Electroconvulsive Therapy Practice in Thailand: A Nationwide Survey

Introduction

Electroconvulsive therapy (ECT) was introduced in 1938 by Ugo Cerletti and Lucio Bini.^1,2 After successful use had been demonstrated, ECT was widely implemented across the world, especially for the treatment of schizophrenia and mood disorders. In the 1950s, psychotropic drugs were introduced, and their use has continually increased ever since. In parallel, the popularity of ECT declined such that it became the treatment of choice only for patients who did not respond to psychotropic drugs, who required rapid symptom control, or who had conditions that respond better to ECT. The practice of ECT varies among countries: Western countries are more likely to use it to treat mood disorders, while it is applied more widely for treating schizophrenia in Asia.^3–8 Anesthetic agents and muscle relaxants are more commonly used in the United States and Europe to reduce the negative effects of ECT and reduce the risk of injury, but this is not the case in Asia, Africa, Latin America, or Russia.⁸ Regardless of country, manufacturers, dosing strategies, and electrode placement vary among hospitals.

In Thailand, ECT was first introduced into clinical practice in 1945 by Professor Arun Paksuwan.⁹ It was subsequently adopted by some psychiatric, university and general hospitals providing psychiatric services at that time. The first study about general ECT practice in Thailand was conducted in the period 2001–2002.⁴ Of the 28 hospitals providing ECT services at that time, 2 did not participate in the study. The majority of the patients were seen in psychiatric hospitals because there were more specialists in this field in such institutions. The most prevalent diagnoses of patients selected for ECT were schizophrenia (74%), mania (8%), and depression (7%).⁴ Electrode placement was bilateral in all cases, and almost all treatments (94.2%) were performed without anesthetic agents because of a lack of equipment, personnel and anesthesiologists, as well as the risks posed by anesthesia, inconvenience, and economic reasons, among others.⁴ Unmodified ECT can induce dread and anxiety in patients, as well as post-ictal disorientation, fracture, and various other side effects.

Nowadays, more psychiatrists, anesthesiologists and anesthesiology nurses are available. Moreover, there is more knowledge about diseases, treatments, and procedures than ever before. In 2013, a public health policy was established to reduce physical and mental trauma among ECT patients, and to destigmatize the treatment. We believe that the overall practice of ECT in Thailand has evolved markedly since the first survey was conducted 17 years ago, and conducted this study to characterize current ECT practice in Thailand and aid further development of Thai ECT services.

Materials and Methods

Setting and Study Design

The study protocol was approved by the Human Research Ethics Committee of the Faculty of Medicine, Ramathibodi Hospital, Mahidol University (COA. No.: MURA2021/578). We conducted a cross-sectional survey of ECT practice in Thailand in October 2021 by sending a questionnaire to all 34 hospitals in the database of the Psychiatric Association of Thailand. We requested that staff providing ECT services at each hospital complete the questionnaire. Informed consent was obtained from all respondents at the beginning of the survey, which was conducted according to the Declaration of Helsinki and Good Clinical Practice guidelines.¹⁰

Questionnaire

The questionnaire (see Supplementary File) was developed inhouse on the basis of a review of the literature^{3,4,6,7,11–16} and approved by psychiatrists working at Ramathibodi Hospital. The questionnaire was divided into six sections covering the characteristics of ECT services, ECT administration, anesthetic procedures, acute-course ECT, continuation/maintenance ECT, and patient assessments during ECT. The questionnaire, which takes around 30–45 minutes to complete, was originally developed in Thai. The draft questionnaire was sent to staff providing ECT service in our hospital for evaluation of the clarity of the questions and completion time; it was then revised in response to staff comments.

ECT Services

Data pertaining to the ECT services of the hospitals were obtained in the first section of the questionnaire, including case types and diagnoses, indications for ECT, the individual supervising the informed consent process, pre-treatment investigations, the location in which treatments were carried out, and the treatment guidelines (if any). The average number of patients receiving treatment and cost of each session were also determined.

ECT Administration

The ECT administration section includes questions about the person who administered it, the type and brand of ECT device used, electrode placement, pulse width, patient monitoring procedures, and pharmacological management during the treatment.

Anesthetic Procedures

This section contains questions about the anesthetic procedure and use of modified ECT procedures. Information about the person responsible for providing the anesthesia was obtained, as well as the anesthetic agents and muscle relaxants used during the procedure.

Acute-Course ECT

Information about acute-course ECT was obtained, including the average number of treatments done for each diagnosis, intervals between treatments, and the protocol for efficacy evaluation and terminating the course.

Continuation/Maintenance ECT

Information was obtained on continuation/maintenance ECT treatments from hospitals providing this service, including the diagnoses of the patients and whether a specific protocol was followed.

Patient Assessments During ECT

Information about the tools used for symptom and cognitive function assessments during ECT, and the side effects of treatment, was obtained in the final questionnaire section.

Statistical Analysis

Nominal data are summarized as numbers and percentages, while continuous data are summarized as mean ± standard deviation or median and interquartile range, depending on the normality of the data distribution. All statistical analyses were performed using SPSS software (version 26.0 for Windows; IBM Corp., Armonk, NY, USA).

Results

We received responses from all 34 hospitals providing ECT services in Thailand. The hospitals are distributed throughout the country: 10 (29.4%) are in the central part, 11 (32.4%) in the northeastern region, 6 (17.6%) in the northern region, 5 (14.7%) in the southern region, 1 (2.9%) in the eastern region, and 1 (2.9%) the western region. There were 13 (38.2%) psychiatric hospitals, 12 (35.3%) general hospitals, and 9 (26.5%) university hospitals; the average number of psychiatric beds in these three types of hospital is 23 ± 7 (range: 12–30), 305 ± 196 (range: 90–750), and 22 ± 18 (range: 11–70), respectively.

Characteristics of ECT Services

Nineteen hospitals (55.9%) had psychiatrists specifically providing ECT services. Most hospitals (n = 26; 76.5%) had ECT guidelines, especially psychiatric hospitals. Twenty-three hospitals (67.6%) performed ECT on special populations, including patients aged < 12 years (n = 1), adolescents (aged 13–17 years; n = 16), elderly patients (n = 22), and pregnant women (n = 9).

Informed consent for ECT was obtained from patients or family members in all hospitals. In seven psychiatric hospitals, if the patients or their relatives were unable to give consent, the decision to perform ECT was made by institutional committees, in accordance with the Thai Mental Health Act of 2008.

ECT was performed in a special ECT unit in all psychiatric hospitals. In general and university hospitals, ECT was performed in locations including inpatient and outpatient departments, operation rooms, and post-anesthesia care units.

The number of ECT-treated patients per year are shown in Table 1 according to diagnosis. The most common diagnosis was schizophrenia, followed by bipolar disorder and major depressive disorder. Reasons for ECT treatment included drug resistance, high suicidal risk, aggressive behaviors, history of a good response to ECT, poor oral intake, and medication intolerance.

Table 1 The Number of ECT-treated Patients per Year in Thailand

For pre-treatment investigations, a complete blood count (CBC) was routinely ordered in all hospitals. Electrolytes (97.1%, n = 33), renal panels (76.5%, n = 26), electrocardiograms (88.2%, n = 30), and chest X-rays (94.1%, n = 32) were also checked/performed in most hospitals. The liver function and anti-HIV tests, among other investigations, varied among hospitals.

The average price of ECT was 64 ± 33 US dollars (range: 8–152.5 US dollars) per ECT session.

ECT Administration

A psychiatrist or psychiatric resident was responsible for performing ECT and administering the electrical charges in all hospitals. A device providing a brief pulse (0.5–1 ms) was used in all 34 hospitals, although some (8.8%, n = 3) reported using an ultra-brief pulse (0.25–0.3 ms) more frequently. None of the hospitals used devices that can produce sine waves. Device models included spECTrum 5000Q (MECTA, Lake Oswego, OR, USA) (n = 18 hospitals; 52.9%), Thymatron System IV (Somatics, LLC, Lake Bluff, IL, USA) (n = 17; 50%), and spECTrum 5000M (MECTA) (n = 4; 11.8%). The Σigma device (MECTA) was used in one (2.9%) university hospital.

Regarding electrode placement and dosing strategy, bitemporal ECT was the most commonly used approach (n = 30 hospitals; 88.2%). The stimulus intensity was determined by the titration method in most hospitals (n = 24; 70.6%) (Table 2).

Table 2 Electrode Placement and Dosing Strategy

Reasons for dose increases included inadequate seizure (n = 34 hospitals; 100%) and a lack of clinical improvement (n = 10; 29.4%).

Guidelines for managing patients’ current medications before ECT were followed by 17 hospitals (50%). Among those hospitals, drugs that had to be discontinued before starting the treatment (according to the guidelines) included anticonvulsants (n = 15; 88.2%), benzodiazepines (n = 15; 88.2%), lithium (n = 13; 76.5%), antipsychotics (n = 6; 35.3%), antidepressants (n = 3; 17.6%), and anticholinergics (n = 1; 5.9%). Changes in psychotropic drugs during ECT were made in most hospitals (n = 28; 82.4%).

During ECT, blood pressure, heart rate, and pulse oximetry were monitored in all hospitals, while EEG was monitored in all university hospitals and some of the other hospitals (n = 29; 85.3%). ECG, motor seizures, the bispectral index, and carbon dioxide were monitored in 28 (82.4%), 26 (76.5%), 3 (8.8%), and 4 hospitals (11.8%), respectively.

Modified ECT was always used in 25 hospitals (73.5%), including all university hospitals, 6 psychiatric hospitals (17.6%) and 10 general hospitals (29.4%). Three psychiatric hospitals (8.8%) used both modified and unmodified ECT in certain cases. Two general (5.8%) and four psychiatric hospitals (11.8%) used unmodified ECT in all cases. The reasons for using unmodified ECT are listed in Table 3.

Table 3 Reasons of Unmodified ECT

Anesthesia in Modified ECT

Preanesthetic assessment and anesthetic procedures were performed by an anesthesiologist or anesthesiology nurse in most hospitals. However, in most psychiatric hospitals, anesthesia was provided by nurse anesthetists only. The primary anesthetics used were thiopentone (n = 17 hospitals; 60.7%) and propofol (n = 11; 39.3%). Ketamine, etomidate, and fentanyl were only used in university hospitals. All hospitals used succinylcholine as the muscle relaxant. Preoxygenation was performed in all except one general hospital. Hyperventilation was performed in 20 hospitals (71.4%). Two hospitals (5.9%) reported the use of endotracheal tube intubation for modified ECT in some cases, such as patients with a difficult airway, pregnancy, or unstable vital signs.

Acute-Course ECT

Regarding acute treatment for schizophrenia or schizoaffective disorder, 21 hospitals reported the use of 4–6 ECT sessions on average; the next most common amount was 10–12 sessions (n = 8 hospitals), followed by 7–9 sessions (n = 6), 1–3 sessions (n = 3), and > 12 sessions (n = 2). For major depressive disorder and bipolar disorder, the pattern was similar, with ECT being performed three times per week in most hospitals (n = 31; 91.2%). The response to ECT was reportedly assessed after 4.4 ± 1.5 sessions, and reasons for discontinuation included intolerable side effects (n = 28; 82.4%), clinical improvement (n = 27; 79.4%), a lack of response to ECT (n = 15; 44.1%), and a plateau in the response (n = 7; 20.6%).

Continuation/Maintenance ECT

In total, 22 (64.8%) hospitals performed continuation/maintenance ECT, most commonly for schizophrenia (followed by bipolar disorder, schizoaffective disorder, major depressive disorder, and organic psychosis). There were no clear guidelines for continuation/maintenance ECT in most hospitals (n = 18; 52.9%).

Assessing Patients During ECT

Eighteen hospitals (52.9%) assessed patients clinically using various assessment tools before and after ECT, fifteen (44.1%) did not perform any assessments and one (2.9%) performed assessments only before treatment. Various assessment tools were used, including the Brief Psychiatric Rating Scale (BPRS),¹⁷ Positive and Negative Syndrome Scale (PANSS),¹⁸ Young Mania Rating Scale (YMRS),¹⁹ Hamilton Depression Rating Scale (HAM-D),²⁰ Montgomery–Åsberg Depression Rating Scale (MADRS),²¹ Health of the Nation Outcome Scales (HoNOs),²² and Clinical Global Impression (CGI) scale.²³ Twelve hospitals assessed patients’ cognitive function using the Thai Mental State Examination (TMSE),²⁴ Mini-Mental State Examination–Thai version (MMSE-Thai)²⁵ and/or Montreal Cognitive Assessment–Thai version (MoCA-T),²⁶ while 22 (64.7%) hospitals did not perform any cognitive assessments. Regarding the side effects of ECT, headache was the most frequent, followed by cognitive side effects and myalgia. Other side effects included cardiovascular problems, delirium, oral cavity trauma, and “others” (eg, falling and bone fractures). No deaths were reported.

Discussion

In this nationwide survey of ECT practice in Thailand, we received responses from all hospitals providing ECT services throughout the country. The study was performed almost 20 years after that of Chanpattana and Kramer,⁴ which was the first of its kind, and provides an up-to-date picture of ECT practice in Thailand. Currently, 34 hospitals offer ECT services in Thailand, compared with 28 in the previous survey. Even though the hospitals are widely distributed throughout the country, and have increased in number, they remain concentrated in certain areas. For example, 7 of the 10 hospitals in the central part of the country are located in Bangkok. The unequal distribution of hospitals providing ECT services means that accessibility remains relatively low for some people.

According to our results, the most common diagnosis of patients receiving ECT is still schizophrenia (64.1%), followed by bipolar disorder (10.6%) and major depressive disorder (9.3%). These trends are similar to those in Asia overall^3,5,14 but differ from those in the USA, Australia and New Zealand, and most other Western countries,^{8,11–13,15,16} in which affective disorders are more common. The severity of the symptoms of schizophrenia, which require rapid control, may explain the high proportion of such patients in our survey.

Pre-treatment investigations were provided by most of the hospitals in our survey and included CBC, renal panels, electrolyte tests, electrocardiogram, and, if necessary, chest X-ray, similar to many countries in Europe.²⁷ We suggest that standardized guidelines be developed for all hospitals to enhance patient safety during ECT.

Our results showed that modified ECT is being used significantly more often today compared with 2002.⁴ This can be attributed to increasing numbers of anesthesiologists and anesthesiology nurses, in accordance with public health policy enacted in 2013 to better treat the physical and mental problems of trauma patients and destigmatize ECT. In most of the psychiatric hospitals surveyed herein, anesthesia was performed mainly by anesthesiology nurses, which does not accord with international guidelines.²⁸ The general lack of anesthesiologists in psychiatric hospitals necessitated that nurses be trained to perform anesthetic procedures. According to our survey, thiopental is still the most common anesthetic drug used in Thailand, although the use of propofol has increased. Methohexital remains unavailable.

The number of ECT sessions typically performed was quite low in our survey, inconsistent with a study reporting that an average of 11.8 ± 4.7 sessions were required to achieve remission in Thai psychiatric patients.²⁹ Fifteen of the hospitals surveyed herein cited nonresponse to ECT among the reasons for discontinuation of treatment; we assume that, in some of the cases, treatment may have been stopped too early.

None of the hospitals in our survey used devices that can produce sine waves; brief and ultra-brief pulses were used instead. Regarding the stimulation method, our results indicate that dose titration is being increasingly used. Regarding electrode placement, bilateral ECT was typically used, albeit not exclusively (in contrast to the 2002 survey).⁴ Unilateral ECT was used to reduce the cognitive side effects of ECT.³⁰

Despite the recommendations of the Royal College of Psychiatrists (London, UK),³¹ most of the hospitals that we surveyed do not use any tools to monitor patients’ clinical and cognitive function; this is important when evaluating treatment efficacy, and to detect and monitor patients at risk of cognitive impairment.

Some potential limitations of our research should be noted. First, rather than conducting an audit, data were obtained from representative ECT staff at each participating hospital, and the outcomes may not fully reflect real practice. Second, given the self-administered nature of the survey, misinterpretation of certain questions cannot be ruled out. Third, no data were obtained regarding patient characteristics, ECT utilization, the response rate, or difficulties experienced by hospitals in providing ECT services; further research is therefore required.

Conclusions

Our survey showed that ECT practice in Thailand has developed over the past two decades in many aspects. The most notable change is that the majority of patients are now treated with modified ECT. Moreover, pre-treatment investigations, brief pulses, unilateral electrode placement, and monitoring of treatment parameters are being used more often to maximize treatment efficacy while minimizing side effects. However, standard treatment protocols are not being adhered to in all respects; for example, it is likely that acute ECT treatment is being stopped prematurely in some cases. Improving ECT education for psychiatrists and psychiatry residents could improve the standard of care. We suggest that training nurses in the performance of anesthesiology may improve the accessibility of ECT services in some parts of Thailand, given the lack of availability of anesthetists; anesthesia training for psychiatrists could also be an option. The provision of support by the Royal College of Psychiatrists for the implementation of ECT services in certain parts of Thailand would be useful, as would the formation of, and subsequent monitoring of adherence to, standards for ECT. Finally, our research focused on ECT practice before the coronavirus disease 2019 outbreak. Some medical practices, especially ones involving anesthetics, were modified during the pandemic; further study could focus on the impact of the pandemic on ECT practice.