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BOOK REVIEW Table of Contents   
Year : 2005  |  Volume : 47  |  Issue : 3  |  Page : 179-180
The ECT handbook

Professor, NIMHANS, Bangalore 560029, India

Click here for correspondence address and email

Date of Web Publication24-Sep-2009

How to cite this article:
Gangadhar B N. The ECT handbook. Indian J Psychiatry 2005;47:179-80

How to cite this URL:
Gangadhar B N. The ECT handbook. Indian J Psychiatry [serial online] 2005 [cited 2022 Dec 6];47:179-80. Available from:

Allan I.F. Scott (ed). The ECT handbook. 2nd ed.

The Third Report of the Royal College of Psychiatrists' Special Committee on ECT. Gaskell: Royal College of Psychiatrists; 2005. ISBN:1 904671 225, 244pp, £ 35

Electroconvulsive therapy (ECT) attracts attention from different circles. The media sensationalizes ECT and patients' rights groups are alert to make their presence felt on this issue. Select groups within the psychiatrist community also comment on ECT at times in a controversial manner, sending ambiguous messages to professionals as well as the public.

A notable report by Pippard and Ellam in 1982 had pointed to a need for improving practice standards of ECT in the UK. Leading journals carried editorials. A repeat survey 10 years later noted that many aspects of practice had improved. The psychiatrists' component still had scope for change. A similar situation can be expected from centres in other parts of the world too. To overcome this and set standards for good clinical practice, ECT guidelines are released from time to time. The first edition of the guidelines was published by the Royal College of Psychiatrists (RCP) in 1994. The latest one (second edition) is the ECT handbook of 2005. The Royal College's Special Committee on ECT has been providing training courses on ECT since 1992 and has been responsible for formulating a report on ECT practice. Dr Scott has edited this report in the form of a book (The ECT handbook).

The book has 20 chapters by different authors. The contributors are from a variety of specialties including, other than psychiatry, nursing anaesthesiology, neurology and psychotherapy. These 20 chapters are grouped into four parts: Clinical guidelines, psychotropic drugs during treatment, administration of ECT, and the law and consent. There is a set of relevant, brief, yet very helpful, appendices on the mechanism of action of ECT, information for users and carers, nursing guidelines, etc.

The National Institute for Clinical Excellence (NICE) was commissioned to undertake a health technology appraisal of ECT in the treatment of depression, mania, schizophrenia and catatonia in consultation with the RCP. In 2003, NICE published its guidelines on ECT that excluded the use of ECT in schizophrenia. The RCP ECT handbook supports this position with an exception that in patients with treatment­ resistant schizophrenia who also fail to respond to clozapine, ECT may be considered. It is notable that a study on ECT in schizophrenia from India may also have influenced the RCP to take this cautious position. The book notes that this negative study, though with a small sample size, has a sounder design than studies that demonstrate ECT to be of benefit in schizophrenia.

Issues related to ECT in special populations such as the elderly, and those with learning disability, neuropsychiatric disorders and physical illnesses have been extensively covered. Though ECT prescriptions in such situations are infrequent, practising psychiatrists may wish to refer to a reference guide when faced with such a situation. This forms a useful section for psychiatrists from general hospital settings and from different subspecialties of psychiatry (e.g. geriatric, child psychiatry, etc.).

Concurrent psychotropic drugs are widely prescribed in the Indian setting. This book reviews the practice of concurrent psychotropic drug use during ECT and notes a need for pragmatic randomized controlled trials. However, there is evidence that continuation of antidepressant drug therapy after a course of ECT confers a prophylactic benefit from relapse. The book cautions about the use of a lower ECT stimulus in patients taking selective serotonin reuptake inhibitors (SSRIs) to avoid the risk of prolonged seizures. As regards continuing lithium, the book relies on a randomized controlled trial done 20 years ago that used lithium continuation for prophylaxis and demonstrated a merit. It is unlikely that lithium would augment the benefit of ECT or vice versa. There is evidence from studies which are not randomized controlled trials that either discontinuing or reducing the dose of lithium reduces the side-effects. The suggestion that 'therapeutic responses to ECT may be augmented by antidepressants, lithium and pindolol without any major risks to patients' may hence be interpreted with caution. However, antipsychotics must be continued during ECT (if prescribed) for schizophrenia.

In Part III are discussed the issues of standards of actual practice including ECT suite, anaesthesia, prescribing ECT, practical administration and seizure monitoring. There is a general consensus on these standards the world over. However, the use of anaesthesia can be a concern in India. The modified procedure is limited by the availability of an anaesthesiologist and concerns of additional ECT costs to patients. As regards the ECT stimulus source, the pulse ECT device is the accepted standard today. Brief-pulse ECT machines meeting accepted standards and yet inexpensive have become available in India in the past decade. This Handbook lists British manufacturers of ECT equipment. It is likely that the Committee has reviewed the features and standards of ECT machines from these manufacturers. Often, the psychiatrist buying an ECT machine needs to be educated on the minimum requirements of the ECT stimulus as well as the standards of the device. Depending on the product information provided by the manufacturers alone can be inadequate in making a choice of ECT machine.

The previous edition mentioned the advantages of EEG seizure monitoring in ECT. It had encouraged practitioners to use EEG in addition to motor convulsion monitoring. Considerable research data have accumulated on the merits of EEG monitoring. Of note is a recent Indian study that found a risk of about 12% errors that could occur if EEG is not monitored. The errors in clinical decisions can have adverse consequences. It is again likely that the findings of this study influenced the RCP's guidelines. The RCP through these guidelines now mandates EEG monitoring. Expectedly, clinics using ECT have been given time till January 2006 to equip their ECT centres with an EEG-monitoring facility. In the previous edition of this book, a minimum EEG seizure duration of 25 seconds and motor convulsions of 15 seconds was suggested as a guideline to consider a seizure response as adequate. However, in the current edition, this is done away with; it is suggested that the aim of ECT is to produce a seizure of any length with characteristic EEG and/or motor manifestations. This is done in the background of a well­-replicated finding of no association between seizure duration and therapeutic outcome, and the observation that many patients, especially the elderly, make good clinical improvement despite experiencing a short duration of tonic-clonic seizures. This suggestion will make a substantial impact on ECT practice-the current practice has been to restimulate with a higher dose if the EEG seizure lasts for less than 25 seconds. There is a need in this context to consider if the ECT team, psychiatrists in particular, should also receive training in EEG monitoring, particularly so that they can identify the characteristic seizure wave morphology that defines adequacy.

The practice of ECT has been substantially and progres­sively refined over the past few decades. There are several areas of research that must be pursued so that more clarity emerges. The circumstances and conditions prevailing in other countries vary widely. Though most recommendations in the Handbook are based on sound evidence, practitioners in India need to consider a caveat that the evidence is obtained largely from studies conducted in the West. A recent survey suggests that there are many differences in the practice of ECT in India and in the West (unpublished data). For example, ECT is prescribed predominantly for younger patients in India compared with the West. The fact that anaesthesiologists are scarce and giving unmodified ECT is substantially inexpensive has led many psychiatrists in India to practise unmodified ECT. Also, many centres have neither the equipment nor the expertise to administer EEG-monitored ECT. The Indian Psychiatric Society could therefore develop comprehensive ECT guidelines suitable for India.

Overall, the Handbook is very informative and useful as it contains many evidence-based recommendations that ECT practitioners should use in their daily practice.

Correspondence Address:
B N Gangadhar
Professor, NIMHANS, Bangalore 560029
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Source of Support: None, Conflict of Interest: None

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