What is the process by which a decision to administer electroconvulsive therapy (ECT) or not is made? A grounded theory informed study of the multi-disciplinary professionals involved.

PURPOSE: To develop a grounded theory-informed model explaining the decision-making process professionals in multi-disciplinary teams go through in deciding whether to administer electroconvulsive therapy (ECT) or not. METHODS: A grounded theory informed methodology was used to analyse the data offered by ten participants who had all been involved in the process of deciding if someone has ECT or not. RESULTS: The core categories, described as 'layers' in this research, 'personal and professional identity'; 'subjective vs objective'; 'Guidelines or Clinical Instinct?'; 'Someone has to take Responsibility' and 'the decision in action', were constructed from the data. CONCLUSIONS: The study describes a useful insight into the layers of the decision-making process that could be further considered in clinical settings. The model highlights the decision to give ECT that has many different layers including professional identity, how a person understands the evidence base, past experiences, and the amount of power they have in the process. The consultant psychiatrist and the patient were seen as holding most power in the process depending on whether the Mental Capacity Act (2005) or Mental Health Act (2007) was being followed. Patients were seen to experience a very different decision-making process dependant on the personal views of the professionals in relation to ECT.

Cognitive therapy for people with schizophrenia spectrum disorders not taking antipsychotic drugs: a single-blind randomised controlled trial.

BACKGROUND: Antipsychotic drugs are usually the first line of treatment for schizophrenia; however, many patients refuse or discontinue their pharmacological treatment. We aimed to establish whether cognitive therapy was effective in reducing psychiatric symptoms in people with schizophrenia spectrum disorders who had chosen not to take antipsychotic drugs. METHODS: We did a single-blind randomised controlled trial at two UK centres between Feb 15, 2010, and May 30, 2013. Participants aged 16-65 years with schizophrenia spectrum disorders, who had chosen not to take antipsychotic drugs for psychosis, were randomly assigned (1:1), by a computerised system with permuted block sizes of four or six, to receive cognitive therapy plus treatment as usual, or treatment as usual alone. Randomisation was stratified by study site. Outcome assessors were masked to group allocation. Our primary outcome was total score on the positive and negative syndrome scale (PANSS), which we assessed at baseline, and at months 3, 6, 9, 12, 15, and 18. Analysis was by intention to treat, with an ANCOVA model adjusted for site, age, sex, and baseline symptoms. This study is registered as an International Standard Randomised Controlled Trial, number 29607432. FINDINGS: 74 individuals were randomly assigned to receive either cognitive therapy plus treatment as usual (n=37), or treatment as usual alone (n=37). Mean PANSS total scores were consistently lower in the cognitive therapy group than in the treatment as usual group, with an estimated between-group effect size of -6.52 (95% CI -10.79 to -2.25; p=0.003). We recorded eight serious adverse events: two in patients in the cognitive therapy group (one attempted overdose and one patient presenting risk to others, both after therapy), and six in those in the treatment as usual group (two deaths, both of which were deemed unrelated to trial participation or mental health; three compulsory admissions to hospital for treatment under the mental health act; and one attempted overdose). INTERPRETATION: Cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable alternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs. Evidence-based treatments should be available to these individuals. A larger, definitive trial is needed. FUNDING: National Institute for Health Research.