2025 surveillance of electroconvulsive therapy (technology appraisal guidanceTA59, NICE guideline NG222, NICE guideline CG178, NICE guideline CG185, NICE guideline CG192)

Comment on section: ContextContext

Electroconvulsive therapy has been used to treat depressive illness, mania, catatonia, and, in some cases, schizophrenia. Although it has been in use since the 1930s, its exact mechanism of action remains unclear. During the procedure, electrodes are placed on the head, and a brief electric current is passed through them to the brain, inducing a seizure. ECT is administered under general anaesthesia, along with a muscle relaxant to prevent body spasms. It is usually given twice a week for 3 to 6 weeks, totalling 6 to 12 sessions per course. In some cases, maintenance ECT is provided once every 2 weeks or monthly to help prevent symptom recurrence. While ECT can affect heart rate and blood pressure, the most commonly reported side effect is memory loss, either short-term or long-term, which many find distressing.

NICE guidance TA59 recommends ECT only for rapid, short-term improvement in severe cases of catatonia or prolonged mania when other treatments have failed, or the condition is life-threatening. The decision to use ECT should be based on a thorough risk-benefit assessment, with special caution in vulnerable populations such as pregnant women, older adults, and children. Informed consent must be obtained without coercion, and cognitive function should be closely monitored throughout treatment. ECT is not recommended for general use in the management of schizophrenia and repeat ECT should only be considered for individuals who previously responded well. Regular assessments are required, and treatment should cease if adverse effects occur (recommendations 1.1 to 1.10).

NICE guideline NG222 on depression recommends considering ECT for severe depression when preferred by the patient, when a rapid response is needed, or other treatments have failed. Informed consent is essential, with discussions about the risks, benefits, and legal considerations. If a person lacks capacity, ECT should align with any advance decisions. Clinics must be accredited by the Electroconvulsive Therapy Accreditation Service (ECTAS) and follow strict standards. Treatment should stop if side effects outweigh the benefits or remission is achieved. After ECT, ongoing care with antidepressants or psychological interventions is recommended (recommendations 1.13.1 to 1.13.9).

NICE guideline on Antenatal and postnatal mental health: Clinical management and service guidance CG192 recommends considering ECT for pregnant women with severe depression, mixed affective states, mania, or catatonia when there is a serious risk to their health or the health of the fetus (recommendation 1.8.22).

This surveillance review focuses on NICE Technology Appraisal TA59 and NICE Guideline NG222 on depression. NICE guideline CG178, CG185 and CG192 are also relevant to this surveillance review.

Comment on section: Triggers for the exceptional reviewTriggers for the exceptional review

Concerns have been raised by enquirers that NICE guidance TA59 is outdated and based on weak evidence. They have also criticised the guidance for presenting an unbalanced view of risks and benefits in some populations, such as pregnant women, older adults, and children, without considering the greater dangers of untreated illness. Additionally, they challenged the guidance's recommendations on the continuation and maintenance of ECT, which is not routinely recommended. The enquirers argued that ongoing treatment may have fewer cognitive side effects than acute courses and could help reduce hospital readmissions.