Electroconvulsive therapy in the Republic of Ireland

Electroconvulsive therapy (ECT) has been in the news recently in the Republic of Ireland, where there is a campaign to delete section 59b of the Mental Health 2001. Section 59b is the section that deals with the use of ECT on non-consenting patients. At the moment it is legal in the Republic of Ireland to give ECT to patients who are unable to consent to treatment (that is those who lack capacity) and patients who are unwilling to have treatment (that is those who have the capacity to make a decision and say “no”). This is in line with what used to be the situation in Scotland, Wales and England; Scotland gave capable patients the right to say no to ECT in 2003, followed by England and Wales a few years later (except in emergencies). There is one important difference: in the Republic of Ireland the “second opinion” to authorise the use of ECT on a non-consenting patient can come from any psychiatrist, while in England, Scotland and Wales it comes from a psychiatrist on a panel belonging to the regulatory authority. (In Northern Ireland ECT may be given to both incapable and unwilling patients; I haven’t been able to find out where the “second opinion” comes from.)

Psychiatrist Pat Bracken, writing in this week’s Irish Medical Times, puts the case for the abolition of section 59b:

“I believe that as Section 59(B) specifically authorises ECT without consent, it serves to protect the doctor and not the patient… I would also question whether simply having a second opinion from another consultant offers real protection for patients. It is often difficult for one doctor to question the opinion of another.

I believe that Section 59(B) should be removed in its entirety. This will not outlaw ECT without consent, but a doctor who prescribes it will do so under common law (as is the case for most other medical procedures) and will not have the protection of the MHA. Therefore, removing Section 59(B) will, at least with regard to ECT, put psychiatric patients in the same position as other medical patients….

I believe it is wrong that it is the doctor and not the patient who is offered protection by the current Mental Health Act. Endorsing the status quo is not acceptable. Simply removing the word ‘unwilling’ from Section 59(B) of the MHA is not enough. We need to remove 59(B) altogether and start a debate about the MHA itself”.

The College of Psychiatrists of Ireland meanwhile are arguing that section 59b should be retained, with the word “unwilling” removed. Both sides of the debate can be read on the website of the Department of Health and Children. The question was debated in the Seanad (the upper house of the Irish parliament) last month after Green senator Dan Boyle introduced a private members bill. In the end the vote went in favour of the College of Psychiatrists’ preferred option (deletion of the word “unwilling” rather than deletion of the whole section) but the bill now goes to the Dáil (the lower house). It was interesting to see an article in the Irish Examiner refer to the arguments around the use of ECT as “very nuanced”; too often words such as “emotive” or “polarised” are used when discussing the debate about ECT.

The Mental Health Commission in the Irish Republic recently published statistics on the use of ECT in approved centres 2009. They can be seen here. According to the statistics  there were 373 courses of ECT in 2009, 44 of them given to people without their consent. Just over two-thirds were women. The most common diagnosis was depression (in 78 per cent), followed by schizophrenia and mania. There were wide variations in the use of ECT between hospitals, with one hospital, St Patrick’s Hospital, Dublin, accounting for a third of all ECT used.

Pat Bracken comments on the wide variation in use of ECT in the Irish Republic in his recent article in the Irish Medical Times:

“Figures from the Mental Health Commission show some psychiatrists continue to prescribe ECT at rates much higher than their colleagues. A study from Limerick in 2010 demonstrated an eightfold difference in the frequency of use of ECT across the general adult sectors in that city. It would appear that some consultants have a much lower threshold for using ECT than their colleagues. While some variation in the use of different medical interventions is to be expected, the extreme level of variation in use of ECT is a cause for serious concern.”

Meanwhile two psychiatrists from St Patrick’s Hospital (the highest ECT using hospital in the Irish Republic), Ross Dunne and Declan McCloughlin, argue in the March issue of the Irish Medical Journal that regional variation in the use of ECT is “possibly due to local service factors”.

The 2009 statistics from the Mental Health Commission show a fall in the use of ECT from the previous year of 8.4 per cent, and a fall of 88 per cent since 1981 when an estimated 3000 people annually were being treated with ECT in the Irish Republic. In those days too there was wide variation between different regions and different hospitals.

 

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2 Responses to Electroconvulsive therapy in the Republic of Ireland

  1. Ross Dunne says:

    First of all thanks for your energies – this is a really useful site for people interested in the area. I know you try to be as objective as possible.

    Thanks also for posting a link to the paper, too often these things are summed up with no reference to the original article. The online article unfortunately has poor image quality.

    I’d like to clarify a few points though. First about the MHA 2001 in Ireland.
    The College of Psychiatry of Ireland has repeatedly advocated for a Mental Capacity Act, which would enshrine the presumption of mental capacity in Irish law. This would effectively separate a person’s capacity to take on, understand and form an opinion about their treatment from any risk they might pose to themselves. In other words, separating their right to leave hospital when at risk from their right to make a healthcare decision. Currently, the area is not clear. In Ireland there is no capacity legislation and both ourselves and the College have pushed for it. This is clearly a breach of the person’s rights as it stands, but is a much broader issue than just ECT.

    http://www.ijpm.org/content/pdf/423/Editorial.pdf

    The Law Reform Commission has produced a draft bill, but it is very rough and needs clear procedures to be in place before it would work

    http://www.lawreform.ie/_fileupload/consultation%20papers/Consultation%20Paper%20on%20Capacity.pdf

    http://www.lawreform.ie/2009/report-on-bioethics-advance-care-directives.193.html

    The position advocated for by Dr. Bracken and some others is that the whole section should be deleted and that people would be treated under “common law”. This would represent even less protection for people from paternalistic doctors, it just dodges the issue of mental capacity and it is, really, a little bit weak as a patient advocacy position.
    There are potential controversies around any mental capacity bill too, of course. The case of Kerrie Wooltorton is an example of how such legislation is open to interpretation. It can be reviewed here in press, but opinions abounded and the RCPsych came out with a statement too:

    http://www.guardian.co.uk/society/2009/oct/01/living-will-suicide-legal

    I don’t know which way to lean on this case, not having, I think, all the facts. Did Kerrie write a living will or a suicide note? How does a living will differ from a suicide note? Should we not resuscitate a depressed patient who has attempted suicide because they have written a “will/note”. Who gets to decide? Do we do psychological post mortems on the deceased? Capacity is not something you either have or don’t, it’s spectral, so how *much* capacity do you have to have to take your own life? “Personality disorders” as we call them are pervasive patterns of behaviour but they are not necessarily lifelong. Who’s to say Kerrie wouldn’t have changed her mind in a couple of years? The law seems to state that there is an absolute autonomy exercised by the individual. That’s fine as a philosophical position, but I think most people have a little bit of difficulty with the idea that people with a remediable and temporary mental disorder can decide to take their own life, manifestly to escape that distress, and be supported in this by a laissez-faire society and profession. Does the argument extend to delirium? We need a more and clearer discussion and the ramifications have not yet been fully thought through.

    Second, the variation in ECT use.

    I think, to be fair, you’ve summarily dismissed the major point of the article. The major contributor to variation in ECT use in Ireland is private healthcare going uncounted. If you “repatriate” patients to their public sectors/counties – where they would have had ECT had they not been insured – then at least half the variation disappears. However, there is statistically significant remaining variation. This may indeed be a cause for moral panic – but the questions are 1)what is the scale of the variation and 2) how does it compare to variation in other procedures? Variation in ECT use is often a reason for indicting the treatment – either as lacking efficacy or being open to psychiatrists’ subjective opinion about the threshold for its use.

    So, let’s look at other procedures where there is little media controversy. The NHS Atlas of Variation in Healthcare, The Dartmouth Atlas, The NSW Atlas all demonstrate massive variations in the rates of various procedures throughout the geographical and administrative areas described. I’m sure you must be aware of these studies as variation is a major feature of your blog however, there is little mention of these studies in the media. Imagine, then that you are at higher risk of having your leg amputated in Kent than in Cornwall, if you have gangrene because of your diabetes. What about Coronary Artery Bypass? – massive variation. Ditto chemotherapy. This – it turns out – is a fertile area of health economics research, particularly by John E. Wennberg, as described by two articles in the BMJ last month.

    http://www.rightcare.nhs.uk/atlas/

    http://www.health.nsw.gov.au/pubs/2010/pdf/NSW_Health_Care_Atlas.pdf

    http://www.dartmouthatlas.org/

    http://www.bmj.com/content/342/bmj.d1884.extract

    http://www.bmj.com/content/342/bmj.d1513

    The gist of my article is that : we need better data in order to explain the causes of variation. Then we can say whether there is *Unwarranted* variation, then we can try to explain that. At no point is there a reason to press the “moral panic” button, unless one has an ideological point to make- which, if that’s the case, fine.

    Thanks

  2. How many abused children received ECT to burn out memories of child rape and abuse?
    I came across this in Meath 1995 and did not believe it at first.

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