Monday, 21 May 2012

Electroconvulsive Therapy (ECT) and the Mental Health Act

No, ECT is NOT like this still from One Flew Over the Cuckoo's Nest!

Electroconvulsive Therapy was first introduced as a treatment for mental illness in 1938. Today, its main use is in severe treatment resistant depression, as well as in catatonia and the depressive phases of bipolar affective disorder. It is estimated that around 12,000 people a year in the UK receive ECT, although accurate figures can be hard to find. For more information on ECT statistics, take a look at this excellent blog, the title of which says it all.

Despite public misconceptions about ECT, not helped by its depiction in the Jack Nicholson film One Flew Over The Cuckoo’s Nest, it is probably a lot safer than most antidepressant medication. The mortality rate for ECT treatment is 0.002% (Abrams R: The Mortality Rate with ECT, Convuls Ther 1997), that is, the chances of dying as a direct result of receiving ECT are only 1 in 100,000. When compared to the suicide risk for people with severe depression, that seems like good odds, if it works. For a positive account of ECT, take a look at this recent Guardian article.

ECT even compares well to mortality rates for antidepressant medication. A study from 2009 (Smoller JW et al. Antidepressant use and risk of incident cardiovascular morbidity and mortality among postmenopausal women in the Women's Health Initiative study. Arch Intern Med 2009) found that death rates for people taking SSRI antidepressants (such as paroxetine, fluoxetine or sertraline) were 12.77 per 1000 person-years, compared to 7.79 per 1000 for people not taking an antidepressant.

The main risks and adverse side effects relate to cognitive impairment, in particular difficulty in retaining new memories following ECT (this is reported to resolve within 1-3 weeks), and forgetting memories from the time before treatment. – this will often resolve over time, with subsequent recovery of memories.

In the past, patients were given vast amounts of ECT. I have worked with a woman with a very long history of bipolar affective disorder, who was incarcerated in an old-style asylum for 10 years during the 1960’s. She reports that she received several hundred ECT treatments, and I have no reason to doubt her. However, nowadays a patient will typically receive ECT in batches of 7, with a total number of treatments of 14 being the usual total. They would normally be given twice a week.

The whole issue of ECT has a special place in the Mental Health Act. One of the amendments to the Act in 2007 was the addition of Sec.58A. In the words of the code of Practice, this section “applies to detained patients and to all patients aged under 18 (whether or not they are detained)”. An important change is that as the default, ECT cannot be given to a detained patient unless they consent and are deemed to have the capacity to consent. Equally importantly, ECT cannot be given to a patient lacking in capacity who has made a valid advance decision to refuse ECT.

There are, however, still circumstances in which patients can receive ECT even though they lack the capacity to consent, or when they do have capacity and have refused.

In the case of a person lacking capacity, the Code of Practice (24.12) states:
“A patient who lacks the capacity to consent may not be given treatment under section 58A unless a SOAD [Second Opinion Approved Doctor] certifies that the patient lacks capacity to consent and that:
  • the treatment is appropriate;
  • no valid and applicable advance decision has been made by the patient under the Mental Capacity Act 2005 (MCA) refusing the treatment;
  • no suitably authorised attorney or deputy objects to the treatment on the patient’s behalf; and
  • the treatment would not conflict with a decision of the Court of Protection which prevents the treatment being given.”
This means that ECT can only be given if an independent, specially approved psychiatrist has looked at the individual’s case and has authorised it.

In the case of a person who does have capacity, but has refused to have this treatment, the only circumstances in which ECT can still be given, under Sec.62(1A & 1B) MHA are when treatment with ECT is either “immediately necessary to save the patient’s life”, or is “immediately necessary to prevent a serious deterioration of his condition”, or is “immediately necessary to alleviate serious suffering by the patient”, or is “immediately necessary and represents the minimum interference necessary to prevent the patient from behaving violently or being a danger to himself or to others.”

Important Note: If you are a service user (or potential service user) who objects to the idea of ECT, but thinks there may possibly be a situation in the future in which they may be given ECT, it is important to make an advance decision now (under the Mental Capacity Act) stating clearly what their wishes for treatment are. Ideally, you should get a solicitor to draw up this document to ensure that it is legally sound.

There are two main situations in which the issue of ECT is likely to arise in a professional context for AMHP’s.

The first is when an AMHP is asked to make an application for the detention under Sec.3 for treatment of an inpatient for the specific purpose of giving them emergency ECT. This can present an AMHP with a dilemma: should the MHA be used to compel a treatment which the MHA itself regards as being of a different order from other treatments for mental illness, to the extent that the 1983 Act was amended specifically to reflect the unease with which many people regard ECT?

Whatever the personal view of an AMHP regarding the use of ECT, an AMHP must remember that their role is to make a decision as to whether or not a particular patient needs to be detained under the Act in order to receive treatment; it is not their role to decide what form that treatment should take.

The other occasion in which an AMHP may become involved is for consultation under Sec.58A(6): the SOAD, before certifying that a patient should have ECT but is lacking in capacity, must consult with two other professionals who have been involved with the patient’s treatment; while one of these has to be a nurse, the other must be “neither a nurse nor a registered medical practitioner”. An AMHP who has assessed the person and made a decision about detention could therefore be the second consultee.

I have so far been careful to avoid discussing the Masked AMHP’s own views on the merits or otherwise of ECT. I can avoid it no more.

Having worked in a CMHT for a quarter of a century, I have been very closely involved with the full range of treatments for mental disorder. As a social worker, I lean heavily towards a non medical model of intervention: this involves the use of practical interventions to improve the lives of service users, such as assisting with housing or benefits problems; psychological therapies; counseling; or simply allowing someone the space to talk about what is bothering them – listening and understanding can in itself can be very therapeutic.

But while I am dubious about medicalising what might be unfortunate but normal life events, such as bereavement, relationship breakdown, or domestic violence, I am also aware that medication can be very helpful in a wide range serious mental illnesses, having seen for myself the beneficial effects of medication on people with severe depression, psychosis, and bipolar disorder.

But what about ECT?

Over the years I have seen many severely mentally ill people treated with ECT. I have seen it used when all other treatments have failed, and I have seen it used when the patient’s symptoms clinically lead to the view that ECT is most likely to be effective. I have seen it used with people with intractable depression, who have spent many months in hospital with no positive result from medication. I have seen it used with people with bipolar affective disorder trapped in the deepest of depressive troughs.

I have to say that I have seen almost invariably positive outcomes from its use. And far more quickly than with the use of medication.

I have seen people who have been unable to speak or think or eat be laughing and joking and taking an interest in life again within only 3 or 4 treatments.

I have seen people who have been so severely disabled by depression that they have spent years unable to work or receive any enjoyment from life, within weeks functioning as well as they were before they became ill.

And I have seen the positive effect on their loved ones of having the person they have cared about for so long, and despaired of, being delivered back to them as a whole person again.

So despite being a wishy-washy dogooding social worker, I’m not going to condemn ECT. I still remember one of my trainers when I was learning to be an ASW many years ago saying to us: “If I became clinically depressed, what treatment would I rather have? A long course, perhaps for years, of psychotropic drugs that have all sorts of undesirable side effects? Or a few episodes of being given a general anaesthetic and having a mild electrical current passed through my brain? I’d go for the ECT.”

When you put it like that, I think I would, too.

Friday, 11 May 2012

A Stroll Down Memory Lane: The Lunatic Asylums Act 1853

The 1983 Mental Health Act has been in force for so long (since 1983, curiously) that most people professionally involved with the Act cannot remember a time before it. Some of us of advanced years (me included) may recall the Mental Health Act 1959, and some of us (me included) may have actually been “Mental Welfare Officers” under that Act.

But there was mental health legislation even before then. The Mental Treatment Act 1930 introduced the concept of “treatment” for mental illness, rather than just containment, although it only required two medical recommendations to detain someone in hospital. The concept of an “informed layman” to adjudicate in detentions to hospital was a major innovation of the 1959 Act.

And then in the distant past there was Victorian legislation to contain and control people with mental illness (or “lunatics” as they were then known).

(Digression: It’s fascinating how the terminology used to describe people with disabilities has changed over time. The term “lunatic” is now considered a pejorative term, a terrible insult. Equally, language to describe people with learning difficulties has changed enormously over the years. Even into the 1950’s and 1960’s, clinical terms to describe people with learning difficulties included “idiot”, “imbecile” and “cretin”. Even within my time as a social worker, it was normal to categorise certain people as being “deaf and dumb”; nowadays, of course, we refer to “sensory impairment”. )

I have an original copy of An Act to consolidate and amend the Laws for the Provision and Regulation of Lunatic Asylums for Counties and Boroughs, and for the Maintenance and Care of Pauper Lunatics, in England, or the Lunatic Asylums Act 1853, as it was otherwise known. It makes interesting, and even surprising, reading. Within it, one can detect the origins of today’s legislation.

Much of this Act, unsurprisingly, lays down requirements and regulations concerning lunatic asylums. Much of this is laudable, as it establishes basic welfare requirements for the care of mentally disordered people. This was the Act which resulted in the building of most, if not all, of the Victorian asylums, some of which still exist.

The Act established Committees of Visitors, whose responsibility it was to build and maintain lunatic asylums, as well as to ensure the welfare of their inmates. Section 54, for example, states that “Every Committee of Visitors shall fix a weekly Sum to be charged for the Lodging, Maintenance, Medicine, Clothing, and Care of each Pauper Lunatic confined in such Asylum.” This sum was not to exceed “Fourteen Shillings per Week.”

Within this Act were the embryonic requirements of Sec.136 of the 1983 Act, relating to police powers to detain people who appear to be mentally disordered in places to which the public have access. Sec.68 of the Lunatic Asylums Act states: “Every Constable of any Parish or Place...who shall have knowledge that any Person wandering at large within such Parish or Place.… is deemed to be a Lunatic, shall immediately apprehend and take or cause such person to be apprehended and taken before a Justice.” The Justice could then arrange for the person to be examined and if necessary detained in an asylum.

This section also gave Constables powers and duties concerning the welfare of a Lunatic “who is not under proper Care and Control, or is cruelly treated or neglected by any Relative or other Person having the Care of Charge of him”.

One can also find the origins of Sec.2, Sec.3 and even Sec.4 of the 1983 Act for detaining people. Back in Victorian times, there was a very clear distinction made between “Pauper Lunatics” and others. The lunatic asylums could contain both Pauper Lunatics and Private Patients; it appears, however, that they were treated differently.

Sec.73 relates specifically to the detention of Paupers, stating that Pauper Lunatics had to have the appropriate paperwork for their detention to be legal. This included an order from a Justice, a clergyman, an Overseer, or the Relieving Officer (under the Poor Law), along with a medical certificate signed by “One Physician, Surgeon, or Apothecary, who shall have personally examined him not more than Seven clear Days previously”. It was a misdemeanour to admit to an asylum without such order and medical certificate.

Sec.54 is devoted to people who are not paupers. They have to have a medical certificate signed by not one, but two physicians, surgeons, or apothecaries.

In both cases, a statement also had to accompany the patient. This had to include the following information: name of patient; sex and age; married, single of widowed; condition of life and previous occupation; religious persuasion; whether first attack; age on first attack; duration of existing attack; supposed cause; whether subject to epilepsy; whether suicidal; and whether dangerous to others.

Also within this section is the origin of Sec.4 of the 1983 Act: “Any Person may, under special Circumstances preventing the Examination of such Person by Two Medical Practitioners as aforesaid, be received into an Asylum upon the Certificate of One Physician, Surgeon or Apothecary alone” providing that it was accompanied by a statement setting forth these “Special Circumstances”. In any case, a second medical recommendation had to be provided within 3 days.

There were also rules for discharge from asylums. While there appears to be no provision for appealing against detention, a lunatic could be discharged on the application of a relative or friend, as long as they “shall be properly taken care of, and shall be prevented from doing Injury to himself or others”. Commissioners in Lunacy could also order the removal of a lunatic from an asylum.

Interestingly, large parts of this Act relate to payments: payments to medical practitioners, payments to Visitors, and payments for the building and maintenance of the asylums. Although the Victorians liked to consider themselves philanthropists, they also expected to get paid for it.

Before I conclude, it is worth having a look at one or two of the forms that were used at that time.

One is the “Form of Annual Return” which all asylums had to produce. This consisted of “A True List of all Lunatics, Idiots, and other Persons of Unsound Mind” within their walls. This form included such headings as “Weekly cost of maintenance and clothing”, “Whether lunatic or idiot”, “Dangerous to himself or others”, whether they were “Of dirty Habits” (whatever that meant), and “For what length of time supposed to be of unsound mind.”

The Medical Certificate accompanying a detained patient had to state that the patient was a “Lunatic, or an Idiot, or a Person of unsound Mind”. The medical practitioner also had to explicitly state the “Facts indicating Insanity observed by myself”, as well as “Other Facts indicating Insanity communicated to me by others”.

Eerily familiar, isn’t it?

Tuesday, 1 May 2012

Diogenes Syndrome, Hoarding – or Merely an Avid Collector?

I know it's in here somewhere

There was an interesting article in the Guardian a week or so ago about hoarding. The article described the lifelong difficulties that Jasmine Harman has had with her mother. As she said in the article: “I literally couldn't get into her house. There was so much stuff in the hall that the front door wouldn't open properly and then, if you did manage to squeeze yourself in through the tiny gap, the whole place was piled high with junk. You could barely stand upright and most of the rooms were completely inaccessible."

The article refers to Paul Salkovskis, professor of clinical psychology at the University of Bath, who makes an interesting analysis of this problem. He says that about 1% of the population have hoarding issues to the extent that it dominates their lives.

According to Salkovskis, hoarders fall into one of three categories. “The first group, around 25% of the total, are people with what might be termed "obsessive compulsive hoarding": their problem is harm avoidance, because they fear things could be contaminated and worry about contaminating others if they get rid of them. The second group, who make up about half of all those affected, are deprivation hoarders: they have been through a period of massive deprivation (for example, war, displacement or another sort of loss) and they hoard because, having lost so much once, they feel a need to hold on to possessions in case catastrophe strikes again. The third group… are sentimental hoarders. They have been damaged by unpredictability and possibly even neglect during childhood: for them, possessions have become more reliable than people and they invest in them accordingly.”

I’ve written a couple of times on this blog about the problems of hoarding (here and here). It can be called Diogenes Syndrome or domestic squalor syndrome, but hoarding is probably the best description, since it avoids unduly medicalising this phenomenon.

According to the Blogger statistics, which I avidly read, my blog posts on this subject interestingly receive by far the greatest number of page views; these posts continue to receive dozens of page views weekly. I also regularly receive comments and emails on thethis subject which indicate the anguish that having a neighbour or relative displaying this behaviour can provoke.

It is clear, therefore, that many people throughout the world make searches on these topics, and this must mean that many people have personal experience of people with this problem and want to find some sort of solution.

AMHP’s are fairly often asked to assess people under the Mental Health Act who are living in extreme conditions of clutter or squalor, and reaching a decision that takes full account of an individual’s right under the Human Rights Act to their right to privacy (Article 8) can be very difficult.

The HRA states “Everyone has the right for his private and family life, his home and his correspondence”. However, this is a conditional right, as the Act goes on to say:

“There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.”

A balance therefore has to be struck between the individual’s right to privacy in his own home, to live as he or she wishes, and the rights of the wider community in terms of public safety and others’ right to have their freedoms protected.

The AMHP, as well as having to take into account the effects on the individual of their hoarding habits, and the effects on relatives, carers and those who live in their vicinity, also has to be satisfied that the person is suffering from a mental disorder of a nature or degree which warrants their detention in hospital.

This is where it gets really difficult.

In the article about Jasmine’s mother there is no suggestion that she needs to be in hospital; it is also far from clear that she is suffering from anything other than an obsessive/compulsive disorder. The article does identify a talking treatment for her mother, which according to the article is having some beneficial effect.

I will state for the record here that I have a close relative who is a hoarder. I dread visiting her home and would never accept anything cooked in her kitchen. I have attempted on several occasions over the years to clear up and declutter the house. Not only is she remarkably ungrateful and ungracious when I have done so, but she manages to restore the house to its default state of chaos within weeks.

However, although she is now in her 80’s, not only does she show no signs of dementia, but she shows no signs at all of any diagnosable mental disorder. She is not depressed, she is not psychotic – she just likes to buy stuff, and doesn’t like to throw anything away.

I have learnt to let it be. If, one day, she spontaneously tells me that living like that is a bit of a nuisance, and would I help her sort things out, then of course I would. But that time may never come, and I have to live with it.

As Jasmine says in the Guardian article: "People so often say, why don't you just get a skip and get rid of everything. Don't they think we've tried that? It's not the answer. Unless you address the deeper issues, the hoarder just goes out and buys a whole lot more stuff to replace what has gone."

It has been my experience as an AMHP that people presenting with excessive hoarding rarely have a clearly identifiable mental disorder – they just have a behaviour which most people find baffling or personally unacceptable. And that is not sufficient to detain someone in hospital against their will.

Many people collect things. Some people spend all their spare money on collecting stamps, or bone china, or books, or horse figurines, or obsolete computers or tractors, or even more outlandish objects. There’s someone in the Guiness Book of Records who has the biggest ball of string. Other people might be interested in these collections, or amused, or intrigued. But they don’t demand that these people be incarcerated in a psychiatric hospital.

Whatever I say, AMHP’s will always be called on to make judgments about such behaviours. In the end, however, it is still necessary not just to identify the existence of a significant mental disorder (other than “hoarding” or “Diogenes Syndrome”) but also to make an assessment of the severity of the impact of the behaviour on the person and others affected by their behaviour.

If that can’t be done, then we have no option but to respect their privacy and leave them to get on with it.