabetics should have blood sugar, U&E and ECG done and a BM result should be available in the notes on the morning of ECT ) Liver disease or problems Yes /No ( If yes , details , liver functions tests , U&Es ) Thyroid disease or problems Yes / No ( If yes , details, ECG & thyroid function tests ) Regular heartburn or Acid reflux : Yes /No ( If yes , follow Lanzoprazole policy )

Renal Kidney disease or problems : Yes / No ( If yes , details , FBC & U&E ) Renal failure Yes / No ( If yes, details, FBC, U&E , refer )

Neurological Any neurological problems ? Yes /No ( If yes, details ) CVA / TIA Yes /No ( If yes, & less than 6 months refer ) Fainting /blackouts : Yes /No ( If yes, details - frequency & precipitating factors & refer )

Muscular & Skeletal Any Muscular disease or disorder ? Yes /No ( If Yes, details and refer ) (i.e. muscular dystrophy ) Any skeletal disease ? Yes/No ( If yes, details & refer ) (i.e. ankylosing spondylitis ) Anaesthetists : Patients requiring an anaesthetic referral can be referred to : Dr. Thillai : tel 07770954052 on Tuesdays Dr. Haemeed : tel 07946293366 on Fridays Where urgent anaesthetic review / ECT is required out of hours -contact on call anaesthetic registrar or consultant


CONTRAINDICATIONS (ABSOLUTE /RELATIVE ) TO ECT Recent MI (< 6 months ) Recent CVA (< 6 months ) Coronary stenting < 6 months Cardiac failure Severe valvular heart disease Aneurysm Space Occupying lesions Unstable cervical spine The anaesthetist should be informed at least 24 hours in advance of the first ECT treatment of all patients. However patients with medical problems may require early referral for assessment & further workup before ECT is commenced.

ANAESTHETIC REFERRAL Refer the following patients to the anaesthetist for Assessment & further workup as indicated. Previous Anaesthetic reactions or problems Patients with moderate to severe heart disease or poor exercise tolerance Recent heart surgery on warfarin Recent MI (< 6 months) Recent coronary angioplasty with stenting ( < 6 months) Patients with pacemaker Poorly controlled hypertensive Recent CVA (less than 6 months) Patients with palpitations , dizziness and syncope Patients with muscular , skeletal and neurological disorders ( myotonia, spondylosis, Myasthenia gravis, etc ) Renal failure on dialysis Severe liver disease. Chronic or severe respiratory disease or patients requiring oxygen supplements . Investigations : (Please ensure ECG & CXR report / film is attached or available on day of ECT) 1. ECG - Men over 40 , women over 45 All patients with heart disease All patients with hypertension All diabetics All patients with palpitations , history of syncope or dizzy spells All patients with thyroid disease 2. CXR - All patients with chronic , moderate – severe lung disease All patients with recent onset breathlessness Patients on Home oxygen supplementation Patients with chest infections Chronic cough (lasting > a month ) All patients with heart disease and hypertension


3. ECHO - All patients with valvular heart disease. Patients with heart disease associated with reduced or poor exercise tolerance. Patients with heart rhythm , other than sinus, i.e atrial fibrillation. 4. BLOOD - FBC & Blood glucose for all (Diabetics will require blood sugar levels done on the morning of ECT ) U&E - All patients (mandatory if on diuretics, lithium, if heart disease & high BP and any of renal, liver and metabolic disorders) Clotting Screen : - All patients on anticoagulants ( i.e.warfarin ) - All patients with severe renal & liver disease. Thyroid function tests : All patients with thyroid disease Liver function tests : All patients with liver disease Chronic alcoholics PLEASE WRITE RESULTS IN HERE: (HB, WCC, Glucose; U+E, creatinine etc) -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- PREOPERATIVE

1. Fasted - 6 hours 2. All regular medications that the patient is on should be administered with the

exception of ACE –INHIBITORS & DIABETIC medications (see below)

3. All diabetics (IDDM & NIDDM ) - Should not receive their diabetic medications before treatment but can have their diabetic medications following breakfast after ECT .

4. All patients who suffer from heartburn or acid reflux should receive 30mg Lanzoprazole 2 hours before the anaesthetic . ( This will not be necessary if the patient is already on regular antacid, i.e ranitidine or omeprazole )


Appendix 7: PRE- ECT MEDICAL ASSESSMENT GUIDELINES These guidelines have been written in conjunction with the medical pre-assessment documentation (Medical Assessment Forms). They are to be used together and as a guide for the benefit of the assessing doctor. The guidelines contain questions that need to be answered with regard to common medical problems. These questions must be asked and the answers recorded in the assessment form. It may be necessary to check patients previous notes for all significant medical, surgical and anaesthetic history. Please bear in mind that patients with significant medical problems are at higher risk from complications related to anaesthesia and ECT. Hence these group of patients should be referred to the anaesthetist as soon as possible, to avoid any delays in the treatment. Allergies 1. It is important to list not only drug allergies, but other types of Allergies, particularly important are nuts and eggs. Patients with allergies to banana, kiwi or avocado may be at risk of latex allergy. 2. Note what type of reaction occurs. 3. Inform the anaesthetist if there is known allergy to any anaesthetic drug. 4. Latex/rubber allergy - please highlight on assessment form and inform the ANAESTHETIST and ECT COORDINATOR. Previous General Anaesthetic (GA) 1. List the year of last GA. 2. Refer to anaesthetist if Previous Anaesthetic Problems, ie - Cardiac Arrest - Respiratory Arrest - Severe bronchospasm - unexpected post-op in ITU - History of difficult airway/intubation 3. Note and inform anaesthetist of suxamethonium (scoline) apnoea. 4. Note any post-operative nausea and vomiting. 5. Blood relatives with problems - refer if malignant hyperthermia Social History Smoking/ drinking / illicit drugs 1. Heavy Smokers (20 -40 a day) need to be asked breathlessness questions 2. Heavy drinkers (over 40 units per week) need U&Es and LFT 3. For drug abusers, note and highlight use. Advise to stop prior to


admission . Inform anaesthetist if on crack/cocaine Surgical History Note all relevant history and the year performed Medical History Note all relevant history and the year occuring. Medications 1. List all current medications and dosage taken. 2. Ensure that medication list is consistent with answers to health questions. Section 1 : Cardiovascular All patients with cardiovascular concerns must have ECG and U &E’s All patients with worsening cardiovascular symptoms must be referred. Exercise Tolerance : All patients who answer yes to any question in section 1 must be asked the following exercise tolerance question: 1. Can you walk up a flight of stairs without stopping to catch your breath? If yes, accept, if no refer but continue with questions 2. How far can you walk on a flat surface and at what pace? 500 meters accept, slow pace and less than 500meters refer. 3. Do you get breathless when just sitting or laying flat? (How many pillows used at night?). If yes refer. 4. Do you get breathless dressing / undressing? If yes, refer. Observe patients for obvious signs of breathlessness. They may be so used to their breathlessness state that they don’t think it is abnormal. Hypertension Known hypertensive patients must have had an ECG & U &E’s within 3 months. Ask the following: 1. How long have you been on medication? 2. Does someone regularly check your BP? 3. Is your hypertension controlled? 4. Have you changed your medication in the last 3 months ? 5. Any recent readings with the GP? Accept diagnosed hypertension that is treated and stable (DBP below 100mmHg, SBP below 170 mmHg ). Undiagnosed Hypertension will need further work-up and treatment prior to receiving treatment. However if ECT is required urgently then refer to the Anaesthetist.


Angina /Chest Pain Further questions to be asked: 1. How frequently do you get chest pain? 2. What brings on your chest pain? 3. Do you use GTN spray or tablets to control it? 4. How often do you use GTN? 5. How long does it take for the pain to resolve? 6. How far can you walk and at what pace before getting chest pain? 7. Have your symptoms worsened in the last 6-12months? 8. Has your GP investigated you for this and what was the outcome? Refer Patients if : 1. Their angina is more frequent than 2 -3 times per week. 2. Their angina occurs with limited or no exertion. 3. They can walk less than 500 meters at a slow pace before stopping. 4. Their symptoms have worsened in the last 6 -12 months. 5. If their chest pain is undiagnosed. Recent Myocardial Infarction (MI) All patients with MI within 12 months must be referred to the anaesthetist. If MI is recent , less than 6 months then cancel. But if ECT is absolutely necessary than refer to anaesthetist for evaluation and discuss. (see notes on anaesthetic referral). All patients who have been stented post MI must be referred if they are taking clopidogrel/ warfarin or if the stent was done less than 6 months ago. Palpitations /Irregular Heart Beat Undiagnosed, symptomatic palpitations must have ECG and then referred. Young fit patients on antipsychotic medications can have palpitations from their medications . They must be referred and may require further investigation. All patients with AF should be asked about angina & exercise tolerance. Patients on warfarin should have their average INR listed. All previously undiagnosed AF should have TFT, Echo and be referred Heart Murmur Further enquiry: 1. When was the murmur diagnosed? 2. Who diagnosed it? 3. Have you had any investigations - Echo, etc?


Patients with symptomatic murmur which has not been investigated, should be referred. All other asymptomatic murmur can be treated but inform anaesthetist. Rheumatic Fever Patients who receive antibiotic prophylaxis at the dentist may have underlying valvular lesions and will require further questioning. Trace any previous echo report. Pacemaker Questions to be asked : 1. When was the pacemaker inserted? 2. What was the indication for the pacemaker? 3. Ensure the last check was done within last 12 months. 4. What is the pacing mode? 5. Does the patient have an implanted automatic defibrillator (ICD)? If unsure, contact the pacemaker clinic for information. All patients with cardiac pacemaker and ICD should be referred to the anaesthetist prior to ECT Bilateral Pitting Oedema Refer if associated with breathlessness or worsening symptoms. Section 2 : Respiratory : Asthma / Bronchitis / COPD Questions to be asked: 1. Do you use inhalers? 2. How often do you use inhalers? (especially ventolin) 3. What degree of exercise makes you use ventolin? 4. Have you taken oral steriods, and when last taken? 5. How many pillows do you sleep on at night? 6. Have you ever been admitted into hospital with breathing problems? 7. Have you ever been in ITU after an operation? 8. Do you have productive cough? Patients who have had hospital admissions for breathing problems should be referred. Any patients admitted to ITU post GA must be referred. Patients should have peak flow performed. If less than 300, refer. Any previously undiagnosed breathing problems should be referred. Sleep Apnoea: ALL patients with sleep apnoea should be referred Questions to be asked: 1. When was sleep apnoea diagnosed? 2. How was it diagnosed? 3. Do you use CPAP /BiPAP?


4. Are you sleepy during the day? Be vigilant for BMI > 35 and short thick neck (collar size > 17) Section 3 : Neurological Any undiagnosed fits/blackout or those under investigation must be referred. Those with a proven neurological /muscle disease may not be suitable for day case and should be referred. Stable MS is acceptable. Epilepsy Well controlled epilepsy can be done as day case and rarely complicates ECT (e.g prologed seizures). Epileptics tend to have a higher seizure threshold (anticonvulsant medication). Uncontrolled epilepsy may be unsuitable for day treatment. Myasthenia Gravis and Myopathies Must all be referred to the Anaesthetist for evaluation. CVA /TIA : Refer all patients with history of CVA or TIA within 6 months All patients with recurrent CVA should be referred. Section 4: Endocrine IDDM and NIDDM All patients can be done as day case. Patients must have been diagnosed for at least 3 months Patients must have been on the same medication for at least 3 months. Normal morning BM (before breakfast) should be less than 10mmol. All patients falling outside these criteria must be discussed with the anaesthetist All diabetics should omit their diabetic medication before ECT and have a BM done every 2 hours until after treatment when they can than have their breakfast and resume their normal diabetic regime All patients should have U&E’s and ECG done. Other Endocrine Diseases Thyrotoxicosis, Phaeochromocytoma, etc. Should be referred to the anaesthetist.


Section 5: Haematology Sickle Cell Anaemia All afro-carribean patients should be tested for sickle cells. Refer all patients to the anaesthetist. Section 6: Other Diseases Liver and Kidney Diseases All patients with moderate to severe liver or renal disease must be referred to the anaesthetist. All patients with hepatic or renal failure should also be referred. Arthritis Neck involvement or moderate to severe joint involvement, inform the anaesthetist. Acid Reflux /Hiatus Hernia. Should have H2 BLOCKER (Ranitidine) or proton pump inhibitor (eg omeprazole) prior to ECT. Anxiety/depression/psychotic illness: Patients on medication for psychiatric disorders may have side-effects or drug interactions and may require close monitoring (nb lithium levels).


Appendix 8: Barnet, Enfield & Haringey Mental Health NHS Trust

Electroconvulsive Therapy (ECT) : information for patients and their families CONTENTS

1. Introduction 2. What is ECT? 3. Why has ECT been recommended for me? 4. Is ECT used for other conditions? 5. How is ECT given in Barnet, Enfield & Haringey Mental Health Trust? 6. What investigations will I need if I have ECT? 7. What happens on the day of ECT? 8. How will I feel immediately after ECT ? 9. How well does ECT work? 10. How many treatments are usually necessary? 11. What ECT can't do 12. What are the risks and side effects of ECT? 13. What else is known about Memory Impairment and ECT? 14. Does ECT cause Brain Damage? 15. Are there other serious risks from the treatment? 16. What other treatments could I have? 17. Will I have to give consent? 18. What Safeguards Are There? 19. Can I refuse to have ECT? 20. Can Relatives Give Consent To ECT? 21. Are there any risks in not having ECT as recommended? 22. Can ECT be given as an Emergency? 23. Why has ECT been controversial? 24. Advocacy services 25. Summary 26. Further information


1. Introduction This leaflet has been produced in order to try to answer some of the questions you may have about ECT. You will probably want to know what it is, why it is used and what it is like to have ECT. You will also want to know about the possible risks and benefits of ECT. The leaflet has been written by clinicians from the ECT department in this Trust but is based on a similar leaflet produced by the Royal College of Psychiatrists and the Scottish ECT audit network (SEAN). When you are depressed, it is often quite difficult to concentrate. Don't be concerned if you can't read through all of this leaflet - just pick out the sections that seem important at the time and come back to it later. You may wish to use it to help you ask questions of staff, relatives or other patients who have had ECT. 2. What is ECT? ECT is a physical treatment for severe depressive illness. During ECT a small amount of electric current is passed across the brain for usually 3 to 6 seconds. This produces a brief seizure (like an epileptic fit) which affects the entire brain, including the parts which control thinking, mood, appetite and sleep. Repeated treatments alter some of the chemical messengers in the brain and bring them back to normal. This helps you to recover from your illness. ECT is only given under a general anaesthetic and with drugs to relax the body's muscles. This means that unlike a person experiencing a natural epileptic fit, you will be asleep before it starts. Your arms and legs will not thrash around, usually there will just be a flickering of the eyelids. You should have no memory of the treatment itself. A special machine is used to precisely control the amount of electricity used to make sure that you are given as little as possible. For most people ECT acts more quickly than medication and in some cases this can be life-saving. The improvements produced by ECT will usually need to be maintained with anti-depressant medication. As with any form of treatment, there are possible side effects. The most common ones are headache for a short time immediately after each ECT treatment and memory loss for periods around the treatment. This is discussed in more detail later on. 3. Why has ECT been recommended for me?


ECT is given for several reasons, most commonly it is given for severe depression. If you are not sure why you are being given ECT, don't be afraid to ask. It's sometimes difficult to remember things when you are depressed, so you may need to ask several times. Your consultant may recommend that you be treated with ECT if:

• You have had a severe depressive illness for some time and a number of different drug treatments have been tried without success.

• You have tried several different anti-depressants but have had to stop them because of side-effects.

• You have responded well to ECT in the past. • Your life is in danger because you are not eating or drinking enough • Your life is in danger because you feel so bad you want to kill yourself. • If your depression is so bad that you may die, ECT can literally be life-

saving. 4. Is ECT used for other conditions? Occasionally ECT may be used to treat mania and catatonia and rarely for schizophrenia. 5. How is ECT given in Barnet, Enfield & Haringey Mental Health Trust? The ECT service at Chase Farm Hospital has been accredited with excellence by ECTAS, a department of the Royal College of Psychiatrists responsible for setting and maintaining high standards of care in accredited clinics. The ECT service is based at Chase Farm Hospital in a purpose built unit and ECT is given twice a week, on Tuesday and Friday mornings. If you are an inpatient in Barnet or Haringey, arrangements will be made for you to travel to and from Chase Farm hospital with a nurse escort. Some people who have had it before may have ECT given as an outpatient, in which case arrangements will be made for you to be escorted to and from the unit. 6. What medical investigations will I need if I have ECT? Once you and your doctors have agreed that you will receive a course of ECT, they will need to do some tests to make sure that it is safe for you to have a general anaesthetic. They will also ask about your medical history and if you have had any previous operations or general anaesthetics. Do not worry if you cannot remember exact times and dates. The doctors will take a blood test – this is to make sure that your blood chemistry is normal. They will also take a tracing of your heart, (an ECG), and sometimes a chest X-ray to make sure that you have no problems with your heart or lungs. 7. What exactly happens on the day of ECT?


You will be asked to have nothing to eat or drink from midnight on the night before treatment because you will be having a general anaesthetic. The only exception is if you take essential medication for conditions like high blood pressure, which should be taken as usual if prescribed in the mornings, with a small sip of water. You will be able to wear your own day-clothes, which should be loose fitting and comfortable. You should also remove any earrings, necklaces and watches and leave them on the ward for safekeeping. You may keep your wedding ring on. Your ward nurse will have removed any nail polish. You will have an allocated ward nurse who will attend the treatment with you and help you to get ready. Your nurse will remain with you throughout the procedure. Don’t be afraid to ask about anything you are unsure of as they will be there to support you. Before each treatment your nurse will check your blood pressure, pulse and temperature. If you have diabetes the nurse will also measure your blood sugar level. When you get to the ECT suite you will be shown into a waiting room. The treatment takes place in a separate room with special equipment. Other patients will not be able to see you having the treatment. You will then be asked into the treatment room. You may find this unusual and possibly frightening at first as the room contains lots of equipment and some members of staff whom you may not have met before. All of these staff are there to ensure that you have a safe and uneventful treatment session. They will try to make you feel as comfortable as possible. The staff will include a psychiatrist who is responsible for giving you the ECT treatment, an anaesthetist and an anaesthetic assistant who will be giving you a general anaesthetic and an ECT nurse, who will assist the psychiatrist and anaesthetist, and who has overall responsibility for the smooth running of the clinic. From time to time student doctors and nurses may attend the ECT clinic for training purposes. You will be asked in advance if this is acceptable to you. If you do not want students to attend your treatment session please inform the ECT nurse. It is your choice and will not affect your treatment session whatsoever. The ECT staff will introduce themselves to you, but if you are unsure about who they are, or you have forgotten, please do not be afraid to ask. You will be asked to lie down on a treatment trolley. Your pulse and blood pressure will be checked again. Some small electrode pads will be attached to the front of the chest to allow us to measure the heart rate and similar pads are placed on the forehead, which allows us to record the duration of the seizure when you have the actual treatment. You will not feel any pain from this. The anaesthetist will ask you to hold out your hand so you can be given an anaesthetic injection into a vein on


the back of your hand. Inserting the small needle should be the only part of the treatment which may be slightly painful. The anaesthetic will make you go to sleep and cause your muscles to relax completely. You will be given some oxygen to breathe as you go off to sleep. Once you are fast asleep a small, carefully calculated electric current is passed across your head and this causes a fit (seizure) in the brain. Unlike normal epileptic fits, there is little movement of your body because of the relaxant injection that the anaesthetist gives, there will usually only be slight twitching of the muscles around the eyes, fingers and toes. This usually lasts for around 30 seconds. Note that there is no incision or surgical operation. After about 15 to 20 minutes you will start to wake up and you will be in a separate room called the “recovery” area, where a specially trained nurse will be with you at all times. When you are ready to leave this area you will be able to have a drink and snack before leaving the unit with your escorting nurse. When you return to the ward you will have breakfast, a drink and your normal medication. You may still feel sleepy and want to rest on your bed for a while, but you should soon be able to take part in your usual activities. If you have any worries or concerns following your treatment please speak to your ward doctor or the nursing staff who are there to help you. 8.How will I feel immediately after ECT ? Most people will feel “woozy” or “muzzy-headed” for up to an hour after the treatment, don’t worry about this as it will clear. The nurse will be there to help you through any problems. 9. How well does ECT work? Research evidence shows that 8 out of 10 patients with severe depression respond well to ECT, either showing full recovery from depression or a substantial improvement. In fact, ECT is the most effective treatment for very severe depression. People who have responded to ECT report that it makes them feel "like themselves again" or "as if life was worth living again". Severely depressed patients will become more optimistic and less suicidal. Most patients recover their ability to work and lead a productive life after their depression has been treated with a course of ECT.


10. How many treatments are usually necessary? ECT is given twice a week. It is not possible to say exactly how many treatments you may need. Some people get better with as few as 2 or 3 sessions, others may need as many as 12 and very occasionally more. 11. What ECT can't do The effects of ECT will relieve the symptoms of your depression but will not help all your problems. An episode of depression may be due to problems with relationships or problems at home or at work. It may also cause such problems. These may still be present after your treatment and you may need further help with these. Hopefully, because the symptoms of your depression are better you will be able to deal with these other problems more effectively. You may then find that you are able to make good use of counselling or psychotherapy. 12. What are the side effects of ECT? Some patients may be confused just after they wake from the treatment and this generally clears up within an hour or so. The commonest side effect is transient headache. If this persists then your nurse will arrange for you to have a pain-killer (analgesic) for this. Some people also experience minor muscle discomfort and nausea. Your memory of recent events may be upset and dates, names of friends, public events, addresses and telephone numbers may be temporarily forgotten. In most cases this memory loss goes away within a few hours or days although sometimes patients continue to experience memory problems for several weeks or months. There may be gaps in your memory for events before and after the ECT for this period of time and in some cases events around the time of ECT may be permanently forgotten.

13. What else is known about Memory Impairment and ECT? Memory impairment can be associated with severe depression and can be marked even when patients have not had ECT.

Memory impairment for events occurring around the course of ECT and the few weeks afterwards is very common (60-70% of patients). Past memories can also be affected. It is difficult to know how much of this is caused by ECT and how much by severe depression. Memory impairment due to ECT tends to recover gradually over the six months following treatment, though some patients only very slowly recover past memories and some may have permanent gaps in their memory for some past events.

Despite these concerns it is important to note that the research evidence indicates that the ability to use our memory (working memory) may actually


improve after ECT, as depression lifts. To the best of our knowledge and after nearly 70 years of experience with ECT, we can say that ECT does not appear to have any long- term effects on the ability to use memory in the future, once your depression has improved, nor should there be any harmful effects on overall intelligence or other brain functions. The side effects on memory are more likely with bilateral ECT than unilateral ECT, although unilateral ECT may take longer to work. Your doctor will explain the difference between the two and will discuss the advantages and disadvantages of these 2 forms of ECT with you.

14. Does ECT cause Brain Damage? The straightforward answer is ‘NO’.

Brain damage can be of two types:

1. Shrinkage of the brain or loss of particular groups of cells. There are many studies using modern brain scans which have shown that ECT does not cause such damage.

2. Impairment of function

o This might not show up on brain scans.

o It might be detected by tests of memory, concentration or ability to plan.

o Most studies show that these abilities improve in patients who have had ECT. This is because ECT reverses depression not because of a direct positive effect on brain function.

o This emphasises that depression itself has profound effects on memory, concentration and other mental tasks.

Could there be a small number of people who do have permanent memory changes after ECT?

• Yes, there are certainly patients who have lost memories from their past which have not returned even after many years.

• Detecting these gaps in individual memories has proved very difficult in large research studies.

• Even in this very small number of patients the ability to learn new facts remains intact.


15. Are there other serious risks from the treatment?

ECT is amongst the safest medical treatments given under general anaesthesia. The risk of death or serious injury with ECT is rare and occurs in about one in 50,000 treatments. For example this is much lower than reported for childbirth. Very rarely deaths do occur and these are usually because of heart problems. Patients with a pre-existing medical condition are at increased risk of experiencing cardiac or respiratory problems following treatment. For this reason pre-treatment medical assessments to identify and minimise any risk are carried out. If you do have heart disease it may still be possible for you to have ECT safely as long as the doctors take special precautions, such as heart monitoring. Your doctor will ask another specialist to advise if there are grounds for concern.

In some cases severely depressed people treated with ECT may develop a swing in mood and become manic, the risk of a swing into manic mood is the same as for treatment with antidepressant drugs.

Not having ECT also has risks. Studies have shown that depressive illness increases mortality rate. There is evidence that suicide rate in severe depression is decreased in patients who are treated with ECT in comparison with those who are not.

16. What other treatments could I have? Anti-depressant and other drugs may be available to treat your particular condition and it is possible that some of them may work as well as ECT. You may also be offered psychotherapy. The advantage and disadvantages of other treatments should be discussed with you by your doctor.

17. Will I have to give consent?

If you have the “capacity” to make a decision, which means that you are able to understand the likely risks and benefits of ECT, can remember the information for long enough to make a decision and can communicate your decision, then ECT can only be given with your agreement. At some stage before the treatment you will be asked, by your doctor to sign a consent form for ECT. If you sign the form you are agreeing to have up to a certain number of treatments, although you can withdraw your consent at any time. Before you sign the form your doctor should explain what the treatment involves and why you are having it, and should be available to answer any questions you may have about the treatment.


18. What Safeguards Are There? Usually ECT does not have to be given urgently. There should be plenty of time to discuss the treatment. It’s always important to talk to someone, a doctor, your GP, a nurse, close friend or trusted family member or an advocate. Try to talk to other patients who have had ECT. If there is no one close to you that you can confide in, ask the ward staff for advice as there is an advocacy service available to you. If you are unsure don’t be afraid to ask your doctor to arrange a second opinion. Make sure that the alternatives to ECT have been explained to you.

19. Can I refuse to have ECT? You can refuse to have ECT and you may withdraw your consent at any time even before the first treatment has been given. The consent form is not a legal document and does not commit you to having the treatment. It is a record that an explanation has been given to you and that you understand to your satisfaction what is going to happen to you. Withdrawal of your consent to ECT will not in any way alter your right to continue treatment with the best alternative methods available. No one should be put under undue pressure to have ECT. If there are doubts independent advice should be sought. In some cases a person may become particularly seriously ill with depression. They may be suicidal, convinced that they are too wicked to be treated, or eat and drink too little to stay alive for much longer. In these circumstances ECT may be given to patients without their consent. For this to happen, two doctors and a social worker must agree that the person is so unwell that they need to be kept in hospital under a section of the Mental Health Act. Then another independent Psychiatrist, sent by the Care Quality Commission (Previously called the Mental Health Act Commission), must agree that the treatment is necessary. If you are detained in hospital under a section of the Mental Health Act and are uncertain about your rights, ask to speak to the Mental Health Act administrator for the hospital.

20. Can Relatives Give Consent To ECT? A relative cannot give consent to treatment on behalf of another. The only exceptions to this would be in the case of a minor or where a Lasting Power of attorney for Health and welfare is in place. It is good practice to always inform and then involve relatives in arriving at a decision.


21. Are there any risks in not having ECT as recommended?

If you choose not to accept your doctors' recommendation to have ECT you may experience a longer and more severe period of illness and disability than might otherwise have been the case. The alternative is treatment with anti-depressant and other types of drugs and psychotherapy if you are able to use it. Medication also has risks and complications and may not be any safer than ECT

22. Can ECT be given as an Emergency? In very urgent situations this can happen. If a consultant believes that a patient’s life is in danger because of severe depression then ECT can be given as an emergency. This usually only applies to the first one or two treatments. The Mental Health Act Commission must be contacted as soon as possible.

23. Why has ECT been controversial?

In the 1930s it was noticed that people who had both epilepsy and mental health problems often became brighter or indeed, happier, after an epileptic seizure. ECT was introduced as a result of this and was first given in 1938. In the past, ECT was used for a wide variety of problems, without anaesthetic and very long courses were given. THIS IS NO LONGER THE CASE. However, ECT remains controversial. Some people want it banned, others have claimed it saved their lives.

A great deal is known about how it works. We know more about how ECT and drug treatments work than we do about how psychotherapy works.

It is viewed in the medical profession as safe, effective and painless, with a low risk of unacceptable side effects. Furthermore, psychiatrists believe it can save lives.

However, this view has not always been shared by the public; this is perfectly understandable. Much of what people believe about ECT comes from the way it is portrayed in films, television drama and documentary, where the purpose is often to entertain or to be controversial. In addition, there is a lot of misinformation about ECT. ECT has become an important target for anti-psychiatry groups. Several such groups want ECT to be banned. Claims are made that ECT causes brain damage, irreversibly changes personality or even causes breast cancer. The majority of ECT web sites on the internet are strongly anti-ECT. The most extreme ones state that ECT never does any good, if patients appear to get better it is because they are stunned, shocked or brain damaged. There is no scientific evidence to back these claims.


A common claim is that ECT works because it impairs memory, in other words it makes you forget why you were depressed. This is not true, getting better with ECT does not depend on memory impairment

Other frequently expressed concerns are that ECT is ineffective and always causes unacceptable side effects. There is no scientific evidence to back up these concerns. The results of an important national audit carried out from February 1996 to August 1999, covering all ECT sites in Scotland, show these fears to be without foundation.

Remember that people can say almost anything on the internet, and it is important to be selective about what you read. If you feel overwhelmed by negative views, speak to other patients, to staff or ask to speak to an advocate. Don’t be embarrassed about doing so. Discuss any information you have with members of the team treating you. If you are not happy ask for a second opinion.

24. Advocacy Services

Advocacy services are available to you and can provide a sympathetic, supportive and helpful role by listening to your views and questions which you may not feel able to ask of the clinical team. Advocates will act as intermediaries for you and can be very helpful particularly if you either have no immediate family member available to do so or you would prefer not to involve your family. In some situations, where a person may lack capacity, an Independent Mental Capacity Advocate (IMCA) will be involved. For people detained under the Mental Health Act, an Independent Mental Health Advocate (IMHA) may be involved. Please ask your care coordinator or ward nurse for details of local advocacy services. Their contact numbers are as follows: Barnet: 0208732 6540 Enfield: 0208884 5000 Haringey: 0208340 2474

25. In Summary

ECT is a very effective treatment for certain conditions such as severe depression. The degree and rate of improvement is better than would be expected for either medication or talking treatments.

ECT is not effective for everyone, but for patients with the most severe forms of depression the majority are likely to show some improvement.

Many of the public perceptions and fears about ECT are not corroborated by research evidence and audit.


26. Further information The National Institute for Clinical Excellence (NICE) provides guidance for both the NHS and patients on the use of medicines, medical equipment, diagnostic tests and medical and surgical procedures and under what circumstances they should be used. NICE was asked to look at the available evidence on ECT and to provide guidance on ECT practice. These guidelines have been recognised and incorporated into the ECT service provided by this NHS Trust. An information booklet on the use of ECT has been produced by NICE for service users, advocates, carers and the public. There is a copy of the booklet on each of the wards. Please ask your doctor or nurse if you would like to read it. Alternatively, you can order a copy from the NHS Response Line by phoning 0870 1555 455 and quote reference NO205. Please let your Doctor or Nurse know if you would like to discuss any aspect of ECT treatment with the ECT team before you decide about the treatment.


APPENDIX 9: OUT-PATIENT ECT INFORMATION (to be kept by patient) Name: Date: Unit number: Consultant: Key worker: Doctor: Out-of-hours telephone number: Today you received electroconvulsive therapy. This involved a general anaesthetic; therefore you should not do any of the following for at least the next 24 hours:

• Operate machinery or electrical appliances • Consume alcohol • Sign any legal documents

You should not drive if you have a severe depression and would usually be advised not to drive throughout the course of ECT and thereafter only if assessed as competent to drive. You should discuss this with your Consultant. You should have another responsible adult to remain with you for the first 24 hours after treatment. You should have a responsible escort home and continuous responsible adult supervision at home for 24 hours after treatment and access to a telephone,

If you suffer any serious side-effects, then contact your own general practitioner in the first instance and pass on the information on this sheet.

If you have any concerns relating to your treatment or develop a cold or physical illness, then contact the ward or team that organised your ECT treatment. The information will be passed on to your hospital doctor. The evening before your next treatment, please remember not to eat any food after midnight, and take the tablets or medicines only as agreed with your hospital doctor.


Out Patient Post ECT Agreement (To be signed by patient and retained in notes) Today you will be receiving electroconvulsive therapy. This involves a general anaesthetic; therefore you should not do any of the following for 24hours: 1) operate machinery 2) consume alcohol 3) sign any legal documents. You should not drive if you have a severe depression and would usually be advised not to drive throughout the course of ECT and thereafter only if assessed as competent to drive. You should discuss this with your Consultant. A responsible adult must accompany you when you leave the department and this person should stay with you for 24 hours after treatment. I am in agreement with the above advice. Name:__________________________________________________ Signed:_________________________________________________ Date:______________________ Out Patient Post ECT pre-discharge checklist for ECT Staff


signed: ________________ practitioner (name & grade)__________ signed: _________________ patient / carer__________________ date / time/ discharged to the care of _______________________

Prior to discharge confirm that patient has: YES NO N/A

Blood pressure & pulse stable, within normal range

Is fully awake & orientated

Minimal nausea & no vomiting

i.v. cannula removed

mobile without feeling faint

taken fluids

passing urine as normal where relevant

has their post operative instructions

knows follow-up arrangements

has someone to take them home

has someone to stay with them overnight

aware not to drive during an acute course of ECT and thereafter only if assessed as competent to drive (nb see appendix on driving & ECT)

aware not to have alcohol for 24 hours

aware not to sign legal documents for 24 hours


Appendix 10: ECT Protocol – the responsibilities of nursing staff in ensuring appropriate standards of care for patients receiving Electro-convulsive Therapy

Policy statement: This policy has been written in order to assist in ensuring that the statutory requirements for the administration of ECT are met, in addition to ensuring that the highest standards of clinical care is provided for patients, including attention to their dignity and comfort.

Preparing a patient for ECT

1. The ECT information document is to be given to the patient and his/her relatives.

2. The ward manager/named nurse/care coordinator should contact the ECT

coordinator, Karl Sunkersing, on 0845 111 4000 bleep number 3886, once it has been decided that the patient will be offered ECT.

3. Transport (Metropolitan and London, tel: 020 8442 6000, transport office)

should be informed of the details of commencement date for ECT, the ward from which the patient will be departing, the number of escorting staff and any special requirements in order to ensure the safe transport of the patient.

Procedure before ECT treatment (treatment day)

1. The named nurse/care-coordinator reminds the patient, in understandable terms, what the procedure will entail.

2. Nursing staff will ensure that the patient has fasted for a period of six

hours before ECT is administered.

3. Nursing staff to ensure that patients are wearing loose-fitting, comfortable day clothes before presenting to the ECT department.

4. Make-up and nail varnish is to be removed.

5. Jewellery and valuables are to be retained on the ward for safekeeping.

6. The patient’s vital signs (temperature, pulse rate, respiratory rate, blood

pressure) should be recorded prior to the patient departing for ECT treatment.


Documentation checklist

The ward manager/care coordinator should ensure the following:

1. The patient’s health records are in good order and are available on the day the patient departs for ECT.

2. Legal documentation, specifically Mental Health Act forms, when

applicable, including form 39 authorizing treatment under the Mental Health Act, is available in the case notes.

3. Patient agreement (consent form) signed by the prescribing consultant

and the patient (when applicable), is available.

4. Results of recent blood investigations (and X-rays, scan reports if applicable), ECG and anaesthesia pro-forma (this must be completed by the ward doctor) is available in the notes.

5. Current prescription sheet/sheets available and conveyed to the ECT

department.

6. Any other relevant documentation.

7. To receive the patient back on the ward after returning from treatment, ensuring that he/ she is offered support, encouragement, re-orientation and resumption of their ward-based programmed activities as appropriate.

8. Ensure that lunch will be available for the patient upon their return to the

ward. Responsibilities/duties of the escorting nurse (first level nurse)

1. The escorting nurse should be known to the patient and would ideally be the patient’s named nurse

2. The escorting nurse should always be a qualified nurse.

3. The escorting nurse should have up-to-date training in basic life support.

4. The escorting nurse should be familiar with emergency equipment.

5. The escorting nurse should identify and introduce the patient to the ECT clinic staff.


6. The escorting nurse should offer reassurance before and after ECT treatment to the patient.

7. The escorting nurse should ensure the safety and dignity of the patient is

maintained at all times.

8. Ensure that the patient is encouraged to drink and to eat a light snack after leaving the recovery room and prior to leaving the department.

8. Ensure that all necessary notes and documents are returned to the ward.

The role of the recovery nurse

1. A trained nurse is to assume overall responsibility of the recovery room.

2. At any given time, there should be two trained nurses in the recovery

room.

3. Recovery nurses will be familiar with the operation of emergency equipment.

4. The recovery nurse will be competent in airway management.

5. The recovery nurse will be capable of understanding instructions from the

anaesthetists in relation to oxygen therapy, administration of intravenous fluids and other procedures relative to the recovery process.

6. The recovery nurse will ensure a safe environment is maintained.

7. The recovery nurse will address any concerns raised by the escorting

nurse.

8. The recovery nurse will assume responsibility for communicating to the anaesthetist any known adverse events which have occurred during prior treatment with ECT.

9. The recovery nurse will participate in re-orientating the patient.

10. The recovery nurse will ensure that the patient has fully recovered (ie, vital

signs are stable, breathing spontaneously, has normal colour, is responding verbally and is re-orientated before leaving the recovery room. If there are any concerns, the recovery nurse will seek the advice of the anaesthetist prior to the patient departing from the ECT unit.

11. The recovery nurse will ensure that day- or outpatients are escorted home

by a responsible adult.


12. The recovery nurse will ensure that day- or outpatients are provided with

the appropriate patient information document advising them against driving or operating any machinery/equipment for the rest of the day, after treatment.

Role of the ECT coordinator

1. To ensure the safe and efficient running of the ECT department.

2. To ensure that ECT equipment is maintained in good working order.

3. To assist the anaesthetists and operating department practitioner to safely administer anaesthetic agents and supervise the recovery of patients post-administration of anaesthesia.

4. To ensure that drugs used in the ECT department are within date and

available when required.

5. To ensure that ECT apparatus is in good working order and regularly maintained.

This policy is to be read in conjunction with the following Trust documents

1. Clinical Risk Assessment and Management Policy

2. Consent to Treatment for Patients Detained Under the Mental Health Act, 1983

3. Making equipment safe prior to repair of medical devices

4. Refusal of Treatment

5. Resuscitation

6. Use of a “Living Will”

7. Mental Health Act, 1983

8. Mental Capacity Act, 2005

9. Mental Health Act, 1983 – Code of Practice

10. Mental Capacity Act, 2005 – Code of Practice

11. ECT Handbook, The Royal College of Psychiatrists, 2005


APPENDIX 11: TREATMENT RESISTANT DEPRESSION: PHARMACOLOGICAL STRATEGIES TO CONSIDER Extracted from the Report on the Dundee AI/NMD service – January 2006 The following extract has been included in this protocol as a guide to additional pharmacological maintenance treatment options for patients who have completed a course of ECT in order to attempt to avoid frequent recurrences of severe depressive episodes. In general patients should not be treated with the same antidepressant medication regime on which they became unwell originally as this is unlikely to be effective in the prophylaxis of further episodes. Treatment Resistant Depression (TRD) Physical Treatment Methods As a guiding principle, all of the physical treatments that have been shown to be effective in ‘treatment-resistant-depression’ (preferably in randomised, controlled trials) must have been tried in adequate dosage for an adequate period of time. In general terms, this will reflect the prescription of antidepressant drugs within, or above, the dose range recommended by the British National Formulary (BNF) for a period of at least six weeks. It is important to note that a proportion of individuals with chronic, refractory depression will have unrecognised or ‘undeclared’ Bipolar Disorder. Therefore, the following also considers the application of “bipolar depression” treatment strategies as part of the framework for treatment ‘adequacy’ prior to ablative NMD. At present, the use of plasma drug concentration monitoring (where possible) is not included as a mandatory requirement, but this is sometimes desirable, particularly where ‘rapid metaboliser’ status is suspected. N.B. For some of the following treatments, particularly those where drug doses exceed those listed in the British National Formulary and where drug treatments are combined, regular physiological monitoring (e.g. blood pressure, ECG) is required to facilitate safe and continuing review of the relative risks and benefits of treatment. Most patients referred for assessment will have already have been exposed to many different treatment trials. The following represent those deemed ‘essential’ before proceeding to ablative surgery. The minimum inclusion criteria are: a) at least two ‘adequate’ courses of treatment with a tricyclic antidepressant drug. One of these trials must be with either clomipramine, imipramine or amitriptyline. b) at least two ‘adequate’ courses of treatment with a selective serotonin re-uptake inhibitor (SSRI). c) at least one ‘adequate’ course of treatment with a ‘classical’ monoamine oxidase inhibitor (i.e. not moclobemide). d) at least one of the above (TCA, SSRI or MAOI) plus lithium carbonate augmentation for a period of 4-6 weeks with a 12 hr post-medication plasma lithium level of 0.5-0.8 mmol/l. e) at least one ‘adequate’ course of treatment with a tricyclic antidepressant drug as defined above plus thyroid hormone augmentation for a period of 6 weeks. This involves the administration of liothyronine sodium / T3 hormone (not T4) [at a maximally tolerated dose up to 20 μg t.d.s.]. Failure to respond within 6 weeks ought to lead to termination of T3 administration. Where the patient is known to suffer from hypothyroidism and is taking replacement T4 (biochemically euthyroid), this strategy of T3 augmentation is still advised. f) at least two ‘adequate’ courses of treatment with an antidepressant drug as


defined above, plus the prescription of two atypical antipsychotic drugs for a period of six weeks at a dose within the BNF recommended range. There is probably greatest evidence to support the selection of olanzapine and risperidone, although others (quetiapine, amisulpride, aripiprazole) may be worth considering. Where psychotic symptoms are prominent in the clinical presentation, trials of both typical and atypical antipsychotic drugs should be considered. g) at least two ‘adequate’ trials of electroconvulsive therapy (ECT), spaced 6 months apart. Adequacy in this context is defined as a minimum of 12 bilateral applications of ECT with recorded evidence of seizure duration exceeding 15 s per treatment. Failure to respond is defined as either no clinical response, minimal clinical response or a brief response with relapse within a period of four weeks, despite antidepressant drug maintenance treatment. Where available, and considered more acceptable/appropriate for the patient, a trial of high dose unilateral ECT (5X seizure threshold) can substitute for bilateral ECT. h) at least one ‘adequate’ course of treatment with an antidepressant drug as defined above plus the essential fatty acid ethyl-eicosapentaenoate (EPA) at a dose of 1g per day. i) at least one ‘adequate’ course of treatment with an SSRI as defined above plus the addition of bupropion (SR) at a dose of 150-300mg/day. j) at least one trial of an anticonvulsant drug shown to have some evidence for efficacy in bipolar depression. This includes lamotrigine at a dose of up to 400mg day, divalproex sodium (Depakote) at a dose of up to 2.5g per day and carbamazepine at a dose of 800-1200mg per day. k) at least one trial of an antipsychotic drug shown to have efficacy in bipolar depression. This includes olanzapine (5-20mg/day) and quetiapine (300- 600mg /day). NB: There is also some preliminary evidence for increased response rates in the treatment of Bipolar I depression where olanzapine (6- 12mg/day) is combined with fluoxetine (25-50mg/day). l) at least one of the following: 1. combination therapy with clomipramine, lithium carbonate and Ltryptophan. The clomipramine to be administered at a maximally tolerated dose (150-300 mg / day), with a 12 hr post-medication plasma lithium level of 0.5-0.8 mmol/l. This ought to be administered for a minimum period of 6 weeks. 2. combination therapy with phenelzine, lithium carbonate and Ltryptophan. The phenelzine to be administered at the maximally tolerated dose (45-90 mg / day), with a 12 hr post-medication plasma lithium level of 0.5-0.8 mmol/l. This ought to be administered for a minimum period of 6 weeks. Alternative Recommended Pharmacological Treatment Strategies (Desirable but not essential prior to ablative NMD. Either: an absence of unequivocal evidence of efficacy in TRD, or, only suitable for selected patients on the basis of increased risk to physical health) 1. Prescription of an antidepressant drug beyond BNF recommended maximum daily dose. For example, gradual escalation to highest tolerated dose of venlafaxine (>500 mg / day). Beyond 375 mg / day, weekly ECG recordings are advisable, with regular BP monitoring required beyond 200 mg / day. Alternatively, gradual escalation to highest tolerated dose of imipramine (>300 mg / day). Similar close physiological monitoring is required. Measurement of plasma levels may be indicated, with a target concentration of 200-250 ng/ml. This ought to be continued for 6 weeks. 2. Combination of venlafaxine (375mg/day or maximally tolerated dose) with mirtazapine (30-45mg/day) with appropriate physiological monitoring (BP measurements and ECG recordings). 3, Psychostimulant Drug Treatment. Prescription of a maximally tolerated dose of a tricyclic drug (preferably imipramine), to which methylphenidate (Ritalin) is added, initially as a single 10 mg test dose, gradually increasing to 30 mg t.d.s. This ought to be continued for 6 weeks.


Appendix 12: ECT Treatment record: sticky label to be affixed in patient’s case notes following each treatment by the ECT staff

ECT TREATMENT Session No: ________________ Date: _____________ Patient: _________________________________ Procedure Explained: Yes/No

Consent: Yes / S62 / S58 / MCA Comment:_______________________ Stimulus: Bilateral/Unilateral Dose: % / mc ______________________ Visible seizure duration _______________ EEG ____________PSI_________ ECT Consultant: _____________________Anaesthetist: __________________ Administered by: ______________________Sign: _______________________ Comments: _______________________________________________________ __________________________________________________________________ __________________________________________ *Consultant Prescription for 2 further treatments:________________________


Appendix 13: Montgomery-Åsberg Depression Rating Scale

(MADRS)

1. Apparent sadness Representing despondency, gloom and despair (more than just ordinary transient low spirits), reflected in speech, facial expression, and posture. Rate by depth and inability to brighten up. 0. = No sadness. □ 2. = Looks dispirited but does brighten up without difficulty.

□

4. = Appears sad and unhappy most of the time.

□ 6. = Looks miserable all the time. Extremely despondent.

□

2. Reported sadness Representing reports of depressed mood, regardless of whether it is reflected in appearance or not. Includes low spirits, despondency or the feeling of being beyond help and without hope. 0. = Occasional sadness in keeping with the circumstances. □ 2. = Sad or low but brightens up without difficulty.

□ 4. = Pervasive feelings of sadness or gloominess. The mood is still influenced by external circumstances.

□

6. = Continuous or unvarying sadness, misery or despondency.

□


3. Inner tension Representing feelings or ill-defined discomfort, edginess, inner turmoil, mental tension mounting to either panic, dread or anguish. Rate according to intensity, frequency, duration and the extent of reassurance called for.

0. = Placid. Only fleeting inner tension.

□ 2. = Occasional feelings of edginess and ill-defined discomfort.

□

4. = Continuous feelings of inner tension or intermittent panic which the patient can only master with some difficulty.

□

6. = Unrelenting dread or anguish. Overwhelming panic.

□

4. Reduced sleep Representing the experience of reduced duration or depth of sleep compared to the subject’s own normal pattern when well.

0. = Sleeps as usual.

□ 2. = Slight difficulty dropping off to sleep or slightly reduced, light or fitful sleep.

□

4. = Sleep reduced or broken by at least 2 hours.

□ 6. = Less than 2 or 3 hours sleep.

□


5. Reduced appetite Representing the feeling of a loss of appetite compared with when well. Rate by loss of desire for food or the need to force oneself to eat.

0. = Normal or increased appetite.

□ 2. = Slightly reduced appetite.

□ 4. = No appetite. Food is tasteless.

□ 6. = Needs persuasion to eat at all.

□

6. Concentration difficulties Representing difficulties in collecting one’s thoughts mounting to an incapacitating lack of concentration. Rate according to intensity, frequency, and degree of incapacity produced.

0. = No difficulties in concentrating.

□ 2. = Occasional difficulties in collecting one’s thoughts.

□ 4. = Difficulties in concentrating and sustaining thought which reduces ability to read or hold a conversation.

□

6. = Unable to read or converse without great difficulty.

□


7. Lassitude Representing difficulty in getting started or slowness in initiating and performing everyday activities.

0. = Hardly any difficulty in getting started. No sluggishness.

□ 2. = Difficulties in starting activities.

□ 4 = Difficulties in starting simple routine activities, which are carried out with effort.

□

6. = Complete lassitude. Unable to do anything without help.

□

8. Inability to feel Representing the subjective experience of reduced interest in the surroundings, or activities that normally give pleasure. The ability to react with adequate emotion to circumstances or people is reduced.

0. = Normal interest in the surroundings and in other people.

□ 2. = Reduced ability to enjoy usual interests.

□ 4. = Loss of interest in the surroundings. Loss of feelings for friends and acquaintances.

□

6. = The experience of being emotionally paralysed, inability to feel anger, grief or pleasure and a complete or even painful failure to feel for close relatives and friends.

□


9. Pessimistic thoughts Representing thoughts of guilt, inferiority, self-reproach, sinfulness, remorse and ruin.

0. = No pessimistic thoughts.

□ 2. = Fluctuating ideas of failure, self-reproach or self-depreciation.

□

4. = Persistent self-accusation, or definite but still rational ideas of guilt or sin. Increasingly pessimistic about the future.

□

6. = Delusions of ruin, remorse or irredeemable sin. Self-accusations, which are absurd and unshakable.

□

10. Suicidal thoughts Representing the feeling that life is not worth living, that a natural death would be welcome, suicidal thoughts, and preparations for suicide. Suicide attempts should not in themselves influence the rating.

0. = Enjoys life or takes it as it comes.

□ 2. = Weary of life. Only fleeting suicidal thoughts.

□ 4. = Probably better off dead. Suicidal thoughts are common, and suicide is considered as a possible solution, but without specific plans or intension.

□

6. = Explicit plans for suicide when there is an opportunity. Active preparations for suicide.

□


APPENDIX 14

Royal College of Psychiatrists ECT Competencies:

The trainee by year 3 ought to be able to administer ECT without direct supervision, prepare patients for ECT, explain to patients and relatives about ECT, its indications and broad place within psychiatric treatment. Trainees ought to be able to monitor a patient’s mental state and cognitive functioning during a course of ECT. Consultants and trainees by the end of year 6 ought to have a good understanding of the place of ECT in modern clinical practice sufficient to obtain informed consent from patients to reach level 1 competency. Only consultants responsible for the ECT clinic or trainees (ST4-6) with a special interest in the administration of ECT would be expected to have level 1 competency in the practical aspects of the administration of ECT (sufficient to run an ECT clinic). Name:………………………. 1 = fully conversant (FC) 2 = working knowledge (WK) 3 = awareness (A) Verbally assessed 1 FC = Is able to explain accurately all the important features to a standard that shows sufficient understanding that would allow them to competently and independently apply the knowledge 2 WK = Is able to explain the key features to a standard that shows sufficient understanding that would allow them to apply the knowledge in common situations and access further information if necessary 3 A = Is aware of the topic and knows where to get further information but not to a level that provides a WK 2 Observed 1 FC = Is able to carry out the procedure to a standard that shows sufficient skill and understanding that would allow them to competently and independently carry it out. 2 WK = Is able to carry out the procedure to a standard that shows sufficient skill and understanding that would allow them to carry it out in usual situations but to know their limitations and access further help if necessary 3 A = Is aware of the topic and knows where to get further information but not to a level that provides a WK


1. Theory and background

Competency How evidenced Level Date Signature 1. Demonstrate a knowledge of NICE Guidelines. Verbally

2 Demonstrate an awareness of Royal College and ECTAS Guidelines.

Verbally

3. Demonstrate a knowledge of local policies and procedures, including a. emergency ECT b. outpatient ECT c. high risk patient

Verbally

4. Demonstrate a knowledge of the Consent to treatment requirements, including Common Law and MHA documentation/ requirements 0(p. 20 NICE)

Verbally

5. Knowledge of the indications for ECT with special reference to NICE

Verbally

6. Able to describe the contra-indications to ECT. Verbally

7. Able to describe the possible side effects, risks and benefits of ECT.

Verbally

8. Able to describe the pre-treatment preparations required to be undertaken by referring doctor.

Verbally

9. Able to describe the procedure for the administration of ECT.

Verbally

10 Able to describe the procedure for the referral of an outpatient for ECT

Verbally


11 Demonstrate a knowledge of: NICE Guidance on a. Continuance ECT. b. When ECT should be discontinued. Unilateral or bilateral treatment.

Verbally

12 Knowledge of current theories of mechanism of action of ECT

Verbally

13 Knowledge of physiological effects of ECT verbally

2. Practical Aspects of ECT

Competency How evidenced Level Date Signature 1. Attaching EEG leads Observed 2. Set correct stimulus Observed 3. Apply Electrodes bilateral Observed 4. Apply Electrodes unilateral Observed 5. Impedance testing Observed 6. Observe motor seizure and EEG monitoring Observed

7. Understand clinic dosing protocol Verbally

8. Understand when to restimulate verbally

9. Understand procedure for prolonged seizure verbally

10 Understand how to interpret EEG verbally

11 Correct recording of treatment in patient record Observed

12 Knowledge of anaesthetics and muscle relaxants used in ECT

Verbally

13 Basic resuscitation training* Written

14 ILS training Written


3. Other aspects of ECT practice a) Competency How evidenced Date Signature

1. Attended Induction to ECT 2. Observed clinical application of

ECT Observed

3. Supervised clinical application 1 Observed



6. Additional clinical application 1 Observed




10 Additional clinical application 5 Observed

11 Additional clinical application 6 Observed


b) Competency How evidenced Level Date Signature

1. Participation in audit of ECT

2. Participation in one day of CPD relating to ECT each year

3. Able to advise consultant colleagues on relative merits of bilateral/ unilateral treatment

4. Able to advise colleagues on suitability of patient for ECT

5. Involved in regular review of policies and procedures in ECT clinic

6. Evidence of training and supervising doctors in training in ECT practice

7. Able to advise colleagues on drug treatments during ECT

8. Able to advise colleagues on the management of side effects during ECT

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Required competencies: Foundation doctors Theory & background awareness 1-13 Practical aspects of ECT not required Other aspects of ECT practice a not required Other aspects of ECT practice b not required ST1-3 Theory & background working knowledge 1, 3-13 Awareness 2 Practical aspects of ECT fully conversant 1-11, 13 Working knowledge 12 Other aspects of ECT practice a 1-5 to be achieved Other aspects of ECT practice b not required ST4-6 & Prescribing Consultants Theory & background fully conversant 1-13 Practical aspects of ECT working knowledge 1-13 Other aspects of ECT practice a not required Other aspects of ECT practice b not required ECT consultants Theory & background fully conversant 1-13 Practical aspects of ECT fully conversant 1-12,14 Other aspects of ECT practice a not required Other aspects of ECT practice b 1-8 to be achieved

* for resuscitation training: • Fully conversant = training in last year • Working knowledge= last 5 years

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Appendix 15: Blood results chart Barnet , Enfield and Haringey Mental Health NHS Trust

AFFIX PATIENT LABEL HERE Laboratory Results Flow Chart Surname: ECT Care Pathway First Names:

Hospital Number: DOB: Age:

DATE TIME Normal ref. HB 11.0 – 18.0 WCC 4.0 – 11.0 Neutrophills 1.5 – 7.50 Platelets 130 - 450 PCV ..370 - .540 INR 0.8 – 1.2 APTT 27- 38 sec Fibrinogen 1.5 – 4.5 D-Dimer 0 - 300 APTT Ratio 0.8 – 1.2 Sodium 136 -145 Potassium 3.5 –5.1 Creatinine 60 - 120 Urea 3.0 – 7.5 Glucose 3.0 –6.0 Osmolality 280 -300 Creat Clearence 60- 120 CRP 0 -5 ESR 1 - 10 Bilirubin 0 - 17 Alk Phosphatase 35 - 115 ALT 10 - 60 Gamma-GT 5 - 60 Total Protien 60 - 83 Albumin 32 - 53 Globulin 16 - 36 Magnesium 0.85 – 1.15 Phosphate 0.74 – 1.52 Calcium 2.1 – 2.7 CPK 40 - 360 Troponin I <0.01 Amylase 25 -125 Lithium level TSH T3 T4

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Appendix 16: RCPsych. advice on Driving and ECT: Depression, ECT and fitness to drive The DVLA changed its guidance on driving and severe mental illness in March 2009. Given that most, if not all, patients having ECT would qualify as severely mentally ill, it is timely to review the College guidance in advance of the next ECT Handbook. DVLA guidance is updated twice a year in March and September: there were no new changes relating to psychiatric conditions in September 2009 What does DVLA Guidance say? The current guidance is dated September 2009 and psychiatric disorders are in chapter 4 pages 32-34. 1. Anxiety or depression without significant memory or concentration problems, agitation, behavioural disturbance or suicidal thoughts does not need to be notified to the DVLA 2. More severe depression with any of the above features requires that driving ceases pending the outcome of a medical enquiry. Patients who have a group 2 (Heavy Goods Vehicle licence) must be well and stable for 6 months before they can drive again. Holders of group 1licence require “a period of stability”. 3. Acute psychotic disorders of any type. For group one drivers driving must cease and relicensing will be considered when all of four conditions are met. These include remaining well and stable for 3 months. For group 2 drivers driving must cease pending a medical enquiry and it is normally a requirement that the person is well and stable for 3 years. What is a medical review? This is carried out by a DVLA medical advisor and is not simply a review by the responsible clinician. The DVLA warns that this can be a relatively lengthy process. It is clear that the guidance remains more concerned with the risk of suicide and the potential risk to others from a suicidal driver than it is with any cognitive impairment from depression and /or ECT. It does make the helpful comment that it is the “illness rather than the medication which is of prime importance” stressing that it is the underlying depressive disorder, rather than treatment, which matters most when making a judgement. There are a number of areas to consider in making a clinical judgement about driving after ECT: 1. The 24 hour rule following anaesthetic. This is the least important and is trumped by all other factors. It is important that a false impression of being fit to drive after 24 hours is not given by simply stating that the patient should not drive or operate machinery for “at least 24 hours after each treatment.” Day case information sheets may need to be amended to avoid this. 2. The cognitive impairment caused by severe depression. This can be marked, and can involve all cognitive abilities, including slowing of reaction time.

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This is an issue for all those treating depressed patients whatever treatment they are getting. 3. The added effect of ECT. ECT both impairs cognitive function and improves it if it successfully treats the underlying depression. Despite the marked subjective complaints from patients, what evidence we have is that cognitive function is worse or at least no better than pre ECT levels for approximately two weeks after a course and after that patient are functioning better than they were pre ECT. That of course does not mean they are not impaired. 4. Suicidal risk. This should be assessed separately from cognitive Function 5. Confidentiality. The guidance quotes the GMC confidentiality handbook “when a patient has a condition which makes driving unsafe and the patient is either unable to appreciate this or refuses to cease driving, the GMC advise breaking confidentiality and informing the DVLA”. Conclusions and Recommendations 1. We are concerned that little attention appears to have been paid to this issue and that many information sheets include advice about not driving for 24 hours post ECT. This advice is misleading and should be removed. Day case information sheets should be amended and the 24 hour clause removed or qualified. 2. Patients should be advised not to drive during a course of ECT: this includes not driving when on pass/ on leave from a ward between treatments. 3. Most patients who are depressed enough to have ECT should be advised not to drive for 3 months after recovery because this is the law. They may be advised that this is because of the nature of their depression, not because of ECT. Given that ECT may bring about a more rapid remission, they may be driving again more quickly if they have ECT than if they don’t. 4. How long after a course of ECT a patient is considered unfit to drive is a matter of clinical judgement and there may be occasions when a moderately depressed patient has had ECT, improved and is considered fit to drive before 3 months. 5. Depressed patients referred for ECT should routinely be given advice on driving related to their level of depression by their RMO. 6. Patients should be advised to inform the DVLA about their circumstances. 7. If there is evidence that patients are driving during or shortly after ECT against clear advice the RMO and/ or the lead ECT Consultant should consider, if it is appropriate, breaching confidentiality and should inform the DVLA directly. 8. Remember the much more stringent rules that apply to group 2 licence holders.

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Special situations 1. Maintenance ECT: Patients receiving maintenance ECT may not be depressed or have only mild symptoms. Maintenance ECT given once every two weeks or less frequently does not produce cumulative cognitive deficits. Unfortunately there are no studies which can help with guidance in this area as to when a patient is fit to drive. The decision when, after each maintenance treatment, a patient is fit to drive has to remain a matter of clinical judgement. 2. Patients under section of Mental Health Act can drive if they meet requirements set out above. Chris Freeman October 2009

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APPENDIX 17: Guidelines on Dental Management for ECT (Adapted from Beli & Bentham, Psychiatric Bulletin 1998) For referring teams: 1. Patients should be asked about relevant dental information, including the frequency of visits to the dentist, presence of dental restorations and prostheses, symptoms such as toothache, temperomandibular joint pain, loose teeth and bleeding gums. 2. Patients should undergo a brief oral examination with the aim of identifying: (a) loose, broken, decayed or missing teeth, gross dental tartar, failed restorations and abnormal occlusions: (b) removable dental prostheses (dentures and partial dentures): (c) non-removable dental prostheses (cemented crowns, bridges and dental implants); (d) soft tissue lesions and swellings: (e) mandibular deformities: (f) temporomandibular joint dysfunction (popping, clicking, crepitus and locking). 3. Patients with significant dental symptoms or abnormalities on examination (other than simply being edentulous) should be referred for an opinion from a dentist with knowledge and experience of the effects of ECT on oral structures. 4. Consideration should be given to dental risks during the consent procedure. 5. Information on the patients dental state should be made available to the ECT treatment team. For the ECT team: 6. A mouthguard should be used for all patients including the fully dentate and edentulous. 7. The mouthguard should be constructed of a material that is partly compressible, and extend sufficiently far back into the mouth to separate the first and second molar teeth. The guard should displace the tongue and buccal mucosa from opposing teeth or ridges and avoid overloading anterior dental structures. More than one size should be available. 8. The decision to retain partial dentures is dependent on the position, composition and stability of the prosthesis, the aim being to evenly distribute the load through structures with the ability to cope. 9. The jaws should be firmly held together by hand pressure on the mandible throughout the seizure in order to prevent the mouthguard from becoming displaced. 10. Attention should be paid to any abnormal sound coming from the mouth during the seizure. The mouthguard must be carefully removed and the oral cavity inspected for evidence of bleeding or loose and missing teeth. In recovery the patients should be asked about oral pain and difficulty in opening and closing the mouth. If significant abnormalities are identified these should be documented and the patient referred for a post-ECT dental evaluation.

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Appendix 18: ECT Treatment record

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Barnet, Enfield & Haringey Mental Health NHS Trust ECT Treatment Record Form ……. of……… Patient Details (affix sticky label if available) Surname: …………………………………………. Forenames: ………………………………………. RiO number: ……………………………………… DoB: ………………………………………………. Address: ………………………………………….. ……………………………………………………… ……………………………………………………… ……………………………………………………… Previous ECT course/s: ………………………. ……………………………………………..

Legal status: informal / formal (please circle) MHA Treatment given under s.62 (please circle) Treatment given under s.58 (please circle) MCA Section 5 of MCA s.5 (please circle) Ward: ………………………………… Prescribing Consultant: ………………………….. Laterality: Unilateral / Bilateral (please circle)

Medications: ……………………………………… ……………………………………… ………………………………………. ………………………………………. ……………………………………….. ……………………………………….. KNOWN DRUG SENSITIVITIES/ ALLERGIES: ……………………………………….. ………………………………………..

DIAGNOSIS – psychiatric: …………………………………… ……………………………………. Physical health problems: …………………………………….. …………………………………….. …………………………………….. ASA GRADE (circle) 1 2 3 4 5 …………………………………….. ……………………………………..

Treatment number: …………………. Date: ………………….. ASA Grade: 1 2 3 4 5 (please circle) Anaesthetic Agents:

Monitoring: ECG (HR):

Recovery, Discharge &Comments: Anaesthetist name (print) & signature:

FiO2:

SPO2:

ETCO2:

NIBP:

ECT stimulus no. 1 2 3

Dose mC / % Unilateral / bilateral Seizure length Clonus / EEG

PSI Comments: Administered by + signature:

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Treatment number: …………………. Date: ………………….. ASA Grade: 1 2 3 4 5 (please circle) Anaesthetic Agents:



FiO2: SPO2:

ETCO2:

NIBP:

ECT stimulus no. 1 2 3


PSI Comments: Administered by + signature:

Treatment number: …………………. Date: ………………….. ASA Grade: 1 2 3 4 5 (please circle)

Anaesthetic Agents



FiO2: SPO2:

ETCO2:

NIBP: ECT stimulus no. 1 2 3


PSI Comments Administered by + signature

ECT Trust Wide Medical Protocol UPDATE

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Transcript of ECT Trust Wide Medical Protocol UPDATE