From a historical perspective László Meduna, Hungarian Neuropsychiatrist was the first to introduce convulsive therapy (COT) to treat a patient named L. Zoltán with 4 years of catatonic stupor. The Convulsive Therapy (COT) resulted in the remission of the catatonic stupor and psychotic symptoms. Initially intramuscular camphor was used to induce convulsions, later replaced with Cardiazol. Later these circumstances inspired Ugo Cerletti and Lucio Bini to use electricity as tool for inducing seizures. The growing database of research evidence for neurobiological mechanisms exerting the therapeutic effects has replaced Meduna's earlier concept regarding the antagonistic relationship between schizophrenia and epilepsy 1.

Electroconvulsive therapy (ECT) can ameliorate the neuropsychiatric symptoms providing rapid, significant improvement in a few mental health conditions 2. Even after 80 years ECT is still used for treatment³ of:

Mental Healthcare Act 2017 replaced the extant Mental Healthcare Act 1987 which had been broadly critiqued for banning “ECT as an emergency treatment option” and for implementing "unmodified ECT". In addition, ECT in minors is anticipated to come under stringent regulation. The new clauses of bill made ECT, to include under the “advance directives”4.

During the COVID-19 pandemic ECT still remains as critical and live saving treatment modality for in the following set of patients5:

Convulsive therapy was initially used as a curative procedure for schizophrenia. Nevertheless, it was soon found to be even more effective for the treatment of affective disorders. Severe depression is the most common indication for ECT. Apart from treating depression cases ECT is also useful in treating suicidal cases. Therefore, in patients at high risk of suicide ECT is recommended as the first choice of treatment. In several developing countries ECT remains the treatment of choice for schizophrenia even in India3.

Although antipsychotic medications are similarly successful in treating schizophrenia, resistance to pharmacotherapy and financial constraints gives the rationale for common application of ECT in India. The augmentation of anti-psychotic drugs with ECT may enhance their effect which was observed in clozapine-resistant patients. Catatonia, pregnancy depression and postpartum psychotic states are conditions that respond well to ECT3.

Electroconvulsive Therapy is a procedure, done under anesthesia where a brief electrical stimulation of the brain is done. It is typically administered by a team of trained medical experts that comprises an anesthesiologist, psychiatrist and a nurse.

The patient shall be evaluated thoroughly before subjecting to ECT. The following are carried out:

The duration of ECT procedure usually takes about 5 to 10 minutes, with extra time to prepare and recover. ECT is done as an inpatient procedure.

Before commencing the procedure, the patient is administered general anesthesia. Electrode pads are positioned on the patient’s head. ECT can be one-sided, where electrical currents applied on only one side of the brain (right unilateral placement), or two sides (bitemporal), where the brain receives concentrated electrical currents to both sides10.

Patient is administered IV medications including an anesthetic and a muscle relaxant while starting the procedure. During the process the doctor shall monitor the heart rate, blood pressure, brain, and oxygen level. The patient is provided with safety measures for oral protection to prevent from teeth and other intra oral injuries. Internally, activity in patient’s brain increases acutely. An electroencephalogram (EEG) test records the electrical activity of the brain. Patient is shifted to recovery room after the procedure is over and monitored.

Few of the adverse effects of ECT11 include:

Attempts have been made to reduce the cognitive side effects of memory impairment by shifting from brief to ultra-brief pulse stimulation12. While a few patient summaries reported long lasting and severe memory disturbances after ECT. Psychological tests could not detect significant memory deficits beyond period of six months following a course of ECT.

The patient can recommence the normal activities a few hours after the treatment. However, few individuals may be instructed not to resume working, making important decisions and driving for up to one to two weeks after 24 hours after one treatment during maintenance therapy. Alleviation of confusion and improvement of memory loss dictate resumption of day to day activities by the individual.

After about six treatment series with electroconvulsive treatment majority of patients, improvement in their symptoms are observed. However, complete improvement may take a long time and ECT might not be effective in a few10. The exact mechanism as to how ECT helps in the treatment of affective disorders, schizophrenia and psychotic states is not clear. It is well-known; however, that many of the chemical components of brain function are altered during a coma. Along with the earlier discussed mechanisms the ECT may be effective.

Indian mental health professionals are worried about the limitations placed on ECT and the insufficient mental health resources. It is essential that all parties, especially those responsible for funding, receive more education on the Mental Healthcare Act of 2017 to avoid restricting ECT in India13.

The Mental Healthcare Act of 2017 (MHCA) has significantly changed India's mental health laws to align with the United Nations Convention on the Rights of Persons with Disabilities (CRPD). This law prioritizes patient-centered mental health rights and represents a paradigm shift. The implementation of CRPD and MHCA has faced criticism, and many psychiatrists have concerns about the changes, particularly in regards to electroconvulsive therapy (ECT)14, 4, 15.

The implementation of the Mental Healthcare Act of 2017 (MHCA) will significantly affect the use of electroconvulsive therapy (ECT) in India. The new law replaces involuntary admissions with supported admissions (Sections 89-90), and while ECT can be administered to supported patients, it involves several regulatory and administrative requirements. The MHCA's Section 95 prohibits unmodified ECT (i.e., without anesthesia), and ECT can only be performed on minors with the consent of their guardians and the Mental Health Review Board (MHRB). Additionally, Section 94 prohibits ECT in emergency situations outside of mental health institutions14.

ECT is a common treatment method in India, with one survey of 66 hospitals identifying nearly 20,000 patients who underwent over 110,000 ECT sessions in one year. Over half of these patients received unmodified ECT. Some psychiatrists are concerned that the restrictions on ECT in the MHCA could result in certain patients being denied life-saving treatments. However, others have raised ethical concerns about ECT in India, and negative media portrayals have increased stigma surrounding the practice16.