At the very mention of the term 'electroconvulsive therapy' (ECT), people imagine something shocking, barbaric, demeaning, undignified, inhuman and so on. The reason lies partly in the history of ECT and partly in its media portrayal. The introduction of ECT was serendipity. It was noticed that the symptoms of schizophrenia improved when the patients developed seizures. Thus it was speculated that a therapy that artificially induced seizures could benefit such patients.
However, in its early years, ECT was delivered in a very crude manner. The patients convulsed and sustained musculoskeletal injuries, and were often tied up or manually restrained as they went through the painful experience. And this is exactly how it is portrayed in various movies even today. In the popular Hindi movie Kyon Ki for instance, we see a draconian Om Puri (the psychiatrist) delivering ECT to a restrained Salman Khan (the patient) who is left to scream in sheer agony.
" It is a short, painless intervention and the patient can be sent home after monitoring for a few hours."
This mindset about and portrayal of ECT is far from the present-day truth. ECT today is delivered in a special, well-equipped ECT room, just like a mini operation theatre. It is administered - after obtaining written, informed consent -- by a psychiatrist and anaesthetist. The anaesthetist gives short-acting general anaesthesia and a muscle relaxant, while the psychiatrist delivers the current to the scalp from the ECT machine. It is a brief and painless intervention.
The purpose of giving a muscle relaxant is to prevent violent convulsions and injuries. Anaesthesia is given to make the patient unconscious during the procedure. Ventilatory support with oxygen is provided. The electric current is delivered for 1-2 seconds. Just as long as it takes the eyes to blink once or the fingers to snap! The current causes seizure activity in the brain, which is often monitored by a separate EEG machine. This resets the neurotransmitter systems in the brain and brings about improvement. This entire technique is known as "modified ECT".
ECT is often given to patients with severe depression, schizophrenia and sometimes to patients with a bipolar disorder. It has two distinct advantages over medicines. First, while psychiatric medicines begin to act only after a lag of at least one week, ECT can bring about immediate relief in symptoms. This makes it the best choice for patients who have suicidal thoughts. For the same reason, it is also recommended for patients who are extremely agitated and at risk of causing harm to themselves or others. Second, it saves one from the side-effects of medicines. For this reason it sometimes becomes the treatment of choice for pregnant patients, so that we don't expose the unborn child to the medicines. At times the mental illness is such that the patients either deny having an illness or so suspicious about those around them that they refuse to take medicines at all. Sometimes the patient is in a catatonic stupor, immobile and unresponsive. In such clinically difficult situations, ECT has been found to be extremely beneficial. In many cases, when medicines have failed, ECT has worked.
One of the side effects of ECT however, is that it can impairment in retrograde and autobiographical memory. The good news is that this reverses within six weeks to six months of stopping the therapy. Also, often, the illness itself can cause problems with memory, which actually improve after giving ECT. Therefore, while taking a decision for or against ECT, the risks of an untreated mental illness and the side effects of medications have to be weighed against the reversible memory impairment that ECT can cause -- vis-a-vis the likely benefits.
"We need to look at [ECT] scientifically, just like any other interventional procedure, and not as an attack on human dignity."
As clinicians, we witness diverse responses from patients and their families when we first discuss the option of ECT, ranging from vehement refusal to fear to openness to even demanding and insisting on receiving ECT. Once ECT brings about improvement, the acceptance is very high. For those who refuse and/or are scared, explaining in detail about the procedure and making them talk to and meet someone else who has received such a treatment, usually works. The initial resistance is due to the lack of awareness, stigma or perhaps the name of the therapy itself! The nobel laureate Paul Greengard has, in fact, suggested that the name be changed to 'electrocortical therapy'.
The recent Mental Health Care Bill puts a ban on 'unmodified ECT' i.e. ECT without anaesthesia and muscle relaxant; because of the high risks of injury involved. It also introduces the concept of advance directive, which means that any individual can state his/her clear preference for or against ECT, in advance. Thus in future, if a condition arises in which he/she cannot give consent and ECT is one of the treatment options, one has to respect the choice stated in advance.
Certain mental illnesses are such that the patient does not have insight into his/her condition and is not in a position to take treatment-related decisions. In the absence of an advance directive, there is an ethical issue of autonomy and informed consent here and usually the decision whether to give ECT is taken jointly by the treating psychiatrist and the primary care-giver of the patient, keeping in mind the principle of beneficence, and doing what is in the best interest of the patient.
In a nutshell, ECT is a safe, effective and time-tested treatment for some serious psychiatric disorders. We need to look at it scientifically, just like any other interventional procedure, and not as an attack on human dignity. ECT not only saves lives, but also improves the quality of life of patients and their caregivers.
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