APNA Position: Electroconvulsive Therapy

Introduction 

The American Psychiatric Nurses Association (APNA) was founded in 1986. It is one of the largest professional membership organizations committed to the practice of psychiatric-mental health (PMH) nursing. 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 U.S. PMH nursing organization whose membership is inclusive of all PMH nurses at basic (RN), advanced practice (NP and CNS), academic faculty and research scientist levels. APNA’s members come from every state and include international members (APNA, 2020).

We are pleased to provide comments and evidence to support the continued use of electroconvulsive therapy (ECT) in the treatment of severe depression and other mental health disorders including those that have been shown to be refractory to medication administration and other therapies.

Discussion

For more than seven decades, PMH nurses have provided individualized care for patients receiving ECT and the role of PMH nurses in this area are developing and expanding.  Advanced practice nurses are administering ECT and directly managing related care (Hardy et al., 2015; Rosedale et al., 2015; Svensson et al., 2016; Tor et al., 2020). In addition to advancing evidence-based treatment in ECT, PMH nurses have been vital patient advocates, assuring that patients receive accurate information about ECT, educating the public, and influencing public policy (Dillon, 1995; Fitzsimons, 1995; Gass, 1998).

ECT is a non-invasive, safe, effective, evidence-based treatment for severe depression and other treatment-resistant psychiatric disorders (Kellner, Obbels, & Sienaert, 2020; Shibasaki & Takebayashi, 2017).  There is a large body of literature supporting the efficacy of ECT (Luccarelli et al., 2020; Pagnin et al., 2004); moreover, ECT is a rapidly acting treatment. For patients who have not responded to or cannot tolerate medications because of untoward side effects, multiple co-morbid health conditions (Travino et al., 2004; Kellner, 2006; Kellner, 2007), pregnancy (Dong et al., 2020; Ward et al., 2018), advanced age or frailty (Socci et al., 2018), ECT may be the safest alternative.  Morbidity and mortality rates associated with ECT are low (less than those associated with childbirth), with one to two deaths per 10,000 patients treated with ECT (Rose et al., 2020; Rundgren et al., 2018).  Advancements in anesthetic (Chawla, 2019; Gelb & Maties, 2021) and ECT administration techniques have greatly mitigated risks and side effects (Merkl, Heuser, & Bajboug, 2009).  In fact, ECT remains the treatment of choice for treatment-refractory patients with other concurrent health risks (Gelb & Maties, 2021; Kellner et al., 2016).  The most significant concern about ECT is treatment-related cognitive impairment; however, this effect has been markedly reduced with advances in ECT administration (Bai et al., 2019; Tor et al., 2015).  Modern techniques, including the use of ultra-brief and brief pulse, have helped to decrease the potential cognitive side effects of ECT (Bai et al., 2019; Luccarelli et al., 2020; Martin et al., 2020; Niu et al., 2020).  Furthermore, ECT-induced cognitive and memory side effects have primarily been temporary (APA, 2021; Kirov et al., 2016; Mohn & Rund, 2018; Tornhamre et al., 2020; Porter et al., 2020).

Multiple trials of ECT have demonstrated response times at least equivalent to antidepressants in patients experiencing severe, major depressive episodes (Fox & McLoughlin, 2021; Husain et al., 2004). 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 (Pagnin et al., 2008; Petrides et al., 2001).  ECT is also an effective evidence-based treatment for catatonia (Leroy et al., 2018), bipolar disorder and mania (Elias, Thomas, & Sackheim, 2021; Perugi et al., 2017), and treatment resistant schizophrenia (Grover et al., 2019). These conditions often put patients at risk for life-threatening medical issues (including dehydration, weight loss, and self-harm). ECT has been shown to be helpful in quickly reducing symptoms in these populations (Ali et al., 2019; Schoeyen et al., 2014). Less studied but significant areas of use for ECT include agitation in dementia (Aracharya et al., 2014; Hermida et al., 2020), injurious behavior in autism spectrum (Wachtel, Shorter, & Fink, 2018), mental disorders in pregnancy (Rundgren et al., 2018), and Parkinson disease with co-morbid depression (Rodin et al., 2021; Takamiya et al., 2021). There are other medical disorders for which ECT may be considered such as neuroleptic malignant syndrome, intractable seizures, some types of encephalitis (Coffey & Cooper, 2019) and certain symptoms of Huntington’s Disease (Adrissi et al., 2019).

For many years, ECT treatment has been portrayed incorrectly in the media which has contributed to a great deal of stigma associated with this treatment as well as misconceptions about its use, efficacy, and potential side effects (Fitzsimons & Mayer, 1995; Tsai, Huang, & Lindsey, 2019).  Patient advocacy groups and peer specialists with lived experience can facilitate PMH nurses in providing patient education and support efforts (Burke et al., 2019; Repper & Carter, 2011).

Conclusion

It is the position of the American Psychiatric Nurses Associaiton that ECT is an evidence-based treatment for patients with severe depression and other serious treatment-resistant mental health disorders. ECT, when provided by properly trained clinicians (including specially trained and credentialed APRNS) is a safe and effective treatment option. APNA stands ready to assist in development of standards for nursing training and practice in the proper administration, monitoring, and care of patients receiving ECT.

 

Approved by the APNA Board of Directors January 2011; Revised and approved July 2021. Special thanks to the Neuromodulation Task Force who provided the latest updates to the position.

 

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References

Acharya, D., Harper, D. G., Achtyes, E. D., Seiner, S. J., Mahdasian, J. A., Nykamp, L. J., …                  Forester, B. P. (2014). Safety and utility of acute electroconvulsive therapy for agitation and aggression in dementia. International Journal of Geriatric Psychiatry, 30(3), 265–273. https://doi.org/10.1002/gps.4137

Adrissi, J., Nadkarni, N. A., Gausche, E. & Bega, D. (2019). Electroconvulsive therapy (ECT) for refractory psychiatric symptoms in huntington’s disease: a case series and review of literature. Journal of Huntington’s Disease, 8(3), 291-300. doi: 10.3233/JHD-190361

Ali, S. A., Mathur, N., Malhotra, A. K., & Braga, R. J. (2019). Electroconvulsive therapy and schizophrenia: a systematic review. Molecular Neuropsychiatry, 5(2), 75-83.

American Psychiatric Association (APA). (2021) What is Electroconvulsive therapy (ECT)? Retrieved on June 23, 2021 from https://www.psychiatry.org/patients-families/ect

American Psychiatric Nurses Association. (2020) About the American Psychiatric Nurses Association: An Introduction.  Retrieved from https://www.apna.org/i4a/pages/index.cfm?pageid=3277

Bai, S., Martin, D., Guo, T., Dokos, S., & Loo, C. (2019). Computational comparison of conventional and novel electroconvulsive therapy electrode placements for the treatment of depression. European Psychiatry, 60, 71-78.

Burke, E., Pyle, M, Machin, K., Varese, F. & Morrison, A.P. (2019).  The effects of peer support on empowerment, self-efficacy, and internalized stigma: A narrative synthesis and meta-analysis. America Psychological Association, 4(3), 337-356. http://dx.doi.org/10.1037/sah0000148

Chawla, N. (2019). Anesthesia for Electroconvulsive Therapy. Anesthesiology clinics, 38(1), 183-195. https://doi.org/10.1016/j.anclin.2019.10.007

Coffey, M.J. & Cooper, J.J. (2019, Jan 10) Therapeutic uses of seizures in neuropsychiatry. Psychiatry Online. https://doi.org/10.1176/appi.focus.20180023

Dillon, P. (1995). Electroconvulsive therapy patient/family education. Convulsive Therapy, 11(3), 188-191.

Dong, M., Zhu, X., Zheng, W., Li, X., Ng, C. H., Ungvari, G. S., et al. (2018). Electroconvulsive therapy for older adult patients with major depressive disorder: A systematic review of randomized controlled trials. Psychogeriatrics, 18(6), 468-475. doi: 10.1111/psyg.12359

Elias, A., Thomas, N., & Sackeim, H. A. (2021). Electroconvulsive therapy in mania: a review of 80 years of clinical experience. American Journal of Psychiatry, 178(3), 229-239.

Fitzsimons, L. (1995). Electroconvulsive therapy: What nurses need to know. Journal of   Psychosocial Nursing & Mental Health Services, 33(12), 14.

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.

Fox, C. A., & McLoughlin, D. M. (2021). Speed of electroconvulsive therapy for depression: Effects of electrode placement. Acta Psychiatrica Scandinavica, 143(5), 444-452. https://doi.org/10.1111/acps.13286

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

Gelb, A.W. & Maties. (2021). Anesthesia for electroconvulsive therapy. UpToDate. Retrieved from: https://www.uptodate.com/contents/anesthesia-for-electroconvulsive-therapy/print

Grover, S., Sahoo, S., Rabha, A., & Koirala, R. (2019). ECT in schizophrenia: a review of the  evidence. Acta Neuropsychiatrica, 31(3), 115-127.

Hardy, S., Cornish, J., Leyden, J., Vaughan, J. J., & O’Neill-Kerr, A. (2015). Should nurses administer electroconvulsive therapy? The Journal of ECT, 31(4), 207-208. doi:10.1097/YCT.0000000000000272

Hermida, A. P., Tang, Y. L., Glass, O., Janjua, A. U., & McDonald, W. M. (2020). Efficacy and safety of ECT for behavioral and psychological symptoms of dementia (BPSD). The American Journal of Geriatric Psychiatry, 28(2), 157-163.

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

Kellner, C. H., Knapp, R. G., & Petrides, G. (2006). Continuation ECT versus pharmacotherapy for relapse prevention in major depression: a multi-site study from the Consortium for Research in Electroconvulsive Therapy (CORE). Archives of General Psychiatry, 63, 1337-1344.

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

Kellner, C. H., Liebman, L. S., Nazarian, R., Knapp, R. G., McCall, W. V., Husain, M. M., … Lisanby, S. H. (2013). Efficacy of right unilateral ultrabrief pulse electroconvulsive therapy (ECT): Data from Phase 1 of the PRIDE Study. The American Journal of Geriatric Psychiatry, 21(3). https://doi.org/10.1016/j.jagp.2012.12.175

Kellner, C. H., Obbels, J., & Sienaert, P. (2019). When to consider electroconvulsive therapy (ECT). Acta Psychiatrica Scandinavica, 141, 304-315. https://doi.org/10.1111/acps.13134

Kirov, G. G., Owen, L., Ballard, H., Leighton, A., Hannigan, K., Llewellyn, D., et al. (2016). Evaluation of cumulative cognitive deficits from electroconvulsive therapy. The British Journal of Psychiatry, 208(2016), 266-270. doi:10.1192/bjp.bp.114.158261

Leroy, A., Naudet, F., Vaiva, G., Francis, A., Thomas, P., & Amad, A. (2018). Is electroconvulsive therapy an evidence-based treatment for catatonia? A systematic review and meta-analysis. European archives of psychiatry and clinical neuroscience, 268(7), 675-687.

Luccarelli, J., McCoy, T. H., Seiner, S. J., & Henry, M. E. (2020). Maintenance ECT is associated with sustained improvement in depression symptoms without adverse cognitive effects in a retrospective cohort of 100 patients each receiving 50 or more ECT treatments. Journal of Affective Disorders, 271, 109-114. doi: 10.1016/j.jad.2020.03.152

Martin, D., Katalinic, N., Hadzi-Pavlovic, D., Ingram, A., Ingram, N., Simpson, B., et al. (2020). Cognitive effects of brief and ultrabrief pulse bitemporal electroconvulsive therapy: A randomized controlled proof-of-concept trial. Psychological Medicine, 50(7), 1121-1128. doi: 10.1017/S0033291719000989

Merkl, A., Heuser, I., & Bajbouj, M. (2009). Antidepressant electroconvulsive therapy: Mechanism of action, recent advances and limitations. Experimental Neurology, 219(1), 20–26. https://doi.org/10.1016/j.expneurol.2009.04.027

Mohn, C., & Rund, B. R. (2018). Neurocognitive function and symptom remission 2 years after ECT in major depressive disorders. Journal of Affective Disorders, 246(2019), 368-375. doi:10.1016/j.jad.2018.12.083

Niu, Y., Ye, D., You, Y., & Wu, J. (2020). Prophylactic cognitive enhancers for improvement of cognitive function in patients undergoing electroconvulsive therapy: A systematic review and meta-analysis. Medicine Journal, 99(11). doi: 10.1097/MD.0000000000019527

Pagnin, D., de Queiroz, V., Pini, S., & Cassano, G. B. (2008). Efficacy of ECT in depression: a meta-analytic review. Focus, 6(1), 155-162.

Perugi, G., Medda, P., Toni, C., Mariani, M. G., Socci, C., & Mauri, M. (2017). The Role of Electroconvulsive Therapy (ECT) in Bipolar Disorder: Effectiveness in 522 Patients with Bipolar Depression, Mixed-state, Mania and Catatonic Features. Current Neuropharmacology, 15(3), 359–371. doi: 10.2174/1570159X14666161017233642

Petrides, G., Fink, M., Husain, M. M., Knapp, R. G., Rush, A. J., Mueller, M., … Kellner, C. H. (2001). ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. The Journal of ECT, 17(4), 244–253. https://doi.org/10.1097/00124509-200112000-00003

Porter, R.J., Baune, B.T., Morris, G., Hamilton, A., Basset, D., Boyce, P., … (2020). Cognitive side-effects of electroconvulsive therapy: what are they, how to monitor them and what to tell patients. BJPsych Open, 6(3), e40. doi: 10.1192/bjo.2020.17

Rasmussen, K. G., Mueller, M., Kellner, C. H., Knapp, R. G., Petrides, G., Rummans, T. A., … Fink, M. (2006). Patterns of psychotropic medication use among patients with severe depression referred for electroconvulsive therapy. The Journal of ECT, 22(2), 116–123. https://doi.org/10.1097/00124509-200606000-00008

Repper, J. & Carter, T. (2011). A review of the literature on peer support in mental health services. Journal of Mental Health, 20(4), 392-411. doi:10.3109/09638237.2011.583947

Rodin, I., Sung, J. H., Appel-Cresswell, S., Chauhan, H., Smith, K., Vila-Rodriguez, F., & Ainsworth, N. J. (2021). Psychiatric, motor, and autonomic effects of bifrontal ECT in depressed Parkinson’s Disease patients. The Journal of Neuropsychiatry and Clinical Neurosciences,1-6. https://doi.org/10.1176/appi.neuropsych.20050133.

Rose, S., Dotters-Katz, S. K., & Kuller, J. A. (2020). Electroconvulsive therapy in pregnancy: Safety, best practices, and barriers to care. Obstetrical & Gynecological Survey, 75(3), 199-203.

Rundgren, S., Brus, O., Båve, U., Landén, M., Lundberg, J., Nordanskog, P., & Nordenskjöld, A. (2018). Improvement of postpartum depression and psychosis after electroconvulsive therapy: a population-based study with a matched comparison group. Journal of affective disorders, 235, 258-264.

Rosedale, M., Knight, C., Standard, J. (2015). The Role of the Psychiatric Mental Health: Advanced Practice Registered Nurse in the Scope of Psychiatric Practice. Journal of ECT, 31(4), 205-206. doi:10.1097/YCT.0000000000000250

Schoeyen, H. K., Kessler, U., Andreassen, O. A., Auestad, B. H., Bergsholm, P., Malt, U. F., … Vaaler, A. (2015). Treatment-resistant bipolar depression: a randomized controlled trial of electroconvulsive therapy versus algorithm-based pharmacological treatment. American Journal of Psychiatry, 172(1), 41–51. https://doi.org/10.1176/appi.ajp.2014.13111517

Shibasaki, C., & Takebayashi, M. (2017). Advances in electroconvulsive therapy for psychiatric disorders. Advances in Modern Medicine, 233, 233-241.

Socci, C., Medda, P., Toni, C., Lattanzi, L., Tripodi, B., Vannucchi, G., & Perugi, G. (2018). Electroconvulsive therapy and age: Age-related clinical features and effectiveness in treatment resistant major depressive episode. Journal of affective disorders, 227, 627-632. https://doi.org/10.1016/j.jad.2017.11.064

Svensson, T. K., Miller, L., & Hurd, C. (2016). Expanding the nurse practitioner role in Treatment resistant major depression. Journal of Hospital & Medical Management, doi: 10.4172/2471-9781.100009

Takamiya, A., Seki, M., Kudo, S., Yoshizaki, T., Nakahara, J., Mimura, M., & Kishimoto, T. (2021). Electroconvulsive therapy for Parkinson’s Disease: a systematic review and meta‐analysis. Movement Disorders, 36(1), 50-58.

Tor, P. C., Phu, A. H. H., Koh, D. S. H., & Mok, Y. M. (2020). Electroconvulsive therapy in a time of coronavirus disease. The Journal of ECT, 36(2), 80-85. doi:10.1097/YCT.0000000000000690

Tor, P.C., Bautovich, A., Wang, M-J., Martin, D., Harvey, S. & Loo, C. (2015). A systematic review and meta-analysis of brief versus ultrabrief right unilateral electroconvulsive therapy for depression. Journal of Clinical Psychiatry, 76(9), e1092-1098. doi: 10.4088/JCP.14r09145

Tornhamre, E., Ekman, C. J., Hammar, A., Landen, M., Lundberg, J., Nordanskog, P., et al. (2020). The effects of pulse width on subjective memory impairment and remission rate 6 months after electroconvulsive therapy. Journal of ECT, 36(4) doi:10.1097.YCT.0000000000000697

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.

Tsai, J., Huang, M., & Lindsey, H. (2019). Perceptions and knowledge related to electroconvulsive therapy: A systematic review of measures. Psychological services, 1-10. http://dx.doi.org/10.1037/ser0000393

Wachtel, L. E., Shorter, E., & Fink, M. (2018). Electroconvulsive therapy for self-injurious behaviour in autism spectrum disorders: recognizing catatonia is key. Current opinion in psychiatry, 31(2), 116-122.

Ward, H. B., Fromson, J. A., Cooper, J. J., De Oliveira, G., & Almeida, M. (2018). Recommendations for the use of ECT in pregnancy: literature review and proposed clinical protocol. Archives of women’s mental health, 21(6), 715-722.