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Discov Ment Health
Discov Ment Health
Discover Mental Health
2731-4383
Springer International Publishing Cham

39251508
85
10.1007/s44192-024-00085-2
Review
The electro-convulsive therapy story of Africa, a systematic review
Abaatyo Joan joandux@gmail.com
2020mmed108std@must.ac.ug

14
Kaggwa Mark Mohan 23
1 https://ror.org/007pr2d48 grid.442658.9 0000 0004 4687 3018 Department of Psychiatry, Faculty of Medicine, Uganda Christian University, Kampala, Uganda
2 https://ror.org/02fa3aq29 grid.25073.33 0000 0004 1936 8227 Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Canada
3 https://ror.org/009z39p97 grid.416721.7 0000 0001 0742 7355 Forensic Psychiatry Program, St Joseph’s Healthcare Hamilton, Hamilton, ON Canada
4 School of Medicine, King Ceasor University, Kampala, Uganda
9 9 2024
9 9 2024
12 2024
4 1 3129 6 2024
14 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Over the years, the use of Electroconvulsive therapy (ECT) has gained increasing acceptance as a viable treatment for managing treatment-resistant mental health conditions, and it is known to deliver more rapid therapeutic benefits than most treatment modalities in psychiatry. However, the practice of ECT exhibits significant variability both within and between countries. This review aimed to shed light on the status of ECT in the African context and its implications for mental health care in the region. In July 2023, databases (Ovid, PubMed, Web of Science, etc.) were searched for articles about ECT in Africa, following the PRISMA guidelines. Eligible studies reporting ECT practices in Africa and those about knowledge, attitudes, and perceptions were excluded. A total of 25 articles met the study criteria. The reviewed studies revealed that unmodified ECT continues to be used in some African countries due to resource limitations, while bilateral ECT is widely practiced across the continent. The primary diagnostic indications for ECT in Africa included severe depression and affective disorders. ECT usage and regulation vary significantly throughout Africa. The studies, primarily observational, detailed numerous challenges in employing the method, particularly concerning resource utilization in healthcare facilities. The review highlights the necessity for adaptable standards and local protocols to enhance ECT practices throughout Africa. It emphasizes the importance of conducting more evidence-based research to develop region-specific guidelines that ensure the safe and effective use of ECT. Policymakers and healthcare practitioners should prioritize resource allocation, training, and standardization to improve ECT delivery and outcomes on the continent.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44192-024-00085-2.

Keywords

ECT
Electroconvulsive therapy
Africa
Review
issue-copyright-statement© Springer Nature Switzerland AG 2024
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pmcIntroduction

Electroconvulsive therapy (ECT) is a historical psychiatric treatment involving the brain’s electrical stimulation to induce seizures [1–3], with mechanisms of action including monoaminergic system regulation and neurogenesis [1, 4, 5]. ECT has gained increasing acceptance as a viable treatment for managing treatment-resistant mental health conditions due to its rapid therapeutic benefits [6–8]. However, the practice of ECT exhibits significant variability both within and between countries [6, 9, 10], yet effective and high-quality ECT relies on adhering to evidence-based guidelines [6, 11]. Notably, there is a gap in ECT research, with most studies originating from high-income countries [9, 12–15]. The review focuses on addressing this gap by examining ECT literature in Africa, aiming to provide insights into the use of ECT and its implications for mental healthcare in the region.

Materials and methods

To conduct this review, we performed electronic searches of published articles about ECT in Africa from inception (1981) to July 2023 in the following databases, i.e., PubMed, Ovid databases (Embase, Medline, PsychINFO, and all EBM reviews), Africa Journals Online (AJOL) and Web of Science., while utilizing the specified keywords (Supplementary File 1). We also conducted searches from the references of the identified articles. Articles included met the following criteria: (i) Peer reviewed publication about ECT use in Africa and (ii) among humans. We excluded articles that were (i) case reports, reviews, commentaries, government documents, reports, and publications concerning knowledge, attitude, and perception towards ECT. For the current review, no language restriction was considered. Articles in languages other than English were translated using Google Translate.

To aid the review process, Covidence website was used to facilitate removal of duplicates, screening of the article, full text review, and data extraction.

All processes were done in pairs and discrepancies were handled following a discussion.

Information extracted from the included articles: first author, year of study, study design, country, sample size, number of males and females, age (mean, median, or range), indications for ECT, type of ECT used, electrode placement method, ECT machine used, pre-, intra and post-ECT practices, ECT frequency, and ECT related complications.

The current review was not registered but it followed the PRISMA guidelines for systematic review [16] and the Joanna Briggs Institute (JIB) tools for the various included study designs [17] and Cochrane Risk of Bias Tool [18] were used to assess the risk of bias (Supplementary file 2).

All data was presented in tables, and due to the significant description of the findings in Africa, a narrative description of the study findings was presented based on the various sub-headings in the result section. The result presentation approach followed the exodus of the patient to and after ECT.

Results

Of the 868 articles identified, 377 were duplicates, and following a thorough review and screening, data were extracted from 24 articles (Fig. 1). See Supplementary File 3 for the reasons for articles excluded (n = 33).Fig. 1 Prisma flow diagram

The bulk of the articles were from studies conducted in Nigeria (n = 9) and South Africa (n = 6), with cross-sectional studies being the most predominant study designs (n = 14), and most studies had less than 100 participants (n = 16). The total number of countries involved was six (Table 1).Table 1 Characteristics of the articles included in the review

Author
(Publication)	Study design	Country	Total sample size (Sample that received ECT)	Male gender for total sample (gender for sample that received ECT)
(F)	Age
All participants [Those who received ECT]	Main findings	
Mean (SD)	Range	
Mugisa et al. [2] 1991	Cross Sectional Study	South Africa	414 (121)	299 (86)	[30.7 (9.9)]	Not reported	ECT patients were generally younger and had slightly longer hospital stays	
Ukpong et al. [19] 2004	Randomized Control Trial	Nigeria	16 (9)	8 (4)	Not reported	Not reported	Both groups of schizophrenia patients showed improvement, but those who received ECT did not experience significantly greater improvement compared to the control group	
Oladeji et al. [20] 2012	Cross Sectional Study	Nigeria	371	159 (174)	Not reported	Not reported	ECT was found to be significantly associated with longer length of stay (LOS)	
Odejide et al. [21] 1987	Cross Sectional Study	Nigeria	198 (198)	Not reported	Not reported	Not reported	Continuous use of unmodified ECT	
Menil et al. [22] 2014	Cross Sectional Study	Kenya	455	303 (153)	36.3 (13.6)	Not reported	16.2% of admitted patients received ECT	
Ali et al. [23] 2020	Case Control Study	Egypt	60 (40 cases (received ECT); 10 controls)	Not reported	Not reported	Not reported	number of ECT sessions received was associated with higher Basal Metabolic Index (BMI) and Fasting blood glucose ( FBG)	
Ukpong et al. [24] 2009	Cross Sectional Study	Nigeria	584	294 (290)	Not reported	Not reported	Having received ECT significantly predicted prolonged LOS	
Mechri et al. [25] 2016	Cross Sectional Study	Tunisia	80 (80)	60 (60)	[42.1 (15.7)]		The average motor seizure duration was 22.3 ± 7.2 s, decreasing with patient age. Depression scores had the highest response rate. Additionally, 20% continued with weekly or biweekly maintenance ECT sessions	
Benson-Martin et al.[1] 2013	Cross Sectional Study	South Africa	110 hospitals (1112)	(302)	Not reported	[18–59 years (89.2%); minors (0.2%); and > 60 years (10.6%)]	Each year, 0.22 individuals per 10,000 population receive ECT, with 1.19 ECT procedures performed per 10,000 population. More patients in the private sector undergo ECT compared to the public sector. ECT is conducted in minor theatres or operating rooms in 79% of units, with the remainder in treatment rooms	
Brahim et al. [26] 2021	Cross Sectional Study	Tunisia	34 (34)	25 (25)	39	Not reported	The primary diagnoses were bipolar disorder (47.1%), schizophrenia (35.3%), and major depressive disorder (14.7%). Treatment resistance and high suicide risk were the main indications for ECT	
Ihezue et al. [8] 1981	Cross Sectional Study	Nigeria	1042	Not reported	Not reported	Not reported		
El-Deeb et al. [27] 2017	Randomized Control Trial	Egypt	66	Not reported	Not reported	Not reported	There was no difference in depression improvement between the Magnetic Seizure Therapy (MST) and ECT groups. However, ECT had significantly more cognitive adverse effects and a much slower time to recovery orientation	
Udendi et al. [28] 2014	Cross Sectional Study	Malawi	30 (30)	(6)	Not reported	[16–54]	Gaps in the provision of ECT services in relation to the required standards	
Selis et al. [29] 2008	Cohort study	Malawi	(47)	(24)	Not reported	Not reported	Unmodified ECT in Malawi is an effective treatment with milder side effects than generally perceived. Efforts are being made to enhance treatment standards	
Odayah et al. [30] 2018	Cross Sectional Study	South Africa	42 (42)	31 (31)	23.5 ([IQR] 20.1–27.0	Not reported	Psychotic disorders were more commonly indicated for ECT than mood disorders in the sample	
Aaron et al. [31] 2020	Randomized Control Trial	Nigeria	27 (27)	11 (11)	34.9 (11.3)	[18–62]	There was no statistically significant difference in convulsion duration, onset of apnea, or duration of apnea between the two suxamethonium doses (0.5 mg/kg vs. 1.0 mg/kg)	
Latif et al. [32] 2020	Randomized Control Trial	Egypt	40 (20)	20 (10)	Not reported	Not reported	Repetitive Transcranial Magnetic Stimulation (rTMS) was well tolerated with less negative impact on cognitive functioning than ECT	
Hodgson et al. [33] 2004	Cohort study	South Africa	47 (47)	10 (10)	40.5	Not reported	The time to loss of verbal contact and eyelash reflex was significantly shorter with propofol compared to sevoflurane. Sevoflurane patients had longer seizure durations and experienced minor adverse effects, but both propofol and sevoflurane were found to be suitable for anesthesia induction in ECT	
Samoye et al. [6] 2014	Cross Sectional Study	Nigeria	(154)	(65)	[35.53 (11.08)]	Not reported	While the ECT procedure is generally similar to that in many other Asian countries, particular aspects like informed consent need more attention	
Shahim et al. [34] 2022	Cohort study	Egypt	60 (45)	43 (32)	Not reported	Not reported	Plasma BDNF levels in patients with treatment-resistant schizophrenia rise following electroconvulsive therapy, correlating with clinical improvement	
James et al. [35] 2010	Cross Sectional Study	Nigeria	(90)	Not reported	Not reported	Not reported	One-third of patients reported experiencing memory impairment after ECT. Headaches and muscle pains were reported by 8.9% and 17.8% of patients, respectively	
James et al. [36] 2013	Cross Sectional Study	Nigeria	66 psychiatrists and trainees	Not reported	Not reported	Not reported	Most psychiatric facilities continue to use unmodified ECT	
Benson-Martin et al. [9] 2015	Cross Sectional Study	South Africa	110 hospitals (1112)	(302)	Not reported	[18–59 years (89.2%); minors (0.2%); and > 60 years (10.6%)]	Informed consent is obtained in all institutions. Pre-ECT assessments typically include a physical examination (95.5%) and basic blood tests (87%). Various electrode placements and dosage-determination methods are used. The majority of ECT patients (89.22%) are aged 18 to 59, with depression being the most common indication (84.77%)	
Ali et al. [37] 2009	Qualitative study	Kenya	33	17	Not reported	Not reported	There is methodological inconsistency in practices related to pre-ECT preparation, stimulus dose calculation, adequacy of seizures, and the adjustment of psychotropic medication before and after ECT sessions. Barriers to adopting evidence-based practices include inadequate infrastructure, insufficient funding, lack of proper training, and negative perceptions from patients, relatives, and even some practitioners	

Quality and risk of bias of included studies.

While generally scoring well on prevalence measures, the studies often relied on self-report, introducing potential recall bias. Cohort and case–control studies inadequately addressed confounding factors (Supplementary file 2).

Indications for ECT use

ECT was recommended for diverse mental illnesses, primarily treatment-resistant conditions [6, 26, 32], and those associated with major suicide risk [6, 26, 32]. Regarding diagnosis, ECT use was mostly recommended for affective disorders (Table 2).Table 2 Indications for ECT in Africa

Indications for recommendation of ECT in Africa	Mental illness diagnosis	
- Resistance to treatment [6, 26, 32]	Mood disorders	
- Augmentation of drug treatment [6]	1) Depression	
- Major suicide risk [6, 26, 32]	- Persistent major depression [1, 9, 21, 25, 27, 29, 31, 32, 35, 36]	
- Prior response to ECT [6]	- Recurring depression [25, 32]	
- Refusal of medication [6]	- Depression with psychotic features [8, 25]	
- Refusal to eat [6, 32]	
- Inability to take medication [6]	- Postpartum depression [1, 9, 29, 31, 36]	
- Psychomotor retardation [6]	
- Presence of affective symptoms [6]	2) Bipolar affective disorder	
- Bipolar disorder [1, 8, 21, 25, 28, 29, 31, 35]	
- mania with psychotic features	
3) Schizophrenia and other psychotic disorders	
- Brief psychotic disorder [21]	
- Schizophrenia [1, 8, 9, 21, 28, 29]	
- Schizoaffective disorder [19]	
- Schizophreniform disorders [1, 2, 21, 28]	
- Postpartum psychosis [1, 8, 9, 21, 28, 29, 36]	
4) Others	
- Catatonia [1, 9, 25, 30, 35, 36]	
- Anxiety disorder [1, 9]	
- Conversion disorder [21]	
- Neuroleptic malignant syndrome [6]	

Modified ECT

Most studies (13/19) reported using modified ECT [6, 9, 19, 22, 25–31, 34, 36]. However, some centers in Uganda, Nigeria, and Malawi still offer unmodified ECT, especially when the logistics and key professionals to administer the modified type are unavailable [2, 21, 29, 36](Table 3).Table 3 ECT techniques and instruments used in Africa

Author
(Publication)	Type of ECT	Electrode placement	ECT machine use/model	Voltage/current	
Mugisa et al. [2] 1991	Unmodified	Not reported	Not reported	Not reported	
Ukpong et al.[19] 2004	Modified	Bilateral	Not reported	40 pulses per second for 3 s	
Odejide et al. [21] 1987	Both Modified and unmodified	Bilateral	Ectonus	Alternating 240 V (90W) with 110 V	
Menil et al. [22] 2014	Modified	Not reported	Not reported	Not reported	
Mechri et al. [25] 2016	Modified	Bilateral	Mecta SRI and Spectrum 5000 type	Range of 40 to 80 J	
Benson-Martin et al.[1] 2013	Modified	Bilateral (48%health units)

Unilateral (39% units)

Bifrontal (13% units)

	Thymatron machine	Not reported	
Brahim et al. [26] 2021	Modified	Bitemporal		50–100 millicoulombs	
Ihezue et al. [8] 1981	Modified	Bitemporal	Ectonus		
El-Deeb et al. [27] 2017	Modified	Bilateral and unilateral	Thymatron brief pulse device	Pulse width of 0.5 ms	
Udendi et al. [28] 2014	Both Modified and unmodified	Not reported	Mecta SR models	225 to 400Mc	
Selis et al. [29] 2008	Both Unmodified and

modified

	Not reported	Mecta SR models	250 mCi	
Odayah et al. [30] 2018	Modified	Not reported	Not reported	Not reported	
Aaron et al. [31] 2020	Modified	Bitemporal	Ectonus	Not reported	
Latif et al. [32] 2020	Modified	Bitemporal	Not reported	Not reported	
Samoye et al. [6] 2014	Modified	Not reported	Thymatron brief pulse device	(100 mC) with increments of 5% in cases of nonresponse but rarely exceeding 40% (200 mC)

Pulse frequency was between

10 and 70 Hz in 10-Hz increments (to 140 Hz for 0.25-ms

pulse). Current was 0.9

	
James et al. [35] 2010	Unmodified	Bilateral	Not reported	150 to 250mC	
Shahin et al. [34] 2022	Modified	Bilateral	Not reported	Not reported	
James et al. [36] 2013	Both Modified and unmodified	Not reported	Not reported	Not reported	
Benson-Martin et al. [9] 2015	Modified	Bilateral (48%health units)

Unilateral (39% units)

Bifrontal (13% units)

	Thymatron machine (both brief and ultra pulse device)	Not reported	

Characteristics of individuals who receive ECT in Africa

Most studies reported more females receiving ECT [1, 6, 9, 19, 28, 31, 33, 38–41] (Table 1). The number of persons treated with ECT per 10,000 persons per year in South Africa was 0.22, whereas the number of ECT procedures performed per 10,000 persons per year was 1.19[1]. Private sector patients received ECT more than public [1]. Individuals who received ECT were between 15 and 62 years [1, 6, 9, 29, 33, 35]. Male individuals were generally younger than female patients (mean 32.8 vs. 35.6 years) [2, 6].

ECT practices

ECT was performed in minor theatres, major operating theatres, within wards, or treatment rooms [23]. The ECT sessions were mainly conducted in the presence of an anesthetic staff and nurse(s) [9, 25]. In Egypt, ECT was conducted by a psychiatrist27, registrar, or general practitioner [23]. However, even clinical officers were involved in Malawi [29]. In Kenya, public facilities commonly had psychiatric registrars conducting inpatient ECT procedures without supervision, while private hospitals had consultant psychiatrists administering ECT, with inpatient and outpatient options [37].

Practices before ECT administrations

In South Africa, medical practitioners indicated obtaining a medical history before initiating ECT [1]. Additionally, 77.2% obtained a dental history to assess risks for dental injuries and trauma [1].

In Kenya, head shaving of patients scheduled for ECT (a procedure done to ensure correct electrode placement to the temporal area) was required in most public but not private facilities [37].

Consenting

In South Africa, oral information about the procedure was provided routinely pre-ECT, and written consent was obtained from the patient or their next of kin [1, 9]. However, informed consent inconsistencies are reported in Malawi [29].

Physical examinations

In South Africa, 95.5% of medical practitioners perform medical examinations pre-ECT; however, only 33.3% conduct a dental review [1]. In Malawi, approximately one-third of patients received no physical examination pre-ECT [28].

Typically, nurses take vital signs pre-and-post-ECT [1, 28, 29]. However, approximately 10% of records of ECT patients in Malawi indicated vital having been taken [28].

Psychiatric medication

Medications (antiepileptic and psychiatric drugs) were stopped 24 h pre-ECT, and nil per os from midnight, pre-ECT, was ensured [29]. However, discontinuation of medication was not uniform; for example, in a South African study, 65% of practitioners stopped benzodiazepines, 57% discontinued anticonvulsants, 48% discontinued lithium, and 17% did not stop any medication [9].

Investigations

A South African study reported variations in the requested pre-ECT investigations, complete blood cell count (86%), renal function tests (86%), liver function tests (46%), blood investigations such as syphilis and HIV testing (50%), chest X-rays (18%), electrocardiographs (61%), and computed tomography brain scans (30%) [9]. While most required laboratory investigations occurred at least one kilometer away from ECT-providing facilities, 30% of ECT patients in Malawi did not undergo any investigations [28].

Records

Record-keeping was considered inadequate and attributed to the lack of dedicated nursing care, which could have resulted in low adherence to pre-and-post-ECT procedures [28]. For instance, a Malawi study found that 14% of the conducted ECT procedures were not documented [29].

Anesthesia during ECT

In South Africa, the carder of anesthetic staff varied, with hospitals using anesthetic consultants, registrars, and general practitioners [9]. To ensure airway patency and prevention of tongue biting, an improvised mouth guard was used after checking the oral cavity [6, 25, 29], and ventilation was ensured through a Copa cannula [25].

Medication

Atropine was commonly used as a premedication to temper cardiovascular response [8, 29]. The medications commonly used for induction were propofol, etomidate [9], thiopental [8], sevoflurane [33], and Suxamethonium [9, 31].

Anesthetic procedure

Anesthetics monitoring machines were often used during ECT procedures, and the most frequently monitored measures were oxygen saturation (100%), followed by blood pressure [non-invasive] (95%), continuous ECG (90.5%), then capnography (35%) [9]. Other aspects included monitoring for the loss of verbal contact and the loss of the eyelash reflex [33].

Recovery period

Following the cessation of seizure activities, inhaled anesthetic agents were stopped, and 100% oxygen was administered [29, 33]. Manual ventilation was employed in case of apnea persistence following seizures or dropping oxygen saturation (< 96%) [33]. Patients were discharged from recovery rooms when they could maintain an oxygen saturation > 96% without supplemental oxygen, demonstrated appropriate responsiveness to commands, and had no nausea [33]. In Malawi, physical restraining agents (i.e., padded leather cuffs, anklets, and belts) were avoided in case of confusion post-ECT to ensure patients’ comfort [29]. When the patient(s) were able to mobilize, a nurse guided them back to the ward [29]. However, nursing staff were infrequently present to assist during recovery in some health units [9].

ECT machines and administration

Various African countries utilize diverse ECT machines with different electrical currents. (Table 3) In Nigeria, ECT doses were determined by the primary physician [21, 31]. In Tunisia, the average energy delivered was 59.4 ± 26.5J, correlating with patients' age but not gender or psychiatric diagnosis [25]. In Kenya, some practitioners consider the half-age rule for dose calculation, but most administer a uniform dose to all patients [37]. Additionally, the study revealed that none of the institutions surveyed had a backup ECT machine in case the currently used one malfunctioned [37].

Electrode placement

In Africa, electrode placements were bilateral, unilateral, or bifrontal [1, 8, 9, 19, 21, 25–27, 31, 32, 34, 35]. Most studies report bilateral electrode placement [1, 8, 9, 19, 21, 25–27, 31, 32, 34, 35], most of which were bitemporal placement (Table 2).

Frequency of ECT

ECT was typically given 2–3 times a week [8, 25, 33], prioritizing a quicker effect over cognitive side effects [29]. The number of sessions depended on illness severity [29] and usually started with 4–6 sessions [6, 19, 21, 29, 35, 37]. If remission happened earlier, sessions were discontinued, and if the response was partial, sessions were extended to 10–14 [2, 21, 29]. Rarely were symptom rating scales used to assess treatment effectiveness [29].

Follow-up ECT treatment

In healthcare facilities in South Africa and Nigeria, continuous/maintenance ECT (once to thrice weekly) was utilized to prevent the early recurrence of an illness episode [6, 8, 9]. However, continuous ECT was not always feasible due to ECT complications, uncontrolled hypertension, financial limitations, and other unspecified reasons [6].

Adverse events

A study in Tunisia found an association between immediate ECT adverse effects and motor/electrical seizure duration [25]. Table 4 shows ECT adverse events documented in African studies. Despite the adverse events, the mortality rate from ECT was low [42].Table 4 ECT adverse events in Africa

Time period	Side effects	
Immediate [8, 25, 29, 35]	bradycardia, respiratory depression, dental trauma, bronchial congestion, confusion, agitation, limb and trunk pain, and headaches	
Medium-term [26, 35]	Retrograde/anterograde amnesia, concentration difficulties	
Others	Some studies are associated with prolonged hospital stay [2, 20, 24]	

Discussion

This review identified that there was increasing use of modified ECT, but the practice varied widely across the continent. The increased use of modified ECT in Africa aligns with international guidelines and trends [43, 44]. However, resource constraints in some African facilities/areas have led to the continuous use of unmodified ECT. The constraints, especially in healthcare staff, hamper record-keeping, documentation, and adherence to international standards [45]. The resource constraints-related effects on practice were more prominent among low-income African countries (such as Malawi and Uganda) than middle-income countries (MICs). Despite this, there is hope since MICs like Nigeria and South Africa have had their practice evolve over the years with improvements in the economy. There was a predominance of literature from MICs that may not be a true reflection of other parts of the continent. Facilities in MICs may have more mental health researchers, resources for research, the privilege of owning ECT machines, and attitudes towards ECT use may be better.

Contrary to the common belief in Asian and African literature that schizophrenia is the main indication for ECT [15, 46], this review found that affective disorders are also a significant reason for ECT use in Africa. This indicates a change in both the perception and actual application of ECT for various psychiatric conditions on the continent.

Another noteworthy finding was the use of low stimulus doses (< 400mC), which might be due to the younger age of the patients receiving ECT. Younger individuals may respond well to lower doses, minimizing the risk of side effects and adverse reactions, which is consistent with observed clinical practices [47].

Like other parts of the globe, ECT indications were relatively similar in most of Africa [10, 15, 48–51]. The practice of ECT varied widely across the continent, with aspects ranging from pre-and-post-ECT procedures, anesthesia, electrode placement, and the ECT administration itself. The variations underscore the need for adaptable standards in ECT practices in Africa. In addition, despite ECT being associated with fewer documented adverse events, more research is needed to provide evidence for a more income-specific regional-specific protocol/guidelines.

Limitations

The review relied on older literature with small sample sizes and methodological issues, heightening the risk of bias. The topic, not extensively studied in the region, resulted in highly heterogeneous results, preventing a meta-analysis. Most of the studies included were observational, with few RCTs emphasizing the necessity for more research in the continent to bolster evidence and draw conclusions. Additionally, the review plan was not registered before its initiation.

Conclusion

ECT practices in Africa exhibit significant diversity, necessitating thorough scrutiny and examination. Activism, improved healthcare infrastructure, and education offer avenues for positive transformation. However, to enhance the evidence base, more research on ECT is necessary to develop region-specific guidelines for its utilization.

Supplementary Information

Below is the link to the electronic supplementary material.Supplementary Material 1.

Supplementary Material 2.

Supplementary Material 3.

Acknowledgements

We acknowledge the important role played by Dr. Atim Letizia in the data collection process.

Author contribution

Conception and design of the study: JA, MMK. Data collection: MMK, JA. Supervision: MMK. Formal analysis and data cleaning: MMK, JA. Initial draft: AJ. Review of the manuscript: all authors. Visualization: All authors. Final editing and critical appraisal of the whole manuscript: AJ. All the authors approved the final version of the manuscript. Dr. Letizia Atim was involved in the data collection process. A.J. and M.M.K. wrote the main manuscript text and A.J. prepared Fig. 1 and Tables 1, 2, 3 and 4.

Funding

This study received no financial support, and no funding body was involved in this study.

Data availability

Data is provided within the manuscript.

Declarations

Ethics approval and consent to participate

The review did not require ethical approval because it used already published data involving human subjects.

Competing interests

The authors declare no competing interests.

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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