The ECT Handbook

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with unilateral ECT, a higher stimulus dose is associated with greater efficacy, but
also increased cognitive impairment compared with a lower stimulus dose.
1.10.4.7 Assess clinical status after each ECT treatment using a formal valid outcome
measure, and stop treatment when remission has been achieved, or sooner if side
effects outweigh the potential benefits.
1.10.4.8 Assess cognitive function before the first ECT treatment and monitor at least
every three to four treatments, and at the end of a course of treatment.
1.10.4.9 Assessment of cognitive function should include:

orientation and time for reorientation after each treatment

measures of new learning, retrograde amnesia and subjective memory impairment
carried out at least 24 hours after a treatment.
If there is evidence of significant cognitive impairment at any stage consider, in discussion
with the person with depression, changing from bilateral to unilateral electrode placement,
reducing the stimulus dose or stopping treatment depending on the balance of risks and
benefits.
1.10.4.10 If a person’s depression has responded to a course of ECT, antidepressant
medication should be started or continued to prevent relapse. Consider lithium
augmentation of antidepressants.
Royal College of Psychiatrists’ Position Statement on ECT for Depression
The Royal College of Psychiatrists similarly holds that ECT is a well-established and safe
treatment option for depressed patients who have an inadequate response to, or poor
tolerability of, antidepressant treatment. The College concurs with NICE’s recommendations for consent and monitoring of ECT. The position statement broadly agrees with
NICE’s recommendations but is more robust in its recommendations regarding the elderly,
more explicit on the place of ECT in management and more up to date regarding the
evidence on cognitive side effects. The evidence supporting these assertions is outlined in
Chapter 3. Whilst the current evidence base for ECT in depression is not sufficiently
detailed to allow certainty about the sequencing of ECT within a patient’s management
plan, it is sufficiently robust to be confident about efficacy in the clinical situations outlined
below. The Committee’s position statement recommends:
ECT as a first-line treatment for patients (including the elderly):
▪ where a rapid definitive response for the emergency treatment of depression is needed
▪ with high suicidal risk
▪ with severe psychomotor retardation and associated problems of compromised eating
and drinking and/or physical deterioration
▪ who suffer from treatment-resistant depression that has responded to ECT in a previous
episode of illness
▪ who are pregnant with severe depression and whose physical health or that of the foetus
is at serious risk
▪ who prefer this form of treatment.
ECT as a second-line treatment for patients (including the elderly):
▪ with treatment-resistant depression
▪ who experience severe side-effects from medication
The Place of ECT in Contemporary UK Psychiatry 3

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