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ECT Service
Patient Information Booklet
What you need to know about
Electroconvulsive Therapy (ECT)
Your Psychiatrist has recommended that you receive treatment with
Electroconvulsive Therapy (ECT). ECT is a treatment performed under the
direct supervision of a Psychiatrist. An Anaesthetist and a team of nurses assist
the Psychiatrist.
During ECT a small electrical current is applied to the scalp, which induces
a seizure. The effectiveness of ECT in severe mental illness is recognised by
the Royal Australian and New Zealand College of Psychiatrists and similar
organisations in the USA, Canada, Britain and many other countries.
The nature of this treatment, including the risks and benefits that you may
experience, will be fully explained to you by your Psychiatrist.
This information booklet is designed to provide you with a description of
ECT, to assist your understanding of the procedure and to answer some of the
questions you may have.
When you are depressed it is often difficult to concentrate, don’t be
concerned if you cannot read through the whole booklet initially. Just pick
out the sections that seem important to you at the time, and come back to it
later. You may wish to use it to help you to ask questions of your Psychiatrist,
nursing staff or relatives.
The ECT staff will be available to take you and your family to the Day
Surgery Unit to assist in providing reassurance and answer your questions.
Unfortunately ECT is portrayed inaccurately and stigma continues to be an
issue. However, it retains an important place in the treatment of moderate to
severe depression.
As with many aspects of medicine, with ongoing research and technological
development modern ECT is now a more complex and refined treatment with
specific training required.
To ensure that our practitioners possess the knowledge and skills required
to provide safe and effective treatment Caloundra Private Clinic provides ECT
training before psychiatrists are granted clinical ECT privileges.
Our commitment to quality patient care and service is demonstrated by
our full accreditation with ISO 9001:2008 Standards for Safety & Quality in
Healthcare.
Why is ECT used?
ECT is a treatment for serious psychiatric conditions. It is important for you
to understand that there may be alternative treatments for your condition,
which may include medications and psychotherapy. Although there is a range
of treatments, individuals will recover and respond in different ways and at
different rates. Some people do not recover completely and others may take
a long time to respond and recover. In severe cases of depression, mania and
schizophrenia, ECT may be the treatment of choice and it can be life saving.
ECT can work quicker and more effectively than medications for some types
of mental illness. ECT will not cure you. ECT will help your current episode of
illness and may help maintain improvement.
Whether ECT or an alternative treatment is most appropriate for you is
based upon a thorough physical and psychiatric evaluation and depends on
your prior experience with these treatments, the nature of your psychiatric
condition, your response to medication and other considerations.
Your Psychiatrist has/will explain to you why ECT has been recommended for
your specific case.
How does ECT work?
The brain is an organ that functions through complex electrochemical
processes, which may be impaired by certain types of mental illnesses.
Scientists believe ECT acts by temporarily altering some of these processes,
thereby returning function towards normal.
ECT artificially stimulates a seizure; but ECT-induced seizures occur under
much more controlled conditions than those that are “naturally occurring”
and are safe.
In the early 1990s research showed us that the actual dose of electrical
current used was critical to the success of the treatment and that doses needed
to be individualised according to the patient’s seizure threshold. After finding
the threshold the dose is increased for subsequent treatments. At the same
time, electroencephalogram (EEG – measures electrical activity of the brain)
monitoring of the seizure is used as a reliable guide to the quality of the
seizure and therefore to its effectiveness.
Evidence indicates that for uncomplicated cases of severe depression, ECT
will produce a substantial improvement in at least 80% of patients.
Can ECT cause brain damage?
There is no evidence that ECT causes any structural cerebral damage. There
are medical conditions (such as epilepsy) that cause spontaneous seizures
that, unless prolonged or otherwise complicated, do not harm the brain.
Studies have found no changes in brain anatomy with ECT, as measured by
very sensitive scans of the brain using magnetic resonance imaging (MRI)
equipment. Other research has established that the electrical current that
actually enters the brain (which is only a small fraction of that which is applied
to the scalp) is much lower in intensity and shorter in duration than that which
would be necessary to damage brain tissue.
What about pregnancy?
The decision whether or not to treat pregnant women with ECT takes
into account the risks associated with alternative treatments, the risks to
the mother and foetus of withholding ECT and any complications of the
pregnancy that may increase the risks of ECT or the anaesthetic. ECT may
be used with confidence during the second and third trimesters. Little
information is available for its use in the first trimester, so until further
data is available, caution is advised during this stage. It does not produce
abnormal uterine contractions and it appears to be safe even in complicated
pregnancies. Foetal monitoring during ECT has not revealed any untoward
effects.
How will ECT help me?
The potential benefit of ECT for you is that it may lead to improvement in your
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 others may
fail to respond at all.
Consent
Mental health legislation determines that ECT may be performed in an approved
facility, on a voluntary patient capable of giving written consent. Your Psychiatrist
will explain the treatment, answer questions and request a written consent.
A voluntary patient who lacks the capacity to give informed consent
cannot be given ECT. A voluntary patient also has the right to refuse or
consent to ECT.
Before consenting to ECT, you have the right to obtain a second opinion from
another Psychiatrist of your choice or one recommended to you. You can also seek
legal advice and you have the right to be represented by another person of your
choice before consenting. This representative is permitted to be with you when
the Psychiatrist explains the treatment.
Written consent may be withdrawn at any time. You should understand the
risks of prematurely stopping ECT and be informed of other treatments. When
ECT is stopped prematurely there is a high risk of relapse and likelihood that
the entire treatment will need to be repeated.
You should read any local information about your rights and discuss further
concerns with your Psychiatrist. Written consent for ECT is required. In
Queensland, written consent is valid for up to 3 months for acute courses and
up to 6 months for maintenance ECT. The average number of treatments to
recovery is about nine but commonly ranges from 6 to 12.
Day patients will also be asked to sign a consent form authorising the
collection, use and storage of information for your health care, in accordance
with Ramsay Health Care’s Privacy Policy, and providing informed financial
consent for the treatment on the day of your treatment.
In-patients complete this paperwork on admission.
What will actually happen to me
when I have ECT?
Depending on your prior experience with these treatments and the nature of
your psychiatric condition, ECT can be performed as either an in-patient or day
patient procedure. Generally, patients with no prior history of ECT commence
treatment as an in-patient.
Day patients please follow the ECT checklist detailed at the end
of this brochure.
ECT involves a number of treatments. The treatments are usually given in the
morning, before breakfast.
Because the treatments involve a general anaesthetic, you should not eat or
drink from midnight before the treatment (fasting up to 6 hours before
each treatment).
You may be advised to take antihypertensive, reflux medication and/or
respiratory medications
2 hours prior to your ECT treatment time.
Guidelines of the Australian & New Zealand College of Anaesthetists
recommend that smoking be ceased for 24 hours prior to having a general
anaesthetic to minimise the risk of excessive bronchial secretions.
As the anaesthetic required for ECT is short acting the Clinic strongly
recommends that patients refrain from smoking at least 8 hours prior
to having ECT.
If you are not able to comply with this recommendation, the anaesthetist
may decide to cancel your ECT on the day.
Routine preparation for ECT also includes:
• Washing your hair the night before your treatment
• Wearing loose clothing during your treatment
• Removing jewellery and nail polish
•If you wear contact lenses or dentures, these need to be removed before
your treatment, which can be carried out immediately prior to ECT in the
ECT Procedure Room for your comfort.
Before each treatment your pulse, oxygen saturation level, blood pressure
and temperature will be checked and you should empty your bladder before
going to the ECT Procedure Room.
To receive each treatment the Registered Nurse will take you to a specially
equipped ECT Procedure Room within the Day Surgery Unit.
You will be introduced to the Psychiatrist and the Anaesthetist. Nursing staff
will ensure you are comfortable and warm on the treatment bed.
To prepare for the treatment a monitoring sensor probe will be placed
on your finger, which will record your heart rate and blood oxygen
saturation levels.
Two monitoring electrodes are placed on your forehead and one on your
chest, and one behind each ear. These help monitor and record the seizure
using an electroencephalogram (measuring brainwaves). This is done to
monitor your response to the treatment. These recordings involve no pain
or discomfort.
The Anaesthetist places an intravenous cannula in your arm or hand so that
the anaesthetic can be administered.
You will be given an injection of two medications, an anaesthetic that
will put you to sleep for a few minutes and a muscle relaxant. The relaxant
prevents excessive muscle contractions or movement during the procedure.
The Anaesthetist will give you extra oxygen to breathe by mask just before
the anaesthetic works.
Stimulus electrodes with conductive gel will then be placed on your head
held on by a rubber strap.
While you are asleep, a small carefully controlled amount of electrical
current will be passed between the stimulus electrodes that have been
placed on your head. Depending on where the stimulus electrodes are placed
you may receive either unilateral, bitemporal, bifrontal ECT or ultra-brief,
unilateral or bifrontal ECT:
•Unilateral ECT – both stimulus electrodes are placed on the same side of
the temple area and crown of the head, usually on the right side or the
non-dominant hemisphere.
•Bitemporal ECT – one electrode is placed on the left side of the temple, the
other on the right side.
• Bifrontal ECT – two electrodes are placed on the forehead.
•Ultra brief pulse stimulation is a new advance in electroconvulsive therapy
and results in more focal stimulation. An ultra brief pulse given in the right
unilateral position retains the high efficacy of standard electroconvulsive
therapy for depression.
When the electrical current is passed a generalised seizure is produced in the
brain. Because you have been given a medication to relax your muscles, the
muscle contraction is usually mild.
The seizure lasts for approximately 10-60 seconds. Within a few minutes
the anaesthetic medication will wear off and you will wake up within a few
minutes after treatment, having experienced no pain or discomfort during
the procedure and not remember anything about what happened after the
anaesthetic.
When you recover from the anaesthetic and are breathing spontaneously,
you will be taken into the recovery bays. The nurse in the recovery bays will
take your general observations and monitor your recovery.
After about 20 minutes you will be transferred by wheelchair back to your
own room, where the nursing staff will complete the final stage of ECT post
recovery observations. In-patients are advised to rest in bed for an hour or two
after treatment.
Day patients will continue to be monitored in the recovery chairs by the
recovery nurse to complete the four hours observations post treatment/
anaesthetic.
You will also be given a breakfast tray and refreshments.
Day patients will need to be picked up by a responsible carer when ready
for discharge.
Though the treatment itself only lasts a few minutes, the process of
preparation for ECT through to recovery typically lasts 15 to 45 minutes.
How many treatments will I need?
The number of ECT treatments that you will need cannot be predicted ahead
of time.
The number of treatments will depend on your psychiatric condition,
how quickly you respond to the treatment, and the clinical judgment of
your Psychiatrist.
Typically, an acute course of ECT can be 6 to 12 treatments. The average
number of treatments to recovery is about nine.
The number of ECT treatments depends on the progress of your recovery.
While most patients start to improve after three to four treatments, some do
not show a response until 10 to 12 treatments and occasionally some may need
20 to 25 treatments.
Treatments are usually given two to three times a week, but this may vary
depending on your response and your Psychiatrist’s recommendations.
Some patients may require maintenance ECT to manage and stabilise their
illness, preventing relapse. Maintenance ECT may be weekly, fortnightly or
monthly depending on your condition and your Psychiatrist. Maintenance ECT
may need to be continued for a period of time.
Maintenance ECT can be performed as a day patient depending on your
condition and recommendations from your Psychiatrist.
What risks are involved?
Like other medical procedures, ECT involves some risks. Your Psychiatrist will
discuss these risks with you.
When you wake up after each treatment, you may experience some
disorientation or confusion; this usually goes away within an hour.
Shortly after the treatment, you may have a headache, muscle soreness,
nausea or vomiting. These side effects usually respond to simple treatment.
It is important to relay these symptoms to your Psychiatrist and/or nursing
staff.
With modern ECT techniques serious medical complications are rare.
As with any general anaesthetic procedure, there are risks involved. Patients
can discuss this with the Anaesthetist prior to the treatment.
As some medical conditions increase the risk associated with ECT, patients
are carefully screened. The Anaesthetist will discuss your physical health with
you prior to treatment.
MALIGNANT HYPERTHERMIA occurs very rarely and is genetically inherited
(runs in a family). It can result in a very high temperature and muscle rigidity
developing during an anaesthetic that can be serious if not recognised
and treated.
If you have had a reaction under a general anaesthetic which had some or
all of the features of malignant hyperthermia or if you have a family member
who has been found to be susceptible to malignant hyperthermia your
Anaesthetist may refer you for further tests before proceeding with ECT.
While also rare, the most common medical complications with ECT are
irregularities in heart rate and rhythm.
Very rarely, myocardial infarction (heart attack), stroke, respiratory failure
or kidney failure can occur.
You may have a severe allergic reaction to the medications given during
the anaesthetic.
How can these risks be reduced?
To reduce the risk of medical complications, you will require a medical
evaluation prior to starting ECT.
•Inform your Psychiatrist and Anaesthetist if you have had problems with
anaesthetics, have diabetes or heart problems.
•ECT does not normally affect cardiac pacemakers but some may need
adjustment before treatment. You must tell your Psychiatrist if you have a
pacemaker.
•Your current medications will be reviewed. Most treatments for medical
conditions should be continued.
•If you have high blood pressure you should have your blood pressure
stabilised prior to ECT. Medications for high blood pressure may be taken
with sips of water 2 hours before morning ECT, as per your Psychiatrist’s /
Anaesthetist’s recommendations.
•Other medications and those that might interfere with ECT may be reduced
and stopped. Antidepressants, benzodiazepines and anticonvulsant (when
used as mood stabilisers) are usually reduced and stopped. Sometimes
this has to occur during the early phase of ECT as abruptly reducing some
medications can lead to serious withdrawal adverse effects.
•You may need to have blood tests, an electrocardiogram (ECG) and chest
X-ray, and computed axial tomography (CT) or other scans of your brain.
•Some patients will need to have an electrocardiograph (ECG) performed.
All patients over 60 years of age will require an ECG.
•This physical examination will be required to be renewed every six months
whilst undergoing ECT.
•Day patients need to arrange for your GP to fax the results of the
examination to the clinic (Fax. 5491 9107) 12 hours before your first
treatment.
However, in spite of these precautions there is a small chance that you may
experience a medical complication. Should this occur, emergency medical care
and treatment will be instituted immediately.
What happens if a complication occurs?
In the event of a medical complication, neither the Caloundra Private Clinic nor
the treating physicians are required to provide long-term medical treatment.
The patient would be responsible for the cost of such treatment whether
personally or through medical insurance or other medical coverage.
No compensation will be paid for lost wages or other consequential damages.
Patients will be transferred to the appropriate medical facility for care.
Are there any side effects?
A common side effect of ECT is poor attention, concentration and short term
memory functioning. The degree of disruption to memory is likely to be
related to the number of treatments given and their type. However memory
difficulties may also occur as part of your psychiatric and/or other condition/s
or your treatment for these conditions.
A smaller number of treatments are likely to produce less memory
impairment than a larger number of treatments.
Brief right unilateral ECT (stimulus electrodes on the right side of the head)
is likely to produce milder and shorter-lived memory impairment than that
following bilateral ECT (where one stimulus electrode is placed 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 the treatment increases, memory functioning
improves.
Shortly after the course of ECT, you may experience difficulties remembering
events that happened immediately before and during your ECT course.
The loss in memory of past events may extend back several months before
you received ECT, and in rare instances, for years.
Some people who have undergone ECT recommend writing down
passwords, pins, phone numbers and special dates and keeping them in a safe
place in case they cannot be recalled after the treatment.
Many of these memories will return during the first several months following
the ECT course. However, you 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, you 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.
After effects of the treatment
You may or may not experience some of the following, if you do or have any
questions related to your treatment please discuss these with the Nursing staff:
•Headache, nausea, general body aches are common experiences after this
treatment. These are due to the treatment and the medications used by the
Anaesthetist. They are only temporary, they can be minimised by rest and
restricted activity during this period and relieved by a simple analgesic such
as paracetamol. Take only as directed.
•Sore muscles are not uncommon after the first treatment. Please let your
Anaesthetist know.
•Pain, soreness or bruising on the back of the hand or at the site of your
injection may be noticed for some days after the anaesthetic. This is due to
a reaction in the vein to the presence of the needles and the medications
that were injected.
•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.
Day Patient ECT Checklist
Communicate with your Psychiatrist regarding your booked outpatient ECT
treatment. The Clinic will telephone you by 11am on the day before your
treatment advising you of your required arrival time.
If you have not been a patient at Caloundra Private Clinic, you will need to
bring photographic identification with you (such as a Drivers Licence) on
your first treatment. A photograph will be taken to be used on your ECT
treatment sheets.
If you develop any illness, even a cold, you may not be able to have your
treatment on the day as planned. Please ring your Psychiatrist if you are
at all unsure about this and in the event that you are unable to attend
treatment please phone the Clinic as soon as possible (Ph. 5492 0270).
If you are unable to attend a scheduled morning ECT treatment for any
reason, or if your Psychiatrist says your previously booked treatment is to
be cancelled, you must advise Caloundra Private Clinic as soon as possible
(Ph. 5492 0270).
On the evening prior to treatment it is important that you do not have
anything to eat or drink after 12 midnight.
We most strongly recommend that patients do not smoke for at least
eight hours prior to having ECT. If you are not able to comply with this
recommendation the Anaesthetist may decide to cancel your ECT on
the day.
It is advisable to wash your hair the day before your treatment (not on the
morning), as your hair should be clean and dry. Do not apply anything else
to your hair after you have washed it.
Any blood pressure medication, and /or reflux medications should be
taken in the morning (2 hours prior to treatment) with a sip of water
before you leave home. Respiratory medications may also be taken.
Do not take any other medicines, prescription medications, over the
counter medications, or any other agents from midnight the night before
treatment. The one exception is if the Psychiatrist who assessed you for ECT
specifically prescribed such medication.
In the morning you may clean your teeth and/or rinse your mouth, but
avoid swallowing water.
Do not bring any valuables with you.
Dress in loose clothing.
Before your treatment you will need to remove all jewellery, nail polish and
hairclips. If you need to keep any rings on they can be taped.
Arrive at the Clinic no later than your requested arrival time. You must
do this for each treatment. Report to the Mental Health Unit where the
staff will greet you and complete your pre-treatment observations and
documentation.
If you wear contact lenses or dentures, these will need to be removed before
you have your treatment. This can be done in the ECT Procedure Room.
Ensure you empty your bladder before treatment and that you do not need
a bowel motion.
You are required to stay in the Clinic 4 hours after your treatment.
When staff are satisfied that you have fully recovered from the anaesthetic
you will be allowed to go home. You are not to drive for 24 hours following
ECT treatment and will need to arrange for a friend or relative to pick you
up from the Clinic.
For the first 24 hours after your treatment you are advised NOT to:
• Drive a car
• Drive or operate machinery
• Consume alcohol
• Travel unaccompanied on public transport
• Make important financial or life decisions
If you require medication after your ECT treatment, bring your medication
with you in its original packaging and hand it to the nursing staff for
safekeeping. Your Psychiatrist must complete a medication order for you to
take this medicine.
The ECT Nursing Staff will give you the required paperwork to complete
before you leave the Clinic. You may also be requested to report to the
front office to complete other paperwork as required.
If you have any concerns with regards to your treatment when you go
home please call the Clinic and speak to nursing staff (Ph. 5492 0270).
Summary
• ECT is given for many reasons.
•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.
•ECT is most commonly used to treat severe mood disorder – either
depression or mania. It can also be used to treat psychosis.
•It may be helpful if you did not get better with anti-depressant medications.
•It may help if you can’t take anti-depressant drugs because of the
side effects.
• It may help if you have responded well to ECT in the past.
•It may help if you feel so overwhelmed by your depression that it’s difficult
to function at all.
•An ECT treatment involves having a short general anaesthetic.
•Over eight out of ten depressed patients who receive ECT respond well,
making ECT the most effective treatment for severe depression.
• ECT is usually given two or three times a week.
• ECT may also be given as maintenance treatment.
•The effects of ECT will relieve the symptoms of your depression but will not
help all your problems.
•Your memory of recent events may be upset and dates, names of friends,
public events, addresses and telephone numbers may be temporarily
forgotten.
•You can refuse to have ECT and you may withdraw your consent at any
time, even before the first treatment has been given. Withdrawal of your
consent to ECT will not in any way alter your right to continued treatment
with the best alternative methods available.
•You have the right to seek a second opinion about having this treatment.
•You have the right to have your family/significant others informed and
educated about your treatment.
It is important that you do not make any important personal or business
decisions during the ECT course or immediately following the course because
of the possible problems with confusion and memory.
This may mean postponing decisions regarding financial or family matters.
After the treatment course, you will begin a ‘convalescence period’, usually for
1 to 3 weeks, but which varies from patient to patient.
During this period you should refrain from driving, transacting business, or
other activities for which impairment of memory may be problematic until so
advised by your Psychiatrist.
It is recommended that in the (24) twenty-four hours after treatment:
• You do NOT drink alcoholic beverages
• You do NOT drive a vehicle or operate machinery
•You do NOT sign any legal documents or take full charge of another
individual
• You do NOT exercise excessively
The Caloundra Private Clinic ECT Information Booklet is an attempt to
be as comprehensive as possible but it cannot cover every eventuality
or query as the circumstances of individuals and patients psychiatric
treatment differ enormously.
This material is not a substitute for advice from your Psychiatrist.
More information
Beyond Blue – ECT Fact Sheet 48.
www.beyondblue.org.au
Blackdog Institute
Electroconvulsive Therapy Fact Sheet
www.blackdoginstitute.org.au
May 2014
Caloundra Private Clinic
96 Beerburrum Street
Caloundra QLD 4551
ph: 07 5491 1522 – fax: 07 5491 9107
www.caloundraprivateclinic.com.au