ECT Manual

Licensing, Legal Requirements

and Clinical Practice Guidelines

Aged, Community and Mental Health

 ECT Manual—Licensing,
Legal Requirements and
Clinical Practice Guidelines

Mental Health Branch

Aged, Community and Mental Health Division
Department of Human Services
January 2000
Acknowledgments
Published by the Aged, Community and Mental
Health Division, Victorian Government Department
of Human Services.

Melbourne, Victoria

January 2000

(1460599)

© Copyright State of Victoria 2000

Foreword

Guidelines for the practice of electroconvulsive therapy (ECT) in Victoria were first published in June 1991.
Since that time there has been significant growth in our knowledge about ECT, advances in the available
technology and major changes to the environment in which mental health services are delivered.

Most importantly, changes to the legislation in 1995 required that all services performing ECT must now be
licensed. Licensing provides a uniform mechanism by which the Department can establish minimum
standards for the provision of ECT and enhance consumer and public confidence in its administration. This
change has led service providers to seek guidance from the Department about its requirements.

At a broader level, the National Mental Health Strategy has encouraged the mainstreaming of mental health
services with the general health system, a shift in the balance towards greater community-based treatment,
an increasing emphasis on standards and a renewed focus on patient rights. These major changes have all
had an impact on the prescription and practice of ECT.

These revised guidelines reflect all these changes and are intended to be a primary reference document for
the performance of ECT. They set the requirements for the licensing of premises for the performance of ECT,
outline the minimum standards for resources and equipment and provide practical clinical guidelines for
staff who prescribe or are involved in the administration of ECT.

I would like to thank the members of the ECT reference group and other senior clinicians from both the
public and private sectors who contributed their time, knowledge and advice to the development of these
guidelines.

I am confident these guidelines will be a valuable resource for both clinicians and administrators to guide
the development of local practices to ensure that ECT is used effectively and safely to optimise the best
possible treatment outcome for people with a mental disorder.

Associate Professor Norman James

Chief Psychiatrist

iii
Contents

Foreword iii
Part A—Introduction 1
Background 1
Purpose 1
Definitions 2
Part B—Licensing 3
Administration 3
Application for a Licence [section 75] 3
Cancelling a Licence [section 76(2)] 4
Renewal of Licence [section 77] 4
Amendment of Licence [section 78] 5
Review of Decisions [section 79] 5
Part C—Resources and Equipment 7
Building Design 7
Equipment 8
Staffing 8
Training and Education 10
Quality Improvement 10
Record Keeping 11
Part D—Clinical Practice Guidelines 13
Decision to Prescribe ECT 13
Legislation 13
Preparation for ECT 13
Informed Consent 14
Passive Consent 14
Consent by Other People 15
Consent by the Authorised Psychiatrist 15
Urgently Needed ECT 16
Penalties for Performing ECT Without Informed Consent 16
Confidentiality 16
Prescription of ECT 16
Administration of Anaesthetic 17
Stimulus Parameters and Seizures 17
Recovery 18
Monitoring Clinical Response 18
Privacy 18
ECT on an Outpatient Basis 18
Part E—Criteria for Licensing ECT Premises 21
Suitability of the Applicant to Hold a Licence [section 75(5)(a)] 21
The Suitability of the Premises [section 75(5)(b)] 21
Suitability of Equipment to be Used in the Performance of ECT [75(5)(c)] 21
Suitability of Qualifications of Persons Performing ECT [75(5)(d)] 22
Part F—Appendices 23
Appendix 1: Sample Information Sheet—Additional Information for Patients Receiving ECT as Outpatients 23
Appendix 2: Schedule 17—Application for Licence to Permit the Performance of Electroconvulsive Therapy 24
Appendix 3: Schedule 18—Licence Authorising Performance of Electroconvulsive Therapy 25
Appendix 4: Schedule 19—Application for Renewal of an Electroconvulsive Therapy Licence 26
Appendix 5: Schedule 20—Application for Amendment of an Electroconvulsive Therapy Licence 27
Appendix 6: Schedule 21—Electroconvulsive Therapy Return 28
Appendix 7: Informed Consent to Electroconvulsive Therapy —ECT) (PSY 16) 29
Appendix 8: Authority to Perform Electroconvulsive Therapy (ECT) Where Informed Consent Not Obtained (PSY 17) 30
Appendix 9: Royal Australian and New Zealand College of Psychiatrists—Electroconvulsive Therapy Explained 31
Appendix 10: Royal Australian and New Zealand College of Psychiatrists—Clinical Memorandum #12: 34
Electroconvulsive Therapy
References 51

v
Part A—Introduction
Background
Electroconvulsive therapy (ECT) is a procedure
performed under general anaesthesia and muscle
relaxation in which modified seizures induced by
the selective passage of an electrical current through
the brain are used for therapeutic purposes. ECT is
most commonly prescribed for the treatment of
severe depression, but may also be used for other
types of serious mental illness such as mania,
schizophrenia, catatonia and other neuropsychiatric
conditions. It is most often prescribed as part of a
treatment regime in combination with other
therapies.
Convulsive therapy was first administered early this
century following studies by Ladislaus von Meduna
as a method of relieving the symptoms of mental
illness. In 1938 the first machine was developed by
Cerletti and Bini to produce electrically induced
seizures. This replaced chemically induced seizures
and the treatment first came to be called
‘electroshock’ therapy.
Representations of ECT in popular culture have
been frightening and have had a negative public
impact. However, there have been significant
advances in the technology and knowledge about
ECT over recent years and studies support its use as
a safe and effective psychiatric treatment. Guidelines
to clinical practice published by organisations such
as the Royal Australian and New Zealand College of
Psychiatrists and the Australian and New Zealand
College of Anaesthetists (ANZCA) have contributed
to the high standards now associated with the
treatment.
Government regulation has also played a major role
in setting standards for the performance of ECT. The
Mental Health Act 1986 contains detailed legislative
provisions regulating consent to treatment. The Act
defines the elements of informed consent and
strictly prescribes the circumstances and the
requirements when ECT may be performed without
informed consent. The Act also establishes a
framework for licensing of premises.
Licensing provides a tool by which standards can be
set and monitored while providing a ready
mechanism for responding to concerns, for example,
by placing a specific condition on a licence.
Licensing also acts to enhance consumer confidence
in ECT. The nature of ECT and the history
associated with it means that some patients may
experience distress or fear when it is proposed as an
appropriate treatment. In making an informed
choice, patients are limited in their ability to obtain
information about the quality of available services.
Licensing provides assurance to patients that a
service and the practitioners performing ECT meet
established standards.
Legislation, licensing, guidelines, new technology
and advances in clinical knowledge all act to ensure
that ECT is used in a safe and effective manner and
in a way that is respectful of the person’s rights,
privacy, dignity and self-respect.
Purpose
ECT is an important treatment in modern
psychiatric practice. It is essential that it is
administered properly at premises which have been
licensed to perform ECT.
The purpose of this document is to:
• Provide guidelines, minimum standards and
information about the prescription, practice and
procedures relating to the performance of ECT.
• Set minimum standards for staffing, facilities and
equipment relating to the performance of ECT.
• Prescribe key criteria by which premises will be
assessed for a licence.
As such it is intended to assist service planning by
hospital management, guide the clinical practice of
medical and nursing staff and provide information
for Department of Human Services staff
administering the licensing procedure. The
document may also have a broader educative role
for consumers, carers and other members of the
community about the performance of ECT.
1
Definitions
Approved Course in ECT
This is a training course in the contemporary use of
ECT approved from time to time by the Chief
Psychiatrist.
Approved Mental Health Service
An approved mental health service is premises or a
service proclaimed to be an ‘Approved Mental
Health Service’ under section 94 of the Mental
Health Act.
Authorised Psychiatrist
An authorised psychiatrist is a qualified psychiatrist
appointed as the Authorised Psychiatrist under
section 96 of the Mental Health Act. For the purpose
of this document the term Authorised Psychiatrist
includes their delegate.
Clinical Director (ECT)
Clinical Director (ECT) means a qualified
psychiatrist appointed to have overall clinical
responsibility for ECT at the licensed premises, and
who has undertaken an approved course in ECT.
Premises
Premises means an individual hospital or a campus
of a hospital group or network. The premises may
encompass one or more treatment suites at each
hospital or campus.
Registered Medical Practitioner
Registered medical practitioner means a registered
medical practitioner within the meaning of the
Medical Practice Act 1994.
Registered Nurse
Registered nurse means a nurse whose name is
included in Division 1 or 3 of the register of nurses
kept under Part 2 of the Nurses Act 1993.
Senior Clinical Nurse (ECT)
Senior Clinical Nurse (ECT) means a registered
nurse appointed to have ongoing management
responsibility for coordination of nursing staff and
direct management of the ECT suite and who has
undertaken an approved ECT course.

Course of ECT
A course of ECT is up to six treatments given over a
period with not more than seven days elapsing
between any two treatments. The course is deemed
to be finished if more than seven days elapses
between any two treatments. Further treatment will
need a new consent. One course may immediately
follow another.

Key Licensing Criteria

Key licensing criteria means the criteria developed
by the Department of Human Services by which
premises will be assessed for a licence (see part E).

Occupier
The Occupier of any premises means the body
corporate of the health service.

2
Part B—Licensing
Licensing of ECT premises is fundamental to the
regulation of standards under the Mental Health
Act. ECT may only be performed at premises
licensed for the performance of ECT. This
requirement applies to both public and private
services.
The Mental Health Act provides for inspection of
premises and regulates the suitability of the licence
holder, the standards and conditions of premises
and equipment, and the qualifications of the persons
permitted to perform ECT. The Mental Health Act
defines the elements of informed consent and
strictly prescribes the circumstances and the
requirements when ECT may be performed without
informed consent. The Mental Health Act also
provides penalties in the case of poor practice,
including the revocation of a licence.
The Mental Health Regulations 1998 accompany the
Mental Health Act and their role is to operationalise
the Act. In particular they prescribe the various
forms and fees associated with the licensing of ECT.
Administration
Under the Mental Health Act all the powers, duties
and functions relating to licensing of premises are
assigned to the Secretary to the Department of
Human Services. In practice, all such duties are
performed by the Chief Psychiatrist, under a
delegation made by the Secretary.
All enquires about licensing of premises to perform
ECT should be directed to the Chief Psychiatrist.
Application for a Licence [section 75]
The occupier of any premises may apply to the
Chief Psychiatrist for a licence to perform ECT. In
most cases the Chief Executive of the premises will
make the application on behalf of the Occupier. The
application is to be made in the form of Schedule
17—Application for Licence to Permit the Performance of
Electroconvulsive Therapy (see appendix 2) and a floor
plan of the premises indicating all suites/areas
where ECT is to be performed must be attached. The
floor plan will be incorporated to become part of the
ECT licence. The premises may encompass one or
more treatment suites at each hospital or campus.
For example, a hospital may have a dedicated ECT
suite and an operating suite at which ECT will be
occasionally performed. In such a case, both suites
should be included in the floor plan.
In circumstances where an occupier operates
services from a number of different campuses, an
application for a licence must be made for each
campus.
Enclosed with the application must be the
prescribed application fee. The fee is an
administration fee and will not be refunded if a
licence is not approved.
Inspection
Each service must be inspected before a licence can
be approved. A qualified psychiatrist, a registered
nurse and other staff nominated by the Chief
Psychiatrist will conduct the inspection.
Personnel representing the occupier at the
inspection should be familiar with the premises and
be able to provide information to address the key
licensing criteria. The personnel could include the
Medical Director, the Clinical Director (ECT) and the
Senior Clinical Nurse (ECT).
Inspection Report and Recommendation
Following inspection, a nominated member of the
inspection team will prepare a report for the Chief
Psychiatrist, addressing the key licensing criteria
and making a recommendation. Options are:
• Recommended.
or
• Qualified recommendation, subject to specific
conditions being met. It must propose such terms
and conditions as are necessary to ensure the
service meets the key licensing criteria.
or
• Not recommended. Where an application is not
recommended, a statement of reasons will be
provided.
Licence Approval
The Chief Psychiatrist determines the application.
The decision will be based on the inspection report
and the key licensing criteria. The Chief Psychiatrist
may seek further information as necessary.
Licence Documentation
3
The licence is prepared in the form of Schedule 18—
Licence Authorising Performance of ECT (see appendix
3) and details the following information:
• The licence holder.
• The name of the service.
• The address of the premises.
• The period of the licence which may be for a
period of up to five years.
• The licence number.
• A plan of the premises showing all areas/suites
where ECT can be performed, contained in
Attachment A.
• The terms and conditions to be attached to the
licence, contained in Attachment B.
Attachment B to the licence lists the terms and
conditions of the licence. Standard conditions of the
licence that the licence holder must observe are to:
• Allow the Chief Psychiatrist or nominee to visit
and inspect any part of the licensed premises.
• Allow the Chief Psychiatrist or nominee to
inspect and make copies of any documents kept
at the premises relating to the regulation and
performance of ECT.
• Provide the Chief Psychiatrist or nominee with
any reasonable assistance in the performance of
any duties or functions relating to the regulation
and performance of ECT.
reasons. As a general principle, consultation with
the licence holder will occur before a licence is
cancelled. Other options such as imposing a specific
condition or limitation will be considered.
In accordance with section 79 of the Mental Health
Act, any person who disagrees with any decision of
the Chief Psychiatrist may apply to the Victorian
Civil and Administrative Tribunal for a review of
the decision.
Renewal of Licence [section 77]
The Mental Health Act places the onus on the holder
of a licence to apply to the Secretary to the
Department of Human Services for the renewal of a
licence. To assist licence holders, a notice of renewal
will be sent to the licence holder about two months
before the licence expires.
An application for renewal must be made in the
form of Schedule 19—Application for Renewal of an
ECT Licence (see appendix 4). Enclosed with the
application must be the prescribed application fee
which is an administration fee and will not be
refunded if the licence is not renewed.
The Chief Psychiatrist must renew the licence unless
any of the grounds for cancelling a licence in section
76 of the Mental Health Act apply.

Cancelling a Licence [section 76(2)] Renewal Procedures

The Chief Psychiatrist may cancel a licence if On receipt of the application for renewal and the
satisfied that: prescribed fee, the procedure for renewal will be
implemented. This parallels the procedure for
• There has been a breach of any of the terms or
making a new licence. A service will be inspected
conditions attached to the licence.
and a report will be prepared in accordance with the
or
procedures set out in the earlier part of these
• An offence under section 73 of the Mental Health
guidelines. However, the Chief Psychiatrist may
Act (relating to the requirement to obtain
renew a licence without an inspection of premises if
informed consent) has been committed.
satisfied that the relevant criteria have been met.
or
• The premises are no longer suitable. Licence Approval
or
The Chief Psychiatrist will determine the application
• Equipment on the premises does not comply
based on the key licensing criteria. The renewed
with the prescribed standards and conditions.
licence is issued in the form of Schedule 18—Licence
or
Authorising Performance of ECT (see appendix 3).
• An unqualified or insufficiently qualified person
has been performing ECT on the premises.
Cancellation must be in writing and will give

4
Licence Not Approved
Where an application for renewal is not approved,
the Chief Psychiatrist will notify the applicant in
writing and enclose a statement of reasons.

Amendment of Licence [section 78]

The Chief Psychiatrist may amend a licence by
revoking or varying any of the conditions or by
inserting a new condition or conditions.

The holder of a licence may also apply to the

Secretary for the licence to be amended in the form
of Schedule 20—Application for Amendment of an
Electroconvulsive Therapy Licence (see appendix 5).
There is no fee to have a licence amended.

An amendment will be considered in accordance

with the key licensing criteria. An inspection of the
premises may be necessary at the discretion of the
Chief Psychiatrist. If an amendment is made, a new
licence in the form of Schedule 18—Licence
Authorising Performance of ECT, incorporating the
amendment(s), will be prepared.

If an application for amendment is not approved,

the Chief Psychiatrist will notify the applicant in
writing and enclose a statement of reasons.

Review of Decisions [section 79]

Fundamental to the application of these guidelines
are the principles of communication and
cooperation. Any person who feels aggrieved about
any decision is encouraged to resolve the problem
by communicating with the Chief Psychiatrist. In
accordance with section 79 of the Mental Health Act,
any person who disagrees with any decision of the
Chief Psychiatrist may apply to the Victorian Civil
and Administrative Tribunal for a review of the
decision.

5
Part C—Resources and Equipment
Building Design
Section 75(5)(b) of the Mental Health Act requires
that the Secretary to the Department of Human
Services consider the suitability of the premises at
which ECT is to be performed before issuing a
licence. The Chief Psychiatrist or a nominee will
inspect the premises to determine the suitability.
Licences may be issued for dedicated ECT suites,
theatre suites or multi-purpose treatment suites.
Dedicated ECT Suite
A dedicated ECT suite requires three separate
rooms: a waiting room, a treatment room and a
recovery room. A fourth room or area, to serve as a
recovery lounge where food and beverages are
provided, is desirable, particularly at services which
provide ECT as a day procedure.
All rooms will be linked internally by doors and
each room will preferably have a door opening onto
a corridor. Tipping trolleys, not beds, must be used
in both the treatment and recovery rooms. Internal
and external doorways must be wide enough to
allow trolleys to pass through.
All rooms should be of sufficient size to
accommodate the rate and number of patients
treated per session at the licensed premises. As a
general guide, the minimum space required for each
room is:
• Waiting Room.......................12m2
• Treatment Room...................18m2
• Recovery Room....................12m2
• Recovery Lounge .................12m2
In services where the number of patients receiving
ECT is small, the requirement for a separate waiting
room may be waived. Services may consult with the
Chief Psychiatrist to determine specific
requirements.
The treatment room should contain a stainless steel
sink and drainer and scrub-up basin. A set-up bench
and cupboards for the storage of sterile supplies,
linen, instruments and equipment should also be
provided in or adjacent to the treatment room.
The treatment room must have provision for a
separate, lockable but accessible area for the storage
and preparation of medication, including the
emergency trolley. Adequate reserves of oxygen
must be available in both the treatment and
recovery rooms. An emergency cylinder supply of
oxygen must be available.
The treatment room and the recovery room must
have appropriate lighting for the clinical observation
of patients. Emergency lighting must be available.
There must be a telephone/intercom to
communicate with persons outside the suite in an
emergency.
There must be access to adequate toilet facilities.
While the treatment room will generally only be
used for the performance of ECT, to ensure a better
use of resources the other rooms may at other times
be used for other purposes. For example, the
waiting room may be used as an interview room
and the recovery area as a group room.
Multi-Purpose Treatment/Recovery Suite
ECT may be performed in a multi-purpose
treatment/recovery suite, for example, a day
procedures unit. The suite should preferably be
within reasonable proximity to the psychiatric unit
to ensure access to appropriate equipment and staff
expertise.
The requirements for a multi-purpose
treatment/recovery suite are the same as for a
dedicated suite.
Operating Suite
ECT may be performed in an operating theatre suite
if the patient’s privacy, confidentiality and safety
needs can be assured and ECT is scheduled at
regular and appropriate times that meet patients’
needs. The use of an operating suite may be
indicated when the anaesthetist believes that a
patient with a serious medical condition requires
immediate access to superior resuscitation and
emergency treatment options.
Services which have operating suites and which
may wish to have them licensed should submit floor
plans of these suites to be included in the licence.
7
Privacy
Patients should be protected from unnecessary
observation by other people while ECT is being
performed and during the recovery period. The
layout of the recovery room should facilitate
privacy; in particular, to prevent observation of
patients by other patients.
Internal partitions or curtains in the recovery room
must not, however, prevent observation and
supervision of the recovery of patients.
Equipment
Section 75(5)(c) of the Mental Health Act requires
that the Secretary to the Department of Human
Services, in considering an application for a licence,
must consider whether the equipment to be used in
the performance of ECT complies with the
prescribed standards and conditions.
Equipment means all equipment used during the
performance of and recovery from ECT, however,
primary emphasis is placed on the following:
• The ECT machine.
• Anaesthetics equipment.
• Resuscitation equipment.
• Emergency drug supplies.
ECT Machine
The ECT machine must:
• Be listed with the Therapeutic Goods
Administration.
• Provide electroencephalogram (EEG) monitoring
and recording of the duration of the seizure.
• Permit a charge of up to 1000 mC to be given.
• Be able to give stimulus dose titrated ECT.
Anaesthetic and Resuscitation Equipment
Anaesthetics equipment, resuscitation equipment
and emergency drug supplies must meet the
standards articulated in ANZCA’s policy document
Recommended Minimum Facilities for Safe Anaesthetic
Practice for Electroconvulsive Therapy (ECT) (revised
1994).
8
Checking, Cleaning, Infection Control and
Servicing Equipment
Regular checking, cleaning, sterilising, and
housekeeping routines for the care of equipment
should be established. A documented infection
control policy must be implemented and subjected
to periodic evaluation. Emergency resuscitation
equipment should be tested and checked weekly.
Complete and comprehensive registers must be kept
of:
• Six-monthly maintenance and servicing checks of
anaesthetic and emergency equipment.
• Regular monthly checks and replacement of out-
of-date anaesthetic and emergency drugs.
A review of anaesthetic and emergency drugs kept
in the ECT suite should be conducted by a Specialist
Anaesthetist every 12 months.
ECT machines must be kept in working order and
be serviced at least once a year. The ECT electrodes
should be visually checked weekly.
A service register must be kept. The register must
include details of the date, the name of the service
company and technician, the result of the check and
any action taken.
Staffing
The significant advances in technology and the
knowledge about ECT over recent years have made
it a very effective treatment for some forms of
mental illness. It is therefore imperative that this
knowledge informs the practice of ECT to ensure
that it is delivered in a safe and effective manner.
The Chief Psychiatrist therefore requires that each
licensed premises appoint a qualified psychiatrist as
Clinical Director (ECT) and a senior registered nurse
as Senior Clinical Nurse (ECT). This will facilitate
improvements in ECT practice and patient
outcomes.
Clinical Director ECT
This person will be thoroughly familiar with current
scientific literature on ECT and will have completed
an approved ECT course. The Clinical Director ECT
will have overall clinical responsibility for the ECT
suite including:
• Development, implementation and evaluation of
policies, procedures and standards in relation to
the performance of ECT.
• Training and privileging medical staff who
prescribe and/or administer ECT. To maintain an
appropriate level of skill in the performance of
ECT, the Clinical Director (ECT) might consider
limiting the number of practitioners accorded
privileges in ECT at the licensed premises. This
will enable these practitioners to have regular
experience and develop expertise.
• Maintaining a register of medical staff privileged
to perform ECT at the licensed premises. The
register should keep a record of the number of
treatments performed by individual practitioners
in each year.
• Ensuring all psychiatrists, psychiatric registrars
and medical officers are adequately supervised in
the administration of ECT.
• Conducting quality improvement programs.
ECT Administration
Two registered medical practitioners must be
present at all times when ECT is administered.
One registered medical practitioner must be trained
and experienced in the administration of ECT. This
may be achieved either by the practitioner attending
an approved ECT course or by being personally
trained by a medical practitioner who has done so.
The practitioner must be familiar with the
indications and side effects of the treatment, the
procedures and equipment required and anaesthetic
emergencies and resuscitation procedures. The
practitioner must maintain their level of skills in the
administration of ECT. To demonstrate this it is
expected that practitioners will be administering at
least 25 treatments per year. The practitioner must
also be proficient in cardiopulmonary resuscitation
techniques.
The other registered medical practitioner must be a
Specialist Anaesthetist or, in the absence of a
Specialist Anaesthetist, a registered medical
practitioner accorded privileges in anaesthesia at the
licensed premises in accordance with the ANZCA’s
policy document Privileges in Anaesthesia.
The anaesthetist should have training and
experience in anaesthesia for ECT. Where
anaesthetic registrars are administering the
anaesthetic, adequate supervision and support must
be provided by a specialist anaesthetist.
Senior Clinical Nurse ECT
This person will be thoroughly familiar with current
scientific literature on ECT and will have completed
an approved ECT course and a cardiopulmonary
resuscitation course. The Senior Clinical Nurse
(ECT) will be responsible for the management of the
ECT suite including:
• Development, implementation and evaluation of
nursing standards, policy, practices and
procedures for ECT.
• Coordination and training of nursing staff
including student nurse training.
• Liaison with anaesthetic services.
• Ensuring that appropriate staffing, equipment
and supplies are available.
• Establishing regular checking, cleaning,
sterilising and housekeeping routines for the care
of equipment.
• Ensuring that the recording and reporting
requirements for ECT are met.
• Quality improvement activities.
• Maintenance of a CPR Training Register.
Nursing Staff
All nursing staff must have the necessary training
and experience to enable them to perform the
various roles required in the ECT suite. There
should be a core team of nurses who work in the
ECT suite on a regular basis for the purpose of
continuity. One registered nurse with recent training
in providing assistance to an anaesthetist is to be
responsible for coordinating the delivery of nursing
care at each session.
Nursing staff numbers required to ensure adequate
standards of practice will depend on the number of
patients to receive treatment. As a minimum
requirement there must be :
• A nurse, on Division 1, 2 or 3 of the register of
nurses kept under Part 2 of the Nurses Act 1993,
in constant attendance on patients in the waiting
area. This nurse will provide appropriate
physical and psychological preparation of
9
 patients for ECT and ensure that all
documentation is in order. It may also be helpful
for a patient’s individual case manager to be
present throughout the procedure.
• A registered nurse competent in resuscitation
methods available wholly and exclusively to
assist the anaesthetist in accordance with
ANZCA’s policy document Minimum Assistance
Required for the Safe Conduct of Anaesthesia, except
for the ‘Course of Instruction’ requirements
stated in 3.2 of the document.
• A registered nurse with recent training in
resuscitation and CPR procedures must be in
constant attendance on patients in the recovery
area after the administration of ECT.
Training and Education
Policies and Procedures
The Clinical Director (ECT) must ensure that there
are written policies, procedures and standards for
the performance of ECT at the premises. The
policies must be implemented and subjected to
periodic evaluation. All clinical staff should have
access to and be familiar with the policies and
procedures.
Training Programs
All medical staff involved in the administration of
ECT are expected to have theoretical and practical
training before administering ECT. The Clinical
Director (ECT) is responsible for the ongoing clinical
supervision of medical staff administering ECT. The
Clinical Director should provide or make provision
for an educational program for all staff concerned in
the administration of ECT. Training programs should
be regularly updated to provide the best possible
treatment in the light of current research evidence
and new technologies and techniques. ECT reference
material should be available and regularly updated.
A record of medical and nursing staff trained in the
practice of ECT should be maintained and regularly
updated as part of a quality improvement program.
ECT Machine
The Clinical Director (ECT) must have completed an
approved course in the use of the ECT machine.
This expertise may be taught to other medical staff
10
at the licensed premises who prescribe and/or
administer ECT. The Senior Clinical Nurse (ECT)
must also complete the course and may train other
nurses. However, medical and nursing staff who are
trained by persons who have completed an
approved course cannot in turn train others.
CPR Training
All nursing staff must have undertaken an approved
course in cardiopulmonary resuscitation techniques
and must update their training at 12-monthly
intervals. A register of training must be maintained.
All medical staff must also update their
cardiopulmonary training annually.
Emergency Plan
Plans must exist for the transfer of a patient in an
emergency from the ECT suite under adequate
medical supervision. All clinical staff should be
familiar with the plan.
Communication
All staff associated with the treatment suite should
be trained and supervised to communicate with
patients and families in a sensitive manner. Some
patients and their families have found ECT to be a
distressing experience or have a sense of shame
because of the social stigma they associate with ECT.
For these reasons, special skill and care is needed in
talking to patients and their families about ECT.
Training in communication is particularly important
for staff working in multi-purpose treatment suites
and operating suites who may not have regular
experience in the administration of ECT.
In providing information to family and carers, issues
of confidentiality must always be considered. The
licence holder should ensure that training and
procedures are in place to enable staff to respond
appropriately to requests for information about
patients. If staff have queries about their duty to
maintain the confidentiality of a patient, the licence
holder should obtain independent legal advice.
Quality Improvement
Each service must include various aspects of their
use of ECT in their ongoing quality improvement
program.
The licence holder must provide procedures and Clinical Record
guidelines for responding to complaints about
Various aspects of the performance of ECT should
standards of treatment and care. Information must be
be recorded in the patient’s clinical file by the
available to patients and their families and advocates
responsible clinical staff.
about the procedures. The mechanisms must be readily
accessible, easily understood and the response timely. Information which must be documented in the
clinical file for each ECT given includes:
Record Keeping • Doses of anaesthetic and relaxant drugs given.
ECT Register • The stimulus level and the duration of seizure.
• The complete print-out from the EEG.
Schedule 21—Electroconvulsive Therapy Return (see
appendix 6) sets out the minimum information
which must be recorded for statutory purposes and
may be used as the ECT register. This includes:
• The date, name, UR number, sex and age of each
patient.
• The names of the doctors giving the anaesthetic
and the ECT.
• Whether the treatment was bilateral or unilateral.
• The nature of the consent given for treatment.
• Country of birth.
• Principal diagnostic code relating to treatment.

Individual services should determine other

information which is required for local purposes, for
example, quality improvement programs.

A designated person, preferably the Senior Clinical

Nurse (ECT), is to have management responsibility
for ensuring the register is maintained.

Reporting
The Authorised Psychiatrist or occupier of licensed
premises must send the Chief Psychiatrist a report
of ECT performed at the licensed premises as soon
as practicable after the end of each month.

The report must contain the information as

described in Schedule 21—Electroconvulsive Therapy
Return. If no ECT has been performed in the
preceding month a nil return is still required. The
Chief Psychiatrist reviews and compiles these data
to:
• Monitor trends in the use of ECT.
• Inform the development of recommendations
and guidelines for the improvement of services.
• Identify potential problems and/or areas for
improvement in clinical service delivery at
specific services.

11
Part D—Clinical Practice Guidelines
Decision to Prescribe ECT
The decision to recommend ECT should be based on
a thorough physical and psychological evaluation of
the individual patient, taking into account the
illness, the past history of illness and treatment
response, the degree of suffering of the patient, the
preferences of the patient and their family or
guardian and the prognosis if ECT is withheld.
The decision that ECT be prescribed for a particular
patient is the responsibility of a psychiatrist who
should record the reasons for this decision in the
case notes. ECT may not be prescribed by a
registered medical practitioner who is not a
qualified psychiatrist.
Legislation
The objects of the Mental Health Act require that
people with a mental disorder are to be given the
best possible care and treatment appropriate to their
needs in the least possible restrictive environment
and least possible intrusive manner. The objects also
seek to protect the rights, privacy, dignity and self-
respect of people receiving care and treatment for a
mental disorder.
Section 6A of the Mental Health Act establishes
certain principles which are to apply to the
provision of treatment and care to people with a
mental disorder. These include the requirement that
people with a mental disorder should be provided
with timely and high quality treatment and that
they should have comprehensive information about
their mental disorder, proposed and alternative
treatments and services available to meet their
needs.
Preparation for ECT
Communication
While clinicians see ECT as a valued and effective
treatment for some forms of mental illness, there are
some patients and/or their carers who have doubts
about whether it is a humane form of treatment.
Some patients and their families experience a sense
of shame because of the social stigma they associate
with ECT. For these reasons, special care is needed
in talking to patients and their families about ECT.
Frequent consultation between patient, family and
doctor is essential before and during a course of
ECT. It is recommended that a printed information
sheet be available which describes the nature of the
treatment, the procedures involved and the expected
benefits, discomforts and risks. This ensures that as
much as possible the patient and family understand
the nature of the treatment and its likely effects so
that any personal distress associated with the
treatment is minimised. For example, some patients
who are severely ill may have difficulty recalling
pre-ECT consultations.
Medical Assessment
An appropriate medical history and physical
examination is necessary. Any physical illness that is
likely to compromise the procedure should be
investigated and an appropriate medical history and
physical examination must be conducted prior to
treatment.
A decision to proceed with ECT will always depend
on consideration of the risks versus the benefits.
Liaison between psychiatric and anaesthetic staff is
critical and it may be necessary to arrange further
investigations before treatment. Consideration may
be given to administering ECT in a theatre or day
procedure suite licensed to perform ECT where
more sophisticated medical treatment and
resuscitation facilities may be available.
Medication Review
All medication that either raises or lowers the
seizure threshold should be reviewed prior to ECT
being administered.
A Course of ECT
A course of ECT is defined in section 72(2) of the
Mental Health Act as a ‘course of electroconvulsive
therapy consisting of not more than six treatments
given over a period with not more than seven days
elapsing between any two treatments’. If more than
seven days elapse between any two treatments and
further treatment is recommended then a new
consent must be obtained for either single
treatments or a ‘course’ of up to six treatments. In
practice the average number of treatments in an
episode of care is eight. One course may
13
 immediately follow another provided the various performed has been given the prescribed
clinical and consent provisions are met. brochure Electroconvulsive Therapy—About Your
Rights.
Patient Rights Brochure
In addition to the brochure, the person must be
Every person, whether voluntary or involuntary for
given an oral explanation of the information
whom ECT is proposed must be given a copy of the
contained in the brochure. If the person appears not
prescribed brochure Electroconvulsive Therapy—About
to understand, or to be incapable of understanding
Your Rights. This applies whether the person is in a
the information contained in the brochure,
private or public mental health service. Basic rights
arrangements must be made to convey the
listed in the brochure, which patients should know,
information to the person in the language, mode of
include the right:
communication or terms which they are most
• To obtain legal and medical advice (including a
familiar with. The brochure is available in 12
second psychiatric opinion).
community languages.
• To be represented by a person of their choosing
before giving consent. Documentation
• To have someone of their choice with them when
If the person does provide informed consent to the
discussing ECT with their psychiatrist or doctor.
performance of ECT, the form Informed Consent to
It is the responsibility of the Authorised Psychiatrist Electroconvulsive Therapy (ECT) (PSY 16) (see
in an approved mental health service and the licence appendix 7) must be completed and signed by the
holder in other services (private hospitals) to ensure person and a witness. The person may consent to
that patients are advised about their rights. one treatment or to a course of treatment which may
be up to six treatments.
Informed Consent
Right to Withdraw Consent
A person is able to give informed consent to ECT if
Despite signing a consent to one or more treatments,
they are able to consent to the treatment in writing
a person has the right to withdraw consent at any
after they have been given an explanation and
stage before or during the course of treatment.
understand the matters set out in section 53B of the
Mental Health Act as follows: Consent to Anaesthetic
• The person has been given a clear explanation
A person who gives informed consent to having
containing sufficient information to enable them
ECT is also taken to have consented to the
to make a balanced judgement.
administration of an anaesthetic to enable the ECT
• The person has been given an adequate
to be performed.
description of benefits, discomforts and risks
without exaggeration or concealment. Passive Consent
• The person has been advised of any beneficial
The passively consenting patient presents a difficult
alternative treatments.
clinical situation which is a matter for individual
• Any relevant questions asked by the person have
assessment. Generally, the consent can be accepted,
been answered and the answers have been
even though the person does not believe the ECT
understood by the person.
will work, if the person when giving consent is able
• A full disclosure has been made of any financial
to fulfil the criteria for providing informed consent
relationship between the person seeking
as specified in section 53B of the Mental Health Act.
informed consent or the registered medical
However, if consent is given on the basis of
practitioner who proposes to perform the
delusional thinking—for example, the person
treatment, or both, and the service, hospital or
believes that ECT might kill them, which would be
clinic in which it is proposed to perform the
just reward for some perceived transgression, then
treatment.
the person should not provide consent. In situations
• The person on whom the treatment is to be

14
like this and subject to the criteria in section 73(3) of
the Mental Health Act, only the Authorised
Psychiatrist can provide consent, and the patient
would need to be an involuntary patient under
section 12 of the Mental Health Act.
Consent by Other People
Adults
While it is good practice to involve families in the
decision to prescribe ECT, no relative, carer or
guardian may consent to ECT on behalf of another
person. It is the patient’s personal capacity only that
is considered when determining whether the person
can give informed consent.
If the person cannot consent and the ECT is
necessary, then consideration should be given to
making the person an involuntary patient and,
subject to section 73 of the Mental Health Act,
consent will be provided by the Authorised
Psychiatrist.
If the person is a patient in a private hospital, the
person should be recommended for involuntary
admission to an ‘Approved Mental Health Service’
so that the ECT may be performed with the
authorisation of the Authorised Psychiatrist.
People under 18 Years
If a person under 18 years of age does not have the
emotional or intellectual maturity to consent to
treatment, and in the usual course of events consent
is provided by a parent, then the parent may give
consent to the performance of the ECT.
If the parent refuses to give consent and the ECT is
necessary, then consideration should be given to
making the young person an involuntary patient
and consent provided by the Authorised
Psychiatrist.
If a person is under 18 years of age and would
usually be considered able to give consent on their
own behalf, then it is that person’s consent to
treatment which must be considered. The usual
requirements for informed consent will then apply.
Consent by the Authorised
Psychiatrist
In accordance with section 73(3) of the Mental
Health Act, if an involuntary, forensic or security
patient is incapable of giving informed consent, the
Authorised Psychiatrist may authorise the
performance of ECT after being satisfied that:
• The ECT has clinical merit and is appropriate.
• Having regard to any benefits, discomforts or
risks the ECT should be performed.
• Any beneficial alternative treatments have been
considered.
• Unless the ECT is performed, the patient is likely
to suffer a significant deterioration in their
physical or mental condition (section 73(3) of the
Mental Health Act).
It is important to note that the Authorised
Psychiatrist may only consent for a patient who ‘is
incapable of giving consent’, not a patient who is
unwilling to give consent. The only exception is
where the nature of the mental disorder is such that
the performance of the ECT is urgently needed
(section 73(4) of the Mental Health Act).
Notification to Patient’s Guardian or Primary Carer
If the Authorised Psychiatrist proposes to authorise
ECT for a patient, they must also ensure that all
reasonable efforts have been made to notify the
patient’s guardian or primary carer of the proposed
performance of the ECT (section 73(3)(b) of the
Mental Health Act). Special care should be taken to
ensure that as much as possible the patient’s family
understand the nature of the treatment, why it is
required and its likely benefits so that the personal
distress often associated with the treatment is
minimised.
If the primary carer or guardian opposes the
performance of ECT, the Authorised Psychiatrist
must wherever possible obtain a second psychiatric
opinion and do everything possible to inform and
relieve the anxiety of those concerned.
In all cases the final decision to give ECT, in these
circumstances, rests with the Authorised
Psychiatrist.
15
 Second Opinion
If the Authorised Psychiatrist proposes to authorise
ECT for an involuntary, security or forensic patient,
a second psychiatric opinion should be obtained.
This opinion should be recorded in writing in the
case notes before the ECT is given. In remote areas
where it may not be possible or practical to have a
second psychiatrist examine the patient, other
options including telepsychiatry or telephone
consultation should be considered.
Documentation
If the Authorised Psychiatrist authorises the ECT on
behalf of the patient, the Authorised Psychiatrist
must complete and sign the form Authority to
Perform Electroconvulsive Therapy (ECT) Where
Informed Consent Not Obtained (PSY 17) (see
appendix 8).
Urgently Needed ECT
Informed consent is not required where ECT is
urgently needed because of the nature of the
person’s mental illness (section 73(4) of the Mental
Health Act). The Authorised Psychiatrist will
consent on behalf of the person. While the usual
requirements for substituted consent contained in
section 73(3) of the Mental Health Act do not apply
because of the urgency of the situation, they should
be met wherever possible.
Penalties for Performing ECT without
Informed Consent
A registered medical practitioner who performs ECT
without informed consent is guilty of professional
misconduct unless the medical practitioner can
satisfy the Medical Practitioners Board of Victoria
that there were valid reasons for not obtaining
consent.
The exceptions are:
• The person is either an involuntary, security or
forensic patient and incapable of giving informed
consent—in which case the Authorised
Psychiatrist may consent on behalf of the person
if the relevant criteria are met (section 73(3) of the
Mental Health Act).
or
16
• ECT is urgently needed (section 73(4) of the
Mental Health Act).
Further, a person (including a licence holder) who
permits ECT to be performed without informed
consent is guilty of an offence against the Mental
Health Act.
The Secretary may cancel a licence if an offence
under section 73 has been committed on the licensed
premises.
Confidentiality
Section 120A of the Mental Health Act prohibits any
staff member of a psychiatric service from providing
information about people who are or have been in
receipt of psychiatric services. A psychiatric service
includes any premises licensed to perform ECT.
However, section 120A(3) provides certain
exceptions to these strict requirements of
confidentiality. These include the giving of
information:
• With the prior consent of the person.
• In general terms.
• To a guardian, family member or primary carer, if
the information is reasonably required for the
ongoing care of the person, and the guardian,
family member or primary carer will be actively
involved in providing that care.
• In connection with the further treatment of the
person.
While the patient’s family should be involved in the
decision to perform ECT and discussions during a
course of ECT, clinical staff should ensure
confidentiality requirements are met.
Prescription of ECT
Bilateral versus Unilateral ECT
This is a clinical decision guided on an individual,
case-management basis. There is a continuing
debate about the merits of bilateral versus unilateral
ECT. No clear recommendations can be made,
however, current practice with stimulus dose
titration favours unilateral ECT.
Frequency of Treatment
Both unilateral and bilateral ECT should be given at
a rate of two or three treatments per week. Twice-
weekly ECT is likely to reduce the occurrence of
transient cognitive side effects. Increasing the
frequency of treatment beyond three times weekly
may increase the degree of cognitive impairment
and does not increase the speed of clinical response.
Number of Treatments
The number of treatments to be prescribed should
be determined by clinical need on a case by case
basis and reviewed on a continuing basis depending
on the clinical response. Single treatments may be
prescribed, however, the Mental Health Act permits
a course of up to six treatments may be prescribed at
a time. One course may immediately follow another
if clinically indicated and the necessary consent is
obtained. On average, patients with a diagnosis of
depression usually require 6 to 12 treatments and
the psychotic disorders, such as schizoaffective
disorders usually require 10–20.
Administration of Anaesthetic
Induction agents and anaesthetic agents will be
determined by the specialist anaesthetist if
necessary in conjunction with the psychiatrist.
Documentation
A record must be kept of anaesthetic and relaxant
agents given and of any problems and complications
which occur.
Oxygen
Pre-stimulus ventilation with oxygen will reduce the
risk of cardiovascular complications and may also
reduce adverse effects. Hyperventilation with
oxygen is a useful technique which augments
seizure activity.
Stimulus Parameters and Seizures
It is important to test for adequate contact between
the electrodes and the scalp prior to each treatment.
The self-test function on the ECT machine should be
used for this.
Seizure Threshold
Seizure threshold depends on the type of stimulus
used and on other factors including age, sex,
concomitant medication and recent ECT. Clinical
staff are advised to keep abreast of the current
literature and training on the topic. At present there
are three methods to determine the adequate charge
or ‘dose’ for an individual patient. They are:
• Dose Titration—this is the most accurate method
and is therefore preferred. The clinician should
be aware that the higher the stimulus the greater
the likelihood of transient cognitive disturbance.
• Age Dosing
• Half Age Dosing
Determining an Adequate Seizure
The minimum requirements for a therapeutic
seizure have not been universally agreed upon.
However, current literature indicates that adequate
seizures are determined by a compilation of:
• The clinical response.
• An EEG seizure duration>25 seconds.
• A motor seizure>20 seconds.
• Good post-ictal suppression>87 per cent.
• The quality and amplitude of the EEG recording.
Review of the Stimulus Dose
The dose should be reviewed after each treatment
on the basis of the patient’s clinical response. An
increase in dose may be indicated:
• If the treatment response is poor.
or
• If generalised seizures of sufficient duration, 25
seconds on EEG, are not achieved.
or
• When a reduction in the length of the seizure
occurs. Seizure threshold rises by an average of
80 per cent during a course of treatment (range
25–200 per cent), thus seizure duration shortens.
A decrease in dose may be indicated:
• If the patient is experiencing adverse cognitive
side effects. In instances like this it may be
beneficial to consider less frequent treatments, for
example, twice weekly.
or
• Where prolonged seizures occur.
17
 Monitoring Seizure Activity
Licensing in Victoria requires that the ECT machine
used for the procedure must be capable of providing
EEG monitoring of the seizure. This is currently best
practice in determining the adequacy of the type and
duration of the seizure. Further, it is recommended
that the factors outlined in ‘Determining an
Adequate Seizure’ are monitored, for instance:
• An ‘adequate’ seizure would generally be a
bilateral muscular (tonic/clonic) seizure lasting
20 seconds or more, and/or 25 seconds or more
on an EEG recording.
• The duration of cerebral seizure activity may
exceed that of the peripheral manifestations of
the seizure (muscle twitching) by 10–15 seconds.
Prolonged seizures, lasting longer than 120 seconds,
should be terminated. Options include a further
bolus of general anaesthetic used or midazolam. The
anaesthetist should be advised after 90 seconds of
fitting.
Restimulation
Patients having inadequate seizures, for example,
unilateral ECT, may be restimulated after 90 seconds
with increased charges provided satisfactory
anaesthesia and muscle relaxation are maintained.
A maximum of 3 stimuli in the one session is
advised as marked amnesia may result.
Recovery
While the patient is recovering from the anaesthetic,
ensure that there is an adequate airway. Monitor the
patient’s pulse and blood pressure until stable.
There should be continuous nursing presence and
observation until the patient is fully orientated.
Memory impairment should be monitored and
treatment reassessed if cognitive impairment is a
problem (consider the stimulus, electrode
placement, frequency, and so on).
There may be a small minority of patients who
become acutely agitated immediately after emerging
from the general anaesthetic. Immediate action
should be taken by the intravenous administration
of additional anaesthetic agent or midazolam.
18
Monitoring Clinical Response
Clinical response should be recorded at least weekly
with respect to symptomatic response and adverse
effects. If a patient’s clinical condition is failing to
improve, then all aspects of the ECT treatment must
be reconsidered.
Two-way communication between the ECT staff and
the treating clinical team is essential. This will
depend on local circumstances, but clear local policy
and procedures should be developed so that:
• Before each treatment, the ECT staff know about :
– The charge required to achieve the previous
satisfactory seizure.
– The clinical response so far.
– Changes in physical status.
– Changes in medication.
– Changes in legal status.
– Cognitive and other side effects the most com-
mon being headache, which may be managed
by the prescription of a suitable analgesic
agent such as paracetamol with codeine.
• The treating clinical team knows the stimuli
used, the seizure parameters and any problems
after each treatment.
Privacy
ECT must at all times be performed in such a way
as to respect the privacy, dignity and confidentiality
of the patient. Under no circumstances must the
nature of the treatment be disclosed to patients or
others at shared facilities, such as multi-purpose
treatment suites.
The patient’s consent is required for nursing and
medical students or clinical staff to be present
exclusively for the purpose of training during the
administration of ECT.
ECT on an Outpatient Basis
Clinical Issues
Prescription of ECT on an outpatient basis is a
clinical decision. Matters which must be considered
when selecting a patient for outpatient ECT include:
• That the nature and seriousness of the patient’s
mental illness at the time of ECT must not
 present a contra-indication to management on an
outpatient basis. The treating psychiatrist is
responsible for ensuring the continuing
suitability of the patient for such treatment.
• That the anticipated risks associated with the
ECT course are detectable and manageable both
during the ECT session and in an outpatient
setting.
• The same indications, contra-indications, consent
requirements and pre-ECT evaluations apply.

The use of outpatient ECT poses some special

practical problems which need to be considered
and resolved. For example:
– The patient must be willing and able to
comply with the behavioural limitations that
are necessary prior to and following ECT, such
as fasting (see sample document—Additional
Information for Patients Receiving ECT as
Outpatients; appendix 1).
– The patient must have a responsible adult as
escort to and from the ECT suite and to stay
with them on returning home for 24 hours or
until full recovery.
– The patient must have access to a telephone at
home and must be given a contact name and
number in the event of any problems.
Procedural Matters
The case manager or consultant psychiatrist must
ensure that the patient’s clinical file is in the ECT
suite prior to the treatment being administered.

Food and drink must be made available to

outpatients recovering from ECT while awaiting
permission to leave. A private area must be
provided which also allows appropriate monitoring
of the person’s condition.

The Clinical Director (ECT), Specialist Anaesthetist

or Senior Clinical Nurse (ECT) will make the
decision about when the patient is able to leave the
ECT suite. It is recommended that the patient
remains under observation for a minimum of four
hours post-ECT.

19
Part E—Criteria For Licensing ECT Premises
The following information establishes the
Department’s criteria by which services will be
assessed for an ECT licence based on the four
criteria specified in section 75(5) of the Mental
Health Act. These criteria should be seen as setting
the minimum acceptable standard for premises at
which ECT is to be performed and are known as the
Key Licensing Criteria. These criteria are made
available to licence holders or applicants to assist in
understanding the licensing process and to ensure
the procedures are open and accountable.
Suitability of the Applicant to Hold a
Licence [section 75(5)(a)]
The requirements are:
• Private Hospitals: A private hospital must be
registered in accordance with Division 3 of Part 4
of the Health Services Act 1988 and the registration
must specify that psychiatric health services may
be carried out on the premises of the private
hospital. Psychiatric health services are defined
in Schedule 8—Health Services (Private Hospitals
and Day Procedure Centre) Regulations 1991.
• Public, Denominational and Metropolitan Hospitals:
A public, denominational or metropolitan
hospital must be listed in the schedules to the
Health Services Act.
• Approved Mental Health Services: An Approved
Mental Health Service is a service proclaimed by
the Governor in Council and published in the
Government Gazette to provide treatment to
patients. A Public, Denominational or
Metropolitan Hospital may be an Approved
Mental Health Service.
The Suitability of the Premises
[section 75(5)(b)]
Suitability of the premises will be assessed against
the following principles:
• The premises facilitate the safe administration of
ECT.
• Privacy needs of patients receiving ECT are
maximised.
• ECT is able to be scheduled at a time that meets
patient care needs.
All areas/suites where ECT may be performed are
to be inspected. This includes operating suites in
services which use them. The minimum requirement
for a dedicated ECT Suite is three rooms:
• Waiting room, with access to toilet facilities.
• Treatment room, including scrub-up basin/sink,
oxygen supply, emergency oxygen supply,
adequate lighting, emergency lighting and
telephone/intercom.
• Recovery room of sufficient size to accommodate
rate and number of patients treated per session,
including scrub-up basin/sink, oxygen supply,
emergency oxygen supply, adequate lighting,
emergency lighting and telephone/intercom.
Suitability of Equipment to be Used in
the Performance of ECT [75(5)(c)]
The minimum requirements are:
• ECT machine must be listed with the Therapeutic
Goods Administration, must provide EEG
monitoring and recording of the duration of the
seizure and permit a charge of up to 1000 mC to
be given, and be capable of delivering stimulus
dose titration.
• Documented servicing of the ECT machine must
occur at least once a year.
• Anaesthetics equipment, resuscitation equipment
and emergency drug supplies to be in accordance
with ANZCA’s policy document Recommended
Minimum Facilities for Safe Anaesthetic Practice for
Electroconvulsive Therapy (ECT).
• Existence of demonstrated systems for the
maintenance and servicing of anaesthetic and
resuscitation equipment.
• Existence of demonstrated systems for regular
replacement of out-of-date and missing
anaesthetic and emergency drugs.
• Existence of demonstrated infection control
policy.
• Annual review of anaesthetic and emergency
drugs kept in the ECT suite by a specialist
anaesthetist.
• Designated person, such as the Senior Clinical
Nurse (ECT), is to be responsible for these duties.
21
 Suitability of Qualifications of
Persons Performing ECT [75(5)(d)]
The minimum requirements are:
• Each licensed premises must have a qualified
psychiatrist and a registered nurse with training,
experience and an interest in ECT, designated as
Clinical Director (ECT) and Senior Clinical Nurse
(ECT).
• Only a registered medical practitioner is
permitted to perform ECT. The practitioner must
have demonstrated theoretical and practical
training in the performance of ECT or be directly
supervised by a practitioner with experience in
training medical staff in the performance of ECT.
• A register of practitioners and their
qualifications, with privileges in ECT, is to be
maintained by the Clinical Director (ECT).
• Anaesthesia used for performing ECT must be
administered by a Specialist Anaesthetist or, in
the absence of a Specialist Anaesthetist, a
registered medical practitioner accorded
privileges in anaesthesia at the licensed premises
in accordance with ANZCA’s policy document
Privileges in Anaesthesia.
• A registered nurse with recent training in
assisting an anaesthetist is to have management
responsibility for coordinating the delivery of
nursing care at each ECT session.
• Nursing staff numbers at each session are to be in
accordance with these guidelines.
• Documented training programs should be in
accordance with these guidelines, and include:
– Clinical Director (ECT) and Senior Clinical
Nurse (ECT) must have completed an
approved ECT administration course.
– Nursing and medical staff must undergo CPR
training every 12 months.
– Psychiatric and medical emergency plan.
• Each service must include various aspects of
their use of ECT in their ongoing quality
improvement program.

22
Part F—Appendices

Appendix 1: Sample Information Sheet

This information sheet is a sample only. Services that wish to provide additional information for patients
receiving ECT as an outpatient may use this as a model to develop information brochures that best meet
particular service needs.

Additional Information for Patients Receiving ECT as Outpatients

This information should be read along with your patient information booklet.
If you are having ECT as an outpatient, there are some rules which must be followed because you will
be given a brief anaesthetic by injection into a vein in your arm.
1. Your psychiatrist has prescribed ECT to treat your condition and has recommended that you
receive this treatment on an outpatient basis. They would also have arranged for you to be seen by
an anaesthetist to see if you are medically fit to receive a brief general anaesthetic. Once the
anaesthetist has declared that you are well enough for a general anaesthetic, you will be given a
day to come in for the treatment.
2. ECT will be administered --------- times a week on the following morning/s ------------------------------
--------------- commencing on ---------------------------------------- until -----------.
3. You must not have anything to eat or drink from midnight on the day before each treatment. If
you are taking tablets in the morning don’t take them on the morning of your treatment; bring
them with you and give them to the nurse who will give them to you with a drink after your
treatment.
4. On the day of the ECT treatment you will need to :
• Dress in loose clothing.
• Ensure that your hair is clean and dry.
• Remove any nail polish.
• Ensure that your bowel and bladder are empty before the treatment.
5. If you develop any infection such as a severe cold during the time that you are having ECT this
may mean that you are not able to have an anaesthetic while your cold is bad. If this happens, you
should contact your doctor or case manager who will advise you what to do.
6. You must not drive a car on the day on which you have treatment or travel unaccompanied. A
family member or friend should bring you for treatment and take you home.
7. You should not be alone when you return home for 24 hours or until you have fully recovered from
the anaesthetic; and you should have a telephone available in case you have problems and need to
contact the hospital.
ECT is usually not an unpleasant treatment. You will wake up within a few minutes of the treatment
and not remember anything of it. You may feel a little disorientated initially on waking and have a
slight ‘fuzzy’ feeling or headache. However, these feelings will soon pass. You may also have difficulty
remembering events which occurred around the treatment time, but this almost always clears up very
quickly.
When you have woken sufficiently the staff will assist you from the trolley bed and give you
something to eat and drink.
The ECT generally does not have an immediate effect on your mood so don’t be worried if you do not
feel better after the first few treatments. If you wish to discuss your progress or you have any
questions about the ECT please feel free to discuss this with the nursing staff or your doctor.

23
 Appendix 2: Schedule 17—Application for Licence to Permit the Performance
of Electroconvulsive Therapy

SCHEDULE 17
Regulation 9
Mental Health Act 1986 (section 75)

Mental Health Regulations 1998

APPLICATION FOR LICENCE TO PERMIT THE

PERFORMANCE OF ELECTROCONVULSIVE THERAPY

To the Secretary,

..............................................................................................................................................................................................
(Name of Occupier eg. Body Corporate, Partnership)

is the occupier of premises known as ............................................................................................................................

..............................................................................................................................................................................................
(Name of premises eg. Private Hospital, Approved Mental Health Service, Public Hospital)

located at ............................................................................................................................................................................
SA
MP
..............................................................................................................................................................................................
(Address of premises)
LE
ON
I apply for a licence to perform electroconvulsive therapy at the above premises.

LYindicating all areas/suites where electrocon-

In attachment A, I have enclosed a plan of the above premises
vulsive therapy is to be performed.

Signature:....................................................................................

......................................................................................................
GIVEN NAME(S)/FAMILY NAME (BLOCK LETTERS)
of person authorised to sign for and on behalf of the occupier.

Title: ............................................................................................

Date: ............................................................................................

Attachment A

A plan of the premises indicating all areas/suites where electroconvulsive therapy is to be performed.

24
Appendix 3: Schedule 18—Licence Authorising Performance of
Electroconvulsive Therapy

SCHEDULE 18
Regulation 10
Mental Health Act 1986 (section 76)

Mental Health Regulations 1998

LICENCE AUTHORISING PERFORMANCE OF

ELECTROCONVULSIVE THERAPY

Licence Number

..............................................................................................................................................................................................
(Name of Occupier)

is the occupier of premises known as ............................................................................................................................

..............................................................................................................................................................................................
(Name of premises eg. Private Hospital, Approved Mental Health Service, Public Hospital)

SA
MP
located at ............................................................................................................................................................................

LE
..............................................................................................................................................................................................
(Address of premises)
ON
This licence authorises the performance of electroconvulsive therapy
areas/suites shown in Attachment A.
LY at the above premises in the

This licence is in force from to , and is subject to the terms and

conditions contained in Attachment B.

Signature: ................................................................................

Title: ........................................................................................
(Secretary or delegate)

Date: ........................................................................................

Attachment A

A plan of the premises where electroconvulsive therapy is to be performed.

Attachment B

The terms and conditions to which the licence is subject.

25
 Appendix 4: Schedule 19—Application for Renewal of Electroconvulsive
Therapy Licence

SCHEDULE 19
Regulation 11
Mental Health Act 1986 (section 77 (2))

Mental Health Regulations 1998

APPLICATION FOR RENEWAL OF AN

ELECTROCONVULSIVE THERAPY LICENCE

Licence Number

To the Secretary,

..............................................................................................................................................................................................
(Name of Occupier eg. Body Corporate, Partnership)

is the occupier of premises known as ............................................................................................................................

SA
MP
..............................................................................................................................................................................................

LE
(Name of premises eg. Private Hospital, Approved Mental Health Service, Public Hospital)

ON
located at ............................................................................................................................................................................

LY
..............................................................................................................................................................................................
(Address of premises)

The abovenamed premises are licensed to permit the performance of electroconvulsive therapy.

The licence expires on ......................................................................................................................................................

I apply for the renewal of this licence on the same terms and conditions.

Signature: ..............................................................................

................................................................................................
GIVEN NAME(S)/FAMILY NAME (BLOCK LETTERS)
of person authorised to sign for and on behalf of the Occupier.

Title: ........................................................................................

Date:........................................................................................

26
Appendix 5: Schedule 20—Application for Amendment of an
Electroconvulsive Therapy Licence

SCHEDULE 20
Regulation 12
Mental Health Act 1986 (section 78 (2))

Mental Health Regulations 1998

APPLICATION FOR AMENDMENT OF AN

ELECTROCONVULSIVE THERAPY LICENCE

Licence Number

To the Secretary,

..............................................................................................................................................................................................
(Name of Occupier eg. Body Corporate, Partnership)

SA
is the occupier of premises known as ............................................................................................................................
MP
LE
..............................................................................................................................................................................................

ON
(Name of premises eg. Private Hospital, Approved Mental Health Service, Public Hospital)

LY
located at ............................................................................................................................................................................

..............................................................................................................................................................................................
(Address of premises)

The abovenamed premises are licensed to permit the performance of electroconvulsive therapy.

The licence expires on ......................................................................................................................................................

I apply for the amendment of this licence as follows:

Present term or condition: ..............................................................................................................................................

Proposed amendment: ....................................................................................................................................................

Reasons for proposed amendment: ................................................................................................................................

Signature: ..............................................................................

................................................................................................
GIVEN NAME(S)/FAMILY NAME (BLOCK LETTERS)
of person authorised to sign for and on behalf of the Occupier.

Title: ........................................................................................

Date:........................................................................................

27
 Appendix 6: Schedule 21—Electroconvulsive Therapy Return

28
Appendix 7: Informed Consent to Electroconvulsive Therapy (ECT) (PSY 16)

29
 Appendix 8: Authority to Perform Electroconvulsive Therapy (ECT) Where
Informed Consent Not Obtained (PSY 17)

30
Appendix 9: Royal Australian and New Zealand College of Psychiatrists—
Electroconvulsive Therapy Explained

Electroconvulsive Therapy Explained

This document has been prepared to provide some general information about the
administration of ECT in contemporary psychiatric practice in Australia and New Zealand.
It is intended to accompany the
RANZCP Clinical Memorandum #12, Electroconvulsive Therapy (1999).

What is ECT?
Electroconvulsive therapy, more commonly known as ‘ECT’, is a medical treatment
performed only by highly skilled health professionals under the direct supervision of
a psychiatrist, who is a medical doctor trained in diagnosing and treating mental
illnesses. Its effectiveness in treating severe mental illnesses is recognised by the
Royal Australian and New Zealand College of Psychiatrists and similar organisations
in the United States, Canada, Great Britain and many other countries.

A course of treatment with ECT usually consists of six to twelve treatments given
three times a week for a month or less. The patient is given general anaesthesia and
a muscle relaxant. When these have taken full effect, the patient's brain is
stimulated, using electrodes placed at precise locations on the patient's head, with a
brief, controlled series of electrical pulses. This stimulus causes a seizure within the
brain which lasts for approximately a minute. Because of the muscle relaxants and
anaesthesia, the patient's body does not convulse and the patient feels no pain. The
patient awakens after five to ten minutes, much as he or she would from minor
surgery.

How does it work?

The brain is an organ that functions through complex electrochemical processes,
which may be impaired by certain types of mental illnesses. Scientists believe ECT
acts by temporarily altering some of these processes, thereby returning function to
normal.

When is it used?
The decision to administer ECT is based upon a thorough physical and psychiatric
evaluation of the patient, taking into account the illness, the degree of suffering, the
expected result and the prognosis for the patient if the treatment is not given. When
the risk of suicide is high, or when seriously ill patients are unable to eat or drink,
ECT can be life-saving.

Electroconvulsive therapy is generally used in patients with severe depressive illness

when other forms of therapy, such as medications or psychotherapy, have not been

31
 effective, cannot be tolerated or, in life-threatening cases, will not help the patient
quickly enough. ECT also helps patients who suffer with most forms of mania (a mood
disorder which is associated with grandiose, hyperactive, irrational and destructive
behaviour), some forms of schizophrenia, and a few other mental and neurological
disorders. ECT is also useful in treating these mental illnesses in older patients for
whom a particular medication may be inadvisable.

How effective is it?

Electroconvulsive therapy has been an important and effective treatment in psychiatry
for over half a century. Its effectiveness in a variety of psychiatric conditions has been
well established. Clinical evidence indicates that for uncomplicated cases of severe
major depression, ECT will produce a substantial improvement in at least 80 percent
of patients.1 ECT has also been shown to be effective in depressed patients who do
not respond to other forms of treatment.2 Medication is usually the treatment of
choice for mania, but here too certain patients don't respond. Many of these patients
have been successfully treated with ECT.3

Are there any risks?

Any medical procedure entails a certain amount of risk. However, ECT is no more
dangerous than minor surgery under general anaesthesia, and may at times be less
dangerous than treatment with antidepressant medications. This is in spite of its
frequent use with the elderly and those with coexisting medical illnesses.4 A small
number of other medical disorders increase the risk associated with ECT, and patients
are carefully screened for these conditions before a psychiatrist will recommend them
for the ECT treatment.

Are there any side effects?

Immediate side effects from ECT are rare. Some people will experience headaches,
muscle ache or soreness, nausea and confusion, usually during the first few hours
following the procedure. Over the course of ECT, it may be more difficult for patients to
remember newly learned information, though this difficulty disappears over the days
and weeks following completion of the ECT course. Some patients also report a
partial loss of memory for events that occurred during the days, weeks, and months
preceding ECT. While most of these memories typically return over a period of days to
months following ECT, some patients have reported longer-lasting problems with recall
of these memories. However, other individuals actually report improved memory ability
following ECT, because of its ability to remove the amnesia that is sometimes
associated with severe depression. The amount and duration of memory problems
with ECT vary with the type of ECT that is used and are less a concern with unilateral
ECT (where one side of the head is stimulated electrically) than with bilateral ECT.

Can ECT cause brain damage?

There is no evidence that ECT causes any structural cerebral damage.5 There are
medical conditions (such as epilepsy) that cause spontaneous seizures which, unless
prolonged or otherwise complicated, do not harm the brain. ECT artificially stimulates
a seizure; but ECT-induced seizures occur under much more controlled conditions
than those that are "naturally occurring" and are safe. A recent study6 found no
changes in brain anatomy with ECT, as measured by very sensitive scans of the brain
using magnetic resonance imaging (MRI) equipment. Other research has established
that the amount of electricity which actually enters the brain (only a small fraction of

32
what is applied to the scalp) is much lower in intensity and shorter in duration than
that which would be necessary to damage brain tissue.7

What about pregnancy?

The decision whether or not to treat pregnant women with ECT needs to take into
account the risks associated with alternative treatments, the risks to the mother and
foetus of withholding ECT and any complications of the pregnancy which may
increase the risks of ECT or the anaesthetic. ECT may be used with confidence
during the second and third trimesters.8 Little information is available for its use in the
first trimester, so until further data are available, caution is advisable during this stage.
ECT does not produce abnormal uterine contractions and it appears to be safe even
in complicated pregnancies.9 Foetal monitoring during ECT has not revealed any
untoward effects on the foetus.

What about patient consent?

All patients selected for ECT should receive a careful explanation of the procedure,
including the side effects, by the medical and nursing staff involved in their care, and
their permission for treatment obtained. It should be made clear to the patient that
regardless of whether permission is given for each separate occasion of treatment or
for a course of treatment of unspecified length, consent may be withdrawn at any time.
Occasionally, when a patient is too severely impaired to be able to give proper
consent, permission to proceed with ECT without the patient’s consent can be
arranged through the relevant Mental Health Act. This would happen only in
emergency situations when the illness is causing serious risk to the patient or others.

1 Weiner RD, Coffey CE: Indications for use of electroconvulsive therapy, in Review of
Psychiatry, Vol 7. Edited by Frances AJ, Hales RE. Washington, DC: American Psychiatric
Press Inc., pp 45881, 1988
2 Sackheim, HA, Prudic J, Devanand DP: Treatment of medication resistant depression with
electroconvulsive therapy, in Review of Psychiatry, Vol. 9. Edited by Tasman A, Goldfinger
SM, Kaufman CA, Washington, DC: American Psychiatric Press, Inc., pp 91115, 1990
3 Small JG, Klapper MH, Kellams JJ, Miller MJ, Milstein V, Sharpley PH, Small IF:
Electroconvulsive treatment compared with lithium in the management of manic states. Arch
Gen Psychiatry 45:72732, 1988
4 Weiner RD, Coffey CE: Electroconvulsive therapy in the medical and neurological patient, in
Psychiatric Care of the Medical Patient. Edited by Stoudemire A, Fogel B. New York: Oxford
University Press, pp 207224, 1993
5 Devanand DP, Dwork AJ, Hutchinson ER, Bolwig TG and Sackheim HA (1994) Does ECT
alter brain structure? Am J Psychiatry 151, 957-970.
6 Coffey CE, Weiner RD, Djang WT, Figiel GS, Soady SAR, Patterson LJ, Holt PD, Spritzer CE,
Wilkinson WE: Brain anatomic effects of ECT: A prospective Magnetic resonance imaging
study. Archives of General Psychiatry 115:10131021, 1991
7 Weiner RD: Does ECT cause brain damage? Brain Behav Sci 7:153, 1984
8 Lock T. ECT and Obstetrics. In: Freeman C, ed. The ECT Handbook: The Second Report of
the Royal College of Psychiatrists’ Special Committee on ECT. London: Royal College of
Psychiatrists, 1995: 22-23.
9 Ferril M, Kehoe W, Jacisin J. ECT during pregnancy: physiologic and pharmacologic
considerations. Convulsive Therapy 1992; 8(3): 186-200.

33
 Appendix 10: Royal Australian and New Zealand College of Psychiatrists—
Clinical Memorandum #12 Electroconvulsive Therapy

THE ROYAL AUSTRALIAN AND NEW ZEALAND COLLEGE OF PSYCHIATRISTS

Clinical Memorandum #12

ELECTROCONVULSIVE THERAPY

Guidelines on the administration of electroconvulsive therapy (ECT).

INTRODUCTION

1.1 Electroconvulsive therapy has been an important and effective treatment in

psychiatry for over half a century. Its effectiveness in a variety of psychi-
atric conditions has been established beyond doubt. For many years the
practice and technique of ECT remained relatively unchanged but in the
1990s there have been new developments, based on research, which have
resulted in changes to the way in which ECT is understood and practised.
While there continues to be debate about some controversial issues, partic-
ularly in relation to dosage techniques, there are nevertheless many areas
of general agreement. This memorandum is an attempt to outline, for prac-
titioners and other interested parties, currently acceptable guidelines for the
prescription, practice and procedure of ECT. It is intended to mainly guide
and assist clinicians and is not intended to be an extensive review of ECT,
with an exhaustive list of references. Some key references however, are
provided for the interested reader.

INDICATIONS

2.1 The principal indications for ECT will always be based upon a thorough
physical and psychiatric evaluation of the individual, taking into account the
illness, the degree of suffering of the patient, the expected therapeutic effect
and the prognosis if such treatment is withheld.

2.2 The primary indication for ECT is major depression, especially with melan-
cholia, psychotic features and/or suicidal risk. Other indications are mania
and schizophrenia with acute features. ECT may also be helpful in certain
conditions such as neuroleptic malignant syndrome and Parkinson’s
disease1.

CONTRAINDICATIONS

3.1 With the exception of raised intracranial pressure, there are no absolute
contraindications to ECT although there are a number of clinical situations
in which extra caution is required. ECT is among the least risky of medical
procedures carried out under general anaesthesia2, and substantially less
risky than childbirth3.

SITUATIONS OF HIGH RISK

4.1 Although there are no absolute contraindications to ECT, there are certain
situations of high risk which necessitate the adoption of appropriate precau-
tions. It is strongly recommended that appropriate consultation with the
anaesthetist and/or the patient’s treating physician is made prior to a course
of ECT in all of the following situations.

34
4.1.1 HYPERTENSION
Elevation of blood pressure during the tonic-clonic phase of ECT is
usual and may at times be marked. Patients with pre-existing hyper-
tension should have their blood pressure stabilised with appropriate
treatment prior to commencing a course of ECT. The use of antihy-
pertensive agents during the procedure for patients with hypertension
may be necessary to prevent excessive elevation of blood pressure.

4.1.2 MYOCARDIAL INFARCTION

Recent myocardial infarction is generally regarded as a situation of
high risk for ECT. There are no reliable data to indicate when, after
myocardial infarction, it is safe to proceed. Extreme caution is rec-
ommended within the first 10 days and the risk in general decreases
over the ensuing 3 months.

4.1.3 BRADYARRHYTHMIAS
Slowing of the heart rate is usual in the few seconds immediately fol-
lowing the application of the electrical stimulus. Patients with a pre-
existing bradycardia or heart block are therefore at risk of a clinically
relevant bradycardia or asystole. The risk is theoretically increased
in the case of stimuli which do not produce a convulsion, such as
during a dose titration procedure. The pre-treatment use of an anti-
cholinergic agent such as atropine should be considered in these sit-
uations.

4.1.4 CARDIAC PACEMAKERS

Electrical stimulus is normally prevented from reaching the heart by
the high resistance of the intervening tissues. All monitoring equip-
ment must be properly grounded and patients must not be touched or
held during the stimulus by anyone in electrical contact with ground.
It is recommended that such patients should be treated in a setting
which provides ready access to coronary care.

4.1.5 INTRACRANIAL PATHOLOGY

ECT has been safely and effectively used in the presence of a variety
of intracranial lesions, including infarction, haemorrhage, dementias,
intracranial aneurysms, trauma and tumors not associated with raised
intracranial pressure4/5. However, if intracranial pressure is raised,
treatment with ECT is contraindicated1 6. Caution should also be
exercised in the presence of recent brain injury, infection, stroke or
haemorrhage7. Patients with organic brain lesions are likely to be
more susceptible to the cognitive side effects of ECT and appropriate
caution is recommended.

4.1.6 ANEURYSMS
Particular care to avoid treatment-induced hypertension is required in
the presence of vascular aneurysm, including intracranial and abdom-
inal aneurysms. It is recommended that a thorough evaluation by the
appropriate surgeon/neurosurgeon be done before proceeding with
ECT in the presence of vascular aneurysm.

35
 4.1.7 EPILEPSY
Epilepsy does not represent a significant risk factor for ECT as long
as it is diagnosed and treated and the underlying structural or vascu-
lar lesions are excluded7 . There may be an increased risk of induc-
ing status epilepticus and EEG monitoring for these patients is neces-
sary. The risk of status epilepticus may be modified by the continua-
tion of the patient’s anticonvulsant medication during the course of
ECT, though this will raise seizure threshold so the medication
dosage should be reduced to mitigate any possible loss of seizure
quality and efficacy. It should be noted that ECT is often, but not
always, associated with a rise in seizure threshold and patients with
epilepsy are not likely to have spontaneous or prolonged seizures
during the course of ECT7 .

4.1.8 OSTEOPOROSIS
Patients with osteoporosis are at risk of fracture during unmodified or
poorly modified ECT. Muscle relaxants should be given in adequate
doses and sufficient time allowed for the relaxant to take full effect
before treatment proceeds. The use of an electronic device to test
for full muscle relaxation is recommended. The assessment of
quadriceps relaxation by testing the patellar reflex is simple and use-
ful to ensure full relaxation. The holding down of patients during the
procedure is not necessary with adequate relaxation and is likely to
increase the risk of fracture.

4.1.9 SKULL DEFECT

Special care must be taken to place electrodes away from skull
defects to avoid local excessive current density through the defect.

4.1.10RETINAL DETACHMENT
ECT induces raised intraocular pressure and may predispose sus-
ceptible patients to retinal detachment. Pre-ECT ophthalmic consul-
tation and adequate control of blood pressure are required for these
patients.

4.1.11 CONCURRENT MEDICAL ILLNESS

The anticipated effects of the patient’s medical status, including cur-
rent medications, upon the risks and benefits of ECT should play a
part in the decision as to whether to administer ECT. The evaluation
of medical conditions and their interaction with ECT should incorpo-
rate pertinent laboratory and other tests and consultation with appro-
priate medical personnel when indicated. The ECT procedure should
be modified to lower morbidity, e.g. changes in ECT technique, the
use of pharmacological agents, administration of ECT in a general
hospital and the presence of additional medical personnel or monitor-
ing procedures.

36
EVALUATION FOR ECT

5.1 Pre-ECT Evaluation

5.1.1. It is the task of the psychiatrist caring for the patient to ensure that
the patient suffers from a condition for which ECT is indicated. If
there is doubt about the clinical condition, or ability to consent, of the
patient, then it is recommended to obtain a second psychiatric opin-
ion about the suitability for ECT.

5.1.2 Full medical history and physical examination, including fundoscopy,

are necessary. No laboratory investigations are specific for ECT, but
investigation of blood and urine, chest x-ray, and ECG may be per-
formed according to clinical need. Similarly, cerebral CT scan may be
required, in particular if raised intracranial pressure is suspected.
Spinal Xray, EEG and pseudocholinesterase testing are not required
for routine screening8 .

Anaesthetic consultation is suggested for the purpose of establishing

the relative individual risk of general anaesthesia within the condi-
tions under which ECT is performed. Other specialists from internal
medicine may also be consulted as appropriate.

5.2 Review of Patient Progress During Course of ECT

5.2.1 It is inadvisable to prescribe a pre-determined number of treatments.
The patient must be reviewed after each ECT treatment by a medical
officer, who should assess the efficacy of treatment and any adverse
events, especially delirium. Standardised rating scales for the longitu-
dinal assessment of mental state (such as the Hamilton or Beck rat-
ing scales for depression) and of cognition (such as the Folstein
Minimental State Examination) may be useful in assessing clinical
progress.

5.2.2 ECT should continue until optimal clinical improvement is noted, but
there is no rationale for continuing beyond this point. ECT should be
discontinued if the patient revokes consent or develops a medical
condition which impacts significantly upon the on-going use of ECT.
Failure to improve should lead to review of the relative electrical
charge delivered, electrode placement, EEG quality, the number of
treatments delivered, and indeed the clinical presentation of the
patient.

USE OF CONCURRENT MEDICATIONS

6.1 The following guidelines are derived from limited human and animal
research findings9 .

It is recognised that many patients receiving ECT will be administered con-

current psychotropic medications with the potential to alter significantly
seizure propagation, and therefore impact negatively on the efficacy of ECT.

37
 6.2.1 ANTIDEPRESSANTS
a) Given that many patients with depression receive ECT because of the
failure of antidepressant medication and that concurrent use of antidepres-
sants has not been demonstrated to improve the efficacy of ECT, there
would seem to be no rationale in continuing the same antidepressant during
the course of ECT. However, it is reasonable practice to commence main-
tenance post-ECT pharmacotherapy towards the end of a course of treat-
ment.

b) Whilst associated with seizures in 4-9% of cases at both therapeutic

doses and in overdose10 11 , little is known about the combined effects of tri-
cyclic antidepressants (TCAs) and ECT on seizure threshold. Deaths have
been reported in patients with known cardiac illness who had received con-
current TCAs12. Whilst a number of anecdotal reports suggest that the
selective serotonin reuptake inhibitors (SSRIs) are associated with pro-
longed seizures, the only study of the combination of ECT and a SSRI (flu-
oxetine) did not show statistically longer seizures13 . The combination of
ECT and irreversible monoamine oxidase inhibitors appears to be safe14 ,
but there is no information on moclobemide.

6.2.2 BENZODIAZEPINES
Benzodiazepine tranquillisers and hypnotics including the shorter acting
compounds, are not recommended for routine use, given their anticonvul-
sant nature. It would be advisable to minimise total dosage of, or withdraw
completely, these medications either before or early in the course of ECT.
The short term use of sedative antipsychotics in low dose would seem to
represent the best alternative for both night sedation and agitation.

6.2.3 MOOD STABILISERS

Both carbamazepine and sodium valproate increase seizure threshold,
although it may be appropriate to continue these drugs during ECT if they
are used for mood stabilisation. Similarly, patients with epilepsy should
continue to receive their anti-epileptic medication, and consultation with a
neurologist is recommended. In both instances, the dose of anti-convul-
sants may require temporary reduction. Lithium prolongs the neuromuscular
blockade of succinylcholine15 and has been reported to increase the risk of
post-ECT delirium16 . Although concomitant administration is not a con-
traindication to ECT4, it is generally advisable to withdraw lithium prior to
the commencement of ECT. For certain bipolar patients who are well con-
trolled on lithium, the risk of ECT-induced mania may outweigh the risk of
delirium, in which case lithium should be continued during ECT.

ANAESTHESIA

7.1 Anaesthesia for ECT should be administered by fully trained specialists, i.e.
registered medical practitioners with Fellowship of the Australian and New
Zealand College of Anaesthetists (FANZCA) or equivalent qualifications. In
some facilities, a trainee anaesthetist who has received adequate training
and who has access to appropriate supervision may administer anaesthe-
sia. A suitably trained member of the nursing staff must be available to
assist the anaesthetist. Adequate equipment including a breathing system
for administration of 100% O2, suction apparatus, pulse oximeter and a car-
diac defibrillator should be available17 .

38
7.2 It is the anaesthetist’s responsibility to stay with the patient until they are
safely transferred to the care of the recovery area staff. All patients recov-
ering from anaesthesia must be supervised in an area designated for that
purpose18 . Standard precautions must be adopted for all anaesthetic prac-
tice in terms of infection control.

TREATMENT PROCEDURES

8.1 Preparation of the Patient

All patients selected for the administration of ECT should have the proce-
dure including the side-effects carefully explained to them by the medical
and nursing staff involved in the care of such patients. Educational pam-
phlets and videos of the procedure are useful for this purpose. Patients
should be fasted from midnight, unless otherwise advised by the anaes-
thetist. Patients should be advised to refrain from smoking at least for 2
hours prior to treatment to minimise risk of excessive bronchial secretions.
Appropriate attention should be paid to hair, dentures and jewellery.

8.2 Location and Equipment

A dedicated ECT suite or area should be available and this should comprise
a waiting area, treatment room, and recovery area with appropriate privacy.
A designated member of nursing staff in charge of the ECT suite and main-
tenance and checking of all equipment along with co-ordination of all
aspects of carrying out the treatment is recommended. Nursing staff caring
for patients in the recovery room should have adequate training in recovery
room procedures.

8.3 ECT Devices

In recent years a number of hospitals across Australia and New Zealand
have begun to use modern ECT devices which have a number of safety
features and allow for easy determination of stimulus dose of current and
EEG monitoring of seizures. It is recommended all hospitals should be
equipped with a modern ECT device.

8.4 Electrode Placement

8.4.1 It is now well established that unilateral placement of electrodes over
the non-dominant hemisphere causes less severe cognitive side
effects than bilateral placement19 20 . However, the relative efficacy of
right unilateral and bilateral ECT is still controversial. Some studies
have found superior efficacy with bilateral therapy21 22 23 whereas oth-
ers have reported equivalent efficacy24 25 26 . Given this uncertainty, it
is recommended that electrode placement be determined on a case-
by-case basis. For unilateral ECT to be effective, the electrical dose
has to be much higher than the patient’s seizure threshold. Seizure
threshold varies widely between patients27.

8.4.2 As a standard practice, one should start off with non-dominant unilat-
eral ECT using the d’Elia position, but if there is no response after 4 -
6 treatments, changing to bilateral treatment should be considered.
However, if a particular patient has responded only to bilateral treat-
ment in the past, or faster therapeutic response is necessary (e.g.
patient being highly suicidal or compromised food intake), treatment
can reasonably commence with bilateral ECT.

39
 8.5 Stimulus Dosing
8.5.1 Stimulus dosing refers to the electrical dosage required to elicit ade-
quate therapeutic seizure. Higher doses are generally more effec-
tive, but they also cause more cognitive side effects. Hence, an opti-
mal dose has to be determined for each patient and for each treat-
ment for that patient. This is not a simple task. It can be approached
in a number of ways:

8.5.2 Establishing the seizure threshold by titration method on the first

treatment, then administering higher doses (e.g. twice the strength)
during subsequent treatment. However, as seizure threshold tends to
increase during a course of ECT, this has to be taken into account.

8.5.3 Using established algorithms (e.g. age and/or gender based) to

determine the initial dose and then vary the dose according to clinical
progress and quality of seizure as judged from the EEG tracing.
Standard text books28 29 and operational manuals from the manufac-
turers of the ECT device should be consulted. Each hospital should
determine their preferred method of stimulus dosing and provide
training accordingly to their staff who administer ECT.

8.6 EEG Monitoring

8.6.1 Preliminary evidence suggests that seizure quality and degree of
post-ictal suppression are related to treatment efficacy.

8.6.2 EEG monitoring is essential in determining the quality, duration and

end point of seizures during ECT. EEG monitoring should be consid-
ered best practice. Without EEG monitoring prolonged seizures in
the absence of motor manifestations can be easily missed resulting in
adverse consequences to patients.

8.7 Physiological Monitoring

8.7.1 During the ECT procedure, pulse, blood pressure and oxygenation
should be regularly monitored until stabilisation is reached. ECG
monitoring should be carried out from prior to anaesthesia induction
until recovered from anaesthesia.

8.7.2 A stop-watch is useful to monitor ictal motor activity. The longest

duration of any seizure-related motor activity should be used to deter-
mine the motor end point. The measurement of seizure-related
motor activity is facilitated by using the cuff technique.

8.8 Management of Missed, Inadequate or Prolonged Seizures

8.8.1 MISSED OR INADEQUATE SEIZURES

a) The muscular contraction that usually accompanies the delivery of
the electrical stimulus should not be mistaken for a seizure. With
missed seizures there should be a 20 - 40 second delay before res-
timulation to take into account the possibility of a delayed onset of
seizure. Restimulation should be at a higher intensity, after a quick
check that the electrical connection is not at fault, including the elec-
trode contact.

40
 b) If the seizure duration is inadequate (e.g. less than 15 - 25 sec.
motor manifestation or 20 - 30 sec. EEG evidence), restimulation at a
higher intensity may be considered after an interval of 60 - 90 sec-
onds because of the refractory period. It should be noted that during
the course of the ECT, especially in the elderly, there is a tendency
for shorter seizures and it may not be necessary to restimulate.

8.8.2 PROLONGED SEIZURES

a) Seizures persisting for more than 120 seconds by motor and/or
EEG criteria should be considered prolonged seizures. EEG monitor-
ing is recommended to monitor prolonged seizures. These should be
terminated pharmacologically by either administering more if the
anaesthetic agent (except Ketamine) or by intravenous fast-acting
benzodiazepine such as midazolam 1 - 2 mg.

b) Oxygenation should be maintained during and immediately follow-

ing prolonged seizures.

POST-ECT MANAGEMENT

9.1 Immediate post-anaesthetic care should be provided in an appropriately

equipped recovery area by a registered nurse, trained in recovery proce-
dures and resuscitation techniques, with access to prompt medical assis-
tance. The patient should be nursed in the left lateral or supine position
with a clear airway being maintained. A nurse should be present with the
patient at all times and monitor consciousness and other routine observa-
tions on a regular basis. The intravenous line should be maintained in case
rapid medication is necessary. The patient should not leave the recovery
area until alert, and should be assisted back to the ward on a wheelchair or
trolley, if appropriate.

ADVERSE EFFECTS AND THEIR MANAGEMENT

10.1 A number of immediate side effects, such as headache, myalgia, nausea,

and drowsiness are benign and should respond to symptomatic or support-
ive therapy.

10.2 The cognitive side effects of ECT are of most concern to clinicians and to
patients. It should be noted that evidence for much of this is based on
older studies which used ECT machines with sine wave stimulus and bilat-
eral electrode placement. It should also be noted that severe depressive ill-
ness per se is associated with cognitive impairment, and that this may
improve as the depression responds.

10.3 The features of an acute post-ECT delirium may vary from impaired com-
prehension and disorientation, which is not unexpected in most patients and
for which close nursing supervision and support is adequate, to severe psy-
chomotor restlessness, which may require the administration of intravenous
psychotropics. A persistent post-ECT delirium may be observed in a small
proportion of patients, in which case physical investigations should be con-
sidered. Techniques which may minimise the extent of delirium include the
use of unilateral ECT in association with moderate suprathreshold electrical
dosage, reduction in the frequency of treatment and minimisation of concur-
rent psychotropic medications.

41
 10.4 Unilateral ECT using modern brief-pulse machines is associated with mini-
mal anterograde amnesia (inability to learn new information) and minimal
retrograde amnesia (memory loss for events or information before ECT);
complete resolution by six months after treatment is expected. However,
bilateral ECT is associated with greater levels of amnesia, which may be
more persistent, although new learning, judgement and reasoning are not
affected. Retrograde memory problems, especially for autobiographical
events for up to 6 months before ECT, may continue to be noted. In some
cases, persistent subjective complaints of memory disturbance after ECT
seem to show greater correlation with residual depression, rather than with
any objective evidence30 .

10.5 There is no evidence that ECT causes any structural cerebral damage31 .

SPECIAL POPULATIONS

11.1 ECT in Children and Adolescents

11.1.1 Recent research32 33 suggests that the indications, effectiveness and

side effects of ECT in adolescents are similar to those in adults. The
predictors of response and non-response also appear to be similar.
Although there has been concern in the literature about young per-
sons having increased rates of prolonged seizures compared to
adults, the data is not compelling. Nevertheless, in the case of a
young person having ECT who experiences prolonged seizures,
propofol may be the preferred anaesthetic, especially early in the
treatment course when prolonged seizures appear more likely29 .
Concerns have been raised regarding the possibility that propofol
may reduce seizure efficacy as well as seizure length, but this has
not been adequately demonstrated by clinical trials. There is current-
ly no evidence to suggest that ECT causes damage to a young per-
son’s brain or adversely affects brain development. However, there
is very little empirical data on this subject and therefore no definite
conclusions can be drawn.

11.1.2 Consent issues warrant particularly close attention when adolescents

have ECT. It is advisable to seek the opinion of a child and adoles-
cent psychiatrist prior to the treatment. Where possible, psychomet-
ric assessment should be performed at baseline and six months after
completion of ECT.

11.1.3 Because there is little known about seizure threshold for ECT in ado-
lescent patients, the method of stimulus dosing by individual titration
of seizure threshold is recommended, starting with doses in the lower
range of the ECT machine.

ECT is very rarely given to children prior to puberty. Therefore, no clear

recommendations can be made for this age group. In the few cases
in which ECT was used, there were no problems reported34 .

42
11.2 Pregnancy
The decision whether or not to treat pregnant women with ECT needs to
take into account the risks associated with alternative treatments, the risks
to the mother and foetus of withholding ECT and any complications of the
pregnancy which may increase the risks of ECT or the anaesthetic.
Pregnancy is not a contraindication to ECT and it may be used with confi-
dence during the second and third trimesters35 . Little information is avail-
able for its use in the first trimester, including any potential teratogenic
effects of drugs associated with ECT and until further data are available
caution is advisable during this stage. ECT does not produce abnormal
uterine contractions and it appears to be safe even in complicated pregnan-
cies36 . Foetal monitoring during ECT has not revealed any untoward
effects on the foetus, although non-significant bradycardia has been noted
during the tonic-clonic phase. In selected cases, treatment may need to be
carried out in a setting which enables sophisticated maternal-foetal monitor-
ing. Careful maternal physiological monitoring is necessary and adequate
control of ECT induced hypertension may be required. Modifications to
anaesthetic technique, particularly in the third trimester, may be required to
ensure adequate oxygenation and for prevention of aspiration. Close con-
sultation and joint management with the obstetrician and anaesthetist is rec-
ommended.

11.3 The Elderly

Old age per se is not a risk factor for ECT, although many elderly will have
concurrent medical morbidity. ECT may be particularly appropriate for use
in this group of patients, given the increased incidence of psychomotor
changes and psychotic features in old age depression37 , and potential diffi-
culty in tolerating antidepressant medication.

11.4 Cultural Considerations

Special cultural factors will need to be considered in the preparation of
patients from certain cultural backgrounds and sensitivity to these needs is
urged. Care will often be needed in preparing such patients and their fami-
lies regarding treatment with ECT. For example, among the New Zealand
Maori the head is sacred and a patient’s family will need to be closely
involved and consulted. In these circumstances the indications for ECT and
all aspects of the process need to be very carefully explained and due sen-
sitivity shown at the time of treatment.

POST-ECT RELAPSE PREVENTION

12.1 ECT is an acute treatment which is associated with high rates of illness
recurrence in the absence of maintenance physical therapy38 . It would
seem best practice that all patients receive adequate pharmacotherapy for
a pre-determined period following the completion of a successful course of
ECT.

12.2 Limited data suggests that a tricyclic antidepressant or lithium at therapeutic

dosage may help reduce the risk of depressive relapse or recurrence27 ,
and there is also some experience with the use of serotonin reuptake
inhibitors39 . Preliminary evidence suggests that where any particular anti-
depressant,

43
 used in adequate dose and duration, has failed to produce a therapeutic
response prior to ECT, that antidepressant is probably not suitable as a
maintenance agent38 . It has also been speculated that the addition of an
antipsychotic drug may improve the outcome of patients with psychotic
depression.

MAINTENANCE ECT

13.1 There is a very small proportion of patients with depression who have
responded to ECT during the acute phase of their illness, but do not
respond to adequate maintenance pharmacotherapy, do so for only short
periods, or are unable to tolerate such medications. The use of intermittent
individual ECT treatments on a continuing basis, the frequency of which is
titrated according to the severity of illness, may be an effective alternative
strategy for relapse prevention in such patients. However, it should be
noted that there is a paucity of controlled trials examining the efficacy, opti-
mal duration or cognitive complications of maintenance ECT41 .

OUTPATIENT ECT

14.1 Given the safety of ECT, it may be appropriate or at times preferable for the
treatment to be given as an outpatient procedure42 . In the case of mainte-
nance or continuation ECT, treatment is given commonly on an outpatient
basis and is considered standard practice, but it may also be appropriate for
selected patients to be given an index course of ECT (two or three times
weekly) during the acute illness, as an outpatient. Individual units are
advised to develop their own criteria for patient selection, based on local
facilities and circumstances, but in general the following criteria are recom-
mended:
a) Low risk of suicide
b) Relatively less severe illnesses
c) No impairment of nutrition or hydration
d) Absence of significant concurrent medical illness
e) Low anaesthetic risk
f) Adequate family support, including providing transport to and from the
hospital
g) Adequate ability to comply with pre-ECT procedures, such as fasting
h) Minimal cognitive impairment during the course.

14.1.1Patients having outpatient ECT should not drive or operate machin-

ery on the day of treatment, and in the case of patients having an
index course, should be advised not to work or drive until after the
course is completed.

14.1.2Patients will normally require to be observed for approximately 4

hours post-ECT, as is the usual procedure for any day only proce-
dure.

14.1.3Procedures should be in place to ensure that patients are reviewed

by the treating psychiatrist at appropriate intervals between treat-
ments and that adequate communication occurs between the treating
psychiatrist and the operator performing the treatment, especially
when the treating psychiatrist is not ‘on site’.

44
EDUCATION AND TRAINING

15.1 The technique of ECT has now become a complex procedure which
requires practitioners to be adequately trained. It is no longer appropriate
for ECT to be administered by junior psychiatry trainees who have not been
trained by experienced senior practitioners. It is recommended that
trainees in psychiatry satisfy the requirements of training in ECT set down
by the RANZCP before being allowed to administer ECT unsupervised.
Practicing psychiatrists who wish to administer ECT are strongly recom-
mended to undergo specific training in modern methods of ECT, including
the use of EEG monitoring, at a recognised ECT training program.

PRIVILEGING IN ECT

16.1 It is recommended that individual hospitals consider the granting of privi-

leges to administer ECT only to those medical practitioners who have been
appropriately trained. In developing guidelines for privileging, consideration
should be given to the ongoing maintenance of skills and the frequency with
which operators are likely to be giving ECT. Giving an occasional ECT may
not be adequate to maintain the necessary skills.

ADMINISTRATIVE ISSUES

17.1 Staffing
Each facility should determine minimum standards of staffing for the proce-
dure of ECT for their own purposes, but as a guideline a minimum of three
people should be present at the treatment i.e. the operator (an appropriately
trained medical officer), a qualified anaesthetist and an ECT nurse trained
in anaesthetic and resuscitation techniques and modern ECT practice. At
least one additional registered nurse should be available to recover patients
– this number should be increased as patient numbers increase.

17.2 Consent
The following are guidelines only and are to be read in conjunction with the
relevant Mental Health Acts of New Zealand and each Australian state
which will denote the specific code of practice.

17.2.1Irrespective of the Mental Health Act in current use, all patients should be
advised of the decision to use ECT and their permission for treatment
obtained.

17.2.2It should be made clear to the patient that regardless of whether per-
mission is given for each separate occasion of treatment or for a
course of treatment of unspecified length, consent may be withdrawn
at any time.

17.2.3It is not necessary for patients to sign a consent for each treatment.
However, if there is a substantial interval between each group of
treatments then permission should again be sought and a new con-
sent form signed. In the case of maintenance (continuation) ECT, it
is recommended that patients renew their written consent at regular
intervals, e.g. every three to six months.

45
 17.2.4In certain emergency situations the specialist psychiatrist may decide
to proceed with ECT without the consent of the patient. This would
occur in the following circumstances:

a) the illness is regarded as causing serious risk to the patient or

others, or seriously impairing self care
b) ECT is deemed to be the most appropriate treatment and
c) the patient is of involuntary status and is detained under the
Mental Health Act.

17.2.5If the relevant Mental Health Act contains provisions to enable the
patient to be given ECT without consent, then treatment should pro-
ceed according to the Act. The psychiatrist should also inform the
family and seek the opinion of at least one other senior colleague.
Having obtained agreement and the opinion having been noted in the
case file, the psychiatrist in charge shall also sign and date the con-
sent form.

17.3 Documentation

17.3.1It is recommended that documentation be used which records the fol-

lowing:
a) an order for each treatment, specifying electrode placement
and signed by the treating psychiatrist
b) details of the anaesthetic agents and dosages used, signed by
the anaesthetist
c) ECT treatment parameters, namely electrical dose used,
electrode placement and seizure duration, signed by the
administering medical officer.

17.3.2Space should also be available to record comments about treatment

adequacy or untoward events.

17.3.3Separate forms should also be in use for the documentation of pre-

ECT observations and nursing procedures as well as post-ECT
recovery details.

17.3.4Care should be taken to ensure that ECT documentation complies

with any requirements which may be imposed by various Mental
Health Acts.

17.4 Organisation of ECT Service

17.4.1It is recommended that within hospitals, the provision of ECT should

be organised as an ECT Service or Department, under the direction
of a psychiatrist, which will take the responsibility for:
a) the development of Policies and Procedures for ECT,
b) supervision and quality control of ECT
c) clinical consultation
d) training of medical and nursing staff
e) post graduate education
f) research.

46
 17.4.2As far as possible, the number of clinicians involved in giving ECT on
a regular basis should be limited, to avoid loss of skills from infre-
quent practice. Hospitals should aim to have a medical practitioner
experienced in ECT present at each treatment session to deliver the
treatment and to supervise trainee psychiatrists who have not yet
reached the standard of adequate training in ECT prescribed by the
College.

17.4.3A system of clinical review should be in place to allow for the commu-
nication of information between relevant clinicians regarding the treat-
ment of each patient (e.g. EEG analysis, electrode placement and
dosage used, progress and the development of side-effects) to
ensure adequate continuity of care.

17.5 ECT Committees

The ECT service within hospitals needs good coordination and a committee
of appropriate representatives, eg of ECT-expert psychiatrists, nursing staff,
anaesthetists and administrators, is recommended. The existence of an
ECT Committee tends to raise the profile of the ECT service, should facili-
tate the settling of administrative and staffing problems and should help to
ensure appropriate ongoing funding and quality assurance.

Clinical Memorandum #12

Adopted: October 1982
Revised: January 1983; November 1986; September 1992 (GC2/92. R49. Item
4.8.1), April 1999 (GC1/99, R40)
Currency: Review no later than 5 years after initial approval and each subse-
quent 5 years (Initial review by GC1/04).

47
 REFERENCES

1 Hoflich, G. Kasper, S. Burghof, K.W. Scholl, H.P. Moller, H.J.

Maintenance ECT for treatment of therapy-resistant paranoid schizophrenia
and Parkinson’s disease. Biological Psychiatry 1995; 37(12): 892-4.

2 Fink, M.F: Convulsive Therapy: Theory and Practice. Raven Press, New
York, 1979.

3 Kramer, B. Use of ECT in California, 1977-1983. American J. of Psychiatry

142: 1190-1192, 1985.

4 Zwil A, Pelchat R. ECT in the treatment of patients with neurological and

somatic disease. International Journal of Psychiatry in Medicine 1994; 24:
1-29.

5 Price T, McAllister T. Safety and efficacy of ECT in depressed patients with

dementia: a review of clinical experience. Convulsive Therapy 1989; 5(1):
61-74.

6 Maltbie A, Wingfield M, Volow M, Weiner R, Sullivan J, Cavenar J.

Electroconvulsive therapy in the presence of brain tumor. The Journal of
Nervous and Mental Disease 1980; 168(7): 400-405.

7 Hsiao J, Messenheimer J, Evans D. ECT and neurological disorders.

Convulsive Therapy 1987; 3(2): 121-136.

8 Abrams R. Electroconvulsive therapy (3rd Edition) New York: Oxford

University Press, 1997.

9 Curran S and Freeman CP. ECT and Drugs. (In the ECT Handbook.
Second report of the Royal College of Psychiatrists Special Committee on
ECT). Ed. CP Freeman. London: Royal College of Psychiatrists 1995.

10 Betts TA, Kalra PL, Cooper R et al. (1968) Epileptic fits as a probable side
effect of Amitriptyline. Lancet 1, 390-392.

11 Foulke GEN, Albertson TE (1987) QRS Interval in Tricyclic Antidepressant

Overdosage; inaccuracy as a toxicity indicator in emergency settings.
Annals of Emergency Medicine, 16, 160-163.

12 Freeman CP and Kendell RE (1980). ECT; patients experiences and atti-

tude. British Journal of Psychiatry 137, 8-16.

13 Gutierrez-Esteinou R and Pope HG (1989) Does Fluoxetine prolong electri-

cally induced seizures. Convulsive Therapy 5, 344-348.

14 Freese KJ (1985) Can Patients Safely Undergo Electroconvulsive Therapy

while receiving monoamine oxidase inhibitors? Convulsive Therapy 1, 191-
194.

15 Hill GE, Wong KC, Hodges MR (1976) Potentiation of succinylcholine neu-

romuscular blockade by Lithium Carbonate. Anaesthesiology 44, 439-442.

48
16 Penney JF, Dinwiddie SH, Zorumski CP, Wetzel ID (1990) Concurrent and
close temporal administration of Lithium and ECT. Convulsive Therapy 6,
139-145.

17 Recommended minimum facilities for safe anaesthetic practice in ECT.

Review T4 (1994). Australian and New Zealand College of Anaesthetists.

18 Guidelines for the Careof Patients Recovering from Anaesthesia. Review

P4 (1995). Australian and New Zealand College of Anaesthetists.

19 Sackeim, H.A. et al. Effects of stimulus intensity and electrode placement

on the efficacy and cognitive effects of electroconvulsive therapy. New
England Journal of Medicine 1993; 328: 839-846.

20 Murugesan, G: Electrode placement, stimulus dosing and seizure monitor-

ing during ECT. Australian and New Zealand Journal of Psychiatry 1994:
28: 675-683.

21 Gregory, S. Shawcross, C.R. Gill, D. The Nottingham ECT study. A double-

blind comparison of bilateral, unilateral and simulated ECT in depressive ill-
ness. British Journal of Psychiatry 1985; 146: 520-524.

22 Abrams, R. et al. Bilateral versus unilateral electroconvulsive therapy: effi-

cacy in melancholia. American Journal of Psychiatry 1983; 140; 463-465.

23 Sackeim, H.A. Decina, P. Kanzler, M. Kerr, B. Malitz, S. Effects of elec-

trode placement on the efficacy of titrated, low-dose ECT. American Journal
of Psychiatry 1987; 144: 1449-1455.

24 Weeks, D. Freeman, C.P. Kendall, R.E. ECT:III. Enduring cognitive

deficits? British Journal of Psychiatry 1980; 137: 26-37.

25 Horne, R.L. Pettinati, H.M. Sugarman, A.A. Varga, E. Comparing bilateral

to unilateral electroconvulsive therapy in a randomized study with EEG
monitoring. Archives of General Psychiatry 1985; 42: 1087-1092.

26 Abrams, R. Swartz, C.M. Vedak, C. Antidepressant effects of high-dose

right unilateral electroconvulsive therapy. Archives of General Psychiatry
1991; 48:746-748.

27 Sackeim, H.A. Decina, P. Prohovnik, I. Malitz, S. Seizure threshold in

electroconvulsive therapy; effects of sex, age, electrode placement, and
number of treatments. Archives of General Psychiatry 1987; 44:355-360.

28 American Psychiatric Association. The practice of electroconvulsive therapy:

recommendations for treatment, training and privileging. Washington D.C.:
American Psychiatric Association, 1990.

29 Abrams, R. Electroconvulsive therapy. Second edition. New York: Oxford

University Press, 1992.

30 Weiner RD, Rogers HJ, Davidson JRT, Squire LR. Effects of stimulus para-
meters on cognitive side-effects. Ann NY Acad Sci 1986; 462:315-325.

49
 31 Devanand DP, Dwork AJ, Hutchinson ER, Bolwig TG and Sackheim HA
(1994) Does ECT alter brain structure? Am J Psychiatry 151, 957-970.

32 Rey JM, Walter G. Half a century of ECT use in young people. American
Journal of Psychiatry 1997; 154: 595-602.

33 Walter G, Rey JM. An epidemiological study of the use of ECT in adoles-

cents. Journal of the American Academy of Child and Adolescent Psychiatry
1997; 36: 809-815.

34 Hill MA, Courvoise H, Dawkins K, Nofal P, Thomas B. ECT for the treatment
of intractable mania in two prepubertal male children. Convulsive Therapy
1997; 13: 74-82.

35 Lock T. ECT and Obstetrics. In: Freeman C, ed. The ECT Handbook: The
Second Report of the Royal College of Psychiatrists’ Special Committee on
ECT. London: Royal College of Psychiatrists, 1995: 22-23.

36 Ferril M, Kehoe W, Jacisin J. ECT during pregnancy: physiologic and phar-

macologic considerations. Convulsive Therapy 1992; 8(3): 186-200.

37 Brodaty H. In Melancholia. A disorder of movement and mood. (Eds

Parker and Hadzi-Pavlovic) New York: Cambridge University Press 1996.

38 Sackheim HA, Prudic J, Devanand DP et al. (1990) The impact of medica-

tion resistance and continuation pharmacotherapy on relapse following
response to electroconvulsive therapy in major depression. J Clin
Psychopharmacol 10, 96-104.

39 Lauritzen L, Odgaard K, Clemmensen L, Lunde M, Ohrstrom J, Black C,

Bech P. (1996). Relapse prevention by means of paroxetine in ECT-treated
patients with major depression: a comparison with imipramine and placebo
in medium-term continuation therapy. Acta Psychiatr Scand 94, 241-251.

40 Flint AJ and Rifat SL (1998) Two-year outcome of psychotic depression in

late life. Am J Psychiatry 155, 178-183.

41 Monroe RR (1990) Maintenance electroconvulsive therapy. Psychiatr Clin

North Am 14, 947-960.

42 Fink M, Abrams R, Bailine S, Jaffe R. Ambulatory Electroconvulsive

Therapy: Report of a task force of the Association for Convulsive Therapy.
Convulsive Therapy 1996; 12(1): 42-55.

50
References

Australian And New Zealand College Of Petrides, G. and Fink, M. (1996), The ‘Half- Age’
Anaesthetists (1991), Privileges in Anaesthesia Faculty Stimulation Strategy for ECT Dosing, Convulsive
Policy, Review P2, Faculty of Anaesthetists, RACS. Therapy, 12, pp 138-146.

Australian And New Zealand College Of Pippard, J (1988), ECT Custom and Practice,
Anaesthetists (1992), The Pre-Anaesthetic Consultation, Psychiatric Bulletin, 12, pp 473-475.
Review P7.
Pippard, J (1992), Administration of ECT, Psychiatric
Australian And New Zealand College Of Bulletin, 16, pp 59-62.
Anaesthetists (1993), Minimum Assistance Required for
Royal Australian and New Zealand College of
the Safe Conduct of Anaesthesia, Review P8.
Psychiatrists (1999), Clinical Memorandum #12:
Australian And New Zealand College Of Electroconvulsive Therapy.
Anaesthetists (1994), Recommended Minimum
Royal Australian and New Zealand College of
Facilities For Safe Anaesthetic Practice For
Psychiatrists (1999), Electroconvulsive Therapy
Electroconvulsive Therapy (ECT), Review T4.
Explained
Australian And New Zealand College Of
Royal College of Psychiatrists (1995), The ECT
Anaesthetists (1994), The Supervision of Trainees in
Handbook Council Report, CR 39.
Anaesthesia, Review E3.
Sackeim, H.A; Decina, P; Kanzeler, M; et al (1987),
Australian And New Zealand College Of
‘Effects of Electrode Placement on Efficacy of
Anaesthetists (1995), Monitoring During Anaesthesia,
Titrated, Low-Dose ECT’, American Journal of
Review P18.
Psychiatry, 144, pp 1449-1455.
Australian And New Zealand College Of
Swartz, C.M; Abrams, R; (1995), ECT Instruction
Anaesthetists (1995), Joint Consultative Committee on
Manual, Chicago: Somatics Inc.
Anaesthesia Guidelines for Accreditation/Re-
Accreditation of Rural GP Anaesthetists.

Mental Health Act 1986, (Reprint No.5)

Incorporating amendments up to 1 July 1998).

51
 Notes

52
Notes

53
 Notes

54