VIEWPOINT/PERSPECTIVES (THEMESECTION: MENTAL HEALTH CAREBILL, 2013)
Year : 2015 | Volume
: 31 | Issue : 2 | Page : 148--152
Mental Health Care Bill 2013: The Place of Electroconvulsive Therapy
Bangalore N Gangadhar, Channaveerachari Naveen Kumar, Jagadisha Thirthalli
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
Bangalore N Gangadhar
Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru - 560 029, Karnataka
Electroconvulsive therapy (ECT) is one of the oldest medical treatments in psychiatry. The practice has evolved over the years, and the indications have become better defined now. Notwithstanding these, it remains a highly regulated and scrutinized practice. Indian laws specifically related to ECT do not exist till date though this would change if the purported mental health care bill 2013 becomes the law of the land. ECT gets both direct and indirect mention at various places in the bill with far-reaching consequences impacting patients, families, and the professionals. Ban on “ECT as an emergency treatment option” and on “unmodified ECT” is being sought. In addition, ECT in minors is slated to come under stricter regulation. ECT could also get implicated under the “advance directives” provisions of the bill. This naturally has triggered vociferous debates throughout the country between the supporters as well as detractors of ECT. A number of ethical, professional, logistic, and clinical concerns are being discussed. In this background, we attempt to critically evaluate the bill with regard to ECT in the background of the existent scientific and legal literature. We provide possible future directions with regard to ECT practice and its regulation.
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Gangadhar BN, Kumar CN, Thirthalli J. Mental Health Care Bill 2013: The Place of Electroconvulsive Therapy.Indian J Soc Psychiatry 2015;31:148-152
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Gangadhar BN, Kumar CN, Thirthalli J. Mental Health Care Bill 2013: The Place of Electroconvulsive Therapy. Indian J Soc Psychiatry [serial online] 2015 [cited 2021 Sep 29 ];31:148-152
Available from: https://www.indjsp.org/text.asp?2015/31/2/148/173295
Electroconvulsive therapy (ECT), while being one of the most effective treatment modalities for certain psychiatric disorders is also a highly scrutinized and regulated practice. Many factors including the defective capacity (to consent for treatment) of the patient, myths, feared adverse effects, inadequate awareness among the public, negative media portrayal over the years, as well as aspirations and persuasions of the patient advocacy groups have all contributed to this situation. In India, no laws directly regulating ECT practice existed till date. ECT was being looked at as one of the treatment options for mental disorders and the laws (e.g., mental health act, 1987) governing treatment aspects, in general, were also applicable for ECT. This scenario could change if the current mental health care bill (MHCB) 2013 becomes the law of the land. The MHCB-2013 is awaiting clearance by the parliament. Regulation of ECT practice gets a direct mention in the bill thrice: Clause 103 (3; Chapter XII: Admission, treatment, and discharge) states that at any cost, option of ECT cannot be exercised during “emergency treatment.” Subsection 1 of clause 104 (Chapter XII) prohibits (a) ECT without the use of muscle relaxants and anesthesia and (b) ECT for minors (those below 18 years of age). In case, a psychiatrist opines that ECT is required for a minor, prior permission of a duly constituted board in addition to the consent of the guardian is required before administering ECTs. In addition, the proposed law may influence ECT practice in the context of “advance directives.” These issues are being debated throughout the country, and a number of ethical, professional, logistic, and clinical issues are being raised. In this background, we attempt to critically evaluate the bill with regards to the “place of ECT.” In addition, we provide possible future directions to look for with regards to ECT practice and its regulation.
Electroconvulsive Therapy as an Emergency Treatment Option
Clause 103 of the MHCB-2013 deals with “emergency treatment” of persons with mental illnesses. It states:… Notwithstanding anything contained in this act, any medical treatment, including treatment for mental illness, may be provided by any registered medical practitioner to a person with mental illness either at a health establishment or in the community, subject to the informed consent of the nominated representative, where the nominated representative is available, and where it is immediately necessary to prevent:
Death or irreversible harm to the health of the person; orThe person inflicting serious harm to himself or herself or to others; orThe person causing serious damage to property belonging to himself or herself or to others where such behavior is believed to flow directly from the person's mental illness.
Further, the clause also goes on to mention thus nothing in this section shall allow any medical officer or psychiatrist to use ECT as a form of treatment. This essentially implies that even in cases of dire necessities, ECT shall not be used in cases of psychiatric emergencies. This issue surprisingly has received scant attention and debate in the country. This provision in our opinion would deprive patients (and indirectly their family members), a life-saving treatment option in emergency situations. This would be a violation of ethical principles of treatment as well. ECT's efficacy is undisputedly established in different kinds of emergency situations viz., catatonia, acute suicidality as part of depression or psychotic processes, severe aggression/arousal as part of mood disorders/psychotic disorders, rapidly deteriorating physical status due to complications of depression, neuroleptic malignant syndrome, etc. Emergency psychiatric conditions are among the primary indications of ECT that appear in all major treatment guidelines on ECT.,,, Despite these realities, the ECT's prohibition under 103 clause does not have justification. In addition, it is not clear in the bill as to why ECT should not be used as an emergency treatment option. This particular clause can be questioned on scientific and ethical grounds. The bill is also silent on the issue of what to do when patients/families ask for ECT as a treatment option during emergency conditions. This clause 103 is not only unscientific but also unethical in denying much required treatment. In addition, this clause is against article 21 of the Indian Constitution (right to life and liberty). ECT is a potentially life-saving treatment option in emergency situations. A review of legal provisions from developed countries such as Canada, the United States of America (USA), the United Kingdom, or Australia  reveals that none of them ban ECT in emergency situations at least for adults. Revoking this provision from MHCB-2013 would help patients/families when confronted with life-threatening psychiatric emergencies.
Modified Versus Unmodified Electroconvulsive Therapy
Once the MHCB-2013 becomes the law, unmodified ECT would be banned totally. This issue has seen the maximum debate and even now continues to generate strong opinions both for and against. The detractors of this modality invoke the apparent “barbarity” of the procedure, higher risk of musculoskeletal complications and lack of ethical justifications (in terms of beneficence and nonmaleficence) against recommending its use. On the other, ground realities appear to be different. Unmodified ECT is still very much used in several centers in India because of a variety of practical and logistic reasons. This practice is unlikely to stop soon. Professional bodies such as the Indian Association of Private Psychiatrists (endorsed by the Indian Psychiatric Society; the largest conglomeration of psychiatrists in India) have favored its continuance. Hence, the ban would be against the view of the majority of psychiatrists of the country. In addition, a complete ban on the use of unmodified ECTs would deny an efficacious treatment option to a considerable proportion of patients. In this context, it would be prudent to review certain statutory provisions related to ECT.
Laws pertaining to electroconvulsive therapy in developed countries
In the developed world, the practice of unmodified ECT is nonexistent. Only modified ECTs are prescribed. Even this practice is highly regulated though smaller proportions of psychiatric patients are prescribed ECT when compared to India. In the USA, ECT remains the most regulated among all the medical treatments that are currently available. Different states have formed their own administrative codes and legislations related to ECT. Though there are differences in standards of care for ECT, some commonalities exist as well. For example, most of these legislations require clearance from the court for administering ECT for involuntary patients. Even in the United Kingdom, ECT is a procedure requiring multiple levels of clearances before it is administered to involuntary/incapacitated patients. For such cases, apart from the treating consultant, an independent medical practitioner (designated for the purpose by the Mental Act Commission) needs to examine the patient and concur with the decision. In Western Australia too, while considering ECT to involuntary and mentally impaired patient, apart from the recommendation by the treating psychiatrist, an independent psychiatrist needs to approve the same.
Electroconvulsive therapy and the legal perspective in India
ECT has been dragged to court in a couple of instances: Way back in 1998, the high court of Bombay has favored modified ECT for patients. Notably, it has not restricted or banned unmodified ECT. In 2001, a nongovernmental organization petitioned the supreme court of India requesting among other issues, directives for banning unmodified ECT, and establishing a process for sanctioning modified ECT without consent. The verdict of the court on this petition, with regard to ECT, is still awaited.
It appears that a larger and more comprehensive process of consensus building is in order to resolve this controversy regarding unmodified ECT. Wider deliberation involving all stake holders could throw better light in easing the confusion. In this regard, it may be noted that the views/opinions of the users are not considered in the promulgation of this provision. As pointed out by Gangadhar, what are the provisions of the bill in case patient/family members prefer unmodified ECT for a variety of reasons? Is it not unethical and unjustified to deny unmodified ECT in such situations? Although the available literature on patients/family members' knowledge and attitude on ECT favors the treatment, their attitude and preferences on “unmodified ECT” has not been adequately explored at all. More information on this issue is clearly needed. Taking into account users' perspective also in decision making is another way out of solving this dilemma. What about adverse effects of anesthesia relative to those of unmodified ECT? A direct way of resolving whether unmodified ECT is safer or not is to compare the complications associated with unmodified ECT and those of anesthesia in a prospective randomized clinical trial. Unfortunately, this line of research with acceptable standards has not been pursued and may even be impractical to conduct. Another relevant issue is the one that “targets” ECT alone for regulation. Why is that only ECT needs to be regulated while other forms of treatments including depot medications, clozapine, etc., do not have any specific clauses for their regulation? For example, clozapine is associated with potentially life-threatening adverse effects (albeit rarely) including agranulocytosis and myocarditis. Typical antipsychotics especially depot antipsychotics can cause serious adverse effects, albeit rare, in the form of neuroleptic malignant syndrome or tardive dyskinesias. Notably, their prescription is not regulated by any specific restrictions. There are no clear answers for this dilemma. If adverse effects of these modes of treatment are weighed against those of ECT, it may so happen that ECT is a safer treatment option. Again, we do not have any literature on this particular issue.
Hence in the light of all these issues, how to go forward with regards to the practice of ECT in the country? Apart from the issue of patient preference, the other way forward could be related to the levels of accreditation of ECT facilities. For example, at level A, the facility can provide modified ECT with electroencephalographic monitoring; at level B, modified ECT without EEG monitoring; and at level C, only unmodified ECT. Patients can make an informed choice of the level of care they prefer or can afford. We need to think seriously of setting up accreditation of treatment facilities especially related to ECT. We must build into our system the scope for education to patients/families. This will help optimal utilization of the bill in the interest of the psychiatric patient/family. Other way out of this controversy could be bringing in an additional layer of regulation to the decision making instead of completely banning it. For example, in the United Kingdom, giving ECT to an “incapacitated” patient who is noncompliant is possible under their statutes. In order for these provisions to be applied, a doctor appointed by the mental health act commission will have to assess the patient and authorize the treatment. In addition, it is a requirement that the proposed maximum number of treatment sessions is specified. In addition, when emergency or urgent treatment is required, ECT may be given under the condition that it is necessary for one of the following purposes: (a) To save the patient's life; (b) to prevent a serious deterioration; (c) to alleviate serious suffering; and (d) as the minimum necessary to prevent the patient from behaving violently or being a danger to himself or herself or to others. Likewise, in India, the treatment can be allowed after an independent psychiatrist (appointed by the mental health review commission or otherwise) endorses the original decision of the treating team. Here, the issue of “capacity to consent” also can factor in. If the patient has full capacity to consent as determined by the treating psychiatrist (requiring him/her to testify this in writing) and he/she agrees for unmodified ECT, then this could be allowed without any further restrictions. In cases where patients are deemed to lack the capacity to make independent and voluntary treatment decisions, provisions could be made for obtaining independent opinion/endorsement for using unmodified ECT. For this to materialize, there should be the mechanism of educating the patients and/or their family members regarding the pros and cons of unmodified ECTs. The following issue has philosophical connotations: Any law of the land needs to reflect the collective aspirations of its society because the law is to be followed by its own people. Going by the vehement and strong “for” and “against” opinions, there is enough scope for a neutral observer to speculate that this particular clause may not reflect that “collective aspiration.” Finally, it should be noted that the authors of this paper do not hold a supportive view toward unmodified ECTs. There can be no justification for not striving toward making all treatment facilities in the country compliant to modified ECTs. If the government is serious about stopping the use of unmodified ECT, then it should be equally serious in making modified ECT accessible and affordable at taluk or at least district level across the country. This may be achieved by making sure government anesthetists are available at taluk level (else provide remuneration to private anesthetist for providing anesthesia during ECT) so that poor patients would not have to pay more for ECT just because unmodified ECT is prohibited. Until such a consensus is reached on the use of unmodified ECT, the issue of completely banning unmodified ECTs could be set aside.
Advance directives and electroconvulsive therapy
”Advance directives” is another issue that can impact on ECT administration. Advance Directives are statements reflecting patients' aspirations about future treatments in case they fall ill again (clause-5). These are supposed to be given by patients during their “well” periods. In addition, “… it shall be the duty of every medical officer in charge of a mental health establishment and the psychiatrist in charge of a person's treatment to propose or give treatment to a person with mental illness, in accordance with his valid advance directive.” Some patients may foresee the need for ECT in the next episode of illness with an advanced directive to receive ECT with/without modification. In such a situation, the treating psychiatrist's options are limited, and he/she will have to follow the directives. On the other, patients could opt out of a potentially helpful treatment irrespective of reasons for its use. Therefore, the clause of “advance directives” deserves a second look.
Electroconvulsive Therapy in Minors
Clause 104 of the MHCB seeks to ban ECT in minors (for those below the age of 18). Again, this particular issue has generated criticism by professionals and has not been received well. As opined by Balhara and Mathur, ECT among children and adolescents has been used particularly for those with resistant severe mental disorders. Though ECT for minors has been in vogue for the past seven decades, it is used sparingly when compared to adults. Accordingly, there is very less research evidence on this issue. There are hardly any controlled studies on ECT in minors. In addition to the rarity of ECT use, serious ethical issues preclude such studies in the near future. However, it is notable that the available scientific information depicts ECT for minors in not-so-negative position. There are two notable retrospective reports on ECT experience for children and adolescents from India. Grover et al. evaluated retrospectively the clinical profile and effectiveness of ECT in adolescents aged between 13 and 18 years. A total of 39 eligible patients had received ECTs during the years 1999-2011. Schizophrenia (n = 14; 56%) was the most common diagnosis followed by depression (n = 3; 12%). ECT was given as a first choice treatment for about three-fourths of the patients (n = 19; 76%). On an average, each patient received 10 ECTs during their respective treatment course. The mean (standard division) response rate to ECT was 76%. Prolonged seizures, nausea and vomiting, and headache were reported in 2 cases each. The authors concluded that ECT is used less frequently in children and adolescents compared to adults. In addition, they opine that ECT is an effective treatment choice for severe psychiatric disorders in adolescents and is associated with the same frequency of adverse effects as the adults. In another retrospective chart review, Jacob et al. studied the pattern and practice as well the outcome of ECT in children and adolescents admitted to a tertiary care child psychiatry center. During the 10 years studied, 22 children had received ECT. All had received modified ECT. Majority of them were severely ill. Catatonia was the most common reason for ECT prescription (n = 12; 54%). ECT was efficacious in 77.3% patients. Most patients experienced no acute side effects. 15 of the 22 who were on follow-up did not experience any long-term adverse effects due to ECT. The authors conclude that ECT has a place in the acute management of severe mental disorders in children. Call for prospective studies was another conclusion. Going by the available evidence, ECT in minors seems to have an important role in the management of severe mental disorders. Absence of proof is not proof of absence. Prohibiting the use of ECT at this juncture would not only stop furtherance of the scientific quest in the area but also can result in depriving this important therapeutic tool for those children with severe mental disorders. Even here, an extra layer of regulation can be introduced before posting a minor for ECT. An example of this is to have concurrence with a psychiatrist unrelated to the child's care. However, considering the urgency of the clinical situation, a mechanism needs to be built for faster processing.
Conclusions and Future Directions
In the background of the issues discussed above, it appears ECT deserves a better deal in the MHCB-2013. A more comprehensive and wider process of consensus building would clear the controversies surrounding this issue. Having restrictions on well-established and efficacious treatment modality would discourage clinicians from using ECT. Building in adequate checks and balances for judicious use of ECT is the need of the hour.
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Conflicts of interest
There are no conflicts of interest.
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