A shock to the system of care

 

A major debate is unfolding over the use of forced ECTon psychiatric patients

SHOULD A mentally ill patient in distress be forced to undergo electric shock treatment against his or her will?

It’s a question which goes to the heart of a growing debate over one of the most controversial and invasive procedures used in psychiatric care.

Rightly or wrongly, no other treatment arouses as much fear as electroconvulsive therapy (ECT). Depending on who you talk to, ECT is an effective and fast-acting treatment for severe depressive disorders, or it is a potentially dangerous procedure unsupported by research and whose side effects include long-term memory loss.

The growing recognition of patients’ human rights, as well as lobbying by organised advocacy groups, means the issue is now on the political agenda. But the debate is wider than just use of this procedure; it also touches on the key question of just how much power and responsibility should we place in the hands of consultant psychiatrists?

A Joint Oireachtas Committee is due to hear all sides of the argument at a special meeting in the coming weeks. Minister of State John Moloney, who has responsibility for mental health, has said he will make a recommendation on whether changes are needed to existing legislation governing ECT use by March.

In the meantime, a major lobbying drive is taking place by both consultant and patient groups to try to win public support for their respective positions.

Official rules on ECT state it should be used only when alternative therapies have been considered or proved ineffective. In general, the procedure may be administered only with the patient’s written consent. However, where a patient is unable or unwilling to give consent, it can be approved by two consultant psychiatrists.

Latest figures show that 400 psychiatric patients received ECT treatments during 2008. Of these, at least 43 involuntarily detained patients were either unable or unwilling to consent to about 300 doses of the treatment. (The real scale of ECT use may be significantly higher, as the figures do not include patients who were referred to other hospitals for treatment.)

John McCarthy, a mental health campaigner and founder of the Mad Pride Ireland group, is among those leading the charge for change.

Along with other mental health campaigners he has set up a website (www.delete59b.com) to remove section 59(b) from the Mental Health Act. This allows for the use of the procedure where patients are “unable or unwilling to give such consent”.

“This amendment won’t outlaw ECT,” McCarthy says. “But it would prevent treatment being given to non-consenting patients on the direction of two consultant psychiatrists.”

Along with Dr Pat Bracken, a consultant psychiatrist with the Health Service Executive based in west Cork, McCarthy says forced ECT is no longer acceptable on moral or scientific grounds.

In a joint statement, they point to the latest studies which indicate that memory loss is a persistent side effect for at least a third of recipients of ECT. They even say that longer term studies show that any benefits of ECT are very short term in duration and disappear after six months.

“Just as the voices of victims of institutional abuse are now being heard, it’s time for us to listen to those who use our mental health services, including those who are critical of the care they have received,” says McCarthy, who has been hospitalised for depression in the past.

“We must stop the forced used of ECT. Recovery in mental health is all about hope. But the forced use of this procedure is generating fear. Is that the kind of environment we want to create for vulnerable people in need of support?”

The College of Psychiatry of Ireland takes a different view. It says it cannot ethically support any change in legislation that would prevent the use of a “well-established, scientific evidence-based treatment” for any group of patients.

“Whether a patient is voluntary or involuntary should not affect their access to any highly effective, evidence-based treatment including ECT,” says college president Dr Justin Brophy.

He says the procedure remains an important and potentially life-saving treatment which has helped many patients recover from mental ill health – particularly where all other treatments have failed.

The college also cites recent Scottish evidence which indicated that 86 per cent of people who received ECT in circumstances where consent was not given recorded an improvement in their condition.

“Proposing to remove section 59(b) discriminates against those with most severe and life-threatening illness, and denies them an 86 per cent chance of clinical response to a highly effective, evidence-based treatment,” Brophy says.

“Removing the possibility of involuntary ECT for those patients who lack capacity as a result of severe mental illness may also violate section 25 of the Universal Declaration of Human Rights: the right to medical care.”

The Mental Health Commission, the State’s mental health watchdog, appears to have some sympathy with the position advocated by patient groups. Informed sources say the commission has advised the Minister that the word “unwilling” should be removed from section 59(b).

“If a patient doesn’t wish to receive it, that decision should be respected,” says a well-placed source, familiar with the advice provided to the Minister.

Whatever about the differing views, the entire debate could well prove premature. A significant piece of long-awaited legislation on legal capacity is due to be published this year. It is expected to define for the first time where patients are deemed to have decision-making capacity. This, then, could have major implications for any changes made to mental health legislation.

The debate, it seems, has just begun.

In numbers:

400psychiatric patients received ECT treatments during 2008

43involuntarily detained patients were either unable or unwilling to consent