Turkey's largest psychiatric hospital has cut overall use of
electroconvulsive therapy (ECT) and has stopped performing the procedure
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
"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
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. ▪