7 Implementation and audit
7.1 When NICE recommends a treatment 'as an option', the NHS must make sure it is available within the period set out in the paragraph above. This means that, if a patient has catatonia or a prolonged or severe manic episode and the doctor responsible for their care thinks that electroconvulsive therapy is the right treatment, it should be available for use, in line with NICE's recommendations.
7.2 NHS Trusts should ensure that ECT is carried out in accordance with the recommendations in section 1 and only by clinical staff trained in its application. Such staff should maintain an appropriate level of skill through routine practice and continuing professional development.
7.3 NHS Trusts currently offering ECT, and all clinicians involved in the care of individuals receiving ECT, should review policies and practices regarding its use to take account of the guidance set out in section 1.
7.4 Local guidelines or care pathways involving ECT should incorporate the guidance in section 1.
7.5 To measure compliance locally with the guidance, the following criteria could be used. Further details on suggestions for audit are presented in appendix D.
7.5.1 ECT is used only for an individual with any of the following:
severe depressive illness
a prolonged or severe manic episode.
7.5.2 ECT is used only to achieve rapid and short-term improvement of an individual's 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.
7.5.3 An assessment of the risks and potential benefits to the individual undergoing ECT is documented. If the individual is pregnant, an older person, or a child or young person, the clinician(s) involved should exercise particular caution and the individual or their advocate or carer should be made aware that the risks associated with ECT may be enhanced in these circumstances.
7.5.4 The individual undergoing ECT provides valid consent if he or she has the ability to grant or refuse consent. In situations where joint decision making, informed discussion and consent are not possible, advance directives are fully taken into account and the individual's advocate and/or carer is consulted.
7.5.5 The consent process provides that the clinician(s) responsible for treatment:
involves the individual's advocate and/or carer where possible
provides full and appropriate information in a suitable format and language to enable an informed discussion
explains and discusses the general risks of ECT, risks specific to the individual and potential benefits to the individual
does not pressure or coerce the individual into consent to the treatment
reminds the individual that he or she has the right to withdraw consent at any point.
7.5.6 The individual's clinical status is assessed following each ECT session and the individual's cognitive function is monitored on an ongoing basis and at a minimum at the end of each course of treatment.
7.5.7 ECT treatment is stopped once a response is achieved, if there is evidence of adverse effects, or if the individual withdraws consent.
7.5.8 A repeat course of ECT is considered only for an individual:
under the circumstances described in 7.4.1 and 7.4.2 above who has previously responded well to ECT
who has not responded previously but is experiencing an acute episode and all other options have been considered, and following discussion with the individual and/or where appropriate the carer/advocate of the risks and benefits of such a course of action.
7.5.9 ECT is not used as a maintenance therapy in depressive illness.
7.5.10 ECT is not used in the general management of schizophrenia.
7.6 Local clinical audits should include input from service users on at least criteria 7.4.4–7.4.9 and reference to standards in the current handbook on ECT published by the Royal College of Psychiatrists and the Royal College of Nursing, and the suggested indicators for audit of anaesthesia for ECT published by the Royal College of Anaesthetists.