Electroconvulsive Therapy (ECT)- For Referring Physicians and Providers

We welcome the opportunity to assist in the care of your patient’s psychiatric needs. To learn more about our referral process, please review Referring Provider Information below.

We request that all providers who are referring patients to Santa Barbara Cottage Hospital (SBCH) be available for initial discussion with our Electroconvulsive Therapy (ECT) provider as well as be able to maintain ongoing contact during the treatment series. Our team will be responsible for ECT specific treatment timing and administration, and we will provide recommendations and guidance regarding pharmacotherapy modifications to ensure the best possible outcome for the patient during and after the series. However, it is expected that all referring providers will continue to monitor their patients individually during the treatment course. We will work to maintain open communication with each provider, both for updates as well as any questions or concerns that may arise during treatments.

Though we accept initial referrals from and will collaborate with mid-level providers during a course of ECT, an outpatient supervising psychiatrist is needed to co-sign the referral. This requirement is specifically requested given the complex psychiatric presentation of many patients who will be referred to and undergo ECT. Further, there is a moderate subset of patients who undergo ECT that respond well to the treatments but once tapered off the initial acute (index) course, will relapse within one to three months and require ongoing maintenance ECT spacing. This subset of patients is strongly recommended to be followed by a psychiatrist, or have direct physician review of their case on a regular basis.

Electroconvulsive Therapy Information for Referring Providers

Initial Referral packet to be emailed to neuromodulation@sbch.org or fax to 805-569-8314.

1. Electroconvulsive Therapy Referral Form
2. Patient contact information - phone number and email address
3. Most recent Progress Note detailing discussion and patient/family agreement to initiate ECT
4. Initial Outpatient psychiatric H&P from your clinic
5. Full list of all prescribed medications (current as well as previously known trials)
6. Patient Insurance information – please send a copy of front & back of insurance card (if available)
7. Lab work – we recommend holding this lab draw until patient is ready to be seen for their intake. Any missing labs will be ordered by the SBCH ECT Provider during the intake process. Each patient will need the following:
   1. CBC, CMP, TSH, FT4 – completed within 30 days of Medical Clearance
   2. A1C – Required for all patients with Diabetes or if Fasting Glucose is over 100
   3. Pregnancy test – completed within 30 days of Medical Clearance
      1. At present time, we are not able to treat pregnant women
      2. If a woman is attempting to get pregnant, please contact our department and discuss with one of our providers
      3. A pregnancy test will be completed before every treatment per SBCH policy

Next Steps

Once the packet is received, our ECT Nurse Navigator will reach out to the patient and verify the patient’s agreement to proceed with an intake evaluation. The patient will have an opportunity to ask any questions they have about ECT and the process at that time.

Electroconvulsive Therapy Pre-Consultation Form will be sent out via MyChart, email, fax, or USPS based on patient preference. This form needs to be completed prior to their ECT Consult appointment.

Insurance verification and coverage will be completed by our team after which time a consult with the ECT psychiatrist will be scheduled.

ECT Consultation

Each patient will have an intake evaluation by one of our ECT providers. During this interview, the following will occur:

• The patient will be evaluated for appropriateness as well as expected benefit from ECT. If appropriate, alternative treatments will also be discussed at that time.
• The patient and their designated support person will be provided with an educational overview of what to expect during the treatment series.
• The patient and their designated support person will be given the opportunity to ask any questions they may have about the procedure with the ECT expert.
• ECT benefits, risks, side effects will be discussed at this meeting. Though the written consenting for ECT occurs the day of the first treatment, a full verbal review (Advisement) of what is included within the consent will occur.
• An individualized plan will be created for the patient and discussed with both patient and support person. Medication changes/recommendations will be discussed, however the patient will be referred back to their primary psychiatric provider to initiate these changes.
• Once completed, the ECT consult will be sent to the referring provider and the ECT provider will contact the outpatient provider to discuss any recommendations.
• Please Note: Patient appointments are scheduled for 2 hours. This allows for the full psychiatric assessment, completion of required screenings and assessments (PHQ-9, QIDs-SR, MADRS, MoCA), and time for education of patient and support person.

Medical Clearance

All patients recommended and approved for ECT intervention must undergo a Pre-Anesthesia Medical Clearance. If you are aware of any medical conditions that may preclude/delay ECT interventions, please be sure to note in the referral form and contact our team for further discussion.

Other specific items of note:

• ECG: All patients, regardless of age, will have baseline ECG completed prior to starting ECT interventions. This evaluation is important given the potential of psychiatric and other medications to impact QTc baselines, regardless of age.
• Imaging (please discuss with team prior to ordering as need is on a case-by-case basis):
  • CT Head – if history of brain injury. May require more detailed evaluation with MRI Brain
  • Spine imaging – if history of back injury or ongoing symptoms are present
  • Chest X-ray/imaging
• Other workups: If patient has other significant medical co-morbidities, we may request further clearance by a specialist before initiating treatments.

Medications

We will review all medications prior to initiating treatments. There may be times where we will ask for certain medications to be either discontinued or temporarily held prior to or during treatments. This will be discussed on a case-by-case basis.

It is recommended that patients do remain on certain medications or begin a transition to a new, or untried medication during the taper phase of treatments. Individuals have the best chance of remaining in remission when medications are utilized after an ECT course is completed.

Common Medications and Holding Instructions

Lithium: When prescribed along with ECT, patients have an increased risk of memory fog and potential delirium. However, if lithium has been a helpful tool in maintaining mood elevations/lability up until this point, reducing the dose down vs. stopping may be warranted. Additionally, changing the timing of dosing to 24 hours before a treatment, then holding until after fully recovered on the treatment day may reduce the cognitive effects associated with lithium and ECT.

Benzodiazepines: Either discontinue (preferred) or switch to shorter acting formulation (i.e., lorazepam or alprazolam). Hold at least 12 hours before treatment.

Metformin/Glucophage: May be given 24 hours before treatment and can resume after treatment.

Antiepileptic agents:

• Psychiatric use only: hold evening before and morning of treatment.
• Seizure disorder: please discuss with ECT provider.

Coumadin: INR must be <2.4

Outpatient Referring Provider Responsibilities During ECT

All patients undergoing ECT should be evaluated by their referring psychiatrist/psychiatric NP/PA within two weeks after the start of treatments and then at least monthly thereafter to assess their response to this treatment.

Additionally, in the state of California, a patient must be consented monthly while undergoing ECT. Prior to this re-consenting, a verbal education (ECT Readvisement) must be performed at least 24 hours before. Specific review of benefits, risks, side effects, expectations of treatment, and need for further treatment are to be discussed.

• It is expected that the primary outpatient team of the patient will complete this verbal education and complete the ECT Readvisement form.
  • This form must be completed in its entirety and returned to the ECT service in a timely manner, thus reducing any delays in patient care.
• Our service can perform Readvisement for patients whose primary provider is an NP/PA, however we still request updates to the outpatient plan for each patient undergoing ECT in our service.

Acute Course (Index)

An initial recommended series of ECT, traditionally occurs over a 3-6 week period. Initially treatments are scheduled 2-3 times per week. Once a patient’s symptoms have improved and are stable, a taper phase is recommended to ensure that the symptoms being treated do not return. This timing is unique for each individual but typically will including weekly ECT for 1-2 treatments, followed by 1-2 treatments at every 2 weeks, before the series is completed.

Maintenance ECT (Continuation)

Maintenance (or continuation) ECT is recommended for patients who initially achieve remission of psychiatric symptoms during the acute phase of ECT, but over a period of months find that their symptoms re-emerge.

Should a provider feel that a patient may need maintenance ECT after the index course is completed, please contact the ECT department for further assistance. A discussion with one of our ECT providers is always available if further discussion/questions occur.

Other Important Items to Consider When Referring for ECT

All patients must have at least one designated support person to bring them back and forth for each treatment. Patients are not allowed to drive themselves or use public transport (unless with companion) after an ECT treatment.