Limiting Legal Intrusions in ECT Practice, a Commentary on “Regulation of Electroconvulsive Therapy: A Systematic Review of US State Laws”

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To the Editor:
We would like to thank the authors for this valuable contribution.1 The authors appropriately point out that the bulk of the regulatory framework for the provision of electroconvulsive therapy (ECT) is without basis in the medical and scientific literature, likely represents codified stigma toward ECT, and places undue restrictions on patients seeking a potentially life-saving intervention. We would like to comment on 2 additional points worth considering from these data and discuss practical implications.
First, the authors' data show that 21 states have age restrictions under which court approval must be sought or other legal procedures inhibiting or delaying treatment must be followed—including 6 where there is an absolute age stricture (ie, forbidding administration of ECT to patients below a certain age under any circumstances). This restriction is imposed even though it is well established that ECT is efficacious for the same conditions across the life span, and there is no evidence to suggest that ECT poses increased risk in children or adolescents.2 Parental consent is sufficient in medicine for far more toxic treatments (eg, chemotherapy) without the need to invoke special laws or court approvals. As such, there is no reason for it not to suffice for ECT.
Second, as in several other states, the law in our state of practice, Illinois, appears in the “Mental Health and Developmental Disabilities Code”3 or its similarly named equivalent. Consistent with the law's placement, not only must court approval be sought before administering ECT to an incapacitated patient or a minor, the primary criterion for obtaining such approval is “that the recipient has a serious mental illness or developmental disability.” However, in some cases, ECT-responsive conditions may not meet this criterion—for example, status epilepticus4 or those cases of catatonic stupor that can arise from a myriad of systemic disorders.5 Neuroleptic malignant syndrome as well responds promptly to ECT, and while the patient usually has an underlying psychiatric condition, its proximate cause is clearly an adverse drug reaction. It thus seems quite logical to assert that these are not “mental illnesses,” but rather medical conditions. In Illinois at least, a medical condition cannot be subject to the ministrations of the Mental Health and Developmental Disabilities Code, and no other state laws specifically regulate ECT given for medical conditions. Thus, depending on the nature of the underlying illness, the same treatment might be administered only after a prolonged and burdensome legal process—or without any regulatory oversight at all.
Another illustrative clinical example is catatonia secondary to anti-N-methyl-D-aspartate receptor encephalitis (aNMDARE), for which successful use of ECT has been reported multiple times.6 Catatonia can often impair decisional capacity and the ability to provide informed consent, and aNMDARE presents often in children and adolescents, whose age may also be a legally incapacitating factor. In addition, we suspect that readers can identify from their own practices and reading other conditions that raise similar dilemmas.
There are a few ways out of this legal morass that ECT providers can follow. One is to raise public awareness, via whatever communication means are available, that the laws currently regulating the administration of ECT are based on outdated information—or plain misinformation (or stigma as Livingston et al have articulated it). Another is to lobby legislators to pass legal reforms based on better information about the safety and efficacy of ECT. Such reforms ought not to be confined to changes in the various states' mental health codes but must address the reality that ECT is a safe and medically appropriate treatment for a variety of medical conditions.
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