Teaching therapeutic seizure criteria to psychiatrists

J ECT. 2014 Sep;30(3):220-3. doi: 10.1097/YCT.0000000000000087.


Objectives: Following on from our previous work looking at the interrater reliability of assessing seizure adequacy for electroconvulsive therapy (ECT), we sought to examine whether a specific teaching module could improve the reliability of visual inspection of electroencephalography (EEG) recordings for specific features of seizure length, presence of polyspike, δ wave activity, and post-ictal suppression.

Methods: Twelve medical practitioners at varying levels of training and ECT experience rated 15 EEG traces after minimal training and a further set of 15 EEG traces after a more detailed training. Results were analyzed to examine the interrater reliability of the EEG features and the overall assignment of traces as meeting "old" (1995) or "new" (2005) Royal College of Psychiatrists criteria for therapeutic seizures compared with the agreed ratings of 2 experienced ECT practitioners ("standard ratings").

Results: There was evidence for a specific training effect for the "old" criteria with an improvement in the interrater reliability (generalized κ, 0.590 vs 0.813) associated with a significantly better estimation of seizure length as assessed by comparison of the root mean square difference from the standard ratings (mean, 7.83 vs 4.49; P < 0.003). The interrater reliability for the new criteria did not improve (generalized κ, 0.599 vs 0.581) but was already at quite a good standard. Examination of individual features did demonstrate improvement in the rating of δ activity (generalized κ, 0.564 vs 0.655) and post-ictal suppression (generalized κ, 0.553 vs 0.611) after the training. When these 2 criteria were grouped together (δ suppression), interrater reliability was shown to be significantly improved after the training (generalized κ, 0.568 vs 0.659). Although not statistically significant, the participants reported that the training improved their confidence in using both criteria for therapeutic seizures (old: 49% vs 67%; new: 27% vs 48%).

Conclusions: The reliability of assessments of seizure length, presence of δ activity, and post-ictal suppression can be measurably improved with a specific teaching module. Using the δ suppression criteria together with the accurate estimation of seizure length on EEG may have greater clinical utility when it comes to instructing trainees in ECT administration, assessment of therapeutic seizures, and developing protocols for dose adjustment.

MeSH terms

  • Adult
  • Clinical Competence
  • Curriculum
  • Education, Medical, Continuing
  • Electroconvulsive Therapy*
  • Electroencephalography*
  • Female
  • Humans
  • Male
  • Psychiatry / education*
  • Reproducibility of Results
  • Seizures*