ECT and neurostimulation — consultant viva

Station structure

Time: 8–10 minutes. Depth: consultant teaching registrar. Expect named trials, placement physics without equations, legal humility (no invented sections), and clear device tiers.[1][7][8]

Core questions and model points

1. What is ECT and why does it work clinically? Brief-pulse electrical induction of a generalised cerebral seizure under anaesthesia/muscle relaxation. Motor convulsion is a monitoring proxy (cuff technique). Mechanisms multi-pathway (neuroplastic, monoamine, anticonvulsant adaptation). Efficacy strongest for severe depression; also catatonia, mania, selected psychosis pathways.[8]

2. Evidence elevator pitch? UK ECT Review Group: real greater than sham; bilateral moderately greater than unilateral; often greater than drugs short-term. CORE: rapid response; continuation strategies matter because relapse is common without a plan.[1][2]

3. RUL vs BT — how do you choose? Cognition priority and less urgency → RUL/ultrabrief at high suprathreshold dose. Severity, urgency, RUL non-response → BT. Sackeim: placement and pulse width drive efficacy–cognition trade-off.[3][8]

4. Cognitive adverse effects — how do you counsel? Post-ictal confusion; temporary anterograde impairment; variable retrograde autobiographical risk (most feared). Mitigate with placement/pulse width; never gaslight; balance against untreated illness risk.[3][10]

5. Catatonia card. Examine with BFCRS structure; lorazepam trial; urgent ECT if malignant features or benzo failure. Do not delay for weeks of SSRI trials.[9][8]

6. Clozapine-resistant schizophrenia. After optimised clozapine, ECT augmentation has randomised evidence (Petrides) — name it.[4]

7. rTMS/iTBS card. Outpatient TRD option; sham-controlled trials; THREE-D iTBS non-inferior to 10 Hz with shorter sessions. Not a substitute for emergency ECT.[5]

8. DBS card. Early open-label SCC hope; BROADEN failed primary endpoint — not routine care.[6]

9. Governance. RANZCP ECT PPG (Weiss): consent, training, facilities, monitoring standards for ANZ. Capacity decision-specific; involuntary only under local law.[7]

Examiner probes (corners)

• "Why might seizure threshold rise during a course?" Anticonvulsant adaptation; dose may need increase; review benzos/anticonvulsants.[8]
• "She remitted after eight ECTs — are you done?" No — continuation pharmacotherapy and/or C-ECT plan.[2]
• "Family wants 'natural therapy only'." Acknowledge values; state mortality risk of untreated severe depression/catatonia; offer second opinion; legal pathway if capacity absent and risk extreme.[7][8]

Pass behaviours

Names trials accurately; places devices on evidence tiers; discusses memory without minimising; plans continuation; respects jurisdiction-specific law without fabricating statutes.[1][2][6][7]