PS13.1 | Therapeutics in Psychiatry — Graded Quiz

Correct. Modified ECT requires a short-acting induction agent (thiopentone or propofol) for general anaesthesia, succinylcholine/suxamethonium as the depolarising muscle relaxant, and supplemental oxygenation.

Modified ECT pharmacology: induction agent (thiopentone/propofol) + succinylcholine/suxamethonium + oxygenation. Benzodiazepines are avoided as they impair seizure induction.

The pharmacological triad of modified ECT: (1) short-acting general anaesthetic induction agent (thiopentone or propofol); (2) depolarising muscle relaxant succinylcholine/suxamethonium; (3) oxygen. Midazolam and diazepam raise the seizure threshold and are avoided.

Correct. ECT is an established evidence-based treatment for pharmacotherapy-refractory catatonia, regardless of the underlying diagnosis (schizophrenia, affective disorder, etc.). Benzodiazepine failure for more than a few days, combined with nutritional compromise, is a recognised trigger for ECT consideration.

Catatonia that is refractory to lorazepam (or other benzodiazepines) is a recognised ECT indication. ECT is effective for catatonia regardless of whether the underlying diagnosis is schizophrenia, bipolar disorder, or a medical condition.

ECT is not contraindicated in schizophrenia. Catatonia that fails to respond to benzodiazepines within a few days is a recognised ECT indication, especially with nutritional compromise.

Correct. The most common cognitive effects are transient disorientation immediately post-seizure, and gaps in autobiographical memory around the treatment period. These typically resolve within weeks to months. Persistent severe memory impairment occurs in a minority. Bilateral electrode placement is associated with greater cognitive side-effects than unilateral placement.

ECT cognitive side-effects: (1) immediate post-ictal disorientation (minutes to hours); (2) peri-treatment autobiographical memory gaps (weeks to months, usually recover); (3) bilateral > unilateral electrode placement for cognitive impact. Persistent severe amnesia is uncommon.

Current evidence characterises ECT cognitive effects as predominantly transient — disorientation and peri-treatment autobiographical memory gaps that resolve within weeks to months. Claiming no cognitive effects is inaccurate, but so is claiming permanent anterograde amnesia is the most common outcome.

Correct. The one-cuff technique isolates one forearm from the muscle relaxant by occluding venous and arterial flow before succinylcholine injection. The unparalysed hand/forearm then shows tonic-clonic movements during the generalised cerebral seizure, providing a bedside motor indicator of seizure adequacy and duration.

One-cuff technique: cuff inflated above systolic BP on one forearm BEFORE succinylcholine → isolated forearm shows motor seizure activity → clinical confirmation of adequate seizure when EEG is unavailable. An adequate seizure is ≥25–30 seconds of motor activity.

The one-cuff technique is a seizure-monitoring measure. By inflating the cuff above systolic pressure before succinylcholine, the drug is prevented from reaching the isolated forearm. This forearm's observable convulsive movements confirm an adequate seizure has been induced.

Correct. Severe depression with psychotic features and severe depression with active suicidal risk are well-established, guideline-endorsed indications for ECT. These situations combine high risk with a need for rapid response that antidepressants alone cannot reliably provide within a safe time frame.

Core ECT indications: (1) severe depression with psychotic features; (2) severe depression with active suicidality or food/fluid refusal; (3) treatment-resistant depression; (4) catatonia; (5) severe manic episode refractory to pharmacotherapy.

ECT indications are specific to severity and risk. Mild depression and anxiety disorders are not ECT indications. Schizophrenia with only negative symptoms is not a primary ECT indication. Severe depression with psychosis or active suicidality is the clearest, best-established indication.

Correct. The MHCA 2017 explicitly prohibits unmodified ECT — that is, ECT administered without general anaesthesia and muscle relaxant — under all circumstances in India. There is no rural or resource-limited exception.

MHCA 2017 key provisions for ECT: (1) unmodified ECT absolutely prohibited; (2) ECT in minors requires High Court approval; (3) informed consent is mandatory; (4) emergency ECT without consent is permissible under specific life-threatening provisions with documentation.

MHCA 2017 specifically and absolutely prohibits unmodified ECT. It does not prohibit ECT for prior responders, bipolar patients, or require a second opinion (though good practice recommends it for minors and certain complex cases).

Correct. ECT is a legally regulated, medically prescribed, evidence-based treatment — not coercive torture. Cognitive effects are real and must be disclosed, but the evidence shows they are predominantly transient. The MHCA 2017 provides clear legal safeguards against coercive or unmodified use.

Addressing ECT misconceptions: always pair the 'not punitive/not torture' statement with honesty about cognitive effects. Describing effects as 'always minimal' is as misleading as calling them 'permanent'. Regulated + transient-effects = the accurate dual message.

Both misconceptions require correction: (1) ECT is not coercive torture — it is a legally regulated, consent-based medical treatment with MHCA 2017 safeguards; (2) cognitive effects exist but are predominantly transient, not lifelong in most patients.

Correct. Seizure adequacy refers to the induction of a generalised cerebral seizure of sufficient duration — at least 25–30 seconds of motor or EEG activity. This threshold is associated with therapeutic benefit. Absence of visible movements only reflects successful neuromuscular blockade, not the absence of a cerebral seizure.

Seizure adequacy = generalised cerebral seizure ≥25–30 seconds. Modified ECT abolishes visible convulsions (muscle relaxant) but the brain seizure must still occur and be monitored via EEG or the one-cuff motor method. Sub-threshold or missed seizures are re-stimulated.

Seizure adequacy is about the cerebral seizure, not surface motor activity. The goal is a generalised cerebral seizure lasting ≥25–30 seconds, confirmed either by motor activity in the isolated one-cuff forearm or by EEG monitoring. Absence of full-body convulsions simply means succinylcholine has worked.

Correct. After a successful acute ECT course, post-acute pharmacotherapy (antidepressants with or without lithium) is the standard approach to relapse prevention. Maintenance ECT (at reducing frequency) is a validated option for patients who cannot tolerate pharmacotherapy or who have relapsed despite it.

Post-ECT relapse prevention: (1) pharmacotherapy first-line (antidepressants ± lithium); (2) maintenance ECT (weekly → fortnightly → monthly) for medication-intolerant or relapse-prone patients. Abrupt discontinuation after remission carries a high relapse risk.

ECT remission is not self-sustaining without relapse prevention. Post-acute pharmacotherapy is the first-line maintenance strategy. Maintenance ECT at progressively longer intervals is an option for those intolerant of or non-responsive to medication.

Correct. Pre-procedure fasting (minimum 4–6 hours) is the primary measure to prevent aspiration under general anaesthesia. A full stomach during anaesthetic induction and the muscle-relaxed post-ictal state significantly increases aspiration risk.

Pre-ECT fasting (≥4–6 hours) prevents aspiration under anaesthesia. This is the same principle as nil-by-mouth for any general anaesthetic. The bite-block prevents dental/tongue injury; these are separate safety measures addressing different risks.

Aspiration prevention in modified ECT relies primarily on fasting — as it does for any general anaesthetic. The bite-block protects against dental and tongue injury during the seizure, not aspiration. Electrode placement is a therapeutic parameter, not a safety measure for aspiration.