Psychiatry has history of using damaging interventions such as lobotomy and insulin-coma treatment, so it’s time to end the magical faith in electroconvulsive therapy, argues consultant psychiatrist Pat Bracken.
There are two central dimensions to Ireland’s current national mental health policy A Vision for Change. One is about the design and resourcing of a truly multi-disciplinary mental health service. This has received most attention of late and the slow pace of moves towards implementation have been rightly criticised.
Less attention has been paid to the other dimension: the move from the dominance of a singularly medical way of understanding and framing mental health problems towards the adoption of a genuinely user-centred, recovery orientation. Moves towards this do not demand new resources but a willingness to give up the old culture of medical paternalism (essentially the idea that the doctor will always know what is best for the patient and will always act accordingly).
In its place, A Vision for Change demands a new more democratic culture that is guided by an ethic of partnership, consultation and genuine multi-disciplinary decision making.
This month, the Irish parliament is to debate an amendment to the Mental Health Act (MHA) 2001 relating to treatment with electroconvulsive therapy (ECT).
At present, ECT can be given to a detained patient without their consent under the terms of section 59 (B) of the act, which puts the authority to order this treatment in the hands of the consultant psychiatrist who has care of the patient and one other consultant psychiatrist. Therefore the act, as it currently stands, leaves the power to order ECT in the doctors’ hands alone. In fact, the current MHA puts enormous powers and responsibilities in the hands of consultant psychiatrists. We believe that these are not consistent with the sort of knowledge and science available to psychiatry and are, in fact, simply a continuation of the medical paternalism that A Vision for Change seeks to replace.
The proposed amendment will not deny any patient the possibility of receiving ECT. The treatment will be available to voluntary patients as before. But ECT is a highly controversial treatment. The amendment will mean that non-consenting patients cannot be given the treatment simply on the orders of a consultant psychiatrist and his/her colleague. The patient’s view (as expressed in a signed advance directive for example), the carer’s view and the views of the other professionals involved should all be given due weight.
Removing section 59(B) will merely put ECT alongside any other significant medical intervention that is being proposed for a patient who is unable to consent. It is anticipated that the new Mental Capacity Bill will provide clear guidance on how decision-making will proceed in such circumstances in the future.
Why is a change to the MHA 2001 being sought? ECT involves the patient being given a general anesthetic, the passage of electricity across the brain and the induction of a grand-mal epileptic seizure. This is a dramatic and contentious intervention and any decision to use it without the active consent of the patient should be seen as a very grave undertaking. Psychiatry has a history of using damaging interventions (such as lobotomy and insulin-coma treatment) and being so convinced of their efficacy that it failed to recognize the damage they caused. Many psychiatrists continue to express an almost magical faith in the efficacy and safety of ECT.
A recent editorial in the Irish Journal of Psychological Medicine contained the assertion that ECT is ‘one of the most effective and safe treatments in medicine’ (1). Such a statement is completely out of line with the scientific research on ECT from the past 10 years. In a review of consumer’s views on ECT, a team from the Institute of Psychiatry in London wrote in 2002: ‘it is evident that memory loss is a persistent side-effect for at least a third of recipients of ECT.
For some, this memory loss profoundly affects their lives and sense of self’ (2). Permanent amnesia is now recognized in the scientific literature as a common side-effect after treatment and it is now recommended that, prior to being given ECT, patients are warned that this amnesia has been known to extend to 10-20 years (3) Even researchers who are in favour of ECT are now reporting ‘substantial’ effects on memory (4) and it is currently recommended that a programme of cognitive rehabilitation (similar to that provided to victims of head injury) should routinely be made available to those who suffer in this way (5).
While psychiatrists will often quote figures of 80 to 90% of patients responding to ECT, these high percentages have only been achieved with patients who have not undergone prior treatment with a full course of anti-depressants. Most patients who are deemed suitable for ECT have had substantial prior drug treatment and in such circumstances the response rate is usually accepted to be in the range 50-60% (6). (The most prevalent reason given for using ECT is Ireland, in 2008, was ‘refractory to medication’ (7)). However, even these figures for efficacy are now challenged by the results of a recent large-scale study from New York. Interestingly, this was carried out by a pro-ECT group of researchers. They reviewed outcomes from ECT in the ‘real world’ of hospital psychiatry, not the usual research settings of previous clinical trials, following 347 patients in seven different hospitals in the city. They found that only 30.3% – 46.7% of the patients had a remission from depression three days after the treatment, and, furthermore, ‘…on average, 10 days after ECT, patients had lost 40% of the improvement that accrued over the ECT course’ (8).
Some psychiatrists maintain that ECT is a ‘life-saving’ treatment. The decline in its use, and the variability of its use internationally and locally, casts serious doubt over such claims. ECT is effectively abolished in Italy, and in Belgium and Germany is available in specialist centres only (9). In the 1988-1989 APA survey in the USA, ECT was not used at all in over a third of the 317 US metropolitan areas, and in the remaining areas annual rates ranged massively from 4 to 812 patients per 100,000 population (10). In Ireland, only 24 out of 64 approved centres (37.5%) indicated that they used ECT in 2008 (7). While some patients were referred from one centre to another specifically for this treatment, there can be little doubt that there are very wide variations in the use of ECT across the country. This would be a cause of scandal if the intervention was genuinely ‘life-saving’, as we would be witnessing a corresponding variation in mortality rates among psychiatric patients. What it does reveal is a very wide variation in consultant thresholds for the use of ECT. This has also been found in the UK. One study found an 18-fold difference in use of ECT between 11 general adult psychiatric teams within one teaching hospital in Edinburgh (11).
In our opinion, while a growing number of psychiatrists are becoming much more tentative in their use of ECT (many do not use it al all), there are some who continue to overestimate its benefits and underestimate the damage it can cause. In these circumstances, decisions about its use in patients who are ‘unable or unwilling to give consent’ should not be left to the medical profession alone. In the end, the proposal to remove section 59(B) is not really about ECT at all, but about power and authority in the Irish mental health system. It is about trying to advance the values and vision of A Vision for Change. It is also an attempt to position psychiatry in a more positive, democratic relationship with patients, carers and other professionals. It is also hoped that by removing powers such as those in Section 59(B), psychiatry will be rendered a less feared and more approachable profession. If you are in agreement, please consider signing the petition at: www.delete59b.com
* Dr Pat Bracken is Clinical Director at West Cork Mental Health Service, Bantry, Co Cork, Ireland
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