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These are the first guidelines on electroconvulsive therapy (ECT) published by RANZCP. Based on targeted literature reviews and expert consensus, the guidelines are intended to promote practice consistency and improve outcomes for patients selected for ECT.
ECT is indicated for several mood and psychotic disorders and might also be a first-line treatment for catatonia or delirious mania and for severely depressed patients with high suicide risk and high levels of distress.
Treating psychiatrists should always obtain second opinions with psychiatrists experienced in ECT and other appropriate specialists before administering ECT to child or adolescent patients, pregnant patients, and patients with elevated medical risks.
ECT is safe and well tolerated, with response in older patients superior to that with medication alone.
Pre-ECT assessment should include psychiatric and physical examinations, cognitive screening, medication review, comprehensive blood panels, electrocardiogram, and chest x-ray.
Dosing (stimulation dose relative to seizure threshold), electrode placement (right unilateral, bitemporal, bifrontal, left anterior temporal), pulse width, session frequency, concomitant medication, and anesthesia should balance effectiveness, speed of recovery, and adverse cognitive effects. The guideline offers recommendations for pulse-width and threshold parameters for three electrode placements.
For responding patients, continuation ECT for 6 months (once every 1–4 weeks) often prevents relapse (>50% of responding patients reportedly relapse within 12 months, typically within 6 months). Beyond that, maintenance ECT can be helpful for patients experiencing frequent relapses.
Weiss A et al. Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of electroconvulsive therapy. Aust N Z J Psychiatry 2019 Apr 10; [e-pub]. (https://doi.org/10.1177/0004867419839139)
Comment
These guidelines remind general psychiatrists and other mental health clinicians that ECT can be a useful first-line treatment for specific indications beyond treatment-resistant depressions and psychoses. The guidelines stress the importance of obtaining second opinions and consultations in complex circumstances. Evidence on relative benefits and harms for various treatment parameters will inform ECT specialists. RANZCP will review the guidelines every 3 years to maintain their currency.