Book Review: Electroconvulsive Therapy: The ECT Handbook: The Third Report of the Royal College of Psychiatrists' Special Committee on ECT. Second Edition

Abstract

Electroconvulsive Therapy The ECT Handbook: The Third Report of the Royal College of Psychiatrists' Special Committee on ECT. Second Edition Allan I F Scott, editor. London (GB): Royal College of Psychiatrists; 2005. 243 p. CDNS49.60. Reviewer rating: Fair In the United Kingdom, the atmosphere in which electroconvulsive therapy (ECT) is practised can perhaps best be described as chilly, and the reason for this is described below. The resulting defensive practice of medicine may have the benefit that much time is spent with the patient in obtaining well-informed consent for treatment, but it is generally accepted that this type of practice is not likely to be in the patient's best interest. The UK National Health Service funds the National Institute for Health and Clinical Excellence (NICE), which in 2003 released a technology appraisal on ECT1 (this document and the complete NICE report on the efficacy and cost-effectiveness of ECT are fully accessible at http://www.nice.org.uk). The guidance was very restrictive, and NICE expected that its application would not increase the use of ECT in England and Wales above current levels,1119 which had already declined by one-half between 1985 and 1999. The guidance emphasized the negative cognitive consequences of ECT and recommended that ECT be used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with: severe depressive illness; catatonia; or a prolonged or severe manic episode.p5 Among other potential uses, ECT was specifically not recommended as maintenance therapy for depressive illness. Health practitioners in the United Kingdom are expected to take NICE guidance fully into account when exercising their clinical judgement. Much of the first chapter of The ECT Handbook is focused on dealing with the NICE guidance and how to deal with clinical practice that is at variance with the guidance. The rest of the book makes repeated references to the lack of randomized controlled trials (RCTs) in specific groups or conditions, and the recommendations for the use of ECT tend to be very conservative. One wonders just what type of RCT would be ethical, for example, in patients with severe depression and intellectual disability (mental retardation)-surely not a sham ECT study. Some chapters and appendices are strong-for example, those on anesthesia and nursing-but this book also contains information of limited value to the North American reader, unhelpful advice, and even some inaccuracies. For instance, it is recommended that ECT machines be purchased that can deliver stimuli up to 1000 mC,p U5 considerably higher than provided by those routinely available in North America. Given the known association of electrical dose and cognitive side effects, widespread availability and use of such machines is likely to result in greater and unnecessary side effects, especially given the common recommendation (also seen in this book) that right unilateral ECT be given at an electrical dose of at least 200% and up to 500% over seizure threshold. …