Appendix B

Sample ECT Consent Documents

1. Consent Form : Acute Phase
2. Consent Form: Continuation/Maintenance ECT
3. Patient Information Sheet

Electroconvulsive Therapy (ECT) Consent Form:
Acute Phase

Name of Patient :_________________________________

My doctor, ___________________________, has recommended that I receive treatment with electroconvulsive therapy (ECT). This treatment, including the risks and benefits that I may experience, has been fully described to me. I give my consent to be treated with ECT.

Whether ECT or an alternative treatment, like medication or psychotherapy, is most appropriate for me depends on my prior experience with these treatments, the features of my illness, and other considerations. Why ECT has been recommended for me has been explained.

ECT involves a series of treatments, which may be given on an inpatient or outpatient basis. To receive each treatment I will come to a specially equipped area in this facility. The treatments are usually given in the morning. Because the treatments involve general anesthesia, I will have had nothing to eat or drink for several hours before each treatment. Before the treatment, a small needle will be placed in my vein so that I can be given medications. An anesthetic medication will be injected that will quickly put me to sleep. I will then be given another medication that will relax my muscles. Because I will be asleep, I will not experience pain or discomfort or remember the procedure. Other medications may also be given depending on my needs.

To prepare for the treatment, monitoring sensors will be placed on my head and body. Blood pressure cuffs will be placed on an arm and leg. This monitoring involves no pain or discomfort. After I am asleep, a carefully controlled amount of electricity will be passed between two electrodes that have been placed on my head.

I may receive bilateral ECT or unilateral ECT. In bilateral ECT, one electrode is placed on the left side of the head, the other on the right side. In unilateral ECT, both electrodes are placed on the same side of the head, usually the right side. Right unilateral ECT (electrodes on the right side) is likely to produce less memory difficulty than bilateral ECT. However, for some patients bilateral ECT may be a more effective treatment. My doctor will carefully consider the choice of unilateral or bilateral ECT.

The electrical current produces a seizure in the brain. The amount of electricity used to produce the seizure will be adjusted to my individual needs, based on the judgment of the ECT physician. The medication used to relax my muscles will greatly soften the contractions in my body that would ordinarily accompany the seizure. I will be given oxygen to breathe. The seizure will last for approximately one minute. During the procedure, my heart, blood pressure, and brain waves will be monitored. Within a few minutes, the anesthetic medications will wear off and I will awaken. I will then be observed until it is time to leave the ECT area.

The number of treatments that I will receive cannot be known ahead of time. A typical course of ECT is six to twelve treatments, but some patients may need fewer and some may need more. Treatments are usually given three times a week, but the frequency of treatment may also vary depending on my needs.

ECT is expected to improve my illness. However, I understand that I may recover completely, partially, or not at all. After ECT, my symptoms may return. How long I will remain well cannot be known ahead of time. To make the return of symptoms less likely after ECT, I will need additional treatment with medication, psychotherapy, and/or ECT. The treatment I will receive to prevent the return of symptoms will be discussed with me.

Like other medical treatments, ECT has risks and side effects. To reduce the risk of complications, I will receive a medical evaluation before starting ECT. The medications I have been taking may be adjusted. However, in spite of precautions, it is possible that I will experience a medical complication. As with any procedure using general anesthesia, there is a remote possibility of death from ECT. The risk of death from ECT is very low, about one in 10,000 patients. This rate may be higher in patients with severe medical conditions.

ECT very rarely results in serious medical complications, such as heart attack, stroke, respiratory difficulty, or continuous seizure. More often, ECT results in irregularities in heart rate and rhythm. These irregularities are usually mild and short lasting, but in some instances can be life threatening. With modern ECT technique, dental complications are infrequent and bone fractures or dislocations are very rare. If serious side effects occur, the necessary medical care will be provided.

The minor side effects that are frequent include headache, muscle soreness, and nausea. These side effects usually respond to simple treatment.

When I awaken after each treatment, I may be confused. This confusion usually goes away within an hour.

I understand that memory loss is a common side effect of ECT. The memory loss with ECT has a characteristic pattern, including problems remembering past events and new information. The degree of memory problems is often related to the number and type of treatments given. A smaller number of treatments is likely to produce less memory difficulty than a larger number. Shortly following a treatment, the problems with memory are greatest. As time from treatment increases, memory improves.

I may experience difficulties remembering events that happened before and while I received ECT. The spottiness in my memory for past events may extend back to several months before I received ECT, and, less commonly, for longer periods of time, sometimes several years or more. While many of these memories should return during the first few months following my ECT course, I may be left with some permanent gaps in memory.

For a short period following ECT, I may also experience difficulty in remembering new information. This difficulty in forming new memories should be temporary and typically disappears within several weeks following the ECT course.

The majority of patients state that the benefits of ECT outweigh the problems with memory. Furthermore, most patients report that their memory is actually improved after ECT. Nonetheless, a minority of patients report problems in memory that remain for months or even years. The reasons for these reported long-lasting impairments are not fully understood. As with any medical treatment, people who receive ECT differ considerably in the extent to which they experience side effects.

Because of the possible problems with confusion and memory, I should not make any important personal or business decisions during, or immediately following, the ECT course. During and shortly after the ECT course, and until discussed with my doctor, I should refrain from driving, transacting business, or other activities for which memory difficulties may be troublesome.

The conduct of ECT at this facility is under the direction of Dr.

_________________________________

I may contact him/her at _______________ if I have further questions.

I am free to ask my doctor or members of the ECT treatment team questions about ECT at this time or at any time during or following, the ECT course. My decision to agree to ECT is being made voluntarily, and I may withdraw my consent for further treatment at any time.

I have been given a copy of this consent form to keep.

Date ------------------------------ Signature

_________ --- _________________________

Person Obtaining Consent:

Date ------------------------------ Signature

_________ --- _________________________

Electroconvulsive Therapy (ECT) Consent Form:
Continuation/Maintenance Treatment

Name of Patient: _________________________________

My doctor, ____________________________ has recommended that I receive continuation or maintenance treatment with electroconvulsive therapy (ECT). This treatment, including, the risks and benefits that I may experience, has been fully described to me. I give my consent to be treated with continuation ECT.

I will receive ECT to prevent relapse of my illness. Whether ECT or an alternative treatment, like medication or psychotherapy, is most appropriate for me at this time depends on my prior experience with these treatments in preventing, the return of symptoms, the features of my illness, and other considerations. Why continuation/maintenance ECT has been recommended for me has been explained.

Continuation/maintenance ECT involves a series of treatments with each usually separated in time by one or more weeks. Continuation /maintenance ECT is usually given for a period of several months or longer. These treatments may be given on an inpatient or outpatient basis.

To receive each continuation/maintenance treatment I will come to a specially equipped area in this facility. The treatments are usually given in the morning. Because the treatments involve general anesthesia, I will have had nothing to eat or drink for several hours before each treatment. Before the treatment, a small needle will be placed in my vein so that I can be given medications. An anesthetic medication will be injected that will quickly put me to sleep. I will then be given another medication that will relax my muscles. Because I will be asleep, I will not experience pain or discomfort or remember the procedure. Other medications may also be given depending on my needs.

To prepare for the treatment, monitoring sensors will be placed on my head and body. Blood pressure cuffs will be placed on an arm and leg. This monitoring involves no pain or discomfort. After I am asleep, a carefully controlled amount of electricity will be passed between two electrodes that have been placed on my head.

I may receive bilateral ECT or unilateral ECT. In bilateral ECT, one electrode is placed on the left side of the head, the other on the right side. In unilateral ECT, both electrodes are placed on the same side of the head, usually the right side. Right unilateral ECT (electrodes on the right side) is likely to produce less memory difficulty than bilateral ECT. However, for some patients bilateral ECT may be a more effective treatment. My doctor will carefully consider the choice of unilateral or bilateral ECT.

The electrical current produces a seizure in the brain. The amount of electricity used to produce the seizure will be adjusted to my individual needs, based on the judgment of the ECT physician. The medication used to relax my muscles will greatly soften the contractions in my body that would ordinarily accompany the seizure. I will be given oxygen to breathe. The seizure will last for approximately one minute. During, the procedure, my heart, blood pressure, and brain waves will be monitored. Within a few minutes, the anesthetic medications will wear off and I will awaken. I will then be observed until it is time to leave the ECT area.

The number of continuation/maintenance treatments that I will receive will depend on my clinical course. Continuation ECT is usually given for at least six months. If it is felt that continuation ECT is helpful and should be used for a longer period (maintenance ECT), I will be asked to consent to the procedure again.

ECT is expected to prevent the return of my psychiatric condition. While for most patients ECT is effective in this way, I understand that this cannot be guaranteed. With continuation/maintenance ECT I may remain considerably improved or I may have a partial or complete return of psychiatric symptoms.

Like other medical treatments, ECT has risks and side effects. To reduce the risk of complications, I will receive a medical evaluation before starting ECT. The medications I have been taking may be adjusted. However, in spite of precautions, it is possible that I will experience a medical complication. As with any procedure using general anesthesia, there is a remote possibility of death from ECT. The risk of death from ECT is very low, about one in 10,000 patients. This rate may be higher in patients with severe medical conditions.

ECT very rarely results in serious medical complications, such as heart attack, stroke, respiratory difficulty, or continuous seizure. More often, ECT results in irregularities in heart rate and rhythm. These irregularities are usually mild and short lasting, but in some instances can be life threatening. With modem ECT technique, dental complications are infrequent and bone fractures or dislocations are very rare. If serious side effects occur, the necessary medical care will be provided.

The minor side effects that are frequent include headache, muscle soreness, and nausea. These side effects usually respond to simple treatment.

When I awaken after each treatment, I may be confused. This confusion usually goes away within an hour.

I understand that memory loss is a common side effect of ECT. The memory loss with ECT has a characteristic pattern, including problems remembering past events and new information ion. The degree of memory problems is often related to the number and type of treatments given. A smaller number of treatments is likely to produce less memory difficulty than a larger number. Shortly following a treatment, the problems with memory are greatest. As time from treatment increases, memory improves.

I may experience difficulties remembering events that happened before and while I received ECT. The spottiness in my memory for past events may extend back to several months before I received ECT, and, less commonly, for longer periods of time, sometimes several years or more. While many of these memories should return during the first few months following continuation ECT, I may be left with some permanent gaps in memory.

For a short period following each treatment, I may also experience difficulty in remembering new information. This difficulty in forming new memories should be temporary and will most likely disappear following completion of continuation/maintenance ECT.

The effects of continuation/maintenance ECT on memory are likely to be less pronounced than those during an acute ECT course. By spreading treatments out in time, with an interval of a week or more between treatments, there should be substantial recovery of memory between each treatment.

Because of the possible problems with confusion and memory, it is important that I not drive, or make any important personal or business decisions the day that I receive a continuation/maintenance treatment. Limitations on my activities may be longer depending on the side effects I experience following each treatment, and will be discussed with my doctor.

The conduct of ECT at this facility is under the direction of Dr. _________________

I may contact him/her at ___________if I have further questions.

I am free to ask my doctor or members of the ECT treatment team questions about ECT at this time or at any time during or following the ECT course. My decision to agree to continuation/maintenance ECT is being made voluntarily, and I may withdraw my consent for future treatment at any time.

I have been given a copy of this consent form to keep.

Date ------------------------------ Signature

_________ --- _________________________

Person Obtaining Consent:

Date ------------------------------ Signature

_________ --- _________________________

Sample Patient Information Booklet

Electroconvulsive Therapy

What is Electroconvulsive Therapy?

Electroconvulsive therapy (ECT or shock treatment) is an extremely safe and effective medical treatment for certain psychiatric disorders. With this treatment, a small amount of electricity is applied to the scalp and this produces a seizure in the brain. The procedure is painless because the patient is asleep, under general anesthesia.

Who is Treated with ECT?

ECT has been used for over 60 years. In the United States, about 100,000 individuals are estimated to receive ECT each year. ECT is most commonly given when patients have severe depressive illness, mania, or some forms of schizophrenia. Frequently, ECT is given when patients have not responded to other treatments, when other treatments appear to be less safe or difficult to tolerate, when patients have responded well to ECT in the past, or when psychiatric or medical considerations make it particularly important that patients recover quickly and fully.

Not all patients improve when treated with medications or psychotherapy (talk therapy). Indeed, when illnesses such as depression become particularly severe, it is doubtful that psychotherapy alone will be sufficient. For some patients, the medical risks of medications are greater than the medical risks of ECT. Typically, these are people with serious medical problems, such as some types of heart disease. When patients have life-threatening psychiatric problems, such as suicidal tendencies, ECT is also often recommended because it usually provides faster relief than medications. Overall, about 70 to 90% of the depressed patients treated with ECT show substantial improvement. This makes ECT the most effective of the antidepressant treatments.

Who Administers ECT?

A treatment team gives ECT. The team consists of a psychiatrist, an anesthesiologist, and nurses. The physicians responsible for administering ECT are experienced specialists. ECT is administered in a dedicated suite at the (name of facility) The suite contains a waiting, area, a treatment room, and a recovery room.

How is ECT Given?

Before ECT is administered, the patient's medical condition is carefully assessed. This includes a complete medical history, physical examination, and medical tests, as needed. The treatments are usually given three times per week in the morning on Monday, Wednesday and Friday. Before each treatment, the patient should not eat or drink anything after midnight. Patients should also try to refrain from smoking during the morning prior to the treatment.

When the patient comes to the ECT treatment room, an intravenous line is started. Sensors for recording, EEG (electroencephalogram, a measure of brain activity) are placed on the head. Other sensors are placed on the chest for monitoring EKG (electrocardiogram). A cuff is wrapped around an arm for monitoring blood pressure. When everything is connected and in order, an anesthetic medication (methohexital) is injected through the intravenous line that will cause the patient to sleep for 5 to 10 minutes. Once the patient falls asleep, a muscle relaxant (succinylcholine) is injected. This prevents movement, and during the seizure there are only minimal contractions of the muscles.

When the patient is completely asleep and the muscles are well relaxed, the treatment is given. A brief electrical charge is applied to electrodes on the scalp. This stimulates the brain and produces the seizure that lasts for about a minute. Throughout the procedure, the patient receives oxygen through a mask. This continues until the patient resumes breathing on his or her own. When the treatment is completed, the patient is taken to a recovery area for monitoring by trained staff. Usually within 30 to 60 minutes, the patient can leave the recovery area.

How Many Treatments are Needed?

ECT is given as a course of treatments. The total number needed to successfully treat psychiatric disturbance varies from patient to patient. For depression, the typical range is from 6 to 12 treatments, but some patients may require fewer and some patients may require more treatments.

Is ECT Curative?

ECT is extremely effective in providing relief from psychiatric symptoms. However, permanent cures for psychiatric illness are rare, regardless of the treatment given. To prevent relapse following ECT, most patients require further treatment with medications or with ECT. If ECT is used to protect against relapse, it is usually administered to outpatients on a weekly to monthly basis.

How Safe is ECT?

It is estimated that death associated with ECT occurs in one of 10,000 patients. This rate may be higher in patients with severe medical conditions. ECT appears to have less risk of death or serious medical complications than a number of the medications used to treat psychiatric conditions. Because of this strong safety record, ECT is often recommended for patients with serious medical conditions. With modem anesthesia, fractures and dental complications are very rare.

What are the Common Side Effects of ECT?

The patient will experience some confusion on awakening following, the treatment. This is partly due to the anesthesia and partly due to the treatment. The confusion typically clears within an hour. Some patients have headaches following the treatment. This is usually relieved by Tylenol or aspirin. Other side effects, such as nausea, last for a few hours at most and are relatively uncommon. In patients with heart disease, there is an increased risk of cardiac complications. Cardiac monitoring and other precautions, including the use of additional medications if required help to ensure a safe treatment.

The side effect of ECT that has received the most attention is memory loss. ECT results in two types of memory loss. The first involves rapid forgetting of new information. For example, shortly following the treatment, patients may have difficulty remembering conversations or things they have recently read. This type of memory loss is short-lived and has not been shown to persist for more than a few weeks following the completion of ECT. The second type of memory loss concerns events from the past. Some patients will have gaps in their memory for events that occurred in the weeks to months and, less commonly, years prior to the treatment course. This memory loss also reverses following the completion of ECT. However, in some patients there may be permanent gaps in memory for events that occurred close in time to the treatment. However, like with any treatment, patients differ in the extent to which they experience side effects, and more extensive memory loss has been reported by a minority of individuals. It is known that the effects on memory are not necessary to obtain the benefits of ECT.

Many psychiatric illnesses result in impairments of attention and concentration. Consequently, when the psychiatric disturbance improves following ECT, there is often improvement in these aspects of thinking. Shortly following, ECT, most patients show improved scores on tests of intelligence, attention, and learning.

Does ECT Cause Brain Damage?

The scientific evidence strongly speaks against this possibility. Careful studies in animals have shown no evidence of brain damage from brief seizures, like those given with ECT. In the adult, seizures must be sustained for hours before brain damage can occur, yet the ECT seizure lasts only for about a minute. Brain imaging studies following ECT have shown no changes in the structure or composition of the brain. The amount of electricity used in ECT is so small that it cannot cause electrical injury.

How Does ECT Work?

Like many other treatments in medicine, the exact process that underlies the effectiveness of ECT is uncertain. It is known that the benefits of ECT depend on producing a seizure in the brain and on technical factors in how the seizure is produced. Biological changes that result from the seizure are critical to effectiveness. Most investigators believe that specific changes in brain chemistry produced by ECT are the key to restoring normal function.

Considerable research is being conducted to isolate the critical biochemical processes.

Is ECT Frightening?

ECT has often been portrayed in the movies and TV as a painful procedure, used to control or punish patients. These portrayals have no resemblance to modem ECT. One survey found that following ECT most patients reported that it was no worse than going to the dentist, and many found ECT less stressful. Other research has shown that that the vast majority of patients report that their memory is improved following ECT and that if needed, they would receive ECT again.

ECT is an extremely effective form of treatment. It is often safer and more effective than medications or no treatment at all. If you have any questions about ECT, please discuss them with your physician. You may also wish to read one of the following books. Both books were written by psychologists who were against people having ECT until they each had a severe depression and needed the treatment. Drs. Endler and Manning describe their illness, their experience in treatment with medication and psychotherapy, and their experience with ECT.

HOLIDAY OF DARKNESS
by Norman S. Endler
Wall & Thompson, Toronto
1990

UNDERCURRENTS: A THERAPIST'S
RECKONING WITH DEPRESSION
by Martha Manning
Harper, San Francisco
1995

next: Adverse Psychological Effects of ECT
~ all Shocked! ECT articles
~ depression library articles
~ all articles on depression