The Practice of Electroconvulsive Therapy

Recommendations for Treatment, Training, and Privileging

A Task Force Report of the American Psychiatric Association

The APA Task Force on Electroconvulsive Therapy:

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

APA Staff

Harold Alan Pincus, M.D.
Sandy Ferris

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

11.4.3. Electrical Safety Considerations

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

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

11.5. Stimulus Electrode Placement

11.5.1. Characteristics of Stimulus Electrodes

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

11.5.2. Maintenance of Adequate Electrode Contact

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

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

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

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

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

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

11.5.3. Anatomic Location of Stimulus Electrodes

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

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

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

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

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

11.6. Stimulus Dosing

a) The primary consideration with stimulus dosing is to produce an adequate ictal response (see Sections 11.8.1 and 11.8.2). Regardless of the specific dosing paradigm used, whenever seizure monitoring (see Section 11.7.2) indicates that an adequate ictal response has not occurred, restimulation should be carried out at a higher stimulus intensity.

Informed Consent

Since a considerable time period is involved, however, care should also be taken to ensure that the informed consent process continues across the complete period during which ECT is administered. Patient memories of consent for medical and surgical procedures in general are commonly faulty (Roth et al. 1982; Meisel and Roth 1983). For patients receiving ECT, this difficulty with recall may be exacerbated by both the underlying illness and the treatment itself (Sternberg and Jarvik 1976; Squire 1986). For these reasons, the consentor should be reminded in an ongoing fashion of his/her option to withdraw consent. This reminding process should also include a periodic review of clinical progress and side effects.

The occurrence of a substantial alteration in the treatment procedure or other factor having a major effect upon risk-benefit considerations should be conveyed to the consentor on a timely basis. The need for ECT treatments exceeding the range originally conveyed to the consentor as likely (see Section 11.10) represents one such example. All consent-related discussions with the consentor should be documented by a brief note in the patient's clinical record.

Continuation/maintenance ECT (see Section 13) differs from a course of ECT in that its purpose is the prevention of relapse or recurrence, and that it is characterized by both a greater inter-treatment interval and a less well-defined endpoint. Because the purpose of continuation/maintenance treatment differs from that used in the management of an acute episode, new informed consent should be obtained prior to its implementation. As a series of continuation ECT typically lasts at least 6 months, and because continuation/ maintenance ECT is, by its nature, provided to individuals who are in clinical remission and who are already knowledgeable regarding this treatment modality, a 6-month interval before readministration of the formal consent document is adequate.

There is no clear consensus as to who should obtain consent. Ideally, consent should be obtained by a physician who has both an ongoing therapeutic relationship with the patient and, at the same time, has knowledge of the ECT procedure and its effects. In practice this can be accomplished by the attending physician, treating psychiatrist, or their designees acting individually or in concert.

Information Provided

The use of a formal consent document for ECT ensures the provision of at least a minimum measure of information to the consentor, although consent forms vary considerably in scope, detail, and readability. For this reason, a sample consent form and sample supplementary patient information material are included in Appendix B. If these documents are used, appropriate modifications should be made to reflect local conditions. It is also suggested that any reproductions be in large type, to ensure readability by patients with poor visual acuity.

Earlier task force recommendations (American Psychiatric Association 1978), other professional guidelines, and regulatory requirements (Mills and Avery 1978; Tenenbaum 1983; Winslade et al. 1984; Taub 1987; Winslade 1988), as well as a growing concern regarding professional liability, have encouraged the use of more comprehensive written information as part of the ECT consent process. Such material is often contained wholly within the formal consent document, while others use an additional supplementary patient information sheet. A copy of the major components of such information should be given to the consentor to facilitate learning and understanding of the material and assimilation by significant others.

To rely entirely upon the consent form as the sole informational component of the informed consent process would be ill-founded. Even with considerable attention to readability, many patients understand less than half of what is contained in a consent form (Roth et al. 1982). It is interesting to note, however, that psychiatric patients do not perform more poorly than medical or surgical cases (Meisel and Roth 1983). Besides problems with limited patient comprehension, members of the treatment team may see the consent form as relieving them of any additional responsibility to supply information to the patient/consentor over the ECT course. Alternatively, the consentor may perceive the signing of the consent form as a single, final act in the consent process, after which the matter is "closed." Both of these attitudes should be eschewed.

The written information supplied within and accompanying the consent document should be supplemented by a discussion between the consentor and the attending physician, treating psychiatrist and/or designee, that highlights the main features of the consent document, provides additional case-specific information, and allows an exchange to take place. Examples of case-specific information include: why ECT is recommended, specific applicable benefits and risks, and any planned major alterations in the pre-ECT evaluation or the ECT procedure itself. Again, as with all significant consent related interactions with the patient and/or consentor, such discussions should be briefly summarized in the patient's clinical record.

To improve the understanding of ECT by patients, consentors, and significant others, many practitioners use additional written and audiovisual materials, which have been designed to cover the topic of ECT from the layman's perspective. Videotapes, in particular, may be helpful in providing information to patients with limited comprehension, although they may not serve as a substitute for other aspects of the informed consent process (Baxter et al. 1986). A partial listing of such materials has been included as part of Appendix C.

The scope and depth of informational material provided as part of the consent document should be sufficient to allow a reasonable person to understand and evaluate the pertinent risks and benefits of ECT as compared to treatment alternatives. Since individuals vary considerably in terms of education, intelligence, and cognitive status, efforts should be made to tailor information to the consentor's ability to comprehend such data. The practitioner should be aware that too much technical detail can be as counterproductive as too little.

The specific topics to be covered in the consent document generally include the following: 1) a description of the ECT procedure; 2) why ECT is being recommended and by whom; 3) applicable treatment alternatives; 4) the likelihood and anticipated severity of major risks associated with the procedure, including mortality, adverse effects upon cardiovascular and central nervous systems, and common minor risks; 5) a description of behavioral restrictions that may be necessary during the pre-ECT evaluation period, the ECT course, and the recuperative interval; 6) an acknowledgement that consent for ECT is voluntary and can be withdrawn at any time; and 7) an offer to answer questions regarding the recommended treatment at any time, and the name of whom to contact for such questions.

The description of the ECT procedure should include the times when treatments are given (e.g., Monday, Wednesday, Friday mornings), general location of treatment (i.e., where treatments will take place), and typical range for number of treatments to be administered. In the absence of precise quantitative data, the likelihood of specific adverse effects is generally described in terms such as "extremely rare," "rare," "uncommon," and "common" (see Section 4). Because of ongoing concern regarding cognitive dysfunction with ECT, an estimate of the potential severity and persistence of such effects should be given (see Section 4). In light of the available evidence, "brain damage" need not be included as a potential risk.

Capacity and Voluntariness to Provide Consent

Informed consent is defined as voluntary. In the absence of consensus as to what constitutes "voluntary," it is defined here as the consentor's ability to reach a decision free from coercion or duress.

Since the treatment team, family members, and friends all may have opinions concerning whether or not ECT should be administered, it is reasonable that these opinions and their basis be expressed to the consentor. In practice, the line between "advocacy" and "coercion" may be difficult to establish. Consentors who are either highly ambivalent or are unwilling or unable to take full responsibility for the decision (neither of which are rare occurrences with patients referred for ECT) are particularly susceptible to undue influence. Staff members involved in clinical case management should keep these issues in mind.

Threats of involuntary hospitalization or precipitous discharge from the hospital due to ECT refusal clearly represent a violation of the informed consent process. However, consentors do have the right to be informed of the anticipated effects of their actions on the patient's clinical course and the overall treatment plan. Similarly, since physicians are not expected to follow treatment plans which they believe are ineffective and/or unsafe, an anticipated need to transfer the patient to another attending physician should be discussed in advance with the consentor.

It is important to understand the issues involved in a consentor's decision to refuse or withdraw consent. Such decisions may sometimes be based upon misinformation or may reflect unrelated matters, e.g., anger towards self or others or a need to manifest autonomy. In addition, a patient's mental disorder can itself severely limit the ability to cooperate meaningfully in the informed consent process, even in the absence of psychotic ideation. Patients who are involuntarily hospitalized represent a special case. A number of suggestions have been offered to help guarantee the right of such individuals to accept or refuse specific components of the treatment plan, including ECT. Examples of such recommendations include the use of psychiatric consultants not otherwise involved in the case, appointed lay representatives formal institutional review committees, and legal or judicial determination. While some degree of protection is indicated in such cases, overregulation will serve to limit the patient's right to receive treatment.

Informed consent requires a patient who is capable of understanding and acting intelligently upon information provided to him/her. For the purpose of these recommendations, the term the chronic dysthymia or whether dysthymic symptomatology also improves. However, some practitioners believe that dysthymic symptoms do improve and that focusing treatment termination on resolution of the major depressive episode alone may result in incomplete treatment, with possible heightened risk of relapse. In contrast, some patients with schizoaffective disorder present with relatively chronic forms of thought disorder (e.g., delusions), upon which is superimposed prominent episodic affective symptomatology. In a number of these patients, ECT may ameliorate the affective component without influencing the chronic thought disorder. Prolonging the ECT course to attempt such resolution may result in unnecessary treatment.

After the start of ECT, clinical assessments should be performed by the attending physician or designee after every one or two treatments. These assessments should preferably be conducted on the day following a treatment to allow for clearing of acute cognitive effects and should be documented. The assessments should include attention to changes in the episode of mental disorder for which ECT has been referred, both in terms of improvement in signs and symptoms present initially and the manifestation of new ones. During the course of ECT, switches from depression to mania may occur on an uncommon basis. In this context, it is important to distinguish between an organic euphoric state and mania (Devanand et al. 1988b) (see also Section 11.9). Formal assessment of changes in cognitive functioning may help in making this differential diagnosis.

In patients treated for prominent catatonic symptomatology, the nature of other symptoms may have been difficult to discern at pretreatment due to mutism or negativism. With introduction of ECT and the clearing of catatonia, other aspects of psychopathology may become evident and should be assessed and documented. Some patients may have experienced delusions or hallucinations prior to or during the ECT course, but, due to patient guardedness or other factors, these symptoms may have been difficult to verify With clinical improvement, the clinician may ascertain their presence, a determination which may impinge on discharge planning and future treatment.

12.2. Adverse Effects

Cognitive changes. The impact of ECT on mental status, particularly regarding orientation and memory functioning, should be assessed both in terms of objective findings and patient report during the ECT course (see Section 4). This assessment should be conducted prior to the start of ECT in order to establish a baseline level of functioning and repeated at least weekly throughout the ECT course. It is suggested that cognitive assessment, like assessment of therapeutic change, be conducted at least 24 hours following an ECT treatment to avoid contamination by acute postictal effects.

The evaluation may include either bedside assessment of orientation and memory and/or more formal test measures. It should include determination of orientation in the three spheres (person, place, and time), as well as immediate memory for newly learned material (e.g., reporting back a list of three to six words) and retention over a brief interval (e.g., reporting back the list 5-10 minutes later). Remote recall might likewise be assessed by determining memory for events in the recent and distant past (e.g., events associated with the hospitalization, memory for personal details: address, phone number, etc.).

Formal testing instruments provide quantitative measures for tracking change. To assess global cognitive functioning, an instrument such as the Mini-Mental State exam (Folstein et al. 1975) may be used. To track orientation and immediate and delayed memory, subtests of the Russell revision of the Weschler Memory Scale could be used (Russell 1988). To formally assess remote memory, tests of recall or recognition of famous people or events can be used (Butters and Albert 1982; Squire 1986). When cognitive status is assessed, the patient's perception of cognitive changes should also be ascertained. This may be done by informally inquiring whether the patient has noticed any changes in his/her abilities to concentrate (e.g., to follow a television program or a magazine article) or to remember visitors, events of the day, or recall of more remote events. Patient perception of memory functioning may also be examined using a quantitative instrument (Squire et al. 1979).

In the event that there has been a substantial deterioration in orientation or memory functioning during the ECT course that has not resolved by discharge from the hospital, a plan should be made for post-ECT follow-up of cognitive status. Most commonly there is marked recovery in cognitive functioning within days of the end of the ECT course (Steif et al. 1986) and patients should be reassured that this will likely be the case. The plan should include a description of when follow-up assessment would be desirable, as well as the specific domains of cognitive function to be assessed. It may be prudent in such cases to conduct additional evaluations, e.g., neurological and electroencephalographic examinations, and if abnormal to repeat until there is resolution.

It should be kept in mind that the cognitive evaluation procedures suggested here provide only gross measures of cognitive status. Furthermore, interpretation of changes in cognitive status may be subject to a number of difficulties. Psychiatric patients frequently have cognitive impairments prior to receiving ECT and a therapeutic response may therefore be associated with improvement in some cognitive domains (Sackeim and Steif 1988). However, while some patients show improved scores relative to their pre-ECT baseline, they still may not have fully returned to their baseline level of cognitive functioning (Steif et al. 1986). This discrepancy may be a basis for complaints about lingering cognitive deficits. In addition, the procedures suggested here only sample limited aspects of cognitive functioning, for example, deliberate learning and retention of information. Patients may also have deficits in incidental learning. Likewise, the suggested procedures concentrate on verbal memory, although both right unilateral and bilateral ECT produce deficits in memory for nonverbal material (Squire 1986).

Other adverse effects. During the ECT course, any onset of new risk factors, or significant worsening of those present at pre-ECT, should be evaluated prior to the next treatment. When such developments alter the risks of administering ECT, the consentor should he informed and the results of this discussion documented. Patient complaints about ECT should be considered adverse effects. The attending physician and/or a member of the ECT treatment team should discuss these complaints with the patient, attempt to determine their source, and ascertain whether corrective measures are indicated.

13. Management of Patient's Post-ECT Course

Continuation therapy, which is defined as the extension of somatic therapy over the 6-month period following induction of a remission in the index episode of mental illness, has become the rule in contemporary psychiatric practice. Exceptions may include patients who are intolerant to such treatment and possibly those with either an absence of prior episodes or a history of extremely long periods of remission (although compelling evidence for the latter is lacking). Unless residual adverse effects necessitate a delay, continuation therapy should be instituted as soon as possible after remission induction, since the risk of relapse is especially high during the first month. Some practitioners believe that the onset of symptoms of impending relapse in patients who are ECT responders may represent an indication for institution of a short series of ECT treatments for a combination of therapeutic and prophylactic purposes, although controlled studies are not vet available to substantiate this practice.

Continuation pharmacotherapy. A course of ECT is usually completed over a 2- to 4-week period. Standard practice, based in part on earlier studies (Seager and Bird 1962; Imlah et al. 1965; Kay et al. 1970), and in part on the parallel between ECT and psychotropic drug therapies, suggests continuation of unipolar depressed patients with antidepressant agents (with the possible addition of an antipsychotic drug in cases of psychotic depression), bipolar depressives with antidepressant and/or antimanic medications; and manics with antimanic and possibly antipsychotic agents. For the most part, dosages are maintained at 50%-100% of the clinically effective dose range for acute treatment, with adjustment up or down depending upon response. Still, the role of continuation therapy with psychotropic drugs after a course of ECT is undergoing assessment, and our recommendations should be considered provisional. Disappointment with high relapse rates, especially in patients with psychotic depression and in those who are medication resistant during the index episode (Sackeim et al., 1990), compels reconsideration of present practice, including a renewed interest in continuation ECT (Fink 1987b).

Continuation ECT. While psychotropic continuation therapy is the prevailing practice. few studies document the efficacy of such use after a course of ECT, and some recent studies report high relapse rates even in patients complying with such regimens (Spiker et al. 1985; Aronson et al. 1987, 1988a, 1988b; Sackeim et al., in press). These high relapse rates have led some practitioners to recommend continuation ECT for selected cases. Recent retrospective reviews of this experience find surprisingly low relapse rates among patients so treated, although controlled studies are not yet available (Kramer 1987; Decina et al. 1987; Clarke et al. 1989; Loo et al. 1988; Matzen et al. 1988; Thornton et al. 1988). Because continuation ECT appears to represent a viable form of continuation management of patients following completion of a successful course of ECT, facilities are encouraged to offer this modality as a treatment option. Patients referred for continuation ECT should meet all of the following criteria: 1) history of recurrent illness that is acutely responsive to ECT; 2) either refractoriness or intolerance to pharmacotherapy alone or a patient preference.

Appendix B

Examples of Consent Forms and Patient Information Sheet for an ECT Course
[Name of Facility Here]

ECT Consent Form

Name of Attending Physician:

Name of Patient: ______________________________________

My doctor has recommended that I receive treatment with electroconvulsive Therapy (ECT). The nature of this treatment, including the risks and benefits that I may experience have been fully described to me and I give my consent to be treated with ECT.

I will receive ECT to treat my psychiatric condition. I understand that there may be other alternative treatments for my condition which may include medications and psychotherapy. Whether ECT or an alternative treatment is most appropriate for me depends on my prior experience with these treatments, the nature of my psychiatric condition, and other considerations. Why ECT has been recommended for my specific case has been explained to me.

ECT involves a series of treatments. To receive each treatment I will be brought to a specially equipped room in this facility. The treatments are usually given in the morning, before breakfast. Because the treatments involve general anesthesia, I will have had nothing to drink or eat for at least six hours before each treatment. When I come to the treatment room, an injection will be made in my vein so that I can be given medications. I will be given an anesthetic drug that will quickly put me to sleep. I will be given a second drug that will relax my muscles. Because I will be asleep, I will not experience pain or discomfort during the procedure. I will not feel the electrical current, and when I wake up I will have no memory of the treatment.

To prepare for the treatments, monitoring sensors will be placed on my head and other parts of my body. A blood pressure cuff will be placed on one of my limbs. This is done to monitor my brain waves, my heart, and my blood pressure. These recordings involve no pain or discomfort. After I am asleep, a small, carefully controlled amount of electricity will be passed between two electrodes that have been placed on my head. Depending on where the electrodes are placed, I may receive either bilateral ECT or unilateral ECT. In bilateral ECT, one electrode is placed on the left side of the head, the other on the right side. In unilateral ECT, both electrodes are placed on the same side of the head, usually on the right side. When the current is passed, a generalized seizure is produced in the brain. Because I will have been given a medication to relax my muscles, muscular contractions in my body that would ordinarily accompany a seizure will be considerably softened. The seizure will last for approximately one minute. Within a few minutes, the anesthetic drug will wear off and I will awaken. During the procedure my heart rate, blood pressure, and other functions will be monitored. I will be given oxygen to breathe. After waking up from the anesthesia, I will be brought to a recovery room, where I will be observed until it is time to leave the ECT area. The number of treatments that I receive cannot be predicted ahead of time. The number of treatments will depend on my psychiatric condition, how quickly I respond to the treatment, and the medical judgment of my psychiatrist. Typically, six to twelve treatments are given. However, some patients respond slowly and more treatments maybe required. Treatments are usually given three times a week, but the frequency of treatment may also vary depending on my needs.

The potential benefit of ECT for me is that it may lead to improvement in my psychiatric condition. ECT has been shown to be a highly effective treatment for a number of conditions. However, not all patients respond equally well. As with all forms of medical treatment, some patients recover quickly; others recover only to relapse again and require further treatment, while still others fail to respond at all.

Like other medical procedures, ECT involves some risks. When I awaken after each treatment, I may experience confusion. The confusion usually goes away within an hour. Shortly after the treatment, I may have a headache, muscle soreness, or nausea. These side effects usually respond to simple treatment. More serious medical complications with ECT are rare. With modern ECT techniques, dislocations or bone fracture, and dental complications very rarely occur. As with any general anesthetic procedure, there is a remote possibility of death. It is estimated that fatality associated with ECT occurs approximately one per 10,000 patients treated. While also rare, the most common medical complications with ECT are irregularities in heart rate and rhythm.

To reduce the risk of medical complications, I will receive a careful medical evaluation prior to starting ECT. However, in spite of precautions there is a small chance that I will experience a medical complication. Should this occur, I understand that medical care and treatment will be instituted immediately and that facilities to handle emergencies are available. I understand, however, that neither the institution nor the treating physicians are required to provide long-term medical treatment. I shall be responsible for the cost of such treatment whether personally or through medical insurance or other medical coverage. I understand that no compensation will be paid for lost wages or other consequential damages.

A common side effect of ECT is poor memory functioning. The degree of disruption of memory is likely to be related to the number of treatments given and their type. A smaller number of treatments is likely to produce less memory impairment than a larger number of treatments. Right unilateral ECT (electrodes on the right-side) is likely to produce milder and shorter-lived memory impairment than that following bilateral ECT (one electrode on each side of the head). The memory difficulties with ECT have a characteristic pattern. Shortly following a treatment, the problems with memory are most pronounced. As time from treatment increases, memory functioning improves. Shortly after the course of ECT, I may experience difficulties remembering events that happened before and while I received ECT. This spottiness in memory for past events may extend back to several months before I received ECT, and in rare instances, to one or two years. Many of these memories will return during the first several months following the ECT course. However, I may be left with some permanent gaps in memory, particularly for events that occurred close in time to the ECT course. In addition, for a short period following ECT, I may experience difficulty in learning and remembering new information. This difficulty in forming new memories should be temporary and will most likely subside within several weeks following the ECT course. Individuals vary considerably in the extent to which they experience confusion and memory problems during and shortly following treatment with ECT. However, in part because psychiatric conditions themselves produce impairments in learning and memory, many patients actually report that their learning and memory functioning is improved after ECT compared to their functioning prior to the treatment course. A small minority of patients, perhaps 1 in 200, report severe problems in memory that remain for months or even years. The reasons for these rare reports of long-lasting impairment are not fully understood.

Because of the possible problems with confusion and memory, it is important that I not make any important personal or business decisions during the ECT course or immediately following the course. This may mean postponing decisions regarding financial or family matters. After the treatment course, I will begin a "convalescence period," usually one to three weeks, but which varies from patient to patient. During this period I should refrain from driving, transacting business, or other activities for which impairment of memory may be problematic, until so advised by my doctor.

The conduct of ECT at this facility is under the direction of Dr. _________________. I may contact him/her at (phone number: ________________) if I have further questions.

I understand that I should feel free to ask questions about ECT at this time or at any time during the ECT course or thereafter from my doctor or from any other member of the ECT treatment team. I also understand that my decision to agree to ECT is being made on a voluntary basis, and that I may withdraw my consent and have the treatments stopped at any time.

I have been given a copy of this consent form to keep.

Patient:

Date Signature

Person Obtaining Consent:

Date Signature

Sample Patient Information Sheet

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is a safe and effective treatment for certain psychiatric disorders. ECT is most commonly used to treat patients with severe depression. It is often the safest, fastest, and most effective treatment available for this illness. ECT is also sometimes used in the treatment of patients with manic illness and patients with schizophrenia. Treatment for depression has improved remarkably over the past 25 years. The techniques of administering ECT have also improved considerably since its introduction. During ECT, a small amount of electrical current is sent to the brain. This current induces a seizure that affects the entire brain, including the parts that control mood, appetite, and sleep. ECT is believed to correct biochemical abnormalities that underlie severe depressive illness. We know that ECT works: 80% to 90% of depressed people who receive it respond favorably, making it the most effective treatment for severe depression.

Your physician suggests that you be treated with ECT because you have a disorder that (s) he believes will respond to ECT. Discuss this with your doctor. Before ECT begins, your medical condition will be carefully assessed with a complete medical history, physical examination and laboratory tests including blood tests and an electrocardiogram (ECG).

ECT is given as a course of treatments. The number needed to successfully treat a severe depression ranges from 4 to 20. The treatments are usually given 3 times a week: Monday, Wednesday, and Friday. You must not eat or drink anything after midnight prior to your scheduled treatment. If you smoke, please try to refrain from smoking on the morning prior to your treatment.

Before your receive the treatment, a needle will be injected into a vein so that medications can be given. Although you will be asleep during the treatment, it is necessary to begin to prepare you while you are still awake. Electrodes are placed on your head for recording your EEG (electroencephalogram or brain waves). Electrodes are placed on your chest for monitoring your ECG (cardiogram or heart rhythm). A blood pressure cuff is wrapped around your wrist or ankle for monitoring your blood pressure during the treatment. When everything is connected, the ECT machine is tested to ensure that it is set properly for you.

CONTINUING EDUCATION COURSES

FOR PSYCHIATRISTS Duke University

Visiting Fellowship: 5-day course for one or two students, designed to provide advanced training and skills in modern ECT administration. 40 CME credits.

Mini-Course: 1.5 day course designed to enable practicing clinicians to upgrade their skills in ECT. 9 CME credits.
Director: C. Edward Coffey, M.D. 919-684-5673

SUNY at Stony Brook

5-day course for four to six students, designed to provide advanced training and skills in modern ECT. 27 CME credits.
Director: Max Fink, M.D. 516-444-2929

American Psychiatric Association

At annual meetings of the APA, one-day courses are usually presented for classes of students up to 125. These are lecture/demonstrations and aim to provide discussions of such topics as treating the high-risk patient, technical aspects of treatment, and theories of ECT action. For details, see annual course offerings of APA.

Individual preceptorships

From time to time, other experienced clinicians accept visitors for varying lengths of stay at their clinics.

FOR NURSES

Courses for nurses are available at both Duke University and SUNY at Stony Brook. For information, contact Martha Cress, R.N., or Dr. Edward Coffey at Duke University, or Dr. Max Fink at SUNY at Stony Brook.

FOR ANESTHESIOLOGISTS

The courses for psychiatrists at SUNY at Stony Brook include special sessions for anesthesiologists.

Appendix D

Addresses of Present ECT Device Manufacturers in the United States and Major Characteristics of Models Offered as of February 1990

The present devices of these manufacturers meet the recommended standards of the APA Task Force on Electroconvulsive Therapy. In addition, the manufacturers distribute educational materials (books and videotapes), which are useful in learning about ECT.

ELCOT Sales, Inc.
14 East 60th Street
New York, NY 10022
212-688-0900

MECTA Corp.
7015 SW. McEwan Road
Lake Oswego, OR 97035
503-624-8778

Medcraft
433 Boston Post Road
Darien, CT 06820
800-638-2896

Somatics, Inc.
910 Sherwood Drive
Unit 17
Lake Bluff, IL 60044
800-642-6761

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