Authors: Jagadisha Thirthalli, Preeti Sinha, Vanteemar S. Sreeraj
Categories: Clinical Practice Guidelines
Source: Indian Journal of Psychiatry
Electroconvulsive therapy (ECT) is a clinical procedure where a small dose of electric current is passed through the brain for a brief period to induce seizures for therapeutic purposes in psychiatric (and certain neurological) conditions. Modified ECT is the modern form of ECT where the electrical stimulus is given under general anesthesia and muscle relaxation. This is one of the most effective treatments for many psychiatric conditions. Modern modified ECT is a safe treatment when practiced with adequate knowledge, skills, and expertise. Following the basic standards of ECT practice is necessary for better clinical outcomes including minimal cognitive adversities. This guideline document is aimed at enabling consistent, safe, and effective practice of ECT in patients in applicable psychiatric disorders.
These guidelines are developed as part of the initiative of Clinical Practice Guidelines (CPG) subcommittee of Indian Psychiatric Society. The initial draft guideline was developed by the authors. The information was sourced from key research articles, national/international guidelines on psychiatric care, and ECT. No formal systematic literature search was conducted. The current guideline was prepared to suit the existing Indian mental health care system and legislations. The draft was further presented and discussed in the in-person workshop of CPG-2022. The draft was revised following the discussion in the workshop based on the consensus-based recommendation method.
This guideline is not a directive or mandatory instruction but a guidance document for professional practitioners administering ECT. This is not a full and complete review of ECT procedure. But it is intended to improve patient outcomes by facilitating best practice standards by maximizing benefits and minimizing adversities.
Table 1 shows the indications for ECT. Evidence exists for the efficacy of ECT in depressive episodes, manic episodes, and acute exacerbations of psychosis in schizophrenia. Treatment-resistant depression, mania, and schizophrenia, including clozapine-resistant schizophrenia, are well-recognized indications,[1-6] with evidence from comparative trials (comparison across types of ECT or with waitlisted patients). ECT should not be withheld until the failure of several medication/psychotherapy trials in severe depression. Health economics suggest that it is beneficial to consider ECT as a second or third line agent in severe depression. ECT is considered as first-line (primary) treatment for emergency psychiatric conditions across diagnoses. These include high suicidality, catatonia, excitement, aggression, poor oral intake, acute psychotic symptom exacerbations, and severe physical debilitation secondary to psychiatric disorders.[7-13] The rigor of the evidence base is limited for such indications due to ethical and pragmatic considerations in conducting sham-controlled trials in these emergency life-threatening transdiagnostic situations. It may be noted that almost all international standard guidelines suggest ECT as a first-line treatment option for these indications.[8-13]
In general, older age, psychotic symptoms, and shorter episode duration are predictors of response to ECT. Melancholic features and greater baseline depressive symptom severity are also associated with better ECT response. Past good response to ECT is considered a good predictor of response for the current episode.
Continuation/Maintenance (C/M) ECT should be considered for patients with a history of severe, recurrent episodes who have failed to remain well on medications.[14]
ECT is a first-line treatment when rapid and/or definitive response to avert harm to self/others is needed. Acute suicidal risk, agitation, catatonia, and deteriorating physical status secondary to psychiatric conditions are some of such situations. After an acute course of ECT, C/M treatment with pharmacotherapy and/or psychotherapy is needed.
All the indications mentioned above have to be individualized and should be based on the clinical needs, patient’s preferences, and putative risk of adverse effects.
ECT without anesthesia and muscle relaxation is now prohibited under the Mental Health Care Act, 2017. Hence, the staffing shown in Table 2 is advisable for administering modified ECT.
The treatment suite ideally involves three distinct areas, but which are nearby or closely [9,10]
Written informed consent has to be taken before initiating ECT based on principles of shared decision-making. Consent should be taken following due procedures in accordance with the highest ethical standards and applicable laws/regulations. Written information material may be provided to the patient and caregivers, and adequate time should be provided for reverting with any clarifications. Information should be provided regarding the anticipated benefits and possible short-term and long-term adverse effects of modified ECT, including possible risks with both anesthesia and ECT, in the given individual. Discussion on the type of ECT, modification procedure, electrode placement, and expected outcomes should be included in this process. Unless the patient disagrees, it is recommended to make caregivers a part of the consenting process. If a patient does not have the capacity to consent, the same needs to be documented. The advance directives, if any, have to be examined and, in accordance with that, consent may be obtained from the nominated representative. In the case of minors, oral/verbal assent (as per the age) should be obtained along with written informed consent from parents/nominated representative; the decision about initiating ECT has to be taken only after concurrence by two independent psychiatrists or a psychiatrist + a physician, and due permission from the mental health review board as per the law. As and when a patient regains the capacity to consent or attains 18 years of age, his/her consent has to be obtained for continuing ECT sessions then onwards.[15,16] Consent has to be obtained again before initiating C/M ECT, as the clinical condition, purpose (consolidation/relapse prevention), and character of treatment (frequency of ECT sessions and end-point) would have changed.
Pre-ECT evaluation (Supplement 5): This should be performed as close to the ECT course as possible.
Psychiatric evaluation is needed to ascertain indications. Rating scales can be used to determine these indications systematically and measure the changes during the ECT course. If the patient has received ECT in the past, details of the electrode placement and electrical parameters in earlier ECTs, level of achieved response, and associated cognitive deficits would guide the current course of ECT.
It is important to evaluate the psychotropic medications that can potentially interfere with anesthesia and ECT. For instance, anticonvulsants increase seizure threshold; antipsychotics like chlorpromazine and clozapine are known to be pro-convulsants; lithium can increase the risk of postictal delirium; tricyclic antidepressants are known to increase the risk of cardiac adverse events during ECT/anesthesia.
Physical examination is needed to identify any relative contra-indications and prevent complications [Table 3]. It should mandatorily involve fundoscopic examination along with other systemic examinations. Dental evaluation for loose or missing teeth, cardiovascular examination for arrhythmias, assessment for neurological comorbidities, and pulmonary clinical evaluation are mandatory.
Preanesthetic evaluation is recommended to plan for an anesthetic agent and a muscle relaxant. Also, suitable investigations or interventions can be planned in the presence of medical conditions associated with a substantial risk for general anesthesia-related complications. Liaison with other specialist physicians if deemed is necessary by the psychiatrist/anesthetist.
Monitoring of cognitive adverse effects would be necessary for patients receiving ECT. Baseline knowledge of cognitive abilities is crucial in attributing the changes in cognitive abilities with ECT. Hindi Mental Status Examination and Mini Mental Status Examination are simple tools for monitoring, but are not sensitive to subtle cognitive changes associated with ECT. Montreal cognitive assessment battery (MoCA) and brief ECT cognitive screen are assessment tools used internationally. “Battery for ECT-Related Cognitive Deficits” (B4ECT RECODE) is a tool validated in the Indian population and is recommended to be used during the initiation and course of ECT.[10]
For general hemoglobin levels, blood sugar, electrolytes, blood urea, and serum creatinine would facilitate the detection of common risk-enhancing medical comorbidities but are not mandatory. Similarly, X-ray, electrocardiography, echocardiogram, and other tests would be indicated based on physical evaluation and associated medical comorbidities
ECT is mandatorily used as a modified procedure, as per the law in India. The modification involves using muscle relaxants to reduce the neuromuscular injuries and using anesthetic agents to induce sedation and amnesia for the procedure involving muscle relaxation and electrical stimulation.
Figure 1 Steps of preanesthesia preparation
Figure 2 ECT electrode placements
Figure 3 Electrical parameters
Electrical charge = Current intensity × pulse width × pulse frequency × train duration.
The total dose for optimal efficacy through repeated ECT sessions is considered with respect to the seizure threshold; efficacy is also dependent on pulse width and electrode placement.
Marginally suprathreshold charge (1.5 × seizure threshold) is recommended in bilateral (Bitemporal/Bifrontal) ECT with brief pulse ECT (pulse width of 1 ms or more). Some evidence suggests a requirement of a higher charge (2.5 × seizure threshold) when a lower range of brief-pulse (0.5 ms) is used with bilateral ECT. There is strong evidence that a markedly suprathreshold (6 × seizure threshold) is required with ultrabrief (0.3 ms) ECT, with the evidence available for primarily right unilateral ECT, specifically in depression. For right unilateral ECT with brief pulse width, electrical charge is to be considered 4–6 times the seizure threshold. Ultrabrief bilateral (bifrontal/bitemporal at 0.3 ms) is found to be less effective and may not be advisable with the existing evidence. Ideally, the dose increment has to happen for a fixed current amplitude, pulse frequency, and pulse width. Hence, the suprathreshold dose should also be a function of train duration. But most of the standard devices have a limitation of train duration at 4–8 s in default settings, and they increase pulse frequency to increase the total duration. Most studies have used these default increments, and hence this guideline should be read with caution. More studies are needed to ascertain this need.
Dose estimation [26,27]
Stimulus titration method: This will be the recommended method in regular practice. The first session can be spared in finding the lowest dose needed for seizure threshold estimation. Formula-based methods can be used as guidance for identifying the first dose of titration. Faster titration may be attempted with higher increments between stimuli in elderly patients, and slower titration with smaller increments may be attempted in adolescents/younger adult patients. Subsequent sessions can be provided at suprathreshold doses as discussed above.
Formula-based methods: Based on the age and sex of the patient, different formulae are derived. There is a need to be cautious in using the formula, as medications and anesthetic agents may impact the seizure threshold. The stimulus should have the same amplitude, pulse width, pulse frequency, and electrode location from which the formula was derived.
Fixed high dosing: This uses a single high dose, commonly the maximum for all the sessions. The use of a high fixed dosing strategy should be reserved only for patients with sufficiently serious concomitant medical conditions in which avoidance of subconvulsive stimulation is a priority
Dosing from benchmark: A high dose will be administered at the first session. The peak heart rate and tonic-clonic convulsions would be observed. In subsequent sessions, the doses are down-titrated to continue at the lowest dose producing a similar outcome. This could be a better alternative to the continued fixed high dosing method, wherever it is used.
c. Procedure and monitoring [Supplements 7 and 8]i. ECT procedure [Figure 4]
Figure 4 Steps of ECT procedure
Hamilton cuff method is recommended for monitoring motor seizures by isolating the ipsilateral limb (right limb in the right unilateral ECT) from muscle relaxants.
EEG gives a direct measure of seizure activity and is recommended wherever available. Bilateral EEG recording from at least two channels (FP1 and FP2) referenced to the ipsilateral mastoid is preferred. When only a single channel is available, a contralateral channel is preferred.
EEG recording can have artifacts due to muscle movements and other technical issues. Hence, motor monitoring should always be used to supplement EEG.
Figure 5 Phases of electroconvulsive therapy-induced electroencephalogram-monitored seizures
Missed If there is no motor or EEG seizure even after 20 s of completion of electrical stimuli administration, then restimulation may be attempted by increasing the stimulus dose. Delayed onset seizure should be watched out for.
Inadequate If the EEG seizure is of low quality or the motor seizure is nongeneralized, limiting to one side of the body or restricted to the facial region only, restimulation at higher doses may be attempted after 45 s. Restimulation may be attempted till the patient comes out of anesthesia/muscle relaxant. Generally, four to five restimulations can be attempted. If needed, reinduction of anesthesia, or “top-up” dose, can be requested from the anesthetist. It may be noted that top-up doses reduce the quality of seizures. If the seizures are very brief (e.g., 5–10 s duration), and if the patient is showing the expected clinical response, then restimulation with a higher dose need not be administered. Restimulation on the same day after adequate seizure, called the multiple monitored ECT (MMECT), is not recommended. Even in cases of unilateral ECT, markedly suprathreshold stimulation would not be necessary on the first day of titration. This might be considered only extremely rare life-saving conditions like neuroleptic malignant syndrome or intractable seizures.
In the case of a prolonged seizure (seizure longer than 180 s), termination can be attempted if a seizure extends beyond 120 s. Airway and respiration should be closely monitored till the complete cessation of seizure. A seizure may be terminated using benzodiazepines, phenytoin, valproate, or barbiturate (usually, the anesthetic agent used for induction). If the patient is on theophylline or lithium, stopping them temporarily or alternatives may be considered. Shifting to anticonvulsant anesthetic agents may also be considered.
Left lateral positioning and monitoring in the ECT suite should continue under the care of an anesthetist till spontaneous breathing is gained. Then, the patient can be shifted to the recovery room.
ii. Monitoring in the recovery room
iii. During the course of ECT treatment.
The number of ECTs should not be predetermined but should be based on the needs of individual patients. Progress in terms of clinical symptoms and cognitive and other adverse effects should be monitored at least once a week during the course of ECT. ECT may be terminated at any time if complete clinical improvement/remission is achieved. If satisfactory clinical improvement is not observed, a minimum of 8–12 ECT sessions should be provided in acute courses before considering the failure of response to ECT. A longer course may be needed in some slow responders, and this decision to continue more than 12 sessions should be taken after a risk–benefit analysis. In general, the response to ECT is seen after more sessions in schizophrenia than in depression and mania. Switching from unilateral to bilateral and/or ultrabrief pulse to brief pulse ECT can be considered after a risk–benefit analysis if clinical improvement is not noted after four to eight sessions.
Monitoring clinical improvement: A clinical, indication-specific, structured symptom rating tool may be used weekly for assessment wherever feasible. A clinical assessment is a must after every ECT, preferably within 24 h following the ECT session, but certainly before the next session.
Monitor adverse effects: ECT-specific cognitive assessment tools can be used. MoCA, brief ECT cognitive screen, and battery for ECT-Related Cognitive Deficits (B4ECT-RECODE) may be used serially during the course of ECT.[28,29]
ECT can be used as a continuation-phase treatment (up to 6 months of remission) for consolidation of effects and maintenance treatment (after 6 months of treatment) as prophylaxis in major depressive disorder, bipolar disorder, and schizophrenia. Acute courses (of 2–3 sessions/week), if effective, can be gradually tapered down from twice a week to weekly, fortnightly, and monthly. The tapering and frequency of continuation should be tailored to the individual patients’ clinical needs. The course should not be prefixed. It should be planned dynamically during the course and scheduled based on periodic clinical reviews.[7,29]
After 6 months of continuation based on clinical needs, maintenance ECT may be planned. It is usually given at a frequency ranging from one session every 1–12 weeks. Alternative pharmacological and psychological interventions should be considered for risk–benefit analysis while planning maintenance treatment.
Frequent inadequate/missed seizures or prolonged seizures:
**Tardive ** Seizures may happen within hours of an ECT session. This requires investigating for other causes of seizures. There may be nonmotoric manifestations of tardive seizures. Seizures need to be aborted using anticonvulsant medicines.
Post-ictal confusion/ Generally, patients regain orientation within 5–45 min after an adequate seizure. If confusion and poor response to commands with or without behavioral agitation continue after this period or if they are very severe during this period, supportive intervention should be considered.
Patients should be secured in a safe environment, and airway, breathing, and circulation should be maintained (IV line should be secured from getting damaged). Environmental stimuli should be reduced and gentle, temporary physical restraint may be used if necessary to prevent the patient from harming himself. IV enzodiazepines or anesthetic agents may be used if agitation is persistent or severe. Low-dose antipsychotics (e.g., haloperidol IM 2–5 mg with repeated dose when necessary) may be used if the benzodiazepines are ineffective. Physical conditions like electrolyte imbalance or infections should be evaluated in cases of recurrent postictal delirium. Nonconvulsive prolonged seizures, status epilepticus, or tardive seizures should be considered as differential diagnoses. A prophylactic higher dose of anesthetic agent or benzodiazepines may be considered in cases of recurrent postictal delirium.
One or more of the following steps may be considered to address these. The decision should be taken balancing with the possible reduction in effectiveness with these methods.
Pain: May manifest as headache, muscle soreness, and joint pains.
Headache: It is generally mild. If severe, analgesics like paracetamol, aspirin, or nonsteroidal anti-inflammatory drugs may be used.
**Muscle ** Can be addressed similar to a headache. Generally, it is intense after the first session and would not be much with later sessions. Intense fasciculations with succinylcholine could contribute to muscle soreness. Reduction of dose or change to another muscle relaxant can be considered.
**Joint ** Temporomandibular joint dislocations due to uncoordinated contractions of the temporalis, pterygoid, and masseters may happen with modified ECT due to direct stimulation. Firm holding of jaws during the stimulus would reduce the risk. Examine for dislocations and relocate using appropriate maneuvers in such situations.
Nausea/Vomiting: These are generally associated with headaches, and they respond to analgesics. If severe, butyrophenones, phenothiazines, and metoclopramide may be used. Ondansetron may also be used as next-line agent.
**Treatment-emergent ** ECT may be continued or frequency may be reduced based on clinical needs.
Patients and families should be given the opportunity to express apprehensions, concerns, and ask questions. Information and fact sheets should be provided, supplementing the consent form. Video materials can be a value addition to this. Group sessions of patients and family caregivers, including those who have received ECTs, would enhance mutual support and enhance knowledge. Anxiety about ECT developing during a course of ECT may sometimes be due to awareness of the effect of muscle relaxants under anesthesia. In such cases, the dose of the anesthetic agent should be modified to ensure unawareness; muscle relaxants should be administered after clearly noting that the patient is deeply sedated.
**Children and ** Literature regarding ECT in this population is limited.[30-32] There is no evidence for differential efficacy or safety in this group. The Mental Health Care Act of 2017 of India mandates preapproval from the mental health review board to administer ECT under dire needy situations in this population. Having two psychiatrists’ opinions regarding the need for and specifics of ECT would be beneficial. ECT is generally chosen only after other options have failed. Prolonged seizures are commoner in this age group, and hence, it is best to avoid proconvulsant/neutral anesthetic agents like etomidate and ketamine.
Pregnancy: ECT is safe and effective in pregnancy and is a preferred option, given its lesser risk of teratogenicity compared to many psychotropics. The risk evaluation should be a joint activity of the psychiatrist, anesthetist, and obstetrician. A few additional steps should be considered in pregnancy (most applicable in second and third trimesters):
ECT is safe and effective in elderly patients.[33] Evidence suggests a higher response rate of elderly depression than the mixed age group population. Cognitive adverse effects would be of greater concern primarily when ECT is indicated for dementia-related behavioral disturbances. Risks of high seizure threshold, missed seizures, medical comorbidities, and postictal delirium are higher in old age. Certain general consideration regarding ECT in older
**Medical ** Table 7 describes the concerns related to medical comorbidities and special care to be taken while administering ECT for patients with different medical comorbidities. In all cases, there should be a thorough consideration of the risk–benefit ratio and a multidisciplinary approach to minimize complications. Appropriate risks should be explained to the patient/caregivers while taking consent.
ECT is an aerosol-generating procedure. Certain additional precautions to curtail the spread of COVID may be taken as per risk assessment by clinicians [Table 8].
Nil.
There are no conflicts of interest.
Supplement ECT consent form (for patients)
Supplement ECT consent form (for the nominated representative in case the patient is considered not competent to provide consent for ECT)
Supplement ECT consent form (for patients after regaining competency to provide consent for ECT)
Supplement Continuation/Maintenance ECT consent form (for patients)
Supplement Pre--ECT evaluation and anesthesia consultation form
Supplement Pre--ECT preparation record
Supplement ECT procedure record
Supplement ECT vitals monitoring record
SUPPLEMENT: 1
ECT Consent form
(for patient)
Please feel free to ask for clarification if you do not understand any part of this form
Information
Considering all aspects of your mental and physical health, we believe that you would benefit from Electro Convulsive Therapy (ECT) as a form of treatment. In this treatment, a controlled dose of electricity will be passed through your head and a brief-lasting convulsion is produced. It is administered under anaesthesia so that you do not experience any discomfort. The treatment will be done in morning in the ECT suite. You will be required not to eat or drink anything, including water, for 8 hours before the procedure. To provide anesthesia, the doctors would give you an injection and after you are put to sleep, they would apply a small electric current to your head. You would wake up after a few minutes. A team of doctors and nurses supervise your condition throughout this time. You will receive ECT on alternate days or twice a week for about 2–3 weeks. We will observe you daily for the effects of ECT and, with your consent, decide on the number of treatments that you may require.
ECT is expected to improve your health. It is not expected to cure your illness. The improvement achieved with ECT should be sustained with the help of medications, counselling (psychotherapy) and/or other treatments. We will attempt to reduce the side effects of ECT by careful evaluation before and through the course of ECT and by adjusting your medications. The side-effects are usually mild and e.g., headache and confusion for some time following ECT session. You may also notice minor lapses in memory for events around the course of ECT. Memory for your past, including all you have learnt weeks or months before the ECT will not be affected in any major way. Overall, the advantages of ECT are expected to outweigh the risks in your case.
The Information Leaflet providing more information on ECT is available. We urge you to go through it and seek clarification if you have questions. You may also discuss with us about alternative treatments suitable for your case and possible course of your illness with and without ECT. We urge you to make a decision about ECT considering all these aspects. ECT will be administered to you only after you provide consent for it. You can refuse your consent now as well as withdraw your consent during the course of the treatment. In either case, the best available alternative treatments will be provided to you without any prejudice.
Information about high-risk (Strike off if not applicable): As you may be aware, in addition to the psychiatric problem for which we have suggested ECT, you are suffering from _________________________ (name of the high-risk condition/s). In this background, administration of anesthesia and ECT may have additional risks to your health. The team of doctors and nurses will do their best to minimize these risks by taking appropriate precautions and measures. Please be informed that your doctors have suggested ECT to you with the full knowledge of your above-mentioned condition and have consulted the anesthetists in this regard.
DECLARATION OF CONSENT FOR ECT
I have been advised that my present health condition requires ECT. I have been sufficiently informed about the procedure of ECT with its benefits and possible risks. I am aware that I have the right to refuse this treatment now or at any time during the course of treatment without compromising my right to obtain all other services in the hospital. I, Mr./Mrs./Ms ____________________________ (Name of the patient) hereby provide my consent for the administration of ECT to me. I have received a copy of this informed consent for my record.
High-risk consent (strike off if not applicable):
I am aware that I have __________________ in addition to my psychiatric condition. The doctors have explained to me that administration of anesthesia and ECT in this background may have additional risks to my health and that they will be taking additional precautions and measures to minimize these risks. I hereby declare that the doctors have explained to me the additional risks involved in providing ECT to me and I am consenting with full knowledge of these risks.
(Signature of the Patient) (Signature and Name of the relative)
(Signature and Name of the witness) (Preferably Nursing Staff)
(Name of the Doctor) (Doctor's signature) (Designation of the Doctor)
Date: Place:
SUPPLEMENT: 2
ECT Consent Form
(for the nominated representative in case the patient is considered not competent to provide consent)
Please feel free to ask for clarification if you do not understand any part of this form
Information
Considering all aspects of the mental and physical health condition of your relative Mr./Mrs./Ms ___________________________ we believe that he/she would benefit from Electro Convulsive Therapy (ECT) as a form of treatment. In this treatment, a controlled dose of electricity will be passed through the patient's head and a brief-lasting convulsion is produced. It is administered under anaesthesia so that he/she doesn't experience any discomfort. The treatment will be given in morning in a specially equipped area. The patient will be required not to eat or drink anything, including water since last night for at least 6-8 hours. To provide anesthesia, the doctors will give him/her an injection and after he/she put to sleep, they will apply a small electric current to his/her head. He/she would wake up after a few minutes. A team of doctors and nurses supervise his/her condition throughout this time. Your relative will receive ECT on alternate days or twice a week for about 2–3 weeks. We will observe him/her daily for the effects of ECT and, with your consent, decide on the number of treatments that he/she may require.
ECT is expected to improve your relative's health. It is not expected to cure his/her illness. The improvement achieved with ECT should be sustained with the help of medications, counselling (psychotherapy) and/or other treatments. We will attempt to reduce the side-effects of ECT by careful evaluation before and through the course of ECT and by adjusting your relative's medications. The side-effects are usually mild and e.g., headache and confusion for some time following ECT session. The patient may notice some lapses in memory for events around the course of ECT. Memory for the past including all he/she has learnt weeks or months before the ECT will not be affected in any major way. Overall, the advantages of ECT are expected to outweigh the risks in your relative's case.
The Information Leaflet providing more information on ECT is available. We urge you to go through it and seek clarification if you have questions. You may also discuss with us about alternative treatments suitable for your relative's case and possible course of his/her illness with and without ECT. We urge you to make a decision about ECT for your relative considering all these aspects. ECT will be administered to your relative only after you provide consent for it. You can refuse your consent now as well as withdraw it during the course of the treatment. In either case, the best available alternative treatments will be provided to your relative without any prejudice.
Information about high-risk (Strike off if not applicable): As you may be aware, in addition to the psychiatric problem for which we have suggested ECT, your relative is suffering from ................ (name of the high-risk condition/s). In this background, administration of anesthesia and ECT may have additional risks to your relative's health. The team of doctors and nurses will do their best to minimize these risks by taking appropriate precautions and measures. Please be informed that your relative's doctors have suggested ECT to him/her with the full knowledge of his/her above-mentioned condition and have consulted the anesthetists in this regard.
DECLARATION OF CONSENT FOR ECT
I have been advised that present health condition of my ___________________________________ (Relation and name of the patient) requires ECT. I have been sufficiently informed about the procedure of ECT with its benefits and possible risks. I am aware that I have the right to refuse this treatment for my relative now or at any time during the course of treatment without compromising my right to obtain all other services in the hospital. I, Mr./Mrs./Ms __________________________ (Name of the relative) hereby provide my consent for the administration of ECT to my __________________________ (Relation and name of the patient). I have received a copy of this informed consent for my record.
High-risk consent (strike off if not applicable):
I am aware that my ___________________________ (Relation and name of the patient) have ___________________________ in addition to my psychiatric condition. The doctors have explained to me that administration of anesthesia and ECT in this background may have additional risks to my relative's health and that they will be taking additional precautions and measures to minimize these risks. I hereby declare that the doctors have explained to me the additional risks involved in providing ECT to my _______________________ (Relation with the patient) and I am consenting with full knowledge of these risks.
(Signature and Name of the Relative)
(Signature and Name of the Relative)
(Signature and Name of the witness) (Preferably Nursing Staff)
(Name of the Doctor) (Doctor's signature) (Designation of the Doctor)
Date: Place:
SUPPLEMENT: 3
ECT Consent Form
(for patients after gaining competence to provide consent for ECT)
Considering all aspects of your mental and physical health, we believed that you would benefit from Electro Convulsive Therapy (ECT) as a form of treatment. Since you were unable to comprehend the information about ECT and decide regarding ECT because of your condition, your relative, ___________________________ (Name of the relative who gave consent for patient's ECT) was explained about your situation, and risks and benefits of ECT. He/she has consented for ECT. We believe that you are now in a position to understand the information regarding ECT and to make a decision about continuing this treatment.
Please feel free to ask for clarification if you do not understand any part of this form.
Information:
In this treatment, a controlled dose of electricity will be passed through your head and a brief-lasting convulsion is produced. It is administered under anaesthesia so that you do not experience any discomfort. The treatment will be done in morning in the ECT suite. You will be required not to eat or drink anything, including water, for 8 hours before the procedure. To provide anesthesia, the doctors would give you an injection and after you are put to sleep, they would apply a small electric current to your head. You would wake up after a few minutes. A team of doctors and nurses supervise your condition throughout this time. You receive ECT on alternate days or twice a week for a total of about 2–3 weeks. We observe you daily for the effects of ECT and, with your consent, will decide on the number of treatments that you may require.
ECT is expected to improve your health. It is not expected to cure your illness. The improvement achieved with ECT should be sustained with the help of medications, counselling (psychotherapy) and/or other treatments. We attempt to reduce the side-effects of ECT by careful evaluation before and through the course of ECT and by adjusting your medications. The side-effects are usually mild and e.g., headache and confusion for some time following ECT session. You might have noticed minor lapses in memory for events around the course of ECT. Memory for your past, including all you have learnt weeks or months before the ECT will not be affected in any major way. Overall, the advantages of ECT are expected to outweigh the risks in your case.
The Information Leaflet providing more information on ECT is available. We urge you to go through it and seek clarification if you have questions. You may also discuss with us about alternative treatments suitable for your case and possible course of your illness with and without ECT. We urge you to make a decision about further ECT considering all these aspects. ECT will be administered from now onwards to you only after you provide consent for it. You can refuse your consent now as well as withdraw your consent during the course of the treatment. In either case, the best available alternative treatments will be provided to you without any prejudice.
Information about high-risk (Strike off if not applicable): As you may be aware, in addition to the psychiatric problem for which we have suggested ECT, you are suffering from ................. (name of the high-risk condition/s). In this background, administration of anesthesia and ECT may have additional risks to your health. The team of doctors and nurses will do their best to minimize these risks by taking appropriate precautions and measures. Please be informed that your doctors have suggested ECT to you with the full knowledge of your above-mentioned condition and have consulted the anesthetists in this regard. And the ECTs you have received till now has not led to untoward consequences to your physical health.
DECLARATION OF CONSENT FOR ECT
I have been advised that my present health condition requires further ECT. I have been sufficiently informed about the procedure of ECT with its benefits and possible risks. I am aware that I have the right to refuse this treatment now or at any time during the course of treatment without compromising my right to obtain all other services in the hospital. I, Mr./Mrs./Ms ___________________________ (Name of the patient) hereby provide my consent for the administration of further ECT to me. I have received a copy of this informed consent for my record.
High-risk consent (strike off if not applicable):
I am aware that I have _____________________________ in addition to my psychiatric condition. The doctors have explained to me that the administration of anesthesia and ECT in this background may have additional risks to my health and that they will take additional precautions and measures to minimize these risks. I hereby declare that the doctors have explained to me the additional risks involved in providing ECT to me and I am consenting with full knowledge of these risks.
(Signature of the Patient) (Signature and Name of the relative)
(Signature and Name of the witness) (Preferably Nursing Staff)
(Name of the Doctor) (Doctor's signature) (Designation of the Doctor)
Date: Place:
SUPPLEMENT: 4
Continuation/Maintenance ECT Consent Form
(for Patient)
After examination and considering all aspects of your mental and physical condition we opine that you would require ECT (Electro Convulsive Therapy) beyond the sessions you have received to date. You would be aware of the procedure of ECT. This is to inform you again its details and to discuss about continuation of ECT.
Please feel free to ask for clarification if you do not understand any part of this form
Information
In this treatment, a controlled dose of electricity will be passed through your head and a brief-lasting convulsion is produced. It is administered under anaesthesia so that you do not experience any discomfort. The treatment will be done in morning in the ECT suite. You will be required not to eat or drink anything, including water, for 8 hours before the procedure. To provide anesthesia, the doctors would give you an injection and after you are put to sleep, they would apply a small electric current to your head. You would wake up after a few minutes. A team of doctors and nurses supervise your condition throughout this time.
Initially, ECT is given on alternate days or twice a week for a total of about 2–3 weeks. As in your situation, further ECTs would be given on possibly twice a week and gradually would be spaced out up to once a month. We would observe you regularly for the effects of ECT and, with your consent, decide on the number of treatments that you may require. Presently, the continuation of ECT is required for you as there is further scope of improvement with it and/or possibility of re-emergence of symptoms if ECT is stopped at this stage, even if medications, counselling (psychotherapy) and other required treatments are given concurrently. We hope that further ECTs would lead to a situation where improvement can be sustained with the help of other treatments.
Concurrent with your experience, the side-effects are usually mild and
e.g., headache and confusion for some time following ECT session. You might have noticed minor lapses in memory for some events around ECT. Memory for your past, including all you have learnt earlier and yours learning capacity will not be affected in any major way. Overall, the advantages of ECT are expected to outweigh the risks in your case.
The Information Leaflet providing more information on ECT is available. We urge you to go through it and seek clarification if you have questions. You may also discuss with us about alternative treatments suitable for your case and possible course of your illness with and without ECT. We urge you to make a decision about further ECT considering all these aspects. ECT will be administered from now onwards to you only after you provide consent for it. You can refuse your consent now as well as withdraw your consent during the course of the treatment. In either case, the best available alternative treatments will be provided to you without any prejudice.
DECLARATION OF CONSENT FOR ECT
Information about high-risk (Strike off if not applicable): As you may be aware, in addition to the psychiatric problem for which we have suggested ECT, you are suffering from ............... (name of the high-risk condition/s). In this background, administration of anesthesia and ECT may have additional risks to your health. The team of doctors and nurses will do their best to minimize these risks by taking appropriate precautions and measures. Please be informed that your doctors have suggested ECT to you with the full knowledge of your above-mentioned condition and have consulted the anesthetists in this regard. And the ECTs you have received till now has not led to untoward consequences to your physical health.
DECLARATION OF CONSENT FOR ECT
I have been advised that my present health condition requires further ECT. I have been sufficiently informed about the procedure of ECT with its benefits and possible risks. I am aware that I have the right to refuse this treatment now or at any time during the course of treatment without compromising my right to obtain all other services in the hospital. I, Mr./Mrs./Ms _____________________________ (Name of the patient) hereby provide my consent for the administration of further ECT to me. I have received a copy of this informed consent for my record.
High-risk consent (strike off if not applicable):
I am aware that I have _________________________ in addition to my psychiatric condition. The doctors have explained to me that administration of anesthesia and ECT in this background may have additional risks to my health and that they will be taking additional precautions and measures to minimize these risks. I hereby declare that the doctors have explained to me the additional risks involved in providing ECT to me and I am consenting with full knowledge of these risks.
(Signature of the Patient) (Signature and Name of the relative)
(Signature and Name of the witness) (Preferably Nursing Staff)
(Name of the Doctor) (Doctor's signature) (Designation of the Doctor)
Date: Place:
SUPPLEMENT: 5
Pre-ECT Evaluation and Anaesthesia Consultation Form
Name (First Middle Last Name):
Age (years): Gender:
Department: Unit:
Date of Submission:
Out-patient/In-patient (If ‘in-patient’ is selected → write Ward)
Psychiatric Diagnosis:
Medical Diagnosis:
Neurological Diagnosis:
Past history of ECT: Yes/No (If ‘Yes’ is selected → Write specific details pertaining to procedure of ECT, response to ECT and adverse effects with ECT)
Reasons for prescribing ECT (You may select multiple options)
Catatonia
Less food intake without other catatonic symptoms
Suicidal risk
Speed up response to the medications for reasons other than stated above
Inadequate response to other kinds of treatment
Intolerability to medications
Poor compliance to medications
ECT Parameter details
Electrode Placement Details (Only 1 option to be selected)
Bifrontal
Bitemporal
Right Unilateral
Pulse width (Only 1 option to be selected)
1mm
0.5mm
0.3mm
Pulse Frequency: (pps)
Medical and Neurological History (If any illness is present, mention at least its total duration, current treatment, any related surgery done in the past, and current level of control of its symptoms; following illness to be specifically marked for)
Diabetes Mellitus
Hypertension
Any cardiac illness
Hypothyroidism
Cerebrovascular accident (Infarct, haemorrhage)
Medications Prescribed
(current psychotropic and other medications for psychiatric illnesses; if any medication is in tapering mode or increasing mode, write the related details as well)
General Physical Examination (Write positive findings)
Handedness: Right/Left Weight: (kg) BMI: (kg/m^2^) BP: mm of Hg HR:/min
Airway: Mouth opening Adequate/Mouth opening restricted
Respiratory System:
Cardiovascular System:
Per Abdomen:
Central Nervous
Fundus:
Investigations
Hb: RBS: Urea: Creatinine: Na: K: ECG:
(If TFT done, write its values; If patient is on lithium or valproate, it is better to mention its serum levels; Also mention any test which has positive findings)
Suspected Pseudocholinesterase Deficiency: Yes/No; If ‘Yes’ is selected → then write details.
Anaesthesiologist:
Submitted by
(Name, Designation and Signature of the physician in-charge)