Human-Rights Charges Lead Turkey to Alter ECT Practices

Turkey's largest psychiatric hospital has cut overall use of electroconvulsive therapy (ECT) and has stopped performing the procedure without anesthesia.

The action came soon after publication a year ago of a report on human-rights abuses in psychiatric hospitals, orphanages, and rehabilitation centers in Turkey by Mental Health Disability Rights International (MDRI), an advocacy group (Psychiatric News, November 18, 2005).

“A month after the report came out, the previous director of Barkiköy Hospital was replaced by a psychiatrist from a university hospital where only modified ECT was used,” explained Robert Okin, M.D.“ Within a couple of months, he began to eliminate the use of unmodified ECT, despite the previous claims of a lack of resources.”

Okin is a co-author of the MDRI report and chief of psychiatry at San Francisco General Hospital and vice chair and professor of clinical psychiatry at the University of California, San Francisco.

University hospitals in Turkey have consistently used ECT modified with anesthesia, indicating that resistance to change at Barkiköy was a matter of inertia, not a philosophical or cultural issue, said Okin.

In February, the Turkish government agreed to eliminate unmodified ECT and to assign anesthesiologists to all psychiatric hospitals in the country. The use of ECT in general declined from 25 percent of all new acute admissions, all unmodified, to 14 percent, all modified with the use of anesthesia, by this past July, Okin told Psychiatric News.

The turnaround came quickly after the report appeared, but not without some ruffled feathers within the Turkish psychiatric community, said Alan Stone, M.D., a professor of law and psychiatry in the Faculty of Law and the Faculty of Medicine at Harvard University. The Turkish Association of Psychiatrists said the report was based on anecdotal evidence and was unfairly timed to appear as Turkey's application to the European Union (EU) was up for review.

“They felt they had been condemned in the court of public opinion as torturers without being given the chance to tell their side of the story,” said Stone, who is chair of APA's Corresponding Committee on Misuse and Abuse of Psychiatry. “They felt that MDRI's charges alleging intentional mistreatment and willful violations of human rights by Turkish psychiatrists were damaging and misleading. They were accused of deliberately harming patients, but the problem was lack of resources.”

MDRI disagrees on the issue of resources. “Dr. Medaim Yanik, the new director of Bakirköy, [said] that financial constraints were not a significant obstacle to the conversion to modified ECT and that the directors of the mental hospitals had always had the flexibility to do so if they had wished to,” according to Okin, who is also a member of the APA committee.

A lack of personnel was not a barrier either, he said. “In fact, three anesthesiologists have worked for years in the neurosurgery department that shares the campus with the mental hospital at Barkirköy.”

In any case, Stone's committee adopted a consultative approach to the problem, suggesting to Turkish psychiatrists ways to bring use of ECT up to current standards and advance passage of model guidelines for psychiatry through the government.

The combination of MDRI's public methods and APA's behind-the-scenes efforts seem to have worked. “It was almost like MDRI was the bad cop and we were the good cop,” said Stone.

“I'm happy that hospital administrators made these changes,” said Laurie Ahern, MDRI's associate director, in an interview. “They have a long way to go, but they're certainly making an effort.”

Several factors were responsible for the quick turnaround in policy, said Ahern. Bad publicity across Europe just as Turkey's proposed membership in the EU was up for a review undoubtedly played a role, she said. While there was no overt intervention, the EU has made accession dependent on Turkey's protecting the rights of the disabled.

Further support for shifting clinical practices in Turkey's state hospitals came during the scheduled meeting of the World Psychiatric Association (WPA) in Istanbul in July, said Eliot Sorel, M.D., a professor of psychiatry and behavioral sciences at the George Washington University School of Medicine and School of Public Health

Sorel organized a session on ECT practices, human rights, and ethical practices. Speakers represented both American and European points of view on ECT. Okin spoke on behalf of MDRI, and Prof. Cagri Yazgan presented a survey of Turkish hospital practices of ECT.

“Together, it was a fair and comprehensive review of the topic,” said Sorel, who is also chair of the WPA's Section on Conflict Management and Conflict Resolution.

A consensus panel then recommended that all WPA members and the governments in their countries implement ethics guidelines; consider World Health Organization human rights recommendations; support best psychiatric practices in all clinical, research, educational, and policy activities; make modified ECT the standard of care; and eliminate unmodified ECT.

Although ECT practices have changed in Turkey, there is still little progress to report on passage of a comprehensive mental health law for the country, said Okin.

“There is a large opportunity for organized psychiatry to be much more involved in bringing about these kinds of changes,” he added.

However, there was one sign of progress—the development of the first independent advocacy organization in Turkey for people with mental disabilities, said Ahern.

MDRI will continue monitoring conditions in Turkey and offering support for nongovernmental human rights organizations, she said. ▪