[Electroconvulsive therapy in nonconsenting patients]

Effectiveness of electroconvulsive therapy in patients lacking decision making capacity: A systematic review and meta-analysis

BACKGROUND

Electroconvulsive therapy (ECT) is provided for patients with severe and often life-threatening illness, who lack decision making capacity to consent to treatment (DMC-T) in clinical settings.

OBJECTIVE

The aim of this study is to summarize previous studies investigating clinical outcomes of ECT in patients lacking DMC-T.

METHODS

A systematic review and meta-analysis of studies reporting clinical outcomes of ECT in patients lacking DMC-T with any psychiatric diagnoses was conducted. The primary outcome was clinical improvement. Secondary outcomes were cognitive outcomes and six month readmission rate. Hedges' g and odds ratios were calculated using a random-effects model. The protocol was registered in Open Science Framework (https://osf.io/rxjkm).

RESULTS

Of 3552 identified articles, 41 studies (n = 1299) were included. Approximately 80% of patients lacking DMC-T responded to ECT, and part of the patients regained capacity to consent and consented to further treatment with ECT. A total of seven studies (n = 1081) were included for meta-analysis. Patients without DMC-T showed superior clinical improvement and less cognitive side effects compared with those with DMC-T, whereas the groups did not show any difference in readmission rate. Several clinical characteristics at baseline and ECT techniques were significantly different between the groups.

CONCLUSION

ECT is equally, if not superiorly, effective in patients lacking DMC-T compared to patients with DMC-T. ECT can potentially enhance patients' autonomy, without increasing the risk of cognitive side effects. These results support the clinical and ethical legitimacy of ECT provision for patients with the most severe illness who lack DMC-T at start of treatment.

'Shock tactics', ethics and fear: an academic and personal perspective on the case against electroconvulsive therapy

Despite extensive evidence for its effectiveness, electroconvulsive therapy remains the subject of fierce opposition from those contesting its benefits and claiming extreme harms. Alongside some reflections on my experiences of this treatment, I examine the case against electroconvulsive therapy and find that it appears to rest primarily on unsubstantiated claims about major ethical violations, rather than clinical factors such as effectiveness and risk.

[Importance of electroconvulsive therapy (ECT) in forensic psychiatry]

Hintergrund und Ziel der Arbeit

Für die Elektrokonvulsionstherapie (EKT) liegen Leitlinienempfehlungen zur Behandlung schwerer affektiver und psychotischer Erkrankungen vor, wie sie auch bei Patienten im Maßregelvollzug (MRV) vorkommen. Über die Anwendung der EKT in der forensischen Psychiatrie existieren jedoch keinerlei systematisch erhobene Daten. Ziel der vorliegenden Arbeit ist eine Erhebung des Ist-Zustands sowie des geschätzten Bedarfs an EKT im MRV.

Material und Methoden

Es wurde ein Fragebogen zur Erhebung der aktuellen Anwendung sowie der Einschätzung des Bedarfs an EKT in dieser Population entwickelt. Dieser wurde elektronisch und bei Bedarf postalisch an die forensischen Kliniken in Deutschland versendet.

Ergebnisse

Wir erhielten Antwort von 52 Kliniken (66 %). 29 der Kliniken gaben an, Patienten mit EKT behandeln zu können. Eine Behandlungsindikation wurde klinikübergreifend für 3,4 % der untergebrachten Patienten gesehen. In einem Jahr (2018) wurden insgesamt 32 EKT-Behandlungen an 12 Kliniken des Maßregelvollzugs mit durchschnittlich guter Wirksamkeit (Ø CGI‑I 2,32) durchgeführt. Häufigste Begründung für die fehlende Anwendung der EKT waren mangelnde strukturelle Voraussetzungen. Jeweils etwa ein Drittel der Kliniken sehen einen mittleren bzw. hohen Bedarf an EKT im MRV.

Diskussion

Die EKT kommt im MRV in Deutschland aktuell nur sehr begrenzt zum Einsatz. Auffällig ist, dass die Anzahl der durchgeführten Behandlungen etwa um den Faktor 8 hinter der Indikationshäufigkeit zurücksteht. Ungeachtet dessen sehen zwei Drittel der Kliniken einen mittleren bis hohen Bedarf, womit eine Unterversorgung mit EKT im MRV zu bestehen scheint.

[Treatment against the patient's will exemplified by electroconvulsive therapy : Clinical, legal and ethical aspects]

BACKGROUND

Severe affective and psychotic disorders may be accompanied by legal incapacity. If in this case the patient refuses treatment and in parallel there is a risk of serious damage to health, treatment can be carried out against the patient's non-autonomous will under defined prerequisites. Due to its good and partly superior effectiveness in the treatment of severe and pharmacotherapy-resistant affective and psychotic disorders, electroconvulsive therapy (ECT) is an important treatment option in such constellations.

AIM

Description of the general principles and prerequisites of therapeutic measures against the patient's will.

METHODS

Based on a case report, the application of ECT as a medical measure against the patient's will is discussed and assessed in an interdisciplinary approach from clinical, legal, and ethical perspectives.

RESULTS AND DISCUSSION

The (empirical) evidence on the general effectiveness of ECT, as well as its application against the will of patients with legal incapacity, clearly shows a positive benefit-risk ratio. When performed against the patient's will, ECT as all compulsory medical interventions, represents a severe encroachment on the individual's fundamental rights of both physical integrity and self-determination. Nevertheless, its application may be medically indicated, legally admissible and ethically appropriate in individual cases to prevent the threat of serious damage to the patient's health. Ethical and legal prerequisites of treatment against the patient's will should be evaluated by a multiprofessional team and the patient's legal guardian should be involved from an early stage.

Electroconvulsive therapy against the natural will: Some concerns

In recent years, the scientific interest in "Electroconvulsive therapy (ECT) against the patient's natural" will has grown. Several publications have reported mostly positive outcomes in cases, where ECT has been implemented against the patient's natural will. The author's findings primarily indicate the effectiveness of ECT in non-consenting patients, which confirms earlier findings. All author's overall presumption turned out to be mainly positive. Within the discussion on involuntary ECT treatment, we missed disadvantageous arguments, which also need to be considered for a balanced judgement. By bringing up the following viewpoint, would like to contribute to a balanced decision making process in cases where involuntary ECT is a legal treatment option.

Influence of depressed patients' expectations prior to electroconvulsive therapy on its effectiveness and tolerability (Exp-ECT): a prospective study

Electroconvulsive therapy (ECT) is the most effective therapy for severe depressive disorders. Though there are known clinical predictors of response (e.g., higher age, presence of psychotic symptoms), there is a lack of knowledge concerning the impact of patients' expectations on treatment outcome and tolerability in terms of possible placebo/nocebo effects. In 31 patients with unipolar or bipolar depressive disorder, we used a questionnaire to investigate the patients' expectations of ECT effectiveness and tolerability prior to and in the course of the treatment. Additionally, the questionnaire was used after the ECT course for a final assessment. Depressive symptoms and putative side-effects were measured at each time point. General linear models were used to analyze the course of depressive symptoms and patients' expectation of ECT effectiveness and tolerability. ECT significantly reduced depressive symptoms with large effect sizes. Patients' rating of ECT effectiveness decreased in parallel: While responders' rating of ECT effectiveness remained stable on a high level, non-responders' rating decreased significantly. Group difference was significant after, but not prior to and during the treatment. Regarding tolerability, there was a (temporary) significant increase in the severity of self-rated symptoms such as headache and memory impairment. In contrast, patients' expectation and assessment of ECT tolerability remained unchanged, and their expectations prior to ECT had no impact on the occurrence of side-effects. These findings contradict the presence of relevant placebo/nocebo effects in the context of ECT when investigating a population of mostly chronic or treatment resistant patients with moderate to severe depressive disorder.

Electroconvulsive therapy against the patients' will: A case series

OBJECTIVES

Electroconvulsive therapy (ECT) is the most effective therapy for severe depressive and psychotic disorders. As patients may be subject to legal incapacity and lack of insight, treatment may be administered against the patient's will. There is only limited evidence on the use of ECT against the patient's non-autonomous will.

METHODS

We report a series of eight patients who received ECT against their will in two German university medical hospitals between 2014 and 2016. The effectiveness, tolerability and patients' perspective are described.

RESULTS

Seven of eight patients were much or very much improved according to the Clinical Global Impression Scale. Capacity to consent was restored in seven patients. Transient side effects occurred in four patients. Seven patients agreed to receive further ECT in the treatment course.

CONCLUSIONS

This case series suggests that ECT may (and sometimes should) be administered to severely ill, non-consenting patients against their will with good effectiveness. Potential and mostly moderate and transient side effects have to be weighed up against the potentially life-saving character of ECT in patients with, e.g., suicidality and food refusal. Most importantly, the patients' retrospective appraisal also justifies the administration of ECT in situations of severe mental illness and legal incapacity.