15 January 2014

Torture or abandonment: unmodified ECT and the shocking position of Indian and global psychiatric leaders

Every day hundreds of people in India get electrocuted through their brain without their consent while they are fully awake. A new law being debated by Parliament would ban the use of electroshock without anaesthesia and muscle relaxants. However, the Indian Psychiatric Society and the World Psychiatric Association support the view that this current, terrifying and dangerous practice is acceptable for poor people. They are both on the wrong side of history.

The Indian Psychiatric Society has its annual conference on 16th January in Pune. Read our press statement calling on IPS President Dr. Indira Sharma to end their official support of this practice.


One study found 52% of ECTs given in 66 university teaching hospitals were unmodified in a one year period. Image (c) MDAC

All ECT is controversial

The efficacy of ECT with anaesthesia and muscle relaxants is widely debated. Some people who have experienced it say it is an effective treatment for depression. Others say that it is a dangerous. A meta analysis in the UK in 2003 found that around a third of patients reported significant memory loss. Far too many people point to the Jack Nicholson scene and say “Sure, that was horrific, but it’s not like that any more”, a point elegantly-made in a blog you can read here. Squeamishness does not explain people’s revulsion of ECT. When I was 19 I worked in an orthopaedic unit and saw a hip replacement. After avoiding fainting I nearly threw up, but I’d still have a hip replacement if I needed one! ECT is different because it is frequently carried out without proper consent and often without consent at all.

I’ve witnessed how modified ECT is used as punishment. “What happens to the naughty patients?” I asked a group of nursing students recently in an Indian psychiatric hospital. “They get ECT the next day, Sir.” they dutifully informed me. So while the evidence seems to be that ECT can be used effectively, as a last resort, when all other options have failed and someone is going to die of starvation, even modified ECT is over-used.


Modified and unmodified/direct

ECT is the introduction of an electrical current through the brain to induce a grand mal seizure. Modified ECT means that prior to the procedure a short-acting general anaesthesia and a muscle-relaxant are given. In one hospital I visited in India 80% of new admissions get modified ECT. Patients are normally given six ECT sessions within two weeks. In the UK, ECT is indicated when, “after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with severe depressive illness, catatonia or a prolonged or severe manic episode.”

In unmodified ECT the person is completely awake until they are knocked out by the electricity. Without muscle relaxants, the risk of bone fractures, teeth damage, tendon, and muscle damage is drastically increased. Bilateral hip fractures were commonly reported.

In this post I am focussing on ECT without anaesthesia and muscle relaxant. The movie “One Flew Over Cuckoo’s Nest” shows how it is dressed up as therapy. In one scene, Jack Nicholson is tied to a hospital bed, wheeled into a side room, a rubber tube is put into his mouth and an electrical current forced through his head. You can view the scene by clicking on the video beneath this paragraph. If you can stomach that clip make sure you are sat down and skip six minutes into the clip found here. (WARNING – both videos are disturbing).



Unmodified ECT in India

In India, many psychiatrists use ECT on patients in parallel with medications because they believe it to be better. There is zero evidence for this and no randomised control trials have been done to provide a shred of evidence for this wild claim.

Some hospitals use only modified ECT, but unmodified ECT is also used very widely. A study has found that in 66 university teaching hospitals 52% of all ECTs within one year were carried out in unmodified form. The Indian Psychiatric Society’s claim that it is only “occasionally practiced” is both inaccurate and unsupported.


Flawed arguments

Three common, but flawed arguments used to support unmodified ECT are:

1: Patients like it

In 2002 a prominent psychiatrist argued that physical morbidity is “minimal” and that “patients often request the treatment due to its efficacy, safety and low cost”. No evidence is presented to support this empirical claim. The IPS admits that “[t]here is no empirical evidence to support such a view”. The Bapu Trust has made an important contribution by pointing out that, “patient views on ECT are completely missing in the literature”.

2: It’s cost effective

Professor Vikram Patel explains that comparing unmodified ECT as the preferred option to doing nothing, is a false dichotomy that, in practice, never occurs. Moreover, there is no empirical evidence to support a financial justification. Even if there was, the social cost must be accounted for. There is huge potential for an attempted lawsuit for compensation but, beyond that, allowing a person to be strapped down and have their brain electrocuted against their will paints a picture of a society that disregards a person’s rights simply because they have mental health issues.

3: It is safer

The IPS’s position statement cites as support for unmodified ECT the risks of anaesthesia and muscle relaxants. These mighty risk seems to boil down to drowsiness and “post-treatment body-ache” which “may last for several hours or longer” and “can sometimes be quite distressing to the patient”. Compare the risks of unmodified ECT: oral bleeding, knocking out of teeth, joint dislocation, fracture of long bones, pelvic fracture, muscle or ligament injuries and spinal fracture. Which would you rather choose? Body ache or a fractured spine? The IPS’s position is itself spineless.

4: There are too few anaesthetists

The Indian Society of Anaesthetologists lists nearly 16,000 members. There are few, if any towns in India where there is a psychiatrist but no surgeon or a gynaecologist. It follows, because no surgeon or gynaecologist would carry out surgery without an anaesthetist, that where there are psychiatrists, there are anaesthetists.

Electro convulsive therapy ECT unit machinio.com


So why maintain unmodified ECT?

The main factor prohibiting the necessary progression, says Vikram Patel, is not lack of resources, “but the perspectives of medical practitioners”. In the context where India’s psychiatric leaders are so resistant to concepts of human rights, eager to make money and protect their own power, a top down approach may indeed be the best strategy.

In the IPS’s official position on unmodified ECT it rather openly outlines all the disadvantages of unmodified ECT, and then gives three ridiculous possible benefits (anaesthesia risk, muscle relaxant risk, and anecdotal accounts not backed up by evidence that unmodified ECT is more effective). The statement goes on to hold that while unmodified ECT is not ideal, due to its widespread practice it is better to regulate it than stop it. This is an illogical and immoral stance. It is akin to saying that we know corruption exists in India so rather than stop it let’s just regulate it.

As a justification for unmodified ECT the IPS uses the situation “where there is a contraindication for anaesthesia or muscle relaxant”. Besides the fact that there is always access to an anaesthetists, it is discrimination against people with mental health diagnoses to deny anaesthesia when this would not be contemplated in somatic interventions requiring anaesthesia.

The World Psychiatric Association’s position is equally unprincipled and nonsensical. Unmodified ECT can be used “[i]n settings where the current choice in the field is unmodified ECT or no ECT”, it says. One could substitute anything for unmodified ECT in that sentence (lobotomy, insulin shock therapy, eating strawberry-flavoured ice cubes). This is a laughable basis - were it not for the seriousness of the situation -  upon which to make a policy. The WPA’s stance boils down to offering torture or abandonment, and proceeding with the torture.


A ban is coming

Clause 104 of the 2012 Indian Mental Health Bill, already cleared by the Parliamentary Standing Committee, sets out a legal prohibition on the use of ECT without anaesthesia and muscle relaxants. If a doctor performs unmodified ECT when the new law enters into force he or she will be committing a criminal assault. There should be cross-party support for banning unmodified ECT. It is also clearly a human rights issue and The National Human Rights Commission’s view strongly opposes unmodified ECT.

The UN Special Rapporteur on Torture has stated that that “the infliction of forced medication or electroshock, the use of restraints and seclusion, the segregation from family and community” are factors in determining whether torture has taken place. He has called for an absolute ban of non-consensual electroshock. India has ratified the UN Convention on the Rights of Persons with Disabilities, which also bans torture. Indian psychiatrists will claim that their ECTs are given with consent. But having spoken with many users and survivors of Indian psychiatry, I would contest that this consent is voluntarily given in any case of unmodified ECT. Further, it is questionable whether a person can consent to torture.

Further afield, the European Committee for the Prevention of Torture has for over a decade held the view that unmodified ECT “can no longer be considered as acceptable in modern psychiatric practice. Apart from the risk of fractures and other untoward medical consequences, the process as such is degrading for both the patients and the staff concerned.”

The IPS and the WPA condone torture dressed up as therapy. That is not an appealing thing to have on one’s organisational CV and it tarnishes personally the leaders of both organisations. They should change stance. And in the meantime, Indian legislators, under a duty to respect international human rights law above any other considerations, should pass the law banning unmodified ECT.