In recent months, a few reputed psyshiatrists in the nation have argued in favour of administering direct Electro Convulsive Therapy. These arguments, (for e.g. Andrade, 2003) greatly downplay the risk of this procedure with little or no evidence. Equally important, accepting this recommendation will set back the ethical standards of the profession, and grossly violate the human rights of already at-risk patients.
During an ECT procedure, an electrical current of between 70 to 170 volts is passed for between 0.5 and 1.5 seconds. In direct ECT, which is administered without anasthesia, the voltage used is typically lower. Nonetheless, it throws the body into epilepsy-like seizures. While the patient is conscious in the beginning, he or she is rendered unconscious when the grand mal seizure starts. He is held down physically to prevent fractures and internal injuries; nonetheless the risk of injury is high. As the procedure is performed serially, usually this hazard is experienced again and again. In an ideal situation, the procedure is repeated no more than 6 to 10 times. But continuous dosing up to 20 times or more is not unknown in India.
Direct ECT is commonly practiced in India. This procedure was recently placed as a controversial and contested issue before the Supreme Court, through a petition filed by Saarthak, a mental health NGO based in New Delhi. On the advice of psychiatrists with a vested interest in the procedure, the Court has erroneously pronounced it safe.
In its 'modern' or modified form (Modified ECT), the patient is not allowed to eat or drink for four hours or more before the procedure, to reduce the risk of vomiting and incontinence. Medication may be given to reduce the mouth secretions. Muscle relaxants and anesthesia are given to reduce the overt epileptic / muscular convulsions and patient anxiety. The muscle relaxant paralyzes all the muscles of the body, including those of the respiratory system. A crash cart is kept nearby, with a variety of life-saving devices and medications, including a defibrillator for kick starting the heart in case of a cardiac arrest. The brain is subjected to seizure activity induced by the electrical current. The causal mechanism by which the treatment works is not known. Endocrinological, neurotransmitter and other changes have drawn a blank. It is believed that electricity itself and the seizure activity it produces is the curing element. We must remember again that this procedure is repeated several times, increasing risk multifold.
The Italian Ugo Cerletti invented ECT in 1938, drawing inspiration from the fact that pigs being prepared for slaughter in an abattoir were first rendered unconscious by passing electricity through bilateral placement of electrodes against the head. The pigs convulsed and fell unconscious. After a long innings of brutal experimentation and research, the developed world banned direct ECT in the early 1960s. Many European countries have phased out even modified ECT, while in the US its usage has reduced drastically after the 1980s, following class action. The 1978 American Psychiatric Association Task Force reported that only 16% of psychiatrists performed (modified) ECT. ECT research does not receive funding from government bodies, or from large foundations. It is largely funded by private business. International journals will not publish articles on direct ECT.
To make a case for direct ECT in this day and age, establishes a fresh, new low for psychiatric ethics in India. Instead of debating the question whether or not ECT itself - and considering community alternatives we can create in mental health, we are considering a particularly damaging application of it. The fact of not having created interesting and humane alternatives in mental health has been the pathos of the Indian mental health service system. It is disappointing that this fact should lead to advocacy of direct ECT, instead of fuelling the creation of imaginative psycho-therapeutic and community models.
In the West, two important factors led to the phasing out of direct ECT: one was the discovery that between 0.5% to 20% of patients suffered from vertebral fractures; and the second was their evident terror and trauma. Experts including Dr Andrade concede that direct ECT is associated with risk of vertebral / thoracic fractures, dislocation of various joints, muscle or ligament tears, cardiac arrhythmias, fluid secretion into respiratory tract, internal tears, injuries and blood letting - besides fear and anxiety. Kiloh et al. (1988) provide a very long list of common complaints associated with ECT, which are more acutely experienced when given directly.
Advocates of direct ECT sometimes cite research from the Christian Medical
College in Vellore (Tharyan et al., 1993). This highly misquoted study,
however, does not actually provide much assurance. Twelve of the 1835
patients suffered thoracic / vertebral fractures involving almost a third
of the body vertebrae. Also, there was one reported death due to cardiac
arrest and a good percentage experienced
body aches, both local and generalised, and another one percent of the
patients had cardiac complications. These data, especially the spinal
injury and the mortality rate, seem horrific, from a consumer point of
view.
In this study, a high percentage of patients (7.5%) reported fear and apprehension of the procedure, and 50 patients refused the treatment. How did the researchers proceed with the study? They did so by actually sedating the patients!! "Fifty of them [patients] refused further ECT due to this fear while in the remainder (100 patients) the fear was reduced by sedative premeditation enabling them to complete the course of ECT". Such is the prejudicial approach to mentally ill patients that fearful refusal of a hazardous and life-threatening procedure is considered as a mere symptom of insanity, and further treated with sedatives. How do the professionals reconcile ethical issues of consent in such instances?
The recent APA Task Force on ECT (2001) notes that contrary to earlier evidence, mortality rates from ECT procedures (modified) may be as high as 1 in 10,000 patients. Consumers (Frank, 2002) say that mortality rates may be as high as 1% from modified ECT. The mortality rates are probably higher among the elderly, making it a highly risk-prone procedure for them. The Task Force report also notes that 1 in 200 may experience irretrievable memory loss. The Bombay High Court banned the use of direct ECT way back in 1989, following the Mahajan Committee Recommendations. In Goa too, due to legal advocacy and the proactive role of psychiatrists there, direct ECT has been banned. The European CPT (Convention for the Prevention of Torture) 2002 prohibits the use of direct ECT.
Direct ECT is a matter for human rights law, demanding legal instruments for the prevention of torture, as well as regulation and consumer litigation. Doctors and professionals committed to a human rights regime must address this issue in an urgent manner. This would be an important way of making meaningful linkages with those struggling for human rights within the mental health service delivery system.
