A recent issue of the Indian Journal of Psychiatry (which is an open access journal) includes an article by Chittaranjan Andrade and others entitled “Position statement and guidelines on unmodified electroconvulsive therapy”.* The article was commissioned by the Indian Association of Private Psychiatry and approved by the Indian Psychatric Society and the Indian Association of Biological Psychiatry.
India is one of the countries where the use of unmodified electroconvulsive therapy (ECT) exists alongside the use of modified ECT. In unmodified ECT the patient is given an electric shock, which causes immediate unconsciousness followed by a seizure and convulsions. In modified ECT the patient is first given a short-acting anaesthetic and a muscle paralysing drug, so they are unconscious before receiving the electric shock and the convulsions are reduced to twitchings rather than thrashings.
The authors refer to two surveys on the use of unmodified ECT in Indian hospitals, neither of them though particularly recent. In 1991-2 just under half of psychiatrists who responded to a questionnaire always used modified treatments, the rest were fairly equally divided between those who always used unmodified and those who used both techniques. Ten years later a survey of teaching hospitals found that about two-thirds used modified treatment. A survey of ECT use in Asia during 2001-03 revealed a fairly similar picture. The authors also cite several articles from individual countries in Asia, Europe and Africa. For example, in a study from a French Hospital patients given ECT in 1996-7 were always given anaesthetic but rarely a muscle paralysing drug (rather they were held down during the convulsions). Strictly speaking, as the authors point out, anaesthetic alone does not constitute modified ECT, as it is the convulsion that is being modifed in modified ECT and this is done by the muscle paralysing drug, not the anaesthetic. For the use of unmodified ECT in the United Kingdom in the past three decades or so, the authors refer to an article from 1980 about its use in Broadmoor special hospital. But they could have quoted an extensive survey of ECT use in Great Britain from the same year, which found that 5 per cent of ECT clinics still occasionally used unmodified ECT.
Andrade and co-authors go on to discuss the disadvantages and risks of unmodified ECT, as well as its benefits, noting the lack of studies comparing modified and unmodified treatment. They conclude:
“Unmodified ECT is not the ideal form of the procedure. However, a parallel is the use of suboptimal medical and surgical practice in emergencies, as well as in circumstances in which training and infrastructure do not permit the ideal. Whereas suboptimal practice is undesirable, it has long been recognized in primary health care, rural, understaffed, underdeveloped, socioeconomically disadvantaged, and emergency settings that there are circumstances in which suboptimal practice is better than no intervention.”
The authors give examples of circumstances where they consider the use of unmodified ECT to be justified. These include the rather elastic: “Unavailability or unaffordability of facilities for anesthesia” and “Lack of time or opportunity for anesthesiological attendance or clearance”.
India is currently in the process of introducing new leglislation for mental health care. The Mental Health Care Bill, 2011, proposed a prohibition on unmodified ECT but psychiatrists have objected to this. For example, in an article entitled “Ethical aspects of public health legislation: The Mental Health Care Bill, 2011” in the Indian Journal of Medical Ethics, Harish Thippeswamy, Kausik Goswami, Santosh Chaturvedi, argue that:
“In routine clinical practice, there are often situations like life-threatening catatonia wherein a patient may need urgent electroconvulsive therapy. Moreover, modified ECT is expensive and requires the specialised services of an anaesthetist. Given the manpower and financial constraints in our country, a complete ban on unmodified ECT may result in failure to provide this effective and life-saving treatment to all those who need it. This goes against the ethical principle of beneficence. Serious adverse effects are a rarity with unmodified ECT, and we feel that it should be allowed under rare circumstances.”
* Andrade C, Shah N, Tharyan P, Reddy MS, Thirunavukarasu M, Kallivayalil RA, Nagpal R, Bohra NK, Sharma A, Mohandas E. Position statement and guidelines on unmodified electroconvulsive therapy. Indian J Psychiatry 2012;54:119-33