2 Clinical need and practice

2.1 This appraisal considers electroconvulsive therapy (ECT) in the treatment of: depressive illness, schizophrenia, catatonia and mania.

2.2 Depressive illness is associated with discrete episodes that are characterised by feelings of sadness, despair, loss of interest in daily life and discouragement. The severity of depressive illness is determined by the number, intensity and frequency or persistence of depressive symptoms and the presence of specific symptoms such as delusions, hallucinations and suicidal ideation. Severe depressive illness can deteriorate into a 'depressive stupor' where a person is conscious but is non-responsive to any stimulation. This extreme manifestation of depressive illness has become less frequent because of the advent of modern treatments.

2.3 Schizophrenia is characterised by a broad range of cognitive, emotional and behavioural problems, which are in general classified into positive and negative symptoms. Individuals with delusions or hallucinations are described as psychotic.

2.4 Catatonia is a syndrome that is associated with both schizophrenia and affective (mood) disorders. It is characterised by marked changes in muscle tone or activity that may alternate between the extremes of a deficit of movement (catatonic stupor) and excessive movement (catatonic excitement).

2.5 Mania is characterised by elated, euphoric or irritable mood and increased energy. The term may refer to a mental disorder or to a mood state or symptom, and mania is associated with bipolar disorders. In severe manic episodes, individuals are psychotic and require continual supervision to prevent physical harm to themselves or others.

2.6 In 2000, the Psychiatric Morbidity Survey conducted by the Office of National Statistics (ONS) found the prevalence of a depressive episode per thousand population to be 25 in England and 37 in Wales. The prevalence of schizophrenia is estimated at between 2 and 10 per 1,000 in the general population, and the incidence of first-onset schizophrenia is approximately 1 per 10,000 population per year. Recent estimates have suggested that bipolar affective disorder has a point prevalence of up to 50 per 1,000 of the general population, of whom 1% are admitted to hospital for mania each year. There are no recent epidemiological studies on the incidence of catatonia.

2.7 Depressive illness, schizophrenia and mania are frequently chronic, relapsing conditions and are associated with considerable suicide risk. Diagnosable depressive disorders are implicated in between 40% and 60% of suicide attempts. The 2000 ONS Psychiatric Morbidity Survey found that in individuals with a current depressive episode, 5% reported a suicide attempt within the past year. Common estimates are that 10% of people with schizophrenia will eventually have a completed suicide, and that attempts are made at 2 to 5 times that rate.

2.8 Severe mental health disorders are associated with considerable personal suffering, occupational and social disadvantage and impairment in interpersonal and family relationships in the long term. They also have a high economic impact, with the indirect costs far exceeding the direct costs.

2.9 Depressive illness is managed with antidepressants, psychotherapy and counselling, either alone or in combination. Although the management of schizophrenia frequently centres on antipsychotic medication, individuals also require substantial clinical, emotional and social support. Catatonia is usually treated with benzodiazepines; the introduction of effective psychotropic agents has led to a marked reduction in its prevalence. Acute manic episodes are treated with antipsychotics, lithium or anticonvulsants. Many individuals with mental health disorders benefit from self-help techniques including support groups.

2.10 ECT is used in current UK clinical practice as a treatment option for individuals with depressive illness, catatonia and mania. It is also occasionally used to treat schizophrenia. Guidelines for the use of ECT were developed by the Royal College of Psychiatrists in 1995 and are currently undergoing revision. Guidance for nurses has also been produced by the Royal College of Nursing.