Unmodified Electroconvulsive Therapy Research Articles

Exploring the early history of convulsive therapies at the Mysore Government Mental Hospital (currently NIMHANS).

The paper describes the introduction, and early use of chemically and electrically induced convulsive therapies, at the Mysore Government Mental Hospital (MGMH), now the National Institute of Mental Health and Neuro Sciences, Bangalore, India. Cardiazol and ammonium chloride were used at MGMH before the introduction of electroconvulsive therapy (ECT). The study examines the early history, clinical correlates and outcome of convulsive therapies and attempts to contextualize how local conditions influenced implementation. Three sets of archival case-records from 1938 to 1948, each of a period of 9 months following the implementation of a particular mode of convulsive therapy were reviewed. During the examined timeframe, 40 patients received cardiazol, 95 ammonium chloride and 50 unmodified ECT. Schizophrenia was the commonest clinical indication for convulsive therapy across all modalities of treatment. When outcomes were examined, 45%, 48.4% and 62% of patients were clinically reported to have been either cured/improved after receiving cardiazol, ammonium chloride and ECT respectively. Those receiving cardiazol had a high mortality of 22.5%, compared to 3.1% for ammonium chloride and 4% with ECT. Convulsive therapies were one of the first somatic psychiatric treatments, introduced around 1930s and 1940s all over the world, including in India. Our archival records suggest that many international ideas about somatic treatments were quickly adopted in India. Electroconvulsive therapy and other novel neuromodulatory interventions continue to be used and actively researched in India.

Historical Highlights on Electroconvulsive Therapy Practice in Iraq: A Brief Narrative.

Electroconvulsive therapy (ECT) is an established treatment option for severe psychiatric disorders. Electroconvulsive therapy practice began in Iraq in 1946, primarily to treat patients with schizophrenia. Since then, it has developed and expanded to treat mood disorders and major depression. Initially, both modified and unmodified ECT was administered to patients in Ibn Rushd and Al Rashad mental hospitals in Baghdad. The ongoing political turmoil from 3 wars, economic sanctions, and internal conflicts halted the development of mental health services across the country; ECT provision was not an exception. The practice of unmodified ECT-without general anesthesia-ceased in 2009, after the recommendations of the Royal College of Psychiatrists' Iraq Subcommittee. This closure reduced the availability and accessibility of ECT clinics nationwide because of limited access to general anesthesia. This article explores the nature of ECT services, in the context of Iraq's health care system, sociocultural norms, instability, and international codes of practice. This brief report uses the first author's work experience, few available data, and personal communication to describe the brief history of ECT practice in Iraq. This report is a baseline document for future ECT practice regulation in Iraq.

A Focus Group Study of Indian Psychiatrists' Views on Electroconvulsive Therapy under India's Mental Healthcare Act 2017: 'The Ground Reality is Different'.

Background:India's Mental Healthcare Act, 2017 (MHCA) greatly restricts the use of electroconvulsive therapy (ECT) in minors and bans unmodified ECT. Indian psychiatrists have raised concerns that these measures may deprive certain patients of life-saving treatment. This study describes the perspectives of Indian psychiatrists on how ECT is dealt with in the legislation.Methods:We conducted nine focus groups in three Indian states. We explored the positive and negative implications of the MHCA and discussed its implementation, especially in relation to ECT.Results:Many of the themes and concerns commonly discussed in relation to ECT in other jurisdictions are readily apparent among Indian psychiatrists, although perspectives on specific issues remain heterogeneous. The one area of near-universal agreement is Indian psychiatrists' affirmation of the effectiveness of ECT. We identified three main areas of current concern: the MHCA's ban on unmodified ECT, ECT in minors, and ECT in the acute phase. Two broad additional themes also emerged: resource limitations and the impact of nonmedical models of mental health. We identified a need for greater education about the MHCA among all stakeholders.Conclusion:Core concerns about ECT in India's new legislation relate, in part, to medical decisions apparently being taken out of the hands of psychiatrists and change being driven by theoretical perspectives that do not reflect “ground realities.” Although the MHCA offers significant opportunities, failure to resource its ambitious changes will greatly limit the use of ECT in India.

Satisfaction and attitude of bipolar patients regarding electroconvulsive therapy: modified or unmodified

Objective: Ministry of Health of Turkey issued a legislation to use only modified electroconvulsive therapy (ECT) in 2005, and this study aimed to assess satisfaction and attitude of bipolar patients regarding modified and unmodified electroconvulsive therapy.Methods: A total of 100 patients (50 treated with modified electroconvulsive therapy (M-ECT) and 50 treated with unmodified ECT (UM-ECT) with a diagnosis of Bipolar Disorder (depressive or manic episode) were invited to participate in this study. Patients with euthymic mood were included. Satisfaction and attitude towards ECT were evaluated with a structured attitude questionnaire, and M-ECT and UM-ECT patients, and their subgroups (depressive vs. manic) were compared.Results: No significant differences were found between M-ECT and UM-ECT groups regarding age, sex, marital status and occupation. The majority of all patients (78%) were satisfied from treatment with ECT and with the outcome (88%), without significant differences between modified and unmodified groups. Forgetfulness (70%) and headaches (57%) occurred in all groups, with the only significant difference in forgetfulness being reported by more manic patients treated with UM-ECT. Depressive and manic patients treated with UM-ECT reported concerns of brain damage and physical harm significantly more frequently. While 86% of patients treated with M-ECT consented to a future treatment, this was significantly less in patients treated with UM-ECT (50%).Conclusions: Bipolar patients report a high degree of satisfaction treated either with modified or unmodified ECT but there was a significant difference in perception of adverse effects and willingness for receiving ECT in future.

“To suit the occasion, I wore my schizophrenic fancy dress”1 – the life of Janet Frame

Janet Frame (1924-2004) was one of New Zealand's most celebrated authors. Much of her work stems from her experiences as a psychiatric patient. She was hospitalised for about eight years with a diagnosis of schizophrenia. Treatments included insulin coma therapy and unmodified electroconvulsive therapy. Her doctors then planned for her to have a leucotomy, which was cancelled upon discovery that one of her works had won a prestigious literary award. She subsequently moved to England and was assessed at the Maudsley Hospital by Sir Aubrey Lewis. She was found to never have suffered from schizophrenia; her condition was instead attributed to the effects of overtreatment and prolonged hospitalisation. She reflected profoundly on these experiences in her writing, and those who are interested in psychiatry are truly fortunate to have access to her autobiographies, fiction and poetry. Janet Frame has written both autobiographical and fictional accounts of her many years of psychiatric treatment, describing individuals, interpersonal relationships, and everyday life in these institutions. Her own life story demonstrates extraordinary recovery and achievement.

Unmodified electroconvulsive therapy: Concerns about reporting in a retrospective study.

Unmodified electroconvulsive therapy: Concerns about reporting in a retrospective study.

How bad was unmodified electroconvulsive therapy! A retrospective study.

“Unmodified”-electroconvulsive therapy (ECT) being considered unethical remained away from the scientific literature, but continued in practice in many parts of the world. The Mental Health Care Bill, 2011, proposed for its banning in India. The aim of this study is to retrospectively observe “how bad was unmodified-ECT” to the patients in a naturalistic setting. The study was done at the Central Institute of Psychiatry, India. Files of patients receiving unmodified ECT during 1990–1995 were retrospectively reviewed. Outcome was evaluated in terms of desired effectiveness and the side effects as noted in the files by the treating team. Six hundred and thirty-seven patients (6.94% of total admission) received ECT with meticulous standard-of-care except provision of anesthesia. Satisfactory improvement was noted in 95.45% patients with no noticeable/reported complication in 89.05%. Premature termination of ECT for complications occurred in 2.19% patients. “Unmodified”-ECT, though unethical, still could ensure favorable outcome with proper case selection and meticulous standard-of-care.

Mental Health Care Bill 2013: The Place of Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is one of the oldest medical treatments in psychiatry. The practice has evolved over the years, and the indications have become better defined now. Notwithstanding these, it remains a highly regulated and scrutinized practice. Indian laws specifically related to ECT do not exist till date though this would change if the purported mental health care bill 2013 becomes the law of the land. ECT gets both direct and indirect mention at various places in the bill with far-reaching consequences impacting patients, families, and the professionals. Ban on “ECT as an emergency treatment option” and on “unmodified ECT” is being sought. In addition, ECT in minors is slated to come under stricter regulation. ECT could also get implicated under the “advance directives” provisions of the bill. This naturally has triggered vociferous debates throughout the country between the supporters as well as detractors of ECT. A number of ethical, professional, logistic, and clinical concerns are being discussed. In this background, we attempt to critically evaluate the bill with regard to ECT in the background of the existent scientific and legal literature. We provide possible future directions with regard to ECT practice and its regulation.

Electroconvulsive Therapy Practice in Ukraine

Patterns of electroconvulsive therapy (ECT) use have recently been extensively surveyed in Central-Eastern Europe. However, data from post-USSR countries are limited. This study aimed to survey ECT practice in Ukraine. All psychiatric services in Ukraine were identified and contacted to obtain information on the use of ECT in 2011 using a 22-item questionnaire. Of the 146 psychiatric inpatient facilities, only 5 confirmed that they performed ECT in 2011. Three other services also performed ECT but refused to provide further information. In the only private psychiatric institute where ECT was offered, 14.28% of inpatients received this treatment in 2011, whereas the corresponding figure in the 6 public psychiatric facilities was a mere 0.4%. Three centers used unmodified ECT, and only 2 centers had equipment that monitored electroencephalogram. In 7 services, in line with international recommendations, affective disorders were the first indications for ECT in Ukraine, whereas uncommon indications such as anorexia or Parkinsonism were also reported. This was the first survey of ECT practice conducted in Ukraine. The provision of ECT in only 8 centers is clearly insufficient for a large country such as Ukraine, which is reflected in the low rate of inpatients treated with ECT. The very limited availability of this effective treatment modality should be addressed by the Ukrainian health authorities.

Unmodified electroconvulsive therapy: a false dilemma.

A recent statement commissioned by the Indian Association of Private Psychiatry recommends that unmodified electroconvulsive therapy (ECT) should still be used in some settings in India, invoking the principle of beneficence. This paper critically analyses the IAPP statement in terms of both scientific accuracy and ethical principles. It is found that the statement falls short of the ethical principles of beneficence, non-maleficence and justice. It is the duty of psychiatrists and psychiatric associations to offer the best available care to their patients, both on scientific and ethical grounds.

Electroconvulsive therapy pre-treatment with low dose propofol: Comparison with unmodified treatment

BackgroundWhilst electroconvulsive therapy (ECT) is routinely administered under anesthesia in developed nations, in many developing countries, ECT is still administered unmodified. This practice has attracted considerable scrutiny with calls to ban unmodified ECT. However, there are no affordable alternatives for many poor, acutely ill psychiatric patients. We evaluated whether administration of intravenous propofol 0.5 mg/kg for sedation by the ECT psychiatrist just prior to otherwise unmodified treatment improved acceptance of and reduced anxiety surrounding the treatment. MethodWe conducted an open label trial at The King George's Medical University in Lucknow, India. Forty-nine patients received propofol pre-treatment and 50 patients received unmodified treatment as usual. ResultsSocio-demographic profiles, diagnoses and clinical responses were comparable. Patients who received propofol experienced less anxiety monitored by the State-Trait Anxiety Inventory just prior to ECT (p < 0.001), and had a more favorable attitude towards treatment assessed by an established questionnaire (Freeman and Kendell, 1980). Propofol patients were less likely to experience post-ictal delirium monitored by the CAM-ICU (p = 0.015) and had fewer cognitive side-effects on the MMSE (p = 0.004). There were no adverse events associated with propofol administration. ConclusionWhilst unmodified ECT should never be used when modified ECT under anesthesia is available, we have found low dose propofol can be safely administered by the ECT psychiatrist to sedate patients pre-treatment who would otherwise receive completely unmodified treatment. The intervention was associated with reduced anxiety and a more positive attitude towards ECT, without compromising efficacy. A randomized double blind controlled study is necessary to confirm these benefits.

The Mental Health Care Bill 2013: A step leading to exclusion of psychiatry from the mainstream medicine?

Byline: Choudhary. Narayan, Deep. Shikha, Mridula. Narayan After India signed and ratified the United Nations' Convention on Rights of Persons with Disability, 2006 (UNCRPD), Ministry of Health and Family Welfare (MOHFW) initiated the exercise of revising the Mental Health Act - 1987 (MHA-1987) to bring it in harmony with the UNCRPD in 2010. After about 31/2 years long drafting and consultation process, the proposed legislation named Mental Health Care Bill, 2013 (MHCB) was introduced in the Rajya Sabha in August 2013. The Parliamentary Standing Committee on Health Related Matters submitted its report with suggestions of some minor changes in November 2013. [sup][1] Though invited to the consultation process at different stages, Indian Psychiatry Society (IPS) was not assigned any role in drafting of the current Bill. IPS and other professional bodies of psychiatrists have expressed apprehensions about a number of provisions in the Bill, which are not considered to be in the interest of persons with mental illness (PMI). IPS has submitted its representations at various stages expressing these concerns. Antony (2014) said that the Bill has an over-inclusive definition for mental illness, which will hurt a huge number of victims of even minor mental illnesses and their families, because of the wide prevalence of stigma. [sup][2] Though there are provisions of emergency admission on any bed anywhere in the country for a maximum period of 72 h (96 h in NE states), all the hospitals or nursing homes who admit PMI have been brought under the purview of the Bill and are required to be registered as mental health establishments (MHEs). All involuntary admissions in MHE even for a day may be subject to review by Mental Health Review Board to be established throughout the country by the Mental Health Review Commission. Kala (2013) said that the provision is undoubtedly progressive, but expressed his doubt that whether we as a society, are ready for this large scale countrywide post-admission review in almost all cases of involuntary admissions. [sup][3] Unmodified electroconvulsive therapy (ECT) has been totally banned, and ECT to minors can be given only after approval from the board. Many other provisions like those of nominated representative, advance directive etc., are supposed to create an obstacle in the treatment of PMI. The Bill has many positive features as well which, if properly and genuinely implemented, are set to revolutionize mental health care services in our country. The Bill ensures the right of every person to access affordable and good quality mental health services funded by the government. All PMI have the right to equality of treatment, protection from inhuman and degrading treatment, free legal services, right to access their medical records, and right to complain regarding deficiencies in provisions of mental health care. [sup][4] Special emphasis has been given to human rights of PMI, and there is a separate chapter in the Bill for this purpose. The government is mandated to establish good quality mental health services at all levels so as to ensure everyone to have access to mental health care services. Decriminalizing suicide is another welcome feature of the Bill. The single provision, which is supposed to inflict greatest damage to the system of mental health care delivery, is that of bringing all the general hospital psychiatry unit (GHPU) within the ambit of definition of MHE. It will result in moving the clock backwards, so far as the development of psychiatry and mental health care in our country is concerned. In Indian Lunacy Act, 1912, there was no mention of the GHPU. In MHA-1987, "any general hospital or general nursing home established or maintained by the government and which provides also for psychiatric services" were excluded from the ambit of definition "psychiatric hospital/ psychiatric nursing home". Thus, the GHPU established or maintained by the government were exempted from obtaining a "license" for running psychiatric inpatient services. …

Mental Health Care Bill and Electroconvulsive Therapy: Anesthetic Modification

Byline: B. Gangadhar In the recently introduced Mental Health Care bill, electroconvulsive therapy (ECT) practice figures with a caution. The bill allows the use of ECT only under anesthesia (modification). In other words, if the bill is passed and implemented, the unmodified (direct) ECT cannot be practiced. Concerns have been raised by some well-meaning psychiatrist colleagues. The cost of ECT would increase, thus taxing the poor patients. Anesthesiologists to provide modification are fewer. In emergency ECT situations, depending on anesthesiologists would pose challenges in that crucial eleventh hour. The position in the bill and the arguments for or against the unmodified ECT are examples of the issues to be faced by psychiatrists in the days to come. How are we prepared? In its first move, the Indian Psychiatric Society produced the position paper on unmodified ECT. [sup][1] It did endorse the benefits of modification in ECT and also conceded that such a procedure should be the contemporary standard. At the same time, the group recorded the concerns of denying ECT on the grounds of unavailability of resources to support modification. The position of the society is to allow use of unmodified ECT only in exceptional circumstances. Unmodified ECT has been a matter of concern and debate since many years. As early as in 1980, Lancet published several views for and against following a report of use of unmodified ECT in Broadmoor (UK). Arguing for unmodified ECT, Crammer [sup][2] also stated that some patients actually preferred ECT without injections (unmodified). Another supporter of this procedure stated that withholding ECT when modification is not possible amounts to unethical practice. Situations of failing to get a vein for intravenous injections (repeated injections in previous ECT sessions can result in such a difficulty) is one such circumstance when unmodified ECT may be the option. [sup][3] On the other hand, nearly 40 other psychiatrists wrote against unmodified ECT, terming it as anachronistic and indefensible. [sup][4] They also opined that unavailability of anesthesiologist does not condone use of unmodified ECT. It may be noted that some psychiatry textbooks from the West have altogether dropped information on unmodified ECT in their recent editions. There is no doubt that modified ECT should remain the current standard of ECT practice. In reality, however, unmodified ECT is in vogue in many parts of the world, [sup][5] China, [sup][6] Pakistan, [sup][7] and India. [sup][8] Together, this would account for the largest ECT population in the world. In our country itself, a recent survey indicated that over 50% of ECTs are unmodified. [sup][9] Clearly, the bill would affect the majority in this regard. This majority would, therefore, not get the benefits of ECT as unmodified ECT would be disallowed. Even if supported by the position adopted by the Indian Psychiatric Society, most, barring the exceptional ones, would be denied ECT. Psychiatrists may also be tempted to adopt different definitions of this exceptional indication. For example, a social reason was an urgent indication for ECT. [sup][10] It is true that earlier users of unmodified ECT had recognized adverse events such as fractures and even rupture of bladder, [sup][11] apart from others, that discouraged them from using unmodified ECT. In this context, Indian reports have reassured, though not convincingly, that unmodified ECT is not as unsafe as has been projected. [sup][12],[13] Benzodiazepine as a muscle relaxant has been suggested as an alternative to modification. [sup][14],[15] It is arguable, however, as an anticonvulsant this drug may interfere with seizure induction. Suggestions have also been advanced if psychiatrists can be trained in ECT-related anesthesia procedures. [sup][16] This issue surely deserves consideration for debate and consensus. In this background, we need to be also alert to the concerns of patients and their kin. …

Electroconvulsive Therapy: Attitudes and Practice of Iraqi Psychiatrists

Background: Although Electroconvulsive Therapy (ECT) is still regarded as a controversial treatment by some people, it is an important and effective treatment. The practice of ECT is different across the world.&#x0D; Objectives: to obtain an overview of the electroconvulsive therapy practice in Iraq.&#x0D; Method: Forty item self administered questionnaire about the attitude and practice of ECT, was sent (by mail or delivered by the researcher) to 73 Iraqi psychiatrists during the period from March to September, 2007.&#x0D; Results: Half of participants had asked for the patient's consent, and all asked the family for the consent, 72% had asked for written consent and 28% for oral consent only. Majority ( 81%) gave oral information to patient's family before ECT while 36% gave oral information to patients .&#x0D; Average number of ECTs administered per patient were six, 61% perform ECT thrice weekly while 39% twice weekly. Maintenance ECT was used by 16% of participants. Bilateral ECT is exclusively used in Iraq and 74% perform unmodified ECT. Vast majority of the participants (85%) believed in application of ECT as a strongly effective treatment. The majority 79% never stop medications before ECT. Forty eight percent did routine investigations before ECT performance, The main complications associated with ECT were; amnesia (57%) headache (54%), and nine deaths were reported during the practice of the 65 psychiatrists. The main indications for ECT were depression (31%), schizophrenia (26%) , mania (21%) and schizoaffective(16%). Many absolute contraindication mentioned by Iraqi psychiatrists , increased intracranial pressure(79%) , space occupying lesions(74%), Myocardial infarction (64%), aortic aneurysm (56%) and below 15 years of age (41%) &#x0D; Conclusion: Iraqi psychiatrists practice of ECT is a mixture of different international experiences .A legislation and a code of practice for the use of ECT is mandatory .

Electroconvulsive Therapy in China

Electroconvulsive therapy (ECT) was first introduced in China in the early 1950s and has evolved into a significant psychiatric treatment. Research from Chinese psychiatrists provides important clinical data for ECT practitioners. However, most of the research has only been published in Chinese language journals. This article summarizes data from publications in the Chinese scientific community related to the clinical practice of ECT and research on efficacy in the treatment of psychiatric disorders. Descriptive study primarily based on Chinese language literature identified from searches of the China National Knowledge Infrastructure and the Medline databases (1979-2012). More than 900 journal papers on ECT have been published in the Chinese language between 1979 and 2012. Currently, modified ECT has replaced unmodified ECT, and treatments were performed both in inpatient and outpatient settings. Electroconvulsive therapy is primarily used for the treatment of schizophrenia and mood disorders and has been shown to be very effective in both. The primary use of ECT in China is in the treatment of schizophrenia. The Chinese literature provides a rich database on the efficacy of modified and unmodified ECT, with and without adjunctive antipsychotics, in the treatment of schizophrenia. The Chinese medical literature provides an important database that will help advance the practice of ECT in both China and the international community.

Decreasing Adverse Outcomes of Unmodified Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is far and away the most effective treatment for depression and quite effective for a range of other psychiatric conditions that are unresponsive to medication. Electroconvulsive therapy in the developed world has been administered with anesthesia, muscle relaxants, and ventilation since the mid-1950s following 20 years of unmodified treatment. However, in much of the developing world, ECT continues to be administered unmodified because of lack of resources. We review the efficacy of unmodified compared with modified treatment. We also review the potential drawbacks of unmodified treatment including fear and anxiety, worse postictal confusion, fracture risk, and the negative effects of unmodified treatment on how ECT is perceived in the general community. Finally, we consider potential solutions in developing countries to minimize adverse outcomes of unmodified treatment by pretreating patients either with low-dose benzodiazepines or sedating, but not anesthetizing, dosages of anesthetic agents. Randomized controlled trials are necessary before either of these options could be considered an acceptable alternative to completely unmodified treatment when modified treatment is unavailable.

Contemporary use and practice of electroconvulsive therapy worldwide.

To explore contemporary (from 1990) utilization and practice of electroconvulsive therapy (ECT) worldwide. Systematic search (limited to studies published 1990 and after) was undertaken in the databases Medline, Embase, PsycINFO, SveMed, and EBSCO/Cinahl. Primary data-based studies/surveys with reported ECT utilization and practice in psychiatric institutions internationally, nationally, and regionally; city were included. Two reviewers independently checked study titles and abstracts according to inclusion criteria, and extracted ECT utilization and practice data from those retrieved in full text. Seventy studies were included, seven from Australia and New Zealand, three Africa, 12 North and Latin America, 33 Europe, and 15 Asia. Worldwide ECT differences and trends were evident, average number ECTs administered per patient were eight; unmodified (without anesthesia) was used in Asia (over 90%), Africa, Latin America, Russia, Turkey, Spain. Worldwide preferred electrode placement was bilateral, except unilateral at some places (Europe and Australia/New Zealand). Although mainstream was brief-pulse wave, sine-wave devices were still used. Majority ECT treated were older women with depression in Western countries, versus younger men with schizophrenia in Asian countries. ECT under involuntary conditions (admissions), use of ambulatory-ECT, acute first line of treatment, as well as administered by other professions (geriatricians, nurses) were noted by some sites. General trends were only some institutions within the same country providing ECT, training inadequate, and guidelines not followed. Mandatory reporting and overall country ECT register data were sparse. Many patients are still treated with unmodified ECT today. Large global variation in ECT utilization, administration, and practice advocates a need for worldwide sharing of knowledge about ECT, reflection, and learning from each other's experiences.

Practice of Electroconvulsive Therapy in a Tertiary Care Hospital in Pakistan

This study aimed to describe the practice of an unmodified electroconvulsive therapy (ECT) in a typical urban hospital setting in Pakistan. This is a retrospective naturalistic study of patients who received ECT at Rawalpindi General Hospital between June 2000 and June 2008 by chart review. All useful data that could be retrieved from the charts were recorded. The process of administering ECT at the hospital is described. During the study period, of a total of 5240 patients who were admitted to the hospital, 1520 (29%) were administered ECT. Of these, 1352 (88.9%) did not get any kind of anesthesia during the procedure. The mean age of patients was 34.89 years, and the leading diagnoses were depression (60.8%), bipolar disorder (17.8%), and schizophrenia (9.1%). The mean number of ECTs received for these diagnoses were 5.78, 5.52, and 6.34, respectively. A total of 249 (16.7%) patients discontinued ECT against medical advice. In countries with limited resources, ECT is practiced in a markedly different way from more developed countries; although administering ECT without anesthesia is not desirable, in the face of severe economic constraints, it is often necessary.

Position statement and guidelines on unmodified electroconvulsive therapy.

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).

Comparative Effects Of The Haemodynamic Responses Of Modified Versus Unmodified Electroconvulsive Therapy In Nigerians.

Background: Electroconvulsive therapy (ECT) provokes abrupt changes in systemic haemodynamics. We compared the effects of modified (propofol and thiopentone) versus unmodified ECT on haemodynamic responses of patients scheduled for ECT in two Nigerian tertiary hospitals between September 2008 and March 2009.Methods: In a prospective, randomized study, sixty patients slated for ECT were allocated to unmodified (UG), thiopentone (TG) and propofol (PG) groups with twenty in each group. Anaesthesia was induced with either 1mg/kg propofol (PG) or 5mg/kg thiopentone (TG) and 0.5mg/kg suxamethonium. Anaesthesia was not administered to UG. Blood pressure, systolic (SBP), diastolic (DBP) and heart rate (HR) were recorded before ECT and at 1 and 5 minutes after seizure had ended. The means of the post and pre ictal haemodynamic parameters and increases in means were compared. Results: Mean HR and SBP decreased significantly at 1 min in the modified group and increased significantly at 5 min. The mean HR increased significantly in both modified groups at 1 and 5 min. Mean SBP and DBP increased significantly at 5 min in the modified group and insignificantly in both modified groups. Increase in MAP was significant in TG (p = 0.028). Though the increase in SBP was not significant in modified groups, it was significantly greater in the TG than PG (p = 0.012) Conclusion: Modified ECT may not be commonly practiced in our environment because of dearth of qualified anaesthetists. This study has shown that modified ECT minimizes increases in haemodynamic response when compared with unmodified ECT. Propofol at 1 mg/kg minimized increases in DPB and MAP more than thiopentone 5 mg/kg. Propofol with rapid recovery profile is suitable for modified ECT in Nigerian patients.