Underutilization of Electroconvulsive Therapy (ECT): A Call for Urgent Attention

The geriatric psychiatry team of the National Institute of Mental Health & Neurosciences (NIMHANS), Bengaluru, India, recently treated a 63-year-old highly accomplished finance professional. Hailing from India, he held a high-level position at a finance company in a foreign country. He had a two-year history of having low mood, anhedonia, agitation, social withdrawal, severe anxiety and panic attacks, delusions of nihilism and persecution, and passive death wishes. He had resigned from his high-paying job and shifted to India owing to his psychotic symptoms and agitation. Variously diagnosed with depression, bipolar disorder, and schizophrenia, he was treated by psychiatrists in different hospitals, including a reputed academic institute in India, with combinations of antidepressants and antipsychotics, with very little improvement. Rather, his overall condition continued to worsen—he started refusing food; his agitation worsened, and he suffered from severe extrapyramidal symptoms and serotonin syndrome. He developed seizures and severe constipation while on clozapine 300 mg/day; this led to intestinal obstruction, altered sensorium, and aspiration pneumonia. He needed multiple medical and surgical interventions and an ICU stay for weeks. No psychiatrist advised electroconvulsive therapy (ECT) through these two years of immense suffering and frequent hospitalizations.

At NIMHANS, he was initially evaluated as an outpatient. He was diagnosed as having severe depressive episode with psychotic symptoms, ¹ for which he was advised ECT for rapid relief of symptoms. The patient and his caretakers refused it. The notion of it being a “major intervention reserved for only the worst patients,” worries about adverse effects, including cognitive deficits, and several other negative remarks found on the internet influenced their decision to refuse ECT. After two months of his continued suffering, as there was no improvement, they reluctantly agreed and consented to ECT. His condition dramatically improved within the first few sessions of bilateral ECT. After 11 sessions of ECT, his depressive symptoms were better by around 75% (according to the patient and his caretakers), and contrary to what was feared, there was an improvement in his cognitive functions. He could not attempt cognitive assessment before ECT due to agitation; he could attempt cognitive assessment after three ECTs, and his performance on Addenbrooke’s cognitive examination (ACE) ² was 65/100. It improved to 83/100 after 11 ECTs. He was also receiving desvenlafaxine 50mg/day and quetiapine 300mg/day at the time of discharge.

This case illustrates the problem of reluctance to use ECT. Several guidelines recommend the use of ECT to treat psychotic depression (see below). This patient prematurely resigned from his high-level post, made a major decision to migrate to India, experienced potentially fatal medical conditions secondary to depression and its treatment, and improved substantially with ECT. One cannot be absolutely certain of it, but the timely use of ECT could have prevented these major events and provided a much better quality of life for him and his family. This case is just the tip of the proverbial iceberg of the serious underutilization of ECT.

Discussion

Who Should Receive ECT?

Several international^3–6 and Indian guidelines ⁷ recommend the use of ECT, with many of them recommending it as first-line treatment for conditions that warrant rapid improvement in patients’ psychiatric condition. This is specifically true if there is a high risk for harm to self or others, serious intolerance to psychotropic medications, refusal of food, fluids, and medications, catatonia, and neuroleptic malignant syndrome. Reluctance to use ECT in such patients results in them receiving alternative treatments with potentially far slower and/or inferior effects, chemical and/or physical restraints, and higher adverse effects in terms of sedation and extrapyramidal symptoms. The ECT is associated with rapid improvement,^3,4,7 and earlier use of ECT is associated with briefer admission and lower cost of care.^8,9 There is little systematic data on the prevalence of such presentations of psychiatric conditions. However, any psychiatrist would vouch that a substantial proportion of his/her patients present with these challenges.

The guidelines also recommend the use of ECT in case of treatment resistance.^3–5,7 The prevalence of treatment-resistant depression is estimated to range from 6% to 55% in the real-world setting. ¹⁰ The prevalence of treatment-resistant schizophrenia is estimated to range from 22% to 33%; ¹¹ about 40–70% of these do not respond adequately to clozapineeither. ¹² For these patients, ECT may be the only option available. ¹³ Clearly, the number of patients who experience treatment-resistant psychiatric conditions that warrant ECT as one of the treatments is large. Besides these indications, patients receive ECT for a number of other indications, including patient preference, for shortening the duration of inpatient care, treatment intolerance (particularly in the geriatric population), etc. A “back-of-the-envelope” calculation suggests that hundreds of thousands of patients would need ECT as prescribed in the international guidelines. However, the trends suggest that the use of ECT is dwindling despite the frequent occurrence of these conditions.

Decline in the Trend of Utilization of ECT

There has been a trend toward a decline in the number of patients treated with ECTs in the US.^14,15 Between 1993 and 2009, the probability of inpatients with depression receiving ECT fell by 34%, ¹⁵ corresponding with a decline in general hospitals that had ECT facilities from about 15% to about 10%, suggesting that lack of availability of ECT procedures had driven this declining trend of the use of ECT. Declining trends in the use of ECT have been documented in many European countries as well. ¹⁶ In some countries, including Switzerland and Italy (ironically, Italy was the country where ECT was invented), ECT is actively discouraged and is available only in a few centers. ¹⁷

Data about the trends in the use of ECT in India is sparse. The Postgraduate Institute of Medical Education and Research, Chandigarh, reported opposing trends in the frequency of the use of ECT over the past few years—a decrease among children and adolescents, ¹⁸ and an increase among the geriatric age group. ¹⁹ The NIMHANS has recorded a substantial increase in the number of ECTs in the elderly; there is a slight increase in the overall number of ECTs for general adults as well (in a conversation with Preeti Sinha, MD, January 2025). A survey, ²⁰ conducted among 188 “teaching institutes and psychiatric hospitals” in 2001–2002, had only a 39.4% response rate; 8 of the 74 centers did not practice ECT. Non-practice of ECT may have been more common in the centers that did not respond.

Barriers to the Use of ECT

As discussed above, a large number of patients would benefit from ECT. In practice, only a small proportion of them actually receive it. Why is it so? There is a 20-fold variation in the proportion of the general population that receives ECT across the countries; this degree of variation is seen even across countries within Europe, which are relatively homogeneous in terms of regional and socioeconomic aspects. ²¹ Clearly, medical, economic, and ethical factors cannot explain this degree of variation. The use of no other treatment depends on factors other than that which are purely medical. Several barriers influence whether patients who may benefit from ECT indeed end up receiving it.

Stigma

The stigma surrounding ECT is an important barrier. Images of the practice of ECT from the days of its use without muscle relaxants and its portrayal in films as a barbaric procedure that causes significant memory loss have contributed a lot to the stigma against it in the general public. Categorization of ECT as an “invasive” procedure, even in some advanced countries, adds to the stigma. ²² Unfortunately, negative attitudes toward ECT are prevalent even among medical professionals, including psychiatrists. As a testimony to this, not uncommonly, colleagues from other medical fields ask ECT practitioners with genuine surprise as to whether ECT is still being practiced and whether it is not banned in advanced countries!

Need for anesthesia

The ECT needs coordination between anesthetists and psychiatrists. Psychiatry colleagues in many medical colleges in India find this coordination hard to achieve. At least in some medical colleges, this has resulted in a complete absence of ECT services. In many private settings, the cost of arranging for anesthesia support becomes prohibitive for the patients. This leads to a gradual reduction and subsequent complete stoppage of ECT services in these centers. The fear of “losing the patient to another practitioner” may preclude private practitioners from referring patients who need ECT to centers that practice ECT.

Cognitive effects

Concerns regarding cognitive adverse effects are another important barrier to the use of ECT. These concerns seem to linger in patients’ and professionals’ minds despite clear evidence that cognitive deficits associated with ECT are temporary, ²³ and in spite of the development of unilateral ECT and brief and ultra-brief ECT, which minimize even the temporary cognitive deficits.

Legislation

The ECT is one of the most legislated treatments in medicine. Stigma, bad press, and myths surrounding the treatment, along with the fact that a large proportion of patients who require ECT lack the capacity to provide informed consent, may have contributed to this. The fact that ECT was allegedly used against political opponents in some countries, such as Cuba, ²⁴ could have an additional role in this. There are wide variations in the way laws regulate the practice of ECT in different countries; in countries like the USA, there are variations even across the states. ²⁵ In general, the legal restrictions pertain to administering ECT when patients cannot consent or for administering ECT to patients younger than 18 years of age. Additional judicial approvals are required to administer ECT in such cases. This acts as an additional barrier to the use of ECT, as documented in some cases where patients have had to travel to different states to receive ECT. ²⁶ In India, ECT cannot be administered to individuals younger than 18 years without the approval of the Mental Health Review Board (MHRB). ²⁷ Though broad guidelines are available to guide the MHRBs in this regard, ²⁸ since MHRBs are not uniformly functional across the country, administering ECT for this age group has become virtually impossible in many districts.

Training

A barrier that is likely to play a major role in restricting the use of ECT in the near future is the lack of training in ECT for psychiatry postgraduate students. Currently, about 1,300 postgraduates in psychiatry are trained every year through both government and private medical institutes across India. ²⁹ Through anecdotal interactions with faculty from many of these institutes, this author understands that in a sizable proportion of these institutes, hands-on training in ECT is literally or nearly absent. Postgraduates studying in these institutes frequently visit private psychiatry centers or other academic institutes where ECT is practiced to get some training in ECT. This results in poor competency and confidence of postgraduates studying in such institutes in planning, preparing for, administering, and monitoring during ECT and post-ECT care. This could result in a large number of psychiatrists in India not using ECT in their practice. Over time, the rarity of using ECT may contribute to a cascade of unfamiliarity, lack of proficiency of the staff in providing ECT, and more negative attitudes. Such concerns have been raised in advanced countries as well.^15,22

Cost

The cost of receiving ECT varies significantly across settings and countries. For instance, in the USA, those with private insurance were more likely to receive ECT than others. ³⁰ The fine print in insurance coverage also can determine the likelihood of receiving ECT. For example, the Polish National Health Fund (NHF) pays only for ECT treatment delivered to severely ill patients in life-threatening conditions. ²² Such clauses potentially deny timely intervention with ECT, causing artificial deterioration of patients’ health to the extent that they would receive ECT when their condition becomes life-threatening. In India, till recently, mental illnesses were excluded from health insurance. Following the Mental Health Care Act (2017), ²⁷ this scenario is likely to change.

Potential Solutions

The case vignette presented at the beginning of this editorial highlights the problem of withholding a treatment that many guidelines^3–7 have prescribed as both first- and second-line treatment for the specific psychiatric problem that he suffered from. This patient was treated in several reputed hospitals in two different countries, including an academic postgraduate center. He suffered potentially fatal as well as several distressing and disabling adverse effects of medications. Yet, there was significant hesitancy on the part of the treating teams to initiate ECT for him. This was indicative of a larger issue of serious underutilization of an effective treatment. This problem has been highlighted by several authors from other countries as well.^15,16 As discussed, there are many barriers to the use of ECTs. How may we overcome these barriers so that deserving patients get the benefits of ECT at the earliest? Here are a few potential solutions.

Serious efforts should be made to demystify and destigmatize ECT

Such efforts should form an integral part of campaigns to destigmatize mental illnesses in general. Professionals and professional bodies should use mass media and social media to bust myths and misconceptions surrounding ECT. The YouTube video from NIMHANS ³¹ is one such example. Contact-based methods, in which patients who have benefited from ECT speak about their experience, may have even higher chances of conveying a realistic message regarding ECT to the public as well as potential beneficiaries.

Hospital administrators should be sensitive to the critical role that ECT plays in the practice of psychiatry

It is critical to ensure that anesthetists support ECT, and patients should not be denied ECT or referred elsewhere for ECT solely due to a lack of anesthetist services. There are reports of psychiatrists or medical officers providing anesthesia for ECT across several countries. ³² However, endorsing such a practice requires comprehensive deliberations, specifically with respect to patients’ safety, the training needs of task-shifting professionals, and the legal ramifications of such a practice.

Lack of access to effective treatment for severe mental illnesses due to cost should be considered unacceptable in contemporary practice

The Government of India, on its part, has ensured that ECT (up to INR 3000/- per session) and pre-ECT investigations (up to INR 10,000/-) are covered under the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (PM-JAY), ³³ making it accessible to eligible beneficiaries. The Mental Health Care Act (2017) ²⁷ has mandated insurance companies to cover the treatment of mental illnesses in their schemes. The utilization of this for ECT has not been documented. We hope that the insurance companies will follow the Act in its letter and spirit, and this might overcome the cost barrier for wider accessibility of ECT.

Conclusions

The importance of addressing the underutilization of ECT cannot be overemphasized. Concerted efforts should be made to overcome this challenge to ensure that deserving patients who have virtually no alternative treatments are not denied effective treatment.

Note

The author is a Co-Principal Investigator in the Clinical Research Center (CRC) in Neuromodulation in Psychiatry, funded by the Department of Biotechnology (DBT) - Wellcome Trust India Alliance (IA/CRC/19/1/610005).