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APNA Position Paper: 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 positon.

 


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