Assessment before ECT
The adverse effects of ECT are a major concern for people treated with ECT, their families and the public. During the assessment process, before the person consents to treatment, the risk–benefit balance for a particular person will be considered and discussed. If there are reasons why this person might be at greater risk of particular adverse effects, ways in which the risk might be minimised should be considered. For example, people with concurrent dementia may be at increased risk of developing cognitive adverse effects during ECT (Griesemer et al, 1997; Krystal & Coffey, 1997) and for this reason unilateral ECT may be preferred to bilateral ECT (see Chapter 4). Similarly, people with existing cardiac disease may be at risk of adverse cardiac events during treatment and therefore may be treated more safely in a cardiac care unit with specialist staff to hand (see Chapter 19).
As far as possible, patients and their families should be involved in discussions about the treatment, its likely adverse effects, its possible benefits, any alternative treatments and the risks (if any) of not having the treatment. The use of written as well as verbal information is good practice.
Electroconvulsive therapy is a low-risk procedure with a mortality rate similar to that of anaesthesia for minor surgical procedures, despite its frequent use in elderly people and those with major medical problems (Sackeim, 1998; Weiner et al, 2000). An audit in the USA found that there were no deaths directly related to ECT reported in any Veterans Affairs hospital between 1999 and 2010 (Watts et al, 2011). This suggests – based on the number of treatments given – that ECT mortality is less than 1 death per 73 440 treatments.
In earlier studies, Shiwach et al (2001) reported on 8148 patients receiving 49 048 ECT treatments in Texas between 1993 and 1998. No patient died during ECT. Thirty patients died within 2 weeks of receiving ECT; the authors felt that one death, which occurred on the day of treatment, could specifically be linked to ECT and four others could plausibly be linked to the treatment. They estimated mortality associated with ECT to be <2/100 000 treatments. A Danish case-register study found a lower mortality rate from natural causes for in-patients treated with ECT compared with other psychiatric patients (Munk-Olsen et al, 2007).