Sunday 18 March 2018

Procedures protect involuntary patients in psychiatric system

Aaron Lennon is suffering from a stress-related illness
Aaron Lennon is suffering from a stress-related illness

Patricia Casey

Aaron Lennon, the Everton winger, of Irish-Jamacian parentage was detained in a psychiatric unit almost two weeks ago amid reports that the police were called to assist after concerns for his welfare were brought to their attention. The headlines used the word "sectioned" a term often used in Britain to depict that fact of being detained under a particular section of the Mental Health Act (1983, amended 2007) there. I wish him well and hope that he makes a speedy recovery and a full comeback to football.

All countries in the world have legislation to allow for the compulsory assessment and/or treatment of those with mental illness meeting specific criteria. This gives enormous power to psychiatrists and with power to deprive people of their liberty also comes the responsibility to be judicious and cautious in exercising this authority.

In Ireland most people who are admitted to hospital for psychiatric treatment do so voluntarily. Of the total admitted each year, around 18,500 in 2015, only 12pc were involuntary and of those being admitted for the first time the figure is 13pc. The Mental Health Act 2001 governs the compulsory admission process in this country. Those with schizophrenia had the highest rate of involuntary admission, at 20.2 per 100,000, followed by mania at 7.7 and depressive disorders, at 4.8 per 100,000. In the past five years there has been a gradual upward trend in the total number of admissions and in the proportion compulsorily detained. This represents a rate of 16.7/100,000, a much lower figure than in Britain however.

There is a misunderstanding among the public about the process as it is often assumed that a psychiatrist can "lock somebody up" at will and that, for example, those with substance abuse problems can, and should, be detained for compulsory treatment. Some family members assume that when the psychiatrist is informed that one of them is unwell, we have the power to immediately send an ambulance to take them to hospital. These actions are illegal and they stem from a historical understanding of the older legislation when such practices did occur. The 2001 legislation is compliant with the European Convention on Human Rights.

Compulsory detention is something that families are reluctant to participate in as it can alienate those involved from each other. The specific criteria for detaining a person are that by virtue of the mental illness, there is a serious likelihood of them causing immediate and serious harm to himself or herself or to others.

Alternatively, because of the severity of the illness, the judgment of the person concerned is so impaired that failure to admit the person to an approved centre would be likely to lead to a serious deterioration in his or her condition or would prevent the administration of appropriate treatment that could be given only by such admission and would be likely to benefit or alleviate the condition of that person.

Mental illness is defined as mental disorder, dementia and learning disability. Substance misuse or personality disorder are excluded. As highlighted above the mental illness must pose a serious threat to the person concerned as to others. So a quietly psychotic person who believes, for example, that she is the Queen but is looking after herself, could not be detained as the severity criteria would not be met.

The process can begin one of four ways - a family member can complete a written request and give it to the GP who then makes a medical application to the local psychiatric unit (also called an approved centre). The second approach is for a member of the public who is worried for the safety/wellbeing of an individual to initiate the process. A garda may also make a request and finally an 'approved officer' for the health board. They then consult a doctor who makes the medical application. The final method is through the emergency department of a general hospital where many with mental health problems present. A staff member can make the initial request, then one of the doctors the medical application. In each of these scenarios the patient is then assessed by a consultant psychiatrist and is only detailed if the criteria for seriousness specified above are met. At any point along this process either the doctor making the medical application or the psychiatrist evaluating the patient can decide that the person is not detainable either because the level of risk is not met or because the person does not have mental illness as defined in the Act. The pro forma documents that have to be completed are available from GP's, gardaí, etc.

Within three weeks of detention a tribunal meets to decide on the legality of the process; so an independent psychiatrist assessment takes place, a solicitor is appointed to represent the patient's interests and the treating psychiatrist comes before the three person tribunal to justify the detention.

In over 50pc of cases the detention order is revoked before any tribunal takes place as the person will have improved, been discharged or agreed to remain voluntarily. These protections work well and the terrifying fear of being locked up forever in an institution have thankfully been relegated to history.

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