It is important to evaluate any patient's response to any treatment. This is especially the case for an emotive and serious intervention such as ECT. This chapter will offer advice on evaluating response, in terms of the relief of the patient's psychiatric symptoms, monitoring seizures in the ECT clinic and assessing the cognitive effects of ECT.
Establishing a baseline
It is necessary to quantify the severity of the patient's symptoms before starting treatment. Assessments should be undertaken by the referring team before, during and after the course of treatment.
Depression is the most common indication for ECT. The Montgomery– Åsberg Depression Rating Scale (MADRS) (Montgomery & Åsberg, 1979) has been widely used for assessing auditing response to ECT. It has been found to be acceptable to both patients and practitioners and is recommended for routine use. The Hamilton Rating Scale for Depression (Hamilton, 1960), which has often been used in research, would be an alternative. For patients receiving ECT for other indications such as mania or catatonia, the Brief Psychiatric Rating Scale (BPRS) (Lukoff et al, 1986) or Global Assessment of Functioning (GAF) (Piersma & Boes, 1997) could be considered. Whatever the indication for treatment is, a baseline level of severity on the Clinical Global Impression of Severity (CGI-S) (Guy & Bonato, 1976) should be documented before the course starts (Box 6.1).
Before starting a course of ECT, the patient's level of functioning in memory, verbal and non-verbal cognitive domains should be established. Most patients starting a course of ECT will be severely ill. They may be reluctant or unable to participate in detailed neuropsychological assessment. Most UK clinics use the MMSE (Folstein et al, 1975). This is not an entirely satisfactory instrument, but it has the advantage that most clinical staff are familiar with its use. It is suggested that clinics continue to use the MMSE until it is demonstrated that a better alternative exists. Practitioners should be aware that the MMSE is copyright and that there may be clinically relevant cognitive impairment which the MMSE cannot detect (see Chapter 8).