South Asia Citizens Web
April 12, 2003
Appeal to health professionals and human rights activists against the use of Electroconvulsive Therapy in India's Mental Health Institutions
Center for Advocacy in Mental Health
A research center of bapu trust
36B Ground Floor Jaladhara Housing Society
583 Narayan Peth, Pune 411 030, India
T- 0091-20-4451084 Email- wamhc@vsnl.net
Website- http://www.wamhic.com
3-3-2003
Dear friends,
We are making an appeal to all friends, mental health professionals and human rights activists to take note and respond to a most urgent issue concerning DIRECT ECT (Electroconvulsive Therapy).
We are shocked that Dr Chittaranjan Andrade, a very reputed psychiatrist from NIMHANS, should make a case for direct ECT (Electro Convulsive Therapy) in a recent Issue of Medical Ethics (Andrade, 2003). This article comes in the line of a series of very worrying articles and perspectives promoting direct ECT, and urging more research on direct ECT.
In ECT, an electrical current of between 70 to 170 volts is passed for between 0.5 and 1.5 seconds. In direct ECT the voltage may be slightly lower. 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. The risk of injury is high. As the procedure is given in series, usually this hazard is experienced again and again. In an ideal situation, the procedure is repeated between 6 to 10 times. But continuous dosing up to 20 times or more in India is not unknown
Direct ECT is commonly practiced in India. This procedure has recently been placed as a controversial and contested issue before the Supreme Court, through a petition filed by Saarthak, a mental health NGO working from New Delhi. On the misleading advise of psychiatrists with a vested interest in this procedure, the supreme court declared the procedure "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 come down drastically after the 1980s, following class action. The 1978 APA Task Force reported that only 16% of psychiatrists gave (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 issue of åwhether or not ECTÇ, and what community alternatives we can create in mental health, we are placed in this ridiculous situation of debating direct ECT.
Dr Andrade claims that direct ECT is "virtually" risk free. But neither in this article nor in any of the relevant research in India, some of which is mentioned herein, has anyone vouchsafed even the relative safety of ECT, whether direct or modified. The only argument made is that modified ECT is even worse than direct ECT. Of course, we can expect patients will be reassured by this argument.
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. Even Dr Andrade writes 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, other than fear and anxiety.
Kiloh, et. al. (1988) give this long list of common "complaints" following ECT, which are more acutely experienced when given direct: headache, nausea, dizziness, vomiting, muscle stiffness, pain, visual impairment due to conjunctival haemorrhages, tachycardia/bradycardia, BP surges, changes in Cardio Vascular activities, alteration in blood brain barrier, ECG changes, arrhythmias, cardiac arrest, ventricular fibrillation, sudden death, dysrhythmias, transient dysphasia, amenorrhoea, hemiparesis, tactile/visual inattention, homonymous haemianopia. Among the "risks" mentioned are the following: myocardial infarction, pulmonary abscesses, pulmonary embolism, activation of pulmonary TB, rupture of colon with peritonitis, gastric haemorrhage, perforation of a peptic ulcer, haemorrhage into the thyroid, epistaxis, adrenal haemorrhage, strangulated hernia, cerebral haemorrhage and subarachnoid haemorrhages. Infrequent "complications" that arise may be fractures (vertebrae, femu! r, scapula, humerus) and dislocations (jaw, shoulder), cardiac arrhythmias, apnoea and "tardive" convulsions. Among the inevitable "side-effects" are mentioned, cardiovascular responses, postictal clouding of consciousness and memory impairment. With modified ECT, the effects are "less likely" but not completely ruled out.
What is it, about being "mentally ill", that permits society and psychiatric professionals to argue that being exposed to these risks repeatedly is quite all right? Even the professionals never considered ECT as a "cure", but only as palliative. This means that in practice, professionals can use it as and when they like as, palliative care can be seen as an ongoing need, unlike curative care.
Andrade cites "further evidence" of research by Tharyan, et al. (1993), highly (mis)quoted studies done in the early 1990s on direct ECT. He writes that in this study only 12 patients experienced fractures out of a total of 1835 patients receiving 13597 treatments. This sounds as if a few of the patients walked out of the ECT table with a slight twisting of the middle finger. He fails to mention relevant data from this study that these were thoracic / vertebral fractures involving almost a third of the body vertebrae. Andrade also fails to mention that in this study, there was one reported death due to cardiac arrest (i.e. one patient out of 1835 died), 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, which from a consumer point of view seem horrific, are not considered "clinically significant" by the authors of this cont! entious study nor by Andrade. In AndradeÇs own study (2000), 2% of the patients experienced "a musculo-skeletal event".
The recent APA Task Force on ECT (2001) notes that contrary to earlier evidence, they have to now acknowledge that mortality rates with ECT (modified) may be as high as 1 in 10,000 patients. Consumers (Frank, 2002) say that mortality rates may be as high as 1% with modified ECT. The mortality rates are probably higher among the elderly, making it a highly contested procedure among them. The Task Force report also notes that 1 in 200 may experience irretrievable memory loss. The Bombay High Court ordered against 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.
Death in the case of ECT is usually due to cardio-vascular or cerebral-vascular complications, followed by respiratory failure. Shukla (1985), in discussing a case report of death following modified ECT, reviews the mortality data associated with the procedure. Rates between 0.8% and 0.003% have been reported in the western literature. Shukla, finding it a curious fact that deaths have not been reported at all in the Indian professional literature, observes that fatalities are not always publicly reported, particularly in India but every psychiatrist would have experienced such cases in his practice.
The European CPT (Convention for the Prevention of Torture) 2002 prohibits the use of direct ECT as a form of torture. One of the reasons cited is the terror experienced by patients in use of the procedure. The suggestion in relevant literature is that ECT affects the limbic system of the brain, the same system that is affected by deep trauma. Medical narratives regarding direct ECT highlight the very understandable horror of experiencing ECT effects as well as accidents and disabilities following a procedure which is supposed to "cure" (Wiseman, 1995). The motor, physiological and cognitive effects of ECT recipients following treatment are the same as trauma victims. The terror is a sign of trauma, and not a sign of insanity. Victims of direct ECT should be considered as victims of medical torture and brought within human rights and medico-legal jurisprudence.
In Tharyan et al's 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!! Quoting them in full: "A 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. In the earlier half of the decade under review, barbiturates, oral diazepam, parenteral haloperidol and even thiopentone were used to allay anxiety; in recent years, this has been effectively managed by pretreatment with 1 to 4 mg of lorazepam given orally." The authors of this study find it an interesting observation that those who refused the treatment were not among those who were sedated. Their study also suggests that it is common practice to sedate patients who refuse ECT. Amazingly, they recommend the use of ! sedatives to minimize the fear 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?
In many countries, giving even modified ECT to children, elderly and pregnant women is prohibited. In Tharyan et alÇs study, direct ECT has been administered to the age group 14 to 70, including women in all trimesters of pregnancy. How did the IEC of CMC, the site of this study, allow this to happen? The study has continued uninterrupted for 11 years.
Tharyan, et alÇs study further reassures that "trained" professionals were used to give direct ECT. What does training mean in the context of direct ECT? You just need some physically very strong people to tie down the patient in strategic points and to keep the jaw and joint areas from major injury. Note further, in Tharyan et alÇs study, the composition of the full "team" used in this study to prevent injury: four orderlies, three nurses, two postgraduate trainees and a consultant psychiatrist, a total of 10 trained people! The argument concerning the cost-effectiveness of the procedure is not validated by this study. Even with a full load of 10 people tying down a patient from the convulsions, the reported injury rate was not insignificant. Have the costs of disability days following ECT been taken into account? Kiloh et al (1988) reported studies where the ECT took only a few hours, but the patients had to be hospitalized for a week after that, waiting for the confusi! on and suicidal ideation to clear up (p.251)!
Why would presumably rational scientists produce such irrational arguments to safeguard a scientifically dubious and highly hazardous procedure? The fact is that in nearly every city, a majority of private practitioners give ECT in their private clinics. A recent survey in western India showed that nearly 80% of private psychiatrists give ECT, costing anywhere between 500 to 1000 rupees per dose. For a minimum of 6 doses, the cost would be between 3000/- to 6000/- rupees. Repeated dosing is not uncommon in India. ECT is given as palliative care, and not as cure. This means that in practice, professionals can justify repeated and uninterrupted use of direct ECT, exposing the patient to repeated risk as well as increasing the cost of care tremendously. ECT is the only piece of technology that psychiatry can boast of. Psychiatrists make a lot of money by giving ECT in their clinics. There are psychiatrists who ask the patient to first take an ECT before even consultation (Ba! pu workshop, 2002)! ECT has been given to cure "naxalism" (Ramaswamy, 2000) and homosexuality. In private practice, it is difficult to have the medical back up necessary to give anesthesia or for resuscitation. ECT guidelines do not exist in India, making it conducive for doctors to engage in rampant abuse of the procedure. The situation here is similar to sex selection tests as the private market rules the roost and must be confronted in a like-wise manner.
In our view, direct ECT is a matter for human rights law, prevention of torture instruments, regulation and consumer litigation. Andrade suggests that there must be further research on direct ECT. We oppose any future conduct of such research. Statutory authorities, human rights commission, and medical regulatory bodies must proscribe such research. Funding bodies must act strictly against the use of direct ECT in their field areas.
We appeal to all those committed to a human rights regime in mental health care to 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.
Yours sincerely,
Aparna Waikar
Bhargavi Davar
Chandra Karhadkar
Darshana Bansode
Deepra Dandekar
Seema Kakade
Sonali Wayal
Yogita Kulkarni
References:
Andrade, C. (2003) "Unmodified ECT: Ethical Issues", Issues in Medical Ethics, Vol. 11 Issue 1, pp. 9-10.
Andrade, C., Rele, K., Sutharshan, R., Shah, N. (2000) "Musculoskeletal morbidity with unmodified ECT may be less than earlier believed", Indian Journal of Psychiatry, 42, pp. 156-162.
Bapu Workshop, (2002) "Right to Rehabilitation of Persons with Mental Illness", August 24th, Indian Social Institute, New Delhi.
CPT, (2002) European Committee for the Prevention of Torture and Inhuman or degrading treatment or punishment, CPT - 2002, Chapter VI- Involuntary Commitment to psychiatric establishments, Section 39 - ECT. Council of Europe Convention.
Frank, LR 2003, "Electroshock: A crime against the spirit", In a Nutshell, Fall/Winter 2002-2003, pp. 16-22.
Kiloh, L.G., Smith, J.S., Johnson, G.F. (1988) Physical treatments in Psychiatry. Foreword by Sir Martin Roth. Blackwell.
Ramaswamy, G. (2000) "A remembered rage", In Aaina, Vol. 1 Issue 1, January 2000.
Shukla, G.D. (1985) "Death following ECT- A case report", Indian Journal of Psychiatry, Vol. 27, Issue 01, pp. 95-97.
Task Force Reports (1978, 1990, 2001) on ECT. American Psychiatric Association, USA.
Tharyan, P., Saju, P.J., Datta, S., John, J.K., Kuruvilla, K. (1993) "Physical morbidity with unmodified ECT: a decade of experience", Indian Journal of Psychiatry, 35, Issue 4, pp. 211-214.
Wiseman, B. (1995) Psychiatry: The ultimate betrayal. Freedom Publishing Co. A Publication of Citizens Commission for Human Rights, LA, California.
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