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HEAD TO HEAD: Should electric shock treatment be banned?

ECT is a human rights issue: no one should be forced to undergo such a treatment and informed consent should be the minimum legal standard, writes Basil Miller

Psychiatry is a very divided profession. The medical argument on electroconvulsive therapy (ECT) has continued since its introduction, and will continue as long as it is permitted. What is at issue in the private member's Bill currently before the Seanad is not treatments, but the legal protection afforded to users of our mental health services. As Dr Mary Donnelly stated in her letter to The Irish Times of July 2nd: "The protections afforded to patients under the Mental Health Act 2001 . . . are inadequate" because "section 59 of the Mental Health Act 2001 allows ECT to be administered to 'unwilling' patients regardless of their legal competence."

The Bill proposes replacing subsections of section 59 with the following:

(1) A programme of electroconvulsive therapy shall not be administered to a patient unless the patient gives his or her informed consent in writing to the administration of the programme of therapy.

(2) The [Mental Health] Commission shall make rules providing for the use of electroconvulsive therapy and a programme of electroconvulsive therapy shall not be administered to a patient except in accordance with such rules.

This constitutes a minimum level of protection for the human rights of patients in relation to ECT, which they do not have at present.

The World Health Organisation, in its 2005 publication Human Rights and Legislation: WHO Resource Book on Mental Health, states that "ECT should be administered only after obtaining informed consent". The doctrine of informed consent should place a legal obligation on a doctor, as in the US, to make a patient aware of the reason for treatment, the risks and benefits of a proposed treatment, the risks and benefits of alternative treatment, and the risks and benefits of receiving no treatment. The patient then has the opportunity to accept or reject the treatment. ECT or other psychiatric treatments are no exception.

Such protection does not exist in Ireland, thus allowing the use of any form of treatment, including ECT and psychosurgery, on the say-so of two psychiatrists.

On a human rights issue such as this, action is the prime requirement. The minimum standards of observance of human rights, as set out by the WHO and the UN and enacted in other jurisdictions, do not apply here. To accept this Bill and support its enactment would be the courageous and correct course for the State. It would bring Ireland into line not with best practice, but with minimal practice in the developed world. As it is, we rank with less observant countries — a matter for considerable shame, surely, even among psychiatrists who favour the use of invasive treatments.

In the US a judicial proceeding is required, with patients represented by legal counsel, before involuntary ECT. The US surgeon-general's report states: "As a rule, the law requires that such petitions are granted only where the prompt institution of ECT is regarded as potentially life-saving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia." In Britain, amendments to the Mental Health Act will introduce a capacity threshold for the imposition of ECT, which may not then be given to a patient who has "capacity" to refuse consent, whether detention is voluntary or involuntary.

A study in the British Journal of Psychiatry in 2005 described patients' perspectives on electroshock. "About half (45-55 per cent) reported they were given an adequate explanation of ECT, implying a similar percentage felt they were not... One-third did not feel they had freely consented to ECT even when they had signed a consent form... Neither current nor proposed safeguards are sufficient to ensure informed consent with respect to ECT in England and Wales."

Involuntary electroshock contravenes the principle of autonomy in medical ethics, which states that the will of the patient is supreme and that a patient has the right to refuse a treatment such as ECT. As our mental health services employ psychiatrists who, apparently, ignore their own ethics and prescribe ECT against their patients' will, the State is obliged to step in and protect them.

A debate confined to whether ECT is a "good" or "bad" treatment would be sterile and unproductive. The crucial issue is this: those suffering from psychological distress and disturbance are the only group in our society who can be deprived of their liberty without a judicial process, and who can then be forced to undergo "treatments" that they do not want on the word of two members of the very flawed profession of psychiatry.

Let us not have years of delay in implementing simple human rights measures to protect this group. Let the Government accept this Bill and put it to a vote of both Houses immediately.

 

 

• Basil Miller is Head of Communications with The Wellbeing Foundation and a campaigner for reform in the field of mental health

Consilia Walsh argues ECT has come a long way. Properly targeted and responsibly administered, it has been shown to treat severe depression and save lives

It is important that ECT is not banned, as recent research shows that 70 per of patients who received the treatment showed significant clinical benefits. It should continue to be available for selected patients suffering from depressive illness. ECT (electroconvulsive therapy) is recognised as an effective intervention by the World Health Organisation and by medical authorities and clinical experts worldwide.

Depression is a serious illness that affects at least one in four of us at some time in our lives. It brings with it distress and suffering for the individual and their family. It takes its toll on relationships, work and achievement in life. It is associated with a significant mortality and suicide risk. Treatments for depression include counselling, psychotherapy, antidepressant medication and mood stabilisers.

However, a number of patients are not fortunate enough to respond to these treatments or combinations of them. A small number of patients experience depression of such severity that risk is increased by waiting for the standard treatments to possibly work, which can be weeks to months.

These are two groups of patients for whom ECT might be recommended. There is a strong evidence base from scientific research that ECT is not only effective in these groups but also that it is life-saving in some cases. Treatment with ECT has been shown to have a profound effect in reducing suicide in the short term, and as treating doctors with responsibility for our patients, we must never lose sight of this.

When ECT was first introduced, it was used for a wider range of mental illnesses and disorders. Clinical research and audit have allowed us to identify the patients whose clinical condition responds well to ECT. The increase in the availability and sophistication of other treatments for depression, including cognitive behaviour therapy and other forms of psychotherapy, along with greater choice of antidepressant medications, has meant that more patients recover without the need to consider ECT. Other patients, when they have ECT and respond, wonder why they have had to wait so long to be offered this treatment.

The administration of ECT has changed remarkably in recent years and bears little resemblance to the caricatured presentation sometimes seen in the media. Patients have a full medical assessment to ensure their suitability for a general anaesthetic.

All patients have a full general anaesthetic and a muscle relaxant before a short controlled seizure of about 30 seconds is induced. The patient is closely monitored throughout by specially trained staff. A consultant anaesthetist monitors their anaesthesia and recovery. The entire process is supervised by a consultant psychiatrist.

ECT in Ireland is closely regulated by the Mental Health Commission, which has written rules for its administration and a detailed code of practice. This ensures the prescription and administration of ECT is of a very high standard of practice. Many centres in Ireland who administer ECT also participate voluntarily in an accreditation programme run by the Royal College of Psychiatrists in the UK to ensure their service is at the cutting edge.

So what is the evidence that ECT works? An audit in Scotland of all patients receiving ECT, published in 2000, showed that over 70 per cent made significant clinical improvement. Many of these patients had failed to respond to antidepressant medication and made a significant recovery after treatment with ECT. The UK review group on ECT published an article in the Lancet in 2003, concluding that ECT remained an important treatment option for the treatment of severe depressive illness.

Systematic review of patients who have had ECT shows that they have a positive view of their experience of ECT.

What about the potential side effects? There is some evidence of memory impairment after ECT, a retrograde amnesia, more associated with bilateral treatment than unilateral treatment. In 2007, a leading researcher in ECT reported that 10 per cent of patients were still experiencing some memory difficulties after six months. We expect that this number will fall significantly with contemporary ECT practice — and this aspect is currently undergoing further research in Dublin. Another area of current research showing promise concerns the mode of action of ECT. Recent work has shown growth of new nerve cells in the part of the brain regulating emotion following ECT.

ECT has a long-established proven efficacy in the treatment of depression. It is not a first-line treatment but a vitally important intervention option. Standards of administration and regulation must be kept high so that our patients and families are informed and aware of the potential benefits and possible side effects — and this of course applies to many medical interventions. This important treatment must not be evaluated on the view of individuals, but on the well-recognised and evidence-based positive outcomes experienced by patients.

 

Dr Consilia Walsh is chairman of the Irish College of Psychiatrists