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New Developments to consider

Memory loss

Yes! Its official. There is finally recognition that in many cases memory changes occur during and after treatment, but that in a smaller number of cases these memory losses persist - perhaps indefinitely.

Consent

The discussion around the new (planned) mental health act in the UK stresses the increasing right of patients to decide NOT to have ECT. Parallel work on the ADVANCE DIRECTIVE will for the first time permit some patients to agree not to be given ECT -when they become unwell- even if the consequence of this is their likely death! Its a bit more complicated then that, but its certainly a new development.

Stimulus Dosing

Less controversial is the introduction in many places of STIMULUS DOSING - that is, finding the level of stimulus that is the MINIMUM to trigger a generalised seizure- and then setting equipment to deliver a fixed percentage ABOVE this threshold. Treating AT threshold oddly doesn't work- a fit is no longer SUFFICIENT for ECT, fits need to be triggered by stimuli perhaps 50% ABOVE threshold (but still, typically, lower than the older machines did in the 70's and 80's)

Pulse stimuli

Whilst the intensity of the treatment stimulus has to be increased if the patient has a higher threshold (which varied between people), alternative and commoner strategies involve giving the same stimulus longer. A third variable has appeared - the more 'spikey' the electrical wave form -i.e. the narrower the energy pulses, the more likely the fit is to occur -hence narrow pulses and ultra-brief' pulses may allow further energy reductions with continued effect and possibly fewer side effects.

The ECTAcreditation Service

The Royal College of Psychiatrists has collected together enthusiastic clinicians working in all of ECT and assembled a series of STANDARDS. UK ECT clinics
can register with ECTAS and seek accreditation through them. Over 30 clinics have applied thus far. The broader the discussion of these standards, the better they will become, but other countries may like to look them over and make comparisons with their services.

The NICE Guidelines

The National Institute for Health and Clinical Excellence produced an ECT 'technology appraisal' in 1983 which examined evidence and produced a number of recommendations as to the application of ECT. Uncontroversially they said that severe depression, intractable mania and catatonia had been shown to be effectively treated by ECT. Less understandably they came out against the use of ECT in pregnancy, and maintenance ECT was also regarded as of unproven benefit. This leaves pregnant women with the option of medication throughoutpregnancyh seems an odd decisiongivenn the proven effect of ECT in depression. Likewise some patients don't respond to medication at all - but do to ECT. It makes no sense to me that NICE should say that ECT treats depression but should not be used to prevent relapse in people for whom there is no other treatment agent. I don't understand the logic here - and guidance that appears illogical is difficult to justify to clients....
. You can download the guidance here.

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