CORRESPONDENCE
Medical conferences
Please refer to the January 2003 issue of IME.
The letter from Sevagram was positive. There has been a palpable change in
medical conferences over the years. The number has increased manifold, the venue
has shifted from medical colleges to five-star hotels. The quality of food
offered has improved while that of the papers proffered has declined. The
ultimate success of the conference is judged more by the banquet, where there is
a free flow of alcohol. There are gifts galore at the exhibition stalls with
prizes for lucky dips. Smaller continuing medical education (CME) programmes can
be organized without sponsors as participants do not mind making a contribution
if the organ-izer is sincere and the lecture is of common interest. The
local chapter of the Indian Association of Pathologists and Microbiologists
(IAPM) is funded entirely by its members numbering about fifty. We are able to
get good speakers from neighbouring places. Recently, Professor RK Gupta from
Sanjay Gandhi Postgraduate Institute (SGPGI), Lucknow, who is the national
president of the IAPM, gave an excellent talk on interpretation of kidney
biopsy. The talk was much appreciated, especially by younger pathologists and
trainees. At the Allahabad branch of the Indian Medical Association (IMA), a
team of young doctors has started Sunday breakfast meetings. These meetings are
well attended, the speakers are usually good, but the sumptuous breakfast is a
guaranteed attraction, and is sponsored by one or the other drug company. Things
will change only with the active involvement of institutions and organizers.
V K Gupta, Allahabad, India. e-mail:manishag@sancharnet.in
The ECT debate: a response
I have gone through the article 'Unmodified
ECT: ethical issues' by Chittaranjan Andrade (1) which appeared in IME Vol. XI,
no. 1 (p. 9-10). In the event of the voluntary organization Saarthak filing a
PIL in the Supreme Court (2) demanding a ban on unmodified (administered without
anaesthesia) ECT, this article is significant because of its clarity and
strength of arguments in discussing the various relevant issues. I agree with
the article in its entirety.
I agree with Dr Andrade (1) that ECT is as relevant
today as it was six decades ago when it was invented. ECT continues to hold on
to its important position in the therapeutic armamentarium by virtue of its
remarkable efficacy, rapidity of therapeutic effect and safety.
It is a life-saving treatment in severe depression,
a condition in which 15% of untreated patients are known to commit suicide (3).
Almost every psychiatrist has had the unfortunate experience of one or more of
his patients dying due to suicide in situations where ECT, as a treatment
modality, is withheld for some reason.
I also agree with Dr Andrade that the risk:benefit
ratio of unmodified ECT is heavily tilted in favour of ECT. Even if administered
unmodified, only a very small proportion of patients have complications. Tharyan
et al.'s (4) data show that only 12 out of 13,597 ECT treatments were associated
with fracture. Considering the number of suicides or the psychological morbidity
that unmodified ECTs can prevent, the rate of potential complications is not
substantial.
Consider a scenario in which the first-degree
relative of a psychiatrist either has a suicidal depression or a florid,
aggressive psychosis and the former has no facility to administer anaesthesia
with the ECT. I am fairly certain that this close relative-patient will be
administered unmodified ECT by most psychiatrists!
In India, where resources often fall short of
demands, a large number of mentally ill patients will be denied the benefits of
ECT if unmodified ones are banned. Such patients are likely to be in one of the
following situations:
- where no anaesthesiologists are available;
- where the patients cannot afford the additional
expenditure of anaesthesia;
- where administration of anaesthesia can pose a
medical risk; and
- where administering anaesthesia is practically
difficult due to a large number of such patients being posted for
ECTs, e.g. in mental hospitals.
Thus, any legislation against unmodified ECTs will
be an injustice to a large number of the mentally ill in India, with potentially
disastrous consequences for the patients and their families. Dr Max Fink (5), an
American psychiatrist and an international authority on ECT, said during his
recent visit to India: 'If we have to choose between a modified ECT and an
unmodified one for a seriously mentally ill patient, the choice is certainly a
modified one. But if the option is between an unmodified ECT and 'no ECT',
without doubt, it has be an unmodified ECT.'
References
1. Andrade C. Unmodified
ECTs: ethical issues. Issues in Medical Ethics 2003;XI:9-10.
2. Writ Petition(C)(Supreme Court) 334/2201 with Writ Petition (C)
562/2001.
3. Yager J. Clinical manifestations of psychiatric disorders:
comprehensive textbook of psychiatry. Vol. 1. 7th ed.
Philadelphia:
Lippincott Williams & Wilkins, 2000:813.
4. Tharyan P, Saju PJ, Datta S,
John JK, Kuruvilla K. Physical morbidity with unmodified ECT: a decade of
exper-ience. Indian J Psychiatry 1993;35:211-214.
5. Max Fink (personal
communication). 'Current status of ECTs', The MASTERMIND Seminar, Hotel
Meridian, Mumbai, September 9, 2002.
Sudhir Bhave, Associate
Professor of Psychiatry, NKP Salve Institute of Medical Science, Digdoh Hills,
Nagpur, India. e-mail:sbhave@nagpur.dot.net.in
