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Table of Contents
Year : 2022  |  Volume : 4  |  Issue : 3  |  Page : 199-201

Electroconvulsive Therapy without General Anesthesia and the Human Rights of Mental Health Patients: Some Reflections on a Recent Situation in Chile

1 Oxford Health NHS Foundation Trust, Warneford Hospital, University of Oxford, Oxford, UK
2 Department of Psychiatry, Division of Addiction, Geneva University Hospital, Geneva, Switzerland
3 Department of Psychiatry, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland

Date of Submission16-Nov-2022
Date of Acceptance17-Nov-2022
Date of Web Publication21-Dec-2022

Correspondence Address:
Dr. Alvaro Barrera
Oxford Health NHS Foundation Trust, Warneford Hospital, University of Oxford, Warneford Lane, Oxford
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/wsp.wsp_36_22

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The use of unmodified electroconvulsive therapy (ECT), i.e., ECT without general anesthesia, vis-a-vis human rights of mental health patients and standards of care, is discussed. An overview of unmodified ECT is provided, followed by an account of recent events in Chile, where the Minister of Health referred the administration of unmodified ECT to the judicial system. The article concludes with a proposal to launch a voluntary system of accreditation, by which countries willing to have their mental health services accredited by the World Health Organization (WHO) would commit themselves to give unrestricted, unannounced, and at short-notice access to independently appointed the WHO representatives to their community and inpatient mental health facilities.

Keywords: Human rights, standards of care, Unmodified ECT

How to cite this article:
Barrera A, Molodynski A, Penzenstadler L, Khazaal Y. Electroconvulsive Therapy without General Anesthesia and the Human Rights of Mental Health Patients: Some Reflections on a Recent Situation in Chile. World Soc Psychiatry 2022;4:199-201

How to cite this URL:
Barrera A, Molodynski A, Penzenstadler L, Khazaal Y. Electroconvulsive Therapy without General Anesthesia and the Human Rights of Mental Health Patients: Some Reflections on a Recent Situation in Chile. World Soc Psychiatry [serial online] 2022 [cited 2023 Feb 1];4:199-201. Available from: https://www.worldsocpsychiatry.org/text.asp?2022/4/3/199/364584

  Introduction Top

Electroconvulsive therapy (ECT) is an effective treatment for some mental disorders, including severe depression,[1] catatonia, or a prolonged or severe manic episode.[2] ECT can also help the symptoms of schizophrenia that have not improved with medication, but it is not used often in the UK for this.[2] Cerletti and Bini developed ECT in Italy in 1937 based on the work of Ladislas J Meduna, with seizures induced with camphor and cardiazol to treat people with a “diagnosis” of severe mental illness.[3] ECT was at the time administered without general anesthesia (so-called “unmodified ECT”). It was associated with severe side effects such as fractures of the vertebrae, extremities, and teeth, cardiovascular events such as bradycardia or even asystole, and psychological trauma. The latter includes being conscious and aware of being paralyzed.[4] During the 1950s, “modified ECT”, i.e., ECT under general anesthesia, was introduced in the United Kingdom, and by the early 1960s in the UK all ECT treatments were modified.[3],[4]

For ECT to be effective and safe for those receiving it, the highest standards of care must be maintained and be consistently and independently monitored. One aspect where there is significant international variation is whether ECT is administered modified or unmodified. In the UK, ECT cannot be carried out without general anesthesia.[5] Internationally, the situation is varied. In Denmark, Norway, and Sweden, ECT is always modified,[6] but in Thailand, 94% of ECT is unmodified.[7] A survey throughout Russia in 2005 found that fewer than 20% of ECT was modified.[8] Similarly, unmodified ECT was used in Asia in over 90% of countries as well as in some countries in Africa and Latin America.[9] Turkey started a transition from unmodified to modified ECT after critical reports from mental disability rights international and the European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT).[10]

It is important to mention that Article 1 of the Convention Against Torture and Other Cruel, Inhuman or CPT indicates that “for the purpose of this convention, the term “torture” means any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for such purposes as obtaining from him, or a third person, information or a confession, punishing him for an act he or a third person has committed or is suspected of having committed, or intimidating or coercing him or a third person, or for any reason based on discrimination of any kind, when such pain or suffering is inflicted by or at the instigation of or with the consent or acquiescence of a public official or other person acting in an official capacity.”[11] In 2008, the Interim report of the Special Rapporteur on torture and other cruel, inhuman or CPT noted that “unmodified ECT may inflict severe pain and suffering and often leads to medical consequences, including bone, ligament and spinal fractures, cognitive deficits, and possible loss of memory. It cannot be considered as an acceptable medical practice and may constitute torture or ill-treatment.”[12]

In this context, we describe here a recent situation where the national health authorities of a country were informed that unmodified ECT had been taking place in a particular hospital and referred the situation to the judicial system for it to be investigated.

Unmodified electroconvulsive therapy in Chile

The Chilean Ministry of Health issued a policy on ECT in the year 2000, indicating that general anesthesia was a requirement and that there must be an anesthetist present as part of the team administering it. On March 11, 2022, a new government was inaugurated and Dr. Maria Begoña Yarza, an experienced pediatrician and MSc in public health, was appointed as the country's Minister of Health. On May 11, 2022, Dr. Yarza referred findings reported to her that, until recently, ECT without general anesthesia had been carried out at Hospital Del Salvador (a public psychiatric hospital in the port city of Valparaiso) to the National Public Prosecutor. Her report mentioned that such practice could amount to torture or other cruel, inhuman, or degrading treatment, as described in article 150 A of paragraph IV, Title Three, Book Two, of the Chilean Penal Code. Of note, article 175 d) of the country's Criminal Procedure Code creates a duty on medical professionals and health authorities to refer to facts that could amount to a crime.

There have been strong reactions to this action, including from the Chilean Society of Neurology, Psychiatry, and Neurosurgery and the National Council of the Colegio Medico (the Chilean Medical Association), which have been described in detail elsewhere.[13] Others have expressed different views, for example, the Sociedad de Salud Mental Comunitaria de Chile (Chilean Community Mental Health Society), expressed their “solidarity with all those who have been historical victims of an excluding and disintegrating mental health system, being sentenced to live locked up against their will for decades in mental institutions, without having committed any crime.”[14] On June 20, 2022, the Department of Human Rights, Gender, and Ethics, from the local Santiago Regional Council (within the same Colegio Medico), indicated that “the facts denounced by Minister Yarza are extremely serious since there is no justification for human rights violation to exist within hospital facilities. The lack of resources that are known to occur in public health services is not an excuse for the commission of acts that can be considered cruel, inhuman, and degrading treatment in International Conventions.”[15] On June 28, 2022, Lidia Casas, Director of the Diego Portales University Human Rights Centre, asks, among other issues: “Should a public official, such as a Minister of State, refrain from denouncing if the conduct could constitute a crime?”. She also writes “Clearly, these situations show a problem of understanding in the medical profession about the relationship between colleagues, ethical duty, compliance with protocols and technical standards, but, even more serious, about respect for patients and the law.”[16] On July 2, 2022, Minister Yarza informed the health committee from the Chamber of Deputies or MPs, that 1,049 sessions of ECT without general anesthesia had been administered to 116 people between 2016 and August 2021.[17] On July 7, 2022, Minister Yarza, together with the Pan American Health Organization's representative in Chile, Fernando Leanes, and the United Nations High Commissioner for Human Rights for South America, Jan Jarab, launched the work on a National Strategy of Mental Health and Human Rights to design policies incorporating gender and human rights perspectives. The preparation of technical standards, regulations, and protocols will involve the participation of professional associations and unions, scientific societies, and, especially, experts with lived experience.[18]

Reflection and a proposal

Chile, over the past few decades, has made progress in terms of its economy, although high levels of inequality remain. Its public health services cover 80% of the population and have positive indicators such as high life expectancy and very high levels of COVID-19 vaccination. As indicated above, an unequivocal technical standard for modified ECT was issued in 1990. Despite that, in 2022, the administration of ECT without general anesthesia was found to be occurring at a public hospital and the actions of the Minister of Health have been hotly debated. It is hoped that this debate may lead to a strengthening of the standards on ECT as well as an improvement in the overall quality and availability of mental health care, putting at its center the human rights and needs of those affected by mental ill health.

We believe that a powerful lesson can be drawn from the Chilean situation – it is possible that in any country, despite the best intentions and guidelines of politicians, civil servants, and professionals, widely agreed standards of mental health care, such as only having modified ECT, are not consistently maintained. We believe a way of addressing such risks would be to rely on the World Health Organization (WHO) Quality Rights Tool Kit[19] for staff training and to launch a voluntary system of accreditation, by which countries willing to have their mental health services accredited by the WHO would commit themselves to give unrestricted, unannounced, and at short-notice access to independently appointed the WHO representatives to their community and inpatient mental health facilities for a facility assessment report. Although not foolproof, such a system might help to trigger a race toward consistently upholding treatment quality standards and the human rights of people with mental ill health.

Furthermore, as shown in the Chile case, it seems very important to promote civil advocacy resources as well as peer support to promote human rights in mental health care and to create a clinician-civil society network able to promote such changes. Finally, mental health care should be given under the framework of shared, supported decision-making[20] and advance directives[21] when needed to always give the possibility for the patient to have his voice heard.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

NICE Guideline [NG222] Depression in Adults: Treatment and Management. Available from: https://www.nice.org.uk/guidance/ng222. [Last published on 2022 Jun 29].  Back to cited text no. 1
Guidance on the Use of Electroconvulsive Therapy. Technology Appraisal Guidance [TA59]). Available from: https://www.nice.org.uk/Guidance/TA59. [Last published on 2003 Apr 26, Last updated on 2009 Oct 01].  Back to cited text no. 2
Jones C, Jones S. Electro convulsive therapy: Milestones in its history. Ment Health Nurs 2018;38:6-10.  Back to cited text no. 3
Lava-Parmele S, Lava C, Parmele JB. The historical struggles of modified electroconvulsive therapy: How anesthesia came to the rescue. J Anesth Hist 2021;7:17-25.  Back to cited text no. 4
ECT Accreditation Service ECTAS, Standards for the Administration of ECT. 14th ed. Available from: https://duckduckgo.com/?q=ECT+Accreditation+Service+ECTAS%2C+Standards+for+the+administration+of+ECT%2C+14th+edition+revised%3A+January+2019.&ia=web. [Last revised on 2019 Jan 01].  Back to cited text no. 5
Bjørnshauge D, Hjerrild S, Videbech P. Electroconvulsive therapy practice in the Kingdom of Denmark: A Nationwide register- and questionnaire-based study. J ECT 2019;35:258-63.  Back to cited text no. 6
Chanpattana W. One hundred twenty years of mental health care in Thailand and the development of electroconvulsive therapy. J ECT 2010;26:11-3.  Back to cited text no. 7
Nelson AI. A national survey of electroconvulsive therapy use in the Russian Federation. J ECT 2005;21:151-7.  Back to cited text no. 8
Leiknes KA, Jarosh-von Schweder L, Høie B. Contemporary use and practice of electroconvulsive therapy worldwide. Brain Behav 2012;2:283-344.  Back to cited text no. 9
Karacan FA, Bağ s, Karacan m, Yılmaz S, Yanık, M. Attitudes of the mental health professionals towards unmodified and modified types of electroconvulsive therapy: A Turkey sample. Nobel Med 2021;17:99-104.  Back to cited text no. 10
The Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Available from: https://treaties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IV-9&chapter=4&clang=_en. [Last revised on 2022 Nov 08].  Back to cited text no. 11
The Interim Report of the Special Rapporteur of the Human Rights Council on Torture and other Cruel, Inhuman or Degrading Treatment or Punishment, Manfred Nowak, Submitted in Accordance with Assembly Resolution 62/148. Available from: https://psychrights.org/Countries/UN/080728UNRapporteuronTortureA_63_175.pdf. [Last revised on 2022 Nov 08].  Back to cited text no. 12
Available from: https://coercioninpsychiatry.com/events-2/. [Last revised on 2022 Nov 08].  Back to cited text no. 13
Available from: https://www.who.int/publications/i/item/ 9789241548410. [Last revised on 2022 Nov 08].  Back to cited text no. 19
Penzenstadler L, Molodynski A, Khazaal Y. Supported decision making for people with mental health disorders in clinical practice: A systematic review. Int J Psychiatry Clin Pract 2020;24:3-9.  Back to cited text no. 20
Khazaal Y, Manghi R, Delahaye M, Machado A, Penzenstadler L, Molodynski A. Psychiatric advance directives, a possible way to overcome coercion and promote empowerment. Front Public Health 2014;2:37.  Back to cited text no. 21


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