| 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).
Keywords: Adverse effects of ECT, benzodiazepine-modified ECT, electroconvulsive therapy, guideline, position statement, succinylcholine, unmodified ECT
|How to cite this article:|
Andrade C, Shah N, Tharyan P, Reddy M S, Thirunavukarasu M, Kallivayalil R A, Nagpal R, Bohra N K, Sharma A, Mohandas E. Position statement and guidelines on unmodified electroconvulsive therapy. Indian J Psychiatry 2012;54:119-33
|How to cite this URL:|
Andrade C, Shah N, Tharyan P, Reddy M S, Thirunavukarasu M, Kallivayalil R A, Nagpal R, Bohra N K, Sharma A, Mohandas E. Position statement and guidelines on unmodified electroconvulsive therapy. Indian J Psychiatry [serial online] 2012 [cited 2020 Oct 1];54:119-33. Available from: http://www.indianjpsychiatry.org/text.asp?2012/54/2/119/99530
| Mission|| |
Unmodified electroconvulsive therapy (ECT) is occasionally practiced in India and has become the subject of scrutiny from human rights activist and judicial quarters. This document presents the official position that the Indian Association of Private Psychiatry (date of approval, January 03, 2012), the Indian Association of Biological Psychiatry (date of approval, December 04, 2011), and the Indian Psychiatric Society (date of approval, February 09, 2012) hold on the subject of unmodified ECT.
This document is based on the best evidence available at the time of preparation. Addenda to this document will be prepared should newer data on the subject appear. This document, and addenda (if any), will be hosted at the official websites of the psychiatric societies which approved the document.
| Definitions|| |
- Muscle relaxants include all drugs which are used to effect skeletal muscle paralysis during ECT. , Succinylcholine is the most commonly used drug in this category. Drugs such as diazepam which relax skeletal muscles but do not induce paralysis are excluded from the definition.
- Anesthetic agents include all short- and ultrashort-acting treatments that are used as induction agents for ECT. , Examples of anesthetic agents include methohexital, pentothal, propofol, and ketamine. When a muscle relaxant is administered, prior anesthesia is required to induce sleep and hence prevent the panic and fear that the patient would otherwise experience in association with the total body skeletal muscle paralysis and inhibition of breathing induced by the muscle relaxant. 
- Unmodified ECT refers to the administration of ECT without the prior administration of a muscle relaxant. The administration of ECT under anesthesia but without a muscle relaxant does not constitute modified ECT. 
- Modified ECT refers to the administration of anesthesia, muscle relaxant, and the seizure-eliciting electrical stimulus, in that order. ,, ECT seizure modification was introduced because it was recognized that the therapeutic benefits of ECT arose from the central seizure and not from the peripheral convulsion; therefore, abolition of the latter could improve the safety and aesthetics of ECT without compromising its efficacy. ,,
- Benzodiazepine-modified ECT refers to the administration of ECT with an intravenous benzodiazepine administered before the passage of current, in lieu of anesthesia and a muscle relaxant. 
Note on the introduction of modified ECT
With the exception of the occasional use of muscle relaxants such as curare, , the practice of ECT across the world was unmodified from 1938 when ECT was introduced to 1952 when succinylcholine was proposed as a practical, short-acting muscle relaxant to reduce ECT-related musculoskeletal complications. ,
Note on the range of seizure modification with succinylcholine
For maximum muscle relaxation during ECT, such as in patients with orthopedic conditions, a succinylcholine dose of 1-2 mg/kg (or higher) may be necessary. ,, However, such high doses of succinylcholine are probably seldom administered in clinical practice; rather, doses of around 0.5-0.6 mg/kg are usual.  Thus, modified ECT as generally practiced is actually partially modified ECT. 
| The Practice of Unmodified Ect Across The World|| |
Data from India
A postal questionnaire survey of the medical membership of the Indian Psychiatric Society found that, during 1991-1992, only 44.2% of respondents who practiced ECT (n=215) always administered modified treatments; a further 24.2% always administered unmodified treatments, while the remainder administered modified and unmodified treatments in varying proportions. ,
In a 2001-2002 survey of teaching hospitals in India, only 44 (66.7%) of 66 hospitals which offered ECT reported the use of succinylcholine.  The authors estimated that 10,234 patients (52% of the total number of patients receiving ECT) received 52,450 unmodified ECT treatments (46% of the total number of ECTs administered) at 33 institutions (half of the institutions that offered ECT).
Data from other countries
During the past three decades or so, the practice of unmodified ECT has been reported from developing and developed countries, alike. These countries include African nations such as Nigeria, , Uganda,  and Malawi;  European countries such as the United Kingdom,  France,  Spain,  and Russia;  and advancing or advanced Asian countries such as Japan, , Turkey,  and China. 
Some interesting statistics follow. Chanpattana and Kramer  reported that 94% of ECT in Thailand was unmodified. Only 5 of 75 patients received modified ECT in a French series.  In Spain, 5% of units never administered a muscle relaxant and 3% did so only occasionally. 
In a postal questionnaire survey of the practice of ECT in Asia during 2001-2003, Chanpattana et al. estimated that during a 1-year period of the survey, 129,906 unmodified ECTs had been administered to 22,194 (55.7%) patients at 141 (54.9%) institutions in 14 (60.9%) out of 23 countries. These institutions included 62 university hospitals, 46 psychiatric hospitals, and 33 general hospitals. Whereas 93 (36.2%) institutions reported the invariable practice of unmodified ECT, 48 (18.7%) reported the administration of modified and unmodified ECT in varying proportions. The remaining 116 (45.1%) institutions reported that they always administered modified ECT.
Reasons why unmodified ECT continues to be practiced
More than half a century has passed since the introduction of succinylcholine-modified ECT; , nevertheless, it is apparent that unmodified ECT continues to be practiced. What might be the reasons for this? There are several explanations. ,,,,
- Lack of anesthesiological support for ECT for any of a variety of reasons (e.g. lack of facilities for anesthesiological practice at the ECT clinic; absence of qualified anesthesiologists in the geographical vicinity of the center; monopoly of anesthesiologists by surgical specialities; lack of interest of anesthesiologists in a minor procedure which is poorly remunerative; lack of infrastructure and funding)
- Urgent need for ECT (associated with a lack of time for or delay in obtaining anesthesiological clearance for ECT)
- Inability to administer anesthesia (e.g. because of inaccessibility of veins for intravenous administration of anesthesia and muscle relaxant)
- Contraindication for use of anesthesia (e.g. because of cardiorespiratory disorders)
- Contraindications for use of succinylcholine (e.g. in patients with burns or neuromuscular disease)
- Unaffordability of anesthesiological support.
Unmodified ECT has also been practiced because it takes less time to administer,  and because it is "more convenient" and "safer than modified ECT". ,
| Current Guidance Regarding Unmodified Ect|| |
Some published views on unmodified ECT have supported its use in specific contexts; ,,,,, others have been condemnatory about its practice. ,,,,,, The Bombay Psychiatric Society guideline on ECT  describes the procedures for both modified and unmodified ECT, acknowledges that unmodified ECT continues to be practiced in several countries, but offers no opinion about the desirability or undesirability of unmodified ECT.
In India, the High Court of Bombay at Panaji, Goa, directed the Institute of Psychiatry and Mental Health, Goa, to favor the use of modified treatments.  However, the judgment did not categorically proscribe unmodified ECT. The final order of the High Court on "Prayer to administer modified ECT at Institute of Psychiatry and Mental Health, Goa" (Writ petition no. 357/1998) was delivered on 14.10.1998 and stated as follows: "Learned Adv. General appearing on behalf of the Respondents states that Hospital Authority would as far as possible give modified ECT on patients and would also decide whether the unmodified form of ECT should be continued or not depending upon the medical advice. He states that if there are any further directions issued by the High Court in judgment delivered on 10th November 1989, in the case of Shukri vs. State of Maharashtra, other directions would also follow." This judgment, therefore, does not appear to place strictures upon the use of unmodified ECT in exceptional circumstances, as may be necessary and as described in subsequent sections.
The American Psychiatric Association  and the Royal College of Psychiatrists  offer no comments on unmodified ECT. In these authoritative guidelines, it is assumed that ECT is always modified.
In its resource book on mental health, human rights, and legislation, the World Health Organization  addresses unmodified ECT in two sentences, stating that its practice should be stopped. The text provides no scientific discussion on the subject, nor empirical data in support of the recommendation.
The World Psychiatric Association (WPA) position statement on unmodified ECT has asked national member societies to implement modified ECT as the standard, placing the responsibility for this directive on governments, professional organizations, and individual practitioners. The WPA document asserts that where the necessary infrastructure exists, there is no excuse for the administration of unmodified ECT. However, the document accepts that, in settings when the choice is unmodified ECT or no ECT, case by case decisions can be made based on clinical factors, evidence, informed consent, and the consideration of alternative treatments. 
| Critique of Data and Need for Research|| |
Very little of the data available on unmodified ECT has been obtained from well-designed studies or from comparative let alone randomized controlled trials. Therefore, it is not known to what extent many adverse outcomes attributed to unmodified ECT are due to ECT in general (as opposed to the absence of seizure modification, in particular) or to the environment associated with unmodified ECT.
In most of the historical studies, the procedures adopted were poorly described. There is an especial absence of description of electrical stimulation details. This is unfortunate, because if it could be established that the older studies used high stimulus doses, it could explain why musculoskeletal morbidity was greater in the historical studies relative to the recent studies. 
It is unlikely that a randomized controlled study of modified and unmodified ECT would ever be considered ethical. However, in places where unmodified ECT is administered, it is hoped that careful documentation will allow audits that provide a better understanding of the safety and efficacy of this form of treatment.
| Clinically Important Aspects of The Physiology of Unmodified Ect|| |
- The peripheral convulsion is far more vigorous and lasts longer with unmodified ECT than with modified ECT. As a result, there is an increased risk of musculoskeletal complications with unmodified ECT. In this context, compression fractures of the vertebrae have been reported in tetanus;  a 10.4%  to 34.2%  incidence of vertebral compression fractures was reported in idiopathic epilepsy; and a 26.1% incidence of fractures was reported in association with pentylenetetrazol convulsive therapy  [cited by Dewald et al. ]
- With very few exceptions, anesthetic agents used for modified ECT raise the seizure threshold.  This means that, relative to modified ECT, a lower electrical dose will suffice to induce an adequate seizure when unmodified ECT is administered.
- There is peripheral pooling of blood in venous channels when a muscle relaxant is administered. As a result, the ECT-induced blood pressure surge is probably lower with modified than with unmodified ECT.  This may explain why unmodified ECT is associated with a risk of hemorrhage in sites such as the conjunctiva and elsewhere.  Adequate control of the intra-ECT blood pressure surge may therefore be important in certain patients who receive unmodified ECT, such as those with hypertension or those at risk of bleeding from injury sites.
- The mean oxygen saturation during unmodified ECT was 46-94% (mean, 71%) in the only study which reported on this parameter.  This suggests that, as with patients who receive modified ECT, patients receiving unmodified ECT should also be provided with 100% oxygen through a face mask. 
- In serial measurements before, during (twice) and after a course of unmodified ECT in 8 patients, Ohaeri et al. found that levels of the acute phase proteins C-reactive protein, alpha-2-macroglobulin, ceruloplasmin, factor B, C-4 protein, C-3 protein, transferrin, and alpha-1-antitrypsin were not raised by ECT. They concluded that unmodified ECT does not result in occult or subclinical internal tissue damage.
- In a carefully designed series of experiments using an animal model, higher electrical charge but no other electrical parameter (pulse amplitude, pulse width, pulse frequency, or stimulus duration) nor seizure duration were associated with spinal fracture following unmodified treatment.  This may explain why historical studies, which employed high dose sinusoidal wave ECT, were associated with a high rate of spinal fracture.  It may therefore be prudent to keep electrical dosing as close to the seizure threshold as feasible when administering unmodified ECT.
Succinylcholine is rapidly metabolized within 5-8 min by pseudocholinesterase (also known as butyrylcholinesterase or plasma cholinesterase) in the liver and in plasma.  The metabolism of succinylcholine is impaired in persons with an atypical form of this enzyme or a deficiency of this enzyme.  The metabolism of succinylcholine is also impaired in persons in whom this enzyme has been inactivated by organophosphorus poisons. , Finally, pseudocholinesterase deficiency may occur in liver disease and other conditions.  The administration of succinylcholine in such situations will therefore result in prolonged apnea. Mivacurium is not a suitable alternative to succinylcholine in such situations because mivacurium is also metabolized by pseudocholinesterase.  Other contraindications for succinylcholine have been listed by Swartz  and Mallon et al.;  these contraindication include burns, crush injuries, denervation syndromes, malignant hyperthermia, and others.
In patients with pseudocholinesterase deficiency, whatever the cause, nondepolarizing muscle relaxants such as atracurium or rocuronium can be used. However, the former causes histamine release and may result in bronchoconstriction and hypotension while the latter has a long duration of action, resulting in the need for continued anesthesia (lest the patient regain conscious while in a paralyzed state) and/or treatment with parenteral neostigmine and glycopyrrolate for reversal of paralysis. 
Rapacuronium is another possibility, and reversal with edrophonium and atropine has been described.  These options may not be available or feasible in most Indian settings.
| The Disadvantages and Risks of Unmodified Ect|| |
Few studies have directly compared unmodified and modified ECT. , Most of the data in this section, therefore, are based on uncontrolled studies or are impressionistic.
- Unmodified ECT is suggested to be associated with an increased risk of pre-treatment anxiety; a large, uncontrolled chart review cited a 7.5% risk.  The anxiety may be because patients are fully aware of the elements of the ECT procedure and recall many of these elements later, including elements that are potentially anxiogenic, such as the application of physical restraints. In the uncommon event of subconvulsive stimulation, recall of this experience may be particularly distressing though what exactly patients recall is moot. Finally, the anxiety may also be conditioned by the discomfort related to the emergence from postictal confusional states against which anesthesia in modified ECT is partially protective. , The above notwithstanding, the only studies to have directly compared modified and unmodified ECT found no difference in pretreatment anxiety between the two forms of treatment. , This suggests that anxiety with unmodified ECT may be more a function of the environment in which the treatment is administered than the treatment, itself. Importantly, pre-ECT anxiety is reduced by the pretreatment administration of oral benzodiazepines.  Here, it should be added that there is nothing in the practice of modified ECT that will specifically address pre-treatment anxiety. It is possible, however, that the administration of anesthesia may have indirect benefits in this regard: anesthesia, by augmenting the amnesigenic effect of ECT, may decrease recall of the anxiogenic elements of the procedure; and anesthesia will reduce the risk of post-ictal confusion, allowing a more peaceful recovery. As a result, there is less for the patient to dread in future treatments
- Unmodified ECT may be associated with an increased risk of bleeding from various sites. Bleeding at oral sites is the most common; a recent study  noted that 21.4% of patients had a few flecks of blood visible on a wad of gauze that had been used as a bite block during unmodified treatments. Bleeding at other sites, such as the conjunctiva, has also been reported. Patients may rarely bleed from the upper gastrointestinal tract if ulcerative pathology exists.  The increased risk of bleeding from non-oral sites may be a result of increased blood pressure during and for a short period after the seizure
- Unmodified ECT may be associated with an increased risk of loosened or broken teeth. This risk is likely a function of the force and duration of the tonic-clonic convulsion. Tooth injuries, however, have been described with both modified and unmodified ECT,  and there are no hard data to confirm greater risk with unmodified ECT even in the only comparative trials conducted ,
- Unmodified ECT is associated with an increased risk of joint dislocation, fracture of long bones, pelvic fracture, and muscle or ligament injuries. ,,, This risk is likely a function of the force and duration of the tonic-clonic convulsion. The frequency of nonspinal musculoskeletal injury was 3.5% in the only study which formally reported it;  however, the risk may be much smaller, to judge from recent studies. ,, This lower risk in recent studies may be a function of lower electrical dosing, better use of restraints, benzodiazepine-modification of the seizure, and patient characteristics
- Unmodified ECT may be associated with an increased risk of uncomplicated backache, ranging from a low of 9%  to a high of 52%  as reported in recent studies. A historical study  obtained even lower values: just 6.1% in a sample of 212 patients. The risk of backache is likely to depend on the force and duration of the tonic-clonic convulsion; variation in the manner and threshold of ascertainment could at least in part explain the variation in incidence across studies. There are no controlled data on the magnitude of this risk with unmodified relative to modified ECT
- Unmodified ECT is associated with a higher risk of spinal fracture than modified ECT.  Whereas compression fractures of the bodies of the middle thoracic vertebrae have most commonly been described, ,, fractures at other sites have also been reported. , The fracture risk is likely a function of the force and duration of the tonic-clonic convulsion. Spinal fracture with unmodified ECT is potentially the most common and serious among the risks associated with the treatment and is therefore considered in greater detail in the next section
- Unmodified ECT may be associated with an increased risk of restlessness and postictal confusion. The resultant symptoms are distressing to the patient and attendants and may provoke apprehension with regard to future treatments (manifesting as pre-ECT anxiety). Restless patients may also harm themselves or their environment, and increase the burden on the ward staff. A historical study that compared modified (n=94) and unmodified (n=40) ECT observed that post-ECT restlessness was infrequent with modified ECT but developed in over half of the patients treated with unmodified ECT.  A recent study (n=56) of benzodiazepine-modified ECT  however recorded only a 10.7% risk. There are several issues which need to be considered here. First, the administration of conventional doses of electricity may result in considerably suprathreshold dosing when unmodified ECT is practiced; this may increase the risk of postictal confusion. High dosing probably characterized ECT in the early studies, resulting in high rates of post-ECT confusion. Second, it is not uncommon for a patient to experience confusion after a generalized tonic-clonic (epileptic) seizure; in the context of ECT, when unmodified ECT is administered, there is no anesthesia to mask the occurrence of such confusion. Finally, the lower risk of post-ECT confusion in a recent study  was probably due to the use of parenteral benzodiazepines as ECT premedication
- Unmodified ECT is conceptually and visually unaesthetic; conceptually unaesthetic because medical practitioners treat rather than induce generalized tonic-clonic seizures, and visually unaesthetic because of the appearance of a convulsing patient held down by manual or other restraints. The net emotional impact is strongly negative, harms the image of modern day ECT, , and may fuel distorted depictions of ECT in the mass media 
- Whereas one nonrandomized, naturalistically-controlled study  of 70 young patients with depression, mania, or schizophrenia suggested that unmodified ECT is not associated with cognitive risks, the data on the subject are insufficient for reassurance. This is an important point because suprathreshold electrical doses may unwittingly be delivered during unmodified ECT, increasing cognitive adverse effects. In contrast, the absence of anesthesia could lower cognitive adverse effects; consider that at least one study has found that amnesia with ECT is proportionate to the dose of the barbiturate anesthesia administered 
- In the historical literature, deaths have been reported with both modified and unmodified treatments. , These cannot be interpreted in the absence of statistics on the numbers of patients treated, pre-treatment risk factors, cause of death, etc. In the present era, Tharyan et al. reported one death with unmodified ECT but a higher risk of adverse cardiovascular events with modified treatments. The single death with unmodified ECT in this report  must be interpreted in the context of the very large number of unmodified treatments administered (>10,000) across 11 years
- Although a variety of other complications and risks of unmodified ECT have anecdotally been described,  in the absence of randomized controlled trial data or properly collected observational data, it is not possible to determine to what extent these complications and risks were chance observations, findings related to general aspects of ECT, or findings related to the environment in which unmodified treatments were administered, as opposed to the absence of seizure modification, per se
- Readers unfamiliar with ECT should note that, the contents of this section notwithstanding, many of the problems described in this section may be associated with modified ECT, as well
- As an extra note: only one modern study has specifically addressed patients experiences with and attitudes towards unmodified ECT.  This study found that 76% of 90 consecutive patients did not find unmodified ECT stressful, and that 82% found it beneficial. Only 9% of patients experienced headache and 18% experienced muscle pains. A third of the patients had memory impairment. Headache and memory impairment predicted negative attitudes towards ECT. Patient criticism and complaints addressed the ECT service delivery system and consenting procedures. The findings of this study appear related to ECT in general rather than to unmodified ECT in particular, suggesting that the absence of seizure modification does not have an especial influence on attitudes. Attitudes towards unmodified ECT have also been studied in medical students , and psychiatrists.  There are no controlled studies on attitudes towards unmodified ECT in any population 
| Musculoskeletal Complications of Unmodified Ect|| |
Many studies during the 1930s, 1940s, and 1950s described the musculoskeletal complications of unmodified ECT. This section provides critical comments, reviews a few of the important and representative historical studies, and reviews all the relevant studies on the subject published after 1990.
- A true estimate of the skeletal complications of unmodified ECT can be obtained only if X-rays are routinely taken after the ECT course; otherwise, asymptomatic fractures will be missed. For example, Dewald et al. found that 15 (30.6%) of 49 patients who experienced fractures with unmodified ECT had no symptoms related to the fracture(s). Importantly, pre-ECT X-rays are also necessary. Dewald et al. observed that compression of the superior plates of the vertebral bodies can be so minor that unless pretreatment comparison films are available, such fractures may not be recognized. Meschan et al. provided a good description of the nature of vertebral fractures. Initially, there is a central indentation of the superior plate of the vertebral body; later, anterior compression of the vertebral body may develop. The former may be due to a "hammer blow" from the spinal column cephalad to the vertebra, and the latter, due to powerful contraction of the flexor spinal muscles
- Lingley and Robbins  conducted radiological investigations before and after a course of unmodified ECT in 230 consecutive patients. They found that 37% of the men and 13.2% of the women in their sample suffered 1-5 vertebral fractures. The most common fracture was a compression of the vertebral bodies of the third to the sixth thoracic vertebrae. Young adult males and elderly patients of both sexes were overrepresented among those who suffered fractures; the former, apparently in relation to muscularity and the latter, in relation to osteoporosis. The incidence of fracture in patients with and without radiological evidence of osteoporosis was 43% vs 21%, respectively. There was no progression of fracture in 33 of 35 patients who had evidence of old vertebral fracture. There was no progression of fracture in 12 of 15 patients who suffered vertebral compression during the index course of ECT and who were continued on ECT. In this study, five attendants held the patient down (though, not "too rigidly") during the convulsion in order to absorb the initial shock and prevent hyperflexion; restraint, however, did not appear to protect against fracture
- Meschan et al. administered unmodified ECT to 212 male patients. Radiological investigation was conducted before the ECT course, after each of the first five treatments, after the 10 th , 15 th , and 20 th treatments, and after the last treatment in the course. One third (n = 75; 35.4%) of the patients suffered vertebral fractures (mean, 2.6 fractures per patient). The most common sites of fracture were at the third to fifth thoracic vertebrae. Nearly two thirds of patients experienced their fractures by the third ECT; nearly four fifths of the fractures occurred by the fifth ECT. Patients aged 30-39 years were at highest risk. Of 41 patients who received ECT modified with curare, only 8 (19.5%) experienced fractures. Although curare reduced the risk of fracture, it did not arrest the progression of fractures or prevent new fractures in patients who were treated with curare-modified ECT after experiencing an initial fracture. In this study, only 13 of the 212 patients complained of backache; of these, only eight had radiological evidence of fractures (it must be acknowledged that pain or backache was not routinely asked after, and so many symptomatic patients may not have been identified). In this study, four attendants held the convulsing patient down to lightly but not completely immobilize the patient. The ECT table was specially designed to permit hyperextension of the upper dorsal spine. These precautions, however, did not appear to protect against fracture
- Dewald et al. studied 68 men and 195 women, aged 14-76 years, who had received 285 courses of unmodified ECT (mean, 7.5 ECTs per patient; range, 1-21). Radiological investigations were conducted before and after each ECT course, and after any complaint of backache. In 231 course of unmodified ECT, 48 (20.8%) cases of vertebral fracture were identified (mean, 2.2 fractures per patient; range, 1-6). Fractures occurred in 42.9% of men and 13.7% of women. About 71% of the fractures occurred by the third ECT. Most of the fractures occurred in patients aged <40 years. There was little difference in the incidence of fractures between direct (22.6%) and glissando (19.2%) methods of electrical stimulation, but pre-ECT osteoporosis was associated with a doubled risk (43.5%, as compared with 20.9% in patients with normal pre-ECT X-Rays). The most common sites of fracture were at the fourth to sixth thoracic vertebrae. Two patients suffered severe compression fractures; the remaining patients with fractures had minimal compression of the superior cortical plates of the vertebral bodies. Backache was reported by 19.5% of patients; of these, 75.6% had fractures. In 30.6% of patients, the fractures were asymptomatic and were discovered only from the X-rays. In addition to the spinal fractures, 3.5% of patients experienced miscellaneous orthopedic events such as humeral fracture or dislocation, mandibular dislocation, and ligament or joint capsule tear. Strikingly, in 54 courses of ECT modified with decamethonium, there was just one fracture. In this study, the convulsive movements were allowed to follow their own course; only light, manual restraints were applied to the extremities
- Havens  randomized 74 patients to receive unmodified (n=40) or modified (n=34) ECT; 27 and 29 patients, respectively, completed the ECT course. Spinal X-rays were obtained before and after the ECT course in 60 of these 74 patients. A separate group of 60 patients were elderly or had disabilities and were all assigned to modified ECT. There was little difference between groups with regard to number of ECTs administered, duration of hospitalization, or degree of clinical improvement. Pre-ECT anxiety did not differ significantly between groups. Fear of ECT, expressed before or after the ECT course, also did not differ significantly between groups. However, recovery room restlessness was substantially more likely with unmodified than with modified ECT (>50% vs <10%, respectively). In patients in whom X-rays were obtained, the incidence of fractures was 0% with modified ECT and 28% with unmodified ECT. Thirteen of the 40 patients randomized to unmodified ECT had to be switched to modified ECT because of musculoskeletal complications. However, two patients receiving modified ECT had to be switched to unmodified treatments: one because of prolonged (>15 min) apnea and the other because of resistance to injections. Modified ECT patients also experienced other complications: aspiration pneumonia (n=1), loss of three front teeth during airway insertion (n=1), and post-ECT hypotension
- Other historical studies besides these have described musculoskeletal morbidity with unmodified ECT. However, historical data also exist to document the absence of musculoskeletal risk, or lower risks than those described above. For example, Caplan  described the administration of 1183 unmodified ECTs across 3-17 months to 25 patients; routine X-rays obtained before and after ECT identified no case of vertebral fracture. Huddleson and Gordon  reported a fracture risk of only 6.3%; and Worthing and Kalinowsky  reported a risk of only 10%
- In a small, retrospective chart review, Mukherjee and Debsikdar  found complete or almost complete remission of mania in 30 patients treated with an average of 5.4 unmodified ECTs. No patient had post-ictal confusion and no fractures or dislocations were documented
- Tharyan et al. described a large chart review of all patients treated with brief-pulse ECT at their center between 1980 and 1990, both years inclusive. The sample included 1835 patients who received 2002 courses of ECT. The sample was 56% male; 59% were aged 20-40 years. A total of 13,597 ECTs were administered of which 98% were unmodified. Eleven patients suffered compression fractures of the thoracic (n=10) or lumbar (n=1) vertebral bodies, and one had a scapular fracture. The magnitude of compression was less than a third of the vertebral body and was identified by the symptom of pain. Eleven of the 12 patients were male. An additional 63 patients developed muscular pain; X-rays obtained in 38 of these patients were all found to be normal. The patients with fractures were conservatively managed; in six of these patients, ECT was continued, uneventfully, with seizure modification. Follow-up of 10 of these patients across the next 3 months to 8 years revealed no adverse consequences of the fractures. An important limitation of this study is that X-rays were not routinely obtained in all treated patients. Important strengths of this study are the large sample size and long duration of ascertainment of outcome data
- Ikeji et al. used unmodified ECT to treat 70 young patients with depression, mania, or schizophrenia. By the end of the course, muscle pain (31.4%), post-ECT confusion (15.7%), and post-ECT headache (20.0%) had been recorded as adverse effects. Subjective memory was impaired during the ECT course but remitted at follow up. Cognitive testing showed progressive improvement with clinical recovery. These patients were followed up for up to 6 months
- In a small, prospective study of consecutive patients (n=50) who received a fixed course of six unmodified ECTs, routine anteroposterior and lateral radiological assessments of the thoracolumbar spine identified only one patient (2%) to have suffered a (minor, subclinical) vertebral fracture. This was described as an avulsion fracture-disruption at pars-interarticularis at the fifth lumbar (L5) vertebra with subluxation of the L4-L5 facet joint on the left side.  Patients in this study had received a parenteral benzodiazepine minutes before each ECT, as remarked upon in a later study from the same group 
- In a small, prospective study of 56 consecutive patients who received an average of 2.9 unmodified ECTs during the early part of their ECT course, routine digital radiological assessments of the thoracolumbar spine (obtained after the unmodified ECT course) identified a zero incidence of spinal complications even though two patients had evidence of old (pre-existing) spinal fractures.  The authors suggested that, in this as well as in their previous study,  the very low or absent risk of fractures with unmodified ECT may have been a consequence of muscle relaxation associated with the pre-ECT administration of a parenteral benzodiazepine (most commonly diazepam 10 mg, administered a few minutes before the ECT). A limitation of this study is that pre-ECT X-rays were not obtained; as a result, it is theoretically possible that slight degrees of vertebral body compression might have been missed
- Factors that lower the musculoskeletal risks of unmodified ECT have been proposed. These include younger age (and hence a lower risk of osteoporosis), slim frame (associated with lower muscle mass and hence a less vigorous convulsion), physical restraints (and hence a lesser violence of convulsive movements), lower electrical dose (and hence a lower intensity of seizure), and the administration of intravenous diazepam a few minutes pre-ECT (resulting in partial muscle relaxation, and hence a possibly less vigorous convulsion). ,,,, Interactions among these factors could also play a role; for instance, some of the historical studies found no benefits with restraints alone ,
- The clinical significance of vertebral fractures occurring with ECT is unknown. Polatin and Linn  found no orthopedic or neurologic sequelae nor any musculoskeletal complaints of importance at an approximately 10-year follow-up of 24 patients who had experienced vertebral body compression fractures during pentylenetetrazol convulsive therapy; the benign outcome was particularly notable because eight of the patients had also received from 3 to 43 (mean, >16) unmodified ECTs after the index course of pentylenetetrazol treatment. In none of the cases of fractures reported by Dewald et al. was orthopedic treatment considered necessary. Given the extensive practice of unmodified ECT in Asian countries,  there should be an epidemic of patients with spinal and musculoskeletal disorders if the vertebral fractures with unmodified ECT are dangerous and as frequent as the early studies suggest. The absence of evidence of such an epidemic, even in a practice spanning 11 years,  suggests that the injuries, whatever their frequency, are not of clinical significance. These findings notwithstanding, it must be recognized that clinicians should strive to prevent harm, no matter how insignificant the harm may seem. Importantly, it is unknown whether unmodified ECT-related vertebral injury that is clinically asymptomatic (even at a long-term follow up) during youth or middle age increases the risk of orthopedic morbidity in late life
- In nearly a third of patients, fractures with unmodified ECT are aymptomatic.  This figure is larger in other studies.  Importantly, the fractures are often so minor that they may be missed unless pre-ECT comparison films are available.  The apparently trivial nature of the morbidity may explain why vertebral compression fractures with unmodified ECT do not result in short- or long-term morbidity, as considered in the previous point
- It is interesting that intervertebral disk prolapse has not been described as a complication of unmodified ECT. However, this is not customarily described as a complication of generalized convulsions, either.
| Special Notes on Benzodiazepine-Modified Ect|| |
Unmodified ECT has been practiced with the pre-treatment administration of oral (e.g. Tharyan et al. ) or parenteral (e.g. Andrade et al.;  Shah et al.  ) benzodiazepines. In a survey of the practice of ECT in India during 1990-1991, 25 (11.6%) out of 215 practitioners who reported the use of ECT stated that they used parenteral diazepam instead of an anesthetic agent before ECT. 
In patients who receive unmodified ECT, premedication with an intravenous benzodiazepine such as diazepam (10-15 mg) can provide the following benefits. ,
- Sedation, and hence a reduction in (a) pre-ECT anxiety (b) awareness and subsequent recall of potentially anxiogenic elements of the ECT procedure, such as the application of physical restraints over the body and the ECT electrodes over the scalp
- Muscle relaxation, and hence a reduction in the violence of the convulsion, which in turn reduces the risk of musculoskeletal injuries
- Reduction in the risk of post-ictal confusion or agitation.
These benefits are not proven, such as using controlled trial designs. However, the expectation of these benefits is reasonable, given the known action of benzodiazepine drugs. , With specific regard to potential musculoskeletal benefits in patients receiving unmodified ECT, benzodiazepines have been effectively used by the parenteral route to relieve muscle spasms and rigidity in patients with tetanus.  Diazepam may be the most potent muscle relaxant among the benzodiazepines and, in the dose of 10-17.5 mg intravenously, has even been used for muscle relaxation in orthopedic procedures. 
Other issues to be noted in the context of benzodiazepine modification are: ,
- There is no need to fear that benzodiazepines will unduly raise the seizure threshold. For example, in a study in which 56 patients received a mean of 2.9 unmodified ECTs, the seizure threshold ranged from 64 to 202 mC at the last treatment; the modal dose (in 68% of the sample) was 96 mC. These values are well within the range of thresholds observed with conventional anesthesia
- Concerns have been expressed that the use of benzodiazepines may compromise the efficacy of unilateral ECT.  This may be because the anticonvulsant action of benzodiazepines can impede adequate seizure generalization. It would therefore be prudent to prefer bilateral electrode placement should benzodiazepine-modified ECT be administered
- The sedation occasioned by the benzodiazepine premedication may carry through the day. This, however, may be an advantage because unmodified ECT is most likely to be administered in emergency situations to markedly disturbed patients
- Parenteral benzodiazepines can cause respiratory depression,  especially in patients with significant respiratory disorders. One way of reducing the risk of respiratory depression is to inject the drug slowly rather than as a bolus. Slow injection is also associated with a lower risk of thrombophlebitis. 
| Possible Benefits of Unmodified Ect|| |
- Unmodified ECT is free of the adverse effects and risks associated with the use of anesthesia. These adverse effects are most commonly minor and include nausea, vomiting, dizziness, headache, and drowsiness that can last for a few hours after ECT. Barbiturate anesthesia may increase ECT-induced amnestic deficits for nonverbal material.  Anesthesia has also been associated with falls and the risk of fractures,  no doubt as a consequence of dizziness, sedation, and psychomotor impairment. There may rarely be more serious complications, such as aspiration pneumonitis, cardiac arrhythmias, or even death.  Interestingly, Tharyan et al. observed that unmodified ECT was uneventfully administered to patients with ischemic heart disease, valvular heart disease, cardiac conduction defects, pregnancy (all trimesters), neurosyphilis, organic stupor, and bronchial asthma; in many of these conditions, the administration of anesthesia could have been hazardous and/or would have required skilled anesthesiological management.
- Unmodified ECT is free of the adverse effects and risks associated with the use of succinylcholine, the most commonly used muscle relaxant in ECT practice. The commonest adverse effect of succinylcholine is post-treatment body ache that may last for several hours or longer;  this body ache can sometimes be quite distressing to the patient. In the rare instance of pseudocholinesterase deficiency  or inactivation, , there may be prolonged apnea after succinylcholine use. These disadvantages are not sufficiently serious (body ache) or frequent (prolonged apnea) to justify a routine preference for unmodified ECT
- Some clinicians with experience in the administration of unmodified ECT claim that unmodified treatment is associated with greater efficacy than modified treatment.  There is no empirical evidence to support such a view; in fact, data from historical studies, though based on crude outcome measures, suggest that there is no difference in efficacy between the two forms of treatment. , One study,  however, found poorer outcomes with ECT plus thiopentone relative to ECT alone or ECT plus succinylcholine. As the speed and/or magnitude of response to ECT has been shown to be electrically dose-dependent relative to the seizure threshold (especially with unilateral ECT ,, ), and as the seizure threshold is lower with unmodified ECT because anesthesia is not used, electrical dosing relative to seizure threshold may be the confounding variable in efficacy estimation. Thiopentone and propofol anesthesia are strongly anticonvulsant in action, and if clinicians administer lower electrical doses with unmodified ECT, or if unmodified ECT is compared with ECT under etomidate, ketamine, or alfentanil anesthesia (agents that have less or no anticonvulsant activity  ), no therapeutic advantage for unmodified ECT should logically be apparent.
| Putting Unmodified Ect in Perspective|| |
This section does not defend unmodified ECT. However, it attempts to present the treatment in the perspective of other interventions which are accepted comparatively without challenge from social activists and ethics experts.
A much trumpeted issue is the visually unappealing nature of unmodified treatment and its seeming dangerousness. However, medical parallels abound. For example, in cardioversion far larger electrical shocks are delivered, causing violent jolting of the body. Cesearean sections, open-heart surgery, and orthopedic procedures appear gory or barbaric to the layperson's eye. Neurosurgical procedures lesion the living brain. Many of these and other interventions leave the body and brain with well-defined and permanent vulnerabilities. The risks associated with unmodified ECT pall in comparison.
Unmodified ECT is not the ideal form of the procedure. However, a parallel is the use of suboptimal medical and surgical practice in emergencies, as well as in circumstances in which training and infrastructure do not permit the ideal. Whereas suboptimal practice is undesirable, it has long been recognized in primary health care, rural, understaffed, underdeveloped, socioeconomically disadvantaged, and emergency settings that there are circumstances in which suboptimal practice is better than no intervention. 
| Summary|| |
- There is adequate reason to believe that unmodified ECT is associated with greater clinically relevant risks than modified ECT. From a theoretical perspective, the most important risks are musculoskeletal in nature; from a practical perspective, the musculoskeletal risks are commonly asymptomatic, and their long-term significance is unknown
- Unmodified ECT is widely practiced in the developing world, and it is unlikely that this practice will soon stop.
- Two recent, small prospective studies , with a pooled sample size of 106 patients obtained routine X-rays in all patients at the end of their unmodified ECT course. In both studies, an intravenous benzodiazepine had been administered to all patients immediately before each ECT. There was only one case of fracture detected in the entire pooled sample. Other adverse outcomes were also generally minor and/or infrequent. These data suggest that benzodiazepine-modified ECT carries far lower risks of orthopedic and general medical morbidity than unmodified ECT as described in the pre-1960 historical studies
- Historical longitudinal data,  recent longitudinal data,  and recent epidemiological data  do not indicate that unmodified ECT is dangerous. At least in the historical studies, this may be because the vertebral fractures were sometimes so minor as to be detectable only when pre- and post-ECT X-rays were compared.
| Recommendations Regarding the Practice of Unmodified Ect|| |
This Task Force is of the opinion that modified ECT should be practiced. However, this Task Force recognizes that, for reasons already considered, unmodified ECT is widely practiced in many parts of the world, especially in the developing world, and it is unlikely that its practice will soon stop. This Task Force therefore proposes a set of recommendations regarding unmodified ECT. The recommendations are based on the review of literature presented in this document, on general prudence, on consensus amongst the authors of this document, and on consensus during the participatory processes involved during the preparation and approval of this document.
This Task Force recognizes that, in some circumstances or settings, some of the recommendations made here (e.g. obtaining X-Rays before and after the unmodified ECT course) may be unrealistic for reasons related to cost, availability of facilities, emergency circumstances of treatment, etc. These recommendations are nevertheless made because they represent what should be done wherever feasible. Importantly, adherence to the recommendations would facilitate later audits of the benefits and risks of unmodified ECT. It is hoped that such audits will be conducted and that the results would improve the understanding of the field.
For medicolegal reasons and as part of good clinical practice, meticulous documentation of adherence to these recommendations is necessary when unmodified ECT is administered. If adherence to any recommendation is not possible, the reasons for nonadherence should also be documented so that later audits understand the circumstances involved in the case. In centers in which the administration of unmodified ECT may happen, it is desirable for the recommendations outlined below to be summarized into a checklist. Such a checklist would facilitate the implementation of the recommendations as part of standard operating procedures as well as ensure uniformity and completeness of data for later audits. A sample checklist is provided in the Appendix.
| Recommendations|| |
Examples of circumstances in which the use of unmodified ect may be considered reasonable
- Unmodified ECT should not be practiced as a routine form of treatment
- Unmodified ECT should be administered only on a case by case basis, when ECT is strongly indicated, when modified ECT cannot be administered, and when the expected benefits to the patient clearly outweigh the known risks associated with unmodified treatments. The indication and the risk-benefit analysis should be documented
- Muscularity and osteoporosis should be considered in the risk-benefit analysis. Elderly patients and others at risk of osteoporosis are more likely to suffer fractures with unmodified ECT. Young and male patients also appear to be at higher risk, probably as a function of greater muscle mass. It should also be remembered that patients with certain musculoskeletal disorders and those with uncontrolled hypertension may also be at increased risk of complications with unmodified ECT
- Ideally, the strong indication for ECT should be confirmed by a second psychiatrist; or by another medical practitioner, if another psychiatrist is unavailable. If this is not done or is not considered necessary, the reasons should be documented
- Care should be taken to ensure that all physical conditions (e.g. hypertension, neuromuscular disease, orthopedic conditions, etc.) that may pose a risk with ECT or unmodified ECT are treated to the extent possible and necessary so as to minimize the risk of complications
- In addition to the regular physical examination and investigations that are conducted to determine fitness to receive ECT, a formal dental examination should be conducted to identify loose teeth and other dental pathology that might increase the risk of morbidity with unmodified ECT. Should dental pathology be detected, and the risk-benefit assessment deem that ECT is necessary, appropriate precautions should be taken to reduce the risk of aggravation of this pathology during ECT; towards this, a dental consultation should be obtained, where deemed necessary and feasible
- Legally valid informed consent for ECT should be obtained. The informed consent form should state why unmodified ECT is being administered. The consent form should also contain a paragraph which outlines the risk-benefit analysis of unmodified ECT in the patient for whom the treatment is proposed. Finally, the consent form should also specify how many unmodified treatments are likely to be administered. If this specified number is exceeded, the patients should be reconsented for the additional treatments
- Ideally, anteroposterior and lateral radiological views of the thoracolumbar spine should be obtained before unmodified ECT to assist in the interpretation of X-rays that might be indicated should a patient develop backache or tenderness in the thoracolumbar spine during or after the ECT course. Detection of an old fracture of the spine is not a contraindication for unmodified ECT, as one recent and several historical studies have shown
- Verbal reassurance and support should be provided to reduce pre-ECT anxiety. If required, an oral anxiolytic can be administered, 1-3 h before ECT, in an oral dispersion formulation or along with a small sip of water. An advantage of such medication is that it could also reduce the risk of post-ictal restlessness
- Although there is no randomized controlled trial evidence to support this recommendation, it could be prudent to administer diazepam 10 mg by slow intravenous injection about 1-3 min before unmodified ECT to reduce acute anxiety, induce a state of somnolence, reduce awareness of anxiogenic parts of the procedure (e.g. application of restraints, application of electrodes), effect limited skeletal muscle relaxation in order to reduce the violence of the convulsion, and reduce the risk of post-ECT restlessness or confusion. Diazepam is the preferred benzodiazepine because it has strong muscle relaxant properties
- If intravenous diazapam cannot be administered for any reason (e.g. inaccessibility of veins), the best alternative could be the administration of oral diazepam (10-15 mg) 1-2 h before ECT. If diazepam cannot be administered for any reason (e.g. fear of accumulation of the drug in a patient with liver disease), alternate possibilities that may be considered are midazolam, or low but sedating (yet non-anesthetic) doses of the anesthetic agents that are used for modified ECT. Whereas these agents do not relax skeletal muscles as does diazepam, these agents will benefit the patient in all the other regards that intravenous diazepam will, including reducing the risk of post-ECT confusion
- When administering benzodiazepines as premedication, care should be taken to reduce the risk of respiratory depression (such as by injecting the drug slowly rather than as a bolus). Vital signs should be monitored during the recovery phase until it is deemed that the patient is stable. It may be prudent to avoid benzodiazepine premedication in patients who have significant respiratory disorders
- Particular care should be taken with appropriate mouth guards and mandible support to minimize dental risks during the tonic-clonic phase of the unmodified seizure
- The historical studies found that spinal fractures occurred whether or not restraints were applied; this is probably because fractures are a result of the force of muscle contraction, and this force is not reduced by restraints. Nevertheless, it could be prudent to apply restraints if only to reduce the risk of joint dislocation, self-injury, or fall from the ECT table during a violent convulsion. Belt, sheet, and/or manual restraints should be applied just before the passage of current to minimize limb and trunk movements and hence the violence of the convulsion. The restraints should be applied over the upper body and arms, the hips and forearms, and the knees. One way of doing this is to press down manually at these points. Another way is to cover the patient with a blanket from chest to ankles and hold the blanket tightly at its sides so that the restriction of movement is uniform across the body. Additional pressure may be required over the thighs
- There are no data to guide electrode positioning with unmodified ECT. However, given that almost all the recent data on unmodified ECT were obtained from patients treated with bilateral ECT, and given that clinicians administering unmodified ECT would want to minimize the chances of slow response or nonresponse, it could be prudent to administer bilateral treatments. When benzodiazepine-modified ECT is practiced, there is the additional concern that seizure generalization and hence ECT efficacy may be poorer with unilateral electrode placement. Therefore, again, bilateral ECT may be a better choice
- If facilities are available, patients receiving unmodified ECT should breathe 100% oxygen through a face mask, starting from before the passage of the electrical stimulus and extending to the onset of regular breathing after the end of the seizure
- Although there are no clinical data to guide electrical dosing with unmodified ECT, it could be prudent to use the lowest electrical charge required to elicit an adequate seizure in order to minimize the risks of musculoskeletal complications, postictal confusion, and later cognitive impairment. This goal, however, should not result in the administration of subconvulsive stimuli (which can be distressing to an awake patient). When benzodiazepine-modified ECT is administered, electrical doses necessary to elicit a seizure tend to be similar to those with conventionally-modified ECT
- After each unmodified treatment, patients should be clinically assessed, investigated, and managed, wherever indicated, for adverse outcomes associated with ECT in general and unmodified ECT in particular. Especial attention needs to be paid to possible postictal confusion, conjunctival bleeding, oral bleeding, loosening of teeth, backache, spinal tenderness, or other musculoskeletal problems (clinicians should be proactive in assessing for complications because a depressed or psychotic patient may not complain of symptoms such as backache). The patient's subjective experience should also be assessed. The results of all these assessments should be documented even if there are no positive findings. In case adverse events occur, re-evaluation of the risk-benefit ratio is necessary before continuing with unmodified ECT; this reanalysis should also be documented
- The experience of each treatment should guide the practice of the next. For example, if monitoring discovers an unacceptably high surge in systolic blood pressure during ECT, oral metaprolol or amlodipine, or other suitable interventions, may be administered about 2 h before subsequent ECTs
- Patients should not be exposed to unmodified ECT more than is absolutely necessary. Thus, if the reason why unmodified ECT was administered no longer exists, the patient should receive modified ECT or other treatment. For example, if a severely suicidal or catatonic patient received unmodified ECT as an emergency treatment pending evaluation of fitness for anesthesia, he should be treated with modified ECT after anesthesiological clearance is obtained. The switch away from unmodified ECT, however, should not leave the patient incompletely treated. For example, if a severely catatonic patient receives unmodified ECT in a rural setting, it may be clinically prudent to treat until recovery rather than stop ECT after partial improvement
- Ideally, at the conclusion of the ECT course, anteroposterior and lateral X-rays of the thoracolumbar spine should once again be obtained to check for skeletal complications. Post-treatment X-rays should be compared with pre-treatment X-Rays; otherwise, minor changes may not be detected
- At the conclusion of the unmodified ECT course, the risk-benefit experience with unmodified ECT should be carefully documented. This documentation is important for medicolegal purposes. This documentation will also guide future treatment options in the treated patient. Finally, documentation of experience in individual patients can influence the practice of unmodified ECT in future patients
- At the conclusion of the series of unmodified ECT, patients should be continued on maintenance pharmacotherapy or maintenance ECT, as they might have, had they received a course of modified ECT. In this as in all regards not addressed above, the practice of unmodified ECT should ideally be the same as that with modified ECT ,,,
- These recommendations notwithstanding, centers at which unmodified ECT is practiced should endeavor to improve their facilities to offer modified ECT in the future.
1. A clinical emergency constituting an indication for ECT (e.g. major depression with strong suicidal symptomatology; mania or schizophrenia with extreme violence that is difficult to manage even with optimal use of appropriate drugs) combined with any of the following:
- Unavailability or unaffordability of facilities for anesthesia
- Lack of time or opportunity for anesthesiological attendance or clearance
- Absence of fitness for anesthesia as judged by an anesthesiologist
- Contraindication for the administration of succinylcholine (e.g. burn or crush injuries, organophosphorus poisoning, pseudocholinesterase deficiency, certain neuromuscular diseases) and unavailability of facilities for the administration of nondepolarizing muscle relaxants or the reversal of the action thereof.
2. A non-emergency situation in which ECT is strongly indicated (e.g. severe depression, mania, or schizophrenia; psychotic depression, severe catatonia; refractory psychiatric illness; maintenance ECT associated with refractory illness) combined with (a) along with either (b) or (c) below.
- There should also be strong reasons to believe that ECT would offer benefits far greater than those possible with medications, and that the delay in or denial of ECT would harm the interests of the patient and/or family
- Unavailability or unaffordability of facilities for modified ECT in the treating clinician's facility or in other psychiatric facilities accessible to the patient
- Absence of fitness for anesthesia or contraindication for the administration of succinylcholine which is not likely to resolve in the near future.
The use of unmodified ECT for convenience (e.g. to reduce patient turnover time, or because the procedure is simpler) ,, is not acceptable.
| Acknowledgments|| |
The authors acknowledge with thanks the useful suggestions received from Dr. Max Fink and Dr. Vaughn McCall on an earlier version of this document.
| Appendix|| |
Checklist for and documentation of unmodified ECT
- Document explanations and findings, wherever applicable
- Document data for each ECT in the course, wherever applicable
- Document information before treatment and/or after treatment, as applicable
- Document reasons for noncompliance with items, if noncompliance occurs
- Keep in mind that this documentation has potential medicolegal importance.
Checklist and documentation list
1. Is ECT strongly indicated?
2. Has the strong indication for ECT been confirmed by another psychiatrist or medical practitioner?
3. Are there valid reasons why modified ECT cannot be administered?
4. Are there risk factors for unmodified ECT?
- Youth, male gender, and muscularity
- Presence or risk of osteoporosis
- Musculoskeletal disorders
- Uncontrolled hypertension
- Dental pathology
5. Does the risk-benefit analysis justify unmodified ECT?
6. Have all important comorbid medical conditions been treated?
7. What is the number of unmodified ECTs for which informed consent has been obtained?
[Attach signed and witnessed consent form.]
8. Was reconsenting necessary and was it performed?
[Attach signed and witnessed consent form.]
9. Have spinal X-Rays been obtained?
- Before the unmodified ECT course
- After the unmodified ECT course
10. Was pre-ECT anxiety present?
If yes, how was it addressed?
11. Describe benzodiazepine modification of the seizure, if not contraindicated and if performed.
12. Describe use of other premedication, if any.
13. Specify use of restraints.
14. Specify electrode positioning.
15. Confirm artificial ventilation and hyperoxygenation.
16. Specify electrical dosing.
17. Was a subconvulsive stimulus administered to an aware patient?
18. Post-ECT, were untoward effects of unmodified ECT suspected, investigated, and/or confirmed?
- Post-ictal confusion or agitation
- Bleeding from any site
- Dental complications
- Spinal pain or tenderness
- Other musculoskeletal complications
If yes, describe
19. Did the risk-benefit analysis post-ECT justify the continuation of the unmodified ECT course?
20. Was unmodified ECT continued only for as long as the indication for unmodified ECT persisted?
21. What was the eventual outcome, and did it justify the risk-benefit analysis which led to unmodified ECT?
| References|| |
|1.||American Psychiatric Association. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training and Privileging. Task Force Report on ECT. Washington, DC: American Psychiatric Association; 2001. |
|2.||Scott AIF, editor. The ECT Handbook, 2nd ed. The Third Report of the Royal College of Psychiatrists' Special Committee on ECT. London: Royal College of Psychiatrists; 2005. |
|3.||Andrade C, Thirthalli J, Gangadhar BN. Unilateral nondominant electrode placement as a risk factor for recall of awareness under anesthesia during ECT. J ECT 2007;23:201-3. |
|4.||Andrade C, Shah N, Tharyan P. The dilemma of unmodified ECT. J Clin Psychiatry 2003;64:1147-52. |
|5.||Abrams R. Electroconvulsive Therapy, 3rd ed. New York: Oxford University Press; 1997. |
|6.||Havens LL. A comparative study of modified and unmodified electric shock treatment. Dis Nerv Syst 1958;19:29-34. |
|7.||Seager CP. Controlled trial of straight and modified electroplexy. J Ment Sci 1959;105:1022-8. |
|8.||Ottosson JO. Experimental studies of the mode of action of electroconvulsive therapy. Acta Psychiatr Neurol Scand 1960;Suppl 145:1-141. |
|9.||Shah N, Mahadeshwar S, Bhakta S, Bhirud M, Fernandes P, Andrade C. The safety and efficacy of benzodiazepine-modified treatments as a special form of unmodified ECT. J ECT 2010;26:23-9. |
|10.||Fink M. Convulsive Therapy: Theory and Practice. New York: Raven Press; 1979. |
|11.||Andrade C. Electroconvulsive therapy. In: Bhugra D, Ranjith G, Patel V, editors. Handbook of Psychiatry: A South Asian Perspective. New Delhi: Byword Publishers; 2005. p. 553-68. |
|12.||Holmberg G, Thesleff S. Succinylcholine iodide as a muscular relaxant in electroshock therapy. Am J Psychiatry 1952;108:842-6. |
|13.||Holmberg G, Thesleff S. Succinylcholine iodide (celocurin) as a muscular relaxant in electro-shock therapy. Acta Psychiatr Neurol Scand Suppl 1952;80:135-8. |
|14.||Milstein V, Small IF, French RN. ECT in a patient with Harrington rods. Convuls Ther 1992;8:137-40. |
|15.||Hanretta AT, Malek-Ahmadi P. Use of ECT in a patient with a Harrington rod implant. Convuls Ther 1995;11:266-70. |
|16.||Murali N, Saravanan ES, Ramesh VJ, Gangadhar BN, Jananakiramiah N, Kumar SS. An intrasubject comparison of two doses of succinylcholine in modified electroconvulsive therapy. Anesth Analg 1999;89:1301-4. |
|17.||Andrade C. Variations on a theme of unmodified ECT: Science or heresy? J ECT 2010;26:30-1. |
|18.||Andrade C. The practice of electroconvulsive therapy in India: Considerable room for improvement. Editorial. Indian J Psychol Med 1992;15:1-4. |
|19.||Andrade C, Agarwal AK, Reddy MV. The practice of ECT in India. 2. The practical administration of ECT. Indian J Psychiatry 1993;35:81-6. |
|20.||Chanpattana W, Kunigiri G, Kramer BA, Gangadhar BN. Survey of the practice of electroconvulsive therapy in teaching hospitals in India. J ECT 2005;21:100-4. |
|21.||Ikeji OC, Ohaeri JU, Osahon RO, Agidee RO. Naturalistic comparative study of outcome and cognitive effects of unmodified electro-convulsive therapy in schizophrenia, mania and severe depression in Nigeria. East Afr Med J 1999;76:644-50. |
|22.||James BO, Morakinyo O, Lawani AO, Omoaregba JO, Olotu OS. Unmodified electroconvulsive therapy: The perspective of patients from a developing country. J ECT 2010;26:218-22. |
|23.||Farrant W, Cox JL, Farhoumand N. Attitudes of Ugandan medical students toward 'straight' and 'modified' ECT. Med Educ 1979;13:17-22. |
|24.||Selis MA, Kauye F, Leentjens AF. The practice of electroconvulsive therapy in Malawi. J ECT 2008;24:137-40. |
|25.||ECT at Broadmoor. Lancet 1980;1:348-9. |
|26.||Tecoult E, Nathan N. Morbidity of electroconvulsive therapy. Eur J Anaesthesiol 2001;18:511-8. |
|27.||Bertolin-Guillen JM, Peiro-Moreno S, Hernandez-de-Pablo ME. Patterns of electroconvulsive therapy use in Spain. Eur Psychiatry 2006;21:463-70. |
|28.||Nelson AI. A national survey of electroconvulsive therapy use in the Russian Federation. J ECT 2005;21:151-7. |
|29.||Motohashi N. Present status of ECT in Japan and U.S.A. Brain Sci1999;21:131-7. |
|30.||Chanpattana W, Kojima K, Kramer BA, Intakorn A, Sasaki S, Kitphati R. ECT practice in Japan. J ECT 2005;21:139-44. |
|31.||Levin A. Human-rights charges lead Turkey to alter ECT practices. Psychiatr News 2006;41:14. |
|32.||Leung CM, Xiang YT, He JL, Xu HL, Ma L, Fok ML, et al. Modified and unmodified electroconvulsive therapy: A comparison of attitudes between psychiatrists in Beijing and Hong Kong. J ECT 2009;25:80-4. |
|33.||Chanpattana W, Kramer BA. Electroconvulsive therapy practice in Thailand. J ECT 2004;20:94-8. |
|34.||Chanpattana W, Kramer BA, Kunigiri G, Gangadhar BN, Kitphati R, Andrade C. A survey of the practice of electroconvulsive therapy in Asia. J ECT 2010;26:5-10. |
|35.||Andrade C. Unmodified ECT: Ethical issues. Issues Med Ethics 2003;11:9-10. |
|36.||Andrade C. ECT: A measured defence. Issues Med Ethics 2003;11:44-5. |
|37.||Pond D. ECT: Balancing risks and benefits. BMJ 1980;280:403. |
|38.||Crammer J. Unmodified ECT. Lancet 1980;1:486. |
|39.||Maggs R. Unmodified ECT. Lancet 1980;1:599. |
|40.||Agarwal AK. Minimum standards of care in ECT practice. Arch Indian Psychiatry 2000;6:28-30. |
|41.||Trivedi JK, Mahendru S. ECT practice in India: Special considerations. Arch Indian Psychiatry 2000;6:123-6. |
|42.||Shah N, Rassiwala F. Electroconvulsive therapy: Direct or unmodified technique. Arch Indian Psychiatry 2000;6:142-4. |
|43.||Bebbington P, Birley JLT, Clare AW, Cutting J, Kumar R, Mann A, et al. Unmodified ECT. Lancet 1980;1:599. |
|44.||Wilkinson DG, Shanks M, Prendergast M, Cordess C, Thompson P, Colledge J, et al. Umodified ECT. Lancet 1980;1:599. |
|45.||Channabasavanna SM. Indian psychiatry at the crossroads: What we can do with what we have. Indian J Psychiatry 1992;34:67-77. |
|46.||Andrade C. Unmodified ECT: A note of caution. Indian J Psychiatry 1995;37:99-100. |
|47.||Shukla GD. Modified versus unmodified ECT. Indian J Psychiatry 2000;42;445-6. |
|48.||Gada M, Cholera R, Abhyankar RR. Practical guidelines for clinical use of electroconvulsive therapy: Consensus recommendations. Arch Indian Psychiatry 2000;6:135-41. |
|49.||Andrade C. Modified ECT in Goa. Psychiatry Update 1999;5:20. |
|50.||World Health Organization. WHO Resource Book on Mental Health, Human Rights, and Legislation. Geneva: World Health Organization; 2005. |
|51.||Abou-Saleh MT, Christodoulou G. The WPA position statement on the ethics of the use of unmodified electroconvulsive therapy. Arab J Psychiatry 2009;20:57-65. |
|52.||Lehndorff H. Deformities of vertebral column and ribs in cases of severe tetanus. Wien Med Wochenschr 1907;67:2477. |
|53.||Cook LC, Sands DE. Spinal injuries in convulsive therapy. J Ment Sci 1941;87:230. |
|54.||Reed GE, Dancey TE. Compression fractures of vertebral bodies following induced and "idiopathic" convulsions. CMAJ 1940;42:38. |
|55.||Easton NL, Sommers J. Veertebral fractures in metrazol therapy with and without use of curare as supplement. J Nerv Ment Dis 1944;99:256. |
|56.||Dewald PA, Margolis NM, Weiner H. Vertebral fractures as a complication of electroconvulsive therapy. JAMA 1954;154,981-4. |
|57.||Datto C, Rai AK, Ilivicky HJ, Caroff SN. Augmentation of seizure induction in electroconvulsive therapy: A clinical reappraisal. J ECT 2002;18:118-25. |
|58.||Kendell RE. The present status of electroconvulsive therapy. Br J Psychiatry 1981;139:265-83. |
|59.||Pitts FN Jr. Medical physiology of ECT. In: Abrams R, Essman WB, editors. Electroconvulsive therapy: Biological Foundations and Clinical Applications. Lancaster: MTP Press Ltd; 1982. p. 57-89. |
|60.||Kellner CH, Aloysi A, Popeo DM. Benzodiazepine-Modified Electroconvulsive Therapy (ECT). J ECT 2011;27:268. |
|61.||Ohaeri JU, Hedo CC, Enyidah SN, Ogunniyi AO. Tissue injury-inducing potential of unmodified ECT: Serial measurement of acute phase reactants. Convuls Ther 1992;8:253-7. |
|62.||Andrade C, Thyagarajan S, Vinod PS, Srikanth SN, Rao NSK, Chandra JS. Effect of stimulus dose and number of treatments on ECT-induced retrograde amnesia. Indian J Psychiatry 2002;44(supplement):29. |
|63.||Taylor P. Agents acting at the neuromuscular junction and autonomic ganglia. In: Hardman JG, Limbird LE, Gilman AG, editors. Goodman and Gilman's The Pharmacological Basis of Therapeutics. New York: McGraw-Hill; 2001. p. 193-213. |
|64.||Waghmare A, Kumar CN, Thirthalli J. Suxamethonium induced prolonged apnea in a patient receiving electroconvulsive therapy. Gen Hosp Psychiatry 2010;32:447.e1-2. |
|65.||Omprakash TM, Surender P. Prolonged apnea following modified electroconvulsive therapy with suxamethonium. Indian J Psychol Med 2011;33:191-3. |
|66.||Williams J, Rosenquist P, Arias L, McCall WV. Pseudocholinesterase deficiency and electroconvulsive therapy. J ECT 2007;23:198-200. |
|67.||Swartz CM. Anesthesia for ECT. Convuls Ther 1993;9:301-16. |
|68.||Mallon WK, Keim SM, Shoenberger JM, Walls RM. Rocuronium vs. succinylcholine in the emergency department: A critical appraisal. J Emerg Med 2009;37:183-8. |
|69.||Kadar AG, Kramer BA, Barth MC, White PF. Rapacuronium: An alternative to succinylcholine for electroconvulsive therapy. Anesth Analg 2001;92:1171-2. |
|70.||Tharyan P, Saju PJ, Datta S, John JK, Kuruvilla K. Physical morbidity with unmodified ECT: A decade of experience. Indian J Psychiatry 1993;35:211-4. |
|71.||Andrade C. Decreasing adverse outcomes associated with unmodified ECT: Commentary. J ECT 2012 (in press). |
|72.||Lingley JR, Robbins LL. Fractures following electroshock therapy. Radiology 1947;48:124-8. |
|73.||Meschan I, Scruggs JB Jr, Calhoun JD. Convulsive fractures of dorsal spine following electric-shock therapy. Radiology 1950;54:180-93. |
|74.||Andrade C, Rele K, Sutharshan R, Shah N. Musculoskeletal morbidity with unmodified ECT may be less than earlier believed. Indian J Psychiatry 2000;42:156-62. |
|75.||Andrade C, Shah N, Venkatesh BK. The depiction of ECT in Hindi cinema. J ECT 2010;26:16-22. |
|76.||Miller AL, Faber RA, Hatch JP, Alexander HE. Factors affecting amnesia, seizure duration, and efficacy in ECT. Am J Psychiatry 1985;142:692-6. |
|77.||James BO, Omoaregba JO, Olotu OS. Nigerian medical students attitudes to unmodified electroconvulsive therapy. J ECT 2009;25:186-9. |
|78.||James BO, Omoaregba OJ, Igberase OO, Olotu SO. Unmodified electroconvulsive therapy: Changes in knowledge and attitudes of Nigerian medical students. Afr Health Sci 2009;9:279-83. |
|79.||Andrade C. What is the patient's perspective? Issues Med Ethics 2003;11:101. |
|80.||Caplan G. Electrical convulsion therapy in the treatment of epilepsy. J Ment Sci 1946;784-93. |
|81.||Huddleson JH, Gordon HL. Fractures in electroshock therapy as related to roentgenographic spinal findings. Mil Surg 1946;98:38-9. |
|82.||Worthing HJ, Kalinowky L. Question of vertebral fractures in convulsive therapy and in epilepsy. Am J Psychiatry 1942;98:533-7. |
|83.||Mukherjee S, Debsikdar V. Unmodified electroconvulsive therapy of acute mania: A retrospective naturalistic study. Convuls Ther 1992;8:5-11. |
|84.||Andrade C, Chanpattana W, Kramer BA, Kunigiri G, Gangadhar BN, Kitphati R. The practice of ECT in Asia: Variations, and deviations from the guidelines - A response to Dr. Grunhaus. J ECT 2010;26:34-6. |
|85.||Polatin P, Linn L. Orthopedic and neurologic follow-up study of vertebral fractures in shock therapy. Am J Psychiatry 1949;105:824-7. |
|86.||Andrade C. Psychopharmacology. In: Bhugra D, Ranjith G, Patel V, editors. Handbook of Psychiatry: A South Asian Perspective. New Delhi: Byword Publishers; 2005. p. 517-52. |
|87.||Okoromah CN, Lesi FE. Diazepam for treating tetanus. Cochrane Database Syst Rev 2004;1:CD003954. |
|88.||Bultitude MI, Wellwood JM, Hollingsworth RP. Intravenous diazepam: Its use in the reduction of fractures of the lower end of the radius. Injury 1972;3:249-53. |
|89.||Pettinati HM, Stephens SM, Willis KM, Robin SE. Evidence for less improvement in depression in patients taking benzodiazepines during unilateral ECT. Am J Psychiatry 1990;147:1029-35. |
|90.||Lacey DJ. Status epilepticus in children and adults. J Clin Psychiatry 1988;49 Suppl:33-6. |
|91.||Korttila K, Mattila MJ, Linnoila M. Prolonged recovery after diazepam sedation: The influence of food, charcoal ingestion and injection rate on the effects of intravenous diazepam. Br J Anaesth 1976;48:333-40. |
|92.||Rao SS, Daly JW, Sewell DD. Falls associated with electroconvulsive therapy among the geriatric population: A case report. J ECT 2008;24:173-5. |
|93.||Evers AS, Crowder CM. General anesthetics. In: Hardman JG, Limbird LE, Gilman AG, editors. Goodman and Gilman's The Pharmacological Basis of Therapeutics. New York: McGraw-Hill; 2001. p. 337-65. |
|94.||Wong SF, Chung F. Succinylcholine-associated postoperative myalgia. Anaesthesia 2000;55:144-52. |
|95.||Reti IM, Torres J, Morad A, Jayaram G. Pseudocholinesterase deficiency in an ECT patient: A case report. Psychosomatics 2011;52:392-3. |
|96.||Brill NQ, Crumpton E, Eiduson S, Grayson HM, Hellman LI, Richards RA. Relative effectiveness of various components of electroconvulsive therapy. Arch Neurol Psychiatry 1959;81:627-35. |
|97.||Sackeim HA, Decina P, Kanzler M, Kerr B, Malitz S. Effects of electrode placement on the efficacy of titrated, low dose ECT. Am J Psychiatry 1987;144:1449-55. |
|98.||Sackeim HA, Prudic J, Devanand DP, Kiersky JE, Fitzsimons L, Moody BJ, et al. Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 1993;328:839-46. |
|99.||Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000;57:425-34. |
|100.||Gangadhar BN, Janakiramaiah N, Jayaprakash MS, Parameshwara G. ECT Administration Manual. Bangalore: NIMHANS; 1997. |
Professor and Head, Department of Psychopharmacology, National Institute of Mental Health and Neurosciences, Bangalore 560 029, Karnataka
Source of Support: None, Conflict of Interest: None