The Mental Healthcare Act 2017, Electroconvulsive Ttherapy | Medical Science Optional Notes for UPSC PDF Download

The Mental Healthcare Act 2017

The objective of the legislation is to diminish stigma and enhance social inclusion and support for individuals grappling with mental illness. Additionally, it includes provisions designed to enhance outcomes and safeguard the rights of those experiencing mental health challenges.

The Mental Healthcare Act of 2017 incorporates the following provisions:

• Ensuring the rights of individuals with mental illness to access healthcare, live free from discrimination, and maintain confidentiality.
• Introducing the concept of advance directives, empowering individuals with mental illness to specify their treatment preferences with healthcare professionals.
• Establishing procedures for the admission, treatment, and discharge of individuals with mental illness.
• Decriminalizing suicide and prohibiting electroconvulsive therapy without the use of anesthesia.
• Providing explicit guidelines for the Central and State Mental Health Authorities, as well as other mental health establishments, outlining their responsibilities and efforts.

Electroconvulsive Therapy

Cerletti and Bini pioneered the utilization of electroconvulsive therapy (ECT) as a treatment method.

Procedure

Informed Consent: While the conditions that typically respond to Electroconvulsive Therapy (ECT) primarily impact mental well-being, it is imperative, for both legal and ethical considerations, that patients comprehend the potential risks and benefits of ECT before consenting to the procedure. If a patient is unable to provide informed consent, clinicians must adhere to the legal requirements of the state for alternative methods of obtaining permission.

Precautions:
Following the administration of general anesthesia, a seizure is induced by applying an electric current to the brain through either unilateral or bilateral electrodes on the forehead.

Advantages of Methohexital as an Anesthetic in ECT (compared to other barbiturates):

• It reduces the seizure threshold.
• Ensures rapid induction and full recovery within 30 minutes.

Caution should be exercised when concurrently using Electroconvulsive Therapy (ECT) and each class of psychoactive medications.

• Combining ECT with lithium carbonate, for instance, may result in heightened neurotoxicity.
• Benzodiazepines and anticonvulsant mood stabilizers, like carbamazepine and valproic acid, can complicate the induction of seizures.
• The seizure threshold is generally lowered by antidepressants, potentially increasing the duration of seizures or the likelihood of status epilepticus and spontaneous seizures.
• Specific antidepressants, such as tricyclics, may elevate cardiac irritability when used in conjunction with ECT.
• Antipsychotic medications, when combined with ECT, may lower the seizure threshold and lead to increased neurotoxicity.

This therapy entails the induction of generalized seizures, with the effectiveness of the treatment being optimal when the seizures last for a minimum of 25 seconds. Following each session, the patient is roused. This process is then replicated two to three times weekly, accumulating to a total of 6 to 12 treatments.

Electrode Placement 

The positioning of electrodes on the head plays a crucial role in determining the outcome. The two frequently employed positions are bilateral and unilateral, as illustrated below.

Mechanism of Action

The induction of seizures is believed to bring about alterations in neurotransmitter receptors and secondary messenger systems within the brain, producing effects akin to those observed with antidepressant medications. ECT induces an elevation in Brain-derived neurotrophic factor (BDNF) and vascular endothelial growth factor (VEGF) in the hippocampus.

Indications

Electroconvulsive therapy stands out as one of the safest and most efficacious treatments for depression, gaining broader acceptance with the incorporation of modern anesthetics. Apart from obtaining informed consent, the procedure necessitates comprehensive medical clearance. Particularly for elderly individuals who struggle with tolerating antidepressants or face contraindications to their use, ECT often emerges as a crucial treatment option. While there are no absolute contraindications to ECT, caution is advised for patients with elevated intracranial pressure, unstable angina, recent myocardial infarction, and electrolyte imbalances. Notably, the mortality rate aligns with that linked to general anesthesia. Electroconvulsive therapy involves the induction of seizures through electrical means, offering relief from mental disorders.

Single most coomon Indication for ECT is Depression

When should electroconvulsive therapy (ECT) be considered for depression?

• When the patient has not responded to multiple trials of antidepressant medications.
• When the patient is experiencing urgent and severe symptoms such as intense suicidal ideation, refusal of food, or catatonic stupor that necessitate a swift antidepressant response; ECT can be effective within days, whereas antidepressants typically require 2-3 weeks.
• When the patient exhibits agitation and/or psychotic symptoms, including delusions or hallucinations.
• When unacceptable side effects are associated with antidepressant medications.
• When the patient has a history of positive responses to previous ECT treatments.
• When a medical condition prohibits the use of antidepressants.

Other indications

• Mania
• Neuroleptic Malignant Syndrome
• Lethal Catatonia and Catatonic Schizophrenia (Schizophrenic Decompensation)
• Parkinson's Disease with Pronounced Rigidity

Side Effects

• Temporary Memory Disruption (both anterograde and retrograde memory loss)
• Temporary Disorientation and Headache
• Briefly Elevated Intracranial Pressure (ICP)
• Rare Incidents of Posterior Dislocation of the Shoulder
• It is worth noting that posterior shoulder dislocation is most frequently observed during seizures, convulsions (in this scenario), or an electric shock.

Note: Memory disturbances typically resolve within 1-6 months, and the procedure is considered safe during pregnancy.

Contraindications to ECT

There are no absolute contraindications to ECT

Relative contraindications:

Electro Convulsive Therapy - Repeats

1. Discuss in brief about the indications of Electroconvulsive therapy? (2019)