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Page 1 of 2

  • Old Age Psychiatry in West Cheshire: Gps Views

  • Martin Atkins, Susan M. Benbow
  • Journal:
    European Psychiatry / Volume 11 / Issue S4 / 1996
    Published online by Cambridge University Press:
    16 April 2020, p. 361s
    • Article
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  • Use of Maintenance Ect By North West Psychiatrists

  • M. Susan, Benbow Tench, David Tench
  • Journal:
    European Psychiatry / Volume 11 / Issue S4 / 1996
    Published online by Cambridge University Press:
    16 April 2020, p. 334s
    • Article
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    • PDF
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  • 10 - Training, supervision and professional development: achieving competency

  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published by:
    Royal College of Psychiatrists
    Published online:
    25 February 2017, pp 94-98

  • 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:

    1. organisation of the clinic

    2. treatment policy

    3. training and supervision; achieving competency

    4. 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.

  • 7 - Non-cognitive adverse effects of ECT

  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published by:
    Royal College of Psychiatrists
    Published online:
    25 February 2017, pp 71-75

  • Summary

    Assessment before ECT

    The adverse effects of ECT are a major concern for people treated with ECT, their families and the public. During the assessment process, before the person consents to treatment, the risk–benefit balance for a particular person will be considered and discussed. If there are reasons why this person might be at greater risk of particular adverse effects, ways in which the risk might be minimised should be considered. For example, people with concurrent dementia may be at increased risk of developing cognitive adverse effects during ECT (Griesemer et al, 1997; Krystal & Coffey, 1997) and for this reason unilateral ECT may be preferred to bilateral ECT (see Chapter 4). Similarly, people with existing cardiac disease may be at risk of adverse cardiac events during treatment and therefore may be treated more safely in a cardiac care unit with specialist staff to hand (see Chapter 19).

    Informed consent

    As far as possible, patients and their families should be involved in discussions about the treatment, its likely adverse effects, its possible benefits, any alternative treatments and the risks (if any) of not having the treatment. The use of written as well as verbal information is good practice.

    Mortality rate

    Electroconvulsive therapy is a low-risk procedure with a mortality rate similar to that of anaesthesia for minor surgical procedures, despite its frequent use in elderly people and those with major medical problems (Sackeim, 1998; Weiner et al, 2000). An audit in the USA found that there were no deaths directly related to ECT reported in any Veterans Affairs hospital between 1999 and 2010 (Watts et al, 2011). This suggests – based on the number of treatments given – that ECT mortality is less than 1 death per 73 440 treatments.

    In earlier studies, Shiwach et al (2001) reported on 8148 patients receiving 49 048 ECT treatments in Texas between 1993 and 1998. No patient died during ECT. Thirty patients died within 2 weeks of receiving ECT; the authors felt that one death, which occurred on the day of treatment, could specifically be linked to ECT and four others could plausibly be linked to the treatment. They estimated mortality associated with ECT to be <2/100 000 treatments. A Danish case-register study found a lower mortality rate from natural causes for in-patients treated with ECT compared with other psychiatric patients (Munk-Olsen et al, 2007).

  • 20 - ECT for older adults

  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published by:
    Royal College of Psychiatrists
    Published online:
    25 February 2017, pp 191-195

  • Summary

    A survey of old age psychiatrists in the early 1990s found that they regarded the main indication for ECT in older people to be severe depressive illness (Benbow, 1991), but they also rated the treatment as often or sometimes useful in schizoaffective disorder and depressive illness with dementia. Similarly, ECT was regarded as the treatment of choice for people with depressive illness:

    1. • that has failed to respond to antidepressant drugs

    2. • in which previous episodes responded to ECT but not to antidepressant Drugs

    3. • with psychotic symptoms

    4. • with severe agitation and those with high suicidal risk.

    These clinical views are compatible with literature reporting favourable outcomes for older people treated with ECT (Damm et al, 2010) and for depressive psychosis (Birkenhager et al, 2004). Van der Wurff et al (2003) reviewed efficacy in older adults and found immediate response rates of between 55% and 85% in 10 naturalistic prospective studies and immediate response rates ranging from 48% complete recovery to 92% improvement in 14 retrospective studies. They concluded that immediate response rates are ‘impressive’, although based on non-randomised evidence. Many studies have reported response rates of around 70% or more among older adults (Fraser & Glass, 1980; Gaspar & Samarasinghe, 1982; Karlinsky & Shulman, 1984; Benbow, 1987; Godber et al, 1987; Rubin et al, 1991; Casey & Davies, 1996; Tomac et al, 1997).

    The NICE (2003: p. 5) technology appraisal of ECT recommends that ECT only be used ‘to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be life-threatening, in individuals with:

    1. • severe depressive illness

    2. • catatonia

    3. • a prolonged or severe manic episode.’

    The technology appraisal was reviewed in May 2010: the recommendations on ECT in catatonia and mania were unchanged, and guidance on ECT in depression has been updated by the clinical guideline CG90 (National Institute for Health and Excellence, 2009), which states that ‘the risks associated with ECT may be greater in older people; exercise particular caution when considering ECT treatment in this group’ (p. 41). This is in the context of evidence that older people have been major users of ECT services in the past (Pippard & Ellam, 1981; Duffett et al, 1999).

  • 19 - Safe ECT practice in people with a physical illness

  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published by:
    Royal College of Psychiatrists
    Published online:
    25 February 2017, pp 184-190

  • Summary

    Possible medical contraindications to ECT

    People with a wide range of physical illnesses are successfully treated with ECT (Fink, 1999; American Psychiatric Association, 2001). Abrams (1997) pointed out that the death rate associated with ECT is lower than the spontaneous death rate in the general US population. Some medical problems may cause particular concern, however, especially cardiovascular and neurological problems.

    During the passage of the electrical stimulus, both blood pressure and heart rate fall and then rise rapidly. There is a sudden, short-lived rise in intracranial pressure and cerebral blood flow, and cerebrovascular permeability increases. Vagal stimulation leads to a sinus bradycardia, sometimes with periods of asystole or electrical silence. This is rapidly replaced by a sympathetically mediated tachycardia, which, by decreasing the oxygen supply to the myocardium and increasing its oxygen consumption, increases cardiac work and can result in ischaemia. Subconvulsive stimuli are known to produce longer periods of bradycardia; this may be a concern when people with established heart disease are being treated using a dose-titration protocol to determine seizure threshold (Abrams, 1991; Dolinski & Zvara, 1997). Another risk factor for longer periods of asystole during ECT is the use of beta-blockers (McCall, 1996). Vagolytic drugs, such as glycopyrrolate and atropine, are sometimes used to attenuate the bradycardia (Applegate, 1997). It is not surprising that there is evidence that people with cardiovascular disease are more at risk of cardiac complications during ECT. Burke et al (1987) reported more complications in people on a greater total number of medications and in those on a greater number of cardiovascular medications. Complications during ECT may also increase as the age of the person being treated increases, although, in a naturalistic study, Brodaty et al (2000) found that the number and severity of adverse events were not associated with age.

    Most cardiovascular complications are transient and do not prevent successful completion of an ECT course and so Zielinski et al (1998) concluded that ECT can still be used relatively safely for people with severe cardiac disease. The American Psychiatric Association (2001) also states that, in general, people with cardiovascular disease can be safely treated with ECT. Abrams (2002) has reviewed the use of ECT in people with previous cardiac surgery, myocardial infarction, cardiac pacemakers, aortic aneurysms and intracardiac thrombi, and who were taking drug treatments to reduce blood pressure, prevent arrhythmias or reduce heart rate.

  • Effectiveness increases with integration in primary care

  • David Jolley, Susan M. Benbow, Ian Greaves
  • Journal:
    BJPsych Bulletin / Volume 39 / Issue 4 / August 2015
    Published online by Cambridge University Press:
    02 January 2018, p. 205
    Print publication:
    August 2015
    • Article
      • You have access
      • Open access
    • PDF
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  • 10 - Training, supervision and professional development: achieving competency

    • 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

  • 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.

  • 20 - ECT for older adults

    • By 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 191-195

  • Summary

    A survey of old age psychiatrists in the early 1990s found that they regarded the main indication for ECT in older people to be severe depressive illness (Benbow, 1991), but they also rated the treatment as often or sometimes useful in schizoaffective disorder and depressive illness with dementia. Similarly, ECT was regarded as the treatment of choice for people with depressive illness:

  • • that has failed to respond to antidepressant drugs

  • • in which previous episodes responded to ECT but not to antidepressant drugs

  • • with psychotic symptoms

  • • with severe agitation and those with high suicidal risk.

    • These clinical views are compatible with literature reporting favourable outcomes for older people treated with ECT (Damm et al, 2010) and for depressive psychosis (Birkenhager et al, 2004). Van der Wurff et al (2003) reviewed efficacy in older adults and found immediate response rates of between 55% and 85% in 10 naturalistic prospective studies and immediate response rates ranging from 48% complete recovery to 92% improvement in 14 retrospective studies. They concluded that immediate response rates are ‘impressive’, although based on non-randomised evidence. Many studies have reported response rates of around 70% or more among older adults (Fraser & Glass, 1980; Gaspar & Samarasinghe, 1982; Karlinsky & Shulman, 1984; Benbow, 1987; Godber et al, 1987; Rubin et al, 1991; Casey & Davies, 1996; Tomac et al, 1997).

    The NICE (2003: p. 5) technology appraisal of ECT recommends that ECT only be used ‘to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be life-threatening, in individuals with:

  • • severe depressive illness

  • • catatonia

  • • a prolonged or severe manic episode.’

    • The technology appraisal was reviewed in May 2010: the recommendations on ECT in catatonia and mania were unchanged, and guidance on ECT in depression has been updated by the clinical guideline CG90 (National Institute for Health and Excellence, 2009), which states that ‘the risks associated with ECT may be greater in older people; exercise particular caution when considering ECT treatment in this group’ (p. 41). This is in the context of evidence that older people have been major users of ECT services in the past (Pippard & Ellam, 1981; Duffett et al, 1999).

  • 19 - Safe ECT practice in people with a physical illness

    • By Susan M. Benbow, Director, Older Mind Matters Ltd, and Visiting Professor of Mental Health and Ageing, Staffordshire University, Jonathan Waite, Consultant Psychiatrist, Nottinghamshire Healthcare NHS Trust
  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published online:
    02 January 2018
    Print publication:
    01 May 2013, pp 184-190

  • Summary

    Possible medical contraindications to ECT

    People with a wide range of physical illnesses are successfully treated with ECT (Fink, 1999; American Psychiatric Association, 2001). Abrams (1997) pointed out that the death rate associated with ECT is lower than the spontaneous death rate in the general US population. Some medical problems may cause particular concern, however, especially cardiovascular and neurological problems.

    During the passage of the electrical stimulus, both blood pressure and heart rate fall and then rise rapidly. There is a sudden, short-lived rise in intracranial pressure and cerebral blood flow, and cerebrovascular permeability increases. Vagal stimulation leads to a sinus bradycardia, sometimes with periods of asystole or electrical silence. This is rapidly replaced by a sympathetically mediated tachycardia, which, by decreasing the oxygen supply to the myocardium and increasing its oxygen consumption, increases cardiac work and can result in ischaemia. Subconvulsive stimuli are known to produce longer periods of bradycardia; this may be a concern when people with established heart disease are being treated using a dose-titration protocol to determine seizure threshold (Abrams, 1991; Dolinski & Zvara, 1997). Another risk factor for longer periods of asystole during ECT is the use of beta-blockers (McCall, 1996). Vagolytic drugs, such as glycopyrrolate and atropine, are sometimes used to attenuate the bradycardia (Applegate, 1997). It is not surprising that there is evidence that people with cardiovascular disease are more at risk of cardiac complications during ECT. Burke et al (1987) reported more complications in people on a greater total number of medications and in those on a greater number of cardiovascular medications. Complications during ECT may also increase as the age of the person being treated increases, although, in a naturalistic study, Brodaty et al (2000) found that the number and severity of adverse events were not associated with age.

    Most cardiovascular complications are transient and do not prevent successful completion of an ECT course and so Zielinski et al (1998) concluded that ECT can still be used relatively safely for people with severe cardiac disease. The American Psychiatric Association (2001) also states that, in general, people with cardiovascular disease can be safely treated with ECT.

  • 7 - Non-cognitive adverse effects of ECT

    • By Susan M. Benbow, Director, Older Mind Matters Ltd, and Visiting Professor of Mental Health and Ageing, Staffordshire University, Jonathan Waite, Consultant Psychiatrist, Nottinghamshire Healthcare NHS Trust
  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published online:
    02 January 2018
    Print publication:
    01 May 2013, pp 71-75

  • Summary

    Assessment before ECT

    The adverse effects of ECT are a major concern for people treated with ECT, their families and the public. During the assessment process, before the person consents to treatment, the risk–benefit balance for a particular person will be considered and discussed. If there are reasons why this person might be at greater risk of particular adverse effects, ways in which the risk might be minimised should be considered. For example, people with concurrent dementia may be at increased risk of developing cognitive adverse effects during ECT (Griesemer et al, 1997; Krystal & Coffey, 1997) and for this reason unilateral ECT may be preferred to bilateral ECT (see Chapter 4). Similarly, people with existing cardiac disease may be at risk of adverse cardiac events during treatment and therefore may be treated more safely in a cardiac care unit with specialist staff to hand (see Chapter 19).

    Informed consent

    As far as possible, patients and their families should be involved in discussions about the treatment, its likely adverse effects, its possible benefits, any alternative treatments and the risks (if any) of not having the treatment. The use of written as well as verbal information is good practice.

    Mortality rate

    Electroconvulsive therapy is a low-risk procedure with a mortality rate similar to that of anaesthesia for minor surgical procedures, despite its frequent use in elderly people and those with major medical problems (Sackeim, 1998; Weiner et al, 2000). An audit in the USA found that there were no deaths directly related to ECT reported in any Veterans Affairs hospital between 1999 and 2010 (Watts et al, 2011). This suggests – based on the number of treatments given – that ECT mortality is less than 1 death per 73 440 treatments.

    In earlier studies, Shiwach et al (2001) reported on 8148 patients receiving 49 048 ECT treatments in Texas between 1993 and 1998. No patient died during ECT. Thirty patients died within 2 weeks of receiving ECT; the authors felt that one death, which occurred on the day of treatment, could specifically be linked to ECT and four others could plausibly be linked to the treatment. They estimated mortality associated with ECT to be <2/100 000 treatments. A Danish case-register study found a lower mortality rate from natural causes for in-patients treated with ECT compared with other psychiatric patients (Munk-Olsen et al, 2007).

  • Narratives in a users' and carers' group: meanings and impact

  • Susan M. Benbow, Yong Lock Ong, Sarah Black, Jane Garner
  • Journal:
    International Psychogeriatrics / Volume 21 / Issue 1 / February 2009
    Published online by Cambridge University Press:
    17 October 2008, pp. 33-39

  • Background: Carers who wished to share their experiences with a national working group (the Consumer Group) prepared narratives as a way of identifying areas for discussion.

    Methods: The narratives were submitted to one author and subjected to thematic qualitative analysis. The themes were fed back to the Group for discussion.

    Results: Five main themes were identified: difficulties in obtaining a diagnosis; acting as an advocate; stresses of caring; practical problems with social care; and emotions experienced by carers.

    Conclusions: The narratives provided a means of sharing carers' experiences and creating initiatives for further action by the Group. They have an impact on the people who hear or read them but may also be therapeutic for those who produce them. Narratives can also be a powerful tool in teaching and training, and in identifying areas for service and professional improvement.

  • Moving consultant post

  • Susan M. Benbow, David J. Jolley
  • Journal:
    Psychiatric Bulletin / Volume 29 / Issue 6 / June 2005
    Published online by Cambridge University Press:
    02 January 2018, p. 232
    Print publication:
    June 2005
    • Article
      • You have access
      • Open access
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  • Subjective experience of electroconvulsive therapy

  • Susan M. Benbow, Joe Crentsil
  • Journal:
    Psychiatric Bulletin / Volume 28 / Issue 8 / August 2004
    Published online by Cambridge University Press:
    02 January 2018, pp. 289-291
    Print publication:
    August 2004
    • Article
      • You have access
      • Open access
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  • Aims and Method

    People receiving electroconvulsive therapy (ECT) in one clinic completed side-effect rating questionnaires during treatment, and a questionnaire rating their experience of different aspects of treatment on completion of the treatment course.

    Results

    Side-effects were commonly reported, but predominantly rated as mild or moderate. Most people reported that ECT had made them a little or a lot better, and that the treatment had been fairly or very well explained. Fewer than a fifth of respondents rated ECT as slightly or much worse than going to the dentist.

    Clinical Implications

    We recommend routine monitoring of the subjective experience of ECT, during treatment and on completion of the course. Ratings should inform the treatment plan, the policies and procedures of the ECT clinic.

  • Anaesthesia for electroconvulsive therapy: a role for etomidate

  • Susan M. Benbow, Priti Shah, Joe Crentsil
  • Journal:
    Psychiatric Bulletin / Volume 26 / Issue 9 / September 2002
    Published online by Cambridge University Press:
    02 January 2018, pp. 351-353
    Print publication:
    September 2002
    • Article
      • You have access
      • Open access
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  • Aims and Method

    Three cases are described to illustrate the elective use of etomidate in electroconvulsive therapy (ECT) anaesthesia.

    Results

    Use of etomidate is described in an individual who was treated with an electrical stimulus at the maximum level for the ECT machine in use; in a person who had severe side-effects with an alternative induction agent; and in a person with severe cardiac disease.

    Clinical Implications

    The anaesthetic drug should be tailored to the individual needs of the person being treated with ECT. Clinics should involve local anaesthetic departments in reviewing their anaesthetic practice.

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