International Journal of Mental Health & PsychiatryISSN: 2471-4372

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Research Article, Int J Ment Health Psychiatry Vol: 2 Issue: 3

Developmental Appropriate Practice of Electroconvulsive Therapy with Major Depressive Patients: A Position Statement of the Applying ECT for the MDD

Abdallah Abu Khait1* and Sara Abu Rashaid2
1School of Nursing, Hashemite University, Zarqa, Jordan
2Zarqa Governmental Hospital, Zarqa, Jordan
Corresponding author : Abdallah Abu Khait
School of Nursing, Hashemite University, Zarqa, Jordan
E-mail: [email protected]
Received: February 05, 2016 Accepted: July 08, 2016 Published: July 12, 2016
Citation: Khait AA (2016) Developmental Appropriate Practice of Electroconvulsive Therapy with Major Depressive Patients: A Position Statement of the Applying ECT for the MDD. Int J Ment Health Psychiatry 2:3. doi:10.4172/2471-4372.1000129


Applying of electroconvulsive therapy for psychiatric disorder is considered as controversial issue since development of the ECT in 1938. Major depression disorder affects millions of people every year and had several negative consequences on human suffering. Electroconvulsive Therapy (ECT) is still the most effective therapy for treatment of major depression and for cases that need a rapid clinical response. But there is practical and ethical limitations around using of ECT that appear from review the opponents and proponents of researchers and articles about it, the purpose of this position statement is to consolidate current knowledge of research and literatures into many fields of decisions for perform ECT with MDD, and its positive and negative effects on patients who experienced it. Early management and treatment for MDD is essential for quick decrease of MDD symptoms and help patients who suffer from this disorder to improve their quality of life. Based on this review paper, there was need for further research about all aspect about ECT to enhance the evidence base and fill gaps in this evidence.

Keywords: Developmental appropriate practice; Electroconvulsive therapy; Major depressive patients


Developmental appropriate practice; Electroconvulsive therapy; Major depressive patients


Good mental health is fundamental to wellbeing of individuals, families and communities. In contrast poor mental health is considered as one of the biggest causes of disability, poor quality of life and reduced productivity [1].
Major depressive disorder (MDD) is one of the most deliberating and prevalent psychiatric disorders [2]. In 2011 world health organization global burden of disease survey estimates that major depression disorders will be second followed ischemic heart disease in the amount of disability experienced from sufferers by the year of 2020 (WHO, 2011), from 3.6% to 24.0 % of population having had major depressive disorder at some point in their life [3] and about 15% of individuals with MDD die by suicide [4].
However, MDD is a serious emotional and biological disorder that affects on thoughts, behavior, mood, feelings and physical health [5] also had adverse effect on patient psychosocial and occupational functioning [6]. MDD may require long term treatment to keep symptoms from relapses. So the need for effective therapy for MDD consider as essential issues that must take into consideration in mental health and illness [7].
Effective management of major depression disorder remains as a challenge [8]. There are patients with major depressive disorders who are unresponsive to any other treatment [9] and other whom there is no alternative efficient treatment (The College of Psychiatry in Ireland). Other may develop suicide and reach to profound level features of depression called catatonia [5]. These patients would be seriously had negative consequences if they were denied access to a treatment which might return them to health [8]. Also with appropriate treatment, about 70-80% of patient with major depressive disorder can achieve a significant reduction in symptoms [5].
Electroconvulsive Therapy (ECT) is a safe and an effective evidence based psychological and medical treatment [9]. It is approved by the American Psychiatric Association (APA) when it done by properly qualified psychiatrists for properly selected patients [4].
Electroconvulsive therapy consider as therapeutic medical procedure for the treatment of severe psychiatric disorders most commonly major depression, mania and psychosis, and it is occasionally for treatment of some neuropsychiatric disorders [10]. The primary purpose for ECT is to quick and significant decrease of psychiatric symptoms (Nordenskjold). However, Electroconvulsive Therapy (ECT) define as type of therapy in which small electric currents are passage through the brain. This can cause intentionally triggering brief seizures and seem to cause changes in brain chemistry [10]. It is estimated that one million patients worldwide receive ECT each year (Nordenskjold).
Electroconvulsive therapy (ECT) remains the treatment of choice for these special cases. Although the weight of evidence supports strong associations between using of ECT and improvement of MDD symptoms [11]. ECT still had debates, legal and ethical issues around applying it [12].
Position statement is brief statement that done by experts [13], an assertion of the beliefs held, supported and encouraged through evidence based knowledge (, aims to consolidate current knowledge of research and literatures into many fields of decisions for specific topic. It involves evidence based information, policies and recommendation about important topic that had debates, or need for change [13]. Also it is in accordance with the bylaws, strategic plan and code of ethics of the organization (, the main aim for it to improve decision making [14].
This position statement is intended to present opponents and proponents viewpoints regarding to promote excellence using of ECT with MDD. Grounded both in the research on using ECT and in the knowledge base regarding of ECT effectiveness on MDD. Specifically, to review a course of actions and recommendations related to the administration of ECT in Jordan.

Background of ECT

Electroconvulsive therapy (ECT) was developed from 1938. At beginning period that following its introduction, ECT was found as an effective and safe for treatment of multiple psychiatric illnesses, especially depression, schizophrenia [15]. At 1960's the use of ECT decline from the development of psychiatric medications with presence of stigma associated with ECT [16]. The use of ECT has increased from the 1970's because of improvement in treatment delivery methods, enhanced anesthesia management and increased safety and comfort measures. ECT seen as the most effective treatment for severe psychotic disorders and is safe treatment [16].

Literature Review

The efficacy of ECT to treat major depressive symptoms has been established by means of multi studies that developed during the last decades. ECT is the most effective physical and biological therapy available for depression, and no other type of therapy up to now has shown to be effective more than it with major depression patients according to controlled trials studies [17]. Despite of that there were controversial issues around using of it.
The aim of this revision is to present proponents and opponents perspective regarding using of ECT with MDD disorder according to reviews, meta analyses, and randomized clinical trials.
Proponents of using ECT with major depressive disorder
National Institute of Mental Health, the American Psychiatric Association, the American Medical Association, and the united states Surgeon General all of them approved ECT as an effective therapy in the treatment of certain psychiatric disorders, including depression [16].
According to National Institute of Clinical Excellence (NICE), with its guidelines about ECT, reported that by done a review of 90 randomized clinical trials about the effect of ECT in major depressive disorder, and concluded that ECT is more effective and benefits than antidepressants and other type of therapy like transcranial magnetic stimulation [18].
According to Royal College of Psychiatrists Registered charity that highly recommended using of ECT with MDD under specific conditions, if there was need for quick symptoms relief like suicide and catatonic behavior, using several antidepressant were ineffective, patients intolerance side effects from medication, patient experience and preferred that, and had resistance to other types of treatment [19].
People with major depression suffer from poorer Health Related Quality of Life (HRQOL) that measure of a person ability to perform physical and mental health over time. So some studies concern to measure it, for example study done in the Journal of Affective Disorders, the researchers is measured HRQOL in 283 patients they had treatment-resistant depression before ECT, several days after ECT, and 24 weeks after ECT. The researchers found that there was significant improvement in HRQOL in people with major depression (Bjelseth et al.).
Although ECT has efficacy, physicians and patients still have a great fear, anxiety and resistance to its use. In the last decades, several articles concerned in assessing the perception of patients regarding ECT and its benefit of this treatment. For example Melekian et al., by performed the assessment of 22 depressed patients, showed that there was an improvement in their perception and attitude regarding ECT after the treatment and most patients and their family found that ECT was beneficial and were satisfied with the treatment [20].
According to study that conduct in 2009 conclude that the benefit goes beyond symptom improvement. There is also improvement in the patients quality of life, functioning and well being. Also, patients who undergo this experience are, in their majority, prefer the experience and show positive attitudes toward ECT [17].
Other findings that verified in the multisite Consortium of Research in Electroconvulsive Therapy (CORE) collaborative study that usually used same populations, with same eligibility criteria, evaluations, and time. After remission, complete resolution of symptoms, the patients were randomly assigned to continue treatment with the same combination of lithium and nortriptyline or with ECT. The result was significant and showed that ECT is an effective treatment and the rate of remission was 87% in CORE. These rates compared with the 20 % - 30% remission rate in patients taking antidepressants [21].
Other studies that done for insured that ECT is not consider as dangerous procedure they found that the risk of mortality is 1 in 10,000 which is equal to minor surgical procedures that done under general anesthesia. Also, ECT is routinely done as an outpatient and patients can go to home after spending a few hours recovering from anesthesia for observation [17].
Other articles conclude that there were Significant improvements in the techniques that include (muscle relaxants, short acting anesthetic drugs, use oxygenation, close and continuous monitoring, better devices) have made ECT much safer and more reliable treatment option (Nordenskjold).
Opponents of using ECT with major depressive disorder
Cognitive side effects consider as the main limitation of ECT [22,23]. Although the decrease symptoms of depression obtained by ECT, the improvement in some neurocognitive functions have been seen, like attention, concentration and general intelligence, some alteration has been observed in abstract thinking and reasoning and creativity (Kellner et al.) and adverse cognitive effects for examples disorientation, impairment in learning, anterograde and retrograde memory loss, may be happened after a convulsive shock [22].
Other study done by Consoli, De Carvalho, and Cohen [24] conclude that ECT treatment effect on decreased intellect, attention, executive functions, perception and visual function, also can slower information processing speed and reaction time, additionally may contribute with language deficits.
Other opponents of ECT Scientologists and a national movement that called Mind Freedom International that opposes many types of psychological treatment also found ECT should be outlawed because of ECT may cause brain damage (Nordenskjold).
There were articles that against using ECT because of it had danger side effects like brain damage, fracture, short and long term side effects (Norman).
According to study done in 2009 founded that some of patients who have received ECT may report short term and long term side effects from the treatment. Although most effects happened around the period immediately after applied the procedure, memory deficits have been reported even three years post exposed to therapy [23].
In a recent study found that based on outdated myths about ECT and its side effects, ECT is often showed in the media as an inhumane, as restrain and sadistic type of therapy [8]. There was a disconnect and misinterpretation between research findings and media, which probably leads to stigma and presence of misconceptions about how ECT can be a benefits treatment for severely mental health disorders [8].

Policy in Jordan

Unfortunately, there is not clear policy that consist all of aspect about performing of ECT in Jordan, despite using of it still exist in Jordan. However there was effective policy that consists of current standards in the practice of ECT and up to dated standards and practice change. Also it consisted of elements organizational documentation process, information plan, documentation approach policy and procedure expertise, technologies (tools), scope, objectives and procedure. These policy from southern health NHS foundation trust policy [25]. The purpose of this policy is to ensure that providing a high quality, safe and efficient ECT service, which meets ethical and legal obligations and nationally agreed standards. It provide assurance that the policy meets legal requirements in relation to capacity and consent form and the use of the Mental Health Act and Mental Capacity Act ( It also put standards in relation to the ECT Clinic facilities. Clinical audit standards for ECT are based on national guidance including relevant NICE Clinical Guidelines The Royal College of Psychiatrists provides an Electroconvulsive Therapy Accreditation Service (ECTAS). The procedures and requirements of this policy meet (ECTAS) standards (
According to this policy all patients who have been prescribed ECT as a treatment option must be assured that their illness has been assessed in proper manner, other treatment options have been considered and discussed and recorded with them, they are advised about the process of ECT and its possible side effects, the treatment is delivered by Practitioners and expertise competent to do it, there is full recording of the process for each client, there is periodic review of the treatment through who responsible of therapy (

Summary and Conclusion

The aim of this position statement was intended to present opponents and proponents viewpoints regarding to promote using of ECT with MDD. With review the action and recommendations about perform ECT with MDD. MDD is one of the largest burdens for health. Modern ECT consider as standard treatment option for MDD. Also the current research of ECT covered some of aspects of contemporary electroconvulsive therapy, reporting on major clinical and research developments worldwide. Review important research results on the effect of ECT and explored difficult legal, ethical, and sociological issues concerning the use of ECT. There are recommendations that can guide clinicians to proper using of ECT. Hopefully there will be presence of advances in methods, medications, anesthesia that used with ECT for treat individual with major depression patients. There was need for increase focus for performing of ECT in Jordan from policies, ethical and legal organizations.

Position Statement

The current author is supporting for doing electroconvulsive therapy for patient who suffering from major depression disorder. ECT are able to positively impact on the well-being of people with major depressive disorder patients through quick decrease of depression symptoms, decrease number of relapses, dealing with depression resistance treatment, and providing improvement in (physical functioning, emotional and physical health, mental health, bodily pain, and general health).


There was need for basic and clinical research evidence to resolve important issues around performing ECT with MDD patients, the current research provide the following recommendations that consists some of possible solutions for reached to best the decision making about performing of ECT with MDD.
At first, when used properly, ECT is a safe and effective treatment which should continue to be available as a therapeutic choice for the treatment of mental disorders.
Second, all patients who have been prescribed ECT as a treatment option must be assured that their illness has been assessed in properly manner, also other type of treatment options have been considered including no treatment then discussed and recorded , they are advised about the process of ECT and its possible side effects, the treatment is delivered by Practitioners and expertise competent to do it, there is full recording of the process for each client, there is periodic asses of the treatment through the audit process. Third, ECT should be used only on the recommendation of a psychiatrist.
Fourth, recommendation about consent forms that done by the most senior doctor available. The consent form must be valid consent and the Mental Health Act is used when appropriate for referral. Patient for ECT must be given with appropriate written and verbal information to allow them to give consent and approved. This needs to include alternatives of treatment and the patient’s rights including the right to withdraw consent at any time.
Fifth, improvement in training and privileging for health care professional. Sixth, maintain quality assessment for quality improvement activities and for maintaining a standard data base which should be kept for all patients receiving ECT anywhere to evaluate their performance and to facilitate inter-hospital comparison of the provision of ECT. Fifth, recommendations for safe administration of anesthesia.
Seventh, presence of practical administration which are intended to maximize the effectiveness of using ECT and minimize any possible adverse effects. Eighth, the local and global health institutions must introduce legal, ethical and technical supports to develop best approach for using of ECT. Ninth, the ECT service within hospital needs good coordination and a committee of appropriate representative, for example (ECT expert psychiatrists, nursing staff, anesthetists and administrators) is recommended to ensure appropriate ongoing finding and quality assurance.
Tenth, Continuances doing of basic and clinical research is recommended in order to improve the mechanism of action of ECT and to further improve the clinical application of the treatment. Eleventh, during a course of ECT, the psychiatrist should reassess and document changes in target symptoms and the occurrence of adverse effects regularly and modification of ECT with brief anesthesia, muscle relaxants and pre-oxygenation should be done by qualified physician.
Twelfth, Attention for concept of concordance (multidisciplinary health care team) shared decision making with patients.


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