Electro-Convulsive Therapy - (ECT)

Electro-Convulsive Therapy - (ECT)

Section 87 to 97  Mental Health Act 2007

Electro convulsive therapy (ECT) is used in the treatment of some types of mental illness, particularly severe depressive illness. In this procedure a general anaesthetic is given to the patient, followed by a muscle relaxing drug. A minimal electric current is then passed through padded electrodes placed on the patients’ head. The effect of the electric current is to produce convulsions, which are minor due to the use of the muscle relaxant. The treatment lasts for minutes only, and the number of treatments given depends on the nature of the illness. Electro convulsive therapy can only be given by a doctor who is experienced in giving ECT and this doctor must be accompanied by a doctor who is experienced in anaesthetics. ECT can only be given in an approved hospital or place.

The Ministry of Health has developed Guidelines - ECT Minimum Standards of Practice in NSW. The Guidelines apply to all facets of care, including the indications for treatment, potential risks and strategies to minimise them, issues of consent, facilities, anaesthesia, application of the procedure, and the required quality improvement framework

When is an application required?

 The Mental Health Review Tribunal becomes involved in decisions about ECT in the following circumstances: 

  • when the mental health facility is uncertain of a voluntary patient’s capacity to give consent to treatment with ECT; and
  • when the mental health facility proposes ECT for an involuntary patient or a person under the age of 16.  For this purpose, this includes patients on an involuntary patient order, detained patients (or assessable persons) who have not been presented for a mental health inquiry, patients on a Tribunal adjournment, forensic and correctional patients.

 Voluntary patients

If a voluntary patient (not under the age of 16 years) can give informed consent to ECT and does so in writing, then the mental health facility may administer ECT treatment. There is no need to apply to the Tribunal. Nevertheless, two medical practitioners (at least one of whom is a psychiatrist) must have: 

  • considered the clinical condition of the patient, the history of treatment and any appropriate alternatives; and 
  • certified in writing that ECT is a reasonable and proper treatment to be administered to the patient, and is necessary or desirable for his or her safety or welfare. 

If the Authorised Medical Officer is unsure whether or not a voluntary patient is capable of giving informed consent, the Authorised Medical Officer may apply to the Tribunal for an ECT Consent Inquiry to determine that issue. The Authorised Medical Officer must do everything reasonably practicable to give notice to the primary carer of the person (s78(1)(e)).

What is Informed Consent?

A patient can give informed consent if he or she understands the nature, purpose and effect of the proposed treatment. Section 91 of the Mental Health Act 2007 sets out a number of requirements for obtaining informed consent. These include: 

  • an explanation of the procedure; 
  • a full description of the possible risks and expected benefits; 
  • information about alternative treatments; 
  • a reply to the person’s questions about the procedure in appropriate terms; 
  • a full disclosure of any financial relationship between the person proposing or administering ECT and the mental health facility; and 
  • notice of the right to obtain legal and medical advice before giving consent and the right to withdraw consent at any time. 

The patient’s consent must be free, voluntary and in writing. The Tribunal’s role at an ECT Consent Inquiry is limited to deciding whether the voluntary patient: 

  • is capable of giving informed consent to ECT; and 
  • has given that consent. 

If the Tribunal decides that the person can consent and the person has given consent in writing, then the hospital may administer ECT treatment. If the Tribunal decides that the person lacks capacity, or if the person has capacity but refuses treatment, then the hospital may not administer ECT while the person is a voluntary patient.

Involuntary patients and persons under the age of 16 years

The following information concerns all involuntary patients or persons under the age of 16, including patients on an Involuntary Patient Order, detained patients (or assessable persons) who have not been presented for a mental health inquiry, patients on a Tribunal adjournment, forensic and correctional patients.

 If a mental health facility intends to administer ECT to any of these involuntary patients or a person under the age of 16, the Authorised Medical Officer must first apply to the Mental Health Review Tribunal for an ECT Administration Inquiry.  The Authorised Medical Officer must do everything reasonably practicable to give notice in writing to the designated carer(s) and the principal care provider of the person.

At an ECT Administration Inquiry the Tribunal will first determine whether or not an involuntary patient or a person under the age of 16:

  • is capable of giving informed consent to ECT; and
  • has given that consent.

 If the Tribunal determines that:

  • an involuntary patient can consent, and has done so, then the hospital may administer the ECT treatment;
  • a person under the age of 16 can consent, and has done so, the Tribunal must then determine if ECT:
    • is a reasonable and proper treatment; and
    • necessary and desirable for the safety or welfare of the patient;

and if so, then the hospital may administer the ECT treatment.

 If the Tribunal determines that the involuntary patient or person under the age of 16 is:

  • incapable of giving informed consent; or
  • is capable of giving informed consent but has refused; or
  • has neither consented nor refused,

 the Tribunal must then determine if ECT is a reasonable and proper treatment, and is necessary and desirable for the safety or welfare of the patient.

The Tribunal must specify the time frame in which the treatments are to be administered (not exceeding six months), the frequency of the treatment and the maximum number of individual treatments, which should not ordinarily exceed twelve in number.  A determination has effect for 6 months from the date it is made, unless a shorter period is specified. There may be, on occasions, exceptions to the twelve treatment limit, based on clinical information presented to the Tribunal.

The Tribunal does not put a limit on how many treatments are clinically appropriate and administered, only on how many may be administered before the Tribunal must be asked to review any further treatment. The mental health facility is to deliver the treatment in accordance with the terms expressed in the order. 

Where the maximum number of treatments has been reached, or where the treatment is not given within the specified time frames and it is considered that further ECT is necessary, a fresh application must be made to the Tribunal. Any substantial change to the course of treatment will also require further consideration by the Tribunal.

Applications for long term patients

Sometimes there is a need for a long term involuntary patient to have maintenance ECT on an ongoing basis. Applications for ECT should be made in accordance with the above requirements.  It may be the opinion of the treating team, based on clinical considerations, that more than 12 treatments are required. If so, this is a matter which can be brought to the Tribunal’s attention.

Legal issues the Tribunal must address

  • is ECT a reasonable and proper treatment in the circumstances? and
  • is ECT necessary or desirable for the safety or welfare of the patient

Before it may make this determination, the Tribunal must have evidence from two medical practitioners, at least one of whom is a psychiatrist. If the application is for a person under the age of 16 at least one of these must be a psychiatrist with expertise in the treatment of children or adolescents.

These medical practitioners must have:

  • considered the clinical condition of the patient, the history of treatment and any appropriate alternatives; and
  • certified in writing that ECT is a reasonable and proper treatment to be administered to the patient, and is necessary or desirable for his or her safety or welfare.

Patient’s views
In considering any application for ECT, the Tribunal must take into account the views of the person and the effect if any, of medication on the person’s ability to communicate. 

Civil Hearing Kit

For further information please select the following link to the relevant section of the Tribunal’s Civil Hearing Kit: