Variation of treatment order - Application for ECT treatment - Tribunal discretion to vary treatment order - Order varied

Mental Health Act 2013 (Tas); ss 6,15A, 39, 40,41 181, Sch 1.

The decision has been anonymised for the purpose of publication

1. NBG (the patient) is a 71-year-old woman who lives in Northern Tasmania. NBG is diagnosed with Bipolar Affective Disorder.
2. Following an application made to the Tasmanian Civil and Administrative Tribunal (TASCAT) NBG was made subject to a treatment order on 8 October 2025, under s 39 of the Mental Health Act 2013 (Tas) (the Act) in the following terms

(a) is authority for the patient to be admitted to and if necessary detained in an approved facility for the purposes of receiving treatment;

(b) authorises a combination of treatment settings and the admission or readmission of the patient to those settings, including treatment in the community; and

(c) authorises the following:

1. The patient is to take the following medication (depending on clinical indication):

   1. Antipsychotic medication

   2. Mood stabilising medication

   3. Benzodiazepine medication

   4. Anticholinergic medication for treatment of any extrapyramidal side effects from taking antipsychotic medication

Medications may be administered orally and/or by intra-muscular injection and/or by depot injection as prescribed by a treating psychiatrist within clinical guidelines, with dosages adjusted according to clinical response and tolerability.

1. Standard medical and/or blood, and/or urine tests and/or radiological and medical imaging tests, as clinically indicated and as directed by the treating team.
2. Older Persons Mental Health Service (OPMHS) appointments (inclusive of home visits as arranged when being treated in the community).
3. On 21 October 2025, the Tribunal received an application to vary the treatment order from Dr PQ to authorise electro-convulsive treatment (ECT). Dr PQ's application stated that the reason for the variation was as follows:

[NBG] is currently receiving treatment for manic relapse of Bipolar 1 disorder, during her admission for 3 weeks, she received optimised doses of mood stabilizers, augmented with antipsychotics. Unfortunately she had no improvement in her mental state. She is currently refusing almost all of the medications, she breached the conditions of leave and came late. She continues to demonstrate psychomotor agitation, being demanding, irritable, intrusive, overfamiliar with staff and other consumers, verbally aggressive and not engaging on interview.

4. Dr PQ indicated in the application that NBG had been consulted regarding the variation of treatment application and noted:

Treating team communicated to patient that ECT is the most appropriate choice at this stage, given no improvement with current treatment. > > [NBG] is against ECT, when it was discussed she became emotionally dysregulated, aggressive, verbally abused staff and threw objects. She is against her current treatment and staying inpatient (sic).

(2) The Tribunal may vary a treatment order at any time -

(a) on its own motion; or

(b) on the application of any approved medical practitioner; or

(c) on the application of any person with the necessary standing.

(2A) The Tribunal may vary a treatment order whether or not it has conducted a review under this section.

2. Section 41 provides for the form and content of a treatment order:

41. Form and content of treatment order > > (1) To be valid, a treatment order must - > > (a) be in a form approved by the President of the Tribunal; and > > (b) be correctly completed. > > (2) A treatment order is taken to be correctly completed if it - > > ...

(a) specifies the treatment, or types of treatment, authorised under the order; and

...

(5) A treatment order may, without compromising its validity, specify or provide for any other matters, incidental to the treatment of the person in respect of whom the order is made, that the Tribunal considers necessary or desirable in the circumstances.

1. When making determinations under the Act the Tribunal is also to consider the right of patients contained in s 15A of the Act. The rights relevant to this matter are as follows:

15A. Rights of patients > > (1) Each person receiving an assessment or treatment under this Act has the following rights: > > (a) the right to receive the assessment, or treatment, under this Act in accordance with the mental health service delivery principles; > > (b) the right to have any restriction on, or interference with, the person's dignity, rights and freedoms to be limited as much as possible when taking into account the person's health and safety and the safety of others; > > (c) the right to promote, and make prominent, the person's decision-making capacity, and to respect the person's wishes, to the maximum extent possible when taking into account the person's health and safety and the safety of others; > > ...

2. Finally, in exercising responsibilities under the Act, the Tribunal must refer to the mental health service delivery principles set out in Sch 1 of the Act. The relevant principles are as follows:

SCHEDULE 1 - Mental health service delivery principles > > 1. The mental health service delivery principles are as follows: > > (a) to respect, observe and promote the inherent rights, liberty, dignity, autonomy and self-respect of persons with mental illness; > > (b) to interfere with or restrict the rights of persons with mental illness in the least restrictive way and to the least extent consistent with the protection of those persons, the protection of the public and the proper delivery of the relevant service; > > ... > > (f) to seek to bring about the best therapeutic outcomes, including the use of evidence-based care, and promote patient recovery; > > (g) to provide services that are consistent with patient treatment plans; > > ... > > (j) to promote the ability of persons with mental illness to make their own decisions, including decisions about the person's assessment, treatment and recovery that involve a degree of risk; > > (m) to respect the wishes of persons receiving services, and the wishes of their families and support persons, to the maximum extent consistent with the health and safety of those persons and the safety of others; > > (n) to promote and enable persons with mental illness to live, work and participate in their own community; > > ... > > (r) to ensure that persons receiving mental health services have their medical and other health needs, including any alcohol and other addiction problems, recognised and responded to; > > ... > > (v) to provide a mental health service that - > > (i) is easily accessible, and safe; and > > (ii) provides persons with mental illness with timely treatment, care and support that is high quality and based on contemporary best-practice principles; and > > (iii) promotes recovery in the least restrictive manner that is consistent with the needs of persons with mental illness; > > ...

3. On 8 October 2025, the matter was listed for hearing before a three-member panel. The matter was adjourned on the application of NBG as she requested that she be legally represented at the hearing. The Tribunal heard evidence from the treating team and on adjournment determined to vary the treatment order to authorise two ECT sessions during the period of the adjournment.
4. The matter was then relisted for hearing on 6 November 2025. The hearing went ahead as scheduled and at the conclusion of the hearing the Tribunal determined to vary the treatment order to authorise up to nine ECT sessions as directed by the treating psychiatrist including the administration of an anaesthetic prior to the ECT sessions.
5. On 11 November 2025, the patient's advocate, Mr Brennan submitted a written request on behalf of NBG for a statement of reasons regarding the determination for variation of treatment order made 6 November 2025 at 2:14 pm. These are the reasons as requested.

1. At the time the application for variation of treatment order was filed with the Tribunal, NBG was an involuntary patient at an approved hospital.
2. In the application to vary the treatment order, Dr PQ sought authorisation to administer an acute course of ECT to NBG to prevent further deterioration of her mental state and reduce risks by improvement of her mental health.
3. In considering whether to vary the treatment order the under the Act the Tribunal considered the s 40 criteria and in particular if the treatment being sought will be appropriate and effective in terms of the outcomes referred to in s 6(1) which are as follows:

(1) For the purposes of this Act, treatment is the professional intervention necessary to -

(a) prevent or remedy mental illness; or

(b) manage and alleviate, where possible, the ill effects of mental illness; or

(c) reduce the risks that persons with mental illness may, on that account, pose to themselves or others; or

(d) assess a person's mental state.

....

1. At the hearing on 6 November 2025, NBG appeared via video link from the approved hospital with the treating team, Dr NC, psychiatric registrar (on behalf of the applicant), Dr KT, consultant psychiatrist and B, registered nurse. Also present was the legal orders co-ordinator GQ, resident medical officer Dr KS and Mr John Brennan from Advocacy Tasmania.
2. At the outset NBG appeared irritable and told the Tribunal she was aware of the application and that she did not want to be treated with ECT and then left the hearing room. Before she left NBG advised she was happy to be represented by Mr Brennan in her absence.
3. GQ raised a preliminary matter. She reiterated that the previous hearing had been adjourned so NBG could obtain legal representation from Tasmania Legal Aid (TLA). With the assistance of hospital staff NBG contacted TLA and was told there was no availability to represent her. GQ reported that staff then assisted NBG to contact her own private lawyer only to be advised he had retired.
4. The Tribunal asked if NBG was seeking another adjournment based on the unavailability of legal representation. Mr Brennan reported that he had discussed this with NBG and given TLA had no immediate capacity to represent people NBG advised him that she was not happy to seek an adjournment only to find herself back in the same position next week. NBG wanted the matter raised as a systemic problem. Mr Brennan said he was not able to obtain a definitive answer from NBG on whether she was seeking an adjournment or not.
5. The Tribunal asked for NBG be invited back to the hearing so we could pose the question to her on whether she was requesting to have the matter adjourned today. NBG did not come back to the hearing room. The legal order co-ordinator took the opportunity to ask her if she was seeking to have the matter adjourned. NBG advised that the hearing should go ahead today as she felt that, in her opinion, an adjournment would not stop the administration of the ECT. On that basis the hearing went ahead.
6. Dr KT reported to the Tribunal that since the last hearing, NBG had received a total of three ECT sessions. One session under urgent circumstances treatment authorisation and two sessions had been authorised under the order varied by the Tribunal on 28 October 2025.
7. Dr NC told the Tribunal:
   1. NBG's mental illness is being managed by the antipsychotic medication Quetiapine SR. She has been trialled on a large array of psychotropic medications and has been sensitive to some of these medications and experienced side-effects to a majority of them.
   2. NBG is well known to Older Persons Mental Health Services and has been case managed by them. Her last admission to the psychiatric inpatient unit was February 2025 for a manic relapse of her illness.
   3. NBG was discharged from hospital on antipsychotic Quetiapine and the dose was reduced by the community treating team. There was poor compliance by NBG in taking the medication and this resulted in the relapse occasioning this admission to hospital for the past three weeks.
   4. During this admission medications have been optimised with the increase in the dose of Quetiapine augmented with other medications and despite this there has not been any notable improvement in NBG's presentation.
   5. Compliance with medications on the ward continues to be poor and NBG's engagement with the treating team also remains poor. NBG remains guarded, labile in her mood, highly irritable and demanding making her treatment difficult.
   6. The inpatient treating team consulted with NBG's treating consultant psychiatrist in the community who advised that the team should consider ECT as NBG had been treated with ECT in the past with good response. This treatment occurred in 1996 and NBG remained well for a number of years following this treatment.
   7. Following the most recent ECT sessions on this admission it has been noted by the treating team, that whilst improvement in presentation has been modest, NBG is more tolerable of and is engaging a little more with the treating team. She is less hostile. NBG has also been more likely to accept medication since the ECT. It is considered essential to continue with the ECT sessions.
   8. NBG continues to meet the treatment criteria and has been assessed as still not having decision making capacity and unable to provide informed consent to treatment. Due to manic relapse of her Bipolar Affective Disorder NBG is unable to demonstrate she understands the information about treatment provided to her, nor is she able to retain this information between reviews because of inattention and irritability and fixation on other racing thoughts. NBG has also been unable to demonstrate she has the capacity to weigh up the pros and cons of the proposed treatment and NBG is unable to remember she has had ECT in the past.
8. Dr NC told the Tribunal she was applying for the full course of up to 12 ECT sessions and since NBG had received three ECT sessions to date, Dr NC was seeking authorisation for a further nine ECT sessions.
9. The Tribunal asked Dr NC what the risks were if NBG did not continue with ECT. Dr NC told us that without ECT at the very least there would be no improvement in NBG's presentation (as has been the case over the past three weeks) or a possible deterioration in her mental state and this in turn would prolong her admission in hospital. Dr NC said this would place NBG in a difficult position as either no improvement or a deterioration in mental state would expose NBG to further risks such as self-neglect and potential risk to others as at times her behaviours are hostile and she has been verbally aggressive towards hospital staff and to others in the community.
10. Dr KT told the Tribunal that when reviewing NBG, she did not want to discuss her mental illness or her medication and told him that she did not believe she needed to be in hospital and does not believe she has a mental illness or that she needs to be treated with medication more than the usual medication she was taking in the community (Quetiapine 250 mg daily). Dr KT said he was in full support of Dr NC's report to the Tribunal and his concern was that without ECT NBG's mental state will deteriorate further.
11. Mr Brennan had no questions for the treating team regarding the application to vary the order or questions relating to the reports given by Dr NC and Dr KT. Mr Brennan submitted that:
    1. NBG disputes her diagnosis and believes she has a post-traumatic stress disorder dating back to 1973 when she was forced to surrender her child for adoption.
    2. NBG agrees that treatments have been beneficial on occasion but disputes that ECT has ever been an appropriate treatment for her.
    3. NBG is happy to continue accepting a treatment plan based around medication but not ECT as the side effects from ECT far outweigh any benefit because she says there is no benefit. NBG identifies the side effects as blurred vision, short term memory loss, weight loss, soreness, stiffness and irritability. NBG also says some of the medications are causing constipation.
    4. NBG is prepared to follow Dr KQ's (Older Persons consultant psychiatrist) medication regime as an inpatient or in the community (which is her preference).
    5. NBG states she has capacity and in fact increased capacity because no-one else has had to suffer the effects of the treatment she has been subject to.
12. The Tribunal asked the treating team to respond to the submission regarding the side effects as identified by NBG. Dr KT told the Tribunal that NBG had been trialled on older and new generation antipsychotic medications with the main side effect being extrapyramidal side effects which were prominent. NBG was able to tolerate Quetiapine medication reasonably well and it was effective. Dr KT reported that unfortunately when trying to optimise the dose to effective levels NBG felt sedated and was then at risk of falls. Hence the dose had to be reduced. Dr KT contacted Dr KQ to discuss treatment and the option next was to treat NBG with antipsychotic Aripiprazole, but compliance was poor and over the past three weeks NBG only complied with taking the medication for about four days.
13. NBG returned to the hearing room following the evidence from both doctors and submissions made by Mr Brennan. NBG stated she had "bipolar or whatever John said" and then she left the hearing room again.
14. Dr KT continued his report by stating that following the three ECT sessions NBG's mood had been improved but still labile and there was less hostility and that there was a further role for ECT in treating her current symptoms and when she reaches a level of engagement the treating team will try to commence NBG on Aripiprazole as it had the least side effect profile of most antipsychotic medications.

1. The Tribunal is satisfied that NBG continues to meet the s 40 criteria under the Act and because of her psychotic symptoms continues to not have the capacity to make her own decisions about treatment and is not able to provide informed consent to treatment.
2. The Tribunal is satisfied on the evidence before us that the variation of the treatment order to authorise ECT sessions to treat NBG's mental illness is warranted, and that the treatment is appropriate in the circumstances as NBG's deterioration in mental state has not responded to oral medication during her three-week admission to hospital. We are also satisfied that without treatment there will be no improvement in NBG's symptomology and NBG could also experience a further deterioration in mental state.
3. We are satisfied that ECT meets the definition of treatment as it is professional intervention necessary to manage and alleviate, where possible, the ill effects of NBG's mental illness. We are also satisfied on the evidence that historically NBG has responded well to ECT.
4. NBG has had a prolonged admission to hospital and her symptoms have caused her distress. The Tribunal acknowledges that NBG does not want to be treated with ECT at this time. Treatment with oral medications alone has not been effective in treating her psychotic symptoms. In making the determination to authorise ECT, the Tribunal is also satisfied that treatment with ECT is in keeping with the mental health service delivery principles, including 'to seek to bring about the best therapeutic outcomes, including the use of evidence-based care, and promote patient recovery'.

1. The treatment order was varied in the terms applied for by the applicant on 6 November 2025 at 2:14pm. The order will expire on 7 April 2026 at 4:14 pm unless discharged sooner or renewed.