Turkey continues its use of unmodified electroshock

Details from the report on ECT use in Turkey, from CPT:

Full report:

http://www.cpt.coe.int/documents/tur/2006-30-inf-eng.htm

C.        ECT and other psychiatry-related issues

1.         Preliminary remarks

58.       As already mentioned, one of the issues focussed on during the December 2005 ad hoc visit were the procedures for the administration of electroconvulsive therapy (ECT) in psychiatric establishments. This subject had been addressed in some detail in the report on the 1997 visit to Turkey (cf. CPT/Inf (99) 2, paragraphs 178 to 182). However, information recently received from various sources indicated that certain of the CPT’s recommendations had not yet been implemented, in particular as regards the discontinuance of the practice of unmodified ECT.  For the purpose of examining this question, the CPT’s delegation visited two State hospitals, Bakırköy Mental and Psychological Health Hospital in I˙stanbul (this establishment, the largest psychiatric establishment in Turkey, had previously been visited by the Committee in 1992 and 1997) and Adana Mental Health Hospital.

In addition to the above-mentioned subject, some comments will be made in this report on procedures relating to involuntary civil placement in psychiatric establishments and living conditions for patients at the Adana Hospital.

59.       At the outset, the CPT wishes to emphasise that relations between staff and patients in the two psychiatric hospitals visited were on the whole found to be positive and tension-free, and many patients spoke favourably about the manner in which they were treated by staff. This is all the more commendable in the light of the often low staffing levels and the paucity of the resources at the staff’s disposal.

However, some complaints were heard of the ill-treatment (notably slaps) of patients by orderlies at the Bakırköy Hospital; allegedly, such acts would occur in the event of a failure to take prescribed medication or of disobedience. Under no circumstances can methods of this kind be tolerated. The CPT recommends that the management of Bakırköy Mental and Psychological Health Hospital deliver the clear message to all categories of staff at the establishment that any form of ill-treatment of patients is unacceptable and will be the subject of severe sanctions.

2.         Electroconvulsive therapy

60.       Electroconvulsive therapy is a recognised form of treatment for psychiatric patients suffering from some particular disorders. However, like certain other forms of therapy, its administration must be accompanied by appropriate safeguards.

The CPT is particularly concerned when it encounters the administration of ECT in its unmodified form (i.e. without anaesthetic and muscle relaxants). As was emphasised in the report on the 1997 visit to Turkey, use of this outdated method entails a heightened risk of untoward medical consequences and can lead to situations which could justifiably be described as degrading.

The Committee also pays attention to whether ECT is being used for the proper indications and to the procedure for obtaining consent to this treatment.

61.       In their response to the report on the 1997 visit, the Turkish authorities stated that they were “paying close attention [to] the discontinuation of the practice of unmodified ECT”.[8] However, in spite of that assurance, the delegation which carried out the December 2005 visit observed a widespread use of unmodified ECT in the two psychiatric establishments in Adana and Bakırköy.

At Adana Mental Health Hospital, ECT is only used in its unmodified form. At the Bakırköy Hospital, there is a single ECT unit with a capacity of 10-15 patients per day, where a part-time anaesthesiologist makes modified ECT possible. However, the great majority of patients to whom ECT is administered at this hospital also receive the therapy in its unmodified form; of the total of 15,877 ECT sessions administered at Bakırköy in 2005, only 512 (i.e. some 3.2 per cent) were modified.

62.       Further, the information gathered by the CPT’s delegation at the Bakırköy Hospital indicated that ECT was being used in an even more extensive manner than had been observed during the 1997 visit. In some units, more than 60 per cent of patients had received ECT in 2005, and the therapy had been administered to 26 per cent of all patients admitted to the establishment during that year. In the CPT’s view, these figures indicate excessive resort to ECT.

Although the management of the Adana Mental Health Hospital was unable to provide the CPT’s delegation with precise statistics on the use of ECT for the whole hospital, it was obvious that ECT was also used extensively there. According to information received from the Director of the hospital, nearly 30 per cent of patients in a female unit had received ECT during the year 2004.

63.       The CPT wishes to make clear that its delegation did not gain the impression in either of the two establishments visited that ECT was being used in a punitive manner or that the patients perceived the treatment as such or had been threatened with ECT. However, the delegation did note that some patients who had received unmodified ECT developed a fear of the treatment, resulting, on occasion, in it being cancelled.

At Bakırköy, the delegation was repeatedly told that the reason for the extensive reliance on ECT was the lack of beds for the high number of patients in need of admission and treatment. From interviews with both patients and staff, it would appear that ECT was sometimes administered only a few times, until the patient was no longer agitated; such a treatment series could commence on the day of arrival of the patient to the hospital. The CPT is very concerned about any possible resort to ECT as a means of quickly subduing agitated patients; this would constitute an improper use of the therapy.

Neither of the two establishments had written policy guidelines regarding the administration of ECT.

64.       In both establishments, ECT was administered out of the sight of other patients, in rooms specifically set aside and equipped for this purpose. However, from interviews with patients at Bakırköy, it would appear that a patient about to be treated may see patients who have already been treated and who are lying unconscious or recovering. This is clearly not desirable.

65.       At the Bakırköy Hospital, recourse to ECT was, as a rule, recorded in both the patient’s medical file and a general ECT book kept on the ward, although at least one of the ECT books only indicated the start of the treatment without mentioning further sessions. At the Adana Hospital, while some wards did have ECT books, in other wards recourse to ECT was only recorded in the patient’s file. Moreover, even in those wards which possessed an ECT book, the registration of ECT sessions was incomplete. A specific (and properly completed) ECT register at ward-level will greatly facilitate supervision by hospital management and discussion with staff about practices followed.

66.       As regards the procedure for obtaining consent to ECT treatment, no written consent was obtained at the Adana Hospital. Special consent forms were used at the Bakırköy Hospital, often signed on admission by the patient, or, in most cases, by his or her guardian or next of kin. However, these forms were often undated, and in a few cases they were signed by the police transporting the patient to the hospital. Further, the examination of patients’ medical files revealed that in several cases no written consent was recorded; the delegation was told by the staff that in certain situations (e.g., in the event of difficulty contacting the patient’s family) the ECT consent form could be signed after the treatment had been started, or even after it had been concluded. It is also noteworthy that some patients did not seem to have been informed about the procedure or the possible benefits and risks involved.

In this connection, it must be stressed that all patients should, as a matter of principle, be placed in a position to give their free and informed consent to treatment, including ECT. The admission of a person to a psychiatric establishment on an involuntary basis should not be construed as automatically authorising treatment without his or her consent. Any derogation from this fundamental principle of consent to treatment should be based upon law and apply only in clearly and strictly defined exceptional circumstances. Of course, consent to treatment can only be qualified as free and informed if it is based on full, accurate and comprehensible information about the patient’s condition and the treatment proposed.

67.       To sum up, the CPT is seriously concerned by the current procedures for the administration of ECT observed in the Adana and Bakırköy Hospitals, and in particular by the continuing frequent recourse to this treatment in its unmodified form.

The Committee’s delegation was informed by the management of the Bakırköy Hospital that two new fully-fledged ECT units would be set up within the establishment in a few months. The Committee takes note of this development. The CPT would like to receive full information concerning these units (in particular, a detailed description of their equipment and staff resources) and to be informed of the planned date of their entry into service.

More generally, the CPT recommends that the Turkish authorities accord a high priority to ensuring that all psychiatric establishments in which ECT is used are provided with the necessary staff, equipment and facilities so that this treatment can be administered in its modified form (i.e. with both anaesthetic and muscle relaxants) and in an effective manner (preferably with the aid of an electroencephalogram).

Further, with a view to ensuring that ECT is only used for the proper indications and is carried out in an appropriate manner, the CPT recommends that a clear written policy on recourse to ECT be elaborated and distributed to each establishment where this treatment is used and that ECT be administered only by staff who have been specifically trained to provide it. As with other psychiatric treatment, recourse to ECT should be part of a written individualised treatment plan, included in the patient’s medical record.

68.       In the light of the other facts found during the visit, the CPT also recommends that:

-           the practical arrangements made for the use of ECT ensure not only that it is administered out of the sight of other patients but also that  patients waiting to be given ECT do not have sight of patients who have just received the treatment;

-           the indications for using ECT, the conditions under which it is administered and the outcome of each treatment session be set out in detail in a special register;

-           the written informed consent of the patient (or of the guardian, if the person concerned is declared incompetent by a court) to the use of ECT, based on full and comprehensible information, be sought and kept in the patient’s file and that, save for exceptional circumstances clearly and strictly defined by law, the treatment not be administered until such time as written consent has been obtained.

C.        ECT and other psychiatry-related issues

 

 

            Preliminary remarks

 

 

            recommendations

 

-           the clear message to be delivered to all categories of staff at Bakırköy Mental and Psychological Health Hospital that any form of ill-treatment of patients is unacceptable and will be the subject of severe sanctions (paragraph 59).

 

 

Electroconvulsive therapy

 

 

            recommendations

 

-           the Turkish authorities to accord a high priority to ensuring that all psychiatric establishments in which electroconvulsive therapy (ECT) is used are provided with the necessary staff, equipment and facilities so that this treatment can be administered in its modified form (i.e. with both anaesthetic and muscle relaxants) and in an effective manner (preferably with the aid of an electroencephalogram) (paragraph 67);

 

-           a clear written policy on recourse to ECT to be elaborated and distributed to each establishment where this treatment is used and ECT to be administered only by staff who have been specifically trained to provide it. As with other psychiatric treatment, recourse to ECT should be part of a written individualised treatment plan, included in the patient’s medical record (paragraph 67);

 

-           the practical arrangements made for the use of ECT to ensure not only that it is administered out of the sight of other patients but also that  patients waiting to be given ECT do not have sight of patients who have just received the treatment (paragraph 68);

 

-           the indications for using ECT, the conditions under which it is administered and the outcome of each treatment session to be set out in detail in a special register (paragraph 68);

 

-           the written informed consent of the patient (or of the guardian, if the person concerned is declared incompetent by a court) to the use of ECT, based on full and comprehensible information, to be sought and kept in the patient’s file and that, save for exceptional circumstances clearly and strictly defined by law, the treatment not to be administered until such time as written consent has been obtained (paragraph 68).

 

 

            requests for information

 

-           full information concerning two new ECT units to be set up at the Bakırköy Hospital (in particular, a detailed description of their equipment and staff resources) and the planned date of their entry into service (paragraph 67).

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