Colleagues from Singapore and Australia published this informative study (out on PubMed yesterday):
Outcomes in patients with and without capacity in electroconvulsive therapy
Tor PC, et al. J Affect Disord 2020. PMID 32056870
The url for the pdf is:
https://drive.google.com/file/d/155Xuna_7S5kMk6m7Um27EN9wJVVQGJPN/view?usp=sharing
This is a retrospective study of 175 patients treated at the Singapore Institute of Mental Health (88 with a diagnosis of schizophrenia, 49 with depression, and 38 with mania). Patients were assessed for capacity to provide informed consent and were rated on symptoms, cognition, quality of life (QOL) and global assessment of function.
75% of the total sample were assessed to lack capacity, likely a reflection of the severity of illness/diagnostic mix of the cohort and possibly the specific criteria used to make this determination. The main findings of the study were that "mood, cognition, QOL and function improved in both groups [with and without capacity], with more improvement in mood and function in the group lacking capacity and a trend towards greater cognitive improvement."
The authors concluded, "Ironically patients with severe mental illness and lacking capacity may benefit as much if not more than patients with capacity as supported by the findings of this study and other prior studies." They discuss legal barriers that prevent or delay access to ECT, stating, "some of the most vulnerable patients are deprived access to treatment that could benefit them the most."
The issue of involuntary ECT (quite rare in most countries- and highly regulated, as it should be) is fraught with misunderstanding and misapprehension. The clinical reality, supported by the findings in this paper, is that failure to provide ECT for appropriately selected, severely ill patients, is unethical and often leads to unnecessary suffering and prolonged illness.
This unique study identifies a large sample of Singapore patients separated by "capacity." The authors apply legal guidelines that find the majority of psychiatric patients as "lacking capacity." Such criteria would be inapplicable in Western communities. Reports in the West apply court guidelines when patient capacity to consent is impaired. It is, however, gratifying to read that the "capacity" defined here is not a factor in ECT treatment outcomes.
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