The ECT debate: a response

I have gone through the article ‘Unmodified ECT: ethical issues’ by Chittaranjan Andrade (1) which appeared in IME Vol. XI, no. 1 (p. 9-10). In the event of the voluntary organization Saarthak filing a PIL in the Supreme Court (2) demanding a ban on unmodified (administered without anaesthesia) ECT, this article is significant because of its clarity and strength of arguments in discussing the various relevant issues. I agree with the article in its entirety.

I agree with Dr Andrade (1) that ECT is as relevant today as it was six decades ago when it was invented. ECT continues to hold on to its important position in the therapeutic armamentarium by virtue of its remarkable efficacy, rapidity of therapeutic effect and safety.

It is a life-saving treatment in severe depression, a condition in which 15% of untreated patients are known to commit suicide (3). Almost every psychiatrist has had the unfortunate experience of one or more of his patients dying due to suicide in situations where ECT, as a treatment modality, is withheld for some reason.

I also agree with Dr Andrade that the risk:benefit ratio of unmodified ECT is heavily tilted in favour of ECT. Even if administered unmodified, only a very small proportion of patients have complications. Tharyan et al.’s (4) data show that only 12 out of 13,597 ECT treatments were associated with fracture. Considering the number of suicides or the psychological morbidity that unmodified ECTs can prevent, the rate of potential complications is not substantial.

Consider a scenario in which the first-degree relative of a psychiatrist either has a suicidal depression or a florid, aggressive psychosis and the former has no facility to administer anaesthesia with the ECT. I am fairly certain that this close relative-patient will be administered unmodified ECT by most psychiatrists!

In India, where resources often fall short of demands, a large number of mentally ill patients will be denied the benefits of ECT if unmodified ones are banned. Such patients are likely to be in one of the following situations:

• where no anaesthesiologists are available;
• where the patients cannot afford the additional expenditure of anaesthesia;
• where administration of anaesthesia can pose a medical risk; and
• where administering anaesthesia is practically difficult due to a large number of such patients being posted for ECTs, e.g. in mental hospitals.

Thus, any legislation against unmodified ECTs will be an injustice to a large number of the mentally ill in India, with potentially disastrous consequences for the patients and their families. Dr Max Fink (5), an American psychiatrist and an international authority on ECT, said during his recent visit to India: ‘If we have to choose between a modified ECT and an unmodified one for a seriously mentally ill patient, the choice is certainly a modified one. But if the option is between an unmodified ECT and ‘no ECT’, without doubt, it has be an unmodified ECT.’