Position statement and guidelines on unmodified electroconvulsive therapy

Abstract

Background:In modern day psychiatric practice, it is assumed as a matter of fact that when electroconvulsive therapy (ECT) is administered, it will be administered under anesthesia and with succinylcholine (or its equivalent) modification. Yet, as surveys indicate, there is considerable practice of unmodified ECT in developing countries and, to a small extent, in the developed world, as well.Materials and Methods:This document examines historical and recent literature on the geographical practice, physiology, efficacy, and adverse effects of unmodified ECT. Particular attention is paid to musculoskeletal risks.Results:Although almost all the research is of poor methodological quality, there is a good reason to accept that unmodified ECT is associated with a wide range of adverse consequences, important among which are musculoskeletal complications, pre-ECT anxiety, and post-ECT confusion. However, it appears from recent data that these risks are not as large as historically portrayed. Possibly explanations are suggested, with seizure modification using parenteral benzodiazepines as a special possibility.Conclusions:Under exceptional circumstances, if ECT is strongly indicated and seizure modification with succinylcholine is not feasible, unmodified ECT, especially benzodiazepine-modified ECT, may be a viable option. A detailed set of recommendations for such use of unmodified ECT is proposed along with necessary checks and balances. This document has been approved by the Indian Psychatric Society, the Indian Association of Biological Psychiatry, and the Indian Association of Private Psychiatry (which commissioned the preparation of the document).

The World Psychiatric Association’s “Bill of Rights”: A curious contribution to human rights

“…As a club of national psychiatric associations that vary widely in their commitment to human rights, the WPA could have used the Bill to establish basic minimum entry requirements that each association would need to meet before it is accepted, or demitted on transgression. For example, if the WPA's position is that electroshock therapy given in its unmodified form (without anaesthesia or muscle relaxants) breaches minimum standards, it would eject its member the Indian Psychiatric Society for endorsing this practice [32].…”

General Anaesthesia Protocols for Patients Undergoing Electroconvulsive Therapy: Retrospective analysis of 504 sessions over a five-year period at a tertiary care hospital in Oman

“…7 Currently, performing ECT on a patient without anaesthesia is considered unethical. 8 During ECT sessions, anaesthesiologists provide diligent cardiorespiratory monitoring services, life support expertise and the pharmacological reduction of actual seizures while allowing unimpeded electrical activity. 9 Globally, anaesthesia protocols during ECT procedures are not standardised, primarily due to the varying availability of drugs and the preferences of individual anaesthetic care providers.…”

Unmodified electroconvulsive therapy: Concerns about reporting in a retrospective study

“…The paper states that there were no chart notes documenting the occurrence of post-ECT headache, a well-known adverse effect of unmodified ECT;[5] how accurate, then, could the rest of the information in the charts be?…”