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Indian group seeks ban on use of electroconvulsive therapy without anaesthesia

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7341.806/a (Published 06 April 2002) Cite this as: BMJ 2002;324:806

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Banning unmodified ECT immediately is not necessarily the answer

An immediate ban on unmodified ECT would be similar to the sudden closure of mental hospitals without ensuring adequate facilities for the community rehabilitation of patients. Dr Bhagat and his organization have rightly called attention to the need to regulate the use of ECT in India, but periodic audits of ECT facilities and practices by the Indian Psychiatric Society, and the establishment and implementation of guidelines appropriate to restructuring economies, including the time bound phasing out of unmodified ECT, would best achieve this.

There is much that ails the practice of ECT in the country and the use of unmodified ECT is only one of them. Insufficient attention is paid to training psychiatrists in the safe and effective use of ECT in training programmes. Informed consent is often not obtained before the procedure, though this merely reflects the prevailing ethos of care in the country and applies to other invasive and non-invasive medical and surgical procedures as well. Excellent and relatively cheap, brief pulse ECT machines are manufactured in the country, and though ECT delivered via sine wave devices is at least as effective as that given via brief pulse machines, cognitive deficits may be greater. Retrospective1, and prospective2 evidence suggests that physical morbidity associated with ECT delivered sans anaesthesia and muscle relaxation can be minimal with both brief-pulse and sine wave ECT devices, and that patients often request the treatment due to its efficacy, safety and low cost. Practitioners often charge exorbitant rates for ECT modified by anaesthesia, and anaesthesia is not without its own risks. Anaesthesia also makes it more difficult to elicit seizures of adequate therapeutic effect and modified, brief pulse ECT requires adequate training in titration of stimulus doses to ensure adequacy of treatments and to equal the efficacy of unmodified sine wave treatments.

Merely banning unmodified ECT without ensuring the continued and effective delivery of ECT would be tantamount to banning ECT altogether in many treatment facilities, which I hope is not the intent or result of the ongoing litigation. ECT is often a life-saving treatment, acts relatively faster than other treatments in certain diagnostic groups, and in many instances works when other currently available treatments fail 3-5. Arguably, Indian psychiatrists may overuse ECT, but in my opinion, ECT is under-utilised in many parts of the world.

References

1. Tharyan P, Saju PJ, Datta S, John JK, Kuruvilla K. Physical morbidity with unmodified ECT- A decade of experience. Indian J Psychiatry 1993; 35: 211-214.

2. Andrade C, Rele K, Sutharahan R, Shah N. Musculoskeletal morbidity with unmodified ECT may be less than previously believed. Indian J Psychiatry 2001; 42: 156-162.

3. Devanand DP, Sackeim HA, Prudic J. Electroconvulsive therapy in the treatment resistant patient. Psychiatric Clinics of North America 1991; 4: 905-23.

4. Mukherjee S, Sackeim HA, Schnur DB. Electroconvulsive therapy of acute manic episodes: a review of 50 years experience. Am J Psychiatry 1994; 151: 169-176.

5. Tharyan P. Electroconvulsive therapy for schizophrenia (Cochrane Review). In: The Cochrane Library, Issue 4, 2001. Oxford: Update Software

Conflict of interest: None

Competing interests: No competing interests

11 April 2002
Prathap Tharyan
Professor of Psychiatry
Christian Medical College, Vellore, 632002, Tamil Nadu, India