No three-month grace period, and a capacitous adult's refusal is final outside a s62 emergency.
What is section 58A of the Mental Health Act?
Section 58A sets the rules for and the medication given as part of it (s58A(1); reg 27(3); Code 25.19). It covers detained patients, and every patient under 18, detained or not (s56(5)). It doesn't cover informal adults.
Three things set it apart from section 58 (Code 25.20). A capacitous refusal is final. Nobody under 18 can have it without a 's approval. And there's no three-month grace period, even for the medication given with the ECT.
ECT certificates: Forms T4, T5 and T6
| Who it's for | Who signs | What it certifies | |
|---|---|---|---|
| T4 | Aged 18 or over, with capacity, consenting | The in charge, or a SOAD | Capacity and consent |
| T5 | Under 18, capable and consenting | A SOAD only | Capacity, consent, and that ECT is appropriate |
| T6 | Any age, lacking capacity | A SOAD, after consulting a nurse and someone who's neither a nurse nor a doctor | Lack of capacity, that ECT is appropriate, and no conflict with an advance decision, attorney, deputy or the Court of Protection |
There's no form for a patient with capacity who refuses, because the Act gives no route. The SOAD should state the maximum number of treatments the certificate covers (Code 25.23).
Can you refuse ECT under the Mental Health Act?
Yes, if you have capacity. A detained adult with capacity who refuses doesn't fit any of the s58A routes, so ECT can't be given (s58A(2) to (5)). The same is true of a capable young person under 18 (Code 19.81).
The only exception is an emergency under s62, where ECT is immediately necessary to save life or to prevent a serious deterioration (Code 13.63). That's a high bar, and it has to be met for each treatment.
Emergency ECT under section 62
- Two grounds only. To save life, or to prevent a serious deterioration where the treatment isn't irreversible (s62(1A)). Relieving suffering and preventing violence don't apply to ECT (Code 25.39).
- Immediately necessary. Not just urgent, and not just likely to help (Code 25.40). It lasts only while that stays true (Code 25.41).
- It can override refusals. For a detained patient, s62 lets ECT go ahead despite a capacitous refusal, a valid advance decision or an attorney's refusal (Code 13.13, 13.63, figure 12).
- Get the SOAD moving. Request a visit as soon as you rely on section 62, and record why each treatment was immediately necessary (Code 25.42).
ECT for a patient who lacks capacity
A detained patient who lacks capacity can have ECT only on a SOAD's T6, outside a s62 emergency (s58A(5)). The SOAD first consults two people involved in the treatment, neither of them the or the AC in charge. One is a nurse, and the other is neither a nurse nor a doctor (s58A(6)).
The can't be used instead for a detained patient. An attorney or deputy can't consent to ECT for them, but outside an emergency they can refuse it. A valid, applicable advance decision refusing ECT also binds you (MCA s28; Code 24.54, figure 12).
ECT for under-18s
- Always a SOAD. Outside a s62 emergency, nobody under 18 can have ECT without a SOAD's approval, detained or not (Code 19.83).
- Capable and consenting. Form T5, from a SOAD, who also certifies that ECT is appropriate (s58A(4)).
- Not capable. Form T6. For a 16 or 17-year-old, the SOAD also checks for conflict with a deputy or the Court of Protection (Code 19.83).
- Informal patients need more. For an informal under-18, the certificate isn't enough on its own. You also need their consent or another legal basis (s58A(7); Code 25.24).
- Parental consent. The Act doesn't rule it out, but ECT may lie outside what parents can agree to. Consider the if the criteria are met, and if not, the court (Code 19.85 to 19.87).
- An IMHA. Every under-18 being considered for ECT can have one, and must be told (s130C(3)(b); Code 19.88). See children and young people.
ECT for informal adults: the Mental Capacity Act
Section 58A doesn't apply to informal adults. With capacity, they decide for themselves. Without it, ECT can in principle be given under the MCA in their best interests. A valid advance decision or an attorney's refusal would stand in the way (MCA ss5, 6(6), 25, 26).
ECT is likely to count as serious medical treatment, so an may be needed if there's nobody appropriate to consult (MCA s37; Code 13.66). For someone under or a court order, think about an independent second medical opinion first. DoLS authorises the deprivation of liberty, never the treatment (Code 13.65).
ECT on a community treatment order
- Capacity and refusing. It can't be given in the community, even in an emergency. Only after recall does Part 4 apply, and even then the refusal binds outside a s62 emergency (Code 24.17, 19.82).
- Capacity and consenting, 18 or over. The AC in charge signs a consent certificate on Form CTO12 (Code 25.29).
- Lacks capacity. A SOAD's Part 4A certificate on Form CTO11 (Code 25.28). In an emergency, s64G allows ECT only to save life or prevent a serious deterioration (Code 24.25).
- Under 18. Only a SOAD's Part 4A certificate will do, whatever their capacity (Code 25.30). See community treatment orders.
When an ECT certificate stops working
- Consent withdrawn. The patient can withdraw consent at any point in a course. The rest then counts as a new treatment, needing its own authority (s60(1)).
- Capacity changes. A consent certificate lapses if the patient loses capacity. A T6 lapses if they regain it (s60(1A) to (1D)).
- New conflicts. A T6 stops covering treatment if you learn of a conflicting advance decision, or an attorney, deputy or the court decides against it (Code figure 15).
- Serious suffering. If capacity changes mid-course and stopping would cause serious suffering, s62(2) can keep it going while a new certificate is sought. It can never continue ECT against a capacitous refusal (Reference Guide 23.54; Code 25.80).
Before a course starts
- Written information. Every patient having ECT, under s58A or not, should get written information first, to help them remember the advice during and after the course (Code 25.25).
- Check the certificate each time. Make sure it still matches the patient's capacity and consent, and that you're within the number of treatments it allows (Code 25.23, 25.74).
What the 2025 Act changes for ECT
Urgent ECT over a capacitous refusal will need a SOAD's certificate under a new s62ZA. So will urgent ECT that conflicts with a valid advance decision, attorney, deputy or court decision. If decides exceptional circumstances will delay a SOAD, the AC can certify a life-saving case until one is appointed (s62ZB). None of this is in force yet. See the 2025 Act.
A worked example
A 71-year-old man on s3 with psychotic depression has stopped eating and drinking. He's dehydrated, his kidney function is falling, and he lacks capacity to decide about ECT. The earliest SOAD visit is three days away.
ECT that's immediately necessary to save his life, or to prevent a serious deterioration, can start under s62 before the T6. Request the SOAD now, look for any advance decision or attorney, and record why each treatment is immediately necessary. Once he's eating and drinking, the emergency test may no longer be met, and further treatment waits for the T6.
The rules in brief
- Adult with capacity who consents. Form T4, from the AC or a SOAD.
- Under 18 who consents. A SOAD must still certify that ECT is appropriate (T5).
- Lacks capacity. A SOAD certifies it's appropriate (T6), and only if it doesn't conflict with a valid advance decision, an attorney, a deputy or the Court of Protection.
- Capacitous adult who refuses. It can't be given, except in an emergency under s62 to save life or prevent serious deterioration.
- Informal under-18s are covered by s58A too.
Read more: MHA 1983, s58A · MHA Code of Practice 2015, chapter 25: Treatments subject to special rules and procedures
Questions trainees ask
Can ECT be given to a detained patient who refuses?
Not if they have capacity, except in an emergency under s62 to save life or prevent serious deterioration.
Does ECT for under-18s need a SOAD?
Yes, even if they consent. A must certify it's appropriate on Form T5, and that applies to informal patients under 18 too.
What is section 58A of the Mental Health Act?
It's the section that regulates and the medication given with it. It applies to detained patients and everyone under 18, and needs a certificate on Form T4, T5 or T6 before treatment.
Can ECT be given in an emergency?
Yes, under s62, but only if it's immediately necessary to save life or to prevent a serious deterioration. The other urgent treatment grounds don't apply to ECT.
Is there a three-month rule for ECT?
No. Unlike medication under s58, ECT needs a certificate from the very first treatment, and so does the medication given with it.
Can ECT be given under the Mental Capacity Act?
Only for someone who isn't detained. An informal adult who lacks capacity can have ECT in their best interests under the , unless a valid advance decision or an attorney refuses it.
Can an advance decision refuse ECT?
Yes. Outside a s62 emergency, a valid and applicable advance decision refusing ECT stops a SOAD certifying it, even for a detained patient.
What does ECT stand for?
Electroconvulsive therapy. The Act spells it electro-convulsive therapy, and s58A covers it.
Test yourself
A woman with capacity, detained under s3, refuses ECT for severe depression. She's eating and drinking. The team thinks ECT would help.
Show the answer
C. Under s58A a capacitous adult's refusal of ECT is final. Section 62 only allows ECT to save life or prevent serious deterioration, and that isn't the situation here.