Electroconvulsive therapy (ECT) Counselling – OSCE Guide

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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 is able to consent to ECT treatment.


Opening the consultation

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 some negative comments or thoughts about ECT from patients due to media portrayal and common misconceptions.

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 put to sleep and a small amount of electrical energy is directed toward the brain which induces a controlled minor seizure. This is thought to alter chemical imbalances in the brain, therefore reducing the severity of psychological 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 antidepressants
  • Severe depressive disorder which is causing harm to the patient (e.g. associated with self-neglect/suicide risk)
  • Catatonia

Link the explanation to whichever illness the patient has.

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 2 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?

A course of ECT usually comprises of 6-12 treatments given twice weekly and the patient is reassessed after every treatment. If improvements aren’t noted after 6 sessions of ECT, the course may be stopped.

What does ECT involve?

Before ECT

Prior to ECT being performed:

  • A pre-procedure assessment is carried out by an anaesthetist.
  • The patient is required to be nil by mouth for 6 hours before the procedure (same as an operation).
  • ECT is carried out in an ECT suite. This may be in a general or psychiatric hospital setting.
  • A short-acting anaesthetic is administered by an anaesthetist.
  • A muscle relaxant (e.g. suxamethonium) is administered in order to minimise the risk of harm to the patient during convulsions.
  • The patient is attached to an EEG machine for continuous monitoring of brain activity.

During ECT

ECT is carried out by a psychiatrist and can be delivered unilaterally or bilaterally:

  • A unilateral ECT electrode is placed on the non-dominant hemisphere of the brain. Unilateral ECT is generally associated with fewer side effects but is less effective than bilateral ECT, therefore, more treatments are required at an increased frequency.
  • Bilateral ECT is more commonly used due to increased efficacy. Two electrodes are placed on either side of the temples.

A small amount of electrical energy is directed through the electrodes towards the brain. The electrical charge lasts around 5 seconds.

The electrical energy to the brain induces a controlled seizure which lasts around 20 seconds. Evidence of this may include visible muscle contractions/spasms and eyelid fluttering. Often the seizure is not visible clinically and can only be identified on the EEG.

After ECT

When ECT is complete the patient will wake up in the recovery room having no 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, nurses and anaesthetists 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
  • 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. Some patients have symptoms that may persist. Long-term memory loss is rare.


Risks

The main risks involved with ECT are related to the use of a general anaesthetic (e.g. airway issues).

There is a small risk that the patient will not respond to the treatment.


Closing the consultation

Summarise the key points back to the patient.

“Today we have discussed ECT, an alternative treatment for your depression. I think this treatment option is something you should consider, 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 chemical imbalance 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.


Further information

Capacity and ECT

The information below refers to England and Wales, other countries will have differing guidance on this matter. 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.

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) is required to assess and agree that ECT is appropriate.

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

  • understand the treatment
  • retain the information given in order to be able to make a decision about treatment
  •  weigh up the risks and benefits of treatment
  • communicate back a decision regarding treatment

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. A patient may withdraw from ECT treatment if they regain the capacity to refuse treatment, even if they lacked capacity when starting ECT treatment.


 

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