Dáil Éireann debate -
Tuesday, 8 Dec 2015

Vol. 899 No. 3

Mental Health (Amendment) Bill 2008 [Seanad]: Second Stage

Minister of State at the Department of Health (Deputy Kathleen Lynch)

I move: "That the Bill be now read a Second Time."

I am pleased to present the Mental Health (Amendment) Bill 2008 to the House. I acknowledge and thank the Opposition Deputies for their support for this short but important Bill. Their co-operation in this matter is much appreciated and has allowed me to secure Dáil time to debate the changes I plan to bring forward on Committee Stage this evening. The purpose of this short Bill is to amend the Mental Health Act 2001 so that when a person with capacity refuses electro-convulsive therapy, ECT, or medicine after a three month period, the decision will be respected. This is a very important change that has been requested for many years by mental health support and advocacy groups, including Mental Health Reform, Amnesty International and the Irish Advocacy Network. The mental health regulator, the Mental Health Commission, and the medical professional body, the College of Psychiatrists of Ireland, have also called for the amendment to be introduced on a priority basis.

I will give a brief history of the Bill and explain why it is only now coming before the House. The Bill commenced in the Seanad in 2008 as a Private Members' Bill sponsored by then Senators Deirdre de Búrca and Dan Boyle and Senator David Norris. The original intention of the Bill was to allow ECT to be administered to patients only with consent but also to delete section 58 of the Bill which included safeguards about the administration of psychosurgery. During the debate in the Seanad there was also a call to consider the case for banning ECT altogether. The Final Stage of the Bill was passed in the Seanad in 2011, very shortly after I took up office in the Department of Health.

Given the discussions in the Seanad and elsewhere about ECT, I indicated to the Seanad that, given that I was planning to establish an expert group to undertake a comprehensive review of the Mental Health Act 2001, I thought it best to allow the group reflect on the issues raised first. I wanted the group to look at all aspects of the administration of ECT and give their opinion on the extent of the changes that should be made. While the expert group took longer than expected to complete its review, the group's report was finally published in March this year. It is a comprehensive and robust review of the 2001 Act and contains 165 recommendations which will provide a roadmap for how we amend our mental health legislation for the better to ensure individuals with mental illness are afforded quality care in the most appropriate environment suitable to their needs. I have received Government approval for the drafting of a general scheme of a Bill to reflect the recommendations of the group in revised mental health legislation. Work is under way in the Department on the Bill. It is, however, at an early stage of drafting and while many recommendations of the group are worthy of extensive debate in themselves, today our work is to focus solely on the priority amendments which I am bringing before the House.

The expert group specifically recommended that the change with regard to ECT that I am planning today should proceed as a matter of priority in advance of other changes recommended.

Under section 59 of the Mental Health Act 2001, the written consent of the involuntary patient is currently required if a programme of ECT is to be administered. If the patient is "unwilling" or "unable" to give such consent, however, the programme may be administered as long as it has been approved by the consultant psychiatrist who is responsible for the care and treatment of the patient and authorised by another consultant psychiatrist. The expert group was very clear in its recommendation that the authority to give ECT without consent in any circumstance in which the patient is capable of giving consent but unwilling to do so should be removed. As I have mentioned, the group recommended that the first possible opportunity should be taken to effect this change. I identified the Mental Health (Amendment) Bill 2008 as the quickest way to revise the existing legislation. In July of this year, I received Government approval for the Committee Stage amendments I am bringing before the House today.

In addition, I am proposing an amendment to section 60 of the Mental Health Act 2001 which deals with the administration of medicine after a three-month period. This section, which uses similar phraseology to section 59, currently provides that where medicine has been administered to a patient for the purposes of ameliorating his or her mental disorder for a continuous period of three months, the administration of that medicine shall not be continued unless the patient gives consent in writing. It provides that if the patient is "unable" or "unwilling" to give such consent, the continued administration of that medicine may only be continued if the consultant psychiatrist responsible for the care and treatment of the patient approves the administration and it is also authorised by another consultant psychiatrist. The members of the expert group were again agreed that the word "unwilling" should be removed from section 60. This will ensure that where any patient who has the capacity to make a decision refuses to take medicine after three months, this decision will be respected.

Everyone in this House and in the wider community of mental health stakeholders is aware that there have been divergent views on the use of ECT for many years. No one denies that it remains a contentious treatment for some people. Anyone with an open mind on the subject will agree that the case to ban this treatment outright has never been fully articulated. Regardless of the views that people in this House may have about the efficacy of ECT, I would be surprised if any of them would seek to have it banned. It is important to remember that international evidence shows that ECT appears to be the only treatment that offers any real possibility of improvement for people with severe resistant depression. I note that a recent publication by the Mental Health Commission, The Administration of Electro-convulsive Therapy in Approved Centres: Activity Report 2013, indicates that in over 90% of cases the treating consultant psychiatrist reported an improvement in the condition of the patient following the administration of ECT. The activity report also notes that in 2013, there was just one case in which both consultant psychiatrists were of the view that the patient was in the "unwilling" category. There were a further six cases in which one consultant psychiatrist indicated that the patients were in the "unwilling" category while the other consultant psychiatrist indicated that they were in the "unable" category. In all the remaining cases, the patients were in the "unable" category. In other words, the vast bulk of cases approved in 2013 under section 59 related to patients who lacked the capacity to consent to treatment, rather than patients who refused treatment. The changes I am bringing forward today will eliminate the "unwilling" category.

The expert group was clear on the need to retain the right to give ECT to patients who are unable to consent to treatment. This view is supported by professional groups. These cases involve patients with depression so severe or intellectual disability so profound that they cannot understand their options, even with the decision-making supports which will be available to them when the Assisted Decision-Making (Capacity) Bill 2013 is passed. I consider it appropriate that people who lack capacity are not denied the full range of services that are provided to other people with capacity. This view is in keeping with the UN Convention on the Rights of Persons with Disabilities. While these patients should never be denied such treatment options, important and robust safeguards must be put in place to ensure their rights are fully respected and such treatments are administered in accordance with procedures laid down in law. This is what sections 59 and 60 of the Mental Health Act 2001 seek to do. They provide the appropriate safeguards for the safe administration of ECT and medicine over three months. The expert group has recommended that after the forthcoming enactment of the Assisted Decision-Making (Capacity) Bill 2013, and in the context of the full revision of mental health legislation, references to the decision-making supports to be provided under the aforementioned Bill should be added to the Mental Health Act 2011 in due course, including where ECT is concerned.

I will briefly set out the specific measures in the Bill before the House. Section 1, as it stands, amends section 59(1)(b) of the Mental Health Act 2001 by deleting the word "unwilling". This covers the essence of the changes I am making. I will come back to this section on Committee Stage as I intend to introduce a new section 1 to the Bill. Section 2 of the Bill as it stands is incorrect. Although it was agreed in the Seanad, I do not believe it reflects the intention of that House. The section as it stands seeks to delete section 59 of the Bill in its entirety. This is simply incorrect as without section 59, there would be no protections in the Bill with regard to ECT. Section 3 relates to the Short Title, collective citation and construction.

I thank Deputies for their support for this Bill and in particular the amendments which I will shortly bring forward on Committee Stage. These amendments have all-party support and will further enhance the rights of people who are involuntarily detained in our mental health approved centres. It will end the practice of forcing patients with capacity to take certain treatments when they are unwilling to do so. I commend the Bill to the House.

Deputy Colm Keaveney

Fianna Fáil welcomes this Bill and will support it. We believe the wishes of involuntary patients in psychiatric hospitals who have the capacity to refuse electro-convulsive therapy, ECT - to say "No" - should be respected. The expert group on the Mental Health Act 2001 published strong recommendations in this regard earlier this year. The law currently provides for two consultant psychiatrists to authorise the application of ECT. The Minister of State will recall that I asked a question on this issue last March. I was alarmed by the parliamentary response I received. The Minister of State and I agreed that something needed to be done in this area. According to figures released to me on foot of a parliamentary question, some 42 patients with mental ill-health were subject to ECT throughout 2014. That figure continues to increase. It is appalling in this day that service users are exposed to ECT. I suppose we have assumed for some time that the practice of ECT has had a positive consequence. There is no doubt that ECT can be an extremely traumatic treatment. The Minister of State and I will agree that this is a human rights issue. People have the right to say "No" to a particular treatment. A couple of years ago, the UN special rapporteur on torture urged this country to ban the practice of ECT in its entirety. We have spent too many decades on this issue. I am delighted to have an opportunity to speak in support of the Minister of State. I am limiting my speaking time to encourage as much participation as possible in this debate. We will support all of the Minister of State's amendments on Committee Stage to facilitate the successful and immediate expedition of this legislation through the House.

Deputy Caoimhghín Ó Caoláin

I would like to share time with Deputy Crowe.

An Leas-Cheann Comhairle

Is that agreed? Agreed

Deputy Caoimhghín Ó Caoláin

Over many years, I have called on this Government and its predecessors to promote awareness of the unacceptability of certain practices in mental health care and to urge that the use of such practices be discouraged. One such practice is the application of electro-convulsive therapy, ECT, on detained persons against their will. That is a very important point. Under the Mental Health Act 2001, the consent of the patient must be received before ECT treatment, which involves sending an electrical current through the brain via electrodes applied to the scalp, can be used. If a patient decides not to consent to ECT treatment, that decision can be overridden if two psychiatrists believe this treatment is in their best interests. Therefore, a patient who is capable of giving or withholding informed consent can be forced to take ECT treatment against his or her will.

Mental health organisations have been actively campaigning against such a practice for many years and their stance was vindicated following a report by the Mental Health Commission who expressed their continuing concern at this practice.

This Bill comes on the back of the review carried out by the expert group on the Mental Health Act 2001 and will see the word "unwilling" removed. It will no longer be possible to administer the controversial therapy to a person who has capacity and does not consent to the treatment. Despite its short length, this Bill is of significant importance and my party and I are happy to support its swift passage through these Houses.

Given the time, I will reflect on a number of other areas. Less than three weeks ago, we had statements on developments in mental health services. I believe that the allocation of time to such a topic is most important in order to establish where we are at and, indeed, how far we have to go in terms of where we want to bring these services. It is imperative that we all work together to push for improvements and progress at all times. This has demonstrated itself in this Chamber and in the Oireachtas all-party mental health group. It is my hope that we not only continue but build on the spirit of interparty co-operation and working together on these issues post the upcoming general election.

There is no doubt that there has been fundamental change in the care regime available to patients with a mental illness over this past decade. The review of the Mental Health Act 2001 was a key step in the provision of revised and more appropriate mental health legislation in this country. Aside from its recommendations in relation to ECT, it contained a number of proposals to strengthen patients' rights, placed a greater emphasis on children's services and supported the extension of responsibility to community mental health teams, something Sinn Féin has advocated for a long time.

A Vision for Change is a very significant but, regrettably to date, a very long-term project. It requires maximum support to ensure that it proceeds apace and that it is not allowed to stall again, as has happened too often in recent years. I believe that there is commitment to the policy objectives contained in A Vision for Change across the political spectrum represented in this Chamber. However, apart from its slow pace, the reality is that the policy is being implemented unevenly and inconsistently across the country.

Mental health is an area in which successive governments have struggled to provide an adequate level of service. This is despite the fact that 644,000 people, one in seven adults, have experienced a mental health difficulty in the past year. The number of suicides has remained high, with between 495 and 554 deaths per year from 2009-2012. The human cost of this on families and on communities is devastating, a point I have made recently but which I make no apology for repeating. The reality is that all sections and all generations of our society are affected, from the very young to the very old, in rural and urban areas alike. The funding allocated to mental health is insufficient. The overarching framework document for this sector, A Vision for Change, proposed a mental health funding target of 10% of the overall health budget. While there have been attempts made to reconfigure health spending in order to afford mental health greater priority, we continue to see funds which have been earmarked for mental health diverted to other areas. Nine years on from the publication of the strategy, just 6% of the total health budget went to mental health in 2014 compared to 7.2% in 2006. In 2015, it is predicted to account for just 6.5%. To reach the budget target of 10% would require an estimated increase of €400 million in its annual allocation.

Lack of staff in the sector is a major problem. Despite a greater need for mental health services, there are 1,200 fewer mental health staff now than there were in 2006. Between 2008 and 2015 there was a loss of over 1,000 mental health staff and staffing levels were only 77% of the recommended level in A Vision for Change. In child and adolescent mental health services, CAMHS, the situation is more severe with just over half of the staff required in post. In terms of crisis supports, more than nine years after the publication of A Vision for Change mental health services are still not uniformly providing the basic model of care that includes 24-7 crisis intervention and home-based and assertive outreach treatment, with crisis houses as the norm in all areas. A clear framework for collaboration and referral between mental health services is lacking and this must be addressed.

Sinn Féin believes that A Vision for Change still needs to be implemented. Additional funding should be provided and directed towards community mental health services. Ireland's new strategy for suicide prevention, Connecting for Life, needs to be incorporated. This sets a target to reduce suicide and self-harm by 10% over the next five years, based on WHO targets. A continuation of the roll-out of suicide crisis assessment nurses, SCANs, is needed. These nurses liaise with GPs where there are concerns about patients who may be suicidal. SCAN deployment has resulted in significantly better outcomes for patients than traditional mental health services and they may result in lower costs. Only 24 of the 35 nurses approved for this programme have been recruited and this is unfortunate.

In January 2015, some 429 children were waiting more than a year to be seen by CAMHS. We need to focus on early intervention. There has been investment in child and adolescent mental health teams but just half that which was recommended in A Vision for Change and not enough to meet the 50% increase in demand for the service. By the end of 2014, there were 63 partially complete community CAMHS teams in place while A Vision for Change had recommended 77 teams. Sinn Féin recognises the merits of the proposed suicide prevention authority and is favourably disposed to the establishment of such an overarching body on an all-Ireland basis to lead the way and set the standards for all who are involved in suicide prevention initiatives.

I reiterate and stress my support, and that of my colleagues, for this Bill. This is a progressive step forward and its importance cannot be underestimated. I commend the Minister of State on pushing ahead and ensuring that it progresses while we still have the opportunity, here today. We are on the right path but so much more needs to be done. I believe that some of the suggestions I have put forward today have the potential to deliver to the greatest extent possible for all those who, from time to time, may require mental health services, treatment or care. Furthermore, I ask the Minister of State to ensure that the heads of the legislation needed to give effect to the other recommendations of the expert group on the review of the Mental Health Act are published as soon as possible, bringing the long-awaited reform of Ireland's mental health services to fruition.

Deputy Seán Crowe

Electro-convulsive therapy is vitally important and a highly complicated procedure. I believe there is general agreement in the House that every time a patient undergoes such an extreme procedure, it must be in the patient's best interest. Under the Nice guidelines, ECT should be used to gain fast and short-term improvement of severe symptoms after at least two other treatment options have failed or when the situation is believed to be life-threatening. The patient should be assessed after every session of ECT with checks for any signs of short-term memory and rigorous medical checks at the end of each treatment.

While it works for many and is described by some as "life changing", it still has a very negative public image. I have talked to many patients and medical practitioners. This morning, I spoke to a nurse who had over 30 years of experience in this field, who said she had full confidence in the procedure and would authorise it for herself or a loved one, if needed.

We all agree that relapse is also an important issue, and more studies must be carried out both here and abroad into why it happens. The National Office for Suicide Prevention states that there were 459 deaths by suicide last year and 475 in 2013. A total of 80% of people who die by suicide in Ireland are men. It is a lucky family that has not been impacted by suicide.

There have been many positive advances in combating the stigma of mental health. Thankfully, an increasing number of people are ready to talk about their mental health challenges. However, many still struggle to get help when they need it. This is a sad fact which compounds and sometimes worsens their problems. If one cannot afford private health care insurance, the chances are that one will struggle to get immediate help when one most needs it through the public care system. The obstacles to mental health care become more acute outside urban areas, as the professional resources required to deal with the demand are simply not there or are so scarce that they are not up to the task.

Austerity has crippled our health service. One cannot make very significant funding cuts over a period of years and, with the flick of a switch, somehow hope that matters will return to how they were previously. A large number of doctors and nurses have emigrated. They will not return through simple recruitment drives, as they are aware of the ongoing chronic problems in our health service. More nurses are leaving the mental health service than are leaving any other sector. That must be addressed.

While this amendment to the Mental Health Act deals specifically with ECT, the Government must reform its entire approach to mental health in Ireland. As Mental Health Reform has stated, there must be a nationwide school programme to build good mental health. We must also ensure that there is easy access to counselling and to 24-7 crisis supports. No family should see a loved one turned away in accident and emergency departments, particularly at weekends, because no psychiatrist is available. Unfortunately, the practice of people being turned away is one we hear about continually. There must be a right to advocacy support and a right to make one's own decisions about mental health treatment through advance health care directives that work and deliver for patients.

People from both sides of the argument might criticise this Bill. Some will say it does not go far enough, and others will say it endangers patients. I believe it goes some way towards achieving a better balance by giving patients a greater say in their treatment. That is positive. On that basis, we will support the Bill.

Deputy John Halligan

This legislation is long overdue and very necessary. The current situation allows for two consultant psychiatrists to authorise a course of ECT to a patient who has been admitted involuntarily for treatment, even if that person has capacity and refuses such treatment. That is absolutely in breach of international norms, not to mention an infringement of the patient's human rights.

I take this opportunity to raise an issue which is becoming an increasing problem for patients in psychiatric care in the south-east region, an area where the rights of mentally ill people to appropriate treatment are being infringed due to where the person happens to live. The amalgamation of the mental health services in Waterford and Wexford has been a disaster, and has had a disastrous impact on the level of services being provided to patients in the south east. The Waterford-Wexford mental health services, which serve a population of approximately 278,000, have spending in the mental health area of approximately €148 million. In Carlow-Kilkenny, the spend is €223 million while in south Tipperary it is €198 million.

Wexford now has no 24-hour mental health service and proposals for an acute mental health ward for Wexford General Hospital appear to have gone by the wayside. Mental health is not a 9 a.m. to 5 p.m. issue. When people are in crisis, they must be able to access the services at all times. Patients in Wexford are obliged to go to the accident and emergency department and wait for hours to be assessed. If it is decided they must be admitted, they are given a letter and sent to the accident and emergency department in Waterford. These are people who are distraught, and perhaps suicidal. That has been described by a doctor in Waterford as inhumane. A worker in the Waterford mental health services recently told me that should a loved one of theirs require mental health treatment, Waterford is the last place they would want that person to be sent.

Staffing shortages and inadequate facilities have resulted in a situation where severe mental health cases are being mixed with less acute cases, with adolescents being accommodated on the same wards. That is shockingly inappropriate. A total of 13 children from the Waterford-Wexford area were admitted to adult mental health services in 2014. The most recent 2015 data indicated that there were 12 such admissions of children to adult services. This is mainly because a bed was not available in the child services. I have encountered more than one horrifying case in which an individual presented at the department of psychiatry, DOP, in Waterford, was given a pill and sent away and then committed suicide. That has happened. There appears to be a complete lack of access to front-line assessment facilities in the community.

Furthermore, delays in accessing child and adolescent mental health services in Waterford are causing untold difficulties, particularly for children waiting for an autism diagnosis. Just months ago, I read, and had it confirmed, that the position of psychologist in the Waterford child services was advertised on JobBridge. That is unbelievable. There is currently no adolescent psychologist available in Waterford. Without a fully trained psychologist, children cannot be given the full diagnostic assessment for autism, which means they cannot access the service to advance in school. A new consultant psychiatrist was appointed to the service in October following a five month vacancy during which the region, with a population of 71,000 minors, had no psychiatrist available. We are still awaiting the appointment of a further two consultants, which have been promised for the Waterford unit. These staff shortages are having a detrimental effect on service provision.

Finally, last April, when a consultant with the child services resigned, there were 138 referrals on the books. A further 95 referrals were received between May and September 2015. The most recent data indicated there were 251 referrals, of which 136 were accepted. The rest are children and adolescents who are continuing to fall through the cracks in an overloaded system. Children and adults in the south east with various mental illnesses are not being given access to the full range of interventions they urgently require. While I support this Bill, I urge the Minister to address these issues in Waterford and Wexford without further delay.

Deputy Maureen O'Sullivan

When considering this Bill certain people come to mind - the Minister of State for her persistence on this issue, consultant psychiatrist Pat Bracken and the late John McCarthy of Mad Pride Ireland. Wherever he or his spirit is, he must be smiling and saying it is about time this has happened. We know how long he campaigned on this and of his total opposition to a system whereby doctors could administer treatments such as ECT without the patient's consent under certain circumstances. He was not opposed to the use of ECT, just the forced use of it.

I do not have the recent figures on ECT but some years ago there was a wide divergence among the counties where this was being administered. Some counties had a much higher rate of use than others. There was also a very high number of senior citizens. Undoubtedly, certain psychiatrists were exceptionally happy to administer ECT treatment. It is an invasive and controversial treatment. Despite what the Minister said, there is conflicting evidence about the benefits of ECT. There is evidence of the short-term benefits for a very small minority, but in the views of some people that does not justify the risks of memory loss and the slight, but significant, risk of death. While I welcome this Bill, a wider debate must be had about the use of ECT at all.

There is a need for advance directives so that people who are in a position to make a decision that they never want to be given ECT at any point can know that their decision will be legally binding. It is immoral and surely unethical that a psychiatrist could decide on forced treatment. We should oppose any forced treatment at any stage as an abuse of human rights.

Nobody who is diagnosed with cancer is forced to take chemotherapy or radiotherapy. He or she discusses it and makes a decision. I hope no one lacking mental capacity has been forced into chemotherapy or radiotherapy at any point.

The late John McCarthy was very practical man with a lot of common sense. He spoke very clearly and passionately of his experience with mental health services. Sadly, he was in a position to compare mental health services with those dealing with physical health, as he contracted motor neuron disease, which led to his death. When he went to accident and emergency with a leg pain, his pulse, temperature and blood pressure were checked regularly and there were scans and X-rays. A tumour was found in his kidney and he was admitted to hospital and had more tests. A team of highly qualified medical experts looked at the test results and decided on an operation because the tumour was malignant. That had been suspected by the doctor at the first point of contact, who nevertheless insisted that all of those tests be carried out. When Mr. McCarthy presented to mental health services with a nervous breakdown, the psychiatrist decided after 20 minutes that he suffered from unipolar depression and prescribed medication. That contrast is stark. While progress is being made, there is a long way to go before those presenting with mental health issues get the range of care strategies available to those presenting with physical health issues. Pat Bracken spoke about the need for dignity, respect and time so that people presenting with mental health issues are listened to, feel empowered and are in control. A Vision for Change was highly lauded in 2006 as the guiding force but we are still looking for its implementation. We know what to do but it is taking a long time to do it. The basis must be equal rights for those with mental health issues. One of the ways to progress that is for an independent complaints mechanism to be put in place.

I am a member of the Oireachtas group on mental health. Deputy Ó Caoláin, who is here, is also a member. We were able to agree a pre-budget submission to the effect that investing in mental health services meant savings in other areas such as housing, health care and social protection. We acknowledge as a group that progress has been made, but the strains are still there. Deaths from suicide and readmission rates to acute inpatient units are static. Staffing of mental health services is still below the recommended strengths. Primary care is not advancing as it should, even though we know that early intervention across the board, including in relation to mental health issues, is vital. Robert Frost, in his poem Stopping by the Woods on a Snowy Evening, spoke of having "miles to go before I sleep". We are taking steps, but there are still miles to go before this issue is resolved.

Deputy Finian McGrath

I am grateful for the opportunity to speak on the Mental Health (Amendment) Bill. I welcome the Bill warmly, as it directly affects thousands of people with mental illnesses, all of whom need our support and commitment to ensure they are treated with respect. Above all, the rights of these people must be guarded and protected. We all know friends, family members or neighbours who have a mental illness, and we must stand up for them in tonight's debate to include them in a modern, inclusive and compassionate Ireland. For too long we have seen many of these people hidden, including, historically, in institutions. We must all open our minds and hearts to ensure that the rights of these people are protected. That is why this legislation is important.

As a society, we must act. As the State, we must be proactive and put in place high-quality mental health services that suit the patient and that also deliver practical benefits for patients and their families. This aspect of public health should never be without the necessary resources to fund services. We must all be strong and implement A Vision for Change. We have had a lot of talk, but now the Government and all Members of the House must act. It is not acceptable to leave a person with a mental illness without services. That is the bottom line. That is the important thing to say in this debate. I accept that a great deal of good work has started on this issue, but we must keep moving and developing so that people can get the maximum benefit. I know exactly where I stand and I urge all colleagues to support the policies in A Vision for Change.

This amending legislation has long been awaited. It will ensure that where an involuntary patient who has capacity refuses ECT, that patient's wishes will be respected. "Respect" is the key word. It is important to draw the attention of the Minister of State to the recent report of the expert group on the review of the Mental Health Act. While I welcome the deletion of the word "unwilling" from the legislation, some analysis shows that there are gaps remaining in mental health legislation - namely, the need for legally binding advance health care directives and an independent complaints mechanism. These gaps must be highlighted. There are people with concerns about the legislation. It is important to reflect their views. Taking the term "unwilling" out of the Mental Health Act in respect of ECT will not necessarily prevent forced treatment and the administration of electro-convulsive therapy, because only those people who are deemed to have capacity will have their wishes respected. Psychiatrists and perhaps other professionals will continue to decide who has capacity rather than support the decision-making, will and preferences of the individual. Legal capacity must be respected as per the Convention on the Rights of Persons with Disabilities, but the change outlined above does nothing to eliminate the palpable fear experienced each day by individuals who have been given ECT against their express wishes. That is a view that must be considered.

Forced treatment is contrary to that convention and to international human rights standards. The UN Committee on the Rights of Persons with Disabilities issued a general comment in September stating in clear terms that forced treatment was not acceptable. The chairman of the UN sub-committee on the prevention of torture, Professor Malcolm Evans, informed a number of groups, including the Tallaght Trialogue group, publicly that his committee hopes to assess the general comments soon, having regard to the issues raised by those groups. Ratification of the convention is not dependent on legislation being in place first. In fact, the UN has concerns about our approach. In June, the UN Committee on Economic, Social and Cultural Rights asked the Minister of State, Deputy Sean Sherlock, and the Government to ratify the convention and then to introduce legislation in line with it.

The voices of civil society groups are not being listened to. It appears the Minister of State has refused to meet the capacity coalition chaired by Dr. Eilionóir Flynn of the Centre for Disability Law and Policy at NUIG. The coalition includes, inter alia, the Mental Health Lawyers Association, the Disability Federation, Inclusion Ireland, the Alzheimer Society of Ireland, and the Tallaght group. Is this true? These groups have expressed concern about the Assisted Decision-Making (Capacity) Bill, which will not make advance directives legally binding in the context of mental health. This again denies people the right to refuse forced treatment, including electro-convulsive therapy. These issues have been raised with me in the last 24 hours and I ask the Minister of State to respond to them. I support strongly the coalition of organisations working to promote improved mental health services and the implementation of A Vision for Change. We must support mental health reform in this society. We must move forward and guarantee maximum rights for all people with a mental illness.

Deputy Joe O'Reilly

I wish to share time with Deputy Neville.

An Leas-Cheann Comhairle

The Deputies have five minutes each.

Deputy Joe O'Reilly

I welcome the Bill and commend this proactive Minister of State on the Bill, which reflects the recommendations of the expert group on the Mental Health Act 2001. The legislation is progressive and to be welcomed in that regard.

Fundamental to everything we do in the area of mental health must be the absolute dignity of people with mental health issues and respect for and full recognition of their rights. This is something that is developing and we must be at the forefront of assisting its further development. People with mental health issues must be fully respected as complete human beings and there must be a recognition that their illnesses are no different from physical illnesses. They deserve everybody's full respect and regard. Any treatment they receive should be provided in the context of an awareness of their dignity as human beings. They should be treated in the way a person with any physical illness would be treated.

I liked the comparison drawn by our colleague, Deputy Maureen O'Sullivan, when she stated that, if a person wished to refuse chemotherapy or radiation treatment, that would be his or her permitted prerogative. We all know of such instances occurring at various stages of people's cancer treatments. The same dignity and right should pertain in this instance.

The Bill seeks to amend the Mental Health Act 2001 to ensure that electro-convulsive therapy, ECT, cannot be administered to a patient who is capable but unwilling to give his or her consent to such a treatment. Deputy Finian McGrath referred to people lacking capacity, but neither is there a reason to deny them a specific treatment should it be deemed appropriate. Obviously, that must be done in a rights environment and in a controlled and considered way.

There are diverging views on the practice of ECT. Some international studies have found strongly against it as a treatment for severe depression and catatonia, viewing it as outdated, unethical, high risk and low benefit. Many individuals and organisations in Ireland share this view. They refer to two side effects, those being, short-term and long-term amnesia. In 2011, however, the College of Psychiatrists of Ireland produced a paper that explored these side effects in some detail. It found that, in the majority of cases, instances of short-term amnesia cleared up after a few weeks. The long-term effects were more difficult to quantify, but this had to be balanced against the condition that the patient had prior to the treatment. The paper differentiated between the extent of memory loss secondary to ECT and the patient's perception of that loss.

It is a vexed and debatable issue. In some extreme cases, ECT might be necessary, but it should never be practised except in a very considered way. Currently, two psychiatrists can use ECT to treat someone who refuses it despite having capacity. It is correct that this provision is being removed, as the individual's human dignity and rights gives him or her the right to refuse.

According to the statistics, 500 people receive ECT in Ireland every year and 1 million worldwide. Some 90% of those in Ireland seek treatment and give their fully informed consent. This therapy is given in cases where a patient's depression is so severe that it has not responded to any anti-depressant drug or psychotherapy. The fundamental point is that ECT is used only when it is unavoidable. In essence, it must be something that one does not want to do. There are anecdotal suggestions that ECT was administered willy-nilly in the past and was too arbitrary and easy an option to take, but that should never be the case. ECT should only be used when it is an absolute necessity, after every other option has been explored and the alternative is unthinkable.

If a person has capacity, the Bill will give him or her the right to opt out. If he or she does not have capacity, there will be a set of controls as well as measures to support the person's rights. The Bill is progressive to the extent that it is a further restatement of the rights and dignity of an individual with a mental health illness. In this regard, it is to be welcomed. This Bill should form part of the forthcoming raft of legislation to ensure the dignity of mentally ill persons further, as they are no different than physically ill persons. Their conditions should be seen as temporary and they should have the same rights and dignity as everyone else. This Bill is an important leap forward. We are not there yet, so we must do everything to get there.

Deputy Dan Neville

I welcome the Bill, which has been in gestation for seven years, and the Minister of State's decision to progress it. ECT is a controversial issue and, in that respect, the removal of the "unwilling" category from the 2001 Act is important. The question of medical professionals involving, consulting and informing mentally ill people has been neglected in psychiatry for decades, if not centuries. We must challenge that in this context.

ECT is a medical procedure in which an electric current is passed briefly through the brain via electrodes applied to the scalp to induce generalised seizure activity, as we often do not understand what takes place. The person receiving treatment is placed under general anaesthetic and muscle relaxants to prevent body spasms. ECT's purpose is to treat specific types of major mental illness. My mother, who was a psychiatric nurse in the 1940s, told me of the level of abuse of ECT at the time. We are moving from an era of extreme abuse to one in which there is a great deal more research and understanding of ECT and an appreciation of the need to inform the patient while ensuring that the psychiatric professional understands the situation.

It is the considered opinion of the College of Psychiatrists of Ireland that ECT is an important and necessary treatment for various serious psychiatric conditions, most commonly severe depression. For some severely ill patients who do not respond to any other treatment, there is no effective alternative. These patients would be seriously disadvantaged if they were denied access to a treatment that might restore them to health.

ECT has a bad image. In some ways, this is due to a misunderstanding, but it is also down to overtreatment or, in some people's words, the misuse or abuse of ECT. It raises anxiety and fear in many people and is usually seen as controversial. It should be used rarely and only where other treatments have failed or treatment is life saving. ECT is given in a clinical setting in the presence of the various psychiatric and other professionals required.

We must inform people of all aspects of mental health and reduce stigma. Like many of those aspects, we need the general public to be informed about ECT so that, when it is proposed by the psychiatric profession, patients and their carers and families can challenge and seek understanding of why it is being administered, the likely outcome and the relevant safety procedures.

Deputy Seamus Healy

I welcome the opportunity to contribute on this legislation. It is a short but significant and progressive Bill and I am happy to support it. As the Minister of State mentioned, its inception was in 2008 as a Private Members' Bill in the Seanad. I suppose it was given fresh impetus by the report of the expert group published this year.

The Bill provides that ECT cannot be administered to a patient who has capacity but is unwilling to consent to the treatment. The same applies in the case of the administration of medication beyond a continuous period of three months.

It is a progressive Bill that I am happy to support and welcome.

It is widely acknowledged by all stakeholders that mental health services, including those referred to in this Bill, should be provided locally and as near as possible to the service user. Unfortunately, that is not the case in Tipperary. I appeal to the Minister of State to examine acute inpatient mental health services in that county. As she will know, the decision to close St. Michael's inpatient unit in Clonmel, which provided services for north and south Tipperary, was made by the last Government, the Fianna Fáil–Green Party Government, and implemented in 2012 by the current Government. It has been a disaster. There is no doubt that the inpatient services provided to citizens of Tipperary in Kilkenny and Ennis are completely dysfunctional. The decision was taken and implemented without any consultation and against the wishes of almost all stakeholders, particularly those in south Tipperary. They include consultant medical practitioners, general practitioners, the public, service users, carers and their families. Unfortunately, the worst fears of all those individuals who advised against the course of action have been realised.

The Kilkenny unit, in particular, is overcrowded daily. It is running at 110% to 115% of capacity. I am told by patients and their families from south Tipperary that it is difficult to be admitted to the unit and that, having gained admission, one is discharged rather quickly. As we have always said, it is difficult for carers and family members to visit and support patients in the Kilkenny unit. This is what service users and their families have told me and other public representatives throughout the county. There is no continuity of care. When patients are discharged from the unit, they are discharged to a different consultant psychiatrist. There have been quite a number of unexplained deaths, 13, associated with the Kilkenny unit in recent times. Circumstances have been disastrous for service users in Tipperary. I appeal to the Minister of State to review them and provide inpatient beds in Clonmel for Tipperary patients.

I have been asked to draw the Minister of State's attention to the question of assessment of mental health service users in the accident and emergency departments throughout the country, particularly in South Tipperary General Hospital. I am told the assessment procedure is very difficult for all concerned in the units. It is inappropriate and unacceptable that this should continue. This would be dealt with if an inpatient acute unit were provided in South Tipperary General Hospital.

We were promised a Rolls-Royce-standard community-based service. We have a good service but the difficulty is that, despite the best efforts of staff, the community-based teams are not staffed to the standard outlined in A Vision for Change. I ask the Minister of State to address that also. I ask her to review the circumstances associated with the inpatient unit and to agree to reopen beds in South Tipperary General Hospital.

Deputy Michael Fitzmaurice

I am thankful for the opportunity to speak on this Bill. Last week, a High Court judge stated the mental health services in Roscommon are in chaos. That is a regrettable statement to have to make. I have been saying this for months on end. I am not laying the blame at the foot of the Minister but ultimately the Minister must call the shots. People seem not to be worried about how people have been looked after in Roscommon and east Galway. The Minister of State is aware of the circumstances in Ballinasloe, where services were withdrawn. We are opting for the new idea of community service. Perhaps there are good parts to it — I am not an expert — but people I have encountered in the past seven to nine months have faced many walls they could not climb because, sadly, the system has failed us.

One night at 8.30 p.m. a woman telephoned me whose brother was suicidal. As a public representative, I spent two hours talking to the hospital trying to get the man assessed but I could not achieve that. Sadly, he had to be brought that night to a private hospital in Dublin to help him. These are the circumstances on the ground in Roscommon and east Galway. We cannot and should not condone the activity of people who are running the service in this way. Ultimately, lives are lost unnecessarily.

I do not know what is wrong when there are good mental health services in some parts of the country and not in others. It may be a matter of personnel but, ultimately, if one does not deliver the goods one should not be doing the job. That is the bottom line with me. People working in the HSE who are not delivering the goods should not be left in their positions. What we have seen in our area is regrettable. No one takes pleasure in saying that. The service is in disarray and there is no joined-up thinking about how to solve the problem.

I know elderly people with a son or daughter with a mental illness and they are afraid of their lives at present. We do not have the answers. Consider the provisions in the mental health legislation that might help those with a drink problem and mental illness at the same time. I can talk about this personally because someone who belongs to me has faced it. Having such people admitted is difficult. They may not hit skid row or realise they have a problem, or they may just keep stonewalling to the extent that one faces a battle to have them admitted anywhere. Everywhere one telephones the staff say the person with the problem must walk in and want to deal with it. In America, circumstances are different if people have a major problem. There are those who never can see the problem but a family member, doctor or member of the police force can go to the courts to secure admission. I am not suggesting a patient should be admitted for a year or six months but for ten, 15 or 20 days. In that period, he may see the light. We have to do this because there are many families throughout the country suffering torture tonight and every night who do not know where to turn. As politicians, we need to address this. It must not be allowed to continue. I have encountered this problem and it is like facing a stone wall. For the betterment of people in every part of the country, we must change admission procedures because families are being torn apart by the obstacle being put in their way.

Minister of State at the Department of Health (Deputy Kathleen Lynch)

I thank Deputies for their contributions. Deputy Maureen O'Sullivan referred to the late John McCarthy. While the Department carried out a review of the Mental Health Act, my view on electroconvulsive therapy, ECT, was informed by Mr. McCarthy. While he was not entirely opposed to ECT, which continues to be the subject of debate, he certainly opposed its use when people were unwilling and had the capacity to make a decision on the treatment.

I plan to group the amendments to this short Bill, as they relate to only two sections of the 2001 Act. The changes involved are similar involving the removal of the word "unwilling" from sections 59 and 60 of the Mental Health Act 2001. Amendment No. 1 to section 1 relates to definitions and is a small, technical amendment recommended by the Office of the Parliamentary Counsel. It defines what the principal Act being amended is. The new definition being included confirms that the principal Act being amended is the Mental Health Act 2001.

An Leas-Cheann Comhairle

We must conclude Second Stage before discussing Committee Stage amendments.

Deputy Kathleen Lynch

I apologise. I am anxious to complete the passage of the Bill. I thank Deputies for their contributions on Second Stage.

Question put and agreed to.