India Together: The need for ethical debate – 01 April 2003

01 April 2003 –

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.

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.

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.

Bhargavi Davar
is with the Centre for Advocacy in Mental Health in Pune.
The CAMH, a research center of Bapu Trust,
promotes human-rights-compliant and non-medical
alternatives in mental health care, including self-help.
A version of this article appeared in the April-June
2003 issue of the journal, Issues in
Medical Ethics