Is electro convulsive therapy, commonly referred to as ECT (some call it shock therapy which is really a misnomer) something to be really afraid of? But before opening the Pandora's box which surrounds the issue, it is important to understand how ECT became one of the most controversial subjects in psychiatric treatments.

ECT began to be used as a cure for schizophrenia after it was observed that people who suffered from both epilepsy and schizophrenia exhibited a considerable decline in the schizophrenic behaviour after an attack of epilepsy. Psychiatrists linked the epileptic convulsions to a decrease in schizophrenia and purported that artificially induced convulsions or epileptic fits could be helpful in controlling schizophrenic fits.

The origin of ECT dates back to research conducted in the 1930's about the effects of camphor-induced seizures in schizophrenics. Italian researchers Ugo Cerletti and Lucio Bini are credited with being the first doctors to give electric shocks to a delusional, hallucinating and schizophrenic man in 1938, to create seizure and induce alteration in the electrical activity of the brain.

Further research and experiments suggested that ECT could be more beneficial for the treatment of depression rather then schizophrenia in cases where psychotherapy and medication failed. ECT, which is said to be a sophisticated treatment, has certain specifications, which lay emphasis on its safe and proper administration.

The single most important aspect is that expert health professionals under the supervision of a psychiatrist are qualified to administer ECT. Treatment usually consists of six to 12 sessions, given three times a week for a month or less. The patient is required to fast for eight to 12 hours prior to the treatment, and is anaesthetized and given muscle relaxant, which reduces muscular contractions during the convulsion.

When these have taken full effect the patient's brain is stimulated with a brief controlled series of electrical pulses using electrodes placed at precise locations, (the motor areas in the brain) on the head. This stimulus causes a seizure within the brain, which lasts for 45 to 60 seconds. The heart rate and other vital organs are monitored throughout the procedure. It is said ECT functions by temporarily altering some of the brain's electrochemical processes.

Psychiatrists agree that the above procedure is safer, effective, far more sophisticated and patient-friendly if compared to the method practised in the West when ECT was newly introduced. Back then it was administered without anaesthesia and muscle relaxants, as modern methods and use of psychiatric drugs and treatment were still nascent.

As a result people began to identify it with something akin to torture when stories of bone fractures taking place during convulsions became an everyday affair. This stirred controversies, which further deepened when complaints of memory loss and relapse were reported by patients receiving ECT.

Moreover, it was speculated that ECT caused brain damage and resulted in impaired cognitive functions. This nurtured mistrust and myths about ECT in people whose belief was already shaky. Their fear of it only increased when observations, which seriously questioned the safety and ethics of ECT became public.

Furthermore, its indiscriminate use to cure a wider range of mental illnesses, cases which could be treated with other available methods, spawned more controversies. Its unnecessary application to control troublesome patients and those who suffered from neurosis, psychosis, schizophrenia, anxiety and depression was disapproved by professionals who supported selective use of ECT.

Besides, some impatient psychiatrists, who overused it, contributed to its negative publicity in the media as well. Some movies depicted terrifying scenes of a patient screaming and sweating in labs while given electric shocks - scenes similar to the one in the Hollywood blockbuster, One Flew Over The Cuckoo's Nest.

ECT was not confined to the labs of psychiatrists. After its abuses became common, some psychiatrists had to face lawsuits filed by those who suffered severe side effects of ECT. This resulted in issuance of strict regulations by the law courts in some states of the US to ensure safe and selective use of ECT. In a way, this was the beginning of the end to its widespread use as psychiatrists began to fear lawsuits, even in cases where they believed ECT was needed.

Perhaps this is the reason, the American Psychiatric Association, (APA) which along with other renowned institutions like the Royal College of Psychiatry that recognizes the effectiveness of ECT, issued strict guiding principles for its mode of administration - this is the most contentious part of ECT. It supports use of ECT when other means of treatment prove ineffective in aiding severe, disabling mental disorders.

The task force report of the APA on ECT says that ECT should not be used only as a last resort, and some medical conditions substantially increase the risks associated with ECT treatment. Elderly patients may be at a greater risk for more persistent confusion and greater memory deficits during and after ECT. It further says that ECT facilities should be appropriately equipped and staffed with personnel to manage potential clinical emergencies.

Much research has been conducted since those dreary days and ECT isn't viewed with that much trepidation. For example, the debate that ECT damages the brain has been countered by studies which claim that ECT artificially stimulates a seizure under controlled conditions. The amount of electricity that enters a brain is low in intensity and short in duration and does not necessarily damage brain tissue.

With regard to memory loss that is associated with ECT, psychiatrists purport the loss is transient and a patient regains it in as little as a week's time. They maintain that any long-term continuing memory loss may be a type of amnesia associated with severe depression. As forarelapse, APA suggests that "ECT can eliminate depression quickly and drugs can serve to reduce relapse rates. The two can be combined for optimum results."

Empirical evidence concerning the efficacy of combining ECT and drug therapy is limited, but it does suggest that the combination of treatment is more effective than ECT alone for relieving depression and reducing relapses. Given the enormous negativity surrounding ECT, one can't help but wonder if there is a danger of death from it. According to some findings cases of death have been rare. In the first few decades of ECT, death occurred in one out of 1,000 patients. Current studies report a very low mortality rate of 2.9 deaths per 10,000 patients.

Considering the amount of information available on the subject, is it easy to determine whether ECT is "good" or "bad"? Are there more plus points than minus ones?

Many argue that earlier fears about ECT are now invalid. ECT secures a place in the good books of psychiatrists who believe that, if given according to the prescribed protocol, ECT is a safe treatment and can give a new lease of life to many untreatable cases of psychotic disorder.

Despite the spin ECT has received from health professionals around the world, it has not significantly uplifted the general perception of it. People continue to be wary of its side effects rather than its benefits. Memory loss, muscle pain, headache and nausea, besides the risk of bone fracture (if the mode of administration is not according to the set standards) are some of the most commonly mentioned side-effects of ECT. These subsequently have generated criticism and dislike in patients and human rights activists. The latter group is known to term it "an abuse of psychiatry".

In recent years, the popularity graph of ECT has gone down considerably, thanks to its much talked about ill effects, that overshadow whatever good it does to the patient.

Dr Syed Haroon Ahmed, a well known psychiatrist of Karachi, said development of newer pharmaceuticals products, research in neurochemistry and brain sciences have limited ECT considerably to a certain class of patients.

Alluding to the situation in the 1960s when its uncontrolled use gave rise to certain complications and misuse, Dr Ahmed highlighted the parameters worked out to ensure its ethical use and prevent its administration in cases where it might not be needed. Identifying the conditions which necessitate ECT, Dr Ahmed believes in the internationally accepted standards of ECT which say that it should be given only to those patients in depression who don't respond to drugs.

"In cases where a patient has not benefited from available antidepressants, and other supportive/combination drugs, and psychotherapies are exhausted, ECT is life saving and as important as an operation," he said.

Effectiveness of using ECT on patients under depression is also mentioned in the 2002 fact sheet of the Royal College of Psychiatry. It states that eight out of 10 depressed patients who received ECT responded well to it. Patients reported that it made them feel "like themselves again", or as if "life was worth living again."

After administration of ECT, severely depressed people became more optimistic and less suicidal. Most patients were able to return to work and lead a productive life after their depression had been treated with a course of ECT.

Dr Ahmed also said that generally 99 per cent of patients respond to drugs. However, those patients who are losing an interest in life or are not taking their medication become a cause for concern, especially those who fall under the senior age group bracket. Their disinterest is similar to a suicidal process, which Dr Ahmed believes "can be controlled with ECT and proper care." He said it could also be given to severely depressed pregnant women if there were chances of the mother or child's life being in danger and additional medication could not be recommended.

Dr Musarrat Hussain, head of department of psychiatry at Jinnah Postgraduate Medical Centre in Karachi, said scounselling, fitness of the patient, his consent, anaesthesia and administration of ECT on the advice and in the presence of a psychiatrist is important. Dr Hussain says that ECT is administered safely at Jinnah Hospital, where all the proper guidelines are followed. "The focus should be on its calculated dose and mode of action," he said, adding that new studies were being taken up to fully understand how ECT functions as it is still not clearly known.

Doctors believe if proper procedure is applied, chances of any risks or adverse side effects of ECT are reduced to a minimum. However, in cases where safety precautions are ignored and the mode of administration is not as humane and sophisticated as it should be, ECT can prove to be an ugly experience.

For instance, a patient who asked to remain anonymous said that after the death of his mother he had become severely depressed. Unable to cope with his condition, he went to a private psychiatric hospital in Nazimabad in Karachi. "The psychiatrist did not ask me much about my mental state, and in the first meeting I was taken for ECT. My consent was not sought, neither was I told what ECT is all about."

The gentleman in his mid-fifties recounted how four people carried him to the ECT room where he was given shocks, without anaesthesia and muscle relaxants. "I kept shouting and wanted to run away. In my forceful attempts to escape from their grip and also as a result of the jerks, I broke both my knee joints." He was crippled and confined to bed rest for about two years, which only further aggravated his mental condition. With five mouths to feed, he was faced with financial problems, as he could not go to work.

It has been years since this dreadful incident happened, and he still can't seem to forget the trouble and pain he faced in the name of psychiatric treatment. "I did not take any legal action against that doctor, though I still recognize him."

Talks with practicing psychiatrists helped validate horrifying stories, regarding the unsafe administration of ECT. Despite the candid comments about this it was difficult to obtain hard core facts.

An insight about how things take place at government hospitals was scraped together through views expressed by a clinical psychologist who had the opportunity to work in the psychiatric ward of a government hospital.

She substantiated the common complaints about the unethical use of ECT by informing TR that anaesthesia and muscle relaxants were not given before administering ECT in that hospital. The room where it was administered had partitions made of sheets. While it prevented other patients from looking in, they could still hear a patient's agonizing screams, which was frightening enough.

"I saw how a patient's consent held no importance," she said. "Besides, house officers were allowed to give ECT, which is against the ethics. It should only be given by a professional psychiatrist in the presence of an anesthetist."

Psychiatrists agree that unsafe administration of ECT can result in various complications. Apart from common cases of bone fractures, another adverse effect is a patient breaking his teeth.

The same psychologist narrated a case of a patient from a private psychiatric clinic who was given ECT without a rubber gag, which is placed in the mouth to prevent tongue bites. Instead a cloth ball was stuffed in its place. Obviously it did not serve the purpose and he broke his teeth; had he choked on the broken teeth, it would have resulted in his death.

Mentioning a few cases to highlight the unsafe practice is just the tip of the iceberg. People's fear about ECT because of their bad experiences with it can simply be worked out by having an informal chat with patients sitting for their turn at the OPD of the psychiatry department at government hospitals. It was quite amazing to note that many of the people with psychiatric illness who belonged to low income backgrounds had some knowledge of ECT, but their instant reaction to it was fear. They had either heard about some bad cases of ECT through acquaintances or they themselves had been the victims.

"It is very dangerous, I have seen my wife suffer because of it," said one man. "Thank God, the doctor has not asked us to get it," said another. Yet another said, "I don't think my son should get it."

Dr Inam ur Rehman, a psychiatrist, said it was the treatment's gross overuse and unethical practice in the country which has given ECT a bad name. He spoke about how some psychiatrists administer ECT unnecessarily as it helps them make quick bucks. If given safely ECT is said to be expensive.

A survey about its cost showed that in well-reputed hospitals, a single session of ECT costs around Rs1,500 or more. The figure comes down to Rs1,000 and Rs800 in small private hospitals. At some places it is being provided for Rs500 to Rs600 but in such cases, it is said, ECT is offered without anaesthesia (this kind of ECT is termed as unmodified ECT, which many psychiatrists say is unsafe). At government hospitals ECT is given free of cost.

Dr Rehman highlighted how patients want 'quick fix' remedies. Drugs take two to three weeks to indicate any signs of recovery, and long counselling sessions are seen as a waste of time. In many instances ECT appears to be the proverbial silver lining around the dark cloud for patients who are left with no choice, but to say yes to ECT, which often has much quicker results than antidepressants.

Patients from far flung areas who are in a hurry to go back to their homes prefer to opt for methods which are less time consuming. Mothers suffering from post-natal depression often opt for ECT so as to recover quickly and care for their newborns. Those who become suicidal stand in need of ECT as they might pose a threat to their own or others' lives. In such situations, ECT can be the best choice, but it also happens that in some cases it is both the patient's and professionals' impatience which makes them turn to ECT as a 'quick fix' option.

"My main concern is how ECT is administered," said Dr Rehman. "I have had patients with dislocated bones, vertebrae and broken teeth because they were given ECT without anaesthesia." However, he added that not all psychiatrists should be blamed for malpractice as it was only a handful who are administering it unethically. He called upon the regulatory bodies to look into the matter and prevent poor standards and practices, which have tarnished the image of ECT.

There certainly is a need for some action against the unchecked administration of ECT by the regulatory bodies. When Dr Hussain, who is the president of the Pakistan Psychiatric Society, was asked to comment on the reported cases of unsafe administration of ECT, he spoke in measured words. He said the Society is a professional body and that implementation and enforcement is the work of law enforcing bodies. "One's own conscience, rules that are laid down and peer pressure are enough to make one adhere to proper procedures," he added.

Dr Ahmed, who is also president of the Mental Health Association, said that although he could not comment on hospitals involved in the unethical practice of ECT, he did acknowledge that he had received patients who were victims of unsafe ECT. In addition there were patients who had received six to 12 ECT sessions but had not shown signs of improvement. Due to lack of education and awareness, many patients put their complete faith in doctors and readily agree to their recommendations.

Iqbal's wife suffered from depression and her fate took her to one of the psychiatric clinics in Nazimabad. For over a month, the woman was periodically given ECT but she showed little improvement. Dismayed, Iqbal took her to another doctor for a second opinion. He was told that her depressive moods could be controlled with drugs and counselling, options he was not offered earlier. He now regrets not having got a second opinion earlier, and feels guilty for having watched his wife suffer unnecessarily.

It should not be ignored that one of the specifications for ECT is that the patient must show an indication for its need; otherwise, if given unnecessarily, ECT fails to show any result. But, the other side of the picture shows that in cases where it was given after making careful analysis, it really brought a positive change in patients' lives.

Ali, 42, narrated his year-long experience of psychiatric treatment to control his depression. In the later stages of his treatment doctors advised him to get ECT. In five weeks he was correctly given 12 ECT sessions. "In the beginning I was very confused but the ongoing counselling and medication have been very helpful." He deemed himself lucky to have approached a doctor who briefed him completely about ECT before starting the treatment, and also provided him with relevant material on it. Ali's treatment only began when he himself understood the ins and outs of ECT and finally gave his formal consent.

Razia, 35, said she suffered from postnatal depression and contemplated suicide. "My husband took me to a psychiatrist who after careful analysis suggested ECT." She had no idea what ECT was, but her doctor provided her all the details before finally asking for her consent.

"In the beginning I was afraid, but after four sessions, I felt better. Plus the drugs are making it easier for me to cope with my condition," she said. This is a dramatic change from her initial reaction when she thought she would die when she got the first electric shock.

Doctors maintain that the very name electric shock/convulsive therapy generates fear in patients. Because of its bad reputation, when explaining all aspects of ECT, doctors use local jargon to describe it, calling it machine ka illaj or bijli ka illaj.

Patients who were interviewed agreed that after getting the treatment the earlier fear of ECT subsided, and they felt encouraged enough to convince others to go for it. Doctors, however, maintain that ECT should be selectively prescribed and ailments, which don't demand ECT, should be treated with other therapies.

Dr Haroon Ahmed stated that in 2003 he had not prescribed or given ECT to his patients. "By and large I see about 1000 patients a year. If a patient needs it I prescribe it. The reason I did not give ECT this year is that the patients responded well to drug treatment and needed no ECT."

Doctors unanimously agree to the use of anaesthesia and muscle relaxant in ECT. The Mental Health Act of Pakistan mentions that ECT should preferably be administered under general anaesthesia. However, there are opposing views about this mode of administration.

Dr Mubeen Akhtar, a proponent of ECT, said that he does not anesthetize patients before giving them ECT. "Most of the time we give ECT without anaesthesia as people cannot afford it." He said that with anaesthesia, the cost of ECT comes to about Rs1,400 and without it, it costs Rs400, an amount a large population could afford. He does this because he believes many people with weak economic backgrounds would not be able to afford ECT otherwise. However, he said, he gave a choice to those belonging to a higher income class, between ECT with or without anaesthesia.

Dr Akhtar also disagreed with most of the psychiatrists who said that ECT without anaesthesia could cause severe side effects. He said that in his career, he had hardly come across any cases of bone fractures during ECT without anaesthesia. "To cut down the cost of ECT, and to reduce dangers of anaesthesia and muscle relaxants, we suggest it's treatment without anaesthesia, and we are confident of this decision," he said, adding that anaesthesia has its own risks.

He also doesn't support the argument that ECT is the last option. He advocates that it should be the first option, and as far as he's concerned ECT isn't used as much as it should be.

Although the internationally laid down rules regarding ECT stress upon the use of anaesthesia in ECT, it seems not all the hospitals and clinics are going by the book. A doctor, requesting anonymity, said administration of anaesthesia was only recommended in specific cases.

The diversity in the methods of administering ECT at hospitals was further established when a staff nurse who worked at a psychiatric ward, provided an insight into the methods of giving ECT at government hospitals. The young nurse expressed her sheer amazement, when asked if patients were anesthetized before given ECT. "How are you supposed to give anaesthesia to an ECT patient?" she asked. "ECT should be given without it, and there are reasons to support this."

She then went on to say that anaesthesia, as she had been taught during her nursing programme and by her seniors, should only be given in specific cases. Administration of muscle relaxants was seen as safe enough, which controls the jerks and prevents any side effects to the patients. She said she had never come across any case of bone fracture or casualty.

This surely leads to complications in understanding what is the safest method of giving ECT. Professionals' difference of opinion about its mode of administration can only be solved to a certain degree, if some regulatory body of medical professionals intervenes. The two divergent schools of thoughts on ECT only confuse patients who must be provided with clear guidelines about its administration.