LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 200.06 Electroconvulsive Therapy
 
Policy Category:  Clinical
Distribution Level:  Directly Operated and Contractors
Responsible Party:  Intensive Care Division
 
Approved by Curley L. Bonds, MD, Chief Medical Officer on December 9, 2021
 
I.  PURPOSE
 
To outline policy and procedures for use of Electroconvulsive Therapy (ECT) in Los Angeles County Department of Mental Health (DMH/Department) programs.

Contracted agencies shall develop an internal policy and associated procedures that are consistent with their organizational practices and meet the requirements set forth in this policy.
 
II.  DEFINITIONS
 
Electroconvulsive Therapy (ECT): A planned induction of a seizure through electrical means for therapeutic purposes (9 CCR § 836(a)).

ECT Treating Physician: Physician that provides ECT treatment to the client.

Intensive Care Division (ICD) Consulting Physician: Physician selected from the Mental Health Plan to authorize ECT treatment in collaboration with the pre-treatment committee.

Local Mental Health Director (Director): Director for DMH and the Local Mental Health Plan.

Local Mental Health Plan (MHP): Local governmental agency at the county or city level contracted with the California Department of Health Care Services (DHCS) to administer the provision of specialty mental health services (SMHS) to residents within that agency’s jurisdiction. The MHPs are required to provide or arrange for the provision of SMHS to beneficiaries in their counties that meet medical necessity criteria, consistent with the clients’ mental health treatment needs and goals.

Outpatient Consulting Physician: Physician from the mental health outpatient clinic referring the client for ECT services.

Outpatient Treating Physician: Physician providing primary mental health services to the client in the outpatient clinic. The outpatient treating physician must consult with the outpatient consulting physician regarding ECT services for a client.
 
III.  POLICY
 
This policy identifies ECT requirements specific for the following:
  • Voluntary clients
  • Clients under guardianship or conservatorship
  • Involuntary clients
  • Minors
This policy does not describe additional requirements specific to persons eligible for regional center services who may require ECT for a mental disorder (17 CCR § 50801 et seq.). This policy does not cover additional requirements for regional center clients (17 CCR § 50830).

ECT services shall not be provided to any minor under the age of 12.

The decision to recommend the use of ECT is derived from a risk/benefit analysis for the specific client. This analysis considers:
  • Diagnosis of the client
  • Severity of the presenting illness
  • Client's treatment history
  • Urgency for and fast-acting efficacy of ECT
  • Medical risks
  • Anticipated adverse side effects
The following must be in place prior to consideration of ECT:
  • Evaluation by a licensed psychiatrist that demonstrates severe symptomatology consistent with a Diagnostic and Statistical Manual (DSM) 5 primary diagnosis known to be responsive to ECT, including major depression, bipolar, mania, schizophrenia, or related psychotic disorder. 
  • There is an urgent need for a fast-acting efficacious treatment.
  • At least two (2) adequate trials of pharmacotherapy have failed to relieve symptoms.
  • The client demonstrates a significant risk to self or others.
  • The client is at significant risk of recurrence of a major mental illness that was successfully treated with ECT in the past.
  • There is an agreement from the outpatient treating physician and an outpatient consulting physician that ECT is the treatment of choice for this client.
The ECT treating physician shall document that there is careful monitoring of mood, psychosis, cognitive factors, and physical symptoms between treatments.

All outpatient ECT shall require prior authorization from DMH.

The standard number of ECT sessions per client shall be:
  • No more than 15 sessions within a 30 day period or
  • No more than 30 total sessions within a one (1) year period
ECT services for minors 12 to 17 years of age may be considered if all requirements specific to involuntary clients and clients under guardianship or conservatorship have been met along with the following:
  • It is an emergency situation and ECT is deemed a lifesaving treatment.
  • The need for and appropriateness of treatment are unanimously certified by a review board of three (3) board-eligible or board-certified child psychiatrists appointed by the local mental health director.
ECT services for minors ages 16 to 17 can be considered if they are voluntary clients.
 
ECT treatment shall be discontinued when:
  • Consent for treatment is withdrawn.
  • It has been determined that involuntary ECT is not a valid legal option.
  • The client is not making progress towards treatment goals and ECT is not required to maintain the current level of functioning.
  • The client’s physical or psychiatric condition necessitates discontinuation of ECT.
When the client can be safely maintained and effectively treated with a less drastic treatment, they shall be excluded from consideration for ECT.
 
IV.  PROCEDURES
 
Procedures - Electroconvulsive Therapy
 
V.  AUTHORITIES
 
California Welfare and Institutions Code Sections 5150 to 5404
California Health and Safety Code Section 123115 (a)
California Code of Regulations Title 9 Sections 835 to 849
California Code of Regulations Title 17 Sections 50801 et seq.
California Code of Regulations Title 17 Sections 50830
 
VI.  ATTACHMENTS
 
Electroconvulsive Treatment (ECT) Informed Consent Form (DHCS 1800) - English
Electroconvulsive Treatment (ECT) Informed Consent Form (DHCS 1800) - Spanish
Electroconvulsive Treatment Pre-Treatment Review Committee Statement
Convulsive Treatments Administered - Quarterly Report