Changes in ECT services in India since the implementation of its mental health care act 2017: a clinician’s perspective

Abstract

Background

The large treatment gap in mental disorders in India also includes a lack of access to electroconvulsive therapy (ECT), a potentially lifesaving treatment. With the introduction of the Mental Health Care Act (MHCA) 2017 in India, an impact was speculated on the utilisation of ECT due to the ban on unmodified ECT and the regularisation of ECTs in children.

Methods

We planned this survey to identify the current status of ECT services in India as perceived by psychiatrists and to explore the barriers to providing ECT, particularly those influenced by the enactment of the MHCA 2017 in India. The psychiatrists practising in India were invited to complete an online questionnaire distributed through social media and professional group forums. A total of 225 consenting participants completed the survey.

Results

A majority of the participating psychiatrists (n = 160; 71.11%) were from urban areas, and 102 (45.33%) worked in private hospitals. Approximately half of the respondents (n = 118; 52.44%) could provide ECT to less than a quarter of patients for whom ECT was recommended. Furthermore, 52.4% of psychiatrists (n = 118) reported a decrease in the number of patients receiving ECT following post MHCA 2017 in India, while 44.9% (n = 101) observed no change. Additionally, 114 psychiatrists (50.67%) noted a reduction in the use of ECT for children since MHCA 2017. A substantial proportion (78.22%; n = 176) regarded patient refusal of consent as a significant factor. Access to anaesthesia services and associated costs was identified as a major barrier by 59.1% of psychiatrists (n = 133), significantly influencing their opinion on the reduction of ECT services post-MHCA 2017 (Odds ratio = 2.024, p = 0.018).

Conclusions

The limited availability of anaesthesia services and associated expenses are significant barriers to using ECT in developing countries such as India. This issue became more pronounced after the implementation of the MHCA 2017 and should be addressed promptly. Training psychiatrists in ECT anaesthetic skills via task-sharing and telementoring can help resolve this issue.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12888-025-07109-3.

Background

Electroconvulsive therapy (ECT) is one of the most effective treatment modalities for many psychiatric disorders, including major depressive disorder, bipolar disorder and schizophrenia. In conditions such as catatonia and high risk of suicide, ECT is considered a lifesaving therapeutic tool [1]. It significantly reduces disability and enhances the quality of life for a substantial proportion of individuals with treatment-resistant psychiatric illnesses [2]. Although some studies have assessed the utilisation of ECT worldwide [3], the treatment gap for ECT has been explored to a limited extent. Retrospective data analyses of different health records have shown that only a limited proportion of patients receive ECT. For instance, in the USA, only 0.25% of patients with mood disorders received ECT in 2014, decreasing to 0.17% in 2017 [4, 5]. Similarly, in France, 1.1% of in-patients with a psychiatric disorder received ECT in 2019 [6].

Stigma and misperceptions towards ECT among patients, the general population, and mental health professionals contribute to its low utilisation [7, 8]. Another concern is inequitable access to ECT services. In Canada, postgraduates, those with spouse/partner support, and residents in high-income areas were more likely to receive in-patient ECT [9]. Similarly, in France, low-income individuals without healthcare schemes used ECT less often. The availability of ECT services was better in government teaching hospitals and less in private hospitals. A greater distance between non-ECT hospitals and those providing ECT services also decreased usage. A total of 137 out of 468 hospitals had no patients who received ECT during the 1-year study period [6]. Additionally, inadequate physical space and limited support from anaesthetists and paramedical staff hinder effective ECT services [10].

In India, the national level mental health survey conducted in 2016 recorded current prevalence rates of 0.42 (0.41 to 0.44) for schizophrenia and other psychotic disorders and 2.84 (2.81 to 2.87) for affective disorders [11]. Consequently, the patient population requiring ECT in this country, with its 1.3 billion people, is expected to be substantial. We did not find any study that specifically looked into the treatment gap for ECT in India. However, a few surveys were conducted to understand the overall picture of ECT services in India. A 1991 survey of psychiatrists providing ECT services in India indicated numerous sub-optimal practices in ECT administration [12]. Notably, 54.8% of psychiatrists used unmodified ECT, and 68.8% did not possess a satisfactory anaesthesia machine for modified ECT. Additionally, 42.8% reported inconsistent services from anaesthetists. A subsequent survey in 2002-03, twelve years after the initial survey, revealed similar usage patterns of unmodified ECT, with 52.5% of patients receiving unmodified ECT and 29.8% of centres lacking access to anaesthesia services [13].

The Government of India enacted the Mental Healthcare Act (MHCA) in 2017 with the aim of enhancing care standards by adopting a rights-based, patient-centred approach to mental healthcare [14]. The legislation prohibited the administration of unmodified ECT, which involves administering ECT without anaesthesia and muscle relaxants and carries a relatively high risk of injuries and adverse events [15]. During the development of the MHCA, the expert views and focused group discussions of Indian psychiatrists suggested that banning unmodified ECT would further reduce its utility in India, thereby widening the ECT treatment gap [16, 17]. Additionally, the requirement for obtaining additional approval from the Mental Health Review Board for administering ECT to minors was viewed as a concern.

It has been about six years since the enactment of the new MHCA in India. There is a need to explore its influence on ECT services. We planned this survey to study the current status of the ECT treatment gap in India as perceived by psychiatrists and to identify changes, if any, that have occurred since the enactment of the MHCA 2017. We also attempted to identify the barriers to providing ECT services.

It has been about six years since the enactment of the new MHCA in India. There is a need to explore its influence on ECT services. We planned this survey to study the current status of the ECT treatment gap in India as perceived by psychiatrists and to determine changes, if any, that have occurred since the enactment of the MHCA 2017. We also attempted to identify the barriers to providing ECT services.

Methods

An online survey was conducted over a 6-month period in 2022, consisting of a 5-minute short questionnaire. The study was approved by the Institutional Ethics Committee of the National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, India. Informed consent was inscribed in the online survey, and only consenting participants were directed to the survey webpage for completion. The questionnaire was prepared with the consensus of all authors and subsequently optimized following an initial pilot involving five subjects. In this questionnaire, we categorised the place of clinical practice into rural, urban and semi-urban were defined as fringe regions of cities or adjacent rural areas where individuals engage in a combination of rural and urban activities, often linked to the city economy but governed by rural administrative bodies [18]. The final version of the questionnaire, along with participant information and the consent form, is available as a supplement here.

Participants were psychiatrists with an MD, Diploma in Psychiatry Medicine, or Diplomate of National Board (DNB) in Psychiatry providing mental health services in India and were registered with the National or state medical council of India. They were contacted through social media groups, websites, and professional forums, with reminders sent every two weeks, up to four times.

Nonparametric descriptive statistics evaluated sociodemography, general clinical practice, ECT service status, and barriers to ECT administration. The primary outcome measured the ECT treatment gap by examining the proportion of patients who received ECT among those for whom it was considered by each participating psychiatrist. Linear regression assessed the impact of clinical practice factors on this gap. The percentage of psychiatrists reporting fewer patients receiving ECT post-2017 MHCA implementation in India was analyzed to identify significant factors using hierarchical logistic regression; Model 1 included general practice factors, and Model 2 added perceived ECT service barriers. Multicollinearity was checked via tolerance value, and significance was set at p < 0.05.

Results

We received responses from 225 psychiatrists. Their characteristics are detailed in Table 1. A total of 71.1% (n = 160) practiced in urban areas, and approximately 49% (n = 111) were based in the southern region of India. The western (20.9%, n = 47) and north-central regions of India (21.8%, n = 49) had similar representation. Additionally, 38.2% of respondents worked exclusively in government hospitals, while 45.3% were employed in private hospitals. Notably, 12.4% operated outpatient clinics independently, without affiliation to any government or private hospital. Overall, 39.6% of the psychiatrists were affiliated with a medical college.

Table 1.

Characteristics of the psychiatrists who participated in the survey (sample size = 225)

Variable		Subgroups	Frequency Number; Percentage (95% Confidence Interval)
Place of clinical practice		Rural	7; 3.11% (1.26– 6.3%)
		Semi-urban	58; 25.78% (20.19– 32.01%)
		Urban	160; 71.11% (64.71– 76.94%)
Zones		East	18; 8% (4.81– 12.35%)
		North-Central	49; 21.78% (16.57– 27.75%)
		South	111; 49.33% (42.63– 56.06%)
		West	47; 20.89% (15.77– 26.79%)
Government vs. Private		Government Hospital only	86; 38.22% (31.84– 44.92%)
		Private hospital only	102; 45.33% (38.71– 52.09%)
		Both Government and Private hospital	9; 4% (1.85– 7.46%)
		None of them*	28; 12.44% (8.43– 17.48%)
Medical College		No	136; 60.44% (53.73– 66.88%)
		Yes	89; 39.56% (33.12– 46.27%)
Private Outpatient clinic		Additional	43; 19.11% (14.19– 24.87%)
		No	154; 68.44% (61.94– 74.46%)
		Only	28; 12.44% (8.43– 17.48%)
Indication for considering ECT	Suicidality	Yes	209; 92.89% (88.71– 95.88%)
		No	16; 7.11% (4.12– 11.29%)
	Treatment Resistance	Yes	206; 91.56% (87.13– 94.84%)
		No	19; 8.44% (5.16– 12.87%)
	Catatonia	Yes	181; 80.44% (74.65– 85.42%)
		No	44; 19.56% (14.58– 25.35%)
	Fast recovery	Yes	126; 56% (49.25– 62.59%)
		No	99; 44% (37.41– 50.75%)
Patients per month where ECT was considered		1–10	172; 76.44% (70.35– 81.83%)
		11–50	49; 21.78% (16.57– 27.75%)
		51–100	4; 1.78% (0.49– 4.49%)
Among whom ECT was indicated, percentage of patients who actually received ECT		0–10%	93; 41.33% (34.83%– 48.07)
		11–25%	25; 11.11% (7.32– 15.96%)
		26–50%	47; 20.89% (15.77– 26.79%)
		51–75%	26; 11.56% (7.69– 16.47%)
		76–100%	34; 15.11% (10.7– 20.47%)

Note: East Zone (Assam, Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Orissa, Sikkim, Tripura, West Bengal); North-Central Zone (Bihar, Chhattisgarh, Himachal Pradesh, Madhya Pradesh, Uttar Pradesh, Uttarakhand); West Zone (Haryana, Goa, Gujarat, Maharashtra, Punjab, Rajasthan); South Zone (Andhra Pradesh, Karnataka, Kerala, Telangana, Tamil Nadu)

*Indicates the place of clinical practice as ‘Private Out-patient Clinic ‘only

Table 1 shows the specifics of ECT services and perceived barriers. About 75% of psychiatrists considered ECT for only 1 to 10 patients a month. Among those patients in whom a psychiatrist considered ECT, only 34.86% (SD = 31.5%) actually received ECT. This proportion was less than 10% for 41.3% (n = 93) of psychiatrists. Only 26.7% (n = 60) of psychiatrists could give ECT to more than 50% of their needy patients. Several reasons were cited for the reduced administration of ECT (Fig. 1). Notably, 78.2% (n = 176) indicated that patient and family refusal was a significant factor. Limited availability or unavailability of ECT was identified by 36.7% (n = 83) of psychiatrists. Additional factors included the cost of a course of ECTs (28.9%; n = 65) and medical conditions relatively contraindicated for ECT (18.7%; n = 42). Linear regression analysis revealed that none of the general clinical practice factors, such as urbanicity of the workplace, public versus private sector, and affiliation with a medical college, was a significant predictor of the ECT treatment gap.

Fig. 1.

Barriers at different levels to ECT services

At the time of the survey, 23.1% (n = 52) of psychiatrists were not providing ECT services. Of these, 61.5% (n = 32) cited the unavailability of anaesthetists and the cost of anaesthesia as major reasons. Among those providing ECT services (n = 173), 40.5% (n = 70) and 43.4% (n = 75) of them perceived the impact of the inconsistent anaesthetist’s services on the initiation and frequency of ECT, respectively. Additionally, 12.7% (n = 22) of them expressed the limited availability of paramedical staff as a concern for ECT administration. Overall, 59.1% (n = 133) of participating psychiatrists opined that the issues related to anaesthesia facilities impeded the currently functioning ECT services or contributed to the closure of the ECT services (Fig. 1).

52.4% (n = 118) observed a decrease in the number of patients receiving ECT after the enactment of the MHCA 2017 in India, while 44.9% (n = 101) noticed no change. The remaining 2.7% (n = 6) perceived an increase in patients receiving ECT after the MHCA 2017. In the logistic regression analysis, all clinical practice-related factors were insignificant (Table 2 However, issues related to anaesthesia services were a significant predictor (p = 0.018). Psychiatrists with inadequate support for anaesthesia services had 2.02 times higher odds of perceiving a decrease in the use of ECT after MHCA 2017 compared to those with adequate anaesthesia facilities. Other barriers to ECT were not significant (Table 2). Regarding the child-adolescent population, 50.7% (n = 114) of psychiatrists reported a reduction in the administration of ECT since MHCA 2017. Additionally, 27.6% (n = 62) were unsure about it, and 19.1% (n = 43) did not notice any change.

Table 2.

Predictors of the impact of MHCA, 2017 on ECT services (binary logistic regression analysis)

Predictor Variable		Estimate	Standard Error	Wald Test		Odds Ratio (95% Confidence Interval)
				Wald Statistic	p
(Intercept)		-1.028	1.194	0.742	0.389	0.358 (0.034–3.712)
Working in Government vs. Private hospital*1	Government hospital	-0.287	0.754	0.145	0.703	0.75 (0.171–3.291)
	Private hospital	-0.398	0.751	0.281	0.596	0.672 (0.154–2.926)
	None of them	-0.635	0.847	0.561	0.454	0.53 (0.101–2.79)
Medical graduation-postgraduation training* (Yes)		0.402	0.317	1.608	0.205	1.495 (0.803–2.784)
Place of clinical practice*2	Semi-urban	1.427	0.944	2.284	0.131	4.164 (0.655–26.486)
	Urban	1.235	0.923	1.79	0.181	3.437 (0.563–20.978)
Refusal of ECT by Patient/ caregivers (Yes)		-0.54	0.391	1.909	0.167	0.583 (0.271–1.253)
Presence of relative Contraindications to ECT (Yes)		-0.303	0.375	0.651	0.42	0.739 (0.354–1.541)
Issues related to anaesthesia services (Yes)		0.705	0.298	5.593	0.018	2.024 (1.128–3.629)
Limited availability/ Unavailability of ECT (Yes)		0.584	0.353	2.728	0.099	1.793 (0.897–3.584)
The predictive model had AIC = 288.3,p = 0.001, pseudoR2(Tjur R2) = 0.11 and Accuracy = 0.627

Note: Decrease in the number of ECTs after MHCA, 2017 level ‘Yes’ coded as class 1

Tolerance of all variables was 0.7 to 0.9, thus ruling out multicollinearity

*Included in the Null Model (Block 1)

¹Reference category = Working in Both Government and private hospitals

²Reference Category = Place of clinical practice is Rural

Discussion

This survey aimed to understand psychiatrists’ views on ECT services in India, gathering responses from 225 psychiatrists. With 8000–9000 active psychiatrists in India [19, IPS, 20], this sample size gave a reasonable margin of error of 6.45% [21]. The response rate cannot be determined due to the varied social media sources and academic organisations used to reach psychiatrists. The final denominator depended on the privacy preferences of those enrolled in these forums. Unlike most ECT surveys targeting psychiatry hospitals, we aimed to understand the barriers in ECT practices as perceived individually by the psychiatrists. About 70% of respondents were from urban areas, reflecting the unequal distribution of mental health services in India and has remained a concern [22, 23]. Most psychiatrists cited suicidality or treatment resistance as the reason for prescribing ECT, aligning with the national and international clinical guidelines [2, 24, 25]. ECT was initiated for faster recovery in 56% of cases. It might be related to aggressive patients having mania or schizophrenia, which accounts for a significant proportion of patients receiving ECT in India [13].

About 40% of the psychiatrists in our survey administered ECT to less than 10% of their needed patients, and another 35% of them could provide ECT to 10–50%. Treatment resistance occurs in 20–30% of the patients with depression [26, 27] or schizophrenia [28, 29]. Up to half of the suicide deaths and non-fatal suicidal behaviours are associated with a psychiatric disorder [30]. Thus, with a large ECT treatment gap, the number of people in India who can benefit from ECT but don’t receive it would be high. Ironically, the unacceptability of ECT by patients themselves is a major cause of the lower utility of ECT services [10, 31]. Almost 80% of the psychiatrists cited the refusal by patients and their families an important reason for not administering ECT. There is a need to address the different kinds of stigma associated with ECT and to provide correct, authentic information about ECT to patients and caregivers. The limited availability of ECT and its high cost were another two important reasons opined by psychiatrists for the ECT treatment gap. The anaesthesia service required for ECT often impacts these two factors and influences ECT services in various ways, as discussed later. A few medical conditions in patients also deter some psychiatrists from using ECT due to its relative contraindications. The affiliation with a medical college, Government or private set-up didn’t influence the proportion of patients receiving ECT.

We also examined the impact of the MHCA 2017 on India’s ECT treatment gap. Over half of the psychiatrists reported a decrease in patients receiving ECT over the last six years. The nature of the workplace did not affect ECT practices post-MHCA 2017. However, psychiatrists experiencing issues with anaesthesia services were more likely (Odds ratio = 2.02) to perceive an increased ECT treatment gap with the MHCA 2017. This was expected due to the ban on unmodified ECT after MHCA 2017 [16, 17]. The use of unmodified ECT remained a major method of administering ECT in India before its ban, as shown in the two previous surveys conducted over a gap of more than ten years [12, 13]. Other reasons for the large ECT treatment gap did not contribute to the effect of the MHCA 2017 on ECT services.

Due to a shortage of anaesthesia services, 40–45% of providers faced challenges in initiating and maintaining timely ECT and offering outpatient-based ECTs. Overall, up to 60% of psychiatrists cited inadequate anaesthesia support as the reason for halting or limiting ECT services. A similar survey in the United States also identified lack of anaesthetist support as a barrier to starting or expanding ECT services [10]. Its respondents noted a need for more well-trained staff. However, our survey found that 84% of psychiatrists were satisfied with the availability of paramedical staff.

ECT is administered 2–3 times a week, requiring repeated anaesthetist services. Due to the scarcity and unequal distribution of anaesthetists in India [32], surgical procedures might be prioritised over ECT. The commitment to multiple ECT sessions and perceived lesser significance compared to surgery by anaesthetists could contribute to this [33, 34]. The delay in the initiation, irregular frequency, and costs may also deter patients from ECT. The authors support the stand of MHCA in India on equal rights for all patients with mental illness and do not favour the resumption of unmodified ECT. Instead, we would like to argue for the rights of the patients who need ECT, and denying this vital treatment, in the situation of absolute clinical necessity, contradicts the United Nations’ commitment towards persons with disabilities and the MHCA [14, 35]. A recent report on the temporary halt of ECT services due to deficient anaesthesia services in a large psychiatric hospital in India calls for an urgent evaluation of possible solutions [36].

Government health insurance schemes like Ayushman Bharat by the Government of India can reduce the cost of modified ECT sessions for economically disadvantaged individuals. However, only a few states currently accept Ayushman Bharat or offer similar provisions for ECT in their state health insurance schemes. Training psychiatrists to provide anaesthesia care alongside ECT administration is another solution. Many LMICs in Asia and Africa have adopted this task-sharing approach for surgical services. This is also implemented in developed countries to manage insufficient anaesthesia care in rural and remote areas [37]. In India, with the Government’s initiative, MBBS (Bachelor of Medicine, Bachelor of Surgery) doctors could be trained in anaesthesia skills to provide emergency obstetric care and newborn care at the primary level [38, 39]. The anaesthetic care provided by trained physicians, nurses, and other health care personnel does not compromise the patient’s safety [40, 41]. Hence, training psychiatrists/ nurses on basic anaesthesia practices for ECT is a feasible option. The training definitely needs to be well thought out under the guidance of psychiatrists who have rich experiences in ECT services and expert anaesthesiology faculty who are familiar with ECT-related anaesthesia care and have experience in providing task-based training beyond the regular training for post-graduate anaesthesia degrees. The course and curriculum should be standardised and certified by appropriate medical authorities. The realm of the capacity of the trained individuals should be well-defined, targeting general adult patients without significant medical comorbidities. The digital training [42, 43] and telemedicine [37, 44] can aid in hybrid training and handholding of trained health professionals. A pilot program can assess feasibility before expansion.

Regarding ECT services in children and adolescents, a similar proportion (50.7%) of psychiatrists opined a reduction in the number after the MHCA 2017 in India. About 28% could not comment, likely due to the limited experience with this age group receiving ECT [13]. Mental Health Review Boards are being established to regulate ECT for minors, with recent recommendations [45] expected to improve administration soon.

This survey had the typical limitations of online surveys [46]. There might have been a further bias secondary to the larger regional representation from southern India. The future surveys can achieve a more balanced distribution by involving state-level psychiatric academic organizations. We also lacked the exact data on number of psychiatrists who received the survey, hindering our understanding of response rates. Additionally, we did not assess psychiatrists’ attitudes toward or knowledge of ECT, assuming positive attitudes based on previous surveys worldwide [47–49]. Other unexamined factors include infrastructure barriers, administrative support, and reasons for patient or family denial of ECT. To ensure the survey could be completed within 10 min and to achieve an adequate response rate, we focused on barriers directly related to our primary objective.

Conclusion

Our web-based survey explored the perceptions of individual psychiatrists in India. The findings indicate a significant treatment gap for ECT services. Besides patient-related factors, systemic issues also contribute to the inconsistent availability of ECT services, both directly and indirectly. A prominent issue is the inadequate provision of anaesthesia services, which has been exacerbated following the enactment of the MHCA 2017 in India. Consequently, there has been a rise in the underutilisation of ECT over the past six years. We propose that implementing a task-sharing approach for anaesthesia care, coupled with telementoring, can help address the ECT treatment gap.

Electronic supplementary material

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Abbreviations

ECT

Electroconvulsive therapy

MHCA

Mental Health Care Act

LMIC

Low and middle income countries

DNB

Diplomate of National Board

Author contributions

PS: Gave substantial contributions to the conception and design of the work, analysis and interpretation of data, and drafting and revision of the manuscript. VSS: Gave substantial contributions to the conception and design of the work, acquisition and interpretation of data, and manuscript revision. ASS: Gave substantial contributions to the design of the work, data interpretation and manuscript revision. JT: Gave substantial contributions to the design of the work, data interpretation and manuscript revision. All authors read and approved the submitted version.

Funding

It is a non-funded study.

Data availability

The dataset used and analysed during the current study is available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Approval received from the Institute Ethics Committee (Behavioural division), NIMHANS [No. NIMHANS/320° IEC (BEH.SC.DIV.)/2021]. Informed consent was sought through providing detailed information about the survey online and participant was moved to the survey webpage only after selecting the ‘Agree to participate’.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not Applicable.