PURPOSE
Electroconvulsive Therapy (ECT) is a treatment that has a complex history. It was first used in 1938. Since that time, many advances have been made in the practice of ECT and the science behind this very effective treatment for severe mental illness.
For many years, the training of doctors and other staff administering ECT was inadequate and highly variable. Medical staff administering this treatment often had very superficial training before they were expected to administer the treatment in their hospital.
Duffett and Lelliott (1998) commented that after a 20-year period only modest improvements in the local practice of ECT within England and Wales were demonstrated, after the Royal College of Psychiatrists (RCP) completed its third large-scale audit. These audits were very extensive and were followed by specific recommendations for change highlighting a lack of expertise and resources that were allocated to the provision of ECT.
Significant changes have been made since the release of National Institute for Health and Care Excellence (2003) guidance on ECT for depressive illness, schizophrenia, catatonia and mania. This document was based upon two systematic reviews sponsored by the Department of Health; UK ECT Review Group (2003) and Rose, Fleischmann, Wykes, Leese and Bindman (2003) highlighted the consumer’s viewpoint. Following these reviews, the guidance for ECT was very critical, stating:
ECT should be used only to achieve rapid and short-term improvement of severe symptoms after adequate trials of other treatments have failed when the condition is considered to be potentially life-threatening with, severe depressive illness, catatonia or a prolonged or severe manic episode. The current state of the evidence does not allow the general use of ECT on the management of schizophrenia to be recommended as the long-term benefits and risk of ECT have not been clearly established, it is not recommended as a maintenance therapy in depressive illness. ECT should be used as a treatment of last resort.
(NICE, 2003)
This guidance was met with strong criticism from psychiatrists within the UK and around the world, as they were not consistent with the common clinical use of ECT in the everyday treatment of depression. The ECT Handbook, 2nd edition (Scott, 2005) was revised to address the criticisms raised by the NICE guidance document and released as The ECT Handbook, 3rd edition (Waite and Easton, 2013). More recently, the Royal College of Psychiatrists released the ECT Accreditation Service (ECTAS): Standards for the Administration of ECT, 12th edition (Royal College of Psychiatrists, 2015), which specifies minimum standards of practice. Australia and New Zealand have followed this lead, with many states making a considerable effort to review ECT practice by developing minimum standards guidelines (Chief Psychiatrist of Western Australia, 2015; NSW Health, 2010; SA Health, 2014; Victorian Government, 2014).
It was within this environment that The Electroconvulsive Therapy Workbook evolved over a 16-year period as part of a competency-based ECT training programme for staff working in this area.
CLINICAL WISDOM 1.1.1
One of the most distressing encounters that junior house staff and psychiatric registrars have to deal with when completing studies in psychiatry is their encounter with the relevant mental health legislation, which often involves dealing with an independent mental health review tribunal (MHRT) in the state/territory in which they practise. In many instances this creates significant ethical concerns within the individual about the pros and cons of administering psychiatric treatment to patients who are unable to provide informed consent.
The adversarial model is particularly paramount in some jurisdictions where the consumer/patient is entitled to legal representation whereas the medical arguments are often presented by a junior member of the medical team. The medical argument necessarily involves breaking the confidence of the patient by expanding the content of significant past events, psychotic delusions or self-harming behaviour. This process can create distress in the doctor who has limited academic knowledge, clinical and legal experience and a superficial understanding of complex clinical details.
The dilemma is magnified when the doctor is also required to ask for a determination to administer a course of ECT. It is not until some time later, when the doctor has followed a number of patients through a course of ECT, that they understand the marked and rapid clinical improvement that occurs with this treatment, providing meaning to what can often be a hostile and unpleasant experience.
The process becomes even more complex as the adversarial model challenges the fundamental core skill of psychiatry, namely establishing a good therapeutic alliance with the patient (Bellis, 2016; Martin, Garske and Davis, 2000). The registrar is obliged to reveal complex, detailed personal information in a semi-legal setting to enable the tribunal to make a determination. This fundamental breach of confidence usually results in the patient resenting the doctor, and often will be reluctant to speak to them for the remainder of the admission if the tribunal has determined that ECT is necessary.
The junior psychiatric registrar can be left feeling disillusioned, confused and angry as this process is at odds with their early impression of psychiatry as a profession that is altruistic, nurturing and caring. The ethical challenge is so intense that it often leads to early withdrawal from the training programme.
This phenomenon is well recognised and has led to the development of some innovative strategies to empathise with the new trainee,...
