APNA Position Statement: Electroconvulsive Therapy

Introduction

The American Psychiatric Nurses Association (APNA) was founded in 1986. It is the largest professional membership organization committed to the specialty practice of psychiatric-mental health nursing (PMHN). Initiatives include wellness promotion, prevention of mental health problems and the care and treatment of persons with psychiatric disorders across the lifespan. APNA is the only PMH nursing organization whose membershipis inclusive of all PMHN at basic (RN), advanced practice (NP and CNS), academic faculty and research scientist levels. APNA’s 8,800 members come from every state and include international members. APNA also has a panel of mental health consumers that offer advice to the governing board in formulating policy statements.

We are pleased to offer our comments in support of the use of electroconvulsive therapy in the treatment of severe depression that has been shown to be refractory to medication administration.


Discussion

For more than 7 decades, psychiatric mental health nurses (PMHN’s) have provided customized care for patients receiving ECT.1-4 In addition to advancing evidence-based treatment modifications and developing advanced practice nursing roles in ECT, psychiatric nurses have been vital patient advocates, assuring that patients receive accurate information about ECT, educating the public, and influencing public policy.5-20 ECT is an effective, evidence-based treatment for severe depression.21-23 The literature on the efficacy of ECT for treatment of depression is as extensive as for almost any medical treatment.24-30 Moreover, ECT is a rapidly acting treatment. Multiple trials of adequately administered ECT have demonstrated the speed of antidepressant response for patients experiencing severe, major depressive episodes.31 For patients who urgently need relief of depressive symptoms (i.e., those who pose a danger to self or to others), ECT can be the treatment of choice. For patients who have not responded to or cannot tolerate medications because of pregnancy, advanced age, multiple co-morbid health conditions or frailty, ECT may be the safest alternative.32 Modern techniques and brief pulse devices have increased the safety of ECT. Morbidity and mortality are less than that of childbirth, with one to two deaths per 10,000 patients treated with ECT.343-34 Advancements in anesthetic and ECT administration techniques have greatly mitigated side effects. The most significant concern about ECT is treatment-related cognitive impairment, but even this symptom has been markedly reduced with advances in ECT administration.35 ECT remains the treatment of choice for severely depressed patients with other concurrent health risks.


Conclusion

It is the position of the American Psychiatric Nurses Association that ECT is a proven therapy and that further clinical trials are not necessary to establish its safety and efficacy. APNA urges the FDA to classify these devices in an appropriate manner to assure that patients have access to ECT while at the same time assuring that ECT devices function safely and in manner intended. APNA believes that ECT operated by properly trained professionals and in circumstances of medical necessity offers patients with severe depression an option that would otherwise be unavailable.

APNA stands ready to assist in development of standards of practice in the proper application of ECT. Thank you for your attention and we urge you to classify these devices in a manner that provides the proper balance between access to evidence-based treatment and patient safety.

Approved by the APNA Board of Directors: January 11, 2011

Click here to download a pdf of this position statement.


References

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2. Janicak, P. G., Mask, J., Trimakas, K. A., & Gibbons, R. (1985). ECT: An assessment of mental health professionals' knowledge and attitudes. The Journal of Clinical Psychiatry, 46(7), 262-266.

3. Burns, C.M. & Stuart, G.W. (1991). Nursing care in electroconvulsive therapy. Psychiatric Clinics of North America, 14(4), 971-988.

4. Bowers, L. (2005). Reasons for admission and their implications for the nature of acute psychiatric nursing. Journal of psychiatric mental health nursing, 12(2), 232-236.

5. Callahan, L. (1990). Anesthesia for electroconvulsive therapy. CRNA: The Clinical Forum for Nurse Anesthetists, 1(1), 36-38.

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8. Fitzsimons, L. M., & Mayer, R. L. (1995). Soaring beyond the cuckoo's nest: Health care reform and ECT. Journal of Psychosocial Nursing and Mental Health Services, 33(12), 10-13.

9. Gass, J. P. (1998). The knowledge and attitudes of mental health nurses to electro-convulsive therapy. Journal of Advanced Nursing, 27(1), 83-90.

10. Harrison, B., & Kaarsemaker, B. (2000). Continuous quality improvement to an electroconvulsive therapy delivery system. Journal of Psychosocial Nursing & Mental Health Services, 38(3), 27-37.

11. Heffern, W. A. (2000). Psychopharmacological and electroconvulsive treatment of anxiety and depression in the elderly. Journal of Psychiatric and Mental Health Nursing, 7(3), 199-204.

12. Arkan, B., & Ustun, B. (2008). Examination of the effect of education about electroconvulsive therapy on nursing practice and patient satisfaction. Journal of ECT, 24(4), 254-259.

13. Brady, B. M., Laurila, D. R., Lewis, C. L., Niemeyer, K. D., Sun, N. M., Marienau, M. (2006). Induction of general anesthesia for electroconvulsive therapy: A randomized crossover trial of sevoflurane and thiopental. AANA Journal, 74(5), 392-392.

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20. Oldewening, K., Lange, R. T., Willan, S., Strangway, C., Kang, N., & Iverson, G. L. (2007). Effects of an education training program on attitudes to electroconvulsive therapy. The Journal of ECT, 23(2), 82-88.

21. Geddes, J. (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 361, 799-808.

22. Kho, K. H., van Vreeswijk, M.F., Simpson, S., & Zwinderman, A.H. (2003). A meta-analysis of electroconvulsive therapy efficacy in depression. Journal of ECT 19 (3), 139-147.

23. Pagnin, D., V. de Queiroz, S. Pini, and G. B. Cassano. "Efficacy of ECT in Depression: A Meta-Analytic Review." Journal of ECT 20, no. 1 (Mar, 2004): 13-20.

24. Trevino, K., McClintock, S.M. & Husain, M.M. (2010). A review of continuation electroconvulsive therapy: application, safety and efficacy. Journal of ECT, 26(3), 186-95.

25. Lisanby, S.H.(ed.). 2004. Brain stimulation in psychiatric treatment. American Psychiatric Publishing Inc.: Arlington, VA.

26. Kellner, C. H. (2007). "Electroconvulsive therapy in a perfect world.” Journal of ECT. 23(2), 63-64.

27. Kellner, C., Knapp, R., et. al. (2006). "Continuation ECT versus pharmacotherapy for relapse prevention in major depression: a multi-site study from CORE.” Archives of General Psychiatry 63, 1337-1344.

28. Rasmussen, K. G., D. A. Ryan, and P. S. Mueller. “Blood glucose before and after ECT treatments in Type 2 diabetic patients.” Journal of ECT 22, no. 2 (2006): 124-6.

29. Rasmussen, K. G., Mueller, M., Kellner, C.H. et. al. Patterns of psychotropic medication use among patients with severe depression referred for electroconvulsive therapy: data from the Consortium for Research on Electroconvulsive Therapy.” Journal of ECT 22 (2), 116-23.

30. Merkl, A., Heuser, I., & Bajboug, M. (2009). Antidepressant electroconvulsive therapy: mechanism of action, recent advances and limitations. Exploratory Neurology 129(1), 20-6.

31. Husain, M.M., Rush, A.J., Fink, M., Knapp, R., Petrides, G., Rumans, T., & Biggs, M.M. (2004). Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for research in ECT (CORE) report. Journal of Clinical Psychiatry, 65(4), 485-491.

32. Baghai, T.C. & Moller, H.J. (2008). Electroconvulsive therapy and its different indications. Dialogues in Clinical Neuroscience, 10(1), 105-17.

33. Kellner, C.H., Tobias, K.G. & Wiegand, J. (2010). Electrode placement in electroconvulsive therapy: A review of the literature. Journal of ECT 26(3), 175-80.

34. Huuhka, M. J., Seinela, L., Reinikainen, P. &. Leinonen, E.V.J. Cardiac arrhythmias induced by ECT in elderly psychiatric patients: Experience with 48-Hour holter monitoring. Journal of ECT. 19(1), 22-25.

35. Taylor, S. (2007). Electroconvulsive therapy a review of history, patient selection, technique, and medication management. Southern Medical Journal, 100(5), 494-8.