NICE has looked carefully at the evidence and has recommended that ECT should only be used for the treatment of severe depressive illness, a prolonged or severe episode of mania, or catatonia if the conditions described in the following paragraphs are applied. 

ECT should be used to gain fast and short-term improvement of severe symptoms after all other treatment options have failed, or when the situation is thought to be life-threatening. 

A risk–benefit assessment for the individual should be made and documented. It should include the risks associated with the anaesthetic, whether the person has other illnesses, the possible adverse effects of ECT (particularly problems with memory), and the risks of not having treatment.

Doctors should be particularly cautious when considering ECT treatment for women who are pregnant and for older or younger people, because they may be at higher risk of complications with ECT. 

Someone who is mentally capable of making a decision about their treatment should decide, after discussion with the doctor, whether or not they want to give their consent to have ECT. To help in the discussion, full and appropriate information about ECT should be given, including information about its potential risks and benefits, both general and specific to the individual. NICE recommends that information leaflets to help people to make an informed decision about their treatment should be developed nationally and should be available in formats and languages that will make them accessible to a wide range of service users.

The doctor should keep strictly to recognised guidelines about consent, should not put any pressure on the person to give their consent and should remind the person that they have the right to change their mind either for or against treatment at any time. NICE considers that doctors should encourage the involvement of an independent person who speaks on behalf of the service user (an ’advocate’) or the person’s carer(s).

If discussion and informed consent are not possible at the time treatment is needed, any advance directive should be fully taken into account and someone who speaks on behalf of the person who is ill, or their carer(s), should be consulted.

The person should be re-assessed after every session of ECT. There should be ongoing checks for any signs of memory loss, and as a minimum, a check at the end of each course of treatment.

The treatment should be stopped as soon as the person has responded, if there are any adverse effects, or if they withdraw their consent.

It is recommended that more than one course of ECT should be considered only for people who have severe depressive illness, catatonia or mania and who have previously responded well to ECT. As for the first course of treatment, it should be used only to gain fast and short-term improvement of severe symptoms after all other treatment options have failed or when the situation is thought to be life-threatening. For someone who is experiencing an episode of severe depressive illness, catatonia or mania and who has not responded to a previous course of ECT, the doctor should consider a repeat course of ECT only if all other treatment options have been considered and after discussion of the risks and benefits with the service user and where appropriate their advocate or carer.

NICE recommends that ECT should not to be used as a long-term treatment to prevent recurrence of depressive illness, and that it should not be used in the general management of schizophrenia.

The recommendations in this technology appraisal relating to the treatment of depression have been replaced by recommendations in NICE guideline CG90. Note that the recommendations in this technology appraisal relating to the treatment of catatonia, prolonged or severe manic episodes and schizophrenia have not changed.

Your responsibility

The recommendations in this guidance represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take this guidance fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this guidance is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable the guidance to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.