Royal Australian and New Zealand College of Psychiatrists professional practice guidelines for the administration of electroconvulsive therapy

Abstract

Objectives: To provide guidance for the optimal administration of electroconvulsive therapy, in particular maintaining the high efficacy of electroconvulsive therapy while minimising cognitive side-effects, based on scientific evidence and supplemented by expert clinical consensus. Methods: Articles and information were sourced from existing guidelines and the published literature. Information was revised and discussed by members of the working group of the Royal Australian and New Zealand College of Psychiatrists’ Section for Electroconvulsive Therapy and Neurostimulation, and findings were then formulated into consensus-based recommendations and guidance. The guidelines were subjected to rigorous successive consultation and external review within the Royal Australian and New Zealand College of Psychiatrists, involving the full Section for Electroconvulsive Therapy and Neurostimulation membership, and expert and clinical advisors and professional bodies with an interest in electroconvulsive therapy administration. Results: The Royal Australian and New Zealand College of Psychiatrists’ professional practice guidelines for the administration of electroconvulsive therapy provide up-to-date advice regarding the use of electroconvulsive therapy in clinical practice and are informed by evidence and clinical experience. The guidelines are intended for use by psychiatrists and also others with an interest in the administration of electroconvulsive therapy. The guidelines are not intended as a directive about clinical practice or instructions as to what must be done for a given patient, but provide guidance to facilitate best practice to help optimise outcomes for patients. The outcome is guidelines that strive to find the appropriate balance between promoting best evidence-based practice and acknowledging that electroconvulsive therapy is a continually evolving practice. Conclusion: The guidelines provide up-to-date advice for psychiatrists to promote optimal standards of electroconvulsive therapy practice.

Protocolization as a method of addressing heterogeneity in electroconvulsive therapy delivery

“…Moreover, RUL ECT up to eight times seizure threshold has demonstrated efficacy [48], further supporting the idea of charge maximization. Both of these charges are in-line with recent guidelines [26]. The next branch point is treatment number ten where RUL charge maximization (if not already done) or switch to BT placement is considered.…”

“…This facilitates precision dosing given variability of individual seizure thresholds and escalating threshold values with high frequency ECT. This may lead to superior outcomes compared to age-based or fixed-dose ECT and is supported in recent guidelines [26,45,46].…”

“…Despite data demonstrating lower relapse rates with C-ECT in mood disorders the optimal frequency remains poorly understood [53][54][55]. Tapering ECT after the index course is recommended in recent guidelines [26] and we propose a conservative weaning approach for several reasons. First, a substantial number of patients relapse upon discontinuation of ECT [56,57].…”

“…While some countries offer ECT practice guidelines (i.e. United Kingdom National Institute for Health and Care Excellence (NICE) [25], Royal Australian and New Zealand College of Psychiatrists (RANZCP) [26], American Psychiatric Association (APA) [27]) they often lag behind contemporary evidence-based practice (e.g. NICE ECT guidelines were most recently reviewed in 2014).…”

“…Thankfully, positive changes in worldwide ECT practice have been effected via quality improvement projects [30], implementation of national guidelines [31] and increased use of specialized ECT treatment centers [10]. Recent national guidelines include the UK NICE [25] and the RANZCP [26], the latter being recognized by the APA [27].…”