Capacity,consent and electroconvulsive therapy: What is the next step forward?

To the Editor

Stigma affects electroconvulsive therapy (ECT) use, and there are several reasons for stigma. Side effects from ECT, in particular memory impairment, is one of the main reasons for stigma attached to ECT. Availability of information before ECT can also influence one’s perception towards ECT (Griffiths and O’Neill-Kerr, 2019).

In relation to ECT consent, an individual’s capacity to process information can lead to either a voluntary (or informed consent) or compulsory consent. Generally, ECT consent is obtained as a block (e.g. 6 or 12 treatments) (Jagadheesan et al., 2021). Given that decision-making capacity is a dynamic cognitive ability, an important question is what processes are in place to identify a change in capacity, particularly when someone starts to regain it. For compulsory patients, capacity needs to be regularly assessed during treatment as per the Mental Health Act 2014 in Victoria. Conversely, there is no clear process for checking capacity regularly during the course of treatment for voluntary patients. Because ECT-related memory impairments can affect an individual’s ability to remember ECT information provided before starting ECT course, there is a need to regularly assess it irrespective of the type of consent.

Also, an individual’s threshold for providing consent might not be same as withdrawing consent, e.g. up to a third of patients did not feel they gave free consent despite signing a written consent (Rose et al., 2005). This risk of patient’s perception of coercion can be reduced by aligning ECT consent process to other medical procedures for which consent is obtained before every treatment. Such an approach will not only be promoting empowerment and autonomy of patients but it will also help to destigmatise ECT treatment in the long term. Needless to say, obtaining consent before each ECT will add substantial administrative burden on ECT practice. On the contrary, without studying patients’ perspectives and monitoring capacity through a clear process, the stigma towards ECT is likely to continue.