Synopsis
Identify when electroconvulsive therapy offers a proportionate treatment option, explain benefits and cognitive risks clearly, and establish valid consent or the correct jurisdiction-specific legal authority before every treatment.
- For severe depression, NICE supports considering ECT when the person prefers it based on previous experience, a rapid response is needed, or other treatments have failed.
- TA59 remains relevant to catatonia and prolonged or severe mania; its depression recommendations have been replaced by NG222.
- ECT uses a controlled seizure under general anaesthesia with muscle relaxation and physiological monitoring.
- Explain short-term confusion and memory effects, including the possibility of persistent autobiographical memory loss, alongside expected benefit and alternatives.
- Assess capacity for the ECT decision specifically and provide practicable communication support; diagnosis or detention alone does not establish incapacity.
- In England and Wales ECT has specific Mental Health Act safeguards under section 58A; ordinary medication authority is insufficient.
- After a successful acute course, arrange relapse-prevention treatment and cognitive follow-up rather than treating the final session as the end of care.
Key red flags
Dehydration, electrolyte disturbance, immobility, autonomic instability or inability to eat in severe depression or catatonia requires urgent medical care during ECT planning.
New prolonged confusion, focal neurological findings, prolonged seizure or cardiovascular instability after treatment needs prompt assessment rather than attribution to ordinary recovery.
A signed consent form does not authorise continuing ECT after a capable person withdraws consent; reassess the legal basis before any further treatment.
Investigation priorities
Define the target syndrome and provide a comparator for benefit.
Management branches
Severe depression, catatonia or a qualifying manic illness prompts ECT consideration.
- Establish the indication, previous treatment response and medical consequences of delaying effective treatment.
- Discuss ECT with the person using accessible information, covering cognitive risks and the alternatives that are realistic now.
- Arrange ECT specialist and anaesthetic assessment, with simultaneous treatment of dehydration, malnutrition and other acute problems.