Five years after implementation: a review of the Irish Mental Health Act 2001

Involuntary status and mental capacity for treatment decisions under Sections 4, 3, and 57 of Ireland's Mental Health Act, 2001: analysis and recommendations for reform

Although significant progress has been made in Irish mental health law in recent decades, the Mental Health Act, 2001 still falls short of properly protecting human rights. A consideration of human rights developments, both domestically and internationally, highlights the urgent need for reform. In this paper we consider Sections 4 ('Best interests'), 3 ('Mental disorder') and 57 ('Treatment not requiring consent') of the 2001 Act and related recommendations in the 2015 Report of the Expert Group on the Review of the Mental Health Act, 2001, and suggest specific areas for reform. Just as medicine evolves over time, so too does our understanding of human rights and law. While embracing a human rights-based approach to the extent suggested here might be seen as aspirational, it is important to balance achievable goals with higher ideals if progress is to be made and rights are to be respected.

Are patterns of violence and aggression at presentation in patients with first-episode psychosis temporally stable? A comparison of 2 cohorts

AIM

The aim of this study is to assess the prevalence and clinical correlates of aggression and violence in individuals presenting with first-episode psychosis (FEP) and to evaluate whether this prevalence has changed in recent years when compared to a similar previous study.

METHODS

Retrospective cross-sectional study of clinical case notes and database records using a keyword search of a sample of patients with FEP (n = 132) aged between 18 and 65 years presenting from a geographically defined catchment area to a secondary referral psychiatric service over a 4-year period (2010-2013 inclusive). Use of the Modified Overt Aggression Scale to retrospectively assess aggression and violence in the week prior to, and post, presentation with FEP.

RESULTS

The overall proportion of individuals found to be aggressive and violent was 36% and 29%, respectively. These rates were similar to the 1995 to 1998 cohort (ie, 33% and 29%). A higher percentage of our sample (22%) was violent in the week prior to presentation compared to the 1995 to 1998 cohort (13%). Aggression was independently associated with involuntary (odds ratio [OR] = 4.085, 95% confidence interval [CI] 1.310-12.733) and inpatient treatment status (OR = 0.109, 95% CI 0.023-0.532) in the week prior to presentation and with high activation (OR = 6.770, 95% CI 1.372-33.394) and involuntary treatment status (OR = 10.163, 95% CI 2.257-45.759) in the week following presentation. Violence was associated with involuntary (OR = 3.691, 95% CI 1.197-11.382) and inpatient status (OR = 0.096, 95% CI 0.020-0.465) in the week prior to and with high activation (OR = 29.513 95% CI 1.879-463.676) the week following presentation.

CONCLUSIONS

Aggression and violence rates in FEP appear relatively stable over time.

A comparison of mental health legislation in five developed countries: a narrative review

OBJECTIVES

To describe similarities and differences in mental health legislation between five jurisdictions: the Republic of Ireland, England and Wales, Scotland, Ontario (Canada), and Victoria (Australia).

METHODS

An in-depth examination was undertaken focussing on the process of involuntary admission, review of Admission Orders and the legal processes in relation to treatment in the absence of patient consent in each of the five jurisdictions of interest.

RESULTS

All jurisdictions permit the detention of a patient if they have a mental disorder although the definition of mental disorder varies between jurisdictions. Several additional differences exist between the five jurisdictions, including the duration of admission prior to independent review of involuntary detention and the role of supported decision making.

CONCLUSIONS

Across the five jurisdictions examined, largely similar procedures for admission, detention and treatment of involuntary patients are employed, reflecting adherence with international standards and incorporation of human rights-based principles. Differences exist in relation to the criteria to define mental disorder, the occurrence of automatic review hearings in a timely fashion after a patient is involuntarily admitted and the role for supported decision making under mental health legislation.

Qualitative exploration of stakeholders' perspectives of involuntary admission under the Mental Health Act 2001 in Ireland

There is international interest in, and continued concern about, the potential long-term impact of involuntary admission to psychiatric institutions, and the effect this coercive action has on a person's well-being and human rights. Involuntary detention in hospital remains a controversial process that involves stakeholders with competing concerns and who often describe negative experiences of the process, which can have long-lasting effects on the therapeutic relationship with service users. The aim of the present study was to explore the perspectives of key stakeholders involved in the involuntary admission and detention of people under the Mental Health Act 2001 in Ireland. Focus groups were used to collect data. Stakeholders interviewed were service users, relatives, general practitioners, psychiatrists, mental health nurses, solicitors, tribunal members, and police. Data were analysed using a general inductive approach. Three key categories emerged: (i) getting help; (ii) detention under the Act; and (iii) experiences of the tribunal process. This research highlights gaps in information and uncertainty about the involuntary admission process for stakeholders, but particularly for service users who are most affected by inadequate processes and supports. Mental health law has traditionally focussed on narrower areas of detention and treatment, but human rights law requires a greater refocussing on supporting service users to ensure a truly voluntary approach to care. The recent human rights treaty, the UN Convention on the Rights of Persons with Disabilities, is to guarantee a broad range of fundamental rights, such as liberty and integrity, which can be affected by coercive processes of involuntary admission and treatment.

Voluntary and involuntary psychiatric admissions in a suburban area: comparison with national rates, diagnosis and other correlates of involuntary admission status

Objectives

To establish if the relatively low rate of involuntary psychiatric admission in a suburban area between 2007 and 2011 was maintained in 2014/2015, and explore key correlates of involuntary status.

Methods

We used existing hospital records and data sources to extract rates and selected potential correlates of voluntary and involuntary admission in south west Dublin (catchment area: 273 419 people) over 18 months in 2014/2015 and compared these with published national data from the census and Health Research Board.

Results

The rate of involuntary admission in the suburban area studied between 2007 and 2011 was 33.8 involuntary admissions per 100 000 population annually, which was lower than the national rate (48.6). By 2014/2015, the rate of involuntary admission in this area had risen to 46.8 involuntary admissions per 100 000 population annually, similar to the national rate (44.9). Nevertheless, the overall (voluntary and involuntary) admission rate in the suburban area (346.7 admissions per 100 000 population annually) was still lower the national rate (387.9), owing to a lower rate of voluntary admission in the suburban area (299.9) compared to Ireland as a whole (342.9). Multi-variable testing demonstrated that diagnosis was the strongest driver of involuntary admission in the suburban area: this area had 28.5 involuntary admissions per 100 000 population annually with schizophrenia or related disorders, compared to 18.9 nationally. Schizophrenia and related disorders accounted for 60.9% of involuntary admissions in the suburban area compared to 42.1% nationally.

Conclusions

Schizophrenia is the strongest driver of involuntary admission in the suburban area in this study.

Mental Capacity Assessments Among Inpatients Referred to the Consultation-Liaison Psychiatry Unit at a University Hospital in Bangkok, Thailand

Clinicians routinely assess patients' mental capacity on a daily basis, but a more thorough assessment may be needed in complex cases. We aimed to identify the characteristics of inpatients in a general hospital, who were referred to a liaison psychiatry service for mental capacity assessment, reasons for the referrals, and the factors associated with their mental capacity. A 6-year retrospective study (2008-2013) was conducted using data collected routinely (e.g., age, gender, diagnosis, Thai Mental State Examination score, reasons for the referral, and the outcome of capacity assessment) on referrals for mental capacity assessment to a Consultation-liaison Psychiatry Unit at a university hospital in Thailand. Among 6194 consecutive referrals to the liaison-psychiatry services, only 0.6 % [n = 37, mean age (SD), 59.83 (20.42)] were referred for capacity assessment, 43.24 % of which lacked mental capacity. The most common requests from referring physicians were for assessment of testamentary capacity (15 assessed, 53.33 % lacking capacity), financial management capacity (14 assessed, 50 % lacking capacity), and capacity to consent to treatment (9 assessed, 22.22 % lacking capacity). Delirium, rather than dementia or other mental disorders, was associated with mental incapacity (p < 0.001) and being more dependent during the admission (p = 0.048). There were no significant differences for mean age (p = 0.257) or Thai Mental State Examination score (p = 0.206). The main request from referring clinicians was to assess testamentary capacity. Delirium and being more dependent during the admission were associated with lack of mental capacity, whereas age and dementia were not.

Exploring and explaining involuntary care: The relationship between psychiatric admission status, gender and other demographic and clinical variables

Involuntary admission and treatment are features of psychiatric care in many countries, but the relationship between involuntary status and gender (among other factors) is not clear. We examined demographic and diagnostic factors associated with involuntary admission in a general adult psychiatry service in a deprived area of Dublin's north inner-city over a 7-year period (2008 to 2014 inclusive). Over this period, there were 1099 admissions, yielding an annual admission rate of 504.8 admissions per 100,000 population per year. When adjusted for deprivation, this rate (387.7) was lower than the national rate (413.9). Consistent with other inner-city areas in Dublin, 14.1% of admissions were involuntary, yielding an involuntary admission rate of 71.2 per 100,000 population per year (deprivation-adjusted rate: 54.8), which is higher than the national rate (39.4). After controlling for age, occupation, marital status and diagnosis, the only independent predictors of admission status were place of origin (p<0.001) and male gender (p=0.001). These findings are consistent with studies showing associations between male gender and involuntary status in the United States, New Zealand, Netherlands, Norway, Belgium, France, and Luxembourg. In contrast, female gender is associated with involuntary status in Switzerland, Brazil, and China. These cross-national differences are likely related to differing legal traditions and different criteria for involuntary admission, possibly related to varying emphases placed on "dangerousness" as a mandatory criterion for involuntary hospitalization. This merits further, cross-national study.

Opinions of key stakeholders concerning involuntary admission of patients under the Mental Health Act 2001

OBJECTIVES

To evaluate and compare the opinions of key stakeholders involved in the involuntary admission and treatment of patients under the Mental Health Act (MHA) 2001 regarding their views towards the operation of the legislation.

METHODS

We employed a descriptive survey design. A questionnaire was distributed to stakeholders involved in the operation of the MHA 2001 (except service users, whose views were explored in a separate qualitative study) via paper or online versions evaluating their opinions regarding the operation of the MHA 2001 in relation to assessment, care, rights, transfer and information available.

RESULTS

Stakeholders agreed that in their opinion that patients generally benefit from the care they receive (79%) and that the MHA 2001 ensures an independent and fair review of the person's detention (65%). However, only 23% of stakeholders were satisfied with the process of transferring patients to hospital and with the clinical assessment procedures therein (37%), with the greatest levels of dissatisfaction amongst Gardai (Police), general practitioners (GPs) and family members.

CONCLUSIONS

While the introduction of the MHA 2001 has assisted delivery of care to patients with improved adherence to international human rights frameworks applicable at the time of its enactment, substantial dissatisfaction with the implementation of the MHA 2001 in practice is experienced by stakeholders particularly at the distressing phase of clinical assessment and transfer to hospital.

Rate of involuntary admission in Dublin South West: a 5-year retrospective review

OBJECTIVE

International figures for involuntary admissions vary widely. Differences in legislation, professionals' ethics and public attitudes towards risk have been known to influence this rate. Comparing involuntary admission rates in different parts of the same country can help control for variability found between international studies. This study assessed the rates of involuntary admissions in the Dublin South West Mental Health Service compared with the rest of Ireland.

METHODS

We examined the demographic and clinical profiles of all involuntary patients admitted to the acute psychiatric inpatient unit in Tallaght Hospital between 2007 and 2011. We compared the rate of admission in Tallaght with the rest of Ireland. Data gathered included all patients detained on Form 6 and Form 13 (change of status) looking at age, gender, diagnosis and number of patients who had a Mental Health Tribunal. Form 7 (renewal orders) was also examined We calculated the rate per 100 000 population per year of Form 6 admissions, Form 13 and Form 7 (certificate and renewal order by responsible consultant psychiatrist) using figures from the 2006 Census. All data were analysed using SPSS.

RESULTS

The rate of involuntary admission in Tallaght Hospital was significantly lower compared with the rest of Ireland (Form 6: t=-11.2; p<0.001, Form 13: t=-3.1; p=0.04, Form 7: t=-13.9; p=0.001). This difference was evident for all methods of involuntary detention and was also the case for Form 7 (renewal orders). Mental Health Tribunals were held for 59% of patients, a rate comparable with earlier findings described in publications, following the introduction of the new Mental Health Act.

CONCLUSIONS

Rates per 100 000 population were lower in Dublin South West compared with the rest of Ireland. The reasons for this are not clear. Further research comparing similar services in Ireland could explain these findings.

Custody, care and country of origin: demographic and diagnostic admission statistics at an inner-city adult psychiatry unit

Involuntary detention is a feature of psychiatric care in many countries. We previously reported an involuntary admission rate of 67.7 per 100,000 population per year in inner-city Dublin (January 2008-December 2010), which was higher than Ireland's national rate (38.5). We also found that the proportion of admissions that was involuntary was higher among individuals born outside Ireland (33.9%) compared to those from Ireland (12.0%), apparently owing to increased diagnoses of schizophrenia in the former group. In the present study (January 2011-June 2013) we again found that the proportion of admissions that was involuntary was higher among individuals from outside Ireland (32.5%) compared to individuals from Ireland (9.9%) (p<0.001), but this is primarily attributable to a lower rate of voluntary admission among individuals born outside Ireland (206.1 voluntary admissions per 100,000 population per year; deprivation-adjusted rate: 158.5) compared to individuals from Ireland (775.1; deprivation-adjusted rate: 596.2). Overall, admission rates in our deprived, inner-city catchment area remain higher than national rates and this may be attributable to differential effects of Ireland's recent economic problems on different areas within Ireland. The relatively low rate of voluntary admission among individuals born outside Ireland may be attributable to different patterns of help-seeking which mental health services in Ireland need to take into account in future service-planning. Other jurisdictions could also usefully focus attention not just on rates on involuntary admission among individuals born elsewhere, but also rates of voluntary admission which may provide useful insights for service-planning and delivery.

Dignity, human rights and the limits of mental health legislation

A right is an entitlement that one may legally or morally claim. Human rights are of particular importance in mental health care owing to the existence of laws that permit involuntary admission and treatment under certain circumstances, and compelling evidence of persistent social exclusion of some individuals with mental disorder. Ireland’s mental health legislation, which is currently under review, meets most international human rights standards in areas of traditional concern (involuntary admission and treatment) but not in other areas (especially social and economic rights). These deficits would be addressed, at least in part, by replacing the principle of ‘best interests’ with the principle of ‘dignity’ as the over-arching principle in Irish mental health legislation. Such a change would help ensure that decisions made under the legislation actively facilitate individuals with mental disorder to exercise their capabilities, help promote human rights and protect dignity. Even following such a reform, however, it is neither practical nor realistic to expect mental health legislation alone to protect and promote all of the broader rights of individuals with mental disorder, especially social and economic rights. Some rights are better protected, and some needs better met, through social policy, mental health policy and broader societal awareness and reform.

Implementing the Mental Health Act 2001 in Ireland: views of Irish general practitioners

OBJECTIVES

The Mental Health Act 2001 introduced important reforms of Irish mental health law and services. This paper aims to provide an evidence-based exploration of general practitioners' views on the implementation of the Mental Health Act 2001.

METHODS

We posted questionnaires to 1200 general practitioners in Ireland seeking their views on their experiences with the Mental Health Act 2001.

RESULTS

Eight hundred and twenty general practitioners (68.3%) responded. Among those who provided comments, a majority (75.2%) provided negative comments. The most commonly occurring themes related to difficulties with transport of patients to inpatient facilities, form filling, time requirements and administrative matters. Other negative comments related to general practitioner recommendations for involuntary admission, training, mental health tribunals, applications for involuntary admission and the position of children. Minorities provided neutral (18.0%) or positive comments (6.8%), chiefly related to user-friendliness, transparency and improved communication.

CONCLUSIONS

General practitioners highlight a need for greater training and clear guidelines in relation to the Mental Health Act 2001. Their forthright responses demonstrate deep engagement with the new legislation and eagerness to see the Mental Health Act 2001 realise its full potential to improve the involuntary admission process and protect human rights, in the best interests of patients.