Electroconvulsive therapy (ECT)

This information is about electroconvulsive therapy (ECT), a treatment for severe symptoms of depression, mania, and catatonia. It is for people affected by mental illness in England who are 18 or over.

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The Royal College of Psychiatrists have produced a 3-minute British Sign Language video on Electroconvulsive therapy (ECT). You can view it by clicking on this link and scrolling down to the bottom of the page: www.rcpsych.ac.uk/mental-health/treatments-and-wellbeing/ect

Overview

Health professionals use electroconvulsive therapy (ECT) to treat severe depression, catatonia, or mania. It may be used to treat schizophrenia, but this is uncommon.
ECT uses an electrical current which passes through your brain. The current causes a fit or seizure.
Doctors may offer you ECT if other treatments do not work, or your symptoms are very bad.
The NHS say that ECT is generally safe. It can cause some side-effects.
You can only be given ECT if you agree to it unless you lack mental capacity. Or you are detained under the Mental Health Act, and you need emergency treatment.
You can make an advance decision to refuse ECT in the future. An advanced decision is legally binding. It must be followed unless you are detained under the Mental Health Act, and you need emergency treatment.
Your doctor should tell you about the risks and possible benefits of having ECT.

Need more advice?

If you need more advice or information you can contact our Advice and Information Service.

What is electroconvulsive therapy (ECT)?

Electroconvulsive therapy (ECT) is a treatment for some mental illnesses.

ECT is when electrical currents are passed through your brain to cause seizures or fits.

How does ECT work?

National Institute for Health and Care Excellence (NICE) say there is still no generally agreed theory that explains how ECT works. But the most accepted theory is that it causes changes to your central nervous system neurotransmitters.

The Royal College of Psychiatrists say ECT.

Triggers the release of some chemicals in your brain. These seem to cause growth of some areas of your brain that can become smaller if you experience depression.
Can change how parts of your brain interact with each other. These are the parts of the brain involved with your emotions.

Researchers are trying to find out more about how ECT works.

How many types of ECT are there?

There are 2 types of ECT.

Bilateral ECT. This is when the current is passed through both sides of your head.
Unilateral ECT. This is when the current is only passes through one side of your head.

What happens before I get ECT?

Before you get ECT:

Doctors will give you a general anaesthetic, so you will be asleep during the treatment
A member of staff will explain the procedure
You should get physical health checks
You should be asked how good your memory is
You should be connected to equipment to measure your heart rate, blood pressure, oxygen levels and brain waves
You should be given a mask so you can breathe oxygen during the procedure.

What happens during ECT?

Doctors will give you muscle-relaxing medicine and a mouth guard will be put in your mouth to protect your teeth.

Staff will place 2 metal discs will on your head. If you are having unilateral ECT both will be placed on the same side of your head. If you are having bilateral ECT one disc will be placed on each side of your head.

You will be given several brief electrical currents to your head to bring on a fit or seizure.

The number of electric pulses you will be given depends on how much is needed to make you have a fit. Medical professionals will look at how you respond to the electric pulses. They will try to give you just enough electric pulses to make you have a fit.

The seizures or fits can be very small and minor. They usually last for an average of 40 seconds but can last up to 2 minutes.

How long does a course of ECT treatment last?

You often get short courses of ECT treatment of about 6-12 sessions.

ECT is usually given twice a week.

Sometimes it is given once every 2 weeks or once a month to stop symptoms from coming back.

What is electroconvulsive therapy used for?

Electroconvulsive therapy (ECT) can be used to gain fast and short-term improvement of severe symptoms:

after all other treatment options have failed, or
when the situation is thought to be life-threatening.

It can be used for the following mental health conditions.

Severe depressive illness.
A long or severe episode of mania. Common symptoms of mania are delusional thoughts and behaviours.
Catatonia. Common symptoms of catatonia are not responding to anyone or anything, and slow movement.
Schizophrenia.

Doctors should offer you other treatments like medication and talking therapy, before ECT.

The National Institute of Health and Clinical Excellence (NICE) recommends that ECT should only be used when:

all other treatments have not worked, or
your illness may be life-threatening.

But NICE say ECT should not be used:

as a long-term treatment to prevent a depressive episode coming back, or
in the general management of schizophrenia.

ECT is occasionally offered as a treatment to people who live with schizophrenia. But it is not recommended by NICE. NICE think that more research is needed about its effectiveness to treat the condition.

Research suggests that ECT may be effective to treat acute episodes of certain types of schizophrenia and reduce relapse. And that ECT used with antipsychotic medication may be more effective than medication alone. But NICE say the design of many of the studies did not reflect current practice and results are not conclusive.

You can find the NICE ‘Guidance on the use of electroconvulsive therapy’ by clicking here: www.nice.org.uk/guidance/ta59

You can find more information about NICE in the Further reading section at the bottom of this page.

When should I be offered ECT for the treatment of severe depression?

NICE have guidelines on ‘Depression in adults: Treatment and management.’ The guidelines say when ECT can be considered for treatment for depression. See point 1.13.1 in the guidelines here:
www.nice.org.uk/guidance/ng222/chapter/recommendations#further-line-treatment

The guidelines say medical professionals can consider using ECT for the treatment of severe depression if:

you choose ECT over to other treatments, based on your experience of it, or
a quick response is needed, like if it’s a life threatening situation, or
other treatments have not worked.

If you are having ECT for treatment for depression, it should be stopped immediately if:

the side effects outweigh the potential benefits, or
the aim of the treatment has been achieved.

For more information see our webpages on the following:

Is ECT safe and are there side-effects?

Is electroconvulsive therapy (ECT) safe?

The NHS say that ECT is generally safe.

There is no evidence that having ECT is more dangerous than any other procedure needing a general anaesthetic.

An anaesthetist will assess you before your ECT treatment starts. If they think it’s not safe for you to have an anaesthetic, you won’t have ECT.

Death from general anaesthetic is rare, with a rate of about 1 in every 100,000 who have it. This means that about 99,999 people who have a general anaesthetic will not die from it. But the risk is higher if:

you are older,
you have an existing health condition such as heart disease,
you’re having major or emergency surgery, or
if you were ill or injured before the operation.

Do ECT clinics need to be accredited?
The National Institute of Health and Clinical Excellence (NICE) say that clinics should only provide ECT if they:

are Electroconvulsive Therapy Accreditation Service (ECTAS) accredited,
provide ECT services in accordance with ECTAS standards,
provide data, including outcomes, on each course of ECT they deliver, as needed for the ECTAS minimum dataset, and
follow the ECT Accreditation Service Standards for Administering ECT, which you can find here: www.rcpsych.ac.uk/improving-care/ccqi/quality-networks-accreditation/ectas/ectas-standards

You can ask if the clinic you are referred to meets the above standards.

What side-effects can ECT cause?

Electroconvulsive therapy (ECT) can cause some side-effects. You can ask your doctor about possible side-effects before you have ECT.

Straight after ECT, you might experience some or all the following:

Tiredness, until the effects of the anaesthetic wears off
Headache
Sickness or nausea
Aching in the jaw
Aching in the muscles
Confusion for a short time, particularly if you are elderly.

You might experience memory problems after ECT. For most people the problems end within 2 months and they are not too distressing.

ECT may cause short or long-term memory problems for current and past events.

About 1 in 5 people say that their memory was already causing them problems before having ECT. Often because of their mental illness. So, it can be hard to say whether the problems were caused by the ECT, their illness, or both.

ECT can trigger a long seizure, but this is very rare.

Can there be other long-term side-effects?

Some report longer-term side-effects after having ECT treatment.

ECT is only used when you are severely ill or other treatments haven’t worked. So, it can be difficult to know whether side-effects that people report are caused by ECT or the illness it’s treating.

Scientific research hasn’t found any evidence of increased risk of brain damage, epilepsy, stroke, or dementia after ECT.

Some people say they experience:

longer term memory loss, and difficulty making new memories, and
gaps in their memory about past events.

How will my side-effects be monitored?

Healthcare professionals should assess you after each session of ECT. This assessment will check if:

you’ve responded to treatment, and
you’ve any side-effects.

Your ECT sessions should stop if:

the aim of the treatment has been achieved, or
there are side-effects that healthcare professionals are concerned about.

The way that you deal with information should also be monitored regularly. This is called your cognition. As a minimum, it should be assessed at the end of each course of treatment.

Are some people at greater risk if they have ECT?

There can be increased risks if some people have ECT.

Doctors need to think carefully before they give you the treatment if you’re:

pregnant,
elderly, or
under 18 years old.

Can I have electroconvulsive therapy (ECT)?

Your doctor should offer you ECT if they think that it is a good option for you.

They should explain the risks and benefits of the treatment. Your relatives, carers or an advocate can be involved in the discussion too if you want.

You should be medically examined to make sure you’re well enough to have ECT.

Mostly, you don’t have to have ECT if you don’t want to. The following sections on this page below will explain when you can be given ECT without your agreement.

Your doctor should not pressure you to have ECT if you do not want it.

You can withdraw your agreement to have ECT at any time.

Can I have ECT if I have had it before?

Your doctor can consider offering you a repeat course of ECT if:

you experience acute, severe, episodes of catatonia or mania, and
you have responded well to ECT before.

If you have had ECT before and you didn’t respond well, it should only be offered to you again if:

all other treatment options have been considered, and
your doctor has spoken to you about the risks and benefits of ECT, or your carer or advocate, if appropriate.

Can doctors give me ECT if I do not consent to it?

In some limited situations, doctors can give you ECT without you agreeing to it. These are if you:

lack the mental capacity to decide, or
need emergency treatment under the Mental Health Act. See the next section for more information.

What does lacking mental capacity mean?

Mental capacity means you can make your own decisions by being able to:

understand all the information you need to make that decision,
use or think about that information,
remember that information, and
communicate your decision to someone else.

What is a ‘best interests’ decision?

Doctors might think ECT is the right option for you. You might not be able to do all the things in the 4 bullet points above to make your own decision. This means you would lack mental capacity to decide whether you agree to ECT.

Doctors might consult with other people, such as your relatives, attorneys, or professionals in your mental health team. They might do this to see if they think if ECT is the right option for you. A law called the Mental Capacity Act gives doctors the right to then make a decision in your ‘best interests.’

They might think it is in your best interests to have ECT if you are very unwell.

A best interest’s decision to give you ECT can be made, even if you are not detained under the Mental Health Act.

But ECT shouldn’t be given if you have a valid advance decision in place to refuse ECT. See the following sections for more information.

There might be a disagreement about if ECT would be in your best interests. The Court of Protection can decide if the treatment is right for you. Their contact details are:

Court of Protection
Make decisions on financial or welfare matters for people who lack mental capacity.

Phone: 0300 456 4600
Address: PO Box 70185, First Avenue House, 42-49 High Holborn,
London, WC1A 9JA
Email: courtofprotectionenquiries@justice.gov.uk
Website: www.gov.uk/courts-tribunals/court-of-protection

When should I get an independent mental capacity advocate (IMCA)?

You might not have anyone who can give their opinion about your treatment. You should have an independent mental capacity advocate (IMCA) to help you. An IMCA is free to use, and they do not work for the NHS.

For more information see our webpages on the following:

Can I be given ECT if I am detained under the Mental Health Act?

You might be detained in hospital under the Mental Health Act. You can decide if you want ECT if you are offered it.

A medical professional will certify that:

you have agreed to the treatment, and
you have the mental capacity to make the decision.

You might be offered other types of treatment if you are detained under the Mental Health Act. You can decline treatment, but if you do you can be forced to have it under the Act.

What happens if I need urgent ECT treatment?

You might be in hospital under the Mental Health Act and doctors might think you need urgent ECT treatment. Whether you have mental capacity or not, you can be given ECT without your consent if:

there is a real risk to your life, or
to stop you from becoming seriously unwell.

What happens if I don’t have the mental capacity to consent to ECT?

You might be in hospital under the Mental Health Act. Your doctor might think it’s in your best interests to have ECT, but you lack mental capacity.

A second opinion appointed doctor (SOAD) must agree with your doctor that it is in your best interests to have ECT.

The SOAD will:

interview you,
talk about your treatment with the doctor in charge of your care, and
talk to a registered nurse and a non-medical professional who are involved in your treatment. They must agree that ECT should be given.

The SOAD must write down if they think you should have ECT or not.

Their decision doesn’t have to be shared with you if they think it would cause mental or physical harm to you or anyone else. But in most cases, you should be able to see the SOAD’s decision.

But you still should not have ECT if:

you have a valid advance decision refusing ECT, or
someone has the legal right to make treatment decisions for you and they refuse it.

See the following section for more information on advanced decisions.

People who can make legal decisions on your behalf are:

an attorney under a Lasting Power of Attorney for health and welfare,
a Deputy appointed by the Court of Protection with appropriate authority to make the decision, or
The Court of Protection.

Can I see an advocate?

You have the right to see an independent mental health advocate (IMHA) for free, independent advice.

If you want to see an IMHA you can ask staff on the ward about this.

For more information see our webpages on the following:

You can find more information about ‘Can someone else manage my money for me?’ at: www.mentalhealthandmoneyadvice.org/en

What is an advance decision?

Under an advance decision you can say what specific medical treatment you do not want to have. The purpose is to have a record, so medical professionals know in case you become mentally incapable in the future.

Advanced decisions are legally binding.

An advanced decision cannot be used for anything else.

To make a valid advance decision you must:

be over 18 and
have mental capacity to make the decision.

You can make an advance decision if you don’t want ECT in the future.

We advise you to put your advance decision in writing and share it with people like:

your relatives,
your carers,
your healthcare team, and
your GP.

It is your responsibility to make people aware of your advance decision.

What if I am detained under the Mental Health Act?

You might:

make a valid advance decision refusing ECT, then later
be detained under the Mental health Act and lack mental capacity.

Doctors can still give you ECT in an emergency. See the previous section for more information. But the Care Quality Commission (CQC) says this only happens in exceptional cases.

See our webpage on Planning your future care – Advance statements and advance decisions for more information.

What should my doctor tell me about ECT?

Your doctor should tell you about the risks and possible benefits of having electroconvulsive therapy (ECT).

The National Institute of Clinical Excellence (NICE) recommends that your doctor should give you an information leaflet. It is to help you decide if you want ECT.

The leaflet should:

be based on evidence,
include information about the risks of ECT,
explain alternative treatments, and
be available in different languages and formats.

You can ask your doctor for information on ECT.

Your doctor should document both the risks and benefits of you having ECT. As part of the assessment the doctor will think about:

your risks of having an anaesthetic,
whether you have other illnesses,
the possible side-effects of ECT, and
the risks of you not having ECT.

Need more advice?

If you need more advice or information you can contact our Advice and Information Service.