Electroconvulsive therapy (ECT) is far and away the most effective treatment for depression and quite effective for a range of other psychiatric conditions that are unresponsive to medication. Electroconvulsive therapy in the developed world has been administered with anesthesia, muscle relaxants, and ventilation since the mid-1950s following 20 years of unmodified treatment. However, in much of the developing world, ECT continues to be administered unmodified because of lack of resources. We review the efficacy of unmodified compared with modified treatment. We also review the potential drawbacks of unmodified treatment including fear and anxiety, worse postictal confusion, fracture risk, and the negative effects of unmodified treatment on how ECT is perceived in the general community. Finally, we consider potential solutions in developing countries to minimize adverse outcomes of unmodified treatment by pretreating patients either with low-dose benzodiazepines or sedating, but not anesthetizing, dosages of anesthetic agents. Randomized controlled trials are necessary before either of these options could be considered an acceptable alternative to completely unmodified treatment when modified treatment is unavailable.
From the *Department of Pschiatry, The Johns Hopkins University School of Medicine; †University of Maryland School of Medicine; ‡Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD; and §The Department of Psychiatry, Chhatrapati Shahuji Maharaj Medical University, Lucknow, India.
Received for publication June 26, 2011; accepted August 31, 2011.
Reprints: Irving M. Reti, MBBS, Brain Stimulation Program, The Johns Hopkins University, 600 N Wolfe St, Meyer 3-181, Baltimore, MD 21205 (e-mail: firstname.lastname@example.org).
I.M.R. received grant funding from The Johns Hopkins Center for Global Health.
The other authors have no conflicts of interest to disclose.