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.