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10 - Training, supervision and professional development: achieving competency
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- By Grace M. Fergusson, Argyll and Bute Hospital, Lochgilphead, Daniel M. Bennett, University of Aberdeen, Susan M. Benbow, Staffordshire University
- Edited by Jonathan Waite, Andrew Easton
-
- Book:
- The ECT Handbook
- Published by:
- Royal College of Psychiatrists
- Published online:
- 25 February 2017, pp 94-98
-
- Chapter
- Export citation
-
Summary
The Royal College of Psychiatrists (2009) recommend that a senior psychiatrist, preferably a consultant, is responsible for the ECT clinic. For a standard clinical service, a minimum of one contracted session per week is recommended for the duties of an ECT consultant. The ECT consultant is responsible for making sure that the clinic keeps up to date with developments in ECT practice, achieves the necessary quality standards, and that all medical staff giving ECT are properly trained and supervised.
The duties of the psychiatrist responsible for ECT can be divided into four main areas:
organisation of the clinic
treatment policy
training and supervision; achieving competency
achieving and maintaining appropriate service standards.
This chapter outlines the role of the psychiatrist responsible for ECT and describes how medical staff achieve and demonstrate their competencies.
Organisation of the clinic
The location and fabric of the ECT clinic, including the ECT machine, should meet the standards set out in Chapter 2.
The clinic should be served by a small core team of senior anaesthetists, supported by appropriately trained personnel with a special interest in ECT and with whom discussion can take place regarding treatment protocols and responsibilities.
Nurse staffing should be as described in Chapter 11 and there should be good liaison with nurse management to ensure that these guidelines are being adhered to.
The ECT rota should be organised in such a way to ensure that continuity of patient care is maximised and that trainees have the opportunity to treat patients over several consecutive treatments. It is important that doctors training in psychiatry receive training in the practice of ECT, and the core curriculum states that ‘all Core training programmes must ensure that there is training and supervision in the use of ECT so that trainees become proficient in the prescribing, administration and monitoring of this treatment’ (Royal College of Psychiatrists, 2009). Electroconvulsive therapy consultants who have difficulty in maintaining the attendance of trainees are advised to consider whether this should be treated as an issue of professional practice/probity. These issues should be raised using the standard routes as set out in the Gold Guide (Modernising Medical Careers, 2010). This is likely to include discussion with the educational supervisor and training programme director in the first instance.
1 - Mechanism of action of ECT
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- By Ian M. Anderson, University of Manchester, Grace M. Fergusson, Argyll and Bute Hospital, Lochgilphead
- Edited by Jonathan Waite, Andrew Easton
-
- Book:
- The ECT Handbook
- Published by:
- Royal College of Psychiatrists
- Published online:
- 25 February 2017, pp 1-7
-
- Chapter
- Export citation
-
Summary
Seventy-five years after its introduction, ECT remains the most effective treatment for severe depressive disorder (UK ECT Review Group, 2003). Nevertheless, ECT is relatively underresearched compared with other forms of treatment for mental disorders; in particular there has been a relative lack of research using newer brain imaging techniques. Possible factors for the neglect of ECT include its adverse public image, funding priorities, the interests of researchers and the practical and ethical difficulties in studying this group of severely ill patients. Here, we briefly review some of the important neurobiological effects of ECT, concentrating on those related to its use in treating affective disorders, its principal indication. For more detailed information, see the reviews by Nobler & Sackeim (2008), Pigot et al (2008), Kato (2009), Merkl et al (2009) and Scott (2011).
A frequent criticism of ECT is that its mode of action is not understood. This is scarcely surprising given that the same can be said of other biological treatments in psychiatry. For example, although we understand much about the pharmacology of antidepressant and antipsychotic drug treatments, we still do not know how these pharmacological effects bring about improvement in mood or psychosis. Similarly for ECT, we know that both the generalised seizure and the dose of electricity used are important in bringing about its therapeutic effects, and that it has multiple, varied and lasting effects on the central nervous system (Merkl et al, 2009; Scott, 2011). Nevertheless, how these are translated into clinical effects remains obscure.
In recent years, advances in neuroscience have led to the development of various models of psychiatric disorders, particularly mood disorders, which encompass biological, psychological, social and developmental aspects (Mayberg, 2002; Seminowicz et al, 2004; Ebmeier et al, 2006; Beck, 2008; Akil et al, 2010). A common feature of these models is that psychiatric disorders are the result of disruptions of neural circuits, the functional networks of neurons that mediate thought, feelings and behaviour. Key areas concerned with networks involved in mood disorders include the hippocampus and amygdala, cingulate cortex (especially sub- and pregenual regions) and other areas of the prefrontal cortex. Underlying these networks are the structural and functional attributes of neurons and their connections. It is at this level that biological treatments are thought to exert their effects. There is good evidence that ECT has important effects on the function, and possibly structure, of neurons in these networks.
12 - Inspection of ECT clinics
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- By Chris P. Freeman, Royal Edinburgh Hospital, Joanne Cresswell, Royal College of Psychiatrists, Grace M. Fergusson, Argyll and Bute Hospital, Lochgilphead, Linda Cullen, Scottish ECT Audit Network
- Edited by Jonathan Waite, Andrew Easton
-
- Book:
- The ECT Handbook
- Published by:
- Royal College of Psychiatrists
- Published online:
- 25 February 2017, pp 109-112
-
- Chapter
- Export citation
-
Summary
The ECT Accreditation Service (ECTAS)
In the early 1980s there was an editorial in The Lancet entitled ‘ECT in Britain: a shameful state of affairs’ (Lancet, 1981). This was at a time when ECT was the main target of the anti-psychiatry movement and there were regular protests outside Royal College of Psychiatrists’ meetings about the use of ECT. Paradoxically, several of the UK randomised controlled trials of ECT had been published and others were under way, so the evidence base for the efficacy was stronger than it had ever been. The College had just completed its first survey of the use and practice of ECT, concluding that standards of practice were low, equipment was outdated and regional variations were enormous. The author of The Lancet editorial concluded that it was not ECT that was bringing psychiatry in disrepute, it was psychiatrists and the way they practised.
The College conducted further surveys of practice in the late 1980s and early 1990s, sadly showing that standards were improving little. The Special Committee on ECT (now Special Committee on ECT and Related Treatments) began running regular training courses which several thousand psychiatrists have now attended. More recently there have been increasing numbers of anaesthetic and nursing delegates.
Thirty years on, we now have a third edition of The ECT Handbook, guidelines from NICE endorsing the use of ECT (National Institute for Clinical Excellence, 2003; National Collaborating Centre for Mental Health, 2010) and we have ECTAS.
Over the first 20 years the rate of ECT steadily fell and if the slope had not levelled out it would have crossed zero in 2012. This did not happen, and the past 10 years have shown a levelling of the rates of giving ECT, with some areas showing a rise. National figures are no longer collected. This contrasts with the situation in North America, where the rates of ECT use have been rising, and raises the view that ECT may be underused, causing patients with severe and chronic depression to suffer for much longer, as antidepressant after antidepressant is changed.
Whatever the future of ECT, it is vitally important that when it is given, it is given appropriately, safely and with due concern to a patient's consent and dignity. The ECT Accreditation Service aims to assure and improve the quality of the administration of ECT.
2 - The ECT suite
-
- By Chris P. Freeman, Royal Edinburgh Hospital, Grace M. Fergusson, Argyll and Bute Hospital, Lochgilphead
- Edited by Jonathan Waite, Andrew Easton
-
- Book:
- The ECT Handbook
- Published by:
- Royal College of Psychiatrists
- Published online:
- 25 February 2017, pp 8-13
-
- Chapter
- Export citation
-
Summary
There should ideally be a designated area for ECT within each general psychiatry unit; this is recommended on the basis of patient convenience and economy of nurse staffing. However, it is recognised that with the numbers of patients undergoing ECT falling, there is an increasing trend for psychiatric services to share one facility in an attempt to maintain standards of anaesthetic and psychiatric practice within the confines of a National Health Service budget.
Suite layout
The design of the ECT suite will depend on the type of service provided. The minimum requirement for a local unit with small patient numbers is two rooms: a treatment room and a recovery room. An ECT unit where patients would be required to wait before treatment will need a waiting room in addition. A suite providing ECT to neighbouring psychiatric units should ideally include an ECT office and a final post-ECT waiting area.
The waiting room should be a comfortable, relaxing and informal environment, with a range of distractions, for example an outside window, pictures and magazines, and toilet facilities should be available. Patients’ arrival should be booked to provide a smooth throughput with the minimum amount of waiting time. Patients waiting for ECT should not be able to see into the treatment area while the treatment is taking place, and patients waiting for treatment should not be in the same room as patients who have completed their treatment.
The treatment room should be accessible from the waiting area. In the treatment area the patient is assisted onto a trolley or bed and prepared for treatment. This room should be well lit and contain all the equipment necessary for routine and emergency treatment. It should be big enough to allow unrestricted staff movements. Adequate work surfaces and a sink with hot and cold water should be available. There should be a clock with a second hand. If nitrous oxide and/or anaesthetic inhalation agents are ever used, the treatment room should be equipped with scavenging equipment and agent monitoring. There should be good sound-proofing between the waiting area and treatment room.
The recovery area must be large enough to accommodate easily the trolleys and associated monitors of all the patients who are regaining consciousness, and there should be enough room for recovery nursing staff to work in.
10 - Training, supervision and professional development: achieving competency
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- By Grace M. Fergusson, Consultant Psychiatrist, Argyll and Bute Hospital, Lochgilphead, Daniel M. Bennett, Consultant Forensic Psychiatrist, NHS Tayside, and Honorary Senior Lecturer in Psychiatry, University of Aberdeen, Susan M. Benbow, Director, Older Mind Matters Ltd, and Visiting Professor of Mental Health and Ageing, Staffordshire University
- Edited by Jonathan Waite, Andrew Easton
-
- Book:
- The ECT Handbook
- Published online:
- 02 January 2018
- Print publication:
- 01 May 2013, pp 94-98
-
- Chapter
- Export citation
-
Summary
The Royal College of Psychiatrists (2009) recommend that a senior psychiatrist, preferably a consultant, is responsible for the ECT clinic. For a standard clinical service, a minimum of one contracted session per week is recommended for the duties of an ECT consultant. The ECT consultant is responsible for making sure that the clinic keeps up to date with developments in ECT practice, achieves the necessary quality standards, and that all medical staff giving ECT are properly trained and supervised.
The duties of the psychiatrist responsible for ECT can be divided into four main areas:
organisation of the clinic
treatment policy
training and supervision; achieving competency
achieving and maintaining appropriate service standards.
This chapter outlines the role of the psychiatrist responsible for ECT and describes how medical staff achieve and demonstrate their competencies.
Organisation of the clinic
The location and fabric of the ECT clinic, including the ECT machine, should meet the standards set out in Chapter 2.
The clinic should be served by a small core team of senior anaesthetists, supported by appropriately trained personnel with a special interest in ECT and with whom discussion can take place regarding treatment protocols and responsibilities.
Nurse staffing should be as described in Chapter 11 and there should be good liaison with nurse management to ensure that these guidelines are being adhered to.
The ECT rota should be organised in such a way to ensure that continuity of patient care is maximised and that trainees have the opportunity to treat patients over several consecutive treatments. It is important that doctors training in psychiatry receive training in the practice of ECT, and the core curriculum states that ‘all Core training programmes must ensure that there is training and supervision in the use of ECT so that trainees become proficient in the prescribing, administration and monitoring of this treatment’ (Royal College of Psychiatrists, 2009). Electroconvulsive therapy consultants who have difficulty in maintaining the attendance of trainees are advised to consider whether this should be treated as an issue of professional practice/probity. These issues should be raised using the standard routes as set out in the Gold Guide (Modernising Medical Careers, 2010). This is likely to include discussion with the educational supervisor and training programme director in the first instance.
2 - The ECT suite
-
- By Chris P. Freeman, Regional Consultant for Eating Disorders, Royal Edinburgh Hospital, and The Old Pencaitland Farmhouse, East Lothian, Grace M. Fergusson, Consultant Psychiatrist, Argyll and Bute Hospital, Lochgilphead
- Edited by Jonathan Waite, Andrew Easton
-
- Book:
- The ECT Handbook
- Published online:
- 02 January 2018
- Print publication:
- 01 May 2013, pp 8-13
-
- Chapter
- Export citation
-
Summary
There should ideally be a designated area for ECT within each general psychiatry unit; this is recommended on the basis of patient convenience and economy of nurse staffing. However, it is recognised that with the numbers of patients undergoing ECT falling, there is an increasing trend for psychiatric services to share one facility in an attempt to maintain standards of anaesthetic and psychiatric practice within the confines of a National Health Service budget.
Suite layout
The design of the ECT suite will depend on the type of service provided. The minimum requirement for a local unit with small patient numbers is two rooms: a treatment room and a recovery room. An ECT unit where patients would be required to wait before treatment will need a waiting room in addition. A suite providing ECT to neighbouring psychiatric units should ideally include an ECT office and a final post-ECT waiting area.
The waiting room should be a comfortable, relaxing and informal environment, with a range of distractions, for example an outside window, pictures and magazines, and toilet facilities should be available. Patients’ arrival should be booked to provide a smooth throughput with the minimum amount of waiting time. Patients waiting for ECT should not be able to see into the treatment area while the treatment is taking place, and patients waiting for treatment should not be in the same room as patients who have completed their treatment.
The treatment room should be accessible from the waiting area. In the treatment area the patient is assisted onto a trolley or bed and prepared for treatment. This room should be well lit and contain all the equipment necessary for routine and emergency treatment. It should be big enough to allow unrestricted staff movements. Adequate work surfaces and a sink with hot and cold water should be available. There should be a clock with a second hand. If nitrous oxide and/or anaesthetic inhalation agents are ever used, the treatment room should be equipped with scavenging equipment and agent monitoring. There should be good sound-proofing between the waiting area and treatment room.
The recovery area must be large enough to accommodate easily the trolleys and associated monitors of all the patients who are regaining consciousness, and there should be enough room for recovery nursing staff to work in.
1 - Mechanism of action of ECT
-
- By Ian M. Anderson, Honorary Consultant Psychiatrist, Manchester Mental Health and Social Care Trust, and Professor of Psychiatry, Neuroscience and Psychiatry Unit, University of Manchester, Grace M. Fergusson, Consultant Psychiatrist, Argyll and Bute Hospital, Lochgilphead
- Edited by Jonathan Waite, Andrew Easton
-
- Book:
- The ECT Handbook
- Published online:
- 02 January 2018
- Print publication:
- 01 May 2013, pp 1-7
-
- Chapter
- Export citation
-
Summary
Seventy-five years after its introduction, ECT remains the most effective treatment for severe depressive disorder (UK ECT Review Group, 2003). Nevertheless, ECT is relatively underresearched compared with other forms of treatment for mental disorders; in particular there has been a relative lack of research using newer brain imaging techniques. Possible factors for the neglect of ECT include its adverse public image, funding priorities, the interests of researchers and the practical and ethical difficulties in studying this group of severely ill patients. Here, we briefly review some of the important neurobiological effects of ECT, concentrating on those related to its use in treating affective disorders, its principal indication. For more detailed information, see the reviews by Nobler & Sackeim (2008), Pigot et al (2008), Kato (2009), Merkl et al (2009) and Scott (2011).
A frequent criticism of ECT is that its mode of action is not understood. This is scarcely surprising given that the same can be said of other biological treatments in psychiatry. For example, although we understand much about the pharmacology of antidepressant and antipsychotic drug treatments, we still do not know how these pharmacological effects bring about improvement in mood or psychosis. Similarly for ECT, we know that both the generalised seizure and the dose of electricity used are important in bringing about its therapeutic effects, and that it has multiple, varied and lasting effects on the central nervous system (Merkl et al, 2009; Scott, 2011). Nevertheless, how these are translated into clinical effects remains obscure.
In recent years, advances in neuroscience have led to the development of various models of psychiatric disorders, particularly mood disorders, which encompass biological, psychological, social and developmental aspects (Mayberg, 2002; Seminowicz et al, 2004; Ebmeier et al, 2006; Beck, 2008; Akil et al, 2010). A common feature of these models is that psychiatric disorders are the result of disruptions of neural circuits, the functional networks of neurons that mediate thought, feelings and behaviour. Key areas concerned with networks involved in mood disorders include the hippocampus and amygdala, cingulate cortex (especially sub- and pregenual regions) and other areas of the prefrontal cortex. Underlying these networks are the structural and functional attributes of neurons and their connections. It is at this level that biological treatments are thought to exert their effects.
12 - Inspection of ECT clinics
-
- By Chris P. Freeman, Regional Consultant for Eating Disorders, Royal Edinburgh Hospital, and The Old Pencaitland Farmhouse, East Lothian, Joanne Cresswell, ECTAS Programme Manager, ECTAS, Centre for Quality Improvement, Royal College of Psychiatrists, Grace M. Fergusson, Consultant Psychiatrist, Argyll and Bute Hospital, Lochgilphead, Linda Cullen, National Clinical Coordinator, Scottish ECT Audit Network
- Edited by Jonathan Waite, Andrew Easton
-
- Book:
- The ECT Handbook
- Published online:
- 02 January 2018
- Print publication:
- 01 May 2013, pp 109-112
-
- Chapter
- Export citation
-
Summary
The ECT Accreditation Service (ECTAS)
In the early 1980s there was an editorial in The Lancet entitled ‘ECT in Britain: a shameful state of affairs’ (Lancet, 1981). This was at a time when ECT was the main target of the anti-psychiatry movement and there were regular protests outside Royal College of Psychiatrists’ meetings about the use of ECT. Paradoxically, several of the UK randomised controlled trials of ECT had been published and others were under way, so the evidence base for the efficacy was stronger than it had ever been. The College had just completed its first survey of the use and practice of ECT, concluding that standards of practice were low, equipment was outdated and regional variations were enormous. The author of The Lancet editorial concluded that it was not ECT that was bringing psychiatry in disrepute, it was psychiatrists and the way they practised.
The College conducted further surveys of practice in the late 1980s and early 1990s, sadly showing that standards were improving little. The Special Committee on ECT (now Special Committee on ECT and Related Treatments) began running regular training courses which several thousand psychiatrists have now attended. More recently there have been increasing numbers of anaesthetic and nursing delegates.
Thirty years on, we now have a third edition of The ECT Handbook, guidelines from NICE endorsing the use of ECT (National Institute for Clinical Excellence, 2003; National Collaborating Centre for Mental Health, 2010) and we have ECTAS.
Over the first 20 years the rate of ECT steadily fell and if the slope had not levelled out it would have crossed zero in 2012. This did not happen, and the past 10 years have shown a levelling of the rates of giving ECT, with some areas showing a rise. National figures are no longer collected. This contrasts with the situation in North America, where the rates of ECT use have been rising, and raises the view that ECT may be underused, causing patients with severe and chronic depression to suffer for much longer, as antidepressant after antidepressant is changed.
Whatever the future of ECT, it is vitally important that when it is given, it is given appropriately, safely and with due concern to a patient's consent and dignity. The ECT Accreditation Service aims to assure and improve the quality of the administration of ECT.
Do patients who receive electroconvulsive therapy in Scotland get better?: Results of a national audit
- Grace Fergusson, James Hendry, Chris Freeman
-
- Journal:
- Psychiatric Bulletin / Volume 27 / Issue 4 / April 2003
- Published online by Cambridge University Press:
- 02 January 2018, pp. 137-140
- Print publication:
- April 2003
-
- Article
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- Open access
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Aims and Method
We aimed to compare the practice of electroconvulsive therapy (ECT) in Scotland with the recommendations of the Royal College of Psychiatrists, to determine the characteristics of patients who receive ECT, to assess the outcome of ECT given in a routine clinical setting and to develop a system of quality assurance for ECT. Between February 1997 and March 2000, an audit of ECT measured the quality of treatment given at all clinics in Scotland. Audit tools were designed and standards set for the process, and outcome of treatment and interventions were identified to address any variance prior to each audit cycle. An electronic data collection system was developed and a website produced for the purpose of continued audit and information sharing.
ResultsThe annual rate of ECT in Scotland was 142 individual treatments per 100 000 of the total population. Electroconvulsive therapy was given mainly to White adult patients with a depressive illness who had consented to treatment. Clinical improvement, as measured by at least a 50% reduction in the Montgomery–Åsberg Rating Scale for Depression (MADRS) score, was evident in 71.2% of patients with a depressive episode.
Clinical ImplicationsThe audit of ECT is achievable at a national level, ECT is effective in a routine clinical setting and the standards at ECT in Scotland are higher than the UK average.
ECT in Scotland
- Carol Robertson, Chris P. L. Freeman, Grace Fergusson
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- Journal:
- Psychiatric Bulletin / Volume 21 / Issue 11 / November 1997
- Published online by Cambridge University Press:
- 02 January 2018, pp. 699-702
- Print publication:
- November 1997
-
- Article
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- You have access Access
- Open access
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Previous audit of electroconvulsive therapy (ECT) standards has identified deficiencies in service provision. Little national information was available on ECT services in Scotland. Survey questionnaires were sent to all consultants in charge of ECT clinics in Scotland. There was a 100% response rate. The service provision varied across Scotland, and in some cases fell below Royal College of Psychiatrists' recommendations. There now exists a base of information on services available and an ongoing national audit system should be considered. Several recommendations have been made for the future of ECT services in Scotland and these have been distributed to consultants in charge of clinics.
Electroconvulsive therapy machines
- Carol Robertson, Grace Fergusson
-
- Journal:
- Advances in Psychiatric Treatment / Volume 2 / Issue 1 / January 1996
- Published online by Cambridge University Press:
- 02 January 2018, pp. 24-31
- Print publication:
- January 1996
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- Article
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Electroconvulsive therapy (ECT) is a long established form of treatment for specific, serious mental disorders, but one which is still surrounded by much misunderstanding and fear. The use of electrical current administered to the brain to ‘treat’ illness remains a barbaric concept to many people. Much research has been conducted to establish the efficacy of ECT, which is now widely accepted. However, the working principles of the ECT machine itself are little understood, and more research remains to be done to establish, more scientifically, which is the ‘best’ way to administer the electrical stimulus. With the recent introduction of the concept of “stimulus dosing” (for a review see Lock, 1994), the need to be aware of the ECT machines available and their abilities and limitations is important.