Electroconvulsive therapy

Catatonia is one of the four licensed indications for ECT in terms of the machines used in NHS Lothian. ECT should be considered via emergency referral for patients who have malignant catatonia, or other forms of catatonia where physical health is compromised (typically due to low/absent oral intake).

Non-emergency referral may be considered for those who do not respond, lose response, or have contraindications to effective doses of Lorazepam. Previous positive response to ECT is also relevant. Consideration may also be given to patient dignity and distress, where improvement is markedly slow or appears incomplete.

Whether or not your patient appears to need a referral to ECT at this point in time, it is advisable to prepare the materials required for referral, in case this more urgently becomes indicated. In addition, liaising with the ECT department early is also helpful to enable a dialogue around treatment need, and allow planning. Families may also benefit from information on ECT being provided, so such concepts are understood in advance of them becoming urgently necessitated.

In NHS Lothian, ECT is conducted at both the Royal Edinburgh Hospital and St John’s Hospital. Please make reference to the ECT intranet page  to aid referral and communication.

Management in pregnancy is not addressed in this guideline, but reference can be made to the British Association of Psychopharmacology 2023 guidelines  for the evidence base.

As per protocol, but even greater importance is paid to postictal baseline suppression. Less than once weekly should only be considered in those requiring maintenance ECT, rather than the acute period. Typically, Lorazepam should be held on the evening before and the morning of treatment, if this is possible, but specific cases can be discussed with the ECT team.

Many patients with catatonia will not have capacity with regard to elements of their investigation, care and treatment. An Adults with Incapacity Act section 47 certificate should be considered for all patients, along with the annex 5 to allow a breakdown of what the individual patient does and doesn’t have capacity for.

The provisions of the Mental Health Act may be indicated for a number of reasons for patients with catatonia, and there should be a low threshold to consider its use. If referring for ECT and under a CTO, a T3 form should be completed; otherwise a T4 form should be completed.

Should there be challenging nuances around legal status or capacity, discussion with the Mental Welfare Commission may be useful:

 0131 313 8777

 mwc.enquiries@nhs.scot