6. Recommendations.

6.1 Use of E.C.T.

1. E.C.T. should be used:

• only when the objective is to achieve rapid and short-term beneficial effects (for at most eight weeks)
• to treat the symptoms of only limited categories of delusional and severe endogenous depressive illness where the patient:
• has a high number of typical features of depressive illness, but only when these include psychotic features and psychomotor disturbance, and
• exhibits symptoms of retardation and/or depressive delusions or
• is in a critical state through no longer eating or drinking, but only as a last resort when no other effective treatment is available that has not already been tried.
• to treat only limited categories of certain manic syndromes, but not as a first-line treatment unless the illness is genuinely life-threatening.
• to treat only limited categories of Type I (acute) schizophrenia in patients with specific indicators.
• to treat people with affective and catatonic disorders only when account has been taken of specific medical risks and appropriate modifications made.

3. E.C.T. should not be used:

• where the objective is to achieve a long-term beneficial effect or to influence long-term survival
• to treat Type II (chronic) schizophrenia
• to treat either Parkinson's Disease or epilepsy
• to treat violent or offending behavior, obsessive-compulsive disorders, anxiety, post-traumatic stress disorder, stroke, dementing illnesses, cardiovascular disease or diabetes.
• to try to prevent suicide.
• to treat patients who have had a recent myocardial infarction (heart attack), a recent cerebrovascular accident (stroke) or an intracranial mass or lesion (brain injury or tumour).

4. The Government should ban E.C.T. for children and young people under 18 years.

5. More careful consideration and guidance is required for the clinically effective use of E.C.T. for patients who are taking psychotropic and other drugs. The use of an increased number of E.C.T. treatments for patients taking psychotropic and other drugs should be avoided.

6.2 Administration of E.C.T.

1. E.C.T. should be used only in accordance with the guidance and recommendations within the Royal College of Psychiatrists' E.C.T. Handbook.

2. The choice of unilateral or bilateral E.C.T. should be made using the guidance and criteria within the Royal College of Psychiatrists' E.C.T. Handbook.

3. Only brief-pulse E.C.T. should be used. The Department of Health should ban sine-wave E.C.T.

4. E.C.T. should not be given to patients more than an absolute maximum of twice per week.

5. Where possible, E.C.T. should be given to patients where this is voluntary, with the patient's informed consent after a full explanation of the treatment, its risks and alternatives, where it is not used (or is perceived as being used) as a threat.

6. Patients who are given "maintenance" or "continuation" E.C.T. should have their memory and cognitive function recorded on a monthly basis.

7. Non-drug ("talking") therapies as well as drug treatments should always be considered as possible alternatives to E.C.T. before it is suggested or prescribed.

8. All nurses involved in dealing with E.C.T. patients should use the measures identified in the Royal College of Nursing's E.C.T. - Guidance for Nurses {(137) to reduce the anxiety of patients before E.C.T. and the level of memory impairment afterwards.

6.3 Training and supervision of clinical staff.

1. Each individual E.C.T. clinic should:

• be genuinely consultant-led, with adequate session time allocated to consultants to supervise E.C.T. services
• have a named consultant with clinical and administrative responsibility for its supervision and for ensuring that it meets the standards set
• have a program of initial and continued training for clinical staff in E.C.T. techniques.

3. The Department of Health and the Royal College of Psychiatrists should establish a mandatory national accreditation scheme for doctors prescribing or administering E.C.T., with complementary accredited training courses.

4. The Department of Health, in consultation with appropriate nursing and user / survivor organizations, should establish at the earliest opportunity national training and competency standards for nursing practicing in E.C.T. clinics. These should be developed from the guidance in the Royal College of Psychiatrists' E.C.T. Handbook (61) and the Royal College of Nursing's E.C.T. - Guidance for Nurses (137).

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

1. E.C.T. should be given according to the good practice guidelines set out by the Royal College of Psychiatrists in The E.C.T. Handbook (61), and the accompanying Checklists for Good Practice in E.C.T. 139.

2. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting, in consultation with user / survivor organizations, should develop national guidance for all nurses involved in E.C.T. developed from that in:

• the Royal College of Psychiatrists' E.C.T. Handbook (61)
• the Royal College of Nursing's E.C.T. - Guidance for Nurses (137) and
• Electro-convulsive Therapy (E.C.T.). A Good Practice Statement by the Working Group on Mental Illness of the Clinical Resource and Audit Group at the Department of Health in The Scottish Office 26.

• E.C.T. should be only be administered in accordance with the most recent guidelines of the Royal College of Psychiatrists, and as a minimum,
• E.C.T. should be undertaken to the same quality standards as apply to surgical procedures that are carried out under general anesthetic in the nearest district general hospital.

5. The Department of Health should set a national specification for E.C.T. machines, including standards for their maintenance and replacement.

6. All E.C.T. machines should be serviced at least every six months and be replaced after no more than five years.

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

1. Those E.C.T. clinics that fail to provide at least adequate care and treatment should be closed.

2. The Department of Health, together with the Royal College of Anaesthetists, should take action to raise the anesthetic standards of care and practice for E.C.T. and the criteria used for E.C.T. to at least the same exacting level as is required for day surgery under general anesthetic.

6.6 Consent, information and explanations.

1. The Department of Health, in consultation with appropriate professional and user / survivor organizations, should institute and develop statutory nationally agreed, evidence-based information on E.C.T., including about all significant risks and alternatives. This should be available and provided in a format and language appropriate to each patient where E.C.T. is being considered. It should include answers to the questions suggested by Mind and give equal weight to the views of both survivors and professionals.

2. Sufficient information and explanations, including about any significant risks and alternative treatments, should be given to a patient (using languages and formats appropriate to their individual needs) before they can make an informed decision about whether or not to give consent.

3. Information given to a patient before E.C.T. should always be repeated at an appropriate time soon after the treatment has been given, at the end of a course of treatment and when they are symptomatically improved.

4. Specific written information (or in another format appropriate to the patient) should be given to people receiving outpatient E.C.T. after their treatment about the precautions they should take for their own safety and well-being.

5. A patient's consent and their capacity to consent should be verified before each individual E.C.T. treatment, and not only at the start of a course of treatment.

6. Patient consent to E.C.T. should never be obtained by coercion or threat by clinical staff or others. Mechanisms to monitor and prevent this should be developed and implemented.

7. The Government should legislate so that E.C.T. cannot be administered without a patient's informed consent unless it is considered the only remaining way available to save their life.

8. The Government should legislate to give all patients (whether or not detained under the Mental Health Act) the legal right to be offered and to be given an independent second opinion where E.C.T. is considered as a treatment of choice.

9. Independent advocacy should always be available and explicitly offered to patients before they are asked to consent to E.C.T., and then both during and after a course of E.C.T.

6.7 The monitoring of E.C.T. and its administration.

1. Each E.C.T. clinic should routinely audit its standards of practice, use, indications for and outcomes of E.C.T.

2. The Department of Health should require all N.H.S. trusts and other providers to record and publicly report on the use of E.C.T., including the diagnosis, gender, age and ethnicity of patients. The Department of Health should collect and collate this information and publish a regular breakdown of all E.C.T. treatments by N.H.S. trust throughout the U.K., with an assessment of outcome.

3. The Department of Health should establish a national audit in England of electro-convulsive therapy. The remit of this audit should include: E.C.T. and its use; the effectiveness of E.C.T.; the risks and side-effects of E.C.T.; alternative treatments to E.C.T.; rules, guidance and criteria for E.C.T.; quality of care and practice of E.C.T.; training and supervision of clinical staff; consent, information and explanations; and the monitoring of E.C.T. and its administration. This audit should take full consideration of patients' and survivors' views, and have full patients and survivor involvement in the groups that undertake the audits.

4. The Royal College of Psychiatrists should immediately withdraw approved training status from every N.H.S. trust or other provider in question where they are not providing E.C.T. in accordance with its current guidelines.

5. The Mental Health Act Commission should incorporate the guidelines from The E.C.T. Handbook (61) of the Royal College of Psychiatrists and the Royal College of Nursing's E.C.T. - Guidance for Nurses (137) into its monitoring of services provided to patients detained under the Mental Health Act.

6.8 Research.

1. The Department of Health should actively encourage the development of a high-quality E.C.T. research program, similar to that already established in Scotland. This should focus on:

• establishing the basic mechanisms through which E.C.T. operates
• the reasons why women and older people are more likely to be given E.C.T., and how far these patterns are based on clinical grounds
• the reasons for the extremely wide variations in the use of E.C.T. between psychiatrists, hospitals and regions
• the reasons why many more people are given E.C.T. in the United Kingdom than in other countries in Europe, some parts of North America and the Far East
• the long-term effectiveness and side-effects of E.C.T. with regard to the quality of life or social functioning of survivors
• the relative effectiveness of E.C.T. and alternative treatments
• the effectiveness of "continuation" or "maintenance" E.C.T.
• establishing the criteria to determine each individual's threshold for the current involved in E.C.T.
• the effects of psychotropic and anesthetic drugs on the efficacy and safety of E.C.T. and their interactions
• survivors' views on E.C.T.
• the level of coercion or threat in practice by clinical staff to obtain patient consent and to what extent coercions and threats are intended or perceived.

B.E.C.T. and its Use in the Mental Health Services of Salford.

6.9 Strategy for change in Salford.

1. The Trust should develop a strategy for change in the use and administration of E.C.T. This initiative should include the consultant psychiatrist responsible for the treatment service, survivors (with their representatives), a named manager and key nurses involved in the treatment process. This strategy should address each of the elements below.

6.10 Use of E.C.T. in Salford.

1. Consultant psychiatrists in the Trust should use the criteria identified in section 6.1 for prescribing E.C.T.

2. Medical staff in the Trust should give much greater consideration to non-drug ("talking") therapies (as well as drug treatments) as alternatives to E.C.T. before it is suggested or prescribed.

6.11 Training and supervision of clinical staff in Salford.

1. The Trust should ensure that its E.C.T. service is genuinely consultant-led by a named consultant with clinical and administrative responsibility for its supervision and for ensuring that it meets the standards set. [E.C.T. is now overviewed by the Trust's Drugs and Therapeutics Committee chaired by the Medical Director and reports to the Trust Board].

2. The Trust should allocate more session time to consultants to allow closer supervision of E.C.T. services. [The Trust altered its arrangements in 1997 to ensure that at least one consultant is in the building when E.C.T. is being administered and available to attend the E.C.T. suite].

3. The Trust should not permit any doctor to administer E.C.T. unless they either are a consultant or have direct supervision of a consultant, and have had approved training, and have demonstrated that they have achieved the appropriate level of competence.

4. The Trust should develop a program of initial and continued training for clinical staff in E.C.T. techniques.

5. The Trust should require all nursing staff working in the E.C.T. clinic to have undergone appropriate approved E.C.T. training and demonstrated that they have achieved the appropriate level of competence.

6.12 Rules, guidance and criteria for E.C.T. in Salford.

1. The Trust should review and revise its guidance on E.C.T. to ensure that it accords with and incorporates all of the recommendations of The E.C.T. Handbook (61) of the Royal College of Psychiatrists, the Royal College of Nursing's E.C.T. - Guidance for Nurses (137) and Electro-convulsive Therapy (E.C.T.). A Good Practice Statement by the Working Group on Mental Illness of the Clinical Resource and Audit Group at the Department of Health in The Scottish Office 26.

2. Clinical staff prescribing and administering E.C.T. within the Trust should develop a clinical protocol for the use and administration of E.C.T. that incorporates each of the items in sections 6.1-6.4 above

3. The Trust, together with consultant anesthetic staff from the Salford Royal Hospitals N.H.S. trust, should rewrite the anesthetic guidelines for E.C.T. so that the criteria and standards of care are at least as high and exacting as those for day surgery under general anesthetic in the Salford Royal Hospitals N.H.S. Trust. These should also take into account issues raised in section 6.1 above.

4. Salford and Trafford Health Authority and other commissioning organisations in Salford should specify in their contracts or service level agreements for mental health services that:

• E.C.T. should be only be administered in accordance with the most recent guidelines of the Royal College of Psychiatrists, and as a minimum,
• E.C.T. should be undertaken to the same quality standards as apply to surgical procedures that are carried out under general anesthetic in the Salford Royal Hospitals N.H.S. Trust.

6.13 Quality of care and practice of E.C.T. in Salford.

1. The Trust should not allow any patient to be given E.C.T. who would be refused day surgery under the anesthetic criteria for day surgery in the Salford Royal Hospitals N.H.S. Trust, unless it is the only remaining option likely to save their life.

2. The Trust should use only E.C.T. machines (including reserve machines) that meet the current national specification. All available machines should be capable of E.C.G. monitoring and E.E.G. traces.

3. The Trust should ensure that all its E.C.T. machines are serviced at least every six months and replaced after no more than five years.

6.14 Consent, information and explanations in Salford.

1. The Trust, in consultation with professionals and survivors, should develop a new source of evidence-based patient information on E.C.T., including about all significant risks and alternatives, to replace the Royal College of Psychiatrists' fact sheet. This should include answers to the questions suggested by Mind and give equal weight to the views of both survivors and professionals.

2. Clinical staff should automatically provide information on E.C.T. to each patient in a format and language appropriate to them where E.C.T. is being considered, to complement the verbal explanation and discussion with clinical staff, before the patient is asked to make an informed decision about whether or not to give consent.

3. Clinical staff should always repeat information given to a patient before E.C.T. at an appropriate time soon after the treatment has been given, at the end of a course of treatment and when they are symptomatically improved.

4. Clinical staff should give every outpatient specific written information (or in another format appropriate to the patient) after their treatment about the precautions they should take for their own safety and well-being.

5. Clinical staff should verify the capacity of each patient to give or withhold consent (as well as their consent itself) before each individual treatment, and not only at the start of a course of treatment.

6. The Trust should completely revise its consent form for E.C.T. to ensure that it can be fully understood by patients and addresses each criterion required to ensure informed consent. The model developed by the Salford Royal Hospitals N.H.S. Trust for surgery should be used within this process.

7. Where a patient's informed consent is in doubt, clinical staff should delay giving E.C.T. while advocacy, second opinions and alternative treatments are explored, unless E.C.T. is considered immediately necessary as the only life-saving treatment available.

8. The Trust, together with the Salford Mental Health Services Citizen's Advice Bureau, should ensure that independent advocacy is always available and explicitly offered to every patient before they are asked to consent to E.C.T., and then both during and after a course of E.C.T.

6.15 The monitoring of E.C.T. and its administration in Salford.

1. The Trust should record and regularly report in public on the use of E.C.T., including the diagnosis, gender, age and ethnicity of patients.

2. The Trust should establish formal mechanisms to assess and monitor the short-term and long-term side-effects of E.C.T. on patients.

3. The Trust should establish a programe of regular clinical audit for E.C.T., focusing on its administration, indications, side-effects, short-term and long-term effectiveness with particular regard to the quality of life and social functioning of survivors.

6.16 Research in Salford.

1. The Trust should urgently develop processes and mechanisms (including the use of information technology) to enable it to monitor the E.C.T. service and easily produce information about its use, the patients who receive it, and its effectiveness.

2. The Trust should hold regular reviews of E.C.T. to ensure that E.C.T. is only administered in accordance with the most recent guidelines of the Royal College of Psychiatrists.

3. The Trust should audit the use of E.C.T. and identify the appropriateness of its use and whether other more effective alternatives could have been used instead.

4. The Trust should investigate the reasons why:

• such a relatively high proportion of patients given E.C.T. within the Trust are detained under the Mental Health Act
• there are such wide variations in the use of E.C.T. for individual consultants year-on-year and between consultants.
• a significantly higher proportion of patients receiving E.C.T. are over 65 in the Trust than in other local N.H.S. trusts

5. The Trust, together with the University of Manchester, should encourage high-quality research on the administration, use, effectiveness and survivors' views of E.C.T. the Trust, focusing on the issues in 6.8 above.

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