The primary indication for ECT is major depression (Weiner and Falcone, 2011). Some see it as the gold standard for treatment-resistant depression (Nahas and Anderson, 2011). ECT’s response rate of 80% or more for most patients is better than response rates for antidepressant medications, and is considered to be the most effective antidepressant in use (Keltner and Boschini, 2009).

It can be used for people in most age-groups who cannot tolerate or fail to respond to treatment with medication. Box 29-1 lists the primary and secondary criteria for the use of ECT as determined by the American Psychiatric Association (APA) Task Force on Electroconvulsive Therapy.

BOX 29-1 CRITERIA FOR THE USE OF ELECTROCONVULSIVE THERAPY (ECT)

Primary Use

Situations in which electroconvulsive therapy may be used before a trial of psychotropic medications include, but are not limited to, the following:

• Need for rapid, definitive response owing to the severity of a psychiatric or medical condition

• Risks of other treatments outweigh the risks of ECT

• History of poor medication response or good ECT response in one or more previous episodes of the illness

• Patient preference

Secondary Use

In other situations a trial of an alternative therapy should be considered before referral for ECT. Subsequent referral for ECT should be based on at least one of the following:

• Treatment resistance (taking into account issues such as choice of medication, dosage, duration of trial, and compliance)

• Intolerance or adverse effects with pharmacotherapy that are deemed less likely or less severe with ECT

• Deterioration of the patient’s psychiatric or medical condition that creates a need for a rapid, definitive response

From American Psychiatric Association: The practice of electroconvulsive therapy: recommendations for treatment, training, and privileging, ed 2, Washington, DC, 2001, The Association.

Primary criteria in which ECT may play a life-saving role involve patients who are extremely depressed and suicidal or are so hyperactive that they are in grave danger of self-harm, such as those with acute mania and affective disorders with psychosis. ECT is considered appropriate for patients with schizophrenia in a few situations. This includes when psychotic symptoms have an abrupt or recent onset, the duration of illness is short, catatonia is present, or the patient has responded well to ECT in the past.

Finally, ECT should be an initial intervention when its anticipated side effects are considered less harmful than those associated with drug therapy in populations such as the elderly, patients with heart block, and women who are pregnant. The potential effectiveness of ECT is reduced in those with personality disorders. Box 29-2 summarizes behaviors for which ECT is and is not effective.

BOX 29-2 TARGET BEHAVIORS FOR ELECTROCONVULSIVE THERAPY (ECT)

ECT Proved Effective

• Catatonia

• Severe psychosis with acute onset

• Life-threatening psychiatric conditions

• Rigidity of parkinsonism or neuroleptic malignant syndrome

ECT Proved Ineffective

• Severe character pathology

• Substance abuse and dependence

• Sexual identification disorders

• Psychoneurosis

• Chronic illness without obvious psychopathology

Critical Reasoning

Why would ECT be particularly indicated for depressed patients with heart block?

Critical Reasoning

Many misconceptions exist regarding ECT. Many of these are perpetuated by movies. Observe ECT in person and then watch the movies One Flew Over the Cuckoo’s Nest, Frances, Ordinary People, and Girl Interrupted and critique the way in which ECT is presented.

Before ECT treatment begins, an informed consent form must be signed by the patient or, if the patient does not have the capacity to give consent, by a legally designated person (Chapter 8). This consent acknowledges the patient’s rights to obtain or refuse treatment. Although it is the physician’s ultimate responsibility to explain the procedure when obtaining consent, the nurse plays an important part in the consent process (Fetterman and Ying, 2011).

Informed consent is a dynamic process that is not completed with the signing of a formal document; rather, the process continues throughout the course of treatment. It is helpful if a nurse is present when ECT is discussed with the patient. It is preferred that this is a nurse who already has established a trusting and therapeutic relationship with the patient.

The nurse also can ensure that, before signing the consent form, the patient has understood fully the explanation of ECT, including its nature, purpose, and implications, and that the patient has the option to withdraw consent at any time. After the consent form has been signed but before the beginning of treatment, the nurse should again thoroughly review the information and discuss the treatment with the patient in an open and direct manner.

Certain patients pose particular challenges to the nurse when obtaining informed consent. If a patient is unable to make independent judgments and meaningful decisions about care and treatment, the nurse is responsible for acting as a patient advocate.

For example, concentration is often impaired in depressed patients, so they are less likely to comprehend and retain new information. For these patients it is essential that the nurse repeat the information at regular intervals because new knowledge is seldom fully absorbed after only one explanation. Then, throughout the patient’s treatment course, the nurse should reinforce relevant information, remind the patient of anything that may have been forgotten, and answer any new questions.

Pretreatment Nursing Care

Providing quality nursing care for the patient receiving ECT includes evaluating the pretreatment protocol to ensure that it has been followed according to hospital policy. This involves reviewing recommended consultations, noting that any abnormalities in laboratory tests have been addressed, and checking that equipment and supplies are adequate and functional.

The treatment nurse is responsible for ensuring proper preparation of the treatment suite. Box 29-3 provides a list of standard equipment needed to provide optimal patient care. A crash cart with defibrillator should be readily available for emergency use.

BOX 29-3 EQUIPMENT FOR ELECTROCONVULSIVE THERAPY