Now a small story: one summer day in 334 BC Alexander the Great fell ill, and while waiting for his doctor, got a confidential message. He went through the letter carefully and quietly kept it aside. Soon the doctor arrived with a specially prepared medicinal-drink which the emperor took in one go with great relish. And then he gave the letter to the doctor. It was actually a caution to Alexander: “do not take the medicine that your physician brings in; it is poison to kill you”!5
This story is recalled here with some nostalgia about the kind of trust patients reposed on us in olden days. Even the mighty Alexander did not want to behave in a manner that would make his doctor feel humiliated or hurt! Indeed, today we have come a long way from Alexander’s time. But even going by our modest modern-day standards, the manner in which our lawmakers want to deal with the doctor-patient relationship in their proposed new law is a huge let-down. The draft law throws all propriety to the winds, while explicitly proscribing a treatment modality which the profession believes is useful! It is as though our wise leaders have no hesitation to undermine the autonomy and self-respect of an entire profession!
The point is not that medical practitioners should not be controlled. Our statutory regulatory bodies are already doing this job. And if authorities want more supervision, they can go for it in a manner in which the whole world does these kinds of things. But when a law explicitly bans unmodified ECT, the issue is not merely that of undermining the morale of psychiatrists in a rude manner. An even more important issue is that a section of patients would be denied a life-saving treatment that they may need badly.
To appreciate the seriousness of this issue, there is a need for every enlightened citizen to know some basic facts about ECT which the present bill wants to prohibit. What kind of a treatment is it? In what all situations doctors give it? Why sometimes it is given in an unmodified version? And so on.
Most enlightened citizens would say that they are not interested to know technicalities of treatments. Their attitude would be: let doctors do the “worrying” on our behalf! But in the present instance, as the Parliament has already initiated a law to “leash” Psychiatrists with a kind of unheard-of-insensitivity, it is time everyone tries to know a few things about ECT.
Ever since ECT arrived in India in 1947 as a new treatment modality, its usefulness has always been acknowledged by the profession. After Dr. DLN Murthy Rao published the first paper about ECT in India, over 250 papers were published on the topic, of which 90 were in Indian Journal of Psychiatry.6
For most of those who practice Psychiatry in India, the efficacy, safety and fast onset of action of ECT are all settled facts. It has two important indications, namely severe depressive disorders and catatonic stupor. Of these, catatonia or catatonic stupor is especially important. Many old-timers would recollect at least few catatonics who came back from the brink of sure death to a state of hundred percent normalcy, thanks to ECT! Even today, though benzodiazepines, especially Lorazepam, are considered useful for treating catatonia, experienced clinicians continue to prefer ECT for many reasons. And this stand has the backing of responsible bodies like the American Psychiatric Association and the Royal College of Psychiatrists.7,8
Though initially the practice was to give ECT without anesthesia, for the past nearly thirty years giving prior anesthesia is the standard norm. But at times ECT may have to be given in the unmodified form for sound clinical reasons. In 2012, Andrade et al. had come out with an exhaustive position statement about unmodified ECT on behalf of various concerned professional bodies, including Indian Psychiatric Society.9 They enumerated many situations where unmodified ECT is to be given. Of all those instances, the problem of those who need ECT even while their general medical condition is compromised warrants our special attention and careful study.
This is because we have one psychiatric condition, namely catatonic stupor, where unless effective treatment is administered promptly, the patient would deteriorate very fast. And once the illness progresses, rigidity, many other psychomotor signs, hyperpyrexia, etc. would set in. In that stage a patient is said to be in the “malignant” or “lethal” stage and the patient has to be viewed as having a critical life-threatening medical illness. Once a patient reaches this “lethal” stage, treatment becomes extremely challenging. In view of this, all good centers emphasize the importance of detecting catatonia at a very early stage both in their teachings and their practice-guidelines. That is the only way deterioration to the lethal stage could be averted to the maximum extent. Also, once catatonia is diagnosed, a speedy clinical work-up is done before the deterioration takes place, so that ECT could be given with anesthesia etc. But, once the patient goes into the “lethal” stage, many issues crop-up. For one thing, differentiating the clinical condition from “Neuroleptic Malignant Syndrome” may be difficult.10In such a situation the psychotropics are contraindicated and even the benzodiazepines are unlikely to help the patient. Only a course of ECT is likely to give the patient a slender chance to come back to life!
While going for ECT in that critical stage, a psychiatrist would be required to go for all possible risk-reduction strategies.11 Doing away with prior anesthesia etc. are all steps in this direction. It is as though the psychiatrist is forced to administer unmodified ECT for the sake of his patient!
It needs to be emphasized that ECT without anesthesia is not a general rule, but only an exception. Let us recall in this context that in very special situations surgeons too do away with anesthesia for “risk-reduction”.
It is also necessary for all enlightened citizens to know that all doctors do a “risk-benefit-analysis” based on teachings, traditions and expert guidelines as part of their day-to-day clinical drill while taking decisions regarding every patient. It is to be done with utmost respect for patients’ right to life, personal autonomy and dignity. An informed consent also would be obtained from the right source. While their oath would keep most doctors on the right track, statutory bodies such as Medical Councils are also in place to oversee and regulate a doctor’s professional activities.
This being the ground reality, if the parliament imposes a blanket ban on unmodified ECT, the major issue is that for patients like those in lethal catatonia it will be a denial of their very right to life. And this certainly would not be the intention of the Indian Parliament!
Apart from the adverse consequences that could be brought about by the 2013 bill, we already have two other very disturbing trends in our present-day healthcare system that affects the quality of patient care very badly. The first is related to our present unhealthy specialist-driven patient care. The second trend, which is even more relevant to us psychiatrists, is the change in our own attitude and mind-sets.
Today, medical practice in India has lost most of its age-old traditions, which incidentally are being followed quite meticulously in most developed countries. In those places, general practice continues to be the strong backbone of their healthcare. But unfortunately, in our country the General Practitioner belongs to a species facing extinction! And, at their expense, an unhealthy growth of specialization is visible all over.
Most specialist doctors who are part of high-end hospitals have brought in an altogether new culture in our healthcare. For one thing, they do not even think that making a thorough, detailed clinical examination is their primary duty. They would start their clinical drill by straight-away ordering a battery of sophisticated investigations!
In this milieu, the diagnosis of many simple diseases would be missed because in such conditions, even today, the diagnosis has to be made on clinical grounds alone. With our “super” specialist doctors depending only on their high-tech investigations, they would fail to identify many common disorders altogether! Catatonic stupor is one of them. As a catatonic looks very much like a medically ill, rather than having a psychiatric disorder, not just the family, even many a specialist doctor would fail to suspect it! Typically, an obstetrician who would see postpartum catatonia developing in one of his patients would refer to a neurologist rather than to a psychiatrist!
Here we have a grim situation where the victims of a very dreaded disease, namely catatonic stupor, not reaching the right specialist at an early phase. The result would be that the catatonic drifts rather fast to reach a “lethal” stage and even die! In this kind of a referral system that is anything but proper, many times a catatonic would reach a psychiatrist quite late in the course of the illness. And if the patient already is in a “lethal” stage, the psychiatrist would be left with no other option than giving unmodified ECT!
It is most disheartening that our law-makers have no clue about the actual state of our specialist-centered healthcare system. With no prior screening by a General Practitioner, the diagnosis of many common diseases is being missed! That too after a patient has spent a fortune for a work-up by a super-specialist! Failure to identify catatonics in the early phase is indeed a typical example. But rather than addressing these sorts of issues, our authorities seem to believe that banning unmodified ECT would improve mental health care in the country!
Now, with regards to all of us psychiatrists, even while we vehemently criticize the 2013-bill or feel concerned about too much specialization, there is also a need to introspect a little about our own changing attitudes and mind-sets. For many of us, it is as though the only important objective is to attain a kind of parity with all others and become part of “mainstream” medicine!For many, their only goal is to function in the grand ambiance of a high-end general hospital. Ordering sophisticated investigations and looking for “causes” based on biology for every disease is the way to become successful!
It is not that psychiatrists should not work in high-end general hospitals or rely on latest investigations. Our general hospital psychiatry must certainly flourish further. But, side by side, Psychiatry must advance in various other areas as well. We want good quality psychiatric management in the mental hospitals to transform those places as good therapeutic communities; we need good rehabilitation facilities for chronic psychotics; we also want Psychiatry to get extended to various correctional and care-giving institutions in the country. Of course there are many more areas where Psychiatry needs to deliver.
But in our present law, Mental Health Act-1987, we do not have provisions that mandate governments to do any of these.12 Nor does our proposed new law address these things. There is not even a provision that requires the government or the state to provide proper care to patients with profound mental retardation, who perhaps are among human beings in the most miserable predicament. Despite this omission being pointed out way back in 2000, even our own professional bodies are not keen to take up such issues!13
The problem with many present day psychiatrists is that they do not like many things that are part and parcel of the practice of Psychiatry. Administering ECT, running mental hospitals properly, and indeed many more things that are central to Psychiatry are not liked by many present-day psychiatrists. Why, even giving psychotherapy based on concepts from dynamic theories is a thing they want to give up altogether! It is as though these people want to completely forget an old era when psychiatrists were pejoratively referred to as ‘alienists’! And the easy method they invented for this is to erase all vestiges that arouse memories of that old era! And for sure, ECT is a vivid relic that would kindle memories of that era!
We have among us many who even want to give up the traditional name of their specialty, ‘Psychiatry’. They are keen to be known as ‘Neuro-Psychiatrists’. It is as though they want to show the whole world that everything they do by way of their clinical practice is based on biological concepts! They even forget the basic fact that for the practice of Psychiatry, a sound understanding of both psychology as well as social sciences is important. In this kind of a milieu, one often gets a nagging suspicion: are many amongst us avoiding giving ECT to patients owing to their changed mindsets? And is this the reason why large sections among us are not bothered about the proposal to ban ECT in the new law?
For many psychiatrists, their only point of concern about the draft law seems to be the controls being brought about in the running of private psychiatric hospitals! We also have ivory-tower academicians indulging in hair-splitting debates regarding setting up high safety standards in all areas of psychiatric practice. For them, insisting on various pre-medications for ECT is a measure to enhance standards.
True, no one in his right sense would question the need to set high safety standards or other refinements for any modern medical procedure. At the same time, critics must be conscious about the fact that if they support a blanket ban of unmodified ECT, it would only betray their lack of understanding of many ground realities about the practice of Psychiatry in our country. This vast nation has many remote nooks and corners where dedicated medical professionals go that extra mile to do their best for patients despite the facilities being meager. It would be a sad day if their hands are tied with thoughtless bans on certain treatments. It may just mean that a section of patients are denied their very right to life! It would also demoralize all psychiatrists who are committed to give patients their very best even in challenging situations. And let us not forget that the best professional opinion is that on some rare occasions unmodified ECT would be life-saving.
Seventy-fourth Report on the Mental Health Care Bill 2013. Rajya Sabha Secretariat, November 2013.
Antony JT. The Mental Health Care Bill-2013: A disaster in the offing? Indian J Psychiatry 2014; 56: 3-7.
Narayan CL, Shikha D, Narayan M. The Mental Health Care Bill 2013: A step leading to exclusion of Psychiatry from the mainstream medicine? Indian J Psychiatry 2014; 56:321-4.
Kala A. Time to face new realities; mental health care bill 2013. Indian J Psychiatry 2013; 55:216-9.
Collier JAB, Longmore JM, Hodgetts TJ. Oxford handbook of Clinical Specialties.Oxford:Oxford University Press; 1995.
Gangadhar BN, Phutane VH, Thirthalli J. Research on electroconvulsive therapy in India: An overview. Indian J Psychiatry 2010; 52,Suppl S3:362-5.
American Psychiatric Association. The practice of electro-convulsive treatment. Recommendations for Treatment, Training and Privileging. Task Force Report on ECT. American Psychiatric Association. Washington DC. 2001.
Scott AIF. The ECT Handbook. The Third Report of the Royal College of Psychiatrists’ special committee on ECT. London:The Royal College of Psychiatrists; 2005.
Andarade C, Shah N, Tharyan P, Reddy MS, Thirunavukkarasu M, Kallivayalil RA et al. Position statement and guidelines on unmodified electroconvulsive therapy.Indian J Psychiatry 2012; 54(2):119–33.
Fear CF. The use of ECT in the treatment of schizophrenia and catatonia. In: Scott AIF, editor.The ECT Handbook. The Third Report of the Royal College of Psychiatrists’ special committee on ECT. London: The Royal College of Psychiatrists; 2005.
ECT Team, Department of Psychiatry.ECT Administration Manuel [second edition], Bangalore:National Institute of Mental Health and Neurosciences [NIMHANS]; 2013.
Mental Health Act 1987; with short notes and with central MHA Rules1990. New Delhi: Delhi Law House; 2003.
Antony JT. A decade with the Mental Health Act 1987. Indian J Psychiatry 2000; 42:347-55