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Perspective/Viewpoint

Electroconvulsive Therapy without General Anesthesia and the Human

Rights of Mental Health Patients: Some Reflections on a Recent Situation
in Chile

Abstract Alvaro Barrera1,

The use of unmodified electroconvulsive therapy  (ECT), i.e., ECT without general anesthesia, Andrew
vis‑a‑vis human rights of mental health patients and standards of care, is discussed. An overview of Molodynski1,
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 Louise
with a proposal to launch a voluntary system of accreditation, by which countries willing to have Penzenstadler2,
their mental health services accredited by the World Health Organization  (WHO) would commit Yasser Khazaal3
themselves to give unrestricted, unannounced, and at short‑notice access to independently appointed 1
Oxford Health NHS Foundation
the WHO representatives to their community and inpatient mental health facilities. Trust, Warneford Hospital,
University of Oxford, Oxford,
Keywords: Human rights, standards of care, Unmodified ECT UK, 2Department of Psychiatry,
Division of Addiction, Geneva
University Hospital, Geneva,
Introduction For ECT to be effective and safe for those 3
Department of Psychiatry,
receiving it, the highest standards of care Lausanne University Hospital
Electroconvulsive therapy (ECT) is an and Lausanne University,
must be maintained and be consistently and
effective treatment for some mental Lausanne, Switzerland
independently monitored. One aspect where
disorders, including severe depression,[1]
there is significant international variation
catatonia, or a prolonged or severe
is whether ECT is administered modified
manic episode.[2] ECT can also help the
or unmodified. In the UK, ECT cannot be
symptoms of schizophrenia that have
carried out without general anesthesia.[5]
not improved with medication, but it
Internationally, the situation is varied. In
is not used often in the UK for this.[2]
Denmark, Norway, and Sweden, ECT is
Cerletti and Bini developed ECT in Italy
always modified,[6] but in Thailand, 94% of
in 1937 based on the work of Ladislas
ECT is unmodified.[7] A survey throughout
J Meduna, with seizures induced with
Russia in 2005 found that fewer than
camphor and cardiazol to treat people with
20% of ECT was modified.[8] Similarly,
a “diagnosis” of severe mental illness.[3]
unmodified ECT was used in Asia in
ECT was at the time administered without
over 90% of countries as well as in some
general anesthesia  (so‑called “unmodified
countries in Africa and Latin America.[9]
ECT”). It was associated with severe side
Turkey started a transition from unmodified
effects such as fractures of the vertebrae,
to modified ECT after critical reports from
extremities, and teeth, cardiovascular events
mental disability rights international and Address for correspondence:
such as bradycardia or even asystole, and
the European Convention for the Prevention Dr. Alvaro Barrera,
psychological trauma. The latter includes Oxford Health NHS Foundation
of Torture and Inhuman or Degrading
being conscious and aware of being Trust, Warneford Hospital,
Treatment or Punishment (CPT).[10] University of Oxford,
paralyzed.[4] During the 1950s, “modified
Warneford Lane, Oxford, UK.
ECT”, i.e., ECT under general anesthesia, It is important to mention that Article 1 of E‑mail: alvaro.barrera@psych.
was introduced in the United  Kingdom, the Convention Against Torture and Other ox.ac.uk
and by the early 1960s in the UK all ECT Cruel, Inhuman or CPT indicates that “for
treatments were modified.[3,4] the purpose of this convention, the term
“torture” means any act by which severe Access this article online
pain or suffering, whether physical or Website:
www.worldsocpsychiatry.org
Submission: 16‑11‑22 Web Publication: 21-12-22 mental, is intentionally inflicted on a person
Acceptance: 17‑11‑22
for such purposes as obtaining from him, DOI: 10.4103/wsp.wsp_36_22
Quick Response Code:
This is an open access journal, and articles are
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows How to cite this article: Barrera A, Molodynski A,
others to remix, tweak, and build upon the work non‑commercially, Penzenstadler L, Khazaal Y. Electroconvulsive Therapy
as long as appropriate credit is given and the new creations are without General Anesthesia and the Human Rights
licensed under the identical terms. of Mental Health Patients: Some Reflections on a
Recent Situation in Chile. World Soc Psychiatry
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com 2022;4:199-201.

© 2022 World Social Psychiatry | Published by Wolters Kluwer - Medknow 199

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Barrera, et al.: ECT without general anesthesia and human rights
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
200
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
World Social Psychiatry | Volume 4 | Issue 3 | September-December 2022
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Barrera, et al.: ECT without general anesthesia and human rights
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
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. NICE Guideline  [NG222] Depression in Adults: Treatment and
Management. Available from: https://www.nice.org.uk/guidance/
ng222. [Last published on 2022 Jun 29].
2. 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].
3. Jones  C, Jones  S. Electro convulsive therapy: Milestones in its
history. Ment Health Nurs 2018;38:6-10.
4. 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.
5. 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+r
evised%3A+January+2019.&ia=web. [Last revised on 2019  Jan
01].
6. Bjørnshauge D, Hjerrild  S, Videbech  P. Electroconvulsive
therapy practice in the Kingdom of Denmark: A  Nationwide
World Social Psychiatry | Volume 4 | Issue 3 | September-December 2022
register- and questionnaire-based study. J ECT 2019;35:258-63.
7. Chanpattana W. One hundred twenty years of mental health care
in Thailand and the development of electroconvulsive therapy.
J ECT 2010;26:11-3.
8. Nelson AI. A national survey of electroconvulsive therapy use in
the Russian Federation. J ECT 2005;21:151-7.
9. Leiknes  KA, Jarosh-von Schweder  L, Høie B. Contemporary
use and practice of electroconvulsive therapy worldwide. Brain
Behav 2012;2:283-344.
10. 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.
11. 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].
12. 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/080728UNRapporteu
ronTortureA_63_175.pdf. [Last revised on 2022 Nov 08].
13. Available from: https://coercioninpsychiatry.com/events-2/.
[Last revised on 2022 Nov 08].
14. Available from: https://radio.uchile.cl/2022/06/08/declaracion-
publica-frente-a-la-denuncia-de-tortura-en-el-hospital-
psiquiatrico-del-salvador/. [Last revised on 2022 Nov 08].
15. Available from: https://www.biobiochile.cl/especial/bbcl-
investiga/noticias/de-pasillo/2022/06/22/denuncia-por-torturas-
en-psiquiatrico-departamento-del-colmed-se-descuelga-y-entrega-
apoyo-a-yarza.shtml. [Last revised on 2022 Nov 08].
16. Available from: https://www.elmostrador.cl/
destacado/2022/06/28/el-deber-etico-y-legal-de-las-autoridades-
de-salud-frente-a-infracciones-en-el-ejercicio -of-the-medical-
profession/. [Last revised on 2022 Nov 08].
17. Available from: https://www.litoralpress.cl/sitio/Prensa_Texto?LP
Key=A5KDGDL3FYYFYH5SQQKWLW5XREBK2CBVSTYO
MK75BR3HJP74ZYQQ. [Last revised on 2022 Nov 08].
18. Available from: https://www.gob.cl/noticias/inicia-su-trabajo-
la-estrategia-nacional-de-salud-mental-y-derechos-humanos/.
[Last revised on 2022 Nov 08].
19. Available from: https://www.who.int/publications/i/item/
9789241548410. [Last revised on 2022 Nov 08].
20. 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.
21. 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.
201