PS13.1 | Therapeutics in Psychiatry — Practice Quiz

Correct. 'Modified' ECT specifically refers to the use of general anaesthesia, a muscle relaxant (succinylcholine/suxamethonium), and pre-oxygenation. These modifications prevent the violent tonic-clonic movements of an unmodified seizure, dramatically reducing the risk of fractures and aspiration.

Modified ECT = general anaesthesia + succinylcholine (muscle relaxant) + oxygenation. The Mental Health Care Act 2017 prohibits unmodified ECT in India.

The key modification is the addition of general anaesthesia, a muscle relaxant (succinylcholine/suxamethonium), and oxygenation — not the waveform type or electrode placement, which are separate technical parameters.

Correct. Severe depression with active suicidality and food refusal constitutes an urgent indication for ECT, because the rapid onset of response (often within 1–2 weeks) can be life-saving when waiting for pharmacotherapy to work is dangerous.

ECT is an urgent or first-line option in severe depression with: (1) active suicidality, (2) food/fluid refusal, (3) previous good response to ECT, (4) treatment-resistant depression, or (5) severe melancholia. It is not reserved solely for pharmacological failures.

The primary clinical logic here is urgency and life-threatening risk: active suicidality combined with food refusal creates an emergency. ECT's rapid onset of action — faster than any antidepressant — justifies its use without requiring a third failed drug trial.

Correct. The one-cuff technique isolates one forearm from systemic succinylcholine by inflating the cuff above systolic pressure before drug administration. The unparalysed forearm will show tonic-clonic movements if a generalised seizure occurs, confirming seizure adequacy — a key safety check when EEG is unavailable.

Seizure adequacy (≥25–30 seconds of motor or EEG seizure activity) is a key therapeutic determinant. The one-cuff technique provides a bedside motor surrogate when EEG monitoring is not available.

The one-cuff technique is a seizure-monitoring tool. The cuff is inflated before succinylcholine to prevent the muscle relaxant from reaching that forearm, so visible convulsive movements can confirm that an adequate seizure was induced.

Correct. Recent myocardial infarction is a relative contraindication because the risk decreases with time and the clinical urgency may outweigh residual cardiac risk. ECT has no absolute medical contraindications; risk stratification determines feasibility. Raised ICP and absence of anaesthetic infrastructure are practical absolute bars.

ECT has no absolute medical contraindications. High-risk states (recent MI, raised ICP, aortic aneurysm, phaeochromocytoma) require careful risk-benefit analysis. The clinical urgency of the psychiatric illness often tips the balance.

ECT has no absolute medical contraindications. Recent MI is a relative contraindication because the cardiac risk diminishes over time. In contrast, raised ICP (risk of herniation from the Valsalva-like effect of induced seizure) is considered a near-absolute bar, and absence of anaesthetic facilities makes safe modified ECT impossible.

Correct. Research consistently shows that post-ECT cognitive effects — particularly autobiographical memory gaps around the treatment period — are transient in the majority of patients and resolve within weeks to months. ECT is a medically prescribed, evidence-based procedure governed by legal frameworks (including the MHCA 2017 in India), not a punitive measure.

Dispelling ECT misconceptions requires acknowledging real but transient cognitive effects while firmly countering the 'punishment' narrative. MHCA 2017 explicitly prohibits coercive use and unmodified ECT, reinforcing the legal safeguard framing.

Accurate counselling requires two components: (1) cognitive side-effects are real but usually transient, not permanent brain damage; (2) ECT is a lawfully regulated, evidence-based treatment — not punishment. Claiming there are no side-effects would also be inaccurate.

Correct. The MHCA 2017 explicitly prohibits unmodified ECT under all circumstances in India. For patients under 18 years of age, ECT requires specific approval from the High Court, not merely parental consent. Emergency ECT in life-threatening situations can proceed with documentation under specific legal provisions.

MHCA 2017 safeguards: unmodified ECT prohibited; minors need High Court approval; informed consent required; emergency provisions exist for life-threatening situations with proper documentation.

MHCA 2017 key points: (1) unmodified ECT is prohibited absolutely — no rural exception; (2) ECT in minors requires High Court approval, not just parental consent; (3) the Act does provide a legal pathway for emergency ECT when life is at risk.

Correct. ECT is an evidence-based treatment for severe, treatment-resistant mania. Indications in mania include failure of adequate pharmacotherapy, life-threatening agitation, or nutritional compromise — all present here. ECT is not restricted to depressive episodes.

ECT indications beyond depression: (1) treatment-resistant or life-threatening mania; (2) catatonia (regardless of underlying diagnosis); (3) certain treatment-resistant schizophrenia presentations. ECT efficacy is not diagnosis-specific but syndrome-specific.

ECT is not contraindicated in mania. It is an established option for treatment-resistant or life-threatening mania, alongside its better-known role in depression and catatonia.

Correct. A standard acute ECT course consists of 6–12 sessions given 2–3 times per week. This schedule allows sufficient inter-session recovery, accumulation of therapeutic effect, and cognitive monitoring. Response is typically assessed after 6 sessions.

Acute ECT course: 6–12 sessions, 2–3 per week. Maintenance ECT (to prevent relapse) uses less frequent sessions (weekly to monthly) after a successful acute course.

The standard modified ECT schedule is 2–3 sessions per week for a total of 6–12 sessions. Daily ECT is not standard practice and greatly increases cognitive side-effects; once-weekly sessions are used in maintenance (not acute) ECT.

Correct. Pre-ECT preparation mandates fasting (minimum 4–6 hours, similar to any general anaesthetic), removal of dentures and jewellery (dental protection, electrode placement), and a pre-anaesthetic assessment. These are standard per-session requirements.

Pre-ECT checklist per session: fasting ≥4–6 hours; remove dentures/jewellery; vital signs; pre-anaesthetic assessment; withhold medications that raise seizure threshold (benzodiazepines, anticonvulsants if possible). Informed consent must be documented before the course begins.

Fasting and removal of dentures/jewellery are standard per-session requirements analogous to any general anaesthetic procedure. Benzodiazepines are generally avoided as they raise the seizure threshold and reduce seizure adequacy. Serum potassium is checked at baseline but not routinely before every session.