11/13/24, 8\:17 PM Guide | ECT counselling

ECT counselling

Table of contents

Introduction

Electroconvulsive therapy (ECT) counselling is a common OSCE topic in psychiatry scenarios. It often includes dealing with a
patient's concerns about treatment and being able to answer questions in a sensitive, but informative manner. This guide
provides a structured approach to explaining ECT treatment in an OSCE setting. For the purposes of this scenario, the patient
has treatment-resistant depression and can consent to ECT treatment.

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain the reason for the consultation\:
" I u n d e r s t a n d t h a t y o u h a v e a d i a g n o s i s o f d e p r e s s i o n a n d h a v e n o t n o t i c e d a n y b e n e
f r o m s e v e r a l d i
e l e c t r o c o n v u l s i v e t h e r a p y ( E C T ) , t h a t w e f e e l m a y b e b e n e
"

Check patient understanding

Ideas

" H a v e y o u h e a r d o f E C T b e f o r e ?" " W h a t d o y o u k n o w a b o u t t h i s t r e a t m e n t ?"
Be prepared for negative comments or thoughts about ECT from patients due to media portrayal and common
misconceptions. Some patients may refer to it by the old term “electroshock therapy”
.

Concerns

" W h a t i s i t t h a t c o n c e r n s y o u t h e m o s t a b o u t E C T ?"
O

Expectations

" I w o u l d l i k e t o g i v e y o u s o m e m o r e i n f o r m a t i o n a b o u t E C T . I w i l l d i s c u s s w h y i t i s u s e d , w h a t h a p p e n s d u r i n g t r e a t m e n t a n d t h e
b e n e
l i k e m e t o c o v e r t o d a y ?"

Explanation of ECT

What is ECT?

“ E l e c t r o c o n v u l s i v e t h e r a p y , a l s o k n o w n a s E C T , i s a p s y c h i a t r i c t r e a t m e n t i n w h i c h a p a t i e n t i s b r i e
a n a e s t h e t i c , a n d a s m a l l a m o u n t o f e l e c t r i c a l e n e r gy i s d i r e c t e d t o w a r d s t h e b r a i n t h r o u gh e l e c t r o d e s o n t h e f o r e h e a d w h i c h
i n d u c e s a c o n t r o l l e d , s m a l l , b r i e f s e i z u r e . M e d i c a t i o n i s g i v e n t o r e l a x t h e m u s c l e s s o t h e s e i z u r e a c t i v i t y i n t h e b o d y m u s c l e s i s
m i n i m i s e d . T h e p a t i e n t i s c l o s e l y m o n i t o r e d t h r o u g h o u t , a n d i t i s s o b r i e f t h a t t h e r e i s n o n e e d f o r t h e p a t i e n t t o b e i n t u b a t e d .
T h e t r e a t m e n t i s t h o u g h t t o r e o r g a n i s e t h e n e t w o r k s i n t h e b r a i n t h a t a r e d i s o r d e r e d i n m e n t a l i l l n e s s .
”
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At this point, acknowledge cues from the patient’s concerns – reassure the patient that they will be put to sleep for ECT and
that you can provide more information to put their mind at ease.

What is ECT used for?

Electroconvulsive therapy is a treatment for severe psychiatric illnesses, including\:
Severe depression, which is resistant to multiple therapies and antidepressants
Severe depressive disorder which is causing harm to the patient (e.g. associated with self-neglect/reduced diet and
intake/suicide risk)
Catatonia
Severe or ongoing mania
Link your explanation to whichever illness the patient has.
Often, patients are in hospital due to the severity of their mental illness when ECT is required, but it is possible for patients to
have ECT from the community when their condition allows.

What are the potential bene

It is one of the most e
Most patients will experience improvements within two weeks.
ECT can have a synergistic e

How many sessions does a course of ECT involve?

ECT usually comprises twice-weekly treatment for a course of 6-12 sessions at a time.
The patient is reassessed after every treatment and may stop before the end of a course or continue to have ongoing courses
depending on clinical presentation. It is not possible to predict how a patient will respond and how many sessions they will
require. There does not appear to be a correlation with illness severity.
Some patients may deteriorate when ECT stops and may bene
apart, usually weekly, then fortnightly, then eventually monthly. This tends to be given for longer periods and can continue
inde

What does ECT involve?

Before ECT
Prior to ECT being performed\:
ECT is carried out in an ECT suite. This may be in a general or psychiatric hospital setting.
The patient is required to be nil-by-mouth for 6 hours before the procedure (same as an operation).
An anaesthetist carries out a pre-procedure assessment.
A psychiatrist will assess the mental health act and capacity status of the patient and ensure appropriate paperwork has
been completed.
The patient is attached to an EEG machine for continuous monitoring of brain activity. Physical observations will also be
monitored throughout.
A short-acting anaesthetic is administered by an anaesthetist.
A muscle relaxant (e.g. suxamethonium) is administered to minimise the risk of harm to the patient during convulsions. A
mouthguard is also used to prevent damage to teeth or the tongue and mouth lining during convulsions.
During ECT
ECT is carried out by a psychiatrist and can be delivered unilaterally or bilaterally. Bilateral ECT is more commonly used due
to increased e
jelly is used to ensure good contact with the skin.
If there are concerns about pre-existing memory di
unilateral ECT may be used where the electrical energy is only applied to the non-dominant hemisphere of the brain by
placing one of the electrodes on the back of the head. This is less e
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A small amount of electrical energy is directed through the electrodes towards the brain. This begins at a low dose with the aim
of using the smallest amount of current possible. The electrical charge lasts around 5 seconds.
The electrical energy to the brain induces a controlled seizure. The clinicians should see motor activity for over 15 seconds for
the treatment (visible muscle contractions/spasms) to be considered successful. The EEG is likely to continue showing activity
after the motor activity has
If the seizure continues for over 180 seconds, it is considered prolonged and will be terminated by benzodiazepines. If the
treatment is unsuccessful (seizure activity is not adequate), a further two administrations of electrical current can be given,
with an increased dose each time. If three administrations have been given without adequate response, no further
administration can be given during the session, but the dose will be increased at the next session.
After ECT
When ECT is complete the patient will wake up in the recovery room without memory of the procedure. They may experience
some side e
" Y o u w i l l b e p u t t o s l e e p u n d e r g e n e r a l a n a e s t h e t i c b y a n a n a e s t h e t i s t , s o y o u w i l l n o t b e a w a r e o f t h e t r e a t m e n t b e i n g
d e l i v e r e d . Y o u w i l l b e g i v e n a m u s c l e r e l a x a n t t o a v o i d a n y h a r m t o y o u r b o d y d u r i n g t h e p r o c e d u r e .
"
" T w o e l e c t r o d e s w i l l b e p l a c e d o n t h e s i d e s o f y o u r h e a d a n d a d o c t o r w i l l p a s s a s m a l l e l e c t r i c c u r r e n t t h r o u gh t h e s e , f o r a f e w
s e c o n d s . Y o u r b o d y m i g h t r e a c t b y h a v i n g a m i n o r s e i z u r e , o r w e m a y o n l y s e e t h e e
t r a c i n g t h a t y o u w i l l b e h o o k e d u p t o f o r m o n i t o r i n g t h r o u gh o u t .
"
" A f t e r t h e t r e a t m e n t , y o u w i l l w a k e u p i n t h e r e c o v e r y r o o m . T h e r e w i l l b e a t e a m o f v e r y e x p e r i e n c e d d o c t o r s a n d n u r s e s
l o o k i n g a f t e r y o u .
"

Side e

Emphasise that not everyone will experience side e
the procedure.
Common side e
Short-term memory loss
Retrograde amnesia (memory loss immediately before/after ECT)
Post-ECT headache, which often resolves with simple analgesia
Post-ECT muscular aches
Brief confusion/drowsiness following administration of the anaesthetic
Side e
Cognition will be formally assessed regularly throughout treatment. Some patients have symptoms that may persist. Long-
term memory loss is rare.

Risks

The main risks involved with ECT are related to using a general anaesthetic (e.g. airway issues, reaction to the anaesthetic,
dental damage). There is a small risk of prolonged seizure.
There is a small risk that the patient will not respond to the treatment. Risks need to be balanced against the bene
treatment.
There are no absolute contraindications to ECT, but the patient must be
contraindications are as follows\:
Recent myocardial infarction or stroke
Increased intracranial pressure
Active bleeding
Retinal detachment

Closing the consultation

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Summarise the key points back to the patient.
" T o d a y w e h a v e d i s c u s s e d E C T , a n a l t e r n a t i v e t r e a t m e n t f o r y o u r d e p r e s s i o n . W e r e c o m m e n d t h i s t r e a t m e n t o p t i o n , g i v e n t h a t
t h e a n t i d e p r e s s a n t m e d i c a t i o n s y o u h a v e t r i e d h a v e n o t r e s u l t e d i n a n y i m p r o v e m e n t i n y o u r m o o d . W e k n o w t h a t E C T c a n h e l p
a p p r o x i m a t e l y 7 0-8 0 % o f p e o p l e w i t h t h e t y p e o f d e p r e s s i o n t h a t y o u h a v e .
"
" Y o u w i l l p r o b a b l y r e q u i r e m u l t i p l e t r e a t m e n t s i n o r d e r t o h e l p s t a b i l i s e y o u r m o o d .
"
" Y o u w o u l d b e p u t t o s l e e p f o r e a c h p r o c e d u r e , w h i c h w o u l d i n v o l v e p l a c i n g e l e c t r o d e s o n e i t h e r s i d e o f y o u r h e a d a n d p a s s i n g
e l e c t r i c a l e n e r g y t o y o u r b r a i n . T h e a i m i s t o a l t e r t h e n e t w o r k s i n y o u r b r a i n i n y o u r b r a i n , w h i c h i s a f a c t o r u n d e r l y i n g y o u r
d e p r e s s i o n .
"
" Y o u m a y h a v e a m i l d h e a d a c h e o r n o t i c e s o m e s h o r t-t e r m m e m o r y l o s s f o l l o w i n g t h e t r e a t m e n t s , a
"
b u t t h i s s h o u l d n o t p e r s i s t o r
Ask the patient if they have any questions or concerns that have not been addressed.
" D o y o u u n d e r s t a n d e v e r y t h i n g w e h a v e d i s c u s s e d ?"
" D o y o u h a v e a n y q u e s t i o n s f o r m e ?"
O
" W e' v e c o v e r e d a l o t o f i n f o r m a t i o n t o d a y a n d i t' s l i k e l y t h a t y o u' l l t h i n k o f s o m e q u e s t i o n s i n t h e c o m i n g d a y s , w h i c h I' d b e
h a p p y t o a n s w e r a t o u r f o l l o w u p a p p o i n t m e n t . H e r e i s a l e a
f u r t h e r i n f o r m a t i o n o n t h e s u b j e c t f o r y o u t o r e a d a t h o m e .
"
Arrange a follow-up appointment including the o
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

Further information

Capacity and ECT

The information below refers to England and Wales. Other countries will have di
refuse ECT treatment if they have the capacity to make this decision, even whilst they are detained under the Mental Health
Act. Capacity should be assessed before every treatment session. Patients may withdraw from ECT treatment if they regain the
capacity to refuse treatment, even if they lacked capacity when starting ECT treatment.
For a patient to be considered to have capacity, they must be able to\:
1. Understand the treatment
2. Retain the information given to be able to make a decision about treatment
3. Weigh up the risks and bene
4. Communicate a decision regarding treatment
If a patient requires ECT treatment and is so unwell that they lack the capacity to consent, ECT may be administered under the
Mental Health Act. In this scenario, a second opinion doctor (SOAD) must assess and agree that ECT is appropriate.
If SOAD agrees that the patient lacks capacity and treatment is in their best interests, ECT can be administered under section
58A of the Mental Health Act.
If a person lacks the capacity to consent and ECT is required urgently, a section 62 for the provision of emergency treatment
“ w h i c h i s i m m e d i a t e l y n e c e s s a r y t o s a v e a p e r s o n’ s l i f e o r p r e v e n t s e r i o u s d e t e r i o r a t i o n” may be used, to allow the patient to
have emergency ECT treatment whilst waiting for an independent assessment from a SOAD.
Source\: geekymedics.com
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