I'm shocked: informed consent in ECT and the phenomenological-self

Investigating the factors that impede or facilitate the acceptance of electroconvulsive therapy (ECT): perspectives from psychiatrists and patients' companions

OBJECTIVES

This study aims to investigate the positive and negative factors that can influence an individual's acceptance of electroconvulsive therapy (ECT) from the perspective of psychiatrists and patients' companions (PCs).

DESIGN

A multicentre qualitative phenomenological study.

SETTING

Cities of Shiraz and Fasa in Fars province.

PARTICIPANTS

Eight psychiatrists and 10 PCs were interviewed.

METHODS AND ANALYSIS

Semistructured interviews were conducted with psychiatrists and PCs in hospitals in Fars Province, Iran. The interviews focused on the positive and negative factors influencing the participants' acceptance of ECT. Subsequently, the interviews were transcribed and subjected to thematic analysis.

RESULTS

In total, 8 males and 10 females participated. The average age of psychiatrists and PCs was 42.43±6.37 and 53.20±16.64, respectively. Furthermore, the average working experience of psychiatrists was 8.57±1.90 years. Five themes emerged from the interviews: feeling supported, awareness, communications between physicians, patients, and PCs, previous experiences of oneself and others, and hospital structure.

CONCLUSIONS

Our study provides valuable insights into the negative and positive factors that influence the acceptance of ECT from the perspectives of psychiatrists and PCs. The findings indicate important ways to enhance perspectives on ECT within the community.

The ethical imperative of trauma-sensitive care for electroconvulsive therapy (ECT)

BACKGROUND

The empirical literature on the lived experience of electroconvulsive therapy (ECT) is limited, divergent, and largely focused on the experiences of procedures, (adverse) effects, information provision, or decision-making.

AIMS

This study aimed to investigate aspects related to the lived experience and meaning-making of people who have had ECT.

METHOD

In-depth interviews with 21 women (21-65 years old) were analyzed using interpretative phenomenological analysis (IPA).

FINDINGS

A subgroup of nine participants described more negative experiences with ECT. A common factor for these participants was the experience of trauma that remained under-treated. The superordinate themes identified were a lack of trauma-based and recovery-oriented treatment. The rest of the sample (12) expressed more positive experiences with ECT.

CONCLUSIONS

This study suggests that exploring more broadly the impacts of ECT at the long term offers insights that can help design more person-centered services aligned to the needs of the treatment recipients. Educational modules for mental health care staff should include, besides knowledge on the methods' effectiveness, additional evidence about treatment recipients' subjective concerns and the relevance of trauma and recovery-oriented care models.

Looking through the lens of stigma: Understanding and anticipating concerns about the responsible development and use of psychiatric electroceutical interventions (PEIs)

Psychiatric electroceutical interventions (PEIs) show promise for treating depression, but few studies have examined stakeholders' views on them. Using interview data and survey data that analyzed the views of psychiatrists, patients, caregivers, and the general public, a conceptual map was created to represent stakeholders' views on four PEIs: electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and adaptive brain implants (ABIs). Stigma emerged as a key theme connecting diverse views, revealing that it is a significant factor in the acceptance and usage of PEIs. Stigma not only discourages seeking mental health services for depression but also inhibits the acceptance of PEIs. Addressing the pervasive and complex effects of stigma highlights the need to change societal attitudes toward mental illnesses and their treatments and to provide support to patients who may benefit from these interventions. The map also demonstrates the value of conceptual mapping for anticipating and mitigating ethical considerations in the development and use of PEIs.

Nigeria's mental health and substance abuse bill 2019: Analysis of its compliance with the United Nations convention on the rights of persons with disabilities

Countries are struggling with reconciling their national mental health legislation with the CRPD approach, which stresses equality as the focal point of legislation, policies, and practices that affect people with disabilities. Several failed attempts have been made over the last two decades to update Nigeria's obsolete mental health legislation. The most recent attempt is the Mental Health and Substance abuse Bill 2019, which aims to protect the rights of people with mental health needs. It addresses many areas neglected by previous bills, such as non-discrimination of people with mental and substance use problems in the exercise of their civil, political, economic, social, full employment, religious, educational, and cultural rights. It categorically prohibits the use of seclusion in the treatment of people with mental health problems, makes provision for service users to be members of the Mental health review tribunal and allows for the protection of privacy and confidentiality of information about people with mental health problems. While keeping to most of WHO's recommendations for mental health legislation, the bill diverges from the CRPD's recommendations by allowing forced admission and treatment based on mental capacity, substitute decision-making by legal representatives or closest relatives, and non-prohibition of coercive practices. The bill does not make provisions for advance directives and is silent on informed consent to participate in research. Despite the bill's deficiencies, it would be a significant step forward for the country, whose current mental health legislation is the Lunacy Act of 1958. Although the CRPD has left it unclear how countries, especially low resource countries, should go about creating a workable legal framework, it is clear that all countries are expected to join the current global effort to eliminate, or at least reduce to the barest minimum, the use of coercion in mental health care. We expect that future revisions of this bill will examine its limitations in light of Nigeria's socio-cultural context.

Recipients' experience with information provision for electroconvulsive therapy (ECT)

BACKGROUND

Despite improvements, studies continue to report unsatisfactory provision of information before, during and after electroconvulsive treatment (ECT).

AIMS

The study explores participants' experiences with information provision about ECT.

METHODS

In-depth interviews with 21 participants (21- 65 year-old) were conducted. Thematic analysis resulted in identification of four themes: pre-treatment knowledge, experience of informed consent, the need for information depth and life after ECT. The study includes user involvement.

RESULTS

Although some participants were satisfied with information provision, the majority experienced an education deficit throughout the treatment period. Their consent was based mostly on oral information, insufficient and unvaried information on official health websites and media. Further, patients reported a lack of follow-up services that can attend to (neuro) psychological concerns.

CONCLUSIONS

Better access to updated factual and narrative information should support patient education and autonomy. Active use of diary writing, better follow-up and more varied representations of experience with ECT in media and health information sites are necessary to educate, improve consent processes and reduce stigma.

[Benefits and risks of psychiatric actions and the patient's right of self-determination]

The history of psychiatry shows that a right of self-determination of the mentally ill was widely unknown in the nineteenth century and became known in medicine through the juridical concept of informed consent as late as in the second half of the twentieth century. Since the beginning of the twenty-first century this human right has been increasingly recognized and respected in medical practice. This change of recognition is contributing to a change from a paternalistic to a participative medical attitude. In the context of an emancipatory development of society the increasing possibilities of effective therapies, which are rarely without risks, stimulate the necessity to inform the patient about the intended benefits and the potential risks of the recommended intervention. This gives the patient the opportunity to exercise the right of self-determination. Furthermore, by the transition from very successful acute medicine, although often with only short-term contact between physician and patient to long-term therapies of chronic diseases, the possibilities to understand the patient are increased, particularly in the mentally ill patient. This also enables the individual characteristics to be recognized better, both the restrictions and capabilities, to experience the patient as an individual, as a human being with individual peculiarities and to respect the right of self-determination by helping the patient to understand the benefits and risks of a recommended intervention and to balance them in a self-determined mode.

Psychological and Medico-Legal Perspectives on Electroconvulsive Therapy and Patient-Centered Care: A Short Review of Cross-Cutting Issues

Electroconvulsive therapy is a treatment that, since its first administration, has been a major topic for debate within the scientific world. In recent years, the debate has become increasingly focused on the short- and/or long-term efficacy of electroconvulsive therapy, its appropriateness in clinical settings, its mechanism of action, the impact evaluation of transient and/or persistent adverse effects, and the drafting of international guidelines,etc.

From the authors’ point of view, these themes are inevitably crossed by three other fundamental issues of significant psychological, relational, ethical, and medico-legal impact. Still, they are less studied than purely biomedical issues in recent times. Therefore, the aim of this article is to focus on the following cross-cutting issues: the therapist-patient relationship, the patient’s perspective, the attitude on electroconvulsive therapy, and informed consent.

This short review refers to the international literature on ECT published since 2000. Analyses of the three previously listed topics are, in part, made within the context of Italian medical settings.