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9 results

  • 12 - Inspection of ECT clinics

  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published by:
    Royal College of Psychiatrists
    Published online:
    25 February 2017, pp 109-112

  • Summary

    The ECT Accreditation Service (ECTAS)

    In the early 1980s there was an editorial in The Lancet entitled ‘ECT in Britain: a shameful state of affairs’ (Lancet, 1981). This was at a time when ECT was the main target of the anti-psychiatry movement and there were regular protests outside Royal College of Psychiatrists’ meetings about the use of ECT. Paradoxically, several of the UK randomised controlled trials of ECT had been published and others were under way, so the evidence base for the efficacy was stronger than it had ever been. The College had just completed its first survey of the use and practice of ECT, concluding that standards of practice were low, equipment was outdated and regional variations were enormous. The author of The Lancet editorial concluded that it was not ECT that was bringing psychiatry in disrepute, it was psychiatrists and the way they practised.

    The College conducted further surveys of practice in the late 1980s and early 1990s, sadly showing that standards were improving little. The Special Committee on ECT (now Special Committee on ECT and Related Treatments) began running regular training courses which several thousand psychiatrists have now attended. More recently there have been increasing numbers of anaesthetic and nursing delegates.

    Thirty years on, we now have a third edition of The ECT Handbook, guidelines from NICE endorsing the use of ECT (National Institute for Clinical Excellence, 2003; National Collaborating Centre for Mental Health, 2010) and we have ECTAS.

    Over the first 20 years the rate of ECT steadily fell and if the slope had not levelled out it would have crossed zero in 2012. This did not happen, and the past 10 years have shown a levelling of the rates of giving ECT, with some areas showing a rise. National figures are no longer collected. This contrasts with the situation in North America, where the rates of ECT use have been rising, and raises the view that ECT may be underused, causing patients with severe and chronic depression to suffer for much longer, as antidepressant after antidepressant is changed.

    Whatever the future of ECT, it is vitally important that when it is given, it is given appropriately, safely and with due concern to a patient's consent and dignity. The ECT Accreditation Service aims to assure and improve the quality of the administration of ECT.

  • 8 - Cognitive adverse effects of ECT

  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published by:
    Royal College of Psychiatrists
    Published online:
    25 February 2017, pp 76-86

  • Summary

    The study of the impact of ECT on memory begins with Janis's studies (1950), when most ECT was given unmodified and with a sine wave stimulus. Sine wave ECT has not been used in the UK for the past 25 years, although it is still used around the world and, surprisingly, still used in the USA (Sackeim et al, 2007). Previous reviews have combined studies undertaken using different electrode placements (see Chapter 4) and different pulse widths, which has made the interpretation of the nature and severity of memory impairment difficult to assess. The recommendations in this chapter are based on studies that have used brief pulse and ultra-brief pulse stimuli carried out mainly from the mid-1980s onwards.

    A couple of studies that do not quite fit into the mould are worthy of comment. Ottoson's (1960) landmark research compared three groups with case-matched controls. The groups were high-dose bilateral ECT, a suprathreshold group and a group where the seizure was triggered with a suprathreshold stimulus and then aborted by intravenous lidocaine. The results led to the influential conclusion that it was the electricity rather than the seizure that caused memory impairment, because the high-dose stimulus caused more memory impairment than the suprathreshold and shortening the seizure length with lidocaine did not protect memory. These results have not entirely been borne out by more modern research and are difficult to interpret because Ottoson used a partial (quarter-wave) sine wave stimulus which lies somewhere between traditional sine wave and brief-pulse stimulus. Further research in this area has not clarified the situation. For example:

    1. • Weiner et al (1986) found no relationship between stimulus dose and autobiographical memory using brief pulse unilateral and bilateral ECT

    2. • Coffey et al (1990) found no relationship between electrical dose and Wechsler Memory Scale scores or time to orientation using brief pulse right unilateral ECT

    3. • Miller et al (1985) found a significant relationship between memory impairment and seizure duration with brief pulse right unilateral ECT

    4. • Sackeim et al (1986) found a significant correlation between seizure duration and post-ictal disorientation brief pulse right unilateral ECT

    5. • Calev et al (1991) found a significant correlation between seizure duration and post-ictal disorientation using brief pulse bitemporal ECT.

  • 2 - The ECT suite

  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published by:
    Royal College of Psychiatrists
    Published online:
    25 February 2017, pp 8-13

  • Summary

    There should ideally be a designated area for ECT within each general psychiatry unit; this is recommended on the basis of patient convenience and economy of nurse staffing. However, it is recognised that with the numbers of patients undergoing ECT falling, there is an increasing trend for psychiatric services to share one facility in an attempt to maintain standards of anaesthetic and psychiatric practice within the confines of a National Health Service budget.

    Suite layout

    The design of the ECT suite will depend on the type of service provided. The minimum requirement for a local unit with small patient numbers is two rooms: a treatment room and a recovery room. An ECT unit where patients would be required to wait before treatment will need a waiting room in addition. A suite providing ECT to neighbouring psychiatric units should ideally include an ECT office and a final post-ECT waiting area.

    The waiting room should be a comfortable, relaxing and informal environment, with a range of distractions, for example an outside window, pictures and magazines, and toilet facilities should be available. Patients’ arrival should be booked to provide a smooth throughput with the minimum amount of waiting time. Patients waiting for ECT should not be able to see into the treatment area while the treatment is taking place, and patients waiting for treatment should not be in the same room as patients who have completed their treatment.

    The treatment room should be accessible from the waiting area. In the treatment area the patient is assisted onto a trolley or bed and prepared for treatment. This room should be well lit and contain all the equipment necessary for routine and emergency treatment. It should be big enough to allow unrestricted staff movements. Adequate work surfaces and a sink with hot and cold water should be available. There should be a clock with a second hand. If nitrous oxide and/or anaesthetic inhalation agents are ever used, the treatment room should be equipped with scavenging equipment and agent monitoring. There should be good sound-proofing between the waiting area and treatment room.

    The recovery area must be large enough to accommodate easily the trolleys and associated monitors of all the patients who are regaining consciousness, and there should be enough room for recovery nursing staff to work in.

  • A new service model for the treatment of severe anorexia nervosa in the community: the Anorexia Nervosa Intensive Treatment Team

  • Calum Munro, Victoria Thomson, Jean Corr, Louise Randell, Jennie E. Davies, Claire Gittoes, Vicky Honeyman, Chris P. Freeman
  • Journal:
    The Psychiatric Bulletin / Volume 38 / Issue 5 / October 2014
    Published online by Cambridge University Press:
    02 January 2018, pp. 220-225
    Print publication:
    October 2014
    • Article
      • You have access
      • Open access
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  • Aims and method

    A community intensive treatment service for severe anorexia nervosa is described. The service is multidisciplinary but driven by a focus on psychological formulation. Psychological and dietetic interventions are grounded in a process of active risk management. Evaluations of safety, cost and acceptability of the service are described.

    Results

    Patients are highly satisfied with their care. A relatively low mortality rate for such a high-risk population was observed. In-patient bed use and costs were substantially reduced.

    Clinical implications

    There is a case for greater use of intensive community care for patients with severe anorexia nervosa, as it can be acceptable to patients, relatively safe and cost less than admission.

  • 8 - Cognitive adverse effects of ECT

    • By Chris P. Freeman, Regional Consultant for Eating Disorders, Royal Edinburgh Hospital, and The Old Pencaitland Farmhouse, East Lothian
  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published online:
    02 January 2018
    Print publication:
    01 May 2013, pp 76-86

  • Summary

    The study of the impact of ECT on memory begins with Janis's studies (1950), when most ECT was given unmodified and with a sine wave stimulus. Sine wave ECT has not been used in the UK for the past 25 years, although it is still used around the world and, surprisingly, still used in the USA (Sackeim et al, 2007). Previous reviews have combined studies undertaken using different electrode placements (see Chapter 4) and different pulse widths, which has made the interpretation of the nature and severity of memory impairment difficult to assess. The recommendations in this chapter are based on studies that have used brief pulse and ultra-brief pulse stimuli carried out mainly from the mid-1980s onwards.

    A couple of studies that do not quite fit into the mould are worthy of comment. Ottoson's (1960) landmark research compared three groups with case-matched controls. The groups were high-dose bilateral ECT, a suprathreshold group and a group where the seizure was triggered with a suprathreshold stimulus and then aborted by intravenous lidocaine. The results led to the influential conclusion that it was the electricity rather than the seizure that caused memory impairment, because the high-dose stimulus caused more memory impairment than the suprathreshold and shortening the seizure length with lidocaine did not protect memory. These results have not entirely been borne out by more modern research and are difficult to interpret because Ottoson used a partial (quarter-wave) sine wave stimulus which lies somewhere between traditional sine wave and brief-pulse stimulus. Further research in this area has not clarified the situation. For example:

  • • Weiner et al (1986) found no relationship between stimulus dose and autobiographical memory using brief pulse unilateral and bilateral ECT

  • • Coffey et al (1990) found no relationship between electrical dose and Wechsler Memory Scale scores or time to orientation using brief pulse right unilateral ECT

  • • Miller et al (1985) found a significant relationship between memory impairment and seizure duration with brief pulse right unilateral ECT

  • • Sackeim et al (1986) found a significant correlation between seizure duration and post-ictal disorientation brief pulse right unilateral ECT

  • • Calev et al (1991) found a significant correlation between seizure duration and post-ictal disorientation using brief pulse bitemporal ECT.

    • Given the above studies, there is probably just sufficient evidence to continue measuring time to re-orientation after each treatment.

  • 2 - The ECT suite

    • By Chris P. Freeman, Regional Consultant for Eating Disorders, Royal Edinburgh Hospital, and The Old Pencaitland Farmhouse, East Lothian, Grace M. Fergusson, Consultant Psychiatrist, Argyll and Bute Hospital, Lochgilphead
  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published online:
    02 January 2018
    Print publication:
    01 May 2013, pp 8-13

  • Summary

    There should ideally be a designated area for ECT within each general psychiatry unit; this is recommended on the basis of patient convenience and economy of nurse staffing. However, it is recognised that with the numbers of patients undergoing ECT falling, there is an increasing trend for psychiatric services to share one facility in an attempt to maintain standards of anaesthetic and psychiatric practice within the confines of a National Health Service budget.

    Suite layout

    The design of the ECT suite will depend on the type of service provided. The minimum requirement for a local unit with small patient numbers is two rooms: a treatment room and a recovery room. An ECT unit where patients would be required to wait before treatment will need a waiting room in addition. A suite providing ECT to neighbouring psychiatric units should ideally include an ECT office and a final post-ECT waiting area.

    The waiting room should be a comfortable, relaxing and informal environment, with a range of distractions, for example an outside window, pictures and magazines, and toilet facilities should be available. Patients’ arrival should be booked to provide a smooth throughput with the minimum amount of waiting time. Patients waiting for ECT should not be able to see into the treatment area while the treatment is taking place, and patients waiting for treatment should not be in the same room as patients who have completed their treatment.

    The treatment room should be accessible from the waiting area. In the treatment area the patient is assisted onto a trolley or bed and prepared for treatment. This room should be well lit and contain all the equipment necessary for routine and emergency treatment. It should be big enough to allow unrestricted staff movements. Adequate work surfaces and a sink with hot and cold water should be available. There should be a clock with a second hand. If nitrous oxide and/or anaesthetic inhalation agents are ever used, the treatment room should be equipped with scavenging equipment and agent monitoring. There should be good sound-proofing between the waiting area and treatment room.

    The recovery area must be large enough to accommodate easily the trolleys and associated monitors of all the patients who are regaining consciousness, and there should be enough room for recovery nursing staff to work in.

  • 12 - Inspection of ECT clinics

    • By Chris P. Freeman, Regional Consultant for Eating Disorders, Royal Edinburgh Hospital, and The Old Pencaitland Farmhouse, East Lothian, Joanne Cresswell, ECTAS Programme Manager, ECTAS, Centre for Quality Improvement, Royal College of Psychiatrists, Grace M. Fergusson, Consultant Psychiatrist, Argyll and Bute Hospital, Lochgilphead, Linda Cullen, National Clinical Coordinator, Scottish ECT Audit Network
  • Edited by Jonathan Waite, Andrew Easton
  • Book:
    The ECT Handbook
    Published online:
    02 January 2018
    Print publication:
    01 May 2013, pp 109-112

  • Summary

    The ECT Accreditation Service (ECTAS)

    In the early 1980s there was an editorial in The Lancet entitled ‘ECT in Britain: a shameful state of affairs’ (Lancet, 1981). This was at a time when ECT was the main target of the anti-psychiatry movement and there were regular protests outside Royal College of Psychiatrists’ meetings about the use of ECT. Paradoxically, several of the UK randomised controlled trials of ECT had been published and others were under way, so the evidence base for the efficacy was stronger than it had ever been. The College had just completed its first survey of the use and practice of ECT, concluding that standards of practice were low, equipment was outdated and regional variations were enormous. The author of The Lancet editorial concluded that it was not ECT that was bringing psychiatry in disrepute, it was psychiatrists and the way they practised.

    The College conducted further surveys of practice in the late 1980s and early 1990s, sadly showing that standards were improving little. The Special Committee on ECT (now Special Committee on ECT and Related Treatments) began running regular training courses which several thousand psychiatrists have now attended. More recently there have been increasing numbers of anaesthetic and nursing delegates.

    Thirty years on, we now have a third edition of The ECT Handbook, guidelines from NICE endorsing the use of ECT (National Institute for Clinical Excellence, 2003; National Collaborating Centre for Mental Health, 2010) and we have ECTAS.

    Over the first 20 years the rate of ECT steadily fell and if the slope had not levelled out it would have crossed zero in 2012. This did not happen, and the past 10 years have shown a levelling of the rates of giving ECT, with some areas showing a rise. National figures are no longer collected. This contrasts with the situation in North America, where the rates of ECT use have been rising, and raises the view that ECT may be underused, causing patients with severe and chronic depression to suffer for much longer, as antidepressant after antidepressant is changed.

    Whatever the future of ECT, it is vitally important that when it is given, it is given appropriately, safely and with due concern to a patient's consent and dignity. The ECT Accreditation Service aims to assure and improve the quality of the administration of ECT.

  • Psychiatric morbidity in patients referred for individual psychotherapy within and outwith the NHS

  • John R. Mitchell, Chris P. Freeman
  • Journal:
    Psychiatric Bulletin / Volume 23 / Issue 3 / March 1999
    Published online by Cambridge University Press:
    02 January 2018, pp. 146-149
    Print publication:
    March 1999
    • Article
      • You have access
      • Open access
    • PDF
    • Export citation
  • Aims and method

    Demographic and medical characteristics of waiting list patients for National Health Service (NHS) psychotherapy, non-NHS psychotherapy or NHS general adult psychiatry were compared by postal questionnaires.

    Results

    One hundred and eighty-three subjects replied. High rates of psychiatric morbidity were reported in both psychotherapy populations but general psychiatric referrals were more disturbed, taking more psychotropic medication than non-NHS psychotherapy but not NHS psychotherapy subjects. The biggest referral source to non-NHS psychotherapy was general practitioners.

    Clinical implications

    Non-NHS psychotherapists should be able to recognise severe mental illness and have a basic understanding of psychotropic medication and psychiatric services.

  • ECT in Scotland

  • Carol Robertson, Chris P. L. Freeman, Grace Fergusson
  • Journal:
    Psychiatric Bulletin / Volume 21 / Issue 11 / November 1997
    Published online by Cambridge University Press:
    02 January 2018, pp. 699-702
    Print publication:
    November 1997
    • Article
      • You have access
      • Open access
    • PDF
    • Export citation

  • Previous audit of electroconvulsive therapy (ECT) standards has identified deficiencies in service provision. Little national information was available on ECT services in Scotland. Survey questionnaires were sent to all consultants in charge of ECT clinics in Scotland. There was a 100% response rate. The service provision varied across Scotland, and in some cases fell below Royal College of Psychiatrists' recommendations. There now exists a base of information on services available and an ongoing national audit system should be considered. Several recommendations have been made for the future of ECT services in Scotland and these have been distributed to consultants in charge of clinics.