(A) The purpose of
this rule shall be to establish standards and criteria, indications,
contraindications and limits for referral of adult ODMH regional
psychiatric hospital (RPH)BHO
inpatients to an outside facility for ECT.
(B) The provisions of this rule shall be
applicable to all RPHsBHOs under the managing responsibility of the
department.
(C) Definitions
(1) "Chief clinical officer" and "CCO"
(CCO)"
means
mean the medical director of
an RPH as defined in division (K) of section
5122.01 of the Revised
Codea BHO.
(2) "Psychiatrist" means a licensed physician
who has satisfactorily completed a residency training program in psychiatry, as
approved by the residency review committee of the American medical association,
the committee on post-graduate education of the American osteopathic
association, or the American osteopathic board of neurology and psychiatry, or
who on July 1, 1989, has been recognized as a psychiatrist by the Ohio state
medical association or the Ohio osteopathic association on the basis of formal
training and five or more years of medical practice limited to psychiatry.
(3) "ECT" is a somatic psychiatric treatment mediated by a modified
grand mal seizure, which is induced by the application of electrical current of
the brain. is the application of electric
current to the scalp resulting in grand mal seizures for the treatment of
mental illness.
(4)
"Informed consent" means the voluntary and knowing permission given by a person
who has received all appropriate information.
(5)
"Significant medical risk" means a condition in
which there is reasonable
clinical evidence
that delay in treatment would result in further deterioration of the
illness.
(D) Requirements for referral
(1) ECT shall not be administered in ODMH
RPHs.
BHOs.
(2) Only adult ODMH
RPHBHO
inpatients shall be referred for ECT.
(3) The RPH
BHO psychiatrist must present clinical data
to the RPH CCO
BHO
chief clinical
officer to obtain approval for ECT referrals.
(4) It is required that any patient,
voluntary or involuntary, competent or incompetent, shall be given a full
explanation of ECT consistent with the specific items cited below:
(a) An explanation of the procedures to be
followed and their purposes including identification of any procedures which
are experimental. This explanation is to be given in such a way as to enable
the individual to make a decision to grant/deny consent;
(b) A description of any attendant
discomforts and risks reasonably to be expected;
(c) A description of any benefits reasonably
to be expected;
(d) A disclosure
of any appropriate alternative procedures/treatments that might be advantageous
for that patient including an explanation of the consequences of those
procedures/treatments;
(e) An
offer to answer any inquiries concerning the procedures and answers to any such
inquiries;
(f) An instruction that
the individual may refuse to consent and that the individual is free to
withdraw his consent and to discontinue the treatment at any time without
prejudice unless informed consent for the ECT is given
by guardian or court-ordered; and
(g) A notification that the individual may
consult with an independent specialist and counsel.
(5) The competence of a patient to give
informed consent shall be determined by the attending psychiatrist. The written
opinion shall be incorporated into the patient's permanent medical record.
(6) The criteria for determining
the competence of the patient, include but are not limited to:
(a) Whether or not the patient is physically
and mentally able to receive the information required to be furnished;
(b) Whether or not the patient is
able to explain his/her understanding of the information provided; and
(c) Whether or not the patient
demonstrates that he/she has evaluated the information provided.
(7) Competent adult patients
No competent adult patient shall be given ECT unless his/her
informed consent has been obtained.
(8) Adult incompetent involuntary patients
(a) If an adult patient has been adjudicated
incompetent to give informed consent for medical treatment by a probate court,
the patient's guardian may give informed consent.
(b) If an adult patient has been determined
to be incompetent to give consent according to the procedure outlined above,
and has no guardian, ECT may be administered only under the following
conditions:
(i) The attending psychiatrist
must certify in writing that an indication for ECT use as outlined in paragraph
(E) of this rule is evident;
(ii)
The chief clinical officer recommends in writing the administration of ECT; and
(iii) If a durable power of
attorney for healthcare issues exist, it should be followed. Otherwise,
approval for ECT shall be obtained from the probate court.
(E)
Indications for use
(1) General statement
Referrals for ECT are based upon a combination of factors,
including the patient's diagnosis, nature and severity of symptomatology,
treatment history, consideration of anticipated risks and benefits of viable
treatment options, and patient preference. At present there are no diagnoses
which should automatically lead to treatment with ECT. In most cases, ECT is
used following treatment failure on psychotropic agents, although specific
criteria do exist for use of ECT as a first-line treatment.
(2) Primary use of ECT Situations where ECT
may be used prior to a trial of psychotropic agents include, but are not
limited to, the following:
(a) Where a need
for rapid, definitive response exists on either medical or psychiatric grounds;
or
(b) When the risks of other
treatment outweigh the risks of ECT; or
(c) When history of poor drug response and/or
good ECT response exists for previous episodes of the illness; or
(d) Patient preference.
(3) Secondary use of ECT
In other situations, a trial of an alternative therapy should
be considered prior to referral for ECT. Subsequent referral for ECT should be
based on at least one of the following:
(a) Treatment failure, taking into account
issues such as choice of agent, dosage, and duration of trial;
(b) Adverse effects which are unavoidable and
which are deemed less likely and/or less severe with ECT; and
(c) Deterioration of the patient's condition
such that criterion in paragraph (E)(2)(a) of this rule is met.
(4) Major diagnostic indications
Diagnoses for which either compelling data are present for efficacy of ECT or a
strong consensus exists in the field supporting such use.
(a) Major depressive disorder
.
ECT is an effective treatment for all subtypes of major depressive
disorder;
(i) ECT is an effective treatment
for all subtypes of major depressive
disorder;
(ii) ECT is an effective treatment
for all subtypes of bipolar disorder depressed episode.
(b)
Mania
Bipolar disorder. ECT
is an effective treatment for all sub-types and phases of bipolar disorder
including manic, depressed and mixed phases.
ECT is an effective treatment for
all sub-types of bipolar I & II
disorder, manic; bipolar disorder, mixed; and bipolar disorder, not otherwise
specified.
(c)
Schizophrenia
, schizoaffective disorder and other
functional psychoses
.
ECT may be an effective treatment for
psychotic schizophrenic exacerbations including catatonia, when prominent
affective symptoms are present and when there is a history of favorable
response. ECT may be effective in other psychotic disorders.
ECT is an effective treatment for
psychotic schizophrenic exacerbations in the following:
(i) Catatonic type;
(ii) When affective symptoms are
prominent;
(iii) When there is a history of a
favorable response to ECT.
(d)
Mental disorders
due to a general medical condition. ECT may be effective in the management of
severe affective and psychotic symptoms concomitant with general medical
conditions, or in treating delirium of various etiologies, including toxic and
metabolic.ECT may be effective in other
psychotic disorders.
(e)
Other diagnostic indications.
(i)
For people with
diagnoses for which efficacy data for ECT are only suggestive, or where only a
partial consensus exists in the field, support its use. In such cases, ECT
should be recommended only after standard alternatives have been considered as
a primary intervention. The existence of such indications, however, should not
deter the use of ECT for treatment of a concurrent major diagnostic
medication.
(ii)
Although ECT has sometimes been of assistance in the
management of mental disorders other than those described above, such usage i
snot adequately substantiated and should be carefully justified in the clinical
record on a case-by-case basis.
(f)
Medical
disorders
(i)
The neurobiologic effects associated with induced generalized seizure activity
may be of benefit in treating a small number of medical disorders.
(ii)
Such
conditions include, but are not limited to:
(a)
Catatonia secondary to medical conditions (ECT is indicated
for catatonia of all causes);
(b)
Hypopituitarism;
(c)
Intractable seizure disorder;
(d)
Neuroleptic malignant syndrome; and
(e)
Parkinson's disease.
(5)
Mental disorders due to a general medical
condition
ECT may be effective in the
management of severe affective and psychotic symptoms concomitant with general
medical conditions, or in treating deliria of various etiologies, including
toxic and metabolic.
(6)
Other diagnostic indications
(a)
For people with diagnoses for which efficacy data
for ECT are only
suggestive, or where only
a partial consensus exists in the field supports it use. In such cases, ECT
should be recommended only after standard treatment alternatives have been
considered as a primary intervention. The existence of such indications,
however, should not deter the use of ECT for treatment of a concurrent major
diagnostic indication.
(b)
Although ECT has sometimes been of assistance in the
management of
mental disorders other than
those described above, such usage is not adequately substantiated and should be
carefully justified in the clinical record on a case-by-case basis.
(7)
Medical disorders
(a) The neurobiologic effects
associated with induced generalized seizure activity may be of benefit in
treating a small number of medical
disorders.
(b) Such conditions include, but
are not limited to:
(i) Catatonia secondary to medical
conditions;
(ii) Hypopituitarism;
(iii) Intractable seizure disorder;
(iv) Neuroleptic malignant syndrome;
and
(v) Parkinson's disease.
(F) Contraindications and situations of high
risk
(1) There are no absolute
contraindications to ECT.
(2)
Situations associated with substantial risk
(a) Situations exist in which ECT is
associated with an appreciable likelihood of serious morbidity or mortality. In
such cases, the decision for ECT should be based upon the premise that the
patient's condition is too grave, (i.e., life threatening) to leave untreated,
and that ECT is the safest treatment available.
(b) In these instances, careful medical
evaluation of risk factors should be carried out prior to ECT, with specific
attention to treatment modifications which may diminish the level of risk.
(c) Specific conditions associated
with substantially increased risk include the following:
(i) Space-occupying cerebral lesion, or other
conditions with increased intracranial pressure;
(ii) Seizure disorder;
(iii) Recent myocardial infarction with
unstable cardiac function;
(iv)
Recent intracerebral hemorrhage;
(v) Bleeding, or otherwise unstable, vascular
aneurysm or malformation;
(vi)
Retinal detachment;
(vii)
Pheochromocytoma; and
(viii)
Significant anesthetic risk.
(d) Concomitant medications. The following
medications should be discontinued or dosage reduced:
(i) Benzodiazapines, as they are anti-convulsants - should be held for at
least eight hours;
(ii)
Lithium, as it can increase postictal delirium
and prolong seizure activity - should be reduced in dose;
(iii) Bupropion, as it can induce late appearing seizures - should be
discontinued;
(iv) Lidocaine
markedly increases seizure threshold - should be held for at least eight hours;
(v) Theophylline
increasesincrease the duration of seizures - should be
discontinued;
(vi) Reserpine can
cause respiratory and cardiovascular problems and should be discontinued; and
(vii) Other medications as
determined by the IBHS pharmacy and therapeutics committee.
(G) Medical
evaluation When a patient remains an ODMH
RPHBHO patient
when receiving ECT, the following medical evaluation will need to be completed
by the ODMH
RPHBHO
staff:
(1) Medical examination;
(2) Neurological examination;
(3) Laboratory evaluations
including CBC and differential; blood and urine chemistries;
(4) Electrocardiogram;
(5) X-ray of lumbosacral region if spinal
problems are suspected;
(6) Chest
x-ray, if clinically indicated;
(7) In the presence of central nervous system
symptoms (seizure disorder or a space occupying lesion), EEG and brain computed
tomographic scan or magnetic resonance imaging;
(8) Dental examination for elderly patients
and those with dental problems; and
(9) Anesthesiologist consults to evaluate
risk of anesthesia. This may be completed at the
facility where ECT is administered prior to ECT occurring.
(H) Referred facility requirement
(1) Properly accredited hospital or
outpatient facility.
(2) The
psychiatrist who is responsible for the administration of ECT has been
credentialed and privileged in ECT by the facility where the ECT is being administered.
(I) Training When ODMH
RPHBHO
patients are receiving ECT as outpatients, the RPHBHO nursing
staff shall be provided with appropriate training on nursing care for these
patients to assure competent care of pre- and post-ECT
treatment.
(J)
Reference "Recommendations for Treatment, Training,
and Privileging: A Task Force Report of the American Psychiatric Association,
2nd ed., 2001".
Notes
Ohio Admin. Code
5122-3-03
Effective:
9/20/2010
Promulgated Under:
111.15
Statutory
Authority: 5119.01,
5122.271,
5122.29
Rule
Amplifies: 5119.01,
5122.271,
5122.29
Prior
Effective Dates: 3-27-1978, 7-1-1980, 1-27-1984, 8-1-1998, 12-1-2000, 12-9-2002
