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It is in any case not at all clear that ECT can ever be an immediately life-saving treatment in comparison with other treatment options. The British Psychological Society has expressed that view. Certainly it is highly unlikely that ECT would ever be the only treatment
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So I believe we should now look at ECT with fresh eyes. Among clinicians it is controversial in terms of the balance between its effectiveness and its often serious adverse consequences. It excites extremes of antipathy among many patients as a process that is uniquely invasive and distressing. These considerations should encourage us to accept not only that the emergency use of ECT should be restricted to the narrowest of circumstances, but also that its use more generally should be limited by law. It is the firm view of the Royal College of Psychiatrists that it should never be administered to any patient without consent if the patient has capacity. That view was accepted in principle by the Government in the 2004 draft Bill. The technology appraisal published by NICE is equally clear about it. In Amendment No. 14 I am proposing that the Act should reflect what the Government and the professions are signed up to: where a patient with capacity refuses ECT, it should not be given; and where a patient is without capacity, it should be given only where the doctor, giving a second opinion, has expressed his opinion in writing that it is likely to have a clear therapeutic benefit.
If we accept that these amendments are necessary and right in the case of adults, as I hope the Minister will, then we undoubtedly need to look carefully at the issue of ECT as it relates to children. In Amendment No. 15, I propose that in the case of any patient under the age of 18, ECT may be given only with their consent and after a second opinion. The consent would have to be that of the patient themselves where they were capable of giving it, or if they were not, then that of a parent or, if need be, the High Court. These proposals represent quite a considerable change from the current position. At the moment, children and young people can have ECT on parental consent alone. If there is no parental consent, or consent is refused, it can be administered against the young person’s wishes if a second opinion authorises it. I do not believe that this situation is any longer acceptable. Certainly it is true that ECT is used only rarely in this country on patients under 18, but that does not make the issue any the less serious. We know that the adolescent brain is still changing and developing in its structure. The guidance issued by NICE in 2003 states that the risks associated with ECT may be enhanced in children and young people and that particular caution should be exercised before it is administered to this group of patients.
The draft Bill of 2004 would have introduced a tribunal or court authorisation of ECT for all patients aged under 16. The amendment tries to provide for a second opinion under the SOAD—second-opinion appointed doctor—system, which goes some way towards matching that safeguard. It also requires that either the young person’s own doctor or the SOAD is a child and adolescent practitioner so as to ensure specialist involvement before ECT is given.
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I very much hope that the Government will respond positively to these amendments, and I beg to move.
5.30 pm
Lord Bragg: I rise briefly to support the amendment proposed by the noble Earl, Lord Howe, and echo what he said, particularly the word “invasive”. ECT is extremely invasive, and people’s experience of it varies enormously. For some it works; for others it is “hell on Earth”, as the Mind survey says.
I have known people who have suffered greatly from this treatment. We now know that it potentially has highly adverse effects on memory, inducing memory loss. In a Mind survey a few years ago on people’s experiences of ECT—and I declare an interest as president of Mind—adverse psychological effects featured prominently. Those who had been abused in the past felt violated again; others felt fear and anxiety. As the noble Earl, Lord Howe, and Mind point out, people with the capacity to make their own decisions should be able to do so. The autonomy of the patient should be pursued. That is especially so with such an invasive treatment and such uncertain outcomes. Once again, this is trying to give those who are mentally ill the same rights as those who are physically ill.
There is no justification for administering ECT, especially against a person’s will, in a service that may not meet minimum safety standards. As has been said, the Royal College of Psychiatrists’ ECT accreditation service already includes about 50 per cent of ECT clinics on a voluntary basis. Accreditation should be required before ECT can be given. I therefore support these amendments.
The Countess of Mar: I also support the amendment. My mother would have been enormously grateful to the noble Earl, Lord Howe, had she lived. From the late 1940s through to 1960 she was regularly given ECT. Initially she used to be strapped down on to a bed with no sedatives or tranquillisers. She bore the scars of the terminals on her forehead for the rest of her life. She also bore the wounds from a leucotomy. The barbarism of psychiatrists in those days is hard to believe.
The actual treatments themselves did her no good whatever and, indeed, impaired her memory. Fortunately she was a very doughty lady—I loved her dearly, though we used to have awful fights sometimes—and in the end her last four years were peaceful and calm. She said that those years were the happiest of her life. In those years she had absolutely no medical treatment as far as psychiatrists were concerned.
Baroness Neuberger: Other noble Lords have said a great deal to support the amendments in this group. I shall speak very briefly to support the noble Earl, Lord Howe, especially on Amendment No. 15, but we on these Benches support all these amendments. The most worrying aspect for me is that it has been relatively easy, with relatively few safeguards, to give ECT to
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Last week some of us received a briefing from the organisation Young Minds. Mike Shooter, the immediate past president of the Royal College of Psychiatrists, is now its chairman. It was very interesting to hear what they had to say about young people, particularly those in the age group composed of 16 and 17 year-olds—those who are considered somewhere on the boundary between adulthood and childhood. Nobody truly knows how young people’s brains develop or what effect ECT has on a developing brain. Kathryn Pugh told us about the views of young people who have experienced ECT and of some of the psychiatrists who have been involved in it. It was distressing indeed. Mike Shooter gave her permission to tell us the following story:
“The one time I treated a young woman under 18 with ECT was one of the hardest decisions of my professional career. This young woman was manic, she couldn’t engage with us in any way and I really feared if we couldn’t reach her and help her, that she would die. We discussed ECT endlessly and sought more than one independent opinion. We went ahead with ECT, and it was the best decision we could have made. ECT didn’t make her well, but it enabled her to accept and engage with other treatment”.
I think that the whole Committee will be fully behind the amendment, which insists on a second opinion, and that that opinion is taken seriously indeed.
Baroness Murphy: ECT is not getting a very good press here tonight. So, while strongly supporting these amendments, I would like to bring us back to some practical science and what we know about ECT.
It is true that ECT has been grossly misused in the past. I remember going to see the film “One Flew Over The Cuckoo’s Nest”, turning to my husband afterwards and saying, “Goodness me, we never use ECT like that”. The following week, the 10-year review inquiring into St. Augustine’s came out. It described ECT being used in exactly that way. It was deeply shocking for me as a trainee at that time.
It is also true that ECT has been used much less often in the past 20 years. It is good to see how little it is used now in most services, but the evidence is that for people with profound depressive, biological types of illness—particularly those in later life, over the age of 60—those illnesses are life-threatening. People die of depression. The mortality rate among those in a depressive stupor is quite high. If you have seen someone near death because they stopped eating and drinking get a little toehold on life again, to enable you to give them the intravenous medications which might enable them to respond over a longer period to medicine, it is very difficult to say, “I will never give that treatment again”.
Unfortunately, it is also true that many of those who do respond relapse within three or four months, but although that sometimes happens, ECT is sometimes the only option that one can think of. Nevertheless, as other noble Lords said, we recognise the deep fear, anxiety and revulsion that this
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As for emergency ECT under Section 62, only very rarely does it seem necessary to give such treatment. I am rather sceptical about it. Someone would have to be profoundly dehydrated to warrant it, and ECT would be a long shot. One would not be able to wait until Monday or a second-opinion doctor was available. I cannot envisage a scenario where a fully capacitated patient who was able to consent would fall into the need for urgent treatment. So this amendment does ensure that a person with capacity who does not consent should not be subject to ECT in emergencies.
I know that Mind has been pressing for a total ban on ECT in children. I say to the noble Lord, Lord Bragg, that initially I was very sympathetic to the idea of tabling an amendment to that effect. Several US states have banned it but not for reasons of science. The literature is poor. There are about a dozen cases every year, few international series and no randomised control trials. Again, though, with regard to the sort of young person who is given this treatment, the recent literature shows that in almost all cases the people concerned in administering ECT have gone out of their way to seek second and third opinions and a consensus decision from the clinical team. So in practice such treatment is happening very rarely. However, it may be life-saving for a child who is seriously ill and in a depressive catatonic stupor, which is a very rare occurrence. NICE considered the options carefully and, on balance, decided that it was not wise to ban the treatment if perhaps one child’s life could be saved by it. The extra safeguards therefore seem to be the way forward. ECT is always a last resort. I personally would not want to ban it if it saved one child from that appalling condition, depressive stupor.
I give my full support to these amendments. We have come a long way, but let us not forget that just occasionally patients ask for ECT because it helped them the last time they had a depressive illness. When it is feared and not sought and the patient has no capacity, however, the treatment should not go ahead.
The Lord Bishop of Ripon and Leeds: I support the amendments and the noble Earl, Lord Howe, in his presentation of them. This is perhaps the most crucial of the examples of valuable safeguards that we have lost through the withdrawal of the 2004 Bill, and it would be good to have them reintroduced here. I speak in particular from contact with chaplains within the mental health service and their own discussions about the use of ECT, its dangers and its desperately invasive nature, as well as the rare occasions on which it is, in their view, the appropriate way forward in treatment. I am aware of circumstances where ECT has indeed been very damaging to people, but also of those where it has been helpful.
The chaplains to whom I have spoken have affirmed the need for consent as a crucial part of the use of ECT. When that consent is there, the patient goes
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Lord Williamson of Horton: I join the noble Earl, Lord Howe, and others in hoping that the Minister will be able to respond favourably to these amendments about electro-convulsive therapy. I think we all know that many patients see it as—and indeed it is—quite different from other types of treatment. It is not at all uncommon to find a mental health patient who considers that his future treatment has been prejudiced by the fact that he had ECT at an earlier stage. I have met patients who feel that way. They may be totally wrong, but they believe it, and it has a serious impact, not just at the time but perhaps for many years afterwards. I hope we can reach a situation where there is no ECT without consent, and where the treatment of patients under 18 is given special attention.
Like many others, I would like there to be no ECT for patients under 18, but I understand the points made by, for example, the noble Baroness, Lady Murphy, and therefore go along with the amendment that introduces a second opinion from a clinician with special training in child and adolescent mental health. That is a step forward; I would have hoped we would have been able to take a bigger step, but at least we ought to try and take that one. I hope the Minister will be able to respond favourably.
Lord Patel: I support these amendments. I agree that if there had been an amendment that banned ECT for under-18s I would have supported it, but, having listened to the noble Baroness, Lady Murphy, I am happy to support Amendment No. 15 as it is. ECT is not a very pleasant form of treatment; it should be used only with safeguards, and these amendments address that.
5.45 pm
Baroness Meacher: I also support Amendment No. 15, tabled in the name of the noble Earl, Lord Howe, and will limit my remarks to the giving of ECT to people under 18. I too was asked to table an amendment that would have banned the giving of ECT to young people in any circumstances, but, having studied the research evidence on the subject, and from my own personal experience of patients who have undergone ECT, I was not persuaded that that was the right course of action. The Howe amendment, on the other hand, allows ECT to be given to young people in extremis, and for me the evidence to date supports that.
The British Psychological Society document Depression in Children and Young People provides a valuable review of the giving of ECT to young people. There are significant concerns about the adverse effects of ECT; as other noble Lords have said, it may cause short- or long-term memory impairment for
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The recommendations of the American Academy of Child and Adolescent Psychiatry in 2002 are also a helpful guide to practice. If ECT is to be given, a number of conditions should apply. The following three are absolutely central, and the noble Earl’s amendment is designed to ensure that these conditions are met at all times. First:
“The symptoms must be severe, persistent and significantly disabling, including life-threatening symptoms such as refusal to eat or drink, severe suicidality, or florid psychosis”.
“Other treatments should have been tried and failed, including at least two or more trials of appropriate psychopharmacology, unless the severity of symptoms precludes waiting for a response to other treatments”.
“A psychiatrist experienced in the use of ECT, but not involved in the case, should give a second opinion”.
In May 2003 NICE published its guidance on ECT for depressive illness, schizophrenia, catatonia and mania. NICE follows a similar line to the American Academy, and recommends that ECT,
- “is used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening”.
The draft Mental Health Bill published on 8 September 2004, which others have referred to, provided for very stringent safeguards. For some reason, those have now been lost. This amendment would at least go some way towards restoring them; it is less stringent, but I think it would achieve the desired objective.
If there are insufficient data on the long-term effects of ECT, and if it is known to carry risks, why not ban it? We can turn to the views of young people who have been given ECT and their parents to provide part of the answer to that question. Three studies, undertaken in 1999 and 2000, of a total of 64 young people who had received ECT and their parents found that a small majority of the young people believed the treatment had been helpful. Most had experienced memory loss—one of the major concerns about ECT, as we know—but “this had largely resolved over time”. A further study, undertaken in 1999, of 87 patients with depression who had been treated with ECT aged 18 years or younger showed that 67 per cent had remitted or showed marked improvement of symptoms after treatment. I just do not think we can ignore the experience of people who have been through the treatment.
We are concerned here with a very small number of the most severely mentally ill, as others have said. Richard Duffett, consultant psychiatrist at Goodmayes Hospital, provides us with, as far as I know, the only
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Lord Acton: Of the studies that the noble Baroness quoted, was the benefit of ECT shown soon after it was given, or was there a considerable gap?
Baroness Meacher: To my knowledge, the effects tend to happen very soon after ECT is given. I think there were studies about the consequences of ECT over a six-month period. The research that I am thinking of showed that, over that longer period, the results of ECT and drugs were similar. Therefore, my conclusion is that wherever possible one gives drugs and not ECT. I have tried to make the point that where a child’s life is in danger—and only when a child’s life is in danger—one should use ECT to save a life. In assessing whether a child’s life is really in danger, one needs a second-opinion doctor and the opinion either of the child, if he or she has some capacity, which, frankly, is unlikely in the circumstances, or the consent of a parent. It is a matter of putting in all the safeguards one can to save a very small number of lives.
Lord Patel of Bradford: As I have previously declared, I am chairman of the Mental Health Act Commission and as such I have an interest in all the debates concerning this Bill.
I wholeheartedly support the part of the amendment that seeks to ensure more effective safeguards in the use of electro-convulsive therapy for under-18s, and I support the noble Lords who tabled it. However, I have a number of questions, on which the Committee might wish to reflect, about an across-the-board introduction of a mental capacity test, as suggested by the first part of Amendment No.14.
I begin by drawing the Committee’s attention to the Mental Health Act Commission's concerns over the Government's previous proposal, in their draft Mental Health Bill of 2004, that ECT should not, except in an emergency, be given to patients deemed capable of refusing consent. The commission's data on second-opinion authorisations of ECT showed that in 2002-03, ECT was authorised by a second-opinion, appointed doctor in the face of a patient's capable refusal of consent on 834 occasions. That amounts to 40 per cent of all the second-opinion doctors' authorisations of ECT in that year.
The Mental Health Act Commission asked the Joint Committee that was considering that Bill in its biennial report to Parliament what would be likely to happen to this proportion of patients who receive treatment under the present legal framework if the proposed change to that framework were made. The possibilities seem to be that such patients would simply no longer receive ECT, they would receive it under emergency powers, or the assessment of their
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