Electroconvulsive therapy (ECT) Counselling – OSCE Guide

Electroconvulsive therapy (ECT) counselling is a common OSCE topic in psychiatry scenarios. It often includes dealing with a patient’s concerns about treatment and being able to answer questions in a sensitive, but informative manner. This guide provides a structured approach to explaining ECT treatment in an OSCE setting. For the purposes of this scenario, the patient has treatment-resistant depression and can consent to ECT treatment.

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Explain the reason for the consultation: “I understand that you have a diagnosis of depression and have not noticed any benefit from several different types of antidepressant medications. I am here today to discuss an alternative treatment, called electroconvulsive therapy (ECT), that we feel may be beneficial.”

Assess the patient’s understanding

Ideas

“Have you heard of ECT before?” “What do you know about this treatment?”

Be prepared for negative comments or thoughts about ECT from patients due to media portrayal and common misconceptions. Some patients may refer to it by the old term “electroshock therapy”.

Concerns

“What is it that concerns you the most about ECT?”

Offer to address the patient’s concerns during the consultation.

Expectations

“I would like to give you some more information about ECT. I will discuss why it is used, what happens during treatment and the benefits and risks of treatment. If you have any questions at any point please feel free to ask. Is there anything else you would like me to cover today?”

Explanation of ECT

What is ECT?

“Electroconvulsive therapy, also known as ECT, is a psychiatric treatment in which a patient is briefly put to sleep with a general anaesthetic, and a small amount of electrical energy is directed towards the brain through electrodes on the forehead which induces a controlled, small, brief seizure. Medication is given to relax the muscles so the seizure activity in the body muscles is minimised. The patient is closely monitored throughout, and it is so brief that there is no need for the patient to be intubated. The treatment is thought to reorganise the networks in the brain that are disordered in mental illness.”

At this point, acknowledge cues from the patient’s concerns – reassure the patient that they will be put to sleep for ECT and that you can provide more information to put their mind at ease.

What is ECT used for?

Electroconvulsive therapy is a treatment for severe psychiatric illnesses, including:

• Severe depression, which is resistant to multiple therapies and antidepressants
• Severe depressive disorder which is causing harm to the patient (e.g. associated with self-neglect/reduced diet and fluid intake/suicide risk)
• Catatonia
• Severe or ongoing mania

Link your explanation to whichever illness the patient has.

Often, patients are in hospital due to the severity of their mental illness when ECT is required, but it is possible for patients to have ECT from the community when their condition allows.

What are the potential benefits of ECT?

It is one of the most effective treatments for severe depression (70-80% response rate).

Most patients will experience improvements within two weeks.

ECT can have a synergistic effect when used in conjunction with antidepressants to help stabilise mood.

How many sessions does a course of ECT involve?

ECT usually comprises twice-weekly treatment for a course of 6-12 sessions at a time.

The patient is reassessed after every treatment and may stop before the end of a course or continue to have ongoing courses depending on clinical presentation. It is not possible to predict how a patient will respond and how many sessions they will require. There does not appear to be a correlation with illness severity.

Some patients may deteriorate when ECT stops and may benefit from maintenance ECT, which is given at longer intervals apart, usually weekly, then fortnightly, then eventually monthly. This tends to be given for longer periods and can continue indefinitely if it continues to be beneficial.

What does ECT involve?

Before ECT

Prior to ECT being performed:

• ECT is carried out in an ECT suite. This may be in a general or psychiatric hospital setting.
• The patient is required to be nil-by-mouth for 6 hours before the procedure (same as an operation).
• An anaesthetist carries out a pre-procedure assessment.
• A psychiatrist will assess the mental health act and capacity status of the patient and ensure appropriate paperwork has been completed.
• The patient is attached to an EEG machine for continuous monitoring of brain activity. Physical observations will also be monitored throughout.
• A short-acting anaesthetic is administered by an anaesthetist.
• A muscle relaxant (e.g. suxamethonium) is administered to minimise the risk of harm to the patient during convulsions. A mouthguard is also used to prevent damage to teeth or the tongue and mouth lining during convulsions.

During ECT

ECT is carried out by a psychiatrist and can be delivered unilaterally or bilaterally. Bilateral ECT is more commonly used due to increased efficacy. An electrode is placed on the two temples, and electrical energy is applied to the whole brain. Ultrasound jelly is used to ensure good contact with the skin.

If there are concerns about pre-existing memory difficulties or the treatment is impacting the patient’s memory as a side effect, unilateral ECT may be used where the electrical energy is only applied to the non-dominant hemisphere of the brain by placing one of the electrodes on the back of the head. This is less effective than bilateral ECT.

A small amount of electrical energy is directed through the electrodes towards the brain. This begins at a low dose with the aim of using the smallest amount of current possible. The electrical charge lasts around 5 seconds.

The electrical energy to the brain induces a controlled seizure. The clinicians should see motor activity for over 15 seconds for the treatment (visible muscle contractions/spasms) to be considered successful. The EEG is likely to continue showing activity after the motor activity has finished, and this will be monitored until all seizure activity on the EEG has stopped.

If the seizure continues for over 180 seconds, it is considered prolonged and will be terminated by benzodiazepines. If the treatment is unsuccessful (seizure activity is not adequate), a further two administrations of electrical current can be given, with an increased dose each time. If three administrations have been given without adequate response, no further administration can be given during the session, but the dose will be increased at the next session.

After ECT

When ECT is complete the patient will wake up in the recovery room without memory of the procedure. They may experience some side effects, as outlined below, but these should be short-lived.

“You will be put to sleep under general anaesthetic by an anaesthetist, so you will not be aware of the treatment being delivered. You will be given a muscle relaxant to avoid any harm to your body during the procedure.”

“Two electrodes will be placed on the sides of your head and a doctor will pass a small electric current through these, for a few seconds. Your body might react by having a minor seizure, or we may only see the effect of the electrical energy on a brain tracing that you will be hooked up to for monitoring throughout.”

“After the treatment, you will wake up in the recovery room. There will be a team of very experienced doctors and nurses looking after you.”

Side effects

Emphasise that not everyone will experience side effects, but you have to fully inform the patient before gaining consent for the procedure.

Common side effects include:

• Short-term memory loss
• Retrograde amnesia (memory loss immediately before/after ECT)
• Post-ECT headache, which often resolves with simple analgesia
• Post-ECT muscular aches
• Brief confusion/drowsiness following administration of the anaesthetic

Side effects are usually mild, and most patients return to baseline cognitive ability after a course of treatment has finished. Cognition will be formally assessed regularly throughout treatment. Some patients have symptoms that may persist. Long-term memory loss is rare.

Risks

The main risks involved with ECT are related to using a general anaesthetic (e.g. airway issues, reaction to the anaesthetic, dental damage). There is a small risk of prolonged seizure.

There is a small risk that the patient will not respond to the treatment. Risks need to be balanced against the benefits of treatment.

There are no absolute contraindications to ECT, but the patient must be fit enough for the anaesthetic, and relative contraindications are as follows:

• Recent myocardial infarction or stroke
• Increased intracranial pressure
• Active bleeding
• Retinal detachment

Closing the consultation

Summarise the key points back to the patient.

“Today we have discussed ECT, an alternative treatment for your depression. We recommend this treatment option, given that the antidepressant medications you have tried have not resulted in any improvement in your mood. We know that ECT can help approximately 70-80% of people with the type of depression that you have.”

“You will probably require multiple treatments in order to help stabilise your mood.”

“You would be put to sleep for each procedure, which would involve placing electrodes on either side of your head and passing electrical energy to your brain. The aim is to alter the networks in your brain in your brain, which is a factor underlying your depression.”

“You may have a mild headache or notice some short-term memory loss following the treatments, but this should not persist or affect you in the long term.”

Ask the patient if they have any questions or concerns that have not been addressed.

“Do you understand everything we have discussed?”

“Do you have any questions for me?”

Offer the patient a leaflet with further information about ECT:

“We’ve covered a lot of information today and it’s likely that you’ll think of some questions in the coming days, which I’d be happy to answer at our follow up appointment. Here is a leaflet which outlines the main points we have discussed and offers further information on the subject for you to read at home.”

Arrange a follow-up appointment including the offer of a visit to the ECT suite if possible.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Further information

Capacity and ECT

The information below refers to England and Wales. Other countries will have differing guidance. A patient has the right to refuse ECT treatment if they have the capacity to make this decision, even whilst they are detained under the Mental Health Act. Capacity should be assessed before every treatment session. Patients may withdraw from ECT treatment if they regain the capacity to refuse treatment, even if they lacked capacity when starting ECT treatment.

For a patient to be considered to have capacity, they must be able to:

1. Understand the treatment
2. Retain the information given to be able to make a decision about treatment
3. Weigh up the risks and benefits of treatment
4. Communicate a decision regarding treatment

If a patient requires ECT treatment and is so unwell that they lack the capacity to consent, ECT may be administered under the Mental Health Act. In this scenario, a second opinion doctor (SOAD) must assess and agree that ECT is appropriate.

If SOAD agrees that the patient lacks capacity and treatment is in their best interests, ECT can be administered under section 58A of the Mental Health Act.

If a person lacks the capacity to consent and ECT is required urgently, a section 62 for the provision of emergency treatment “which is immediately necessary to save a person’s life or prevent serious deterioration” may be used, to allow the patient to have emergency ECT treatment whilst waiting for an independent assessment from a SOAD.