Use of Electroconvulsive Therapy at a University Hospital
in Karachi, Pakistan: A 13-Year Naturalistic Review
Haider Naqvi, MBBS, FCPS and Murad M. Khan, MBBS, MRCPsych
Abstract: There are very few reports of electroconvulsive therapy
(ECT) from developing countries, where lack of regulation and mis-
use has lead to negative publicity. We present our experience of ECT
use at a university hospital in Karachi, Pakistan, over the course of
13 years. During the study period, 4013 patients were admitted to
our inpatient unit, of which 136 (3.38%) received ECT. ECT was
conducted under the supervision of consultant psychiatrist and
anesthetist with continuous monitoring during and after the proce-
dure.The mostcommonindicationswere mooddisorders.Theaverage
number of ECTs administered per patient was 6 (range, 1–20). A total
of 35% of patients had medical comorbidities but did not suffer any
deleterious effect from the procedure. A total of 75% patients showed
improvement in their clinical condition. No major complication was
observed in any of the patients.
Our study demonstrates the effectiveness if ECT in a low-
income, developing country. We strongly recommend following
guidelines to ensure patient safety and minimizing side effects. This
will ensure better patient acceptability and compliance.
Key Words: ECT, Pakistan, developing country
(J ECT 2005;21:158–161)
The nature of the treatment, its historyof abuse, and associated
complications has led to the procedure being viewed quite
negatively.1In developing countries, the lack of regulation, the
arbitrary and—in many instances—overuse of the procedure,
inadequately trained personnel, poor maintenance of equip-
ment, as well as use of unmodified procedure generally has led
to low acceptability by patients, which has resulted in the
procedure being underutilized in these settings.
Pakistan is a developing Southeast Asian country with
a population of 140.7 million. A total 70% of the population
lives in rural areas of the country. Prevalence rates of common
mental disorders range from 10% to 25% for men and 30%
to 66% for women.2Mental health services are rudimentary
at best and limited to psychiatry departments of teaching
hospitals, which are located in urban centers of the country.
espite the proven efficacy of electroconvulsive therapy
(ECT), it remains a controversial treatment in psychiatry.
There are only 150–200 qualified psychiatrists in the country,
making an abysmal ratio of one psychiatrist to almost a million
people. All this is compounded by a health budget of less than
1% of annual budget. Mental health does not have a separate
budget. A public-funded health service is accessed by only the
poorest of the society. Most health care, including mental
of legislation to regulate practice puts patients with mental dis-
orders at great risk.
Very little is known about the use of ECT in Pakistan,
although it is administered regularly in many centers across the
country. There is anecdotal evidence of its abuse. For example,
it is well known that many centers administer the unmodified
procedure with resultant complications. In many cases, it is
used indiscriminately without clear clinical indications. Many
patients have reported being administered ECTwithout proper
explanation or consent. From time to time, complications of
the unmodified procedure are reported in the lay press, leading
to negative publicity among the general public, which further
impacts on its acceptability by patients. With high rates of
depression in Pakistan, it becomes important to evaluate this
important method of treatment in its cultural and societal
We therefore decided to conduct a study on the practice
of ECT at a university teaching hospital in Karachi, Pakistan.
The purposes of this study were as follows: (1) to es-
tablish a baseline of use of ECT in Pakistani patients; (2) to
study the indications, number of treatments, complications and
results of ECTin this group of patients; and (3) to compare our
results with similar studies conducted elsewhere.
MATERIALS AND METHODS
The Aga Khan University Hospital (AKUH) is a 500-bed
tertiary center located centrally in Karachi, Pakistan’s largest
city and its main business and commercial center. The
Department of Psychiatry comprises 8 psychiatrists and 3 psy-
chologists. The department conducts 25 weekly outpatient
clinics, with an average of 5000 patients annually. A 24-hour
cover is provided to the emergency room and general wards of
the hospital. There is a 15-bed inpatient unit, with an average
annual admission of 300 to 500 patients. The inpatient unit
contains a dedicated ECT suite with a separate recovery room.
ECT at AKUH
The decision to administer ECTis made by the attending
consultant psychiatrist, based on the patient’s clinical con-
dition, which is then discussed with the patient and his/her
Received for publication March 17, 2005; accepted July 6, 2005.
From the Department of Psychiatry, Aga Khan University, Karachi, Pakistan.
Reprints: Dr. Haider Naqvi, Department of Psychiatry, Aga Khan University,
P.O. Box 3500 Stadium Road, Karachi 74800, Pakistan (e-mail: haider.
Copyright ? 2005 by Lippincott Williams & Wilkins
J ECT?Volume 21, Number 3, September 2005
family. Once the patient and family agree, written informed
consent is taken. In cases in whichthe patient refuses or cannot
give informed consent but his/her clinical condition is deemed
to be serious enough to require ECT (eg, depression with severe
psychomotor retardation), the family’s consent is obtained.
A pre-ECT examination is conducted by an anesthetist,
including relevant blood and other tests. The patient is re-
quired to fast overnight. The anesthetist also administers the
anesthesia, which is the combination of a short-acting anes-
thetic and muscle relaxant. Throughout the procedure, pulse-
oximetry, electrocardiogram, and blood pressure, among other
variables, are monitored continuously.
ECT is administered with a brief-pulse, constant-current
apparatus. The pulse duration varies from 2 to 4 seconds.
Moderate-to-high current stimulus (200–500 milli-coulombs)
is to start with a current setting determined by multiplying
patient’s age by factor of 5. This method prevents the potential
risk of arrhythmias commonly observed in slow titration of
Electrode placement is bilateral. Electrolyte solution is
used to keep the terminalswet and facilitate passage of current.
pieces are placed between teeth bilaterally.
Because our ECT machine does not have provision for
electroencephalogram recording, peripheral signs of seizure
are observed and timed using a stopwatch. A seizure of at least
25 seconds is considered to be an effective duration.
After the procedure patients are transferred to an ad-
joining recovery room and kept under observation until they
regain full consciousness. In normal circumstances, ECT
usually is administered on alternate days, for a total of 2 to 3
treatments per week, although in severe cases of depression
treatments are given daily.
Between January 1990 and January 2003, a total of 4013
patients were admitted to our inpatient unit. (average 308
patients/year). Of these, 136 patients (3.38%) received ECT.
Complete data was available for 126 patients. The medical re-
cords of 10 patients were unavailable or incomplete; therefore,
we report our findings on 126 patients.
There were 71 (56%) women and 55 (44%) men. Forty-
eight percent of patients were in the age range of 20–40 years,
whereas 38% were between 41and 50 yearsand 7%were older
than 60 years. A total of 77% of patients were married
(Figure 1). Gender specific stratification of some demographic
variables is given in Table 1.
The number of ECTs administered ranged from 1 to 20,
with 6 ECTs being the most common course per patient (n =
30). In most cases, the number of ECTs that patients received
was determined by improvement in their clinical condition.
Details of treatment course are given in Figure 2. In 93% of
cases, seizure duration was for 25 seconds or longer. In 7.1%
cases, it was shorter than 15 seconds, and patients were re-
administered the ECT.
Indication and Diagnosis
In most cases, the indication for treatment was depres-
sive illness (69%). This included depression that was not
life-threatening inanition (6.3%), severe psychomotor retar-
dation (6.3%), or imminent threat of suicide (19%). In a small
minority (3.2%), depression was associated with psychotic
atonic symptoms. Diagnostic breakdown is given in Table 2.
Mean duration of illness after which ECTwas conducted was
7.1 years. This included 18.3% patients who had the illness for
FIGURE 1. Age distribution of patients given ECT.
TABLE 1. Sociodemographic Characteristics of Patients
Women (n = 71)Men (n = 55)
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J ECT?Volume 21, Number 3, September 2005 Naturalistic Review of ECT
less than 1 year and 6.3% patients who had the illness for more
than 20 years.
plications observed were mild in nature and included tongue
biting, loosening of dentures, post-ictal malaise, confusion,
and headache. In only one case, ECTwas terminated because
of imminent risk of arrhythmias.
A total of 65% of patients had no medical comorbidity
and were deemed medically fit for the procedure. In 13%
of patients, preoperative examination showed cardiovascular
abnormalities (such as abnormal ECGs, blood pressure
instability, and incipient heart failure) that required consulta-
tion with a cardiologist. In another 8% of patients, opinion was
sought from general medicine and neurology services for a
variety of disorders.
A total of 24.6% of patients were on anti-depressants,
18.3% on antipsychotics, and 12.7% on a combination of the
two. Eight percent of patients were on a combination of anti-
depressants, antipsychotics, and mood stabilizers. Four patients
were only on benzodiazepines that had been prescribed for
their primary psychiatric illness.
To assess change in clinical condition, an ordinal rating
scale was designed that consisted of clinical remission, partial
remission, and no improvement. This was based on patients’
self-reports as well as observations by attending psychiatrist.
Complete clinical remission was taken as improvement in
target psychiatric (including biologic) symptoms, as well as
social/interpersonal functioning. Partial remission was taken
as improvement in major psychiatric symptoms but with
residual symptoms and functional disability.
We planned to measure outcome at the end of course of
ECTs (usually between 6and 8in most cases) and at 1-, 6-, and
12-month intervals. Unfortunately, of the 126 patients who
received ECT, 50% to 60% were lost at various follow-up
points. We report on the patients who presented at follow-up to
Immediate Outcome (Measured at the End
of Course of Six to Eight ECTs)
A total of 52% of patients showed good clinical re-
mission of their symptoms, whereas 43% showed partial
remission. 4% of patients had no significant change in their
Outcome After One Month
A total of 63 (50%) patients attended outpatient clinic in
the month after discharge from hospital. Of these 25% main-
tained their clinical improvement, whereas 6% showed partial
improvement. 4% of patients relapsed during the same time.
Outcome After Six Months
At 6 months, 40% of patients had been in contact with
psychiatric services. Of these, 22.2% of patients maintained
clinical remission. 6% of patients had relapse of their symp-
toms. Approximately 8% required readmission to hospital.
Outcome After One Year
Information at the end of 1 year was available for 39%
of patients. Of these, 20% had maintained their clinical re-
mission, whereas 9% had relapse of their symptoms, with 4%
We believe our study is the first that describes the
outcome of ECT in a group of Pakistani patients. In this
context the study has important implications. Mental health
issues carry huge stigma in Pakistan and there is very low
acceptability of psychiatric treatment. ECT, commonly known
as ‘‘shock treatment’’ in Pakistan, carries many misconcep-
tions and there is great resistance by patients and their families
in accepting it. A lot of this is related to a general lack of
FIGURE 2. Number of ECTs administered in a single course
TABLE 2. Principal Diagnosis (Based on ICD-10)
Major depressive disorder
Major depressive disorder, recurrent
Major depressive disorder with
Bipolar disorder, currently depressed
Bipolar disorder, mixed type
Bipolar disorder, currently manic
Schizophrenia, catatonic type
Schizophrenia, paranoid type
Brief psychotic disorder
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Naqvi and Khan
J ECT?Volume 21, Number 3, September 2005
awareness of mental health issues, compounded by adverse Download full-text
reports of its unsafe and indiscriminate practice in many
centers in Pakistan.
There are a number of limitations in our study. Because
this was a retrospective study, information was obtained from
medical records and dependent on the quality of documen-
tation. For instance, an uncommon event like arrhythmia is
often recorded whereas common side effects like headaches
and transient amnesia often goes unrecorded, which would
have a bearing on the results we obtained. Similarly the
outcome we report here is far from satisfactory. The level of
improvement we report lacked objectivity and was based on
clinical impression of the attending psychiatrist only.
Large numbers of patients were lost to follow-up. We
can only assume they either remained well and hence did not
feel the need to attend or had relapsed and sought treatment
Despite the limitations, generally, our study shows ECT
to be an effective treatment of the majority of patients for
whom it was prescribed. Although most patients who re-
ceived ECT suffered from mood disorders, other significant
diagnoses included catatonic schizophrenia, postpartum de-
pression, and neuroleptic malignant syndrome. Studies per-
formed elsewhere give similar results.3
The practice of ECTat our center demonstrated that it is
a safe procedure, provided a protocol is followed, which in-
cludes preoperative assessment, induction by an anesthetist,
and monitoring of vital functions during the procedure. The
small number of complications we experienced evidenced this.
ECTalso was found to be a safe and effective treatment
of the elderly and patients with medical comorbid conditions.
This rate is similar to other studies reported in the literature.4
A total of 8% of our sample had medical comorbidity, the
largest group being those with cardiac abnormalities (10%).
The substantial improvement in most patients at the
immediate outcome stage (completion of 6–8 ECTs) and the
maintenance of improvement at subsequent follow-up, points
toward the efficacy of ECTas a treatment modality. We believe
this is related to careful patient selection, based on his/her
clinical condition. Of 4013 patients admitted during 13 years,
only 136, or 3.38%, received ECT. In a study from the United
States, 21, or 0.4%, of all patients admitted over the course of
10 years received ECT.5In Netherlands, 300 patients received
ECT in a year, from a catchment area population of
Our study shows that despite the negative impression
that is prevalent in the society regarding ECT, it is acceptable
by patients. Also, it is safe and effective, provided a proper
protocol of administration is followed. In developing countries
such as Pakistan, it is imperative to follow a proper procedure,
both to avoid the negative publicity as well as unwanted side
effects. Both factors contribute to patient noncompliance and
The cost of a course of ECT (average number: 6) came
out to be US$130, which is quite a large amount in a
developing country. Therefore, further research is needed on
use of ECT in Pakistan and other developing countries. In
particular there is a need to explore attitudes of general
population toward ECT. On the basis of the findings, public
awareness programs could be designed. There is also need for
prospectively designed longitudinal studies to measure me-
dium to long-term outcomes for different conditions. The high
prevalence of depression in Pakistan makes it crucial that we
evaluate different aspects of this important mode of treatment
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3. Mark O, Steven M, Harold S, et al. Use of ECT for the inpatient treatment
of recurrent major depression. Am J Psychiatry. 1998;155:22–29.
4. Sackeim HA. Use Of Electroconvulsive Therapy in Late-Life Depres-
sion. In: Schneider LS, Revnolds CP, Liebowtiz BD, Friedhoof AJ, eds.
Diagnosis and Treatment of Depression in Late Life. Washington, DC:
American Psychiatric Press; 1994:259–277.
5. Alfred S, Benoit M, Chengappa R, et al. Use of electroconvulsive therapy
in a state hospital: a 10-year review. J Clin Psychiatry. 2000;61:534–539.
6. Tom KR, Jan-Willem R, Esther P. One-year follow-up after successful
ECT: A naturalistic study in depressed inpatients. J Clin Psychiatry. 2004;
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