Skip to main content Accessibility help
Hostname: page-component-65dc7cd545-sqtsj Total loading time: 0.382 Render date: 2021-07-24T01:30:38.886Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "metricsAbstractViews": false, "figures": true, "newCiteModal": false, "newCitedByModal": true, "newEcommerce": true, "newUsageEvents": true }

ECT practices in Iraq: a national audit

Published online by Cambridge University Press:  02 January 2018

Nesif Alhemiary
Baghdad University, Iraq
Zainab Ali
Baghdad Teaching Hospital, Iraq
Mohammed J. Abbas
Leicestershire Partnership NHS Trust, Leicester, UK
Rights & Permissions[Opens in a new window]


Aims and method

This national audit examined practice of electroconvulsive therapy (ECT) in Iraq against local standards. Data were collected by a questionnaire sent to heads of departments or medical directors in the 10 Iraqi hospitals which provide ECT and by examining case notes of all patients who had ECT in the first 6 months of 2013.


Of the 26 psychiatric hospitals in Iraq, 10 provide ECT. There were some resource shortcomings in the ECT clinics (e.g. only 2 had a minimum of 2 rooms and all had no EEG monitoring). During the audit period, 251 patients had ECT. The mean age was 36.2 years and 51.8% were males. Bilateral ECT was used in all cases, general anaesthesia in 77.15%. The main indication for ECT was schizophrenia, followed by severe depression, resistant mania, catatonia and others.

Clinical implications

More work is needed to ensure all patients receive modified ECT. ECT is still used widely for schizophrenia. This needs further exploration and training.

Current Practice
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2015 The Authors

Electroconvulsive therapy (ECT) is an effective treatment for a small number of patients who have severe mental disorders. 1,Reference Scott2 Its use has declined in Western countries over the years Reference Eranti and McLoughlin3 and it has been associated with stigma. Reference Fink4,Reference Wilkinson and Daoud5 Unmodified ECT and its portrayal in the media might have contributed to that stigma. Reference Euba and Crugel6

ECT practice varies across countries. Reference Eranti and McLoughlin3,Reference Leiknes, Jarosh-von Schweder and Hoie7 In Asia, a survey of 257 institutions in 23 countries suggested that the practice may be seen as suboptimal, schizophrenia was the main indication, unmodified ECT is commonly used, electroencephalography (EEG) is not common and no formal training was given. Reference Chanpattana, Kramer, Kunigiri, Gangadhar, Kitphati and Andrade8

International guidelines have been developed to ensure good practice in delivering ECT. 1,Reference Scott2 In Iraq, the ECT Policy 2009 was produced by the Ministry of Health as part of a quality and standards project aimed at developing standards for care in psychiatric services. The project was carried out as a collaboration between the Royal College of Psychiatrists' Iraq Sub Committee and the Ministry of Health in Iraq using consensus conferences methodology. Reference Al-Uzri, Abed and Abbas9 The aim of this audit was to assess the practice of ECT in psychiatric hospitals in Iraq by measuring the degree of compliance with the standards of the Iraqi ECT Policy 2009.


Psychiatric services in Iraq are provided in 26 hospitals. Three of these are psychiatric hospitals and the rest are psychiatry wards or units within general hospitals. Reference Al-Uzri, Abed and Abbas9 We contacted medical directors or heads of psychiatry departments by email or telephone to find out how many hospitals have ECT facilities: it transpired that only 10 provide ECT treatment.

The audit was designed to investigate compliance with the Iraqi ECT Policy 2009. The policy is written in Arabic and English. We divided the standards of this policy into two groups: the first group included standards related to the requirements of ECT clinics in terms of number of rooms, equipment, medicines, processes and staff. The second group covered the standards related to individual ECT treatments. The full policy is available from authors on request.

A self-completed questionnaire covering the first group of standards and a data collection form covering the second group were developed by the authors. The questionnaire was sent by email to medical directors or heads of departments in the 10 hospitals. The data collection form was completed by psychiatry trainees (students of the Iraqi Board of Psychiatry) in these hospitals providing data from case notes of all patients who had ECT in the first 6 months of 2013. The patients were identified from the ECT clinics' records. This audit was approved by the Iraqi Board of Psychiatry.

Data were analysed with SPSS version 19.


All 10 hospitals returned the questionnaire regarding the first group of standards. For individual ECT treatments, data were available from 8 hospitals only. One hospital did not provide data and in the other no ECT treatment was given during the audit period.

Results showed that only 2 hospitals (20%) have a minimum of 2 rooms in their ECT clinics. Only 3 hospitals (30%) have an ECT machine which is less than 5 years old. No hospital has a machine which has EEG monitoring. Apart from one hospital, all machines used brief-pulse wave electrical current. Only in 4 hospitals (40%) was there an anaesthesia specialist attached to the department. There was a nurse responsible for the department in 7 out of the 10 clinics (70%). A nominated psychiatrist responsible for the department was available in 6 clinics (60%); all clinics (100%) train their ECT team and 4 (40%) conduct an annual audit of the work of the department (Table 1).

TABLE 1 Responses to the questionnaire in relation to 10 ECT clinics requirements

Yes No No response
Anaesthesia drugs are used according to Iraqi standards 5 0 5
Is there anaesthesia specialist in the ECT department? 4 1 5
Is there is a nurse responsible for the ECT department? 7 3 0
Has a minimum of two rooms 2 8 0
ECT device has EEG 0 10 0
ECT device has different doses 8 2 0
ECT device is less than 5 years old 3 7 0
A nominated psychiatrist is responsible for the ECT department 6 4 0
    If yes, was the ECT team trained by the psychiatrist? 6 0 0
    If yes, did the psychiatrist conduct annual audit? 4 2 0

ECT, electroconvulsive therapy; EEG, electroencephalography.

During the audit period, 251 patients had ECT: 130 male and 121 female. The average number of patients per hospital was 26.1 (range 0-47). The mean age was 36.2 years (range 17-67 years). The majority of patients (n = 181, 72.1%) were 18 to 44 years old, followed by the age group 45 to 64 years (n = 67, 26.7%). There was only 1 adolescent patient (<18 years old) and only 2 elderly patients (>65 years old).

The gender distribution was roughly equal with 51.8% of the patients male and 48.2% female. Only about a third (28.3%) were in-patients. Written consent by the patients or their relatives was obtained in all cases. ECT was given through bilateral electrodes placement in all patients. General anaesthesia was used in 77.15% of the cases. Unmodified ECT was given in three hospitals. Further correspondence with these hospitals revealed that the reason for using unmodified ECT was the unavailability of anaesthetists.

The main indication for ECT was schizophrenia (51%), followed by severe depression (31.5%), resistant mania (10.4%) catatonia (2.4%) and others (4.4%). In those diagnosed as having schizophrenia, only 5.5% had a second opinion before ECT was prescribed and in 40% the reason was poor response to other treatments (Table 2).

TABLE 2 Demographic and clinical characteristics of the sample (n = 251)

n (%)
    Male 130 (51.8)
    Female 121 (48.2)
Service setting
    In-patient 180 (71.7)
    Out-patient 71 (28.3)
ECT prescriber: psychiatric specialist 251 (100)
    Severe depression 79 (31.5)
    Resistant mania 26 (10.4)
    Catatonia 6 (2.4)
    Puerperal psychosis 1 (0.4)
    Schizophrenia 128 (51)
    Other 11 (4.4)
In schizophrenia, reason for ECT
    Previous good response to ECT 3 (1.2)
    Poor response to other treatments 102 (40.6)
    Risk to self or others 20 (8.0)
    Other 3 (1.2)
In schizophrenia, second opinion was obtained: Yes 7 (5.5)
Written consent by patient or relatives: Yes 251 (100)
ECT was done under general anaesthesia: Yes 176 (70.1)
Patient was informed to fast 10 h before treatment: Yes 251 (100)
ECT dose given according to Iraqi standards: Yes 251 (100)
There was a prolonged seizure: Yes 0 (0)
Bilateral ECT: Yes 251 (100)
Patient had ECT previously: Yes 102 (40.6)
Patient notes had documentation about response to previous ECT: Yes 62 (24.7)

ECT, electroconvulsive therapy.

All of the 251 patients (100%) received a physical health examination. However, investigations were done more often in the patients who had modified ECT than those who had unmodified ECT (Table 3).

TABLE 3 Investigations

ECT (n = 75)
n (%)
Modified ECT
(n = 176)
n (%)
Complete blood count 21 (28.0) 171 (97.2) ***
Fasting blood sugar 17 (22.7) 168 (95.5) ***
Urea and creatinine 8 (10.7) 170 (97.1) ***
Liver function test 8 (10.7) 171 (97.2) ***
Chest X-ray 11 (14.7) 176 (100) ***
Electrocardiogram 12 (16.0) 176 (100) ***

*** P<0.001, chi-squared test.

There were no statistically significant differences between males and females across clinical and demographic variables.


As far as we know, this is the first national audit of ECT practice in Iraq against clear and explicit standards. We collected data through two routes, a health professional questionnaire and a review of patient case notes. The audit highlighted areas of good practice and areas which need further improvement.

The majority of our patients were young (72.1% were 18 to 44 years old), which is very similar to Asian patients having ECT Reference Chanpattana, Kramer, Kunigiri, Gangadhar, Kitphati and Andrade8 but different from trends in Western countries, where patients are usually elderly. Reference Prudic, Olfson and Sackeim10 Chanpattana et al Reference Prudic, Olfson and Sackeim10 suggested that this difference in age group trends could be caused by Asian population demographics and the fact that schizophrenia (with higher prevalence in younger patients) is the main indication for ECT in Asian patients. These explanations could also be valid for our Iraqi sample.

The gender distribution of our sample was roughly equal. This is slightly different from what is known in Asian countries, where more males receive ECT, Reference Chanpattana, Kramer, Kunigiri, Gangadhar, Kitphati and Andrade8 and from Western countries, where more females do. Reference Reid, Keller, Leatherman and Mason11-Reference Sylvester, Mulsant, Chengappa, Sandman and Haskett14 A possible reason for this near-equal gender distribution is that, in Iraq, there was found to be no gender difference in depression; Reference Al-Hasnawi, Sadik, Rasheed, Baban, Al-Alak and Othman15 however, it is also possible that our finding was accidental.

Another finding which was very similar to Chanpattana et al's Reference Chanpattana, Kramer, Kunigiri, Gangadhar, Kitphati and Andrade8 was that schizophrenia was the major indication for ECT (51% v. 41.8% in their sample). This finding is slightly different from what Iraqi psychiatrists report about the indications for ECT. In a recent survey which included 73 Iraqi psychiatrists, the first indication mentioned was depression, followed by schizophrenia. Reference Al-Hasnawi16 The use of ECT in schizophrenia could raise a number of questions about the appropriateness and reasons for its use. International guidelines do not recommend ECT in general cases of schizophrenia, but as an option where clozapine has already proved ineffective or intolerable. Reference Scott2 A review concluded that ETC might be an option in patients who show poor response to medication Reference Al-Hasnawi16 and this was also cited as the main reason for ECT in our sample. The lack or unavailability of clozapine and the difficulties associated with blood monitoring in Iraq might be one reason for poor treatment response. The practice of having a second opinion for the use of ECT in schizophrenia is still very rare in Iraq (5.5%) and needs to be encouraged.

It is encouraging that the majority (70.1%) of ECT in our study was modified ECT. This figure indicates a significant improvement in this area: although we do not have exact figures, we are aware that prior to 2003 ECT was mostly given in an unmodified way. This also seems better than the practice of ECT in Asian countries in general, where 55.7% of patients still receive unmodified ECT, Reference Chanpattana, Kramer, Kunigiri, Gangadhar, Kitphati and Andrade8 but is below the 100% standard stipulated by the Iraqi ECT Policy and the practice in high-income countries. 1,Reference Scott2 Unmodified ECT was applied only in three hospitals and the unavailability of anaesthetists was the only reason. Measures to address this resource issue need to be taken by the Ministry of Health. Closure of ECT clinics where general anaesthesia is not available might be one, albeit the last resort, option. In this context, we are aware that the biggest psychiatry hospital in Iraq (which has 1200 beds) has stopped ECT treatment because of the unavailability of anaesthetists and patients who need ECT are transferred to an acute hospital where a modified ECT is given. This has led to a significant reduction in the number of ECTs (Tamimy J, 2011, personal communication).

In addition to human resources, this audit identified other shortcomings such as the number of rooms, the age of the ECT machine and the lack of EEG monitoring facilities. Improving these areas could lead to an improvement in the quality of care patients receive. For example, EEG monitoring, which was absent in all clinics, could mean lower doses being given and subsequently, fewer cognitive side-effects. Reference Sackeim, Prudic, Devanand, Kiersky, Fitzsimons and Moody18 One way of improving these areas could be by nominating a consultant psychiatrist (in our sample, this happened in only 60% of the ECT clinics) and a nurse who are responsible for ECT delivery, oversee its practice and audit it.

Bilateral ECT was performed on all patients in compliance with the Iraqi ECT Policy, which stipulates that bilateral ECT should be used except in patients under the age of 18 (only one patient in our sample) or in elderly patients with cognitive impairment. Bilateral use of ECT seems to be the norm in many countries. Reference Chanpattana, Kramer, Kunigiri, Gangadhar, Kitphati and Andrade8,Reference Prudic, Olfson and Sackeim10,Reference Sienaert, Dierick, Degraeve and Peuskens19,Reference Nelson20


One limitation of our study is that we did not collect data about the number of ECT sessions given to each patient. This information could inform us about Iraqi practice in that area, but not necessarily in measuring compliance with the policy, which does not include a standard about the number of ECT sessions. Another limitation is that we did not record how many of the consent forms were signed by patients as opposed to relatives. This could have shed light on transcultural differences in that area. In Iraq, giving consent by the family on behalf of the patient is seen as acceptable. This is something which needs to be explored further in the absence of an active mental health act. This audit has not covered ECT practice in private clinics. We know from personal contact that this is not uncommon but it is not governed by any policy. Regulations might need to be enforced to ensure good practice. We did not collect data about who administered the ECT treatments; however, we know that in Iraq ECT is administered by a psychiatry specialist or a trainee.

The recent history of Iraq has been very traumatic, with three wars, years of economic sanctions and more than 11 years of civil unrest. These major events have affected the health services', including mental health services', infrastructure. Since 2003, there have been attempts to improve and modernise mental health services in collaboration with international bodies such as the Royal College of Psychiatrists through its Iraq Sub Committee. This subcommittee has contributed to many projects, Reference Al-Uzri, Abed and Abbas9 for example drafting the ECT standards. This audit has examined the practice of ECT in Iraq against these standards and identified areas for further improvement. There are resource issues that need to be addressed by the Ministry of Health and areas which could be improved by training or research. In particular, the use of ECT in schizophrenia needs further exploration.


We thank the medical directors and heads of departments who answered the questionnaire. We also thank the trainee psychiatrists in the Iraqi Board of Psychiatry who helped in the data collection: Dr Ghada Adeeb, Dr Tharaa Wadaah, Dr Lava Dara, Dr Haeffa Ahmed, Dr Akeel Ibraheem, Dr Sadoon Abid, Dr Yassir Saad, Dr Ashwan A. Shwan, Dr Arafat Aldujaili.


Declaration of interest



1 American Psychiatric Association. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging (2nd edn). American Psychiatric Publishing, 2001.Google Scholar
2 Scott, A (ed.). The ECT Handbook (2nd edn). Gaskell, 2005.Google Scholar
3 Eranti, SV, McLoughlin, DM. Electroconvulsive therapy – state of the art. Br J Psychiatry 2003; 182: 89.Google ScholarPubMed
4 Fink, M. Prejudice against ECT: competition with psychological philosophies as a contribution to its stigma. Convuls Ther 1997; 13: 253–65; discussion 266–8.Google ScholarPubMed
5 Wilkinson, D, Daoud, J. The stigma and the enigma of ECT. Int J Geriatr Psychiatry 1998; 13: 833–5.3.0.CO;2-R>CrossRefGoogle ScholarPubMed
6 Euba, R, Crugel, M. The depiction of electroconvulsive therapy in the British press. J ECT 2009; 25: 265–9.Google ScholarPubMed
7 Leiknes, KA, Jarosh-von Schweder, L, Hoie, B. Contemporary use and practice of electroconvulsive therapy worldwide. Brain Behav 2012; 2: 283344.CrossRefGoogle ScholarPubMed
8 Chanpattana, W, Kramer, B, Kunigiri, G, Gangadhar, B, Kitphati, R, Andrade, C. A survey of the practice of electroconvulsive therapy in Asia. J ECT 2010; 26: 510.CrossRefGoogle Scholar
9 Al-Uzri, M, Abed, R, Abbas, M. Rebuilding mental health services in Iraq. Int Psychiatry 2012; 9: 5860.Google Scholar
10 Prudic, J, Olfson, M, Sackeim, HA. Electro-convulsive therapy practices in the community. Psychol Med 2001; 31: 929–34.Google Scholar
11 Reid, WH, Keller, S, Leatherman, M, Mason, M. ECT in Texas: 19 months of mandatory reporting. J Clin Psychiatry 1998; 59: 813.CrossRefGoogle Scholar
12 Gormley, N, Cullen, C, Walters, L, Philpot, M, Lawlor, B. The safety and efficacy of electroconvulsive therapy in patients over age 75. Int J Geriatr Psychiatry 1998; 13: 871–4.Google ScholarPubMed
13 Olfson, M, Marcus, S, Sackeim, HA, Thompson, J, Pincus, HA. Use of ECT for the inpatient treatment of recurrent major depression. Am J Psychiatry 1998; 155: 22–9.Google ScholarPubMed
14 Sylvester, AP, Mulsant, BH, Chengappa, KN, Sandman, AR, Haskett, RF. Use of electroconvulsive therapy in a state hospital: a 10-year review. J Clin Psychiatry 2000; 61: 534–9; quiz 540.Google Scholar
15 Al-Hasnawi, S, Sadik, S, Rasheed, M, Baban, A, Al-Alak, MM, Othman, AY, et al. The prevalence and correlates of DSM-IV disorders in the Iraq Mental Health Survey (IMHS). World Psychiatry 2009; 8: 97109.Google Scholar
16 Al-Hasnawi, S. Electroconvulsive therapy: attitudes and practice of Iraqi psychiatrists. J Fac Med Baghdad 2013; 55: 4652.Google Scholar
17 Pompili, M, Lester, D, Dominici, G, Longo, L, Marconi, G, Forte, A, et al. Indications for electroconvulsive treatment in schizophrenia: a systematic review. Schizophr Res 2013; 146: 19.CrossRefGoogle ScholarPubMed
18 Sackeim, HA, Prudic, J, Devanand, DP, Kiersky, JE, Fitzsimons, L, Moody, BJ, et al. Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 1993; 328: 839–46.CrossRefGoogle ScholarPubMed
19 Sienaert, P, Dierick, M, Degraeve, G, Peuskens, J. Electroconvulsive therapy in Belgium: a nationwide survey on the practice of electroconvulsive therapy. J Affect Disord 2006; 90: 6771.CrossRefGoogle ScholarPubMed
20 Nelson, AI. A national survey of electroconvulsive therapy use in the Russian Federation. J ECT 2005; 21: 151–7.CrossRefGoogle ScholarPubMed
Figure 0

TABLE 1 Responses to the questionnaire in relation to 10 ECT clinics requirements

Figure 1

TABLE 2 Demographic and clinical characteristics of the sample (n = 251)

Figure 2

TABLE 3 Investigations

Submit a response


No eLetters have been published for this article.
You have Access
Open access
Cited by

Send article to Kindle

To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

ECT practices in Iraq: a national audit
Available formats

Send article to Dropbox

To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

ECT practices in Iraq: a national audit
Available formats

Send article to Google Drive

To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

ECT practices in Iraq: a national audit
Available formats

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *