March 19, 1999

By Richard Karel

The Arizona Psychiatric Society (APS), with assistance from APA's Division of Government Relations (DGR), is fighting bills dealing with the regulation of electroconvulsive therapy (ECT) and psychotherapy that could seriously hamper psychiatric practice in that state if approved.

Because the psychotherapy legislation failed to get out of committee, it is not deemed a threat for the balance of the Arizona legislature's term, which ends in April, according to APS President Glenn Lippman, M.D., and DGR Deputy Director for State Affairs Katherine Becker, J.D. But APA and APS will continue to track the legislation, according to both Becker and Lippman.

The psychotherapy bill, as proposed, would have required that the "mental health provider" provide "documentation that the proposed treatment is the most effective and appropriate one for the person" and "a copy of the code of ethics that the mental health provider is required to follow." Payment claims would have to be accompanied by "at least two scientific journal citations that demonstrate that the proposed treatment has been proven reasonable, safe, and effective by reliable and valid scientific studies; a brief and truthful listing of the known and reasonably foreseeable risks, hazards, and relative benefits of the proposed treatment"; and "a brief and truthful list of alternative treatments with a brief description of the benefits and risks of these alternative treatments."

The bill also would have required the provider to give the patient the name and address of the state agency that the patient could contact to file a complaint and an agreement that would establish "measurable goals so that the recipient or that person's representative is able to determine progress." Any test used would have to "include a manual or other published information that fully describes the development of the test, the rationale for the test, the validity and reliability of the test, and normative data," unless the test was strictly for research purposes.

The other bill, dealing with ECT, was introduced at the urging of the Citizens Commission on Human Rights (CCHR), a group started by and associated with the Church of Scientology, according to Becker.

On February 20 the Arizona House Human Services Committee passed the ECT bill with two votes in favor, one opposed, and one abstaining, according to APS President Lippman. At press time, the legislation was awaiting a vote from the full House. If passed by the House, it would then go to the state Senate some time this month.

State Rep. Marc Anderson, who chairs the Arizona House Human Services Committee and is backing a revised version of the ECT bill, said that the odds of the Senate's passing the bill "are less than they are of getting it through the House." Because the Senate consists of only 30 members, as opposed to 60 in the House, an individual member can more easily kill legislation. He summed up the situation, "I'm still hopeful, but I wouldn't bet any money on it."

The version passed by the House Human Services Committee contained minor concessions to psychiatry, said Lippman, but was still deemed unacceptable by the APS. Compared with the original version of the bill, the revised version dropped a prohibition on the use of ECT for anyone under 16 years old and shortened the informed consent section. Despite these changes, "my opinion is we need to reject this bill and work to prevent its passage," Lippman told Psychiatric News. "It's just going to increase the restrictions and regulation on this already difficult to obtain procedure."

Lippman highlighted why the APS and APA continue to see the ECT bill as objectionable. The revised bill still has a mandated informed consent clause and provisions for a survey for 1999. Providers who failed to report any of a long list of topics about their use of ECT would be reported to the Arizona Board of Medical Examiners for unprofessional conduct, said Lippman. The survey is slated to begin in mid-1999, but is for the entire year, so would require retroactive reporting. Among those items to be reported would be the number of people who consented to the therapy while receiving mental health services voluntarily and involuntarily, the number of people who involuntarily received mental health services and whose guardian consented to the treatment; the age, sex, and race of anyone given ECT; the number of treatments administered to each patient; the clinical outcome of the therapy; the number of adverse medical events that occurred within 24 hours after ECT; the incidence of bone fractures, reported memory loss, apnea, and cardiac arrests not resulting in death; the electrical stimulus intensity and the length of time of the shock delivered to each person; and "any other information" requested by the state health department.

APA President Rodrigo Muņoz, M.D., sent a letter opposing the ECT bill to Rep. Anderson.

"At a time when the Arizona legislature and indeed state legislatures throughout the nation are seeking to give individuals greater flexibility to obtain medically necessary health care, it is ironic and unfortunate that [the bill] would curtail the right of certain citizens (or their guardians) to even consider the possibility of ECT as medical treatment," Muņoz wrote.

For some people, ECT "may be the only effective medical treatment," but the bill, if approved, would make access to ECT so difficult as to ban the procedure in effect, he continued. The bill represents a "dangerous and paternalistic intrusion into what should be the personal medical decision of an individual in consultation with his or her physician."

Anderson told Psychiatric News he is receptive to the ECT legislation because "ECT is and always has been a somewhat controversial treatment." He noted that "some people say, 'It's the greatest thing; it saved my life,' while others say, 'It ruined my life; I lost my memory.' "

In particular, said Anderson, he is concerned that some unethical psychiatrists may be "prescribing this treatment because it's paid for by Medicare, whereas psychotherapy might not be." The question is whether this treatment is "being used properly or not," he contended.

Referring to the bill's consent section, Anderson said that "most psychiatrists" with whom he spoke told him they already had a consent form, so the requirement imposed by the bill would do little to alter their practice. "The things they really objected to we took out, including the regulation of the equipment and the ban on administration to those under age 16," he noted.

APA's DGR staff has been "very helpful," Lippman noted, providing him with written information and mobilizing allies in the state on very short notice. "This bill did not pass [the House committee] because of anything we did not do; it passed because of politics," he added. In addition to APA, the state mental health association has provided "very prominent support" in opposing the ECT bill, he observed. The mental health association "did a great job" of enlisting consumer support, including testimony from former CBS newscaster Mary Jo West, who told the legislature how ECT pulled her out of a serious depression when nothing else worked, said Lippman (see box).

The Arizona Division of Behavioral Health was directed by Gov. Jane Hull (R) to "work with the legislature on the bill," although Hull's office did not weigh in on specific aspects of the legislation, other than asking a reworking of since-dropped provisions dealing with the regulation of ECT equipment, said Lippman.

"The APS has told the office of behavioral health that there is no acceptable compromise, and what we have offered to participate in is a voluntary one-year reporting of the frequency of ECT usage," said Lippman. The APS has asked for help with the reporting from both the Arizona Medical Association and the Arizona Hospital Association, he noted.

Arizona psychiatrists see the ECT bill as an interference with psychiatric practice, said Lippman, but it was the bill dealing with informed consent for psychotherapy that most angered psychiatrists and spurred an alliance on the issue between psychiatrists and other mental health providers. At press time the psychotherapy bill had been reassigned to a subcommittee, which means that it is extremely unlikely to be revived this year, said Becker. Prior to the psychotherapy bill's reassignment to subcommittee, Rep. Anderson told Psychiatric News that "if it doesn't get out of committee. . . it's dead, and I'm not going to resurrect it."

Now that the psychotherapy bill is considered dead for this legislative term, the APS and DGR have focused their firepower on defeating the ECT legislation, said Becker.