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PS13.1 | Therapeutics in Psychiatry — PBL Case

CLINICAL SETTING

You are a final-year MBBS student attached to the psychiatry inpatient ward of a tertiary teaching hospital. The attending psychiatrist asks you to review a patient with her before the weekly ECT team meeting. The patient is Mrs Leela Krishnan, a 46-year-old school teacher admitted 11 days ago.

Trigger 1: The Patient Who Stopped Eating

Mrs Leela Krishnan is a 46-year-old school teacher with a 6-year history of recurrent major depressive disorder. She was admitted 11 days ago following her third depressive episode in two years. On admission, she had a PHQ-9 score of 26 (severe), active suicidal ideation with a plan (she had researched methods online), and had stopped eating and drinking for 3 days prior to admission. She was started on escitalopram 20 mg and mirtazapine 30 mg. Eleven days later, she remains profoundly depressed, has resumed minimal oral intake only under close monitoring, denies pleasure in anything, and continues to express passive suicidal ideation ('I don't deserve to live'). She is alert, oriented, and has no psychotic features. Her attending psychiatrist documents: 'Failed two antidepressants at adequate dose over adequate duration. Active suicidal ideation. Nutritional compromise. Modified ECT indicated.' You are asked to be part of the team that explains ECT to Mrs Krishnan and her family.

DISCUSSION POINTS

  • What specific features of Mrs Krishnan's presentation make her a candidate for ECT rather than continuing to try other antidepressants? Identify at least three clinical justifications.
  • The MHCA 2017 requires 'informed consent' before ECT. What information must be shared with Mrs Krishnan before she can give valid consent? What cognitive or emotional factors might affect her capacity to give consent in her current state?
  • Mrs Krishnan's husband says, 'Doctor, she has told you she doesn't want ECT. Can't you just force it since she is so sick?' How would you respond, and what are the legal and ethical considerations under the MHCA 2017?
Click to reveal Trigger 2: The Family Meeting (discuss previous trigger first!)

Trigger 2: The Family Meeting

The next morning, the ECT team holds a family meeting with Mrs Krishnan and her husband, Mr Ramesh Krishnan, and her adult daughter, Priya (age 22). Mrs Krishnan has agreed to hear about ECT but is visibly apprehensive. Mr Krishnan opens with: 'I have read online that ECT is electroshock torture. My wife's friend told me that her cousin had ECT and is now completely brain-dead. How can you recommend this for my wife?' Priya adds: 'I also read that they still use ECT to control patients who are difficult in psychiatric hospitals. Is that true?' Mrs Krishnan herself asks quietly: 'Will I lose all my memories? I'm a teacher — my whole life is in my head.' The attending psychiatrist turns to you and says, 'Please help me address their concerns.'

DISCUSSION POINTS

  • Address Mr Krishnan's 'electroshock torture' and 'brain-dead cousin' concerns using accurate medical evidence. What does the evidence say about ECT and structural brain changes? How would you explain cognitive side-effects honestly without being either dismissive or alarmist?
  • Address Priya's concern that ECT is used to control difficult patients. What safeguards exist in Indian law (MHCA 2017) and in the modified ECT procedure itself that prevent coercive or punitive use?
  • Address Mrs Krishnan's concern about memory loss specifically in the context of her professional identity as a teacher. What are the typical cognitive effects of ECT, their time course, and what factors (e.g., electrode placement, number of sessions) influence their extent? What would you tell her about her autobiographical memory and her ability to continue teaching?
Click to reveal Trigger 3: The Course and Its Outcome (discuss previous trigger first!)

Trigger 3: The Course and Its Outcome

Mrs Krishnan gives valid informed consent. She completes a pre-anaesthetic assessment — no contraindications identified. She is fasted from midnight before each session. Modified ECT is administered three times a week: short-acting thiopentone for induction, succinylcholine 1 mg/kg for neuromuscular blockade, supplemental oxygen. Bilateral electrode placement is used given the severity of her presentation. A bite-block is placed; the one-cuff technique confirms a 35-second generalised motor seizure on each of the first three sessions. By session 6, the ward nurses note she is 'eating her meals unprompted.' By session 9, her PHQ-9 has fallen to 8. She reports difficulty recalling some specific events from the past month and experiences mild headaches after sessions, which resolve within 2 hours. She asks whether she can stop now and what will happen when she goes home.

DISCUSSION POINTS

  • Explain the pharmacological rationale for each agent used in her modified ECT sessions: thiopentone (or propofol), succinylcholine/suxamethonium, supplemental oxygen. Why is succinylcholine preferred over a non-depolarising muscle relaxant for ECT?
  • The one-cuff technique confirmed a 35-second motor seizure. Why is seizure adequacy important, and how is it assessed when EEG is not available? What would you do if seizure duration was less than 25 seconds?
  • Now that Mrs Krishnan has responded to ECT, what is the plan to prevent relapse? Discuss the role of post-ECT pharmacotherapy (antidepressants ± lithium), the option of maintenance ECT, and the factors that would guide the choice between them. How would you address her current peri-treatment memory gaps and reassure her about the trajectory of cognitive recovery?

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [PS13.1] What is the modified ECT procedure, including the specific pharmacological agents (induction agent, muscle relaxant, oxygenation), electrode placement options, seizure adequacy criteria, and the step-by-step procedural sequence from pre-session preparation to recovery?
  2. [PS13.1] What are the established indications for ECT, and what clinical features (severity, suicidal risk, food refusal, catatonia, pharmacotherapy failure) justify its use over continued antidepressant trials?
  3. [PS13.1] What are the cognitive and physical adverse effects of modified ECT, and how do factors such as electrode placement, session frequency, and total number of sessions influence their extent and reversibility?
  4. [PS13.1] What are the key provisions of the MHCA 2017 that govern ECT practice in India, including the prohibition of unmodified ECT, informed consent requirements, provisions for minors, and safeguards against coercive use?
  5. [PS13.1] What are the most common misconceptions about ECT, and how does the evidence-based clinical reality of modified ECT (as a legally regulated, anaesthetic-assisted, evidence-based procedure) correct each misconception?