Building an ECT service: an outcomes-equivalent approach.

OBJECTIVE: Specific guidelines, ongoing controversies in technique and audit reviews have made clinicians wary about continuing in electroconvulsive therapy (ECT). This paper attempts to reassure practitioners by incorporating such changes into a simple approach to ECT based on outcomes equivalence. METHOD: A selected compilation of the recent literature was used to describe a model for starting and/or continuing an effective ECT service. RESULTS: It was suggested that a useful way of approaching ECT service delivery is to focus on what is actually important, getting patients better, and to do so within the context and capability of each hospital. CONCLUSIONS: ECT is a changing field. Remaining true to the core principles of clinical practice, patient selection and technique, provides a basis for beginning, continuing and further developing an effective ECT service.

Does electrode placement predict time to rehospitalization?

We sought to determine whether electrode placement influenced time to rehospitalization. A retrospective review of an elderly, depressed population that had received bitemporal, bifrontal or 6 x RUL ECT was examined to determine time to rehospitalization. Bitemporal ECT was associated with a statistically significant reduction in the number of (P = 0.026) and time to (P = 0.025), rehospitalization. Bitemporal ECT may be a preferred electrode placement, not only because of its demonstrated effectiveness across a range of diagnoses, but for its previously undocumented capacity to delay rehospitalization.

Bifrontal electroconvulsive therapy in the elderly: a 2-year retrospective.

OBJECTIVES: We sought to examine the clinical effect of bifrontal (BF) electroconvulsive therapy (ECT) in depressed patients aged 65 years and older. METHODS: A retrospective chart review of all patients who received BF ECT for a depressive disorder between January 2000 and December 2002 was made. RESULTS: Fourteen patients, with a mean age of 73.9 years, received BF ECT. Nine had unipolar and 5 had bipolar depression. Twelve patients (86%) responded unequivocally after a mean of 8.5 treatments. Five (35%) experienced cognitive side effects. Ninety-two percent of patients were discharged on lithium (0.6 mmol/L) with 86% also receiving antidepressants or antipsychotics. Only 1 patient relapsed, the remainder remaining well at follow-up after a mean of 18.7 months. CONCLUSION: BF ECT was found to be clinically effective and associated with cognitive side effects in elderly patients who were experiencing a depressive episode of either unipolar or bipolar origin.

University and service sector collaboration for undergraduate psychiatric nursing education.

Collaboration between the education and service providers assists with the development of enhanced clinical and educational experiences for students. This paper describes an innovative collaborative program developed by the School of Nursing, University of Ballarat and Grampians Psychiatric Services, Ballarat Health Services. Mental health clinical nursing staff are the student off-campus clinical supervisors and on-campus lecturers, supported by two jointly appointed co-ordinators. Program evaluation reveals that this collaborative approach assists in the provision of a supportive learning environment, increases enthusiasm about psychiatric nursing and draws on relevant mental health nursing skills in the university and service sectors.

Right unilateral electroconvulsive therapy at six times seizure threshold.

OBJECTIVE: To examine the clinical practice of right unilateral electroconvulsive therapy (ECT) administered at six times seizure threshold (6 x RUL ECT). METHOD: A retrospective review of all patients who received 6 x RUL ECT between July 2000 and June 2002. RESULTS: Twenty-one patients across a range of ages and diagnostic groups received D'Elia unilateral ECT at a seizure dosage at or above 388.8 milliCoumbs (mC). In order to sustain predetermined criteria for seizure adequacy, energy was increased in 71% of patients. Final seizure lengths of 45 s electroencephalographic (EEG) activity, 28 s motor activity (cuffed) and a post-ictal suppression index (PSI) of 83% were recorded. Eighty percent of patients responded after a mean of 7.0 treatments. Cognitive side-effects were noted in 21% of patients. Fifty-two percent relapsed on average 6.3 months after the last treatment despite continuation pharmacotherapy. CONCLUSIONS: 6 x RUL ECT was found to be clinically effective, associated with cognitive side-effects and relapse. The debate over electrode placement is likely to continue.

Effectiveness of a training program for ECT nurses.

Electroconvulsive therapy (ECT) is a highly technical procedure requiring a team that consists of an anesthetist, a psychiatrist, a clinical nurse specialist, and recovery nurses. Traditionally, nursing education and training in the context of providing a safe and high standard of care has not been addressed. Ninety-two nurses from 42 different health agencies participated in a training program focusing on defibrillation, electrocardiogram (ECG) and electroencephalogram (EEG) monitoring, intubation, stimulus dosing, setting up the ECT equipment, and caring for the patient. A non-experimental, one-group, pretest-posttest research design was used in this study to evaluate the effectiveness of the training program for nurses working with ECT. Effective training for nurses was hypothesized to make a difference in the standards of practice and clinical effectiveness for patients undergoing ECT. Findings from this study indicated a major knowledge deficit in key components of ECT among nurses who have responsibilities in this area of nursing care. With effective training, nurses' confidence levels increased related to setting up the equipment, administering a double dose, helping with intubation, and using a defibrillator. If nurses are to effectively function as team members in the ECT procedure, they must receive the training necessary to prepare them for this important role. The results of this study support the recommendation of the Royal Australian and New Zealand College of Psychiatrists that ECT nurses should be appropriately trained in anaesthetic and resuscitation techniques and modern ECT practice.

Right unilateral ECT at 6x seizure threshold: is it effective in the psychoses?

OBJECTIVE: To date, right unilateral electroconvulsive therapy administered at 6x seizure threshold (6x RUL-ECT) has been described in relation to unipolar depression alone. For clinicians who have developed an experience and confidence in bilateral ECT, the effectiveness of 6x RUL-ECT in other psychiatric disorders, particularly those who are severely ill, has remained untested and therefore unknown. This article describes the results of 6x RUL-ECT in a select series of patients with a nondepressive psychotic illness. METHOD: Six patients with psychotic disorders of nondepressive origin were selected from a recent 2-year retrospective review of 6x RUL-ECT practice. The clinical presentation, ECT parameters, and responses were recorded. RESULTS: Four patients with severe psychotic disorders, two of whom met broad criteria for catatonia, responded to an index course of 6x RUL-ECT. One psychogeriatric patient who had protracted inpatient mania continues to benefit from outpatient maintenance 6x RUL-ECT over 18 months. Two elderly males, in whom seizures were difficult to elicit and maintain, responded poorly. CONCLUSION: 6x RUL-ECT was effective in 4 patients with nondepressive, psychotic disorders. While clinically viable and although memory was not assessed, it is uncertain what advantage 6x RUL-ECT confers over a bilateral electrode placement. The real focus should remain on clinical responsivity.