As health care professionals we owe a duty of care to our patients. Our patients have a right to autonomy – to make their own decisions. If we impose treatment on them against their wishes, when they have capacity to make a decision to refuse treatment, then we may be committing the tort of battery; if we fail to treat them when they lack capacity to make treatment decisions we may be found to be negligent.

ECT remains one of the most controversial treatments in psychiatry. Although its efficacy and safety are acknowledged and have been confirmed (Chapter 1) there are still attempts (based on flawed reviews of the literature) to claim that its use cannot be scientifically justified (Read & Bentall, 2010). Media accounts of ECT tend to be highly emotive and vary from lauding ECT as life changing (Seelye, 2016) to damning it as abusive (Browne, 2000).

Electroconvulsive therapy (ECT) possesses several key therapeutic actions, having antidepressant, anti-manic and antipsychotic effects. The adverse effects of ECT, particularly loss of autobiographical memories, are also of great clinical importance. Whether the same ‘mechanism’ underpins all these properties is unknown. Most information about the mechanistic effects of ECT has been obtained in relation to the treatment of depression and the current review will focus on this area.

The evidence base for the use of ECT in children and adolescents aged under 18 years (hereafter referred to as ‘paediatric ECT’) consists of individual case reports, case series and retrospective chart reviews, but no Randomised Controlled Trials (RCTs). This limited evidence base alongside concerns about the effects of ECT on the developing brain may help explain the infrequent use of ECT by child and adolescent psychiatrists. This chapter provides a summary of the issues and considerations pertaining to use of paediatric ECT within the British Isles (United Kingdom and Republic of Ireland). Although legal aspects relating to ECT are covered in Chapter 28, some reference specific to paediatric use is made here.

ECT is used more often in the elderly than in younger adults and most often for depression which, in the elderly, is common and is associated with significant morbidity and mortality (Whiteford, et al., 2010). The high rates of treatment resistance (Whiteford, et al., 2010), the relative absence of evidence based guidelines and the risks associated with biological treatments, particularly in view of the high rates of physical co-morbidity, suggest that the decision to use ECT should be considered often, but carefully, and that its application should be thoughtful.

During ECT, a variety of observations and physiological measures should be made simultaneously, including: visible evidence of the length and quality of a motor response, blood pressure, heart rate, oxygen saturation, ECG monitoring, EEG activity and sometimes electromyogram (EMG) measurement. Here we will discuss typical observations regarding the ictal motor activity, cardiovascular response and EEG recordings.

While there is no mention of ECT in the current NICE guidelines on bipolar disorder (NICE Guidelines; CG185, 2014), ECT is included as a recommended treatment for both manic and mixed affective episodes in bipolar disorder in the American Psychiatric Association Clinical Practice Guidelines (2002), the World Federation of Biological Psychiatry guidelines (Grunze, et al., 2010) and the British Association for Psychopharmacology bipolar guidelines (Goodwin, et al., 2016). Since the previous edition of The ECT Handbook, two narrative and one systematic reviews have been published that describe the evidence base regarding the use of ECT in manic and mixed affective episodes (Loo, et al., 2011; Versiani, et al., 2011; Thirthalli, et al., 2012).

The Royal College of Psychiatrists recommends that a specially designated space for ECT treatment should be available (ECTAS, 2018). As the number of patients being referred for ECT continues to decline (Buley et al., 2017) the availability of ECT for patients who require it may be compromised. The College ECT Committee is supportive in helping clinics to find alternative treatments for depression which may be delivered in the ECT centre. A number of centres already provide additional services to ECT, for example clozapine and depot clinics. ECT clinics are also used for the delivery of rTMS (Chapter 15) and ketamine infusions (Chapter 17).

The evidence base for the use of ECT in people with an intellectual disability is composed almost entirely of case reports or case series. An evidence search on the use of ECT for intellectual disabilities and learning disabilities, including those with autism or catatonia, was conducted on 19 May 2017. The limited nature of this evidence, compounded with specific issues around diagnosis and consent, partially explains why ECT seems to be used less frequently in people with an intellectual disability than in the general population. It is clear, however, that adults with an intellectual disability are susceptible to the whole range of psychiatric disorders seen in the general population and that ECT may be a suitable treatment for them in some clinical situations.

This chapter is designed to raise awareness of the risks of damage to dental tissue during ECT, with the possible consequences to the patient, ECT team, psychiatrists and anaesthetists, and to place dental risk into context. Although the first section of the chapter is more applicable to psychiatrists and the second section to anaesthetists, the issue of dental risk bridges both specialties. The entire chapter should be read by all staff involved with the delivery of ECT.

Depressive episodes dominate the longitudinal course of bipolar disorder (BD) (Judd, Schettler et al. 2003, Post, Denicoff et al. 2003, Kupka, Altshuler et al. 2007). Treating the depressive state of BD is a clinical challenge. Although pharmacotherapy is the mainstay treatment, the various pharmacological treatment options often have poor outcomes. The benefits of antidepressant agents remain controversial (Pacchiarotti, Bond et al. 2013). Electroconvulsive therapy (ECT) has been considered an effective treatment option in bipolar depression (Musetti, Del Grande et al. 2013), but the topic is still understudied (Sienaert, Lambrichts et al. 2013).

SEAN continues to have a profound influence on the practice of ECT in Scotland since its inception in 1997. From 2005, in addition to its audit role, it has been involved in the systematic formal accreditation of all 18 clinics in Scotland where ECT is administered.

Poor maternal mental health in pregnancy and postnatally has an obvious negative impact on the mother but may also adversely affect the child and the wider family. The treatment of severe mental illness during this period can be complicated by several factors: the potential for adverse effects of medication on the foetus or breastfed infant; the reduced acceptability of even low levels of risk; the reduced tolerability of adverse effects for women at this critical and demanding time in their lives; the potential for deterioration into extremely severe and high risk illness, particularly postnatally and its rapidity; and the urgency required for achieving recovery to reduce the risk of long term consequences for both mother and child. Electroconvulsive therapy (ECT), as an alternative or adjunctive treatment for severe perinatal mental illness, may offer some patients fewer such disadvantages than medication or psychological therapies, alone or in combination. The indications for ECT in the perinatal period are the same as those in a non-perinatal population. It has been suggested ECT is not considered often enough in the perinatal period (Focht & Kellner 2012). NICE guidelines state ECT should be considered for pregnant women with severe depression, severe mixed affective states or mania, or catatonia, whose physical health or that of the foetus is at serious risk (NICE 2015). There are no prospective randomised control trials assessing the risk and benefit of ECT in the perinatal population but retrospective data have been collected that can help us evaluate whether ECT is both an effective and safe treatment option.

ECTAS was launched in May 2003 coinciding with the publication of the NICE (National Institute for Clinical Excellence) guidance on the use of ECT (NICE, 2003). Its aim was to improve the standard of practice in ECT units in the United Kingdom and Republic of Ireland using a model of continuous quality improvement.

The previous edition of The ECT Handbook was produced in 2013 and was well received. The current edition updates the 2013 one and attempts to find a similar balance between outlining the scientific literature relating to ECT and related treatment modalities and pragmatic and practical advice on their place in management and delivery in a UK context. This chapter concentrates on the guidelines in the UK for the use of ECT and related treatments. The recommendations of NICE for the use of ECT and related treatments are outlined first, followed by position statements from the Committee. Any differences (which are usually minor and of emphasis rather than substance) are highlighted. The position statements were generated in 2017 and have been ratified by the College. They can be found on the Royal College of Psychiatrists’

Ketamine and related compounds, such as esketamine, are of relevance to ECT practice for several reasons. First, as a drug with marked rapid antidepressant activity in people with treatment resistant depression (TRD), it may become an alternative to ECT in some cases. Second, ECT suites are a suitable setting for intravenous or other routes of directly observed therapy and ECT staff have experience with this patient group. Third, there may be synergy between ketamine and neuromodulatory therapies such as TMS.

The Royal College of Psychiatrists’ Good Practice Guide to ECT Training document (2018) sets out training requirements for psychiatrists of all grades and the level to which these competencies should be met. It is recommended that this document be used as the basis for devising ECT training at local level. All psychiatrists should be familiar with the basic principles of ECT which can be found in the College Position statement on ECT (2017).

It is common, indeed usual in many countries including the UK, for patients receiving electroconvulsive therapy (ECT) to continue taking medication for their psychiatric disorder, and in many cases they are also being treated for one or more physical illnesses. This chapter reviews the evidence for interactions between concomitantly taken drugs and ECT, concentrating on safety issues and their management, but also commenting on therapeutic interactions where relevant. Outside the scope of this chapter are drugs specifically given as part of ECT, or administered during the session to modify seizures, reduce the likelihood of adverse effects or affect clinical outcomes.

People with a wide range of physical illnesses are successfully treated with ECT (Tess & Smetana, 2009). Some medical problems may cause particular concern, especially cardiovascular and neurological problems.