The Mental Health Tribunal

I am trying to demonstrate, in a series of installments, how in the 21st century we still often fail to establish effective safeguards for the rights of people who end up in our psychiatric systems.
This particular example is taking place in 2016, in Melbourne, and involves over 50 consecutive electro shock ‘treatments’ and multiple, sometimes very lengthy, periods of being tied to a bed.

This nine-minute TV clip provides more background to this very sad story.

In the last installment, I presented my failed attempt to persuade the Office of the Chief Psychiatrist to live up to its website’s claim that it “promotes the rights of people receiving mental health treatment.” In over a month now I have had no response whatsoever to my formal request to be sent the research that justifies 50 consecutive ECTS, or to my allegation that the Chief Psychiatrist rewrote Victoria’s ECT guidelines to retrospectively provide a defense for Eastern Health management and staff by stating that a series of 12 ECTs can be immediately followed by the commencement of the next one, and so on.

In this third installment, I offer my interactions with another body who is supposed to protect our rights when under the ‘care’ of psychiatrists, the Mental Health Tribunal [MHT].

Its website opens with:

“The Tribunal is an essential safeguard under the Mental Health Act 2014 to protect the rights and dignity of people with mental illness.”

Later, it states:

“The Tribunal will also determine whether ECT can be performed on a compulsory patient if they are considered to not have capacity to give informed consent to ECT, or if they are under the age of 18.”

To begin on a positive note, the MHT is to be commended on keeping excellent records and on making them public. The excessive frequency with which ECT is being used in Victoria, and the extent to which Victorians are doing their best to refuse it, can be seen from the MHT’s most recent report. We read that in the last three months of 2015 alone, psychiatrists applied to the Tribunal 176 times for permission to give ECT to someone who had stated they did not want it and had been strong enough to somehow resist all the psychiatrists’ attempts to talk them into it.

Of these 176 hearings, the Tribunal had turned the psychiatrists down 14 times (8%). So in Victoria, our chances of the organisation explicitly established by law to “safeguard our rights and dignity” actually doing so (versus safeguarding the rights of psychiatrists to administer electric shocks to us to cause general seizures) is about 12 to 1 against.

I will first allow my initial correspondence with the Tribunal speak for itself, and then bring you up to date.

1. January 11: My written research-based submission to the MHT for the January 12 hearing
2. February 2: My formal complaint and call for independent investigation following that hearing
3. February 3: Initial response from MHT
4. February 16: My mail (subsequent to the psychiatrists asking for another hearing to extend even further the ECT treatments) to try to prevent MC and BM sitting on this hearing

 

1. My written submission to the MHT for consideration at the January 12 hearing (Jan 11)

January 11, 2016
SUBMISSION TO MENTAL HEALTH TRIBUNAL HEARING (12.1.2016) REGARDING MR G D, BY PROFESSOR JOHN READ, AT THE REQUEST OF MR D’s FATHER.
[accompanied by two research papers: Sackeim et al. (2007) and Read & Bentall (2010)]

CREDENTIALS
I practiced as a Clinical Psychologist, and manager of mental health services, in the USA, UK and New Zealand for approximately twenty years, before working for 19 years in the Psychology Departments, as Director of Clinical Psychology, of the Universities of Auckland (NZ) and Liverpool (UK). I have published five books, and over 120 peer-reviewed research articles on mental health issues, including two book chapters and two research reviews on ECT. I am currently Professor of Clinical Psychology at Swinburne University of Technology, Melbourne.

I am not commenting on the clinical condition of Mr GD, whom I have never met. I will contain my submission to the research evidence regarding the appropriateness, efficacy and safety of administering ECT beyond the internationally recommended number (6 to 10).

I have been invited by Mr BD [father] to attend the Tribunal hearing on 12th January in order to summarise the relevant research and to answer any questions regarding this written submission.

EFFICACY OF EXCESSIVE USE OF ECT
If an evidence-based approach is taken, as it should, to the decision facing the tribunal, it would need to be established that there is research supporting the belief of the prescribing psychiatrist that continually administering ECT beyond the internationally recognised recommendation of six to ten consecutive treatments is effective. There is none.

In fact, my peer-reviewed review of the efficacy research (published in an international peer-reviewed journal, with Professor Richard Bentall of the University of Liverpool, UK) found that there is no evidence that ECT has any benefit compared to placebo (simulated ECT, where the general anaesthetic is administered but the electric current is not) beyond the end of the treatment period. The temporary lift in mood experienced by some patients during treatment is typically followed by relapse. Thus ECT has no lasting benefit, in either depression or psychosis, or suicide prevention, compared to placebo (Read & Bentall, 2010). There is certainly no evidence that continuing ECT beyond twenty treatments has any benefit to the patient, while exposing her/him to considerable risk of memory loss and a much smaller risk of death (see below).

The case before the Tribunal is rare in the extreme. I have never experienced, or heard of, the continuous use of ECT beyond 25, let alone 40 or more. This is presumably related to the lack of evidence to support such an approach. Occasionally some psychiatrists will try what is known as ‘maintenance ECT’ but this is almost always after a relapse following a temporarily successful initial course of treatment. This does not seem to apply here and the evidence in support of this approach is, anyway, also very weak (Read & Bentall, 2010)’

As an example of the accepted international position, I submit the following, typical, statement on the website of the Royal College of Psychiatrists in the UK, as recently as July, 2015:

“A course will on average be 6 to 8 treatments, although as many as 12 may be needed, particularly if you have been depressed for a long time. If, after 12 treatments, you feel no better, it is unlikely that ECT is going to help and the course would usually stop.”
http://www.rcpsych.ac.uk/healthadvice/treatmentswellbeing/ect.aspx (July 2015, extracted January 10, 2016).

In summary there is no evidence to support the request to continue applying ECT to Mr GD.
In addition, the information provided to me by GD’s father suggests that the approach taken thus far to his son’s treatment contravenes the widely accepted need to leave a gap of at least two to three days between ECT administrations. I read that on at least ten occasions two ECTs were administered on the same day. This is most unusual and not, to the best of my knowledge, recommended by any professional or government body. This approach, in the absence of consent, could be seen as punitive from a human rights perspective. It is my belief that the majority of even the most ardent advocates of ECT would find the administration of ECT four times in a single day quite unacceptable (even if this occurred because of failure to elicit a seizure). According to the records shared with me this occurred to Mr GD on 20th October 2015.

SAFETY
It is well established that among the various adverse effects of applying electricity to the human brain to induce a seizure (ECT), the most common is memory loss, in the form of both anterograde amnesia (inability to retain new information) and retrograde amnesia (loss of memory of past events) (Read & Bentall, 2010; Sackeim et al., 2007).

It is also widely accepted that the most rigorous study to date is that conducted by ECT advocate Dr Harold Sackeim and his colleagues in the USA. This study not only found a range of cognitive deficits (memory and attention) immediately following ECT but that the number of ECTs given was the strongest predictor of gaps in autobiographical memory (retrograde amnesia) six months after the end of the treatment:

“Greater amnesia for autobiographical events (AMISF scores) was significantly correlated with the number of ECT treatments received 6-months earlier (Table 5). In the confirmatory analyses, there were significant linear relationships between the number of treatments administered and post-ECT AMI-SF scores for each of the three electrode placements.” (Sackeim et al., 2007, p. 250).

Furthermore the relationship between number of treatments and memory loss was particularly strong for bi-temporal electrode placements (compared to unilateral). The record shown to me states that Mr GD is receiving bi-temporal ECT (although his father tells me that one of the psychiatrists involved told him it was unilateral).

In summary, if the Tribunal were to permit further use of ECT in this case it would be condoning the exposure of a patient to significant risk of further long-lasting or permanent memory loss beyond that which the research suggests has probably already occurred. And it would be doing so in the absence of any reason to suppose that there is likely to be any benefits to the patient against which that risk could be weighed in a cost-benefit analysis.

Finally there is a small but significant mortality risk associated with every ECT administration, partly because of the usual small mortality risk associated with general anaesthesia and typically resulting from cardiac arrest or stroke (Pippard & Ellam, 1981; Read et al., 2013; Shiwach et al., 2001). The continued administration of ECT to Mr GD therefore exposes him, unnecessarily, to this small risk of death, which may increase with the number of administrations if the voltage is steadily increased to overcome the increased resistance to seizure which can occur during a course of ECTs.

CONCLUSION
If either an evidence based approach is adopted by the Tribunal, and/or what is considered usual practice is taken into account, this extremely unusual request to administer more than 40 ECTs continuously to a patient will be declined, and the wishes of the patient and his family will be respected. This might then lead to discussions regarding what alternative, evidence-based, support and treatment might be offered to Mr GD.

REFERENCES
FOSSE, R., READ, J. (2013). Electroconvulsive treatment: Hypotheses about mechanisms of action.
Frontiers in Psychiatry, 4, 94-103.
PIPPARD, J., ELLAM, L. (1981). ECT in Great Britain. London: Royal College of Psychiatrists/Gaskell.
READ, J. BENTALL, R., JOHNSTONE, L., FOSSE, R., BRACKEN, P. (2013). Electroconvulsive therapy. In J Read, J Dillon (eds.) Models of madness: Psychological, social and biological approaches to psychosis. London: Routledge, pp.90-104.
READ, J., BENTALL, R. (2010). The effectiveness of electroconvulsive therapy: A literature review. Epidemiology and Psychiatric Sciences, 19, 333-347.
SACKEIM, H., et al. (2007). The cognitive effects of electroconvulsive therapy in community settings. Neuropsychopharmacology, 32, 244–254.
SHIWACH, R. et al. (2001). An analysis of reported deaths following electroconvulsive therapy in Texas, 1993-1998. Psychiatric Services, 52, 1095-1097.

Professor John Read

2. My formal complaint and call for an independent investigation following the Jan 12 hearing, and for MC and BM to be stood down during the investigation (Feb 2)

FORMAL COMPLAINT TO THE VICTORIA MENTAL HEALTH TRIBUNAL Re: Conduct of Mr MCl (Tribunal Chair) and Dr BM (Tribunal member) on Jan 12, 2016
Professor John Read
Feb 2, 2016
At the request of the patient’s father I attended the Mental Health Tribunal hearing on January 12, 2016 regarding the ongoing use of ECT on Mr GD. Prior to the hearing I had submitted a summary of the research on the efficacy and safety of ECT, and on the research showing that the best predictor of long-term brain damage is the actual number of ECTs given (Sackeim, 2007).

The patient was not able to exercise his legal right to attend because he was, yet again, tied to his bed. The members of the Tribunal made no effort to question the legitimacy of this, even though their own record of the meeting confirms that there had been no ‘critical incident’ prior to his being tied up, yet again (Statement of Reasons, 1.2.2016). The Tribunal is supposed to have an interest in (a) least restrictive practice and (b) the rights or patients not to be prevented from exercising their legal rights by psychiatrists with a vested interest. Failure to even question the need, or motive, for the psychiatrists’ behavior was disappointing.

The psychiatrist on the Tribunal panel went to the ward and quickly assessed that BD was, yet again, not competent to refuse consent to ECT (even though an independent psychiatrist’s report said he was fully competent), but informed us all that he had nevertheless given consent to some medication that he had previously refused. So it seems he is incompetent when he disagrees with them but competent when he agrees.

One of the treating psychiatrists, Dr SM, admitted that part of the reason that he was incompetent to withhold consent was because his memory was impaired, as a result of the ECT (acknowledged in Statement of Reasons), so they had to keep giving it to him against his will to try to get him better to the point where he might be able to consent to have more of it rather than have to have it against his will. When I tried to point out the various logical flaws in this line of reasoning the supposedly neutral psychiatrist on the Tribunal panel, Dr BM, not only failed to question the curious reasoning (as any unbiased Tribunal member would have done), she actually tried to come to Dr SM’s defence, making several points on her behalf, to try to make her sound more logical (she failed). This constitutes clear bias and suggests ignorance of, or wilful neglect of, her role as a Tribunal member.

Meanwhile the Eastern Health barrister, Mr PH, sat at the back of the room openly (ie he did not stop when I turned round and observed him) controlling the chair of the hearing panel with nods and shakes of his head – about who could speak, who should go to see Mr D on the ward, etc.. I witnessed this on two separate occasions. On one, the chair of the hearing panel paused, looked over to Mr PH, waited for his signal and then proceeded in accordance with that signal. This is clearly unethical conduct on the part of the chair, and is of particularly grave concern because the chair of this particular hearing was the Chair of the Mental Health Tribunal as a whole, Mr MC.

No member of the panel asked any questions or showed any interest in the research I had submitted demonstrating that there was no precedent or rationale for the conduct of the treating psychiatrist (Dr SM) and the Clinical Director (Dr PK), and showing that every additional administration of ECT increased the risk of permanent brain damage (memory loss) and, to a lesser extent, of death. When I tried to exercise what I experienced to be my professional/ethical responsibility to ensure the panel was aware of the risks of what they were considering, by asking to briefly summarise my research submission, the chair instructed me to be silent.

Despite pleas to stop the ECT, from the person himself, and his father, mother, and brother, and a family friend, the Tribunal granted the psychiatrists clearance to give 12 more ECTs.
The record of the meeting, the Statement of Reasons, is similarly biased. I will be happy to point out precisely how at an investigation hearing.

I respectfully submit this as a formal complaint, and one of sufficient gravity that it must be investigated independently.

I further request that pending such an investigation both Mr MC and Dr BM be immediately suspended from any duties relating to the Mental Health Tribunal.

The case of Mr GD and Drs SM and PK involves such an extreme and blatant negation of basic human rights, and the complicity in this situation of a State institution supposed to provide some minimal protection to vulnerable and distressed Victorians is so alarming, that I am making this complaint public. I do so in the hope that this might hasten some action of a humane and logical nature from someone in authority which has been sorely lacking for some time in this case.

Professor John Read

3. Email from MHT February 3

Dear Professor Read
My name is MS and I am the Tribunal’s Executive Officer.
XXXX referred your complaint to me as I generally respond to complaints and feedback received by the Tribunal. As your complaint relates to conduct of members at a hearing, I have referred the matter to the Tribunal’s acting Deputy President, TB, to investigate and respond to you.
I attach the Tribunal’s Feedback and Complaints Guide which is available on the Tribunal’s website.
Regards
MS
Mental Health Tribunal
Level 30, 570 Bourke St, Melbourne Victoria 3000 Australia
T +61 3 9032 3200 F +61 3 9032 3223 T 1800 242 703 (Toll-free)
E [email protected] W mht.vic.gov.au

4. My follow up email (Feb 16) (subsequent to the Upton House psychiatrists asking for another hearing to further extend the ECT treatments – to try to prevent MC and Dr BM sitting on this hearing)

Dear M
Thank you for informing me that my formal complaint against Mr MC and Dr BM is now under investigation.
Please assure me that during the investigation of such a serious complaint (attached again, with my original submission to the Tribunal) neither Mr MC or Dr BM will sit on any Tribunal panels.
In particular please assure me that neither will be on the panel on Feb 18th for the hearing of the same case in relation to which their alleged misconduct occurred (Mr GD).
Please also explain how it is possible for the Tribunal’s acting Deputy President, TB, to conduct an independent investigation when one of the two people accused of misconduct is effectively her boss?

Kind Regards

Professor John Read

cc Minister for Mental Health (Victoria)
Minister for Health (Victoria)
MHCC
Office of the Chief Psychiatrist
Australian Human Rights Commission
Ms Katherine Moorhouse-Perks (solicitor)

Outcome of the MH Tribunal on February 18

A request by the Eastern Health psychiatrists for permission from the Tribunal to give yet another series of 12 ECTs. Neither MC nor BM were on the panel. The MHT wrote to me, however, to explain that this had nothing to do with the ongoing investigation of my complaint but was because of rostering that had taken place months ago (although the hearing had only been scheduled the preceding week).

The MHT hearing on Feb 18 (without MC and Dr BM) ruled that Dr PK and his subordinates could NOT administer any more ECTs to GD, and even went so far as to cancel the two outstanding ECTs from the previously approved series of 12.

The reason for the reversal?

GD was now better, perhaps cured by the ECT, and did not need any more?

No.

Administering more than 50 ECTs is almost bound to cause brain damage and is potentially life-threatening?

No.

The psychiatrists and hospital management had been punitive and/or negligent?

No.

The previous panel had been biased?

No.

The reason stated is that they were “not satisfied that there is no less restrictive way for the patient to be treated.”

This needs thinking about. They did not say how, since the hearing just one month previously, ECT had suddenly become a more restrictive treatment than other treatments, or what new less restrictive treatments had suddenly become available. (I suppose it is possible that Upton House had just discovered clinical psychology, psychotherapy or peer-support groups?) So this was a straightforward repudiation of the previous panel’s decision.

The father informed me that the psychiatrists’ response to the MHT’s denying them the right to continue with the ECTs was to immediately cancel GD’s pre-arranged leave (citing concern for his mental health if not having ECT) which meant he could not attend a long-awaited photography course.

Outcome of my complaints against the MHT and its President

The investigation was indeed conducted by the Acting Deputy President of the MHT (TB), who wrote to me on February 26, concluding: “I consider there are no grounds for the members involved in the hearing on 12 January 2016 to cease performing their duties as members.” The letter made it clear that the process chosen to determine the accuracy of my allegations was nothing more or less than asking the accused whether they thought they were guilty or innocent. It turns out they were either definitely innocent or could not recall.

“All members present at the hearing [i.e. MC, BM and one other] strenuously deny your allegation that the counsel for Eastern Health controlled the presiding member by nods and shakes of his head and that the presiding member waited for counsel’s signal before acting.”

“Dr BM was not able to recall any aspect of her contribution in the hearing which could be considered as coming to the defence of the treating psychiatrist.”

It seems no other evidence was gathered. None of the following five people present at the hearing, and therefore witnesses, were contacted by the investigation: GD’s father, GD’s mother, GD’s brother, a family friend, and GD’s legal representative.

A curious form of investigation, but one that is consistent with all my interactions with all the agencies involved in this case.

To be fair to the individuals involved, I have started to wonder by now whether these failures to apply even the most basic standards of natural justice are so systemic and long-standing in the Victoria’s government agencies, that the individuals might never have seen these standards in operation and therefore simply would not know how unethical their conduct was. Alternatively, they know exactly how unethical it is and have an accurate assessment of the probability of anybody in authority caring.

Just as I was finishing this installment (on February 29th), GD’s father rung me to tell me that GD had just been tied to his bed yet again and that the psychiatrists have re-applied to the MHT for permission to restart the ECTs. Words fail me sometimes.