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Apr-Jun2003-11(2)
CONTROVERSY
ECT: A measured
defence
CHITTARANJAN
ANDRADE
Waikar et al. express forceful opinions about ECT.
I am duty bound to inform readers that their article contains at least 25
serious factual errors, and 17 serious errors of perspective and context. Space
constraints do not allow me to provide a point-wise, scientifically-referenced
refutation of their article; however, if readers with specific concerns write to
me, I will provide clarifications supported by research published in journals of
repute.
I am aware that nongovernmental organisations
require a drum to beat to make their presence felt; however, I would prefer to
ascribe more ethical motives to these authors, and believe that they think as
they do because they have no (stated) medical or psychiatric background nor
direct experience with ECT. My response will therefore be measured and
good-tempered.
The views of Waikar et al. can be resolved under
two headings: that ECT is barbaric, and that unmodified ECT is especially
unethical. I will consider each of these views.
Is ECT barbaric and should it be
discontinued?
From an emotional perspective, a seizure-inducing
treatment could certainly seem barbaric. However, if ECT is barbaric or
unattractive, so too are cardioversions, abortions, Caesarean sections, radical
mastectomies, open heart surgeries, orthopaedic and neurosurgical procedures,
and countless other medical and surgical interventions; so, where does one draw
the line? The answer is simple: if the risk-benefit ratio favours the treatment,
and if the treatment is better than existing alternatives, in the interest of
the patient the treatment must survive. This cold logic has guided medical
practice for decades, and is the reason why ECT remains a valuable treatment
more than six decades after its introduction.
There are certainly countries, such as Japan and
Italy, in which the practice of ECT is dying out for idiosyncratic reasons (and
not because of legislation). However, in countries in which a high quality of
care is assured to patients, ECT continues to be practised. In the USA, where
the standards of medical care are higher than anywhere else in the world, the
use of ECT is, in fact, increasing (1). During the past decade millions of
dollars have been allotted in over a dozen research grants from the US
Government through the National Institute of Mental Health (NIMH) to study
different forms of ECT (2). A multicentre consortium, funded by more
multi-million dollar. NIH grants, NIH grants, is currently examining wider
indications for ECT such as the extension of ECT into the maintenance phase of
treatment (3).
We therefore, do Waikar et al. express the views
that they do? Perhaps it is because they have come across instances of the
sub-optimal practice of ECT. If so I have two responses:
1. If a treatment is abused, the
practitioners are to blame, and not the treatment. Readers will know that
treatments ranging from antibiotics to Caesarean sections are
over-enthusiastically used by unscientific or unscrupulous practitioners; yet,
this is not an argument for withdrawing antibiotics or abolishing Caesarean
section. By targeting the treatment because of its misuse, Waikar et al.
compromise their own judgement and credibility.
2. A treatment is best evaluated at centres at
which it is well practised. I encourage Waikar et al. to visit centres, such as
the one at which I am employed, where ECT is administered only after obtaining
informed consent and in accordance with international guidelines. Waikar et al.
will discover that patients who receive ECT are grateful for the intervention.
None of my colleagues, nor I, have encountered patients who considered that we
used ECT as a form of punishment or torture. If Waikar et al. form opinions from
a few patients who have felt ill-used by ECT, they have a moral duty to moderate
these opinions with the views of the large segment of patients who appreciate
the treatment.
In this context I ask Waikar et al. how many
patients they have personally interviewed who have resented receiving ECT and
whether these patients identified through systematic sampling or did they form a
disgruntled, unrepresentative subgroup? Scientifically, only patients identified
through a recognised method of sampling can be considered representative of the
population this is because dissatisfied patients can be found for all
treatments.
True, ECT is associated with adverse effects; the
commonest problems are transient memory disturbances, headache, and bodyache.
Less commonly, more severe or longer-lasting memory disturbances may occur.
Taken out of context, these adverse effects argue against the use of the
treatment. However, taken out of context, the brutality of open heart surgery
and the cognitive impairment that the procedure produces (4) should, similarly,
argue against the practice of such surgery. As stated earlier treatment
decisions are based on risk-benefit ratios, and on comparisons with existing
alternatives. Thus, when the common and uncommon adverse effects of ECT are
compared with the common and uncommon adverse effects of drugs, and when the
superior benefits with ECT are measured against the unimpressive effects of
drugs in selected sub-populations of patients, it appears that, for these
sub-populations of patients, adverse effects notwithstanding, ECT can be the
treatment of choice.
Is unmodified ECT unethical?
Early during my research career, I found that only
44.2% of Indian psychiatrists who administered ECT always administered modified
treatments, and that as many as 24.2% invariably administered unmodified ECT; I
was appalled (5). When Tharyan et al. (6) published data which suggested that
risks with unmodified ECT were fewer than earlier believed, I reacted with the
same horror that Waikar et al. presently show (7).
I received mixed support. Practitioners in large
institutions, such as my own, supported my views. Practitioners in small
psychiatric facilities, however, chose to disagree. They believed that I had no
right to preach from an ivory tower, ignoring the ground realities of the
environments in which they worked. Their arguments were reasoned. If a patient
who is stuporous or suicidal requires ECT as an emergency intervention, would it
be more ethical to allow him to die because an anaesthesiologist is not
immediately available to supervise ECT? If a patient is psychotically depressed
in a town in which the anaesthesiologists are burdened with surgical caseloads,
would it be more ethical to allow the patient to suffer for weeks to months,
receiving drugs which are less effective, because the anaesthesiologists did not
have time for minor procedures such as ECT? If a poor patient suffers from an
illness for which ECT is the treatment of first choice, would it be more ethical
to allow him to suffer for months or longer with less effective drugs because he
cannot afford the extra hundreds of rupees per ECT that the use of anaesthesia
necessitates?
In the face of these arguments, I realised that the
only way to convince my colleagues against unmodified ECT was to obtain and
publish hard data on the morbidity associated with it. My colleagues and I chose
to focus on spinal fractures with the treatment, the most common complication
recorded in western literature. The study was conducted in a hospital in which
unmodified ECT was routinely administered because of unavailability of
anaesthesiological support. Anterioposterior and lateral X-rays of the
thoracolumbar spine were routinely obtained before and after a course of
unmodified ECT, and after every complaint of backache in 50 consecutive patients
who received the treatment, to utter astonishment only 1 patient (2%)
experienced an adverse spinal event; this was considered relatively minor by the
consultant orthopaedist, and was treatment with non-steroidal anti-inflammatory
drugs alone (8).
I no longer shrilly condemn unmodified ECT.
However, to reassure Waikar et al. I do not condone the procedure either.
When we published our unmodified ECT study, we concluded with several paragraphs
on the limitations of unmodified ECT; we added a strong caveat that our findings
were not an endorsement of its routine practice. Waikar et al. completely
misread my views in my commentary (9); to quote.
'It therefore appears prudent to conclude that
while modified ECT may be the ideal, there can be situations in which unmodified
ECT may be preferable to no ECT. Examples of such situations are those in which
ECT is strongly indicated but anaesthesiological facilities are unavailable or
unaffordable; in such situations, the expected gains with ECT are likely to far
exceed the risks with unmodified treatments. The stage is now set for a
systematic audit of modified as well as unmodified ECT so that better data may
be made available upon which more valid decision-making can be
based.'
I stand by my statements. If Waikar et al. wish to
outlaw the practice of unmodified ECT, they may be shutting the door for
effective treatment for a number of patients who seek psychiatric care in
situations in which anaes-thesiological facilities are unavailable or
unaffordable. Will Waikar et al. take the responsibility for the suffering, or
possible death, of these patients? I remind readers that we are living in a
country in which even minimal standards of healthcare cannot be assured to
enormous segments of the population; under these circumstances, a sub-optimal
form of treatment could be better than no treatment. On the subject of
'sub-optimal form of treatment', I add that there is insubstantial evidence that
unmodified ECT is as bad as it is made out to be.
The inevitable conclusion is that it is necessary
to objectively compare the benefits and risks of modified and unmodified ECT, as
well as patients' experiences with and subsequent attitudes towards these two
forms of treatment because, in an era of evidence-based medicine, only when the
results of such research become available can truly informed, scientifically and
ethically valid opinions be expressed.
References
1. Rosenbach ML, Hermann RC, Dorwart TA. Use of electro-convulsive therapy in the Medicare population between 1987 and 1992. Psychiatr Serv 1997;48:1537-1542.
2. Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisan- by SH, Peyser S, et al. A prospective, randomized, dou-ble-blindcomparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000;57:425-434.
3. Petrides G, Fink M, Husain MM, et al. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J ECT 2001;17:244-253.
4. Newman MF, Kirchner JL, Phillips-Bute B, Gaver V, Grocott H, Jones RH, Mark DB, Reves JG, Blumenthal JA, for the Neurological Outcome Research Group and the Cardiothoracic Anesthesiology Research Endeavors In-vestigators. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J
Med 2001;344:395-402.
5. Andrade C, Agarwal AK, Reddy MV. The practice of ECT in India. 2. The practical administration of ECT.
Indian J Psychiatry 1993;35:81-86.
6. Tharyan P, Saju PJ, Datta S, John JK, Kuruvilla K. Physi cal morbidity with unmodified ECT: a decade of experi-ence. Indian J Psychiatry 1993;35:211-214.
7. Andrade C. Unmodified ECT: A note of caution. Indian J Psychiatry 1995;37:99-100.
8. Andrade C, Rele K, Sutharshan R, Shah N. Musculoskel etal morbidity with unmodified ECT may be less than
earlier believed. Indian J Psychiatry 2000;42:156-162.
9. Andrade C. Unmodified ECT: ethical issues. Issues in Medical Ethics 2003;XI:9-10.
1. Rosenbach ML, Hermann RC, Dorwart TA. Use of electro-convulsive therapy in the Medicare population between 1987 and 1992. Psychiatr Serv 1997;48:1537-1542.
2. Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisan- by SH, Peyser S, et al. A prospective, randomized, dou-ble-blindcomparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000;57:425-434.
3. Petrides G, Fink M, Husain MM, et al. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J ECT 2001;17:244-253.
4. Newman MF, Kirchner JL, Phillips-Bute B, Gaver V, Grocott H, Jones RH, Mark DB, Reves JG, Blumenthal JA, for the Neurological Outcome Research Group and the Cardiothoracic Anesthesiology Research Endeavors In-vestigators. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J
Med 2001;344:395-402.
5. Andrade C, Agarwal AK, Reddy MV. The practice of ECT in India. 2. The practical administration of ECT.
Indian J Psychiatry 1993;35:81-86.
6. Tharyan P, Saju PJ, Datta S, John JK, Kuruvilla K. Physi cal morbidity with unmodified ECT: a decade of experi-ence. Indian J Psychiatry 1993;35:211-214.
7. Andrade C. Unmodified ECT: A note of caution. Indian J Psychiatry 1995;37:99-100.
8. Andrade C, Rele K, Sutharshan R, Shah N. Musculoskel etal morbidity with unmodified ECT may be less than
earlier believed. Indian J Psychiatry 2000;42:156-162.
9. Andrade C. Unmodified ECT: ethical issues. Issues in Medical Ethics 2003;XI:9-10.
CHITTARANJAN ANDRADE
MD (Psychiatry), Member, ECT Task Force, World
Federation of Societies of Biological Psychiatry, Additional Professor,
Department of Psychopharmacology, National Institute of Mental Health and
Neurosciences, Bangalore 560 029, India. e-mail:andrade@nimhans.kar.nic.in;andrade@vsnl.com