I welcome the new Minister of State to the House. I congratulate him on his appointment by the Taoiseach and I wish him well. He has gained a lot of experience through his membership of local authorities and of the Dáil, so he will be well equipped in the coming years and will hopefully go further. I wish him, his wife and his family health and happiness in his new position, which was afforded to him by the Taoiseach.
Mental Health (Involuntary Procedures) (Amendment) Bill 2008: Second Stage.
It is a great honour, as a Laoisman and as Acting Chairman on this historic occasion, to welcome my colleague and friend, Deputy John Moloney, Minister of State at the Department of Health and Children. I wish him well in his new ministry.
I also welcome the Minister of State to the House. On behalf of the Green Party, I am very happy to propose that this Bill be now read a Second Time. It is quite limited in its scope, which is deliberate. There is a much wider debate about the appropriateness of certain psychiatric practices and the model that underpins them. Those of us who have been involved in the mental health services are very aware that the traditional biological or medical model is increasingly being challenged in the field of mental health. There is a very strong call for its replacement by a much more comprehensive bio-psycho-social model. This debate is very important because of the treatments prescribed by each model of mental health disorders. The focus of the Bill is on a couple of procedures that are currently on our statute books and which the Green Party wishes to see amended.
The scope of our Bill relates to involuntary procedures that are prescribed under the biological or medical model. We specifically refer to the practices of psychosurgery and ECT. Section 1 seeks to amend Section 58 of the Mental Health Act 2001, which concerns use of psychosurgery. Most of us became familiar with the treatment of psychosurgery — commonly known as lobotomies — through the famous film starring Jack Nicholson, "One flew over the Cuckoo's Nest." Public awareness of the procedure has meant that over time, its use has almost completely died out. It does not appear to have been used in this State over the last 20 years. However, it is still left on our Statute Book and the option to use it still remains. We are attempting to delete this section in section 1 of this Bill, and to introduce on Committee Stage a prohibition on its use.
Section 2 seeks to amend section 59 of the Mental Health Act 2001, which allows for the involuntary use of ECT in certain circumstances. We are looking for this section to be deleted and replaced with the following wording:"A programme of electroconvulsive therapy shall not be administered to a patient unless the patient gives his or her informed consent in writing to the administration of the programme of therapy". The issue of consent and informed consent is central to this proposed amendment. The Mental Health Commission rules for 2006, governing the use of electroconvulsive therapy, are specific on the issue of consent. These rules state that a patient must be considered capable of giving informed consent for ECT, including anaesthesia, unless there is evidence to the contrary. They also state that capacity to consent must ensure that the patient can understand the nature of ECT, understand why ECT is being proposed, understand the benefits, risks and alternatives to receiving ECT, understand the broad consequences of not receiving ECT, retain the information long enough to make a decision to receive or not receive ECT, make a free choice to receive ECT and communicate the decision to consent to ECT. Consent must be received in written form.
However, in part 2, section 4 of the guidelines entitled "Absence of consent", it is stated that where a patient is unable to give consent or is unwilling to give consent, Section 59(1)(b) of the Mental health Act 2001 applies. This section states:
Where the patient is unable or unwilling to give such consent, the programme of therapy is approved (in a form specified by the Commission) by the consultant psychiatrist responsible for the care and treatment of the patient and the programme of therapy is also authorised (in a form specified by the Commission) by another consultant psychiatrist following referral of the matter to him or her by the first mentioned psychiatrist.
A form 16, entitled "Treatment without consent Electro Convulsive Therapy Involuntary Patient (Adult)" must be completed by both consultant psychiatrists and placed in the patient's clinical file.
This Bill seeks to prohibit the involuntary administration of ECT to a patient. We will propose on Committee Stage that during a period before he or she becomes unwell, and following a full and comprehensive explanation of the procedure of ECT, a patient will be asked to sign an advanced directive, giving or refusing consent for the ECT procedure on them at any stage in the future. We accept that the advanced directive could contain a provision where the patient is empowered to name an individual to make a decision on his or her behalf, in the event that he or she was likely to become unwell. However, this safeguard would deal with the issue of consent and ensure that the patient was consenting in a situation where he or she understood the implications of the decision, and was not under the influence of heavy doses of anti-psychotic or anti-depression drugs while making the decision. Why is the issue of informed consent by patients to the use of electroconvulsive therapy on them so important? Electroconvulsive therapy is a procedure that is primarily used for patients suffering from severe depression — in some cases psychotic depression. It is also used for patients with catatonia or mania. It is certainly a highly controversial treatment and while it is supported by many in the traditional psychiatric profession, it is bitterly opposed by many patients and their families as well as a growing number of mental health professionals.
According to a recent article by Dr. Brian O'Shea inIrish Psychiatrist, October-November 2007, the use of electroconvulsive therapy in Ireland was first officially reported in 2003. He refers to a study by Daly et al which stated that in 2003 in Ireland, 859 had received this treatment although the use of ECT had varied per region. The figure was 38.7 people per 100,000 in the Southern Health Board region compared with 8.4 per 100,000 in the South-Eastern Health Board region. This issue raises two important questions. Why is it, given the controversial nature of electroconvulsive therapy, that no official records have been available until 2003 for those investigating and concerned about its use? Why is there such a level of variability between the different health board regions in terms of the use of electroconvulsive therapy? This is something that must be investigated further by the Department of Health and Children. I have no doubt that, following our debate today, this type of investigation will occur.
Most individuals undergo a course of between four and six treatments of electroconvulsive therapy, usually two per week. The procedure is reported to work quickly, although its effect may not last longer than one month. The literature reports that it is usual to have a memory blank for the time surrounding a course of electroconvulsive therapy. The article I referred to by Dr. Brian O'Shea makes a couple of very worrying remarks about the use of electroconvulsive therapy. It opens with a quotation which basically questions whether electroconvulsive therapy should be a treatment of last resort and seems to be encouraging a much more widespread use of it. There are other comments in the article, however, which should cause concern. Dr. O'Shea says that dementiaper se is not a contraindication to the use of electroconvulsive therapy, although confusion among dementia patients after ECT can be severe and prolonged. He says Down’s syndrome patients can also be given ECT and mentions that psychiatrists do not consider age to be a contraindication in giving electroconvulsive therapy. He refers to a study that predicts an increased use of electroconvulsive therapy in elderly depressives. Another study he refers to stated that electroconvulsive therapy might actually be under-used among the intellectually disabled.
There is a passing reference in Dr. O'Shea's article to the possible side-effects of electroconvulsive therapy, such as amnesia, fractured limb bones, dislocated jaw, broken teeth, bitten tongue, myocardial infarction and angina. There is some reference to cognitive patients who have undergone electroconvulsive therapy and who experienced cognitive difficulties afterwards. Again, not very much attention is given to that issue in the article.
I would like to read a short passage from a psychiatrist who has been a very vocal critic of the practice of electroconvulsive therapy, Dr. Peter Breggin. This highlights why there is a campaign among those who have experienced electroconvulsive therapy and object strongly to its involuntary use in particular. Dr. Breggin writes:
It is impossible to find words that are sufficient to communicate the tragic personal cost to many of the patients who undergo ECT. In my own experience, spanning more than thirty years, I have encountered dozens of individuals whose lives have been wrecked by the effects of ECT on their mental function ... Many have been left with such devastating retrograde amnesia that they can no longer function as professional persons or homemakers. Years of professional training and other key aspects of their lives have been obliterated. Even portions of their past that they can remember may seem remote and alien as if they are watching a movie rather than recalling their own lives. Often they have been impaired in their ongoing ability to focus or pay attention, to concentrate, to make sense out of complex situations, to remember names and places, to learn anything new, to find their way around and to read and think effectively. Frequently they have become irritable and easily frustrated, emotionally unstable and shallow in their ability to feel. Often they feel depressed and even suicidal over the loss of their mental function. In short, they have shown all the typical signs of close head injury, including frontal and temporal lobe dysfunction. Often their families have been irreparably damaged by their inability to function as wage earners, husbands or wives, mothers or fathers. A treatment that can cause such devastation, while producing such limited and questionable results, has no place in the practice of medicine.
Having looked at the research in the area of electroconvulsive therapy in preparing for our Private Members' Bill, it seems to me that there is a great deal of uncertainty as to why it is that the ECT procedure is effective at all, where it is effective in some patients. Given the scientific uncertainty surrounding it, the point the Green Party is making is that its use without the consent of the patient must be prevented until we have the scientific knowledge that can explain how and why it works and on what patients it can be effective. I move the motion and ask other Members of the House to support it.
This Chamber has a proud history of independent thought and action and I believe we have more freedom in this regard than Members of the other House. More use should be made of Private Members' time which should be in putting that independent thought and action into practice. Far too often, when motions on the Government side are moved, they are self-congratulatory. Far too often when they are moved on the Opposition side of the House, they unfairly attribute all the woes of the world to the Government and its actions. However, this proud Chamber has an opportunity for investigation that I do not believe may be found elsewhere in the Irish political system. In moving this Bill tonight, I and my colleague, Senator de Búrca, are trying to use that independence to highlight an issue which otherwise might not get the attention it deserves in terms of public discourse and the need to have appropriate legislation on the Statute Book.
It is clear that greater attention should be paid to whole area of mental health. I am sure the Minister of State, Deputy John Moloney, who has moved into his job recently, is discovering this on a daily basis. There have been moves towards a more humanistic and humane approach to dealing with the issue in our public policy, yet many gaps in provisions remain. We have a far-reaching and generally accepted policy document in A Vision for Change, yet the legislation on the Statute Book contradicts many of the policy goals it recommends. In the legislation we are moving in Private Members' time the Green Party is attempting to point out where those inconsistencies lie.
There is a need for wider debate about the whole question of the rights of mental health patients and the discrepancies that exist between the types of treatment and the freedom of choice on offer to people who are being treated for mental health ailments as opposed to that enjoyed by patients suffering from general medical conditions. We need to have a debate on how people are admitted to institutions and how they are given particular medication, but that is too wide-ranging a subject to deal with in the context of this Bill. The Bill concentrates on two procedures which are the subject of debate in the medical and psychiatric communities and which cause a great deal of discomfort to those suffering from mental health disabilities. If the introduction of the Bill further promotes this debate, it will have performed an important function.
The Green Party wants two sections of the Mental Health Act 2001 amended. The Bill proposes the deletion of section 58 and its references to psycho-surgery or what is more commonly known as lobotomy. I accept deletion of the section would be inadequate because it would create a legal limbo. There is still a need to strengthen the legislation by putting in force a legal prohibition for a practice that, thankfully, no longer is happening on a regular basis. While it exists on the Statute Book, it represents an unnecessary temptation for those who want a surgical approach to dealing with psychological difficulties.
The second procedure, covered in section 59 of the Mental Health Act 2001, is more controversial. There is a debate about the use and extent of electroconvulsive therapy. Even in its current condition, its use is widespread. The most recent statistics show that 840 people have been subject to ECT treatment in one year. The average course for the treatment for an individual averages at four to six incidents in one year. This means the procedure is conducted between 4,500 and 6,000 times on nearly 1,000 people every year. That proves a reliance on a therapy that needs to be questioned. The legislation is purporting to control whether people can opt into the use of this therapy or whether there are circumstances such a therapy can be thrust upon them.
The Mental Health Act specifies the role of the Mental Health Commission in this area. However, the statistics make no differentiation whatsoever as to whether recipients of ECT have done so on a voluntary or involuntary basis. That speaks for the weakness of the existing legislation and highlights the need for it to be reformed in a dramatic way.
Using Private Members' time to introduce this Bill and the request to the Minister to take a particular position is an unorthodox use of the Green Party's position in the House. The Bill is about recognising that a problem exists and the need for an appropriate Government response to have legislation that reflects on an inconsistency for many people who live with mental health difficulties. I ask the Minister to look on the legislation favourably. I accept that the deletion of section 58 would create a legal anomaly. Senator de Búrca pointed out much needs to be added to the Bill on Committee Stage to make it more acceptable and determine whether these procedures are voluntary or involuntary.
The concept of advanced consent does not exist in our legal system and needs to be teased out on Committee Stage. I believe it has validity. If people are affected psychiatrically, their ability to give informed consent is obviously constrained. An important legal concept we are willing to put on the Statute Book is for an individual, who knows in advance when they are fully mentally aware of the nature of the treatment, to be willing to accept it at any date in the future.
I ask the Minister to initiative a review of these two procedures. It is the Green Party's intention to ensure this legislation receives as much support as possible from all Members. The understanding of the Minister will be part of that process. I am confident that having listened to the arguments the Minister of State will ensure this legislation is improved.
I support the fundamental idea behind and intention of the Bill. While it is, as Senator Boyle stated, an unorthodox use of Private Members' time, it is an interesting exercise which should put this topic on the wider agenda. It is a controversial topic within psychiatry and among patient advocacy groups and others who take an interest in mental health issues. The range of views on ECT are evident from the literature on the treatment, particularly that of psychiatrists working on the frontline of mental health services. There is equally a strong body of literature from patient advocates, expressing enormous concerns about this treatment. I look forward to the views of the Minister of State, Deputy Moloney, on this Bill.
I suggest that a next step in the debate would be to invite interested parties, such as the Mental Health Commission, patients' advocates and the Royal College of Psychiatrists, to the Joint Committee on Health and Children to make presentations on the treatment. Introducing this Bill will mean the topic will come out into the open for more discussion.
There are considerable regional variations in the use of ECT. What one finds with such variations is that the criteria for using the treatment are also varied. While I believe ECT is a rather historic treatment, I must take note that some experts have said it may be a treatment of choice in certain circumstances. Such circumstances would have to be defined with clear guidelines and the practice would have to be highly regulated. An informed discussion at the health committee would also allow us to consider recent research on the treatment.
The extraordinary variation in the rate of ECT prescription across the country is a matter of concern and raises questions. Apparently the Mental Health Commission does not have statistics breaking down the cases where patients voluntarily accepted ECT, consent was given or the decision was made by others such as relatives. All that type of information must come to the fore if we are to have the necessary debate on this issue.
I was struck also by the work being done by the organisation MIND in the United Kingdom on patient consent, which is at the core of this Bill. The new UK Mental Health Act 2007 introduces new safeguards for patients. ECT can be given only if the patient consents and the treatment is appropriate. In addition, if the patient is over 18, the doctor in charge of treatment or a second opinion doctor must certify in writing that he or she is capable of understanding the procedure and consenting to it. If the patient is under 18, a second opinion doctor must certify in writing that the patient is capable of understanding and consenting to the treatment. That would meet what the Green Party is suggesting in this Bill. That legislation should be examined and taken on board by the Minister to determine if it can be introduced into our legislation. More detailed points are made by MIND on this issue. We need a detailed debate on the consent issue. As far as psychosurgery is concerned it seems extraordinary that there remains a whole section in the Mental Health Act dealing with that, which clearly is inappropriate.
I want to make some other points regarding mental health. This discussion is helpful because for too long there has been a stigma associated with mental health. It may be helpful also to those patients having ECT or who have had it in the past and had bad experiences. We must talk about issues such as this, examine the parameters and what is happening in the area.
For too long we have ignored mental health issues and we continue to have major problems regarding mental health services. Some psychiatrists have expressed concern that if ECT could not be used without the patient's consent, some patients most in need of treatment would not receive any. There are problems also concerning the capability of some patients either to give or deny consent.
With modern advances in medication and other treatments some of those concerns might be outdated but I would like some discussion about them because it has been said to me that on occasions the use of ECT can be a life or death situation in terms of the patient's needs. I have an open mind on that but we must have a discussion about it. Is this an essential treatment at some point for some patients who might not be able to give consent? I would like to hear more on that and that is why I suggest we have hearings on it. I would like to see that happen but the Mental Health Commission immediately should carry out the audit on the use of ECT in Ireland, examine regional variances and, in a very short time, produce a report to update guidelines for those rare and urgent situations, if they arise.
I am concerned about the lack of funding for mental health services. I am concerned about the €25 million that appears to have gone missing. The Minister for Health and Children told the Committee on Health and Children some weeks ago that she was trying to find out what had happened to it before further funding was allocated this year. The Minister of State might clarify the position in that regard.
Regarding the United Nations declaration on the rights of those with a disability, in its most recent work in this area it has removed the question of force and the fact that any patient could be forced to agree to this treatment. If we ratify that declaration, and the Minister of State might consider that, it would address the issues the Green Party suggests must be dealt with in this legislation. That would be a help to Government in terms of taking action in this area if it brings in this measure.
Much more could be said about the mental health services but I would make the point that several child and adolescent units throughout the country are not taking referrals. They have closed their books. Units in Laois, Offaly, Kildare and Cavan are telling parents who need an assessment or whose children need a referral for psychiatry that the service is closed and they cannot take referrals. That is serious.
I ask the Green Party and the Progressive Democrats in Government to take an interest in that issue, as well as in the issue they have raised in this debate, and examine the overall mental health services, the funding and the service available to people. While an argument can probably be made that ECT belongs to another era, a child being told they must wait two years for an assessment equally should belong to another era.
As far as mental health teams are concerned, many teams throughout the country do not have their full multidisciplinary staffing. I was told today that in many teams people going on maternity leave, for example, are not being replaced. Many teams are missing members and are unable to give a comprehensive service to patients with mental health problems who are attending psychiatric teams throughout the country. That is a serious issue and one I hope the Green Party and the Minister would address also.
This debate is welcome. I congratulate the Green Party on bringing forward the Bill. I would like to see it discussed further in the Committee on Health and Children and to have a hearing on the issue. I support the principles contained in the Bill, with the reservation that we need further discussion on the consent issue for rare cases where it may be seen as an essential treatment. I want a discussion on whether it is still considered an essential treatment in certain circumstances by professionals in this area. If that is the case, it will have to be clearly defined.
There is strong literature from Germany, the United States of America and the United Kingdom indicating that in some very defined circumstances this could be a treatment of choice that would be life-saving. I put that on the record because I believe it needs further discussion and not to take in any way from the principles behind the Bill.
I call the Minister of State. I welcome him to the House.
I express my thanks to the Leader, Senator Cassidy, and to my colleague, Senator Phelan, for their welcome. Coming into the House for the first time as Minister of State, I am pleased the issue is related specifically to the area of mental health. In that regard I thank Senator Boyle and Senator de Búrca. It is not unorthodox for either Senator Boyle or Senator de Búrca to introduce this Bill during Private Members' time. The area of mental health and well-being is an issue to which no party on its own has all the answers. A number of the points raised, including those by Senator Fitzgerald, are relevant and forward-thinking and it is up to us to embrace that.
My job in the Department is not to come to the House and stamp a political party's approval on any proposal but to recognise that in moving forward the area of mental health and well-being there are areas we must re-examine and there is room for amendments. The Bill is timely because the officials in the Department are engaged in drafting amendments to the Act. This Bill is timely but it was never meant to suggest to the parties in Government that it had all the answers. It is fair to record also that the need for the amendments was identified in the review of the operation of the Act. That review is ongoing. That is not to suggest that the review will go on indefinitely. It is quite immediate.
There are several views on aspects of ECT. I welcome Mr. John McCarthy and other people who have met me privately. They have quite trenchantly described to me their areas of concern. I will take on board the concerns of people, matched with the advice from other sectors in the psychiatry profession.
We are prepared to listen to all the groups as we move on with this debate. I agree with Senator Fitzgerald's suggestion that the Joint Committee on Health and Children should be the forum for bringing in people such as the Mental Health Commission, the various advocacy groups, representatives of the psychiatry profession, to deal with the issue of ECT. It is also timely to state that this information is being collated. It will be important to study the results which will show the number of patients who have presented, both voluntarily and involuntarily for this treatment. This data should be studied in advance of any meetings of the Joint Committee on Health and Children.
I also wish to recognise other points made by Senators, such as the issue of the stigma attached to those who present with mental health difficulties. If I am asked for my views and the policy of my Department, my priority as Minister of State will be to implement change and I hope I will be in the position long enough to do so. I refer in particular to the area of the stigma attached to mental illness. I know of many people who will say they are reluctant to present for treatment because it is often given in the old psychiatric hospital system.
I can state with a certain background knowledge that many people have suffered from the disease of alcoholism and related depressive illnesses. I have no problem saying that my father suffered with the disease of alcoholism. He made no bones about it. In the 20 years when he was on the dry, he took time to try to explain to people the very sensible attitude that alcoholism is the same as any other illness and it was clearly up to the State to provide facilities to ensure that people withdrawing from that illness could seek treatment. Unfortunately, in the 1960s and 1970s, the only places available, unless one had private money, were in the local psychiatric hospitals.
I wish to put down a marker for my time in the Department that I want to see support come from the Oireachtas Members throughout the State. I have already asked for an audit of all the State's assets connected with psychiatric hospitals and attached lands. Members of the Oireachtas must prove our bona fides in the constituencies. The funding from securing those assets will go directly back into mental health. If people have concerns that this funding will be swallowed up in some other part of the HSE, I can assure the House that this funding will be specifically used for the upgrading and modernisation of mental health facilities in the country.
The report of the Mental Health Commission recommended that acute psychiatric care units should be located throughout the State. People should be properly housed in psychiatric facilities that are deemed proper for their care. Adolescent patients are currently housed in hospitals that were built not in the last century but in the one before that. I am making a policy commitment to remove the stigma by inviting four or five people from each county who have been successful in the arts, politics, drama or sport, who have presented with mental health difficulties, have been properly treated and are back in the workforce to speak about their experiences. This would be a start in removing the stigma.
I attended a conference in Brussels last week, as did John McCarthy, who is in the Visitors Gallery. I heard the most telling speech I have ever heard from the former Norwegian Prime Minister. He stated that while Prime Minister he had suffered from a depressive illness. He kept this to himself for quite some time but he then realised he could no longer do so. When he told his advisers that he needed to make a statement about his illness his officials beseeched him to say he had some other illness but he disagreed and told the public about his illness. As a result of his public announcement about his difficulties, mental health treatment in Norway moved on years beyond where we are today. I hope we can move on. I have set out my commitment to work to remove that stigma, to work to modernise the mental health service by providing facilities. Senator Fitzgerald was a member of the joint committee when we produced the report on the high levels of suicide. We made 64 recommendations, all of which tie in with the Reach Out programme established by the Government.
I wish to assure the House that the Government is firmly committed to the development of our mental health service and to the protection of people with mental health difficulties. At the end of January last, the office for disability and mental health was established with a remit to bring about greater collaboration across the public service on issues relating to disability and mental health. This office is cross-sectoral and will deal with different Departments such as the Departments of Education and Science, Justice, Equality and Law Reform, Enterprise, Trade and Employment and Health and Children. The office will promote and encourage an integrated "whole-of-government" approach in progressing the Government's agenda in this area, and will make the political commitment to disability and mental health a reality. In response to Senator Fitzgerald, it is clear the commitment can be challenged when we hear of a reduction in funding of €25 million and I have to accept what she says. It is up to the Department and the senior and junior Ministers to establish the reason the HSE removed the €25 million and I have requested this information. It is also necessary to conduct an audit of where the effects of the reduction in funding of €25 million will be seen. We must also ensure the funding initially allocated remains intact. I have requested a meeting with the HSE to seek answers to those questions and I expect this meeting will take place in the next few days.
In recent years there have been significant and very welcome developments within mental health services in Ireland with the launch of A Vision for Change, the report of the expert group on mental health policy in January 2006 and the full implementation of the Mental Health Act 2001. We cannot move on A Vision for Change unless we have the capital funding to do so and this will involve the realisation of the asset value into proper modern facilities. A Vision for Change represents a seven to ten-year action plan for the development of a modern, high quality mental health service which places the person at the centre. The future direction and delivery of all aspects of our mental health services are covered in the report.
The Mental Health Act 2001, which was fully implemented from 1 November 2006, is unquestionably the most significant piece of mental health legislation in Ireland in the past 60 years. It provides improved safeguards for people with mental illness and ensures the protection of the rights of people who are admitted involuntarily for care and treatment. This is the kernel of the issue proposed in this Private Members' Bill.
All involuntary detentions are now automatically reviewed by an independent Mental Health Tribunal. The review is independent, automatic and must be completed within 21 days of the detention or an extension order being signed. This brings Irish mental health legislation into line with the European Convention for the Protection of Human Rights and Fundamental Freedoms.
Part 2 of the 2001 Act has extensive provisions governing the use of involuntary admission procedures and is acknowledged as containing a high level of protective measures in relation to patients' rights. Members will gather from my speech that the overall theme is one of protection. We must work towards and agree on the degrees of protection involved and that is why I am suggesting, particularly to Senator de Búrca, that the amendments will quite properly take into account most of the views that have been expressed here today. I do not want to sign off on that as there is a long road to go but we are prepared to accept such amendments. I am not here to refuse Opposition amendments, nor to ignore the Private Members' motion. I want to establish clearly that it is a matter of us working together towards producing a Mental Health Act of which we can be proud and, more importantly, a legislative measure with which patients and their families can be satisfied.
The discussion here regarding a proposed amendment of the Mental Health Act is timely as my officials are currently engaged in drafting amendments to the Act. The need for these amendments was identified in the context of the review of the operation of the Act which was undertaken by the Department of Health and Children and laid before the House in May 2007. However, while amendments on the lines proposed are not envisaged at this stage, I am here this evening to listen to the views expressed. I am open to considering ways in which we can further improve our legislative protection for people with mental health difficulties. I see that as being the basis for the motion before the House also.
Our current legislation places a much needed focus on the human rights of people receiving care and treatment on an involuntary basis, and we must be careful at all times to ensure that respect and the promotion of the human rights of the service user continue to be the principles underpinning any legislative developments.
The proposal before us seeks to amend the Mental Health Act 2001 concerning two particular forms of treatment, psychosurgery and electro-convulsive therapy, otherwise referred to as ECT, which may be administered to patients who are detained involuntarily under the terms of the 2001 Act. First, let us consider the proposal to delete section 58 of the Mental Health Act 2001, which deals with psychosurgery. Section 58 currently prohibits the carrying out of psychosurgery on involuntary patients, except where the consent of the patient in writing has been given and the procedure has been authorised by a mental health tribunal. Section 58 is clearly a protective provision therefore.
If the proposed amendment were accepted, the administration of psychosurgery would not be prohibited; rather the legislative protection for the patient in terms of requiring his or her consent, and the authorisation of the procedure by an independent mental health tribunal, would be removed. That is where the difficulty arises. The proposed amendment, in effect, reduces the protection for persons suffering from mental illness and its acceptance would undermine our achievements over recent years in securing better protection for such vulnerable people. The place to tease out this matter further could well be the Joint Committee on Health and Children. Psychosurgery is a procedure that is rarely, if ever, used. Nonetheless, it is important that provisions relating to psychosurgery should be retained in our legislation in order to protect involuntary patients against the arbitrary use of the procedure in the future.
I now turn to the second element of the proposal, which seeks to amend section 59 to remove the provision which allows ECT to be administered to an involuntary patient without his or her consent. Our current legislation requires that a patient must consent in writing to the administration of ECT. However, the legislation provides that where a patient is unable or unwilling to give consent, the treatment may be administered if it has been approved by the consultant psychiatrist responsible for the care and treatment of the patient and authorised by another consultant psychiatrist.
There are of course diverging views both within and outside of the psychiatric profession on the necessity and-or efficacy of ECT. Clearly, that is the issue with which we are trying to deal. However, it remains a recognised treatment for severe mental illness and is sometimes used to treat persons with severe depression who do not respond to drug treatment.
A review and meta-analysis which was published in the highly respected medical journalThe Lancet in 2003, concluded that ECT is probably more effective than drug therapy. Of course it can be a feature of severe mental illness that a person’s judgment may be so impaired that he or she lacks insight into his or her own condition. Where a person is involuntarily admitted under the provisions of the 2001 Act for treatment that he or she might not otherwise receive, it is incumbent on the State and treating clinicians to provide that person with the most effective treatment for his or her condition. A duty of care is expected from the State for people who have been admitted involuntarily, and that is the reason for that provision.
If the treating consultant psychiatrist is of the opinion, based on his or her clinical expertise, that ECT is the most effective treatment in the circumstances, the law should make provision for the administration of that treatment to those who are not in a position to give their consent, within the necessary safeguards of the 2001 Act. It could be argued that to do otherwise would be in contravention of the State's duty of care to the involuntary patient. If somebody is admitted involuntarily, where does the duty of care begin or end? I believe the State has to exercise that duty of care.
During the course of the review of the Act which was undertaken by my Department and completed last year, some submissions suggested that the reference to a person who is "unwilling" to consent to ECT should be deleted from section 59. In other words, where capacity to consent exists, any refusal to accept treatment should be respected, and this right respected by law. In principle, I would accept this suggestion, but this matter cannot be dealt with in isolation. Legislation is being prepared which will take into account issues that arise in this debate. The matter will not be parked or shelved because it is part of the ongoing process of arriving at legislation that will be well accepted.
Any amendment of the Mental Health Act on these lines — for example, to delete the word "unwilling" from section 59 — would have to be undertaken within a supporting framework of legislation defining legal capacity. The Office for Disability and Mental Health has already raised this matter in the context of the development of new capacity legislation by the Department of Justice, Equality and Law Reform. I can assure the House that it will be considered further in that context. This aspect defines the importance of the Minister of State with responsibility for disability and mental health. It is a cross-departmental issue that requires continued action, not least under my Department's aegis.
The ethos of the Mental Health Act 2001 was to provide a modern framework within which people who have a mental disorder and require treatment or protection can be cared for and treated. The Act provides mechanisms by which the standards, care and treatment in mental health services to the most vulnerable of all can be monitored, inspected and regulated.
In this regard, the Mental Health Commission published rules on the use of ECT in November 2006 and the inspector of mental health services monitors compliance with these rules on an annual basis. While compliance is important, I take the point made by some Senators that it is also important to have the data to hand, and they are currently being prepared. The rules require that at the conclusion of a programme of ECT, an ECT register is completed for each involuntary patient and a copy placed in the patient's clinical file. The administration of ECT without consent must be recorded in the patient's file and a copy forwarded to the Mental Health Commission, which is an important safeguard. These rules are kept under periodic review by the commission and can be revised as required. Any review of the rules governing the administration of ECT should ensure international best practice continues to be taken into account.
The Mental Health Commission recently published a review of the operation of Part 2 of the Mental Health Act 2001, as required under Section 42 of the Act. The report noted that stakeholders in the mental health services have participated in a significant programme of reform in recent years and that commencement of Part 2 of the 2001 Act has brought a greater level of openness to mental health services in Ireland.
I thank those contributing. I especially thank Senators Boyle and de Búrca for putting this on the agenda of the House. I say that genuinely coming from a position, as we all do, of trying to improve mental health services. It is fair to point out that there have undoubtedly been great strides taken in the development of mental health services in Ireland in recent years, particularly in improving the legislative protection of persons with mental illness.
While I have reservations about deleting section 58 on psychosurgery, further consideration of these provisions in the Act concerning consent to treatment is appropriate and will be progressed in the context of the development of capacity legislation.
I want to confirm that we are saying "Yes". On the concerns raised, we are preparing amendments. In the context of the capacity legislation, it gives us the vehicle to take on board what the Senators are saying. I also see the tremendous sense in properly and openly debating the issue at Oireachtas Joint Committee on Health and Children level, particularly by way of bringing in experts who will voice their positions for or against. It will also deal with the issue of ECT, especially for elderly patients who refuse to eat or drink. It must be underpinned by the Government's commitment by way of a duty of care.
I thank the Senators for giving me this opportunity. I again issue the invitation that we will sit down in September or October with all the Members who represent constituencies where there are the older facilities to see if we can come up with a common programme, rather than a Government programme, as to how we can transfer the assets to modern facilities. I invite everybody to participate in that. To my mind, that is the way to move forward. Not everything will be resolved by way of new buildings. It is equally important to have the back-up professional staff. I am prepared to take all the advice given to me, particularly by the advocacy groups and, more importantly, by the Mental Health Commission.
Before I call the next speaker, I take this opportunity to welcome the Minister of State, Deputy John Moloney, to the Chamber. I do so as a Tullamore woman and a neighbour of Deputy John Moloney from his native Mountmellick. I am delighted to see him in the Seanad taking this debate. I commend him on the honest and personal nature of the earlier part of his presentation. It is a measure of the kind of man he is and, indeed, an indication of the type of Minister of State at the Department of Health and Children that he will be. On a personal note, I wish him well in his Ministry because it is the first time he has been in the Seanad Chamber. I look forward to seeing much more of him here.
It is also a great pleasure for me to be able to welcome the Minister of State to the House. I could not be happier that he has so recently vacated the Chair of the Oireachtas Joint Committee on Health and Children. I would agree with both Senator Fitzgerald and the Minister of State that it is an excellent forum where we should seek to have all types of submissions from interested parties right across the divide.
As somebody who has worked in the health services for a long time and whose partner has been working in psychiatry for the past 30 years, I have a degree of knowledge of the subject. This is an opportunity to have a welcome debate. I am aware that among the Senators there is a wide level of experience in the health services and also psychiatry, and we do not come wanting to the Chamber.
Mental ill-health is widely varied. It affects so many elements in society. Whether it is as a fall-out from taking so-called recreational drugs and the psychotic episodes that might occur as a result, an adverse reaction to cannabis, the age profile of a particular personality trait or the wide umbrella under which mental health issues can arise, there are many aspects to the treatment.
In my professional life as a midwife, I especially remember one occasion when a poor lady deteriorated into puerperal psychosis and there was a very dramatic positive effect from the procedure, but I also will temper that by saying that I was horrified by my first viewing of patients having ECT. There is an element of acceptance. I have a great belief in the capacity of professionals to deliver excellent care and to have different methods, both of specialties and treatments.
It will be important in our deliberations in this welcome debate that there would be inputs from all affected parties and, if possible, from people who may have had this particular treatment, and where they found that it was of benefit. If it was not and they are unable to give a view, that is something we must accept as well. Patient advocacy groups are excellent in putting cases for people who may not be able to articulate their own response.
I am a member of the sub-committee on suicide. In that regard, I have a concern which is somewhat related. I suppose it would be remiss of me not to take the opportunity to bring a few items for the Minister of State's shopping basket. Currently in Clonmel there are lands to the value of €12 million belonging to the former health board and undergoing sale. I would like to see that €12 million being reinvested in mental health services.
As has been stated, we are not talking about buildings but about services. On the issue of whether those resources need to be put into new buildings or into services that will meet the needs of youth, I acknowledge there is a desperate need to have an evaluation system that will fully identify the needs of adolescents where it might be decided that they need admission to a bed. I am aware that not all young adolescents who need to be evaluated will need inpatient treatment. In fact, there are many aspects to treatment and to modern methods of research. There are also many methods of modern drug treatments which are effective and are monitored. There are blind studies and double blind studies. There are all sorts of methods of evaluating the effectiveness of treatments carried out.
I will not delay much longer except to say that I welcome the taking of submissions from interested parties through the Oireachtas Joint Committee on Health and Children. It is a matter of public record that we would welcome the input from affected and interested individuals, parties, professionals, advocacy groups and, indeed, clients of the service.
I thank the Minister of State, Deputy John Moloney, and I wish him every success in his remit as Minister of State. I say without fear of contradiction that he will make such a difference to the mental health services. There is already a mind change in many elements of society where mental health services are no longer seen as the aspect of care that needed to be swept under the carpet. There also will be a great deal of sensitivity towards those who do not wish to have their personal mental issues discussed. I am always careful when speaking about Clonmel in case somebody asks if I was talking about him or her.
I welcome the opportunity to contribute to this debate and commend the Green Party on its thoughtfulness in bringing an issue, such as this, the fore. I am sure that by the time it reaches finality, we will have the fullest information available. We will be a very informed group, which is welcome. Anything which improves an outcome or a particular treatment is welcome. I do not consider it boldness on the part of Senator Dan Boyle in bringing this Bill before the House. It is a welcome opportunity to contribute to the debate and I thank him for that.
I welcome the Minister of State on his first occasion in the House in his new role as Minister of State with responsibility for disability and mental health. He has a significant interest in, and commitment to, the area he outlined and I wish him well inhis portfolio. Like other Members, I have no doubt this area will be the better for his appointment.
I welcome the Minister of State's commitment that moneys allocated to the area of mental health will be spent in that area. It has been a constant source of frustration to me and to other Members that when seeking to ascertain where moneys allocated have been spent, we have not been able to reach satisfactory conclusions. If Members of the Oireachtas vote for a sum of money to be spent in a particular area, it behoves agencies, such as the HSE, to comply with it out of respect for, and courtesy to, them. We would not allocate the moneys if we did not believe there was a need to do so.
I welcome the Minister of State's comments on the work he will undertake to ensure the stigma associated with mental health becomes a thing of the past. I welcome any opportunity to create a greater sense of openness for, and a greater understanding and awareness of, people who experience mental health challenges. One of the welcome consequences of doing so will be that people who experience mental health challenges will be much more open to seeking assistance and intervention. Therefore, it is critical we have the services in place to respond to people who will avail of that openness and understanding to come forward to seek treatment.
Turning to the Bill before us, it is useful to commence by reflecting on the Act it seeks to amend. The Mental Health Act 2001 provides a modern framework within which people who have mental disorders and require treatment or protection can be cared for and treated. It puts in place mechanisms by which the standards, care and treatment in mental health services can be monitored, inspected and regulated. It includes a range of safeguards to ensure the rights of people who are admitted involuntarily for care and treatment are protected. Its enactment brought Irish law into conformity with the European Convention on Human Rights.
Part 2 of the Act has extensive provisions governing the use of involuntary admission procedures and is acknowledged as containing a high level of protective measures in regard to patients rights, including mental health tribunals and legal representation. Part 4 of the Mental Health Act entitled, "Consent to Treatment", contains a range of provisions which govern the administration of certain forms of treatment to involuntary patients.
The Act also established the Mental Health Commission to promote, encourage and foster the establishment and maintenance of high standards and good practice and to protect the interests of people detained under it. It also provided for the establishment of the Office of the Inspector of Mental Health Services replacing the former inspector of mental hospitals.
As the Act came into being, teething difficulties were experienced around its implementation. It has brought about changes in practices, requirements and expectations. Its implementation has certainly proved challenging for all involved, especially with the establishment of the mental health tribunals. However, many of the initial hiccups and uncertainties have been ironed out. While some challenges remain to be addressed, a consensus has emerged that the Mental Health Act has had a very positive impact for patients and that it has ensured that Ireland conforms with the European Convention on Human Rights.
This Private Members' Bill proposes to amend the Act in regard to two forms of treatment which may be administered to patients detained involuntarily, namely, psychosurgery and electroconvulsive therapy, otherwise known as ECT. Section 1 of this Bill proposes that section 58 of the Act, which deals with psychosurgery, be deleted and section 2 proposes that section 59 of the Act be amended to remove the provision which would allow ECT to be administered to an involuntary patient without consent.
Under the Act psychosurgery means any surgical operation which destroys brain tissue or the functioning of brain tissue and which is performed for the purposes of ameliorating a mental disorder. This procedure is rarely, if ever, used. I do not believe it has been used in Ireland since the 1960s. However, as it still remains a possible form of intervention, it is believed necessary to include provision in legislation to protect any involuntary patients against any future use of the procedure.
Would it be possible for research on psychosurgery, its use in Ireland and abroad and its efficacy and appropriateness to be undertaken to inform our thinking on any future amendment that may be necessary? The question which should be before us is whether psychosurgery should remain a possible form of intervention. Undertaking a review of the area, both in Ireland and internationally, to ascertain its exact use and appropriateness would be very informative. I agree with the Minister of State that if we were to proceed with the provision in this Bill to delete section 58 of the Act, unintentionally, the effect could be to remove the protection in place for the involuntary patient whose consent is currently required. The question should be whether to delete psychosurgery as an option and not section 58 of the Mental Health Act.
In regard to electroconvulsive therapy, ECT, the amendment in the Bill would remove the provision whereby it can be administered to an involuntary patient who is unable or unwilling to consent. While there are diverging views, both inside and outside mental health services, on its necessity or efficacy, it remains a recognised and legitimate treatment for some forms of severe mental illness. The evidence available on its necessity and efficacy is mixed, appearing to be stronger in its use for older people where other medical treatment has elicited no effect — for example, in instances of deep depression.
As the Minister of State said, a study published in 2003 inThe Lancet concluded that ECT was more effective than drug therapy. In regard to the Department’s review, we could perhaps consider ECT in the context of the capacity legislation due before us. We should examine the capacity of people to give consent and their right to have it respected and taken on board. I also ask that the capacity to give consent of involuntary patients be considered for a range of situations and not only limited to the use of electroconvulsive therapy, ECT. My understanding is that the legislation we are considering which deals with the capacity of consent will be based on the concept of functional capacity and not based on a broad blanket of capacity. The legislation, therefore, would provide a framework that would allow situational-specific capacity and therefore maximise a person’s autonomy.
I am pleased that we are debating mental health in general. In the short time I have been in the Seanad I have heard several Senators from all parties raise the issues of mental health, its treatment and the resources required for dealing with mental health in Ireland. An excellent document was produced in 2006 called A Vision for Change. The roll-out and implementation of the recommendations of that report is a serious concern for many people involved in the mental health sector in Ireland.
Mental Health Ireland consists of many voluntary groups working with mental health patients and their families and advocates for them on a daily basis highlighting the lack of resources and the issues that affect patients. I am sure, as I have, many Senators have met these groups in recent years. They include Aware, The Irish Advocacy Network, Schizophrenia Ireland, GROW, OANDA, Headway Ireland, The Samaritans, BodyWise, The Alzheimer Society of Ireland and Recovery Inc. These groups advocate on a daily basis and deal with issues such as those we are debating. The Trojan work of these groups to educate the public and politicians about what it is like to live with, work and treat people with mental health issues should be acknowledged by all legislators and policy makers. It is important we listen to these groups as they are at the coalface every day confronting the issues.
On the Bill, it is important that legislators and policy makers keep issues of mental health as the highest priority when debating health in general. I compliment the Green Party on bringing forward this Bill. There is consensus across the House. The general thrust of the Bill is good and it attempts to address some issues of concern to the bodies and patients already mentioned.
The two procedures specifically mentioned in the Bill, psychosurgery and ECT, have been controversial within the health service and among clinicians and the people that treat mental health patients. There is a debate proceeding among those sectors. It is important that we as politicians debate the issues and that we inform ourselves, as much as possible, about the techniques used in mental health treatment. ECT seems to be a stressful treatment. I have consulted with people that have worked in this area, whether it is psychiatrists or psychiatric nurses and they have indicated it should be a treatment of last resort, that all other treatments and therapies should be explored, and that it is important that, where possible, the consent of the patient is approved before any invasive treatments such as ECT are considered. There are concerns about the regional variations of the application of this treatment and this needs to be examined.
I ask the Minister of State, Deputy John Moloney, to ask his Department to carry out studies into the way ECT has been used in Ireland. There are obviously concerns about the treatment. Some people to whom I have spoken suggest it is used too randomly and freely by some psychiatrists. Others say there is a need for ECT, but that the guidelines and protocol for its use need to be stricter and properly regulated. I call for clearer guidelines and protocol. There should be systems which properly inform patients, their families and advocate groups.
It is also important to get the views of clinicians. In psychiatry we often hear of a second opinion, so professionals differ in their views too. We need a wider examination of the treatment system in Ireland. We need to consult extensively with clinicians, patients and their families and the advocacy groups. We need proper regulation and monitoring of how ECT has been used and how it is proposed to be used in future. We need a proper evaluation on how successful it has been. I am sure some will argue it has been a considerable success, whereas others will say it has not been successful. A proper evaluation of the success of ECT should be examined.
It was suggested by my colleague, Senator Frances Fitzgerald, that there is a role for the Oireachtas Joint Committee on Health and Children to examine mental health in general, but also to examine the aspects of mental health this Bill presents. Some guidelines used in other jurisdictions have been recommended and are generally accepted by professionals and clinicians in the area. ECT is used for rapid and short-term improvement of severe symptoms after other treatment has failed, or when the condition is considered to be potentially life-threatening. Some guidelines set down in other areas include the recommendation that the therapy is used for patients with severe depressive illness, types of schizophrenia or a prolonged or severe manic episode. The decision to use ECT should be made jointly by the individual and the clinicians responsible for the treatment. Consent should be obtained where the patient is able to give such permission.
There are many areas that need to be examined. I welcome this debate and the Green Party is to be commended on putting mental health in general on the agenda. I look forward to further debates on this issue as it is certainly an area we need to discuss. The reportA Vision for Change which was introduced two years ago considers a long-term plan. We are already two years into that plan and many of the advocacy groups and politicians representing those with mental health issues would agree we are not achieving our targets. The money and resources that were supposed to be allocated to treat mental health under the recommendations of the report have been cut in the budgets. There is disappointment in the advocacy groups about this. The report promised much and if the recommendations were implemented as proposed we could make serious improvements in the treatment of patients.
I sense as a public representative that we are finally lifting the stigma which in the past was attached to mental illness in Ireland. I acknowledge the role the advocacy groups are playing in educating the public about mental health issues.
I am from County Waterford and there is a institution there called St. Otteran's Hospital which does Trojan work, and I have spoken to staff there. There are concerns as the hospital is due to be sold. Promises were made that the resources and money raised from the sale of extensive property would be ring-fenced and re-invested into mental health facilities. This is only fair, because where mental health patients are returning to the community they will need the financial resources to support themselves. It is only right that any money raised from sales of lands in psychiatric services should be ring-fenced for the benefit of those patients.
I welcome the Minister of State, Deputy John Moloney, to the Chamber, congratulate him on his appointment and wish him well in his role. It is unfortunate that several other Members were not here to listen to his contribution. He spoke with an in-depth knowledge of the challenges that lay ahead for him, and with a passion to resolve those challenges quickly and effectively.
I congratulate my Green Party colleagues on bringing forward this amendment to the Mental Health Act 2001. This Act already includes a range of safeguards to ensure the rights of people who are admitted involuntarily for care and treatment are protected and that Irish law conforms to the European Convention on Human Rights. The amendments proposed this evening set out to further safeguard those rights and to ensure that very invasive treatment procedures are not administered without a patient's consent. The amendments are most definitely inspired by a desire to protect people with mental health difficulties and they offer us an opportunity to discuss a number of important issues in this Chamber.
I agree with the thrust of these Green Party amendments and what they set out to achieve. It is important also to state how this treatment emerged and to set out its history. The concept of having electricity pass through one's brain is daunting enough to frighten even the most well-informed and well educated people. It is broadly accepted that the apparent effectiveness of ECT results from the long-term brain damage it causes.
In 1941, Dr Walter Freeman, the psychiatrist who introduced ECT to America, wrote:
The greater the damage, the more likely the remission of psychotic symptoms ... Maybe it will be shown that a mentally ill patient can think more clearly and more constructively with less brain in operation.
In 1942, another US psychiatrist and proponent of ECT, Dr. Stainbrook, wrote:
It may be true that these people have ... more intelligence than they can handle and that the reduction in intelligence is an important factor in the curative process.
He went on to say:
Some of the best cures one gets are in those individuals who one reduces almost to amentia [a term used to describe total imbecility.]
During the following 30 years, hundred of thousands of patients of all ages across the globe received electroshock treatments for every type of disorder, including depression, mania, schizophrenia and even homosexuality and truancy from school. By the end of the 1960s, ECT treatment had almost vanished from the psychiatric scene. However, it has undergone a makeover in the past 20 years and has regained a huge degree of respectability in some quarters. Many psychiatrists now consider it an efficient way to relieve severe depression or to break a manic cycle for the manic depressive. According to ECT advocates, it can restore a severely depressed or manic patient to health in half the time it takes medication to do so.
Critics of ECT argue it is primitive and outdated. They also believe that positive results are short-term and that patients who undergo ECT suffer cognitive problems, including significant memory loss and the ability to learn. They believe what looks like relief is really just the effect of a head trauma. What is incredible is that doctors still do not know for certain why ECT works to fight mental illnesses. This often makes the decision to have ECT even more difficult for a patient. The leading opponent of ECT, Dr. Peter Breggin, a psychiatrist and author, believes that the price is too high. He describes ECT as playing Russian roulette with your brain. He believes that the procedure is no more sophisticated than hitting someone over the head with a club.
It is obvious that there are very divergent opinions within the field of psychiatry, both from doctors and patients, on the effectiveness and the appropriateness of ECT. There is little information on the use of ECT in Ireland and research is badly needed. Most recent figures reveal that in 2003, 859 persons in the South had treatments and that 628 people in the North of Ireland had treatments. Among other problems, there is no information on gender breakdown, age distribution, the number of people to whom ECT was forcibly applied, and, most importantly, the number of fatalities.
The amendments proposed this evening to the Mental Health Act 2001 do not purport to settle the argument but instead set out to allow the patient the right to decide whether or not to avail of the therapy. In particular, the concept of informed consent is introduced in this new legislation. Under the "informed consent" protocol, permission to administer ECT comes following a careful review of the treatment with the person providing consent. The psychiatrist explains what ECT involves, what other treatments might be available and the benefits and risks of treatment. The person consenting to the procedure is kept informed of progress and may withdraw consent at any time. A psychiatrist may not force a patient to have ECT or decide for the patient that it is the appropriate treatment. He or she must obtain written consent from the patient, or if the patient is too ill to make decisions for himself or herself, from a court-appointed guardian.
At a time when there is such divergence of opinion on the effectiveness of ECT, even within the field of psychiatry here in Ireland, it is most appropriate to begin a discussion of the issue of informed consent in Seanad Éireann. The amendment proposed in the Private Members' Bill would remove the provision whereby ECT may be administered to an involuntary patient who is "unable or unwilling" to consent, if two consultant psychiatrists certify that it is required. Impairment of a person's judgment may be a factor in severe mental illness. It is reasonable to expect that at some point in the patient's history he or she would have had the mental capacity to decide whether to subject himself or herself to ECT. I believe that patients should at that time be allowed to avail of the opportunity to make an informed decision on whether they would ever avail of ECT and that that decision should be fully respected by their doctors.
Again, in a situation where this cannot take place, the informed consent of a court appointed guardian should be sought. In the USA, for example, the Surgeon General's report on mental health requires a judicial proceeding at which patients may be represented by legal counsel prior to initiation of involuntary ECT. It states:
As a rule, the law requires that such petitions are granted only where the prompt institution of ECT is regarded as potentially lifesaving, as in the case of a person in grave danger because of lack of food or fluid intake caused by catatonia.
What is paramount here is the inalienable right of a person or his or her guardian to decide whether to subject that person to a procedure that is invasive, traumatic and bereft of utterly conclusive research as to its benefits or otherwise.
Despite my lack of expertise in this area, my instinct in regard to ECT is that given the inconclusive research in terms of its benefits and having read about and listened to the negative experiences of those who have had this treatment administered, I believe we should seriously consider following some of our European neighbours and severely restrict its use or, following in-depth research and discussion at committee level, as suggested by Senator Fitzgerald, consider banning its use completely as has been done in Slovenia.
Gabhaim comhghairdeas leis an Aire Stáit, an Teachta John Moloney, agus cuirim fáilte roimhe go dtí an tSeanaid.
I commend the Green Party on bringing forth this timely Bill. However, if it thinks that putting this Bill before the House will appease its conscience regarding mental health it is sadly mistaken. For too long, our mental services have been severely and chronically under-funded and under-staffed by this Government, of which the parties opposite are members.
The motion before the House has the broad support of my party. I commend those people outside public office such as John McCarthy in Cork who have been to the fore in making mental health a topic about which we can all speak and which we can all seek to demystify. In this regard we are speaking about people and not statistics, people who deserve respect, support and to be nurtured and loved by society.
Of fundamental importance in this debate is not alone the nature and type of intervention provided to those with significant mental health needs and illnesses which are severely debilitating for them and which prevent them from reaching their potential in the community but the question of what supports and protection are put in place for those deemed by experts to lack capacity in respect of decision-making and, ultimately, in giving consent to a very intensive intervention which carries with it an array of known and documented side-effects. Like Senator Cannon, I am not an expert on psychiatry. However, having researched this issue and having consulted widely on it, I believe the role of ECT is, to say the least, dubious. It is an outdated practice. I hope we will ban its use forever. I welcome what the Minister of State had to say in his speech. We are only beginning this process and it is important we have this debate.
There are known risks in regard to ECT, be they cognitive impairment, memory loss, medical complications or physical issues, that need to be addressed. The central issue of concern for me is not whether ECT should be administered but rather the ability of a person to provide informed and valid consent to a procedure that has well documented side-effects. People are what we are about. If we are to have a truly person-centred mental health service we must put people with mental health needs, individually and collectively, at the heart of the decision-making process.
I believe the Minister of State is genuine and sincere. Since I got to know him in this House I believe he is a man of action and absolute sincerity, whatever about some of the people around him. I hope he can take this issue, along with disability, and make it a central part of his remaining term of office.
We must identify and implement strategies that are long term as well as current and focused, which place a strong emphasis on supporting and enabling people to make their own decisions. The Government's document A Vision for Change is long on rhetoric but short on answers. Under-funding and lack of resources have become by-words and by-products.
Regarding the Minister of State's field of intellectual disability, I have been very involved in this area, long before I became involved in politics. In the United Kingdom the Mental Capacity Act has a number of key principles which emphasise the centrality of the individual and the person within that process. I hope that in the debate on mental health we can take the viewpoint that every adult has the right to make his or her own decision. People must be supported as much as possible to make that decision before anybody concludes they cannot do so. People have the right to make what others might regard as unwise or eccentric decisions.
I repeat that we are talking about people. For too long Government has forgotten about people, being driven by economic indicators and by profits and, in consequence, the HSE and other areas have become restrictive. We lose the core of people in community. A Vision for Change was launched with much fanfare. We were promised that the sale of all institutions would give us huge amounts of money, that we would have a pot of gold and community-based supports. What has happened? What is happening? Every week we get telephone calls from people who are struggling. They cannot get social workers at the weekend, or access to the psychiatric wards in Cork University Hospital. Only two weeks ago I was contacted by members of a gentleman's family who were distressed and at their most vulnerable. The very organ that was there to support them did not admit the person concerned. What does that message say to us? We have never had so much money.
Senator Fitzgerald called for an audit by the Mental Health Commission regarding the use of ECT. I support that. She is absolutely right. It is clear that the practice is outdated and must be jettisoned. I know and respect where the Minister of State is coming from as he approaches this subject. He is the driver of the engine and must look at the whole picture.
Alternative methods must be clear and agreed by all stakeholders, a word I use in the sense of "advocates". Human rights and human dignity are the issues about which we should concern ourselves. Let us not categorise people or put them into boxes. In many ways we all struggle in life and every day we do the best we can. It behoves us, as legislators, and it behoves Government, as the voice of the people, to represent the people whom we support.
We are not only discussing ECT, depression or psychosis. I go back to the point with which I started. We are talking about people — our brothers, sisters, mothers, fathers, uncles, people we know. We must strive for and, as leader on this issue, the Minister of State must create a mental health service that is responsive to people, rather than to models of treatment or care. We must recognise the centrality of the person with mental health needs. Unless we have that person's rights and concerns as our first and foremost concern we will have failed.
I commend the Bill and I look forward to future debate, but we need action.
I welcome the Minister of State, Deputy John Moloney. From my experience of him in the past seven years, I agree with Senator Buttimer. He is a man of action and will want to see the same. I am sure he will not be patient. I offer my best wishes to Deputy Moloney, his wife, Trish, and their children and I hope he may have every success in this position and be happy in doing the very important job the Taoiseach gave him.
I express my sincere gratitude to Senators Norris, de Búrca and Boyle for offering me the opportunity to speak this evening about the mental health involuntary procedures amendment and about the status of mental health services in Ireland. I listened to the Minister of State's very passionate speech in which he mentioned the personal circumstances of his father and spoke of his commitment to make changes. I wish to let Senator Cannon know that although I was not here I was listening. I listen more often when I am not here. Many people would have heard the speech this evening.
The amendment in question relates to electroconvulsive therapy and how it should not be exercised without informed consent, in writing, from the patient. Sections 58 and 59 of this Bill might have led to appalling consequences had they not been highlighted by the Green Party. In A Vision for Change, the Government's expert policy group document of 2006, section 56 (61) provides definitions and guidance on consent, treatment without consent, psychosurgery, electroconvulsive therapy and consent where medication is given for a continuous period of three months.
Every human being, whether born with a physical disability, a mental disability, depression or whatever, is entitled to have aspirations and dreams like the rest of us and is entitled to have the facility to fulfil those dreams. If people are over-prescribed with medication or with electroconvulsive therapy or psychosurgery, this cannot happen. I have seen this occur with two people who were treated with medication. One is a genius but has never been able to utilise her brilliance because of being over-prescribed.
Like the Minister of State, I am a very impatient person and I like action. In his speech he noted that in recent years there have been significant and very welcome developments within mental health services in Ireland, with the launch of A Vision for Change and the report of the expert group on mental health policy in January 2006.
I am sure that Deputy Moloney is up to date on the matter but I shall read from the annual report of the Mental Health Commission, published in May 2008 which states:
Great hopes were expressed in 2007 that the recommendations of A Vision for Change, the national Government policy on mental health, would be addressed in 2007. While acknowledging that A Vision for Change involves a seven to ten year programme of change and development, the Mental Health Commission was disappointed and concerned at the absence of progress in 2007. The Commission highlighted child and adolescent mental health services as an area requiring special attention.
The Minister of State does not need me to tell him — I am sure he already knows — that there are 3,000 children in this country who are waiting to get assessment by a psychiatrist in the public sector. If one has money one can meet a psychiatrist the next day or whenever but there are 3,000 children out there waiting to be treated, with up to two years waiting time. Approximately 300 children are being treated in adult psychiatric wards. The Minister of State knows that, in a week or two, I will have completed my document on suicide prevention, which I have been researching for the past year. It is shocking, horrific and frightening that there are children in economically deprived families who cannot obtain psychiatric help. Every person in this State is born with the right to treatment. The Minister of State knows this and did not receive his brief cold. For the past six years, he was a very successful Chairman of the Joint Committee on Health and Children. He will not have a slow learning curve and is in the middle of the action. He wants to make changes in the health service.
The recommendations are crying out for implementation. A Vision for Change, the report of the expert group on mental health policy, is lying on a shelf and has not been granted funding. I produced a report on child care, ageing and ageism and noted there were hundreds of reports on shelves in respect of both child care and ageing. The same applies to the subject of mental health. We want delivery.
When the Government receives a report, changes should be made automatically. The Minister of State is as passionate as the rest of us about making these changes and delivering on the recommendations contained in A Vision for Change. Dr. John Hillery spoke at the conference I organised on suicide prevention in Citywest Hotel in February and asked me to try to convince the authorities to put in place funding to make the recommendations in the document areality.
I wish the Minister of State the best of luck. At the end of his stewardship in his current portfolio, he will want to be able to say to himself and all of us that he made actual changes in the area of mental health. I know he will.
Gabhaim buíochas leis an gCathaoirleach as an deis labhairt ar an mBille tábhachtach seo atá os comhair an tSeanaid anocht agus as an deis tacú leis. Ba mhaith liom comhghairdeas a dhéanamh leis na Seanadóirí ón Pháirtí Glas as ucht an Bhille seo a thabhairt chun tosaigh agus deis a thabhairt dúinn é a phlé. Tá súil agam, ní hamháin go bpléifimid é ach ina dhiaidh sin go mbeidh muid in ann bogadh ar aghaidh leis na moltaí atá sa Bhille. I am glad to support the Bill and commend the Senators on bringing it forward.
A few years ago Amnesty International produced an excellent report entitled Mental Health: The Neglected Quarter. Despite the implementation of the Mental Health Act, improvements in care and improving awareness of the reality of mental ill health, the mental health service is still the neglected quarter of the health service as a whole. The quarter of the population who will, at some time in their lives, experience mental health problems is still being served badly.
TheIrish Medical News reports this week that lands belonging to St. Mary’s Psychiatric Hospital in Castlebar, County Mayo, were secretly sold for more than €1.3 million. So secret was the transaction that the staff believed the land had been given away. It now emerges that the land was sold and that the HSE never applied to the Department of Finance to be allowed to reinvest the proceeds of the sale in psychiatric services, including necessary capital projects. Apparently the money has been lying in the bank since the sale in 2005. This is just one example and I hope the Minister of State will bear it in mind.
The promised reinvestment in mental health services is not occurring to the extent required. There needs to be a spending programme to remediate decades of under-funding, followed by ring-fencing of 12% of the health budget for mental health services, as recommended by the World Health Organisation.
Resources are essential and so are rights. This Bill focuses on particular rights of people receiving treatment for mental illness. Sinn Féin believes there should be a statutory requirement to ensure full compliance with the international human rights standards set out in the United Nations document, Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care, issued in 1991. There should be legislation to introduce statutory rights to equality and self-determination for people with mental ill health, to ensure empowerment of people with mental health needs, to guarantee a right to participation in decisions affecting them and to advocacy, where necessary. There also should be legislation to introduce a statutory right to timely access to appropriate mental health services.
On the substance of the Bill, I agree with the provision to delete section 58 of the Mental Health Act 2001, which refers to psychosurgery. This is a highly controversial procedure and is widely regarded as medically unsound and a violation of the rights of patients, yet it is provided for in Irish legislation. Clearly, more is needed than the simple deletion of section 58 of the 2001 Act, but that is an issue for another day and one in respect of which the Minister for Health and Children should act.
I support the change to section 59 of the 2001 Act. This would ban the use of electroconvulsive therapy on patients without their consent. It is not acceptable that this procedure, also highly controversial, medically questionable and impinging on patents' rights, should be imposed on patients without their consent and on the say-so of two psychiatrists.
We know that very many people have been damaged by the use of these procedures. They date from a time when people with mental illness were treated like criminals and subjected to incarceration, often in horrific conditions. Care of people with mental illness has been transformed for the better but these procedures remain. It is time to deal with this issue and the Bill addresses that need. I urge the Government side to support this important amending legislation and to support people with mental illness.
I thank the Minister of State, Deputy Moloney, for his open response and the commitments he made to addressing some of the issues raised in the Bill. Many Ministers and Ministers of State come before us but I was very impressed by the extent to which he indicated his willingness to take these issues seriously and make progress in respect of them. I thank him for this and for setting out his priorities for mental health services. He mentioned the removal of stigmatisation, modernising the service and action on suicide. These are three extremely important areas and I will welcome the progress he hopes to make in respect thereof.
On the question of whether this legislation is just a concern of the Green Party, it is obvious from today's debate that the concern over these issues is shared by all parties. I welcome some of the proposals made by members of the other parties, particularly those of Senator Fitzgerald on the need for further debate to allow input by interested parties, including advocacy groups and psychiatric services staff. I welcome the proposal to use the Joint Committee on Health and Children as an important forum to achieve this. However, it is important that this is not used as an excuse to delay or postpone indefinitely action in this area. The proposals will be acceptable to the Green Party as long as they are implemented within an agreed timeframe.
I welcome the proposal to carry out an audit of the regional variations in the use of electroconvulsive therapy. In certain parts of the country, one is four or five times more likely to have electroconvulsive therapy administered than in other parts. As pointed out, we do not have figures on the voluntary and involuntary use of this therapy. This information needs to be collected quickly and with urgency.
I welcome the Minister of State's announcement that amendments are being made to the Mental Health Act and that the Department will be open to accepting amendments pertaining to the issues we raised today.
Our Bill refers to the involuntary use of electroconvulsive therapy. Members have stated we do not understand fully how it works and cannot explain why it works or fails to work. The psychiatric profession cannot predict for whom it will work, nor can it guarantee that its use will not result in harm. The testimony of many who have undergone the procedure would suggest that harm can be quite extensive. We therefore need to take steps to put an end to the involuntary use of the procedure.
While considering involuntary electroconvulsive therapy, will the Minister of State also consider voluntary consent to the procedure? A person who is very unwell and on very heavy psychoactive medication may not be in an ideal position to give informed consent to the use of the procedure. I would like this to be examined.
As it now is 7 p.m., the Senator should move the adjournment of the debate.
I will wrap up. I also mentioned concern about some of the statements in a recent article published in an Irish psychiatric journal, which supported the appropriateness of the use of electroconvulsive therapy on people with Down's syndrome, intellectual impairments and so on. This issue must be considered.
The Minister of State appeared to accept the proposal pertaining to an advance directive. This would allow those who suffer from mental health difficulties to indicate in advance, during a period when they are well, whether they would be willing to accept the future use of electroconvulsive therapy. This may in part be the way forward in respect of the issues raised today. Certainly, as far as psychosurgery is concerned, most Members recognise it has not been used in the State for approximately 20 years. I do not believe anyone would suggest it is a necessary or appropriate intervention and prohibiting its use appears to the Green Party and to me to be the only acceptable way forward.
In conclusion, I thank the Cathaoirleach for the time that was made available today. I thank the Minister of State for his attention and other Members for their input. The Green Party is willing to adjourn this Second Stage debate and perhaps to resume it later, on the understanding that all the steps discussed today will be implemented.
I thank the Senator and the Minister of State at the Department of Health and Children, Deputy John Moloney. I was not present to welcome him to the House and to wish him well in his Department.