Since the last edition of The ECT Handbook was published there have been three important developments: the implementation of accreditation services for ECT clinics, revision of the mental health legislation and the publication of the National Institute for Health and Clinical Excellence (NICE) guidance on the management of depression that significantly amends the recommendations on the use of ECT in depressive disorders.

The ECT Accreditation Service (ECTAS) and the Scottish ECT Accreditation Network (SEAN) had been planned at the time of the last handbook; they are now firmly established as a means of ensuring enhancing the standards of clinical practice in ECT in member clinics. Participating in the accreditation process has led nurses working in ECT to develop their own networks: the Committee of Nurses at ECT in Scotland (CONECTS) and the National Association of Lead Nurses in ECT (NALNECT) in other parts of the UK. Progressive cycles of ECTAS peer review have been successful in improving levels of performance by member clinics.

In Britain, the 2007 amendments of the Mental Health Act 1983 and the Mental Health (Care and Treatment) Act (Scotland) 2003 have changed the legal framework for patients who do not or cannot consent to ECT; patients with capacity who refuse ECT may not be given the treatment contrary to their objections. There is also new legislation on mental health treatment in Ireland (Mental Health Commission, 2009 a,b) and the law in Northern Ireland in being revised.

The NICE (2009) guidelines for the treatment and management of depression in adults include revised recommendations of the use of ECT in depressive illness. The Royal College of Psychiatrists’ Special Committee on ECT welcomes and endorses this new guidance.

The Special Committee on ECT and Related Treatments, like NICE, has reversed its previous recommendation in favour of routine adoption of unilateral electrode placement. New evidence from an adequately powered, methodologically sound study (Kellner et al, 2010) has allowed reconsideration of the balance between maximising the benefit of ECT and minimising adverse cognitive effects. The Committee now feels that for most patients receiving ECT in Britain, treatment should start with bitemporal electrode placement.