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ECT, Mental Health Act and Suicide Risk Assessment
Indications for ECT?
✔️ treatment resistant depression ✔️ melancholic depression ✔️ psychotic depression ✔️ catatonia ✔️ refusal to eat ✔️ previous positive response ✔️ bipolar depression ✔️ mania
Contraindications for ECT?
The only ABSOLUTE contraindication is raised ICP.
Relative contraindications include:
✔️ space occupying lesion (may result in raised ICP)
✔️ recent cerebral haemorrhage or stroke
✔️ unstable cardiovascular disease
✔️ bleeding or unstable vascular aneurysm
✔️ severe pulmonary condition
Briefly outline the process of ECT.
ECT is a procedure in which electric currents are administered to neuronal tissue with the aim of altering electrolyte levels / electrical imbalances within the brain.
Electrodes are placed on the skull (one or two) either in the frontal or the temporal lobes. There are three positions for electrode placement:
- bifrontal
- bitemporal
- right unilateral
ECT is performed under general anaesthetic. There are two medications which are required:
- propofol –> sedative
- succinylcholine –> muscle relaxant
Energy is passed through the electrodes to induce a tonic-clonic seizure.
Patients require between 4 - 20 treatments (average is 6 to 8 treatments).
Outline side effects of ECT.
✔️ headache ✔️ jaw pain ✔️ disorientation ✔️ anterograde or retrograde amnesia ✔️ delirium
Identify the two indications for application of the MENTAL HEALTH ACT (2016).
- patient lacks insight into their condition
2. patient poses a significant harm to themselves or others
Outline the inclusion criteria to be considered when applying the MHA2016.
A. The individual must have a mental illness, defined by the presence of one or more of the following:
✔️ delusions
✔️ hallucinations
✔️ significant thought disorder
✔️ significant mood disorder
✔️ sustained irrational behaviour indicative of one of the above
B. The individual does not have the capacity to give consent to be treated.
✔️ does not understand their symptoms / mental health condition
✔️ does not understand risk / benefits of treatment
✔️ does not understand the risks of not receiving treatment
✔️ cannot communicate thoughts / understanding
C. Because of the patient’s mental health / illness and lack of access to treatment, one or more of the following is likely to result:
✔️ imminent harm to self or others
✔️ serious mental health consequences
Outline the exclusion criteria that relates to the MHA2016.
The following are NOT considered appropriate reasons for the MHA to be applied: ✔️ sexual orientation / preference ✔️ drug / alcohol use ✔️ intellectual impairment ✔️ antisocial or illegal behaviour ✔️ immoral / indecent conduct ✔️ family confluct ✔️ any philosophical, cultural or religious beliefs
Outline the principle of LEAST RESTRICTIVE CRITERIA.
According to the MHA2016, the MHA cannot be applied unless all other forms of less restrictive care have been offered / trialled, with nil success.
Other less restrictive forms of care include: ✔️ verbal de-escelation ✔️ patient agreeing to care ✔️ guardianship act ✔️ advanced health directive ✔️ appointed attorney ✔️ statutory health directive
EMERGENCY EXAMINATION ORDER (EEO)
✔️ who?
✔️ why?
✔️ what?
WHO - QAS and QPS
WHY - can be ordered if a person is:
✔️ acting secondary to a mental illness
✔️ is placing themselves or others at risk
✔️ requires urgent examination and care
WHAT - when an EEO is ordered, it enables an emergency involuntary examination to be conducted; must be actioned in 6 + 6 = 12 hours
INVOLUNTARY EXAMINATION
✔️ who?
✔️ why?
✔️ what?
WHO - any mental health facility or public health service
WHY - can be ordered if a person is:
✔️ acting secondary to a mental illness
✔️ is placing themselves or others at risk
✔️ requires urgent examination and care
WHAT - an involuntary examination enables a physician to conduct an assessment of the patient; physician can order medication for the purpose or sedation of the patient but NOT to treat the mental health condition
Applicable for 6 + 6 = 12 hours
INVOLUNTARY ASSESSMENT (REQUEST AND RECOMMENDATION)
✔️ who?
✔️ why?
✔️ what?
WHO - may be administered by a doctor; request for a psychiatric consultant to see a patient
WHY - doctor believes the patient is behaving secondary to a mental health illness and requires psychiatric attention
WHAT - can be held for 24 + 24 + 24 hours = total of 72 hours
TREATMENT AUTHORITY
✔️ who?
✔️ why?
✔️ what?
WHO - consultant psychiatrist; must be the same physician that saw the patient under the R + R
WHY - the two indications for TA are:
- patient lacks insight / cannot give consent to treatment
- risk of harm to self or others
A TA must be reviewed by a tribunal at 4 weeks and then every six months indefinitely.
JUSTICE EXAMINATION ORDER (JEO)
✔️ who?
✔️ why?
✔️ what?
WHO - JEO may be ordered by a judge or magistrate
WHY - JEO may be ordered if a judge / magistrate believes a legal decision cannot be made without an appropriate psychiatric assessment
WHAT - enables a psychiatrist to go where a patient is to carry out examination; valid for 7 days
Outline components of the SADPERSONS risk assessment tool.
S - sex (male > female) A - age (< 19 years or > 44 years) D - depressed mood / hopelessness* P - previous suicide attempts E - ethanol (alcohol) use R - rational thinking lost* S - spouse is absent (e.g. widowed, single, divorced) O - organised plan N - no social support S - stated future intent*
N.B features / factors marked with an Asterix are worth two points
What are the risk categories for suicide according to the SADPERSONS tool?
MILD - 1 to 3 points
MODERATE - 4 to 6 points
SEVERE / HIGH - 7 to 10 points
