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Marcó-García S, Ariyo K, Owen GS, David AS. Decision making capacity for treatment in psychiatric inpatients: a systematic review and meta-analysis. Psychol Med 2024; 54:1074-1083. [PMID: 38433596 DOI: 10.1017/s0033291724000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Decision-making capacity (DMC) among psychiatric inpatients is a pivotal clinical concern. A review by Okai et al. (2007) suggested that most psychiatric inpatients have DMC for treatment, and its assessment is reliable. Nevertheless, the high heterogeneity and mixed results from other studies mean there is considerable uncertainty around this topic. This study aimed to update Okai's research by conducting a systematic review with meta-analysis to address heterogeneity. We performed a systematic search across four databases, yielding 5351 results. We extracted data from 20 eligible studies on adult psychiatric inpatients, covering DMC assessments from 2006 to May 2022. A meta-analysis was conducted on 11 papers, and a quality assessment was performed. The study protocol was registered on PROSPERO (ID: CRD42022330074). The proportion of patients with DMC for treatment varied widely based on treatment setting, the specific decision and assessment methods. Reliable capacity assessment was feasible. The Mini-Mental State Examination (MMSE), Global Assessment of Function (GAF), and Brief Psychiatric Rating Scale (BPRS) predicted clinical judgments of capacity. Schizophrenia and bipolar mania were linked to the highest incapacity rates, while depression and anxiety symptoms were associated with better capacity and insight. Unemployment was the only sociodemographic factor correlated with incapacity. Assessing mental capacity is replicable, with most psychiatric inpatients able to make treatment decisions. However, this capacity varies with admission stage, formal status (involuntary or voluntary), and information provided. The severity of psychopathology is linked to mental capacity, though detailed psychopathological data are limited.
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Affiliation(s)
- Silvia Marcó-García
- Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain
- Etiopathogenesis and treatment of severe mental disorders (MERITT), Sant Joan de Déu Research Institute, Sant Joan de Déu Foundation, Barcelona, Spain
- Department of Social Psychology and Quantitative Psychology, Faculty of Psychology, University of Barcelona, 08035 Barcelona, Spain
| | - Kevin Ariyo
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Gareth S Owen
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony S David
- Division of Psychiatry, UCL Institute of Mental Health, University College London, London, UK
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Takamiya A, Sienaert P, Gergel T, Gather J, Kishimoto T, Zilles-Wegner D. Effectiveness of electroconvulsive therapy in patients lacking decision making capacity: A systematic review and meta-analysis. Brain Stimul 2022; 15:1246-1253. [PMID: 36089193 DOI: 10.1016/j.brs.2022.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/02/2022] [Accepted: 09/02/2022] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Akihiro Takamiya
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Pascal Sienaert
- Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center, KU Leuven, Kortenberg, Belgium
| | - Tania Gergel
- Institute of Psychiatry, Psychology, and Neuroscience, King's College London, United Kingdom
| | - Jakov Gather
- Department of Psychiatry, Psychotherapy and Preventive Medicine, LWL University Hospital, Ruhr University Bochum, Bochum, Germany; Institute for Medical Ethics and History of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Taishiro Kishimoto
- Hills Joint Research Laboratory for Future Preventive Medicine and Wellness, Keio University School of Medicine, Tokyo, Japan
| | - David Zilles-Wegner
- Department of Psychiatry and Psychotherapy, University Medical Center Göttingen, Göttingen, Germany.
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Takamiya A, Bouckaert F, Sienaert P, Uchida T, Kudo S, Yamagata B, Kishimoto T, Mimura M, Hirano J. Electroconvulsive Therapy for Patients With Depression Who Lack Capacity for Consent: Doing Good and Doing No Harm. J ECT 2021; 37:171-175. [PMID: 33840801 DOI: 10.1097/yct.0000000000000764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Electroconvulsive therapy (ECT) is provided in real-world clinical settings for patients lacking capacity for consent. The aim of this study was to investigate the clinical characteristics and clinical effectiveness of ECT in this population. METHODS A retrospective chart review was conducted to collect data from patients who received ECT to treat their depressive episodes between April 2012 and March 2019. Differences in clinical characteristics and short-/long-term clinical outcomes between patients who received ECT with their relatives' consent and patients who received ECT by their own consent were examined. The short-/long-term clinical outcomes were determined by clinical global impression scores and readmission rate, respectively. RESULTS Of 168 patients with depressive episodes, 34 (20.2%) received ECT with their relatives' consent. Those patients were older, had lower body mass index, and had shorter episode duration. They also exhibited more frequent psychotic, melancholic, and catatonic features. The main indication for ECT in this population was the need for rapid recovery. Patients lacking capacity for consent showed similar remission (61.8%) and response (82.4%) rates to those with capacity for consent. Readmission rate was not significantly different between groups. CONCLUSIONS There were no significant differences in short-/long-term ECT effectiveness between patients with/without capacity for consent. Electroconvulsive therapy is the only established and effective treatment in clinical settings for the most severe cases, wherein patients are incapable of giving consent but need rapid recovery. A general rejection of this practice due to concerns surrounding consent may be unethical under the ethical principles of medical care.
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Affiliation(s)
| | | | - Pascal Sienaert
- Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center, KU Leuven, Leuven, Belgium
| | - Takahito Uchida
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kudo
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Bun Yamagata
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Taishiro Kishimoto
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Mimura
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Jinichi Hirano
- From the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
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Plahouras JE, Konstantinou G, Kaster TS, Buchman DZ, Foussias G, Daskalakis ZJ, Blumberger DM. Treatment Capacity and Clinical Outcomes for Patients With Schizophrenia Who Were Treated With Electroconvulsive Therapy: A Retrospective Cohort Study. Schizophr Bull 2020; 47:424-432. [PMID: 33145601 PMCID: PMC7965065 DOI: 10.1093/schbul/sbaa144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients with schizophrenia are often found incapable to consent to psychiatric treatment. We evaluated clinical outcomes for incapable and capable patients with schizophrenia treated with electroconvulsive therapy (ECT). METHODS We conducted a chart review of all inpatients treated with an acute course of ECT between 2010 and 2018 at the Centre for Addiction and Mental Health, Toronto, Canada. Short-term outcomes included treatment response and cognitive impairment. We assessed whether incapable patients regained the capacity to consent to treatment. Long-term outcomes included readmissions and subsequent courses of acute or maintenance ECT. RESULTS A total of 159 (67%) incapable and 79 (33%) capable patients were included. Patients experienced treatment response (incapable, n = 108, 67.9%; capable, n = 52, 65.8%; P = .771) and few experienced cognitive impairment (incapable, n = 21, 13.2%; capable, n = 19, 24.1%; P = .043). A minority of patients were treated with a subsequent course of acute ECT (incapable, n = 46, 28.9%; capable, n = 16, 20.3%; P = .162). Incapable patients were more likely to be treated with maintenance ECT for at least 6 months (incapable, n = 46, 28.9%; capable, n = 13, 16.5%; P = .039). Both groups had similar readmission rates (incapable, n = 70, 44.0%; capable, n = 35, 44.3%; P = 1.000). Eight (5.0%) incapable patients regained capacity and 7 consented to further treatment. CONCLUSIONS Irrespective of treatment capacity, the majority of patients demonstrated clinical improvement. Incapable patients experienced less cognitive side effects when compared with capable patients, though they had fewer treatments overall. This study informs clinicians, patients, and substitute decision-makers about the outcomes and challenges of ECT in patients with schizophrenia.
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Affiliation(s)
- Joanne E Plahouras
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Gerasimos Konstantinou
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tyler S Kaster
- Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Daniel Z Buchman
- Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada,Bioethics Department, Toronto Western Hospital, University Health Network, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada,Krembil Brain Institute, University Health Network, Toronto, ON, Canada
| | - George Foussias
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Schizophrenia Division, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Zafiris J Daskalakis
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Centre for Addiction and Mental Health, Campbell Family Mental Health Institute, Toronto, ON, Canada
| | - Daniel M Blumberger
- Institute of Medical Science, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Temerty Centre for Therapeutic Brain Intervention, Centre for Addiction and Mental Health, Toronto, ON, Canada,Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada,Centre for Addiction and Mental Health, Campbell Family Mental Health Institute, Toronto, ON, Canada,To whom correspondence should be addressed; Centre for Addiction and Mental Health, 1001 Queen St. W. Unit 4, Room 115, Toronto, ON M6J 1H4, Canada; tel: 416-535-8501 x 33662, fax: 416-583-4613, e-mail:
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Tor PC, Tan FJS, Martin D, Loo C. Outcomes in patients with and without capacity in electroconvulsive therapy. J Affect Disord 2020; 266:151-157. [PMID: 32056870 DOI: 10.1016/j.jad.2020.01.150] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/16/2019] [Accepted: 01/26/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is an effective treatment for severe mental illness but access is limited for patients lacking consent capacity. We aimed to compare the symptomatic, cognitive, quality of life (QOL) and functional outcomes of patients with and without capacity receiving ECT for schizophrenia, depression or mania. METHODS Patients prescribed ECT in a single center had their clinical outcomes pre and post ECT compared with repeated measures ANOVAs. Differences in demographic, clinical characteristics and ECT treatment between the group lacking and having capacity were examined using independent t-tests for continuous variables and chi-squared tests for categorical variables. RESULTS 75.1% of 175 patients lacked capacity. The group lacking capacity had overall poorer cognitive and global functioning pre ECT but higher QOL. Objective psychiatric symptom ratings after ECT improved similarly between groups. Mood, cognition, QOL and function improved in both groups, with more improvement in mood and function in the group lacking capacity and a trend towards greater cognitive improvement (p = 0.051). LIMITATIONS Subgroup analysis by diagnosis was not done due to smaller sample sizes in each group. Cognition was assessed with a general screening instrument not a full neuropsychological assessment. CONCLUSIONS ECT is a safe and effective treatment for schizophrenia, bipolar mania and depression, and may provide similar or greater benefits in patients lacking capacity to consent, compared to those with capacity. These results support the provision of a framework for substitute decision making in the patients' best interests for ECT in patients unable to provide their own consent.
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Affiliation(s)
- Phern-Chern Tor
- Department of Mood and Anxiety, Institute of Mental Health, Singapore.
| | | | - Donel Martin
- School of Psychiatry, University of New South Wales, Sydney, Australia; The Black Dog Institute, Sydney, Australia
| | - Colleen Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia; The Black Dog Institute, Sydney, Australia; St George Hospital, Sydney, Australia
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Kumagaya DY. Acute electroconvulsive therapy in the elderly with schizophrenia and schizoaffective disorder: A case series. Asia Pac Psychiatry 2019; 11:e12361. [PMID: 31106956 DOI: 10.1111/appy.12361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 04/26/2019] [Indexed: 01/05/2023]
Abstract
INTRODUCTION There is a paucity of evidence regarding the use of electroconvulsive therapy (ECT) in the elderly with primary psychotic conditions, such as schizophrenia and schizoaffective disorder. This study examined the efficacy and safety of acute ECT treatment in late-life patients with primary psychotic conditions. METHODS A retrospective chart review was conducted on all patients aged 60 and above, who received ECT within a large metropolitan psychiatric facility in Australia between 2012 and 2018, and who were diagnosed with a primary psychotic condition. Information regarding demographic data, illness correlates, ECT treatment, treatment outcomes, and adverse effects was collected. RESULTS A total of 20 patients met inclusion into the study, 35% of whom were diagnosed with schizophrenia and 65% with schizoaffective disorder. The average age was 69 years. Patients had been trialed on an average of seven distinct antipsychotic agents prior to acute ECT treatment; 50% had been trialed on clozapine. ECT was associated with full (60%) or partial remission (35%) of psychotic illness in 95% (n = 19) of patients. No ECT-related fatalities were encountered. Adverse effects were experienced in 20% of patients, although none precluded the continuation of treatment. DISCUSSION This study found ECT to be a highly effective and safe treatment in the elderly with schizophrenia and schizoaffective disorder, who had not responded adequately to psychotropic medications.
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Kumagaya D, Halliday G. Acute electroconvulsive therapy in the elderly with schizophrenia and schizoaffective disorder: a literature review. Australas Psychiatry 2019; 27:472-476. [PMID: 30920288 DOI: 10.1177/1039856219839470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES This study reviewed the evidence regarding the efficacy of acute electroconvulsive therapy for primary psychotic conditions in the elderly. METHODS A literature search was performed using the Medline, Embase and Cochrane databases. RESULTS Acute electroconvulsive therapy resulted in an improvement of psychotic symptoms in almost all elderly patients, a large proportion of whom had treatment-resistant conditions. No electroconvulsive therapy related fatalities or severe medical complications were encountered. CONCLUSIONS Acute electroconvulsive therapy may present a valuable treatment modality for elderly patients with primary psychotic conditions who do not respond adequately to antipsychotic medications.
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Affiliation(s)
- David Kumagaya
- Psychiatry of old age advanced trainee, Sydney Local Health District, Concord Centre for Mental Health, Concord, NSW, Australia
| | - Graeme Halliday
- Senior staff specialist psychogeriatrician; Sydney Local Health District, Concord Centre for Mental Health, Concord, NSW, Australia
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Abstract
OBJECTIVE We aimed to examine attitudes toward electroconvulsive therapy (ECT) among involuntary patients, voluntary patients, and their relatives. METHODS Patients experiencing a major depressive episode and receiving ECT and their relatives were recruited for the survey. Patients and their relatives answered the self-rating questionnaires with a 7-point Likert scale. We explored differences in the survey results between involuntary and voluntary patients, as well as differences in the survey results between patients and their relatives. RESULTS We recruited 97 participants (53 patients and 44 relatives) for the survey. Approximately 80% of the patients showed positive attitudes toward ECT. There were no statistically significant differences between involuntary (n = 23) and voluntary (n = 30) patients across multiple aspects of the ECT experience, including treatment satisfaction, positive or adverse effects of ECT, and treatment preference in the future. Relatives were more satisfied with the positive effects of ECT and with the information offered before ECT treatment than the patients themselves. CONCLUSIONS Approximately 80% of the patients showed overall satisfaction with ECT irrespective of consent status. Relatives were more satisfied with ECT than patients. Electroconvulsive therapy can be a lifesaving treatment for severely depressed patients, and the subjective experience of involuntary patients should be taken into consideration when discussing involuntary ECT treatment.
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Tor PC, Gálvez V, Ang A, Fam J, Chan HN, Tan SN, Loo CK. Electroconvulsive practice in Singapore: a cross-sectional national survey. Singapore Med J 2019; 60:590-595. [PMID: 31197378 DOI: 10.11622/smedj.2019064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
INTRODUCTION The use of electroconvulsive therapy (ECT) in Singapore dates back to 1947. However, there is little local information on the clinical practice of ECT and its standards. We aimed to conduct a comprehensive national survey of ECT practice in Singapore. METHODS A cross-sectional structured questionnaire assessing the types of ECT (e.g. electrode placement, stimulus parameters), indications, anaesthetic technique, dosing methods, monitoring of outcomes and credentialing was sent in 2015 to all ECT centres in Singapore via email to collect qualitative and quantitative data regarding ECT. RESULTS Data was obtained from all ECT centres (n = 6), which represented that ECT was available in 23.1% of all hospitals and 50.0% of all psychiatric specialist centres. The rate of ECT was 5.89 treatments per 10,000 residents per year, and each patient received an average of 5.4 ECT per course. Only 7.0% of ECT was administered for continuation/maintenance ECT. The most common indication for ECT was depression in 5 (83.3%) out of six centres, with schizophrenia being the second most common. In 5 (83.3%) out of six centres, ECT was brief (0.5 ms) bitemporal ECT with age-based dosing, and 93.0% of the sessions were conducted in an inpatient setting. All ECT was conducted under general anaesthesia, with propofol (66.7%) being the most common type of anaesthetic used. CONCLUSION The practice of ECT in Singapore was highly uniform. The rates and indications for ECT were consistent with those of other developed countries, with greater use of ECT for schizophrenia. Future advances for ECT in Singapore include the use of individualised dosing based on empirical seizure threshold titration, expanded electrode placements and increased utilisation of continuation/maintenance ECT.
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Affiliation(s)
- Phern-Chern Tor
- Department of General Psychiatry, Institute of Mental Health, Singapore
| | - Verònica Gálvez
- School of Psychiatry, University of New South Wales, Sydney, Australia.,Black Dog Institute, Sydney, Australia
| | - Aaron Ang
- Department of Psychological Medicine, Tan Tock Seng Hospital, Singapore
| | - Johnson Fam
- Department of Psychological Medicine, National University Hospital, Singapore
| | - Herng-Nieng Chan
- Department of Psychological Medicine, Singapore General Hospital, Singapore
| | - Sheng-Neng Tan
- Department of Psychological Medicine, Changi General Hospital, Singapore
| | - Colleen K Loo
- School of Psychiatry, University of New South Wales, Sydney, Australia.,Black Dog Institute, Sydney, Australia.,Department of Psychiatry, St George Hospital, Sydney, Australia
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10
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Electroconvulsive therapy against the natural will: Some concerns. Eur Psychiatry 2019; 58:87-88. [PMID: 30878914 DOI: 10.1016/j.eurpsy.2019.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/07/2019] [Indexed: 11/22/2022] Open
Abstract
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.
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Finnegan M, O'Connor S, McLoughlin DM. Involuntary and voluntary electroconvulsive therapy: A case-control study. Brain Stimul 2018; 11:860-862. [PMID: 29643022 DOI: 10.1016/j.brs.2018.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/20/2018] [Accepted: 04/03/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND It is not known whether results of clinical research in ECT can be used to guide treatment decisions for those having involuntary ECT, who are not represented in trial populations. OBJECTIVE We aimed to compare courses of involuntary ECT with matched voluntary ECT courses in terms of clinical and demographic factors, treatment requirements, and outcomes. METHOD We performed a retrospective case-control study examining a five-year sample of involuntary ECT courses and an age-, gender- and time-matched voluntary ECT control sample. RESULTS We examined 48 involuntary and 96 control voluntary ECT courses. While groups differed at baseline in terms of diagnosis, illness severity and illness characteristics, there were no differences in treatment outcomes after ECT or six-month readmission rates. CONCLUSION Our findings suggest that research on capacitous ECT patients is applicable to those having involuntary ECT.
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Affiliation(s)
- Martha Finnegan
- Department of Psychiatry, Trinity College Institute of Neuroscience, Trinity College Dublin, St. Patrick's University Hospital, James's St., Dublin 8, Ireland
| | - Stephanie O'Connor
- Department of Psychiatry, Trinity College Institute of Neuroscience, Trinity College Dublin, St. Patrick's University Hospital, James's St., Dublin 8, Ireland
| | - Declan M McLoughlin
- Department of Psychiatry, Trinity College Institute of Neuroscience, Trinity College Dublin, St. Patrick's University Hospital, James's St., Dublin 8, Ireland.
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Methfessel I, Sartorius A, Zilles D. Electroconvulsive therapy against the patients' will: A case series. World J Biol Psychiatry 2018; 19:236-242. [PMID: 28299981 DOI: 10.1080/15622975.2017.1293296] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Isabel Methfessel
- a Department of Psychiatry and Psychotherapy , University Medical Center Göttingen , Göttingen , Germany
| | - Alexander Sartorius
- b Department of Psychiatry and Psychotherapy, Medical Faculty Mannheim , Central Institute of Mental Health, University of Heidelberg , Heidelberg , Germany
| | - David Zilles
- a Department of Psychiatry and Psychotherapy , University Medical Center Göttingen , Göttingen , Germany
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Spencer BWJ, Shields G, Gergel T, Hotopf M, Owen GS. Diversity or disarray? A systematic review of decision-making capacity for treatment and research in schizophrenia and other non-affective psychoses. Psychol Med 2017; 47:1906-1922. [PMID: 28441976 DOI: 10.1017/s0033291717000502] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Valid consent for treatment or research participation requires that an individual has decision-making capacity (DMC), which is the ability to make a specific decision. There is evidence that the psychopathology of schizophrenia can compromise DMC. The objective of this review was to examine the presence or absence of DMC in schizophrenia and the socio-demographic/psychopathological factors associated. METHODS We searched three databases Embase, Ovid MEDLINE(R), and PsycINFO for studies reporting data on the proportion of DMC for treatment and research (DMC-T and DMC-R), and/or socio-demographic/psychopathological associations with ability to make such decisions, in people with schizophrenia and related illnesses. RESULTS A total of 40 studies were identified. While high levels of heterogeneity limited direct comparison, meta-analysis of inpatient data showed that DMC-T was present in 48% of people. Insight was strongly associated with DMC-T. Neurocognitive deficits were strongly associated with lack of DMC-R and to a lesser extent DMC-T. With the exception of years of education, there was no evidence for an association with socio-demographic factors. CONCLUSIONS Insight and neurocognitive deficits are most closely associated with DMC in schizophrenia. The lack of an association with socio-demographic factors dispels common misperceptions regarding DMC and characteristics such as age. Although our results reveal a wide spectrum of DMC-T and DMC-R in schizophrenia, this could be partly due to the complexity of the DMC construct and the heterogeneity of existing studies. To facilitate systematic review research, there is a need for improvement within research study design and increased consistency of concepts and tools.
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Affiliation(s)
- B W J Spencer
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
| | - G Shields
- South London and Maudsley NHS Foundation Trust,Maudsley Hospital,Denmark Hill,London, SE5 8AZ,UK
| | - T Gergel
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
| | - M Hotopf
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
| | - G S Owen
- King's College London,Mental Health, Ethics and Law Research Group,Department of Psychological Medicine,Institute of Psychiatry, Psychology and Neuroscience,Weston Education Centre,10 Cutcombe Road,London, SE5 9RJ,UK
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Besse M, Methfessel I, Wiltfang J, Zilles D. [Electroconvulsive therapy in nonconsenting patients]. DER NERVENARZT 2017; 88:46-52. [PMID: 26781243 DOI: 10.1007/s00115-015-0043-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) is a potent and successful method for the treatment of severe psychiatric disorders. Severe depressive and psychotic disorders may lead to legal incapacity and inability to consent. In Germany, administration of ECT against the patient's will is feasible under certain constellations and is regulated under the terms of the guardianship law. OBJECTIVE This article outlines the prevalence, effectiveness and tolerability of ECT when applied in nonconsenting patients. MATERIAL AND METHODS Case report and literature review. RESULTS The literature on ECT as a treatment in nonconsenting patients is relatively sparse. In 2008 the prevalence in Germany was less than 0.5 % of all patients receiving ECT. Case reports and case series suggest a good and equal level of effectiveness when compared to consenting patients. In the course of treatment the majority of patients consented to receive further ECT and retrospectively judged ECT as helpful. CONCLUSION The use of ECT is a highly effective treatment in severe psychiatric disorders even when administered as treatment in nonconsenting patients. It can be lifesaving and lead to a rapid improvement of symptoms and relief from severe suffering also from the patients' perspective. Thus, it seems unethical not to consider ECT as a treatment against the nonautonomous will of legally incompetent patients in individual cases. Nevertheless, physicians should always seek to obtain the patients' consent as soon as possible for both legal and ethical reasons.
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Affiliation(s)
- M Besse
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Str. 5, 37075, Göttingen, Deutschland
| | - I Methfessel
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Str. 5, 37075, Göttingen, Deutschland
| | - J Wiltfang
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Str. 5, 37075, Göttingen, Deutschland
| | - D Zilles
- Klinik für Psychiatrie und Psychotherapie, Universitätsmedizin Göttingen, Von-Siebold-Str. 5, 37075, Göttingen, Deutschland.
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