Audits of electroconvulsive therapy

Waikar et al. (1), in their diatribe against ECT (electroconvulsive therapy) in general, and unmodified or direct ECT in particular, were shocked that our institutional ethics committee permitted an 11-year ‘study’ of unmodified ECT (2), where patients whose ‘fearful refusal of a hazardous and life-threatening procedure’ were ‘considered as a mere symptom of insanity, and further treated with sedatives’. They were appalled that ECT was given to children, elderly and pregnant women. They contend that our report trivialised the ‘horrific’ physical complications with direct ECT and ‘the costs of disability days following ECT’. They wonder ‘why presumably rational scientists produce such irrational arguments to safeguard a scientifically dubious and highly hazardous procedure’, concluding that it is because we ‘make a lot of money by giving ECT’.

ECT is an invasive procedure, like neurosurgery, and considerations of morbidity or mortality must therefore be viewed in this context. Untreated or treatment refractory mental illness kills and wastes precious lives. There is incontrovertible evidence that ECT is an effective treatment for depression (3), and substantial evidence that it is effective in mania (4) and schizophrenia (5), especially when other treatments fail. There is no credible evidence that ECT causes brain damage (6). ECT is not contraindicated, and may be especially effective, in pregnant women, children or the elderly (7).

Ours was not a prospective research study but a retrospective chart audit of clinical practice (2). Over 11 years, 6.3% of the 28,929 patients registered at our centre were treated with ECT, hardly the overenthusiastic and indiscriminate use implied by Waikar et al. (1). Of the 13,597 individual treatments given to 1,835 patients, the physical morbidity included spinal compression fractures and transient myalgia in less than 1%, resulting in short-lived pain but no disability, neurological deficits or long-term sequelae over up to 8 years follow-up. One patient died (mortality rate 0.05%) of a cardiac arrhythmia, though the subsequent 12 years and approximately 2,000 additional patients treated have not seen additional mortality.

In spite of this low complication rate for an invasive procedure, all treatment conducted here since 1995 have been modified under anaesthetic supervision, and our practice, frequently audited, conforms to the international technical and ethical standards. No patient has ever received ECT without personally (or a responsible relative) consenting. Fear of ECT is less with modified than with unmodified ECT but in both situations an unknown and reputedly hazardous procedure does generate apprehension, just as with tooth extraction or brain surgery. Pre-ECT sedation reduces apprehension. ECT, as practised in our centre, is hardly a lucrative enterprise since costs are low (Rs 180 per modified treatment, excluding anaesthetic drug costs) and many patients’ treatments are free or heavily subsidised. Finally, our patients and their relatives have endorsed our use of ECT (8).

Unmodified ECT is aesthetically less appealing to patients and clinicians alike than modified ECT. Consideration of ways to phase out direct ECT such as changing from thrice a week to the equally effective twice a week regimen to reduce anaesthetist demand, or forming group practices with shared ECT and anaesthetic facilities, or deputing psychiatric personnel to get specialist anaesthetic training are inevitable, if ECT is to survive another 50 years. However, banning direct ECT overnight by legal action without ensuring the continued and effective delivery of ECT is tantamount to closing down mental hospitals without ensuring adequate community care. Many clinicians, without access to anaesthetists, would face denying seriously mentally ill patients an effective treatment. Such a ‘collateral damage’ resulting from well-intentioned action is as unethical and unacceptable as some recent international events.