Many patients are horrified when ECT is first suggested. The public perception, reinforced by certain sections of the media, is of 'unmodified' ECT as it used to be given 50 years ago without an anaesthetic. There were frequent physical complications such as broken teeth and bones, plus the dehumanizing character of the experience; for example, patients were often treated one after another in a public ward, with no privacy and no tranquillizing medication.

Modern administration of ECT is very different; patients are anaesthetized, treated, and recovered in privacy, and complications are rare. Many patients who have been successfully treated with ECT ask for further such treatment if their illness recurs. Research has shown that over half the patients who have had ECT consider it less unpleasant than going to the dentist.

NICE reviewed ECT in 2003 (NICE, 2003), and 'recommended that electroconvulsive therapy (ECT) is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially, life-threatening, in individuals with:

• severe depressive illness

• a prolonged or severe manic episode.'

This is uncontroversial and in line with modern practice. NICE more controversially opined that 'it is not recommended as a maintenance therapy in depressive illness'. However, maintenance ECT, other treatments having failed, seems to be the only way to keep a tiny number of patients (a handful per district) out of hospital.

The Royal College of Psychiatrists produces guidance on the commissioning and operation of a high-quality ECT service (Royal College of Psychiatrists, 2005).

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