Issues in Mental Health Nursing, 35:73–76, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2014.858568
COMMENTS, CRITIQUE, AND INSPIRATION COLUMN
Electroconvulsive Therapy: Issues for Mental Health Nurses to Consider Michelle Cleary, RN, PhD National University of Singapore, Yong Loo Lin School of Medicine, Singapore
Jan Horsfall, PhD Independent Research Advisor, Sydney, Australia
Edited by Mona M. Shattell, RN, PhD, FAAN DePaul University, School of Nursing, Chicago, Illinois, USA
Brunero, Barclay, & Wijeratne, 2011; Matheson, Green, Loo, & Carr, 2010). ECT’s considered advantage is that it can achieve rapid shortterm improvements, especially when compared with antidepressant medication (Gregory-Roberts et al., 2010; Moksnes & Ilner, 2010; NICE, 2003; Scott, 2005). Matheson and colleagues’ (2010) systematic meta-review of ECT treatment of people with a schizophrenia diagnosis found a small but significant improvement in global symptoms in the short-term, and suggests it can be beneficial when used in conjunction with antipsychotics, particularly when people are not responding well enough to these. Many practitioners (Hunt et al., 2011; Scott, 2005) and a small minority of consumers (Morrison, 2009) object to these narrow recommendations, arguing that using ECT only when life is threatened or for treatment resistance, may prolong some depressed patients’ suffering, and under some circumstances ECT could be considered a first-line treatment option. Furthermore, in some countries, ECT is not used as a last resort or for medication resistant conditions (Leiknes, Jarosh-von Schweder, & Hoie, 2012). Contrary to these reports, many consumers have found ECT unhelpful, resulting in trading some symptoms for others, traumatizing them, or being a trial they will never repeat (Philpot et al., 2004; Rose, Wykes, Leese, Bindman, & Fleischmann, 2003; Vamos, 2008; Van DaalenSmith, 2011). Even though ECT can be fast-acting and life-saving, especially for people with severe depression or catatonia, there are serious concerns about ECT. Post-treatment relapse and memory problems are among the most distressing documented sequelae for patients. Nordenskjold and colleagues (2011) remind us that most research into ECT’s effectiveness is limited to short- to medium-term follow-up and they cite five recent studies that reveal relapse rates of 30–50% within the first year. Following six tests covering global cognition, psychomotor function, attention, anterograde learning and memory, and autographical
Edited by Michelle Cleary, RN, PhD National University of Singapore, Yong Loo Lin School of Medicine, Singapore This column emerges from an awareness that many mental health nurses are involved with electroconvulsive therapy (ECT) directly, or indirectly, with patients who have experienced ECT recently or in the past. From the nursing literature it is unclear how well informed RNs are about the advantages and disadvantages—from patients’ perspectives—of undergoing ECT in comparison to other options. Rationales for ECT, effectiveness evidence, limitations of that evidence, memory impairment—recent research and patient concerns, and the roles of RNs before and after treatment are set out below. The most common psychiatric condition for which ECT is prescribed is acute, severe, depressive illness and it is a wellestablished and effective treatment (Gregory-Roberts, Naismith, Cullen, & Hickie, 2010; Meeter, Murre, Janssen, Birkenhager, & van den Broek, 2011; National Institute for Clincial Excellence [NICE], 2003; Nordenskjold, von Knorring, & Engstrom, 2011). Many clinicians consider that patients with a schizophrenia diagnosis, especially those who are “treatment resistant,” acutely psychotic, or with catatonic or depressive features may benefit from ECT, although the empirical evidence is scant (Lamont,
Address correspondence to Michelle Cleary, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597. E-mail: [email protected] or michelle [email protected]
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memory in depressed patients receiving ECT, Sackheim and colleagues (2007) verify patients’ perceptions that there is a “lack of resolution of specific deficits observed in the immediate post-ECT time period (e.g., retrograde amnesia)” (p. 253). Nordenskjold and colleagues’ (2011) small study of depressed patients showed the depression re-hospitalization rate during the year after the index ECT to be 50%; and 58% for two years. Furthermore, some studies indicate that people whose depression was treatment resistant before ECT have increased relapse rates on maintenance anti-depressants after ECT (Nordenskjold et al., 2011). Clinicians who see miraculous improvement (Van Daalen-Smith, 2011) in hospitalized or day patients after ECT may have no idea how patients are post-discharge, unless the patient returns to hospital for further treatment or care. Anterograde amnesia is the inability to form new memories and is believed to be confined to a short period immediately following ECT (Meeter et al., 2011; Nordenskjold et al., 2011; Rose et al., 2003). Retrograde amnesia, whereby the patient is unable to recall remote memories, can be more persistent (GregoryRoberts et al., 2010; Rose et al., 2003; Sackeim et al., 2007). Philpot and colleagues (2004) developed an ECT-user designed questionnaire and surveyed 108 ECT consumers six weeks posttreatment, Rayner and colleagues (2009) used a similar questionnaire and received responses from 389 consumers who had ECT within the previous six months. The results in both surveys found that half reported memory impairment. Chakrabarti and colleagues’ (2010) review of 35 studies that include patients’ experiences of ECT found that memory impairment was the most common, persistent, and distressing problem reported by patients. Memory difficulties are not a simple matter; they impact on communication competence and the perceptions of family members, undermine self-confidence, and interfere with effectiveness in the workplace and with daily living (Kho, VanVreeswijk, & Murre, 2006; Vamos, 2008). The loss of autobiographical memories—an inability to recall personal experiences and events—is particularly distressing (Rose et al., 2003; Vamos, 2008; Van Daalen-Smith, 2011). As one research participant reports: “I miss the person that got away from me” (Linda, quoted in Van Daalen-Smith, 2011, p. 464). Early research by Gass (1998) revealed 37% of 167 mental health nurses in Wales did not identify memory impairment as an ECT side effect. A confounding factor for studies of amnesia is that depression itself can impair memory (Kho et al., 2006). If memory deficits are primarily associated with recall of remote material—rather than acquisition of new material—then depression-related memory impairment could be relieved by ECT, but be replaced in some patients by ECT-induced amnesia (Meeter et al., 2011). Given patients’ concerns about memory problems and clinicians’ focus on treatment response, what kinds of memory and how they are ascertained, tested, and measured before ECT and 6 or 12 months later is an important issue.
NURSES AND ECT-RELATED RESPONSIBILITIES According to Gass (2008), the role of nurses and their responsibilities regarding ECT—especially technical and practical aspects—are adequately documented, even though how these roles are enacted has not been thoroughly explored. There are clear ECT-related responsibilities that have been set out in hospital documents and in published nursing literature. Perhaps the most important, from a patient’s perspective, is to address and work through the patient’s apprehensions and fears (Chakrabarti et al., 2010; Finch, 2005; Loo, 2007). This is particularly important given fictional and movie portrayals of straight ECT (without anesthesia or muscle relaxant), going back to the 1950s, and which are still considered by many lay people to be relevant in the twenty-first century (Finch, 2005). The process of allowing patients to ask any questions that are on their mind allows for rapport to develop. In the case study outlined by Flint (2005) she considers the action of an ECT nurse who held the hand of a man who was mute and not eating; this gesture provided reassurance, and one could claim that such an action with a catatonic patient provides a silent corporeal rapport. Teaching the patient about ECT involves going over the procedure and working through common positive and negative effects (Kavanagh & McLoughlin, 2009; Lamont et al., 2011). Such teaching also may involve a family member or caregiver, as if a partner or caregiver is apprehensive about the proposed treatment it is likely to be perceived by the recipient (Finch, 2005; Flint, 2005). If the patient is severely depressed, family members may be able to give information about the patient’s personality style and behaviors to help nurses recognize what is “normal” for this person as he or she begins to improve. Teaching is not as simple as making a speech or handing out a pamphlet. But given the usual severity of the condition of patients who are candidates for ECT, along with depressionrelated cognitive limitations, information should be provided in a step-wise manner and may need to be simplified or repeated, with the RN checking that important points have been understood (Chakrabarti et al., 2010; Finch, 2005). Such processes take time. For some prospective patients and their family, the provision of a well-produced information booklet can make ECT more accessible and comprehensible. Gaining informed consent is probably the most challenging process for the nurse, and vexing for patients, at least in retrospect (Philpot et al., 2004; Van Daalen-Smith, 2011). Finch (2005) in his ECT guide for nursing responsibilities claims it “is a dynamic process that is not completed with the signing of a formal document, but . . . [one] that continues throughout the course of treatment” (p. 3). Guidelines from the National Institute for Clinical Excellence (NICE; 2003) state that patients should not be pressured or coerced into accepting ECT if they do not wish to have the treatment. Gass (2008) uses terms such as “persuader” and sometimes “forcer” in his discussion of the complexity of nursing roles regarding ECT, which includes physically manhandling patients
COMMENTS, CRITIQUE, AND INSPIRATION
because it is prescribed by the medical team. Coercion does not necessarily mean bullying, but it can involve patients feeling that they cannot refuse or believing that there is no alternative to ECT and nurses using bribery regarding discharge outlook and future prospects or inveigling partners or other family member into promoting the expected positive results. Patients, given their vulnerability and desperation, will succumb and sign (Philpot et al., 2004; Van Daalen-Smith, 2011). On the other hand 86% of Rayner and colleagues (2009) 258 respondents agreed that they did not feel pressurized or forced. In Lamont and colleagues’ (2011) review of ECT procedures more than half of patients (26 of 43) were treated involuntarily, but legally, under the auspices of the Mental Health Review Tribunal. This clearly means informed consent is not part of patients’ experiences of ECT in many settings. A few ECT-related articles published in nursing journals read as if they are following medical proponents of ECT’s good news (e.g., Gomez, 2004; Weiner & Falcone, 2011). As Chakrabarti and colleagues (2010) point out, there is a stark disparity between the perception of benefit in studies performed by consumer organizations and those carried out by practitioners. Nurses involved with ECT should be able to provide suitably balanced information of a high standard. This means that RNs have to have up-to-date information from both medical sources (some of which are written in promotional mode) and consumer sources (much of which documents severe long-term consequences). The least satisfactory aspects of Rayner and colleagues’ (2009) audit was that only about half of the patients knew what would happen if they did not have ECT and 60% were aware of alternatives. Informed consent cannot be obtained if adequate honest information is not provided. Furthermore, it is unclear if good information is provided to those who are legally required to have ECT against their will. Pre-ECT protocols often recommend a checklist for nurses to go over, which includes technical and informational preparation as well as addressing last minute queries (Finch, 2005; Kavanagh & McLoughlin, 2009). Pre-treatment nursing care also consists of making sure relevant documentation is complete and ensuring that the patient is accompanied by an RN who is aware of the patient’s legal and consent status—and preferably is familiar to the patient—during the waiting time, which should be as short as possible (Finch, 2005; Kavanagh & McLoughlin, 2009). During treatment, the RN assists according to hospital protocols. After treatment, the RN attends to routine post-anesthetic requirements, such as correct positioning, airway patency, and vital signs monitoring until consciousness is regained (Finch, 2005; Gomez, 2004; Kavanagh & McLoughlin, 2009). Immediately after ECT, a patient can be unaware that he or she has had the treatment and may be disorientated, confused, or drowsy (Meeter et al., 2011; Moksnes & Ilner, 2010; Philpot et al., 2004). As such, the RN should be familiar with these effects and stay close to the patient and provide simple, relevant, calming orienting information (Finch, 2005; Gomez, 2004). When the patient is sufficiently settled he or she is es-
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corted back to the ward and any notable information is passed on. Once the immediate phase after regaining consciousness has passed, headache is a common complaint, which should be promptly treated with analgesia (Finch, 2005; Gomez, 2004; Philpot et al., 2004). This column has overviewed a range of topics relevant to mental health nurse knowledge of ECT. This knowledge domain is especially important for RNs to enable them to fulfill their responsibilities to patients who need to be fully informed to consent to ECT, its alternative, or to concomitant treatments. There is a paucity of detailed research-based long-term data relating to the rates, extent, and disabling aspects of retrograde amnesia experienced by a significant minority of people who undergo ECT, even utilizing contemporary best practice. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Chakrabarti, S., Grover, S., & Rajagopal, R. (2010). Electroconvulsive therapy: A review of knowledge, experience and attitudes of patients concerning the treatment. World Journal of Biological Psychiatry, 11(3), 525–537. Finch, S. (2005). Nurse guidance for ECT, April 2005. Retrieved from http:// www.rcn.org.uk/development/communities/rcn forum communities/mental health/good practice/new guidance on ect 21 apr 2005 Flint, V. (2005). The place of ECT in mental health care. Kai Tiaki Nursing New Zealand 11(9), 18–19. Gass, J. P. (1998). The knowledge and attitudes of mental health nurses to electro-convulsive therapy. Journal of Advanced Nursing, 27(1), 83–90. Gass, J. (2008). Electroconvulsive therapy and the work of mental health nurses: A grounded theory study. International Journal of Nursing Studies, 45(2), 191–202. Gomez, G. E. (2004). Electroconvulsive therapy: Present and future. Issues in Mental Health Nursing, 25(5), 473–486. Gregory-Roberts, E. M., Naismith, S. L., Cullen, K. M., & Hickie, I. B. (2010). Electroconvulsive therapy-induced persistent retrograde amnesia: Could it be minimised by ketamine or other pharmacological approaches? Journal of Affective Disorders 126(1–2), 39–45. Hunt, I. M., Windfuhr, K., Swinson, N., Shaw, J., Appleby, L., & Kapur, N. (2011). Electroconvulsive therapy and suicide among the mentally ill in England: A national clinical survey. Psychiatry Research, 187(1–2), 145–149. Kavanagh, A., & McLoughlin, D. M. (2009). Electroconvulsive therapy and nursing care. British Journal of Nursing 18(22), 1370, 1372, 1374–1377. Kho, K. H., VanVreeswijk, M. F., & Murre, J. M. J. (2006). A retrospective controlled study into memory complaints reported by depressed patients after treatment with electroconvulsive therapy and pharmacotherapy or pharmacotherapy only. Journal of ECT, 22(3), 199–205. Lamont, S., Brunero, S., Barclay, C., & Wijeratne, C. (2011). Evaluation of an electroconvulsive therapy service in a general hospital. Issues in Mental Health Nursing, 20(3), 223–229. Leiknes, K. A., Jarosh-von Schweder, L., & Hoie, B. (2012). Contemporary use and practice of electroconvulsive therapy worldwide. Brain and Behavior, 2(3), 283–344. Loo, C. (2007). The NSW Mental Health Bill 2007: Implications for the provision of electroconvulsive therapy. Australasian Psychiatry, 15(6), 457–460. Matheson, S. L., Green, M. J., Loo, C., & Carr, V. J. (2010). Quality assessment and comparison of evidence for electroconvulsive therapy and repetitive transcranial magnetic stimulation for schizophrenia: A systematic metareview. Schizophrenia Research, 118(1–3), 201–210.
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Meeter, M., Murre, J. M., Janssen, S. M., Birkenhager, T., & van den Broek, W. W. (2011). Retrograde amnesia after electroconvulsive therapy: A temporary effect? Journal of Affective Disorders, 132(1–2), 216–222. Moksnes, K. M., & Ilner, S. O. (2010). Electroconvulsive therapy—efficacy and side-effects. Tidsskrift for den Norske lægeforening, 130(24), 2460–2464. Morrison, L. (2009). ECT: Shocked beyond belief. Australasian Psychiatry, 17(2), 164–167. National Institute for Clincial Excellence. (2003). Technology Appraisal Guidance 59: Guidance on the use of electroconvulsive therapy. London, UK: Author. Retrieved from http://www.nice.org.uk/nicemedia/pdf/ 59ectfullguidance.pdf Nordenskjold, A., von Knorring, L., & Engstrom, I. (2011). Rehospitalization rate after continued electroconvulsive therapy—a retrospective chart review of patients with severe depression. Nordic Journal of Psychiatry 65(1), 26–31. Philpot, M., Collins, C., Trivedi, P., Treloar, A., Gallacher, S., & Rose, D. (2004). Eliciting users’ views of ECT in two mental health trusts with a user-designed questionnaire. Journal of Mental Health, 13(4), 403–413.
Rayner, L., Kershaw, K., Hanna, D., & Chaplin, R. (2009). The patient perspective of the consent process and side effects of electroconvulsive therapy. Journal of Mental Health, 18(5), 379–388. Rose, D., Wykes, T., Leese, M., Bindman, J., & Fleischmann, P. (2003). Patients’ perspectives on electroconvulsive therapy: Systematic review. British Medical Journal, 326(7403), 1363–1365. Sackeim, H. A., Prudic, J., Fuller, R., Keilp, J., Lavori, P. W., & Olfson, M. (2007). The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology, 32(1), 244–254. Scott, A. I. F. (2005). College guidelines on electroconvulsive therapy: An update for prescribers. Advances in Psychiatric Treatment, 11(2), 150–156. Vamos, M. (2008). The cognitive side effects of modern ECT: Patient experience or objective measurement? Journal of ECT, 24(1), 18–24. Van Daalen-Smith, C. L. (2011). Waiting for oblivion: Women’s experiences with electroshock. Issues in Mental Health Nursing, 32(7), 457–472. Weiner, R. D., & Falcone, G. (2011). Electroconvulsive therapy: How effective is it? Journal of the American Psychiatric Nurses Association 17(3), 217–218.
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COMMENTS, CRITIQUE, AND INSPIRATION COLUMN
Electroconvulsive Therapy: Issues for Mental Health Nurses to Consider Michelle Cleary, RN, PhD National University of Singapore, Yong Loo Lin School of Medicine, Singapore
Jan Horsfall, PhD Independent Research Advisor, Sydney, Australia
Edited by Mona M. Shattell, RN, PhD, FAAN DePaul University, School of Nursing, Chicago, Illinois, USA
Brunero, Barclay, & Wijeratne, 2011; Matheson, Green, Loo, & Carr, 2010). ECT’s considered advantage is that it can achieve rapid shortterm improvements, especially when compared with antidepressant medication (Gregory-Roberts et al., 2010; Moksnes & Ilner, 2010; NICE, 2003; Scott, 2005). Matheson and colleagues’ (2010) systematic meta-review of ECT treatment of people with a schizophrenia diagnosis found a small but significant improvement in global symptoms in the short-term, and suggests it can be beneficial when used in conjunction with antipsychotics, particularly when people are not responding well enough to these. Many practitioners (Hunt et al., 2011; Scott, 2005) and a small minority of consumers (Morrison, 2009) object to these narrow recommendations, arguing that using ECT only when life is threatened or for treatment resistance, may prolong some depressed patients’ suffering, and under some circumstances ECT could be considered a first-line treatment option. Furthermore, in some countries, ECT is not used as a last resort or for medication resistant conditions (Leiknes, Jarosh-von Schweder, & Hoie, 2012). Contrary to these reports, many consumers have found ECT unhelpful, resulting in trading some symptoms for others, traumatizing them, or being a trial they will never repeat (Philpot et al., 2004; Rose, Wykes, Leese, Bindman, & Fleischmann, 2003; Vamos, 2008; Van DaalenSmith, 2011). Even though ECT can be fast-acting and life-saving, especially for people with severe depression or catatonia, there are serious concerns about ECT. Post-treatment relapse and memory problems are among the most distressing documented sequelae for patients. Nordenskjold and colleagues (2011) remind us that most research into ECT’s effectiveness is limited to short- to medium-term follow-up and they cite five recent studies that reveal relapse rates of 30–50% within the first year. Following six tests covering global cognition, psychomotor function, attention, anterograde learning and memory, and autographical
Edited by Michelle Cleary, RN, PhD National University of Singapore, Yong Loo Lin School of Medicine, Singapore This column emerges from an awareness that many mental health nurses are involved with electroconvulsive therapy (ECT) directly, or indirectly, with patients who have experienced ECT recently or in the past. From the nursing literature it is unclear how well informed RNs are about the advantages and disadvantages—from patients’ perspectives—of undergoing ECT in comparison to other options. Rationales for ECT, effectiveness evidence, limitations of that evidence, memory impairment—recent research and patient concerns, and the roles of RNs before and after treatment are set out below. The most common psychiatric condition for which ECT is prescribed is acute, severe, depressive illness and it is a wellestablished and effective treatment (Gregory-Roberts, Naismith, Cullen, & Hickie, 2010; Meeter, Murre, Janssen, Birkenhager, & van den Broek, 2011; National Institute for Clincial Excellence [NICE], 2003; Nordenskjold, von Knorring, & Engstrom, 2011). Many clinicians consider that patients with a schizophrenia diagnosis, especially those who are “treatment resistant,” acutely psychotic, or with catatonic or depressive features may benefit from ECT, although the empirical evidence is scant (Lamont,
Address correspondence to Michelle Cleary, Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Level 2, Clinical Research Centre, Block MD11, 10 Medical Drive, Singapore 117597. E-mail: [email protected] or michelle [email protected]
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memory in depressed patients receiving ECT, Sackheim and colleagues (2007) verify patients’ perceptions that there is a “lack of resolution of specific deficits observed in the immediate post-ECT time period (e.g., retrograde amnesia)” (p. 253). Nordenskjold and colleagues’ (2011) small study of depressed patients showed the depression re-hospitalization rate during the year after the index ECT to be 50%; and 58% for two years. Furthermore, some studies indicate that people whose depression was treatment resistant before ECT have increased relapse rates on maintenance anti-depressants after ECT (Nordenskjold et al., 2011). Clinicians who see miraculous improvement (Van Daalen-Smith, 2011) in hospitalized or day patients after ECT may have no idea how patients are post-discharge, unless the patient returns to hospital for further treatment or care. Anterograde amnesia is the inability to form new memories and is believed to be confined to a short period immediately following ECT (Meeter et al., 2011; Nordenskjold et al., 2011; Rose et al., 2003). Retrograde amnesia, whereby the patient is unable to recall remote memories, can be more persistent (GregoryRoberts et al., 2010; Rose et al., 2003; Sackeim et al., 2007). Philpot and colleagues (2004) developed an ECT-user designed questionnaire and surveyed 108 ECT consumers six weeks posttreatment, Rayner and colleagues (2009) used a similar questionnaire and received responses from 389 consumers who had ECT within the previous six months. The results in both surveys found that half reported memory impairment. Chakrabarti and colleagues’ (2010) review of 35 studies that include patients’ experiences of ECT found that memory impairment was the most common, persistent, and distressing problem reported by patients. Memory difficulties are not a simple matter; they impact on communication competence and the perceptions of family members, undermine self-confidence, and interfere with effectiveness in the workplace and with daily living (Kho, VanVreeswijk, & Murre, 2006; Vamos, 2008). The loss of autobiographical memories—an inability to recall personal experiences and events—is particularly distressing (Rose et al., 2003; Vamos, 2008; Van Daalen-Smith, 2011). As one research participant reports: “I miss the person that got away from me” (Linda, quoted in Van Daalen-Smith, 2011, p. 464). Early research by Gass (1998) revealed 37% of 167 mental health nurses in Wales did not identify memory impairment as an ECT side effect. A confounding factor for studies of amnesia is that depression itself can impair memory (Kho et al., 2006). If memory deficits are primarily associated with recall of remote material—rather than acquisition of new material—then depression-related memory impairment could be relieved by ECT, but be replaced in some patients by ECT-induced amnesia (Meeter et al., 2011). Given patients’ concerns about memory problems and clinicians’ focus on treatment response, what kinds of memory and how they are ascertained, tested, and measured before ECT and 6 or 12 months later is an important issue.
NURSES AND ECT-RELATED RESPONSIBILITIES According to Gass (2008), the role of nurses and their responsibilities regarding ECT—especially technical and practical aspects—are adequately documented, even though how these roles are enacted has not been thoroughly explored. There are clear ECT-related responsibilities that have been set out in hospital documents and in published nursing literature. Perhaps the most important, from a patient’s perspective, is to address and work through the patient’s apprehensions and fears (Chakrabarti et al., 2010; Finch, 2005; Loo, 2007). This is particularly important given fictional and movie portrayals of straight ECT (without anesthesia or muscle relaxant), going back to the 1950s, and which are still considered by many lay people to be relevant in the twenty-first century (Finch, 2005). The process of allowing patients to ask any questions that are on their mind allows for rapport to develop. In the case study outlined by Flint (2005) she considers the action of an ECT nurse who held the hand of a man who was mute and not eating; this gesture provided reassurance, and one could claim that such an action with a catatonic patient provides a silent corporeal rapport. Teaching the patient about ECT involves going over the procedure and working through common positive and negative effects (Kavanagh & McLoughlin, 2009; Lamont et al., 2011). Such teaching also may involve a family member or caregiver, as if a partner or caregiver is apprehensive about the proposed treatment it is likely to be perceived by the recipient (Finch, 2005; Flint, 2005). If the patient is severely depressed, family members may be able to give information about the patient’s personality style and behaviors to help nurses recognize what is “normal” for this person as he or she begins to improve. Teaching is not as simple as making a speech or handing out a pamphlet. But given the usual severity of the condition of patients who are candidates for ECT, along with depressionrelated cognitive limitations, information should be provided in a step-wise manner and may need to be simplified or repeated, with the RN checking that important points have been understood (Chakrabarti et al., 2010; Finch, 2005). Such processes take time. For some prospective patients and their family, the provision of a well-produced information booklet can make ECT more accessible and comprehensible. Gaining informed consent is probably the most challenging process for the nurse, and vexing for patients, at least in retrospect (Philpot et al., 2004; Van Daalen-Smith, 2011). Finch (2005) in his ECT guide for nursing responsibilities claims it “is a dynamic process that is not completed with the signing of a formal document, but . . . [one] that continues throughout the course of treatment” (p. 3). Guidelines from the National Institute for Clinical Excellence (NICE; 2003) state that patients should not be pressured or coerced into accepting ECT if they do not wish to have the treatment. Gass (2008) uses terms such as “persuader” and sometimes “forcer” in his discussion of the complexity of nursing roles regarding ECT, which includes physically manhandling patients
COMMENTS, CRITIQUE, AND INSPIRATION
because it is prescribed by the medical team. Coercion does not necessarily mean bullying, but it can involve patients feeling that they cannot refuse or believing that there is no alternative to ECT and nurses using bribery regarding discharge outlook and future prospects or inveigling partners or other family member into promoting the expected positive results. Patients, given their vulnerability and desperation, will succumb and sign (Philpot et al., 2004; Van Daalen-Smith, 2011). On the other hand 86% of Rayner and colleagues (2009) 258 respondents agreed that they did not feel pressurized or forced. In Lamont and colleagues’ (2011) review of ECT procedures more than half of patients (26 of 43) were treated involuntarily, but legally, under the auspices of the Mental Health Review Tribunal. This clearly means informed consent is not part of patients’ experiences of ECT in many settings. A few ECT-related articles published in nursing journals read as if they are following medical proponents of ECT’s good news (e.g., Gomez, 2004; Weiner & Falcone, 2011). As Chakrabarti and colleagues (2010) point out, there is a stark disparity between the perception of benefit in studies performed by consumer organizations and those carried out by practitioners. Nurses involved with ECT should be able to provide suitably balanced information of a high standard. This means that RNs have to have up-to-date information from both medical sources (some of which are written in promotional mode) and consumer sources (much of which documents severe long-term consequences). The least satisfactory aspects of Rayner and colleagues’ (2009) audit was that only about half of the patients knew what would happen if they did not have ECT and 60% were aware of alternatives. Informed consent cannot be obtained if adequate honest information is not provided. Furthermore, it is unclear if good information is provided to those who are legally required to have ECT against their will. Pre-ECT protocols often recommend a checklist for nurses to go over, which includes technical and informational preparation as well as addressing last minute queries (Finch, 2005; Kavanagh & McLoughlin, 2009). Pre-treatment nursing care also consists of making sure relevant documentation is complete and ensuring that the patient is accompanied by an RN who is aware of the patient’s legal and consent status—and preferably is familiar to the patient—during the waiting time, which should be as short as possible (Finch, 2005; Kavanagh & McLoughlin, 2009). During treatment, the RN assists according to hospital protocols. After treatment, the RN attends to routine post-anesthetic requirements, such as correct positioning, airway patency, and vital signs monitoring until consciousness is regained (Finch, 2005; Gomez, 2004; Kavanagh & McLoughlin, 2009). Immediately after ECT, a patient can be unaware that he or she has had the treatment and may be disorientated, confused, or drowsy (Meeter et al., 2011; Moksnes & Ilner, 2010; Philpot et al., 2004). As such, the RN should be familiar with these effects and stay close to the patient and provide simple, relevant, calming orienting information (Finch, 2005; Gomez, 2004). When the patient is sufficiently settled he or she is es-
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corted back to the ward and any notable information is passed on. Once the immediate phase after regaining consciousness has passed, headache is a common complaint, which should be promptly treated with analgesia (Finch, 2005; Gomez, 2004; Philpot et al., 2004). This column has overviewed a range of topics relevant to mental health nurse knowledge of ECT. This knowledge domain is especially important for RNs to enable them to fulfill their responsibilities to patients who need to be fully informed to consent to ECT, its alternative, or to concomitant treatments. There is a paucity of detailed research-based long-term data relating to the rates, extent, and disabling aspects of retrograde amnesia experienced by a significant minority of people who undergo ECT, even utilizing contemporary best practice. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. REFERENCES Chakrabarti, S., Grover, S., & Rajagopal, R. (2010). Electroconvulsive therapy: A review of knowledge, experience and attitudes of patients concerning the treatment. World Journal of Biological Psychiatry, 11(3), 525–537. Finch, S. (2005). Nurse guidance for ECT, April 2005. Retrieved from http:// www.rcn.org.uk/development/communities/rcn forum communities/mental health/good practice/new guidance on ect 21 apr 2005 Flint, V. (2005). The place of ECT in mental health care. Kai Tiaki Nursing New Zealand 11(9), 18–19. Gass, J. P. (1998). The knowledge and attitudes of mental health nurses to electro-convulsive therapy. Journal of Advanced Nursing, 27(1), 83–90. Gass, J. (2008). Electroconvulsive therapy and the work of mental health nurses: A grounded theory study. International Journal of Nursing Studies, 45(2), 191–202. Gomez, G. E. (2004). Electroconvulsive therapy: Present and future. Issues in Mental Health Nursing, 25(5), 473–486. Gregory-Roberts, E. M., Naismith, S. L., Cullen, K. M., & Hickie, I. B. (2010). Electroconvulsive therapy-induced persistent retrograde amnesia: Could it be minimised by ketamine or other pharmacological approaches? Journal of Affective Disorders 126(1–2), 39–45. Hunt, I. M., Windfuhr, K., Swinson, N., Shaw, J., Appleby, L., & Kapur, N. (2011). Electroconvulsive therapy and suicide among the mentally ill in England: A national clinical survey. Psychiatry Research, 187(1–2), 145–149. Kavanagh, A., & McLoughlin, D. M. (2009). Electroconvulsive therapy and nursing care. British Journal of Nursing 18(22), 1370, 1372, 1374–1377. Kho, K. H., VanVreeswijk, M. F., & Murre, J. M. J. (2006). A retrospective controlled study into memory complaints reported by depressed patients after treatment with electroconvulsive therapy and pharmacotherapy or pharmacotherapy only. Journal of ECT, 22(3), 199–205. Lamont, S., Brunero, S., Barclay, C., & Wijeratne, C. (2011). Evaluation of an electroconvulsive therapy service in a general hospital. Issues in Mental Health Nursing, 20(3), 223–229. Leiknes, K. A., Jarosh-von Schweder, L., & Hoie, B. (2012). Contemporary use and practice of electroconvulsive therapy worldwide. Brain and Behavior, 2(3), 283–344. Loo, C. (2007). The NSW Mental Health Bill 2007: Implications for the provision of electroconvulsive therapy. Australasian Psychiatry, 15(6), 457–460. Matheson, S. L., Green, M. J., Loo, C., & Carr, V. J. (2010). Quality assessment and comparison of evidence for electroconvulsive therapy and repetitive transcranial magnetic stimulation for schizophrenia: A systematic metareview. Schizophrenia Research, 118(1–3), 201–210.
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Meeter, M., Murre, J. M., Janssen, S. M., Birkenhager, T., & van den Broek, W. W. (2011). Retrograde amnesia after electroconvulsive therapy: A temporary effect? Journal of Affective Disorders, 132(1–2), 216–222. Moksnes, K. M., & Ilner, S. O. (2010). Electroconvulsive therapy—efficacy and side-effects. Tidsskrift for den Norske lægeforening, 130(24), 2460–2464. Morrison, L. (2009). ECT: Shocked beyond belief. Australasian Psychiatry, 17(2), 164–167. National Institute for Clincial Excellence. (2003). Technology Appraisal Guidance 59: Guidance on the use of electroconvulsive therapy. London, UK: Author. Retrieved from http://www.nice.org.uk/nicemedia/pdf/ 59ectfullguidance.pdf Nordenskjold, A., von Knorring, L., & Engstrom, I. (2011). Rehospitalization rate after continued electroconvulsive therapy—a retrospective chart review of patients with severe depression. Nordic Journal of Psychiatry 65(1), 26–31. Philpot, M., Collins, C., Trivedi, P., Treloar, A., Gallacher, S., & Rose, D. (2004). Eliciting users’ views of ECT in two mental health trusts with a user-designed questionnaire. Journal of Mental Health, 13(4), 403–413.
Rayner, L., Kershaw, K., Hanna, D., & Chaplin, R. (2009). The patient perspective of the consent process and side effects of electroconvulsive therapy. Journal of Mental Health, 18(5), 379–388. Rose, D., Wykes, T., Leese, M., Bindman, J., & Fleischmann, P. (2003). Patients’ perspectives on electroconvulsive therapy: Systematic review. British Medical Journal, 326(7403), 1363–1365. Sackeim, H. A., Prudic, J., Fuller, R., Keilp, J., Lavori, P. W., & Olfson, M. (2007). The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology, 32(1), 244–254. Scott, A. I. F. (2005). College guidelines on electroconvulsive therapy: An update for prescribers. Advances in Psychiatric Treatment, 11(2), 150–156. Vamos, M. (2008). The cognitive side effects of modern ECT: Patient experience or objective measurement? Journal of ECT, 24(1), 18–24. Van Daalen-Smith, C. L. (2011). Waiting for oblivion: Women’s experiences with electroshock. Issues in Mental Health Nursing, 32(7), 457–472. Weiner, R. D., & Falcone, G. (2011). Electroconvulsive therapy: How effective is it? Journal of the American Psychiatric Nurses Association 17(3), 217–218.
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