The previous edition of The ECT Handbook was produced in 2005, shortly after the publication of the National Institute for Health and Clinical Excellence (NICE) Technology Appraisal Guidance on the Use of Electroconvulsive Therapy (TA59; National Institute for Health and Clinical Excellence, 2003). There was concern within the Royal College of Psychiatrists’ Special Committee on ECT (now Special Committee on ECT and Related Treatments) about the contents of the NICE recommendations. A Consensus Group was convened to consider the College's response to NICE. The opening chapter of the second edition of The ECT Handbook set out the areas of divergence between the College and NICE.

No full review of TA59 has been undertaken; the NICE guidance on the use of ECT for conditions other than depression remains unaltered. However, in October 2009 NICE published a clinical guideline on depression (CG90), which includes recommendations on the use of ECT in the treatment of depression. There are significant changes in this advice from that which was contained in TA59. The Special Committee welcomes and endorses the revised guidance contained in CG90. There are now no substantial differences between the College's views and those of NICE on the place of ECT in the treatment of depression. The Special Committee's views are also in line with those of the British Association for Psychopharmacology (Anderson et al, 2008).

Depression

The National Institute for Health and Clinical Excellence (2009) states that ECT should be considered for severe depression that is life-threatening, or where a rapid response is required or where other treatments have failed. Electroconvulsive therapy should not be used routinely in moderate depression but should be considered if there has been no response to multiple drug treatments and psychological treatment. If patients have not responded well to ECT in the past, ECT should only be considered again after review of the adequacy of previous treatment, a consideration of other options and after discussion with the patient and their advocates or carers if appropriate.

There is advice on the process of consent and compliance with mental health legislation. The choice of electrode placement and stimulus dose should balance efficacy against the risk of cognitive impairment. Bilateral ECT is more effective than unilateral ECT but may cause more cognitive impairment; with unilateral ECT, a higher stimulus dose is associated with greater efficacy, but also increased cognitive impairment compared with a lower stimulus dose.