Detention

Walking across the hospital grounds I overheard a couple talking as they returned to the ward.

He was saying to her how grateful he was that his Consultant Psychiatrist, ". . . had sectioned me that night, getting me into hospital," because he felt, "I right needed to, if I didn't I'd have been pissed and in [a nearby large city] and right violent."

The psychiatrist in me thought, how wonderful, he got the right care when acutely unwell and now has insight. But then I also thought, what a shame his Consultant Psychiatrist hasn't heard that and, probably, will never know. I also thought how great it was that he could reflect on it and freely talk through how being "sectioned" was a positive thing for him.

Although a formal Advance Decision can only define what treatment can't be given, he could craft an advance directive framing how he'd like future care to be orchestrated, which has no legal power but at least gives a steer as to his preferences, should the situation arise again. It could either be a discrete statement or part of a wellness recovery action plan (WRAP).

I was mildly piqued by the glib "being sectioned" phrase, but that's because in my training that was seen to be a cardinal sin. Detention under the MHA 1983 is a formal, serious business and "I'd section" a patient was seen as a careless, casual, trite comment at variance with the import and formality of the act. We were also scolded over how inaccurate that is, since doctors can't detain patients, we only make recommendations which ASW/now AMHPs choose to accept or decline, with hospital managers receipting the paperwork and then they formally detain the patient. But that's a personal foible I've hung on to, and labour over with my trainees, so in the cold light of day I'll concede that I shouldn't really be piqued that a patient talks of "being sectioned" instead of "being formally detained under the Mental Health Act 1983."

That was my moment of pondering today . . . hearing a patient's comment, thinking of the positive, thinking of his possible futures, thinking of the terminology used and thinking how he was expressing being grateful for the care he'd received.

Odd how but a few moments of snatched conversation can stir thoughts!

Big Brother

We had a letter about a patient.

Nothing too unusual about that.

The patient was on a ward, having been there for a goodly length of time, detained under the Mental Health Act 1983 for treatment of delusions and hallucinations and passivity. It was the patient's first psychotic episode, the delusions had been managed in the community with the patient's family providing rich support, but the effects on work and relationships and health and risk to self resulted in police bringing him to hospital for assessment and care.

The patient felt that a secret military experiment with satellites was affecting her. She wrote to civil servants, her Member of Parliament and the Prime Minister. She was convinced that her experiences were through technological processes the military were developing and she wanted the experiment on her to stop.

We had a letter from FTAC.

Have you heard of them? I hadn't. The Fixated Threat Assessment Centre (FTAC) was apparently set up in October 2006, according to The Times, and consists of police and mental health workers who "identify suspects." Our patient came to light from their 2 or 3 letters to politicians.

Did you know police screened mail to "identify suspects" and then direct mental health services to intervene? Parliamentary questions have been posed, apparently Mr McNulty had "security, counter terrorism and police" within his portfolio, yet he was the chap explaining FTAC to parliament.

Hmmm. It seems that Big Brother is indeed watching us. And Big Brother's mate is a mental health worker . . .

Legal matters

No sooner had I posted on laws on Friday, then Dr Grumble posted about legal matters on Saturday. Odd how themes pop up.

It got me thinking.

How much of my study time, over the last year, has been updates on clinical matters? Mostly I do this online and through journals, I used to do it through conferences a lot too. My external study leave (conferences, meetings, teaching away from the weekly local in-house stuff) on clinical material/updates was just 12% last year. Almost all my courses and training was legal.

The ammended Mental Health Act, the Mental Capacity Act and Deprivation of Liberty Safeguards have a lot to answer for.

Cash

I saw a lady on a medical ward. She is relatively young. She has diabetes, dementia and Down's syndrome. She was confused. She had fallen at home, her family explained that they couldn't manage her at home. Many meetings were held; she wanted to go back home.

The assessment of needs was clear. OT, social work and nursing assessments evidenced deficits that were pervasive (and progressive) throughout the 24 hours of a day, so couldn't be met through home care popping in to do specific activities. She needed ongoing care with appropriate, timely interventions to meet her needs. Her family had been doing this but were too burnt out and frazzled to sustain this, which in itself was a source of sorrow, guilt and abject misery.

The lady was an incapacitated adult, at that point in time, with respect to the specific decision on where she would reside. Best Interest meetings were held. All those involved in her care or interested in her welfare chirped up with their views. Everyone said the same thing. She now needed to be in a 24 hour care setting if her needs were to be appropriately met.

We gave our views to her medical team. She went in to permanent care.

It was a good outcome. On review she's very happy in her care home. She enjoys the company, she's warmed to several staff and really enjoys being around them, following them around and as she sees it helping in their duties (she spends ages in their laundry). Takes staff two to three times as long to get the work done with her help, but she enjoys it and it's meaningful activity for her. Staff see it as therapeutic time spent with her, not nuisance. Brilliant.

Her family visit daily and are very happy with things, too.

She didn't want to go in to care. The decision to place her in care was made within the section 4 framework of the Mental Capacity Act 2005, subsequently with necessary health and social care being delivered through section 5. There's no use of the Mental Health Act 1983. There's no free section 117 aftercare. She and her family pay for care. 10 years ago, requiring someone to reside in a care setting permanently when they didn't wish to be there, she'd have got this for free. Now she pays for it all.

A dismal consequence of the MCA 2005, methinks.

Police

Jess raised the point of police accessing private places, to bring people to a place of safety for assessment.

In theory, this is covered under section 135 of the Mental Health Act 1983.

Someone's in a private place, refuses help, seems to need care, generates significant and risky problems (for themselves or others), what's to be done? An Approved Mental Health Professional presents their concerns to a magistrate who can then issue a warrant for police to access the person, eg forcing their way into their home, to then take them to a place of safety.

Unusually, they're then locked up in a place of safety for 72 hours, but I can't discharge them from the section 135. The police or the Approved Mental Health Professional does that.

In practice, it's hardly ever used. I've seen it used once.

If someone's in their own home or garden or other not-public area, invariably a section 2 is considered instead.

Jess is quite correct that this means someone who's presenting with a health problem, and consequent behavioural changes and evidence of ill health being manifest to one and all, then has an ambulance crew arrive who do . . . what? If detained under the MHA 1983 then they can be conveyed to hospital. If they're evidenced to be incapacitated adults (with respect to this decision) then they can be conveyed to hospital (if it's in their best interests) under the MCA 2005. Our ambulance crews need to be given completed locally agreed forms documenting this lack of capacity before they'll convey.

So locally, the use of the MHA 1983 (with sections 2 and 136) and MCA 2005 (sections 4 and 5) sort most out of hours problems where statutory powers need to be used to orchestrate care. Rarely, very rarely, section 135 is considered.

Section 136

I get called to a lot of section 136 assessments, out of hours. In fact, it's pretty much all that out of hours work typically involves. Section 136 of the Mental Health Act 1983 allows a police constable to stop and manage, ". . . a person who appears to him to be suffering from mental disorder and to be in immediate need of care or control . . ." to, ". . . remove that person to a place of safety . . ."

Locally, that's a 136 suite in our hospital.

Police find someone acting "a bit odd" and have a choice. They can arrest them, with all the attendant paper work, take them to the cells, wrangle with the custody sergeant why the person needs locking up, do that paperwork . . . or they can fill out a paragraph on one of our forms and drop them at our doors.

No surprise, use of section 136 is increasing massively in my corner.

In fairness, much of the time the police get it right. It's just that sometimes it's clear that the alcohol and social situtation has generated the volatile presentation, so taking them to my door for a psychiatric assessment isn't going to generate hospital in-patient or acute psychiatric care since we've simply not been asked to (and therefore aren't resourced to) deal with this. If you're drunk and feisty, it's not a psychiatric problem.

I concede that having mental illness at the same time can ramp up risks of problems, but if the presentation at that point in time, in that place, in that situation, is because of getting roaringly drunk, I don't have an instant cure for that.

Section 136 is an interesting section of the MHA 1983. You can be picked up anywhere the public have access to. You are thought to need care. You're picked up by police. You have no choice. You're taken to a place of safety. You have no choice. You're held in this locked environment. You have no choice. You're detained there for assessment for as long as it takes, up to 72 hours (that's right, 3 whole days). You have no choice.

What rights do you have, how do you appeal, who do you appeal to? Can you get a First Tier Tribunal to discharge your section 136? No. You can't appeal. You're there for the duration. You have no choice.

Quite scary, really. Anyone acting "a bit odd" can be locked up for 3 days with no rights of appeal or redress.

In fairness, section 136 assessments usually are undertaken pretty sharpish. I always do them straight away, attending immediately. It only seems fair. I need to do the assessment anyway, so why wait? Also it's just a stress to me, knowing I've work to do but not doing it. So when a section 136 is 'phoned through, I'm skipping off to see the patient as soon as an Approved Mental Health Professional (AMHP) can get there (which in my corner still means a band 7 social worker).

The last assessment was relatively brief. A gentleman was brought, by police, after saying over many hours in a pub that he was feeling suicidal. He wasn't. It took just an hour to go through history, mental state and formulation. Discharge options were then discussed and off he was, on his merry way. He's been seen subsequently when both he and staff felt he was in fine form, consistently cheerful, with no mental illness evident.

Another gentleman. Another assertion of suicidality. Another assessment over the course of an hour, with no evidence of mental health problems (meaning neither psychological problems nor psychiatric illness) but social upsets (rows with two girlfriends, thrown out by one of them, feeling skint yet owed friends cash, hated his poorly paid sporadic monotonous work). He was told the good news by the AMHP that he wasn't that ill, he didn't need hospital in-patient care and was no longer detained. A free man. He became angry, smashing his fists on walls and kicking doors and screaming like a banshee. He wanted to be in hospital, but wanted to be detained, to show his girlfriend what she had done, what she caused. Police don't like patients being angry and violent aronud NHS staff. Thankfully they take it seriously, here. They arrested him and he had a night in the cells.

A recent section 136 assessment was different.

The gentleman was brought in mid week. He had a curious account of overdose and suicidal thoughts and actions which was inconsistent. Police didn't find his presentation was in keeping with having taken the materials he said he'd taken. When he presented it was clear he was pretty well, physically, when if he'd taken all he said he had, he'd be flat. Odd. Assessing lethality of overdose and ongoing suicidality perplexed the AMHP who sought more information. The section 136 continued after we saw him, so more information could be gleaned, to inform the assessment (and need for discharge or detention). Blood tests were undertaken and showed he'd not taken what he'd asserted. The next day the AMHP tracked down the clinical team in another county that had been looking after him, prior to his drive to my corner and subsequent overdose here. They gave details of two other counties he'd had contact in. More information was gleaned from them. It was on day 3 that he was discharged from his section 136. Only then did the AMHP feel she had sufficient information of psychosocial history, support available, past behaviour, risk, how he'd managed problems historically (with what escalated risks and what reduced risks) and what sensible discharge planning could helpfully and realistically effect support and change. Months on, he's back in his own locality but I heard that he's coping well and is much, much improved. The assessment and care planning and initial local support was of merit, did effect change and this has been sustained back in his own corner.

Maybe then sometimes, just sometimes, detaining someone for 3 days is in their best interests after all.

I still favour getting it all done and dusted in an hour, though . . .

Advocacy

I am sure, of course, that all commissioners have ensured that robust, effective advocacy services are in place for next week. Because they have had to do so. They got the cash last November, but it wasn't ring fenced, so I'm a little uneasy about how much has been used to commission front line staff to do this work.

Why does it matter?

Because every patient in my corner detained under section 2, 3, 7, 37, a Supervised Community Treatment order (SCT) or conditionally discharged will, from next week, be a "qualifying patient" and entitled, nay obliged to have offered to them, an Independent Mental Health Advocate (IMHA). Why? The Mental Health Act 1983 was ammended in 2007 and from next week advocacy is a statutory requirement.

Does it matter? Well, quite probably. There are very few patients detained, in my corner. Although I've a typical (according to the Royal College) size of patient population in my patch, who I'm responsible for, my team and I don't use the Mental Health Act 1983 very often, at all. In case my memory failed me, and in the interests of determining how often SCTs may be considered, my Mental Health Act office kindly let me know how often I've had patients under my care detained under section 3. Since 2003, there have been 3 of them. Not many, then. What can I say, I'm blessed to work with exceptional staff. Nationally, it's a different story. The total number of people detained under the Mental Health Act 1983 is about 42000 in a year. That's a lot of pink forms.

Quite how we'll suddenly, from next week, be awash with advocacy services (that are qualified or will have the national level 4 City & Guilds IMHA qualification within a year), to manage the advocacy needs of 42000 people perplexes me. Every detention, every meeting, every Hospital Managers hearing, every Tribunal, an IMHA should be offered.

The IMHAs have powers. They have a right to see the patient in private. They have a right to interview clinical staff (nurses, psychiatrists, whoever). With the patient's consent, or without if they're incapacitated and it's in their best interests, the IMHA has a right to access the patient's medical records. Good luck to them accessing the electronic medical records in my corner. And even more luck in deciphering the meaning of what's documented. Interesting times.

Okay, I've no patients detained under the MHA 1983 and haven't had any for an age. But in forensic and LD corners, I can see April being a very, very busy month . . .

Death

"Certainty? In this world nothing is certain but death and taxes."
- Benjamin Franklin

Well, he has a point.


This week's been frantic. A lot of folk have been unwell and (as is my wont) a nurse and I've been doing a large number of joint visits. One referral from A&E resulted in a section 136 assessment. What's that? It's when police arrest someone in a public place and convey them to a place of safety (erm, that'll be my hospital, then) for an assessment of mental disorder. In theory a section 136 is applied because the person presents as mentally disordered and is in immediate need of control and restraint. In practice it can be used 'cause someone is acting, "a bit odd," but the police would find it hard (and bureacratic) to arrest the man then go through their custody officer to get him into the cells. Oodles of paper work. Best just cart him off to health, then he's their problem. But on this occasion an assessment was indeed appropriate.

Thus, I was asked to see a retired gentleman who was detained because he wanted to kill himself and had flounced out of his partner's home and driven off (but was curiously found very swiftly after a number of mobile 'phone calls he made) yet notionally he wanted to be left alone and sought to kill himself. He'd injected himself with insulin. He could tell me, to the unit, how much. He had all his papers with him so he could relocate and settle in my patch. He'd brought suitcases and personal effects. But, erm, "I'm suicidal, I'm going to kill myself and going to end it all."

The approved social worker did some sleuthing. He's been assessed in 5 neighbouring hospitals with the same presentation. Euphemism : he's problems of anger management. Truth : he batters his partner and blames it on anger that doctors haven't cured. He feels no responsibility for this, he can be violent since, "It's not my fault." It's other people, "They wind me up, play head games, do my fucking head in, doc." So they deserve it? "Well no, but they're kind've askin' for it, really, aren't they? Kinda got it comin' with what they say." Who is responsible then? "Not me, it's them folk in [town blah 30 miles away] who never helped me. They know I fly off the handle dead easy, like, but don't treat me or anything. Nobody cares." Ah, my colleagues in a neighbouring county fail to control your anger, so you batter your partner, you're not responsible and they are, now I see.

Are there any delusions? No.
Are there any hallucinations? No.
Any cognitive impairement or confusion? No.
Any changes in physical health, medication, wellbeing? No.
Any obsessions, compulsions, odd thoughts? No.
Alcohol misuse, drug problems? No.

Erm, anything to affect your judgement at all? "Yes doc, it's her, she's done this to me."
Done what? "Said she can't live wi' me, asked me to go, so I have. But now I want to kill myself."
Ahhh.

He's assessed. Usually a section 136 assessment takes an hour or so. The approved social worker (ASW) wants more details so it goes on a while. He's observed by nursing staff.

Before this event he's had no tiredness, no loss of pleasure, no initial insomnia, no broken sleep, no early morning wakening, no loss of libido, no diurnal variation, no low mood, no hopelessness, no worthlessness, no guilt, no tearfulness. So, no evidence of somatic features of depression a few hours ago, but suicidal now. Crikey.

He's chatty, enjoys watching the telly, talks with patients about his favourite football team and a match he's looking forward to (and how he might drive up to watch it live). He speaks of new things he's ordered and has to collect next month. He talks of accomodation he wants and support he'd need, "I can't cook, like, so I need looking after."

He's expressive, reactive, no psychomotor retardation, no restlessness, no tearfulness, no distress. He speaks fluently, normal rate, rhythm, volume. Spontaneous with neither poverty of speech nor poverty of content. No dysprosody. Mood subjectively "I'm going to kill myself" but objectively is euthymic. Thoughts are of normal form and content. No perceptual anomalies. No cognitive impairement.

The ASW gets a colleague to see him. Then 'phones another. We talk with 3 nurses who've been with him most of the day, now. Reassauringly, everyone feels the same.
Nobody sees any symptoms of mental illness. Nobody feels he's evidence of mental disorder. Nobody feels he's detainable under the Mental Health Act 1983. Everyone sees him as a capacitated adult, able to make his own choices.

He says, "If you let me go, I'm going to kill myself. Don't you have to detain me, don't you have to stop me killing myself?"
I explain that's not the case, I really hope he won't kill himself, but that's his choice.

We arrange a range of accomodation options for him, for today, in a range of locations. We arrange mental health followup from a CPN and Consultant in his own town but he says he won't go to it. "Your choice, we've offered social support, we've offered mental health follow up, if you want to choose to do something else, we can't stop you."

We send him on his way.

I really, really am not sure he'll live. He's impulsive and reckless. The Mental Capacity Act 2005 states that adults with capacity must be allowed to make unwise choices. He's likely to take overdoses and, intentionally or accidentally, at high risk of killing himself through this.

As Mr Vonnegut would say, "So it goes."

Medical Care

I looked after a chap in his home, with his wife, through much of last year. Notionally he was depressed, but he seemed much more jaded and despondent than clinically depressed, to my reckoning. I saw him at intervals, roughly once every three weeks or so, throughout the Autumn and Winter. His GP asked for help, since the chap wasn't eating or drinking much, was largely bed bound and seemed to be fading away. He's got a good GP who works hard for his patients so I'm always happy to go the extra mile (or 6.8 miles in this case) to help out.

He refused all medication but I'm stubborn so a nurse and I visited every few weeks. He didn't want us to. We got him eating and drinking again. We got him more mobile. He no longer needed his frail wife to carry him to the toilet. He no longer wanted to die. He was no longer chain smoking in bed and burning his sheets/smouldering holes in the carpet. He still didn't want us to visit. By now, 6 months on, with him coping well enough and no evidence of mental illness and telling us to go away, I didn't feel we could keep intruding in to his home and persuade him How It Had To Be any more.

I knew it wouldn't go well.

Once when I saw him he was too breathless to finish sentences and his lips were a glorious shade of puce. Focal signs in his chest. GP tried to arrange admission but he'd not go in. The GP tried this a lot. He always said no.

Earlier this year things broke down. He became confused, wouldn't listen to his wife, didn't appreciate who she was or what she was trying to do, wouldn't accept help from his son or daughter, absolutely refused to go in to hospital. The GP was desperate. The GP asked if I could admit him. I visited the chap, saw a scene of woe, he was thoroughly confused which was just sufficient to persuade an Approved Social Worker to take the pink form the GP and I'd hastily penned and apply for him to be detained under section 2 of the Mental Health Act 1983 for admission and assessment on one of my wards.

Within a couple days on a cephalosporin he improved. Temperature, tachypnoea, dyspnoea, cyanosis, all better. Too, he was less confused. But still too frail to mobilise. Pretty infirm, really. Abdominal masses. Abnormal LFTs. Chest signs. Blood count that's halved in 6 months. Anorexia. Trophic changes of his skin with widespread pressure sores on admission (that are getting better now he's on the right sort of matress and nurses are attending to this). CT imaging is awaited. I suspect something sinister and have said exactly that to his family, along with words like "cancer" so we're all crystal clear we're looking for stuff that's not dysthymia or an adjustment disorder.

Meeting with family, we're all clear his mental health is the last thing that's concerning us now. But when his confusion's resolved and he's no longer detainable under the MHA 1983, he'll not accept informal admission. Saying that, he's too frail to self discharge and flounce out.

What to do, what to do . . .

Mental Health Act 2007

Parts of the new Mental Health Act 2007 are already with us but most of it comes in to force this October. It's a smaller bit of legislation than the original Act, so it will still be known as the Mental Health Act 1983 (MHA 1983) but this new bit of law ammends some key areas.

Some are widely known. No longer will doctors have to look after detained patients, the Responsible Medical Officer (RMO) role ceases to exist and instead we have Approved Clinicians (who could be nurses, psychologists, occupation therapists etc) who can then act as the Responsible Clinician instead of a psychiatrist. So when detained under section 3, it could be almost anyone looking after you and deciding when you are allowed out, with psychiatrists nowhere to be seen.
Interesting times, eh?

The implications of some changes are less well known. It was, oddly, a carers forum that developed this scenario at me. I then spoke with a lawyer :

A patient, Alex, becomes unwell after drinking alcohol and using cannabis and becomes psychotic. He stops work and is admitted under the MHA 1983 for 6 weeks, having a period of time being detained in hospital for treatment under section 3.
After 6 weeks in hospital he's back home again with his family.
2 weeks after this he's back at work.
Alex then drinks alcohol and use cannabis.
He become psychotic and is admitted, again.
His family are cross that he's psychotic again, why did we let this happen?
This pattern repeats itself over time.

Summary : A patient has serious psychotic episodes as a result of lifestyle choices they elect to make.

Implications : We've detained him under section 3 of the MHA 1983 and have a duty of care. Her Majesty's Government has given us an instrument to provide care for him, in the form of the MHA 1983. From October this year, this extends to Supervised Community Treatment (SCT) that has to be considered for all patients detained under section 3 (and other treatment sections). We have to consider this (as in, the law says so, and when we have to, e.g. when you have more than 7 days leave, so it can't be ignored).

If Alex uses alcohol and cannabis, he becomes psychotic. If Alex doesn't, he doesn't. When we look after him, we are attempting to get him well and keep him well (with advice, psychological therapy, medication, support, whatever). We have to, it's our duty of care for a detained patient (and continues to be our duty through section 117, SCT and under the Care Programme Approach). Some sections (7, 25) specifically require more.

How do we exercise our duty to look after Alex and avert psychosis (with the loss of income, distress to him and his family, time out in hospital and so on) when he's discharged from hospital?

We use a SCT that requires he abstains. We say he has to abstain, since to do otherwise is to cause a relapse. Just the way he could be told he has to take his tablets, family/carers were adamant that mental health services should be directing patients who become psychotic on drugs not to take drugs. Under a SCT what happens if they fail to take their tablets or fail to abstain from cannabis? They're recalled back to hospital by their Responsible Clinician, RC (who could be a CPN, ward nurse, psychologist, OT, whoever). After a couple days and an AMHP (from October what an approved social worker will be) a section 3 starts again (note, no medical recommendation has been made for this and they're there for up to 6 months, now).

The stick : abstain from alcohol and drugs, take your tablets, or you're locked up. Again.

The pressure from carers and family : how can the Responsible Clinician not do this? The RC has a duty of care to Alex. The RC knows if Alex uses alcohol/drugs he becomes psychotic so to support community placement Alex must avoid them. The government's given us a tool to effect this care plan and ensure Alex remains well. To not use a SCT, thus allowing him to become psychotic (which is a forseeable event we can reasonably predict) can be seen as a failure of the RC in their duty of care to Alex and as medical negligence. The family can complain that the RC was able to avert this psychotic episode through use of the SCT but didn't, thus a letter from Bastard, Bugger and Brown Solicitors is on it's way to the Trust to sue their asses for an episode of psychosis that was forseeable and could have been prevented if the RC had used an SCT appropriately.

Mental health services enforcing such things, and there are oh so many things that impact 'pon mental wellbeing that we could enforce . . .
. . . may we live in interesting times.

Treatment

There's a presumption that patients have a right to treatment.

There's a duty of care that mental health folk have to patients.

There're laws passed (statutory instruments) that give us the tools to undertake this care.

All well and good, most of the time. But what if it's taken to extremes? Who should be treated, and how much, for how long? At best it's quirky and autocratic care, at it's worst it's paternalistic and tyrannical health care. Gets you thinking, this does, when patients crop up with unmet clinical needs that could be treated.

Let's take a lady and call her Alice. Alice is elderly and depressed. She's often had bouts of depression in the past so has a diagnosis of F33.2 Recurrent depressive disorder, current episode severe, without psychotic symptoms. She was unable to look after herself well, feeling weary and disinterested in "stuff to deal with" to get through a day, wasn't eating anything but gingernut biscuits and wasn't drinking much fluid at all. She smoked over 100 cigarettes in a day (usually it's less than 20) and was too demotivated to go and get more so was withdrawing from nicotine abruptly, too. Life's bleak, she'd rather go to sleep and not wake up. She's no energy, no hope, no joy, no quality sleep, no feeling refreshed, no motivation. She feels utterly worthless and a nuisance to everyone.

2 months ago she was right as rain.

In the past when this has happened she's had ECT, been cured, gone home and stayed well for between 10 to 22 months before another depressive episode occurs.

She refuses people coming in to her home to help. It's started anyway, but she doesn't let them in. She refuses hospital admission and is fading away fast. She's admitted under section 3 of the Mental Health Act 1983 for treatment of her underlying mental disorder, depression.

She refuses medication and historically has poor concordance with prescribed medication on discharge, with the only antidepressants in her flat on this occasion being 4 months out of date and untouched.

She's said in the past that she doesn't want ECT again.

Through her depression she's got marked bradyphrenia, depressive cognitions, cognitive distortions and abberant ideation. She's not frankly psychotic, but her thought process are disturbed through her depression so, within the meaning of the Mental Capacity Act 2005, she has imparied function of her mind and is an incapacitated adult (with respect to the decision to determine current treatment such as ECT).

This time, what should happen?

It's not even up for discussion as the law stands; she should have ECT :
- she has a mental disorder
- we have a duty of care
- she has been detained under the Mental Health Act 1983 for the treatment of this mental disorder
- statistically we know ECT is the treatment of choice (better outcomes than tablets, swifter resolution of symptoms, safer with half the mortality of antidepressants) and specifically we know it works very well for her, very quickly, such that's she's well and functioning independently for a year or two even off all medication. So the clinical intervention of choice, for her, at this stage, is ECT
- she refuses ECT and has, in writing, an Advance Decision refusing ECT treatment. But ECT can be given under Part IV of the Mental Health Act 1983 under section 62 then with a Second Opinion doctor agreeing under section 58, so we've a statutory instrument allowing us to deliver the care she needs.
- ECT is given, she gets better after 4 sessions (two weeks) but has 2 more sessions to consolidate the treatment course, she's regraded and discharged and is well

Outcome : a lady got the care she needed when she was unwell and vulnerable and was cured, for a while at least.

As an aside, having taken advice on this, if her Consultant Psychiatrist didn't give her ECT he'd be open to claims of medical negligence (having a duty of care, admitting her for treatment, having a statutory instrument to use to deliver the treatment but then electing not to do this and thus not providing her with the care she needs and deserves). Like it or not, that's the law as it stands today in England.

I'm totally for people with insight making rational decisions about their current and future care. Some people can very sensibly and very thoughtfully describe why they will or won't buy in to treatments offered to them and make a choice on this. Whether I agree or disagree with that choice then, generally, is irrelevant . . . I'm bound to accept their wishes.

The revisions to the Mental Health Act 1983 are making things slightly different. In the future, if you've an Advance Decision to refuse treatment (including ECT treatment) andf that Advance Decision is undertaken in accordance with the Mental Capacity Act 2005, it'll be legally binding. The Mental Health Act 1983 can't then be used to deliver ECT even if the person's incapacitated with regards to this decision.

I wonder what this will mean for Alice.

Free Care

The NHS, notionally, is free at the point of contact.

Okay, we pay for prescriptions and eye tests and dental work but, for the most part, it's true that most of the NHS is free at the point of delivery.

Excellent.

Health care is delivered without charge.

But, the huge grey cloud dominating the faint silver lining is that social care is not free. We pay a lot in to social care as taxpayers (over twice what we pay in to health) and then the recipients of social care (when patients) invariably pay for it, too.

If I've a patient who's not coping awfully well at home but can manage with support, they're helped and usually manage in their own home for a goodly length of time, sometimes indefinately. Get a cleaner to do the housework, Social Services to arrange 4 social care visits a day to help with personal care, prompting with medication, checking they're alright (although officially that can't be the reason for their visit), helping heat up a meal for them and acting a resource to sort out problems (letters they don't understand, or whatever). Their loneliness and weary days can be addressed in part through social day care where they've more vibrant company with local folk and ongoing support.

But none of this is NHS work, none of it is free. They pay for their cleaner, they pay for each home care visit, they pay for their meals delivering, they pay for their day care.

The exception . . . if you're detained under section 3 of the Mental Health Act 1983 then you're entitled to section 117 aftercare. The Code of Practice states that this, ". . . require health and local authorities . . . to provide after-care for patients who have been detained under the longer-term provisions of the Act . . . until they are satisfied that is is no longer necessary . . . section 117 obligations have statutory force."
This means if I'm involved in a detained patient's care and consider a care package such as social care visits would be useful, we can't force the patient to spend their money on this (but they have no choice but to be in hospital and have treatment) so any social care is paid for by the local authority (i.e. Social Services). On leaving hospital, both health care and social care is free.

Bit of a puzzle, this. If we manage folk as we do, keeping them in their own homes where they wish to be for as long as possible then their family and they choose a 24 hour care home if things progress and it's necessary, they're enjoying time in their own home (i.e. in the least restrictive setting) and all is well. If we drag them kicking and screaming in to hospital under section 3, when they leave hospital everything's free.

The General Medical Council document from 2006, "Good Medical Practice", states the duties of a doctor registered with the GMC with the first and foremost requirement being, "Make the care of your patient your first concern."
Care, not health. Hmmm. Should we be detaining everyone, so their social care is free?

Social Care

It's not often that I recommend that a patient is detained under the Mental Health Act 1983, but this week I had cause to do just that. That makes 3 patients detained this year, not bad for a full time Consultant Psychiatrist and less than my colleagues, but I'm still conscious that it's loss of liberty and choice for 3 people at a distressing time in their lives.

This week it was a gentleman who's thoroughly confused but has never been seen by mental health services. He's been living in squalour for months. Social services visited him, he declined help, they left him. This seems frankly criminal, given the state he was in. His fridge didn't work and had only rotten food that was composting down in it. Milk bottles were full of solid milk. Items on the floor were shredded by rodents. Dead mice and mice droppings littered the rooms and stairs. Urine and faeces was soaked in to him, his clothes, his furniture. He was unkempt, unwashed for months, had debris stuck to him and his clothing and smelt of the urine and faeces that he'd been generating and sitting in for months. Broken glass was on his lawn, porch and stairs. He had no heating and we discovered the reason his fridge wasn't working and he was sitting in gloom was because he had no electricity. Now I know I'm just a medic and not a trained Social Worker, but this does seem a curiously suboptimal state of social wellbeing to leave a chap in.

I've no idea if he's toxic through infection or if he's cancer that's metastasised to his brain (he's had cancer in the past that was cut out but he never attended follow up), if he's nutritional deficits (I can't imagine he hasn't, though) or if he's dementing. So he's now on my ward, detained under section 2, a month after social services visited his home then left him in this state.

I don't believe a Social Worker could necessarily have prevented his confusion but they could have organised the social care he needed and deserved.

Much badness.

Text Messages

A chap broke up with his partner of 3 to 4 months.

They started sending increasingly acrimonious text messages to one another.

Laughing with his brother he said, "this'll wind her up!" and texted her saying he'd go to the woods and kill himself.

She 'phones the police saying she's had 40 texts from him that day and he was suicidal. Police find him late afternoon and detain him under section 136 of the Mental Health Act 1983 and drag him to my hospital. Where he's laughing and smiling and well. Obviously so.

It's hours before an Approved Social Worker (ASW) could visit since they were busy with other distraught folk.

At almost midnight, the ASW arrives so she and I assess him. After a few minutes it's clear he's neither suicidal nor ill. Being zealous I spend an hour and check everything and find him to be absolutely fine and well, far better than most folk are, in truth! Cheerful, happy with his life (and new partner), no stresses, physically well, great relationships with family, no worries about anything and looking incredibly well.

The moral of the tale : Don't text folk saying you're suicidal as a joke, or police will detain you for an evening/night (with risks of it all going pear shaped after that "just in case"). Even after break ups, play nice :-)

Sections

The Mental Health Act 1983 is, obviously, the law. It's a "statutory instrument" that contains provision to detain people with mental health problems and unmet needs in hospital (even though they don't wish to be there). There's a Code of Practice that tells us how we're to use the MHA 1983.

A couple points are worthy of mention.


"Sectioning"

When I was a trainee doctor, we'd get shredded for talking of "sectioning" someone. We were instead to speak of "detaining someone under section blah" which at the time seemed pedantic thought control. One Royal College examiner said he'd failed a candidate for such talk. With hindsight it's sitting increasingly well with me, but p'raps I'm simply becoming more pedantic as time marches on. Being less glib and more professional is important, though.


Being detained

I've never detained anyone. Well, technically not. I've made medical recommendations. Approved Social Workers have made applications to hospital managers for a patient to be detained. Hospital Managers have agreed to detain the patient in their hospital.

Sophistry?

It shouldn't be.

Nurses have to be the patient's advocate, the NMC says so. Curiously, the GMC doesn't have anything like that directing doctors but most of us do feel we have such a role. As such, when we're advocating that a patient has a right to get the help they need and deserve it's useful to be part of the decision making process rather than be painted wholly as the prison warden. We don't detain people, we make recommendations for their care then social workers and hospital managers detain them if that's necessary. As such we can continue to focus on their care. A seemingly tiny point, but such things shift the culture and philosophy of mental health units from paternalistic/abusive to collaborative/clinically driven.

Anyway, I'm a civilian. Should I be locking people up?


Least restrictive setting

We've got to manage patients in the least restrictive setting. Hospital in-patient care should be for folk who have needs that can only be addressed through hospital care and increasingly these are far and few between . . . what can be done in a hospital that teams can't do in the community? There are assessments and interventions, of course. But typically it's rare that there's specific work that a hospital admission does that couldn't be done in the community (which is self evident, given that 1/4 of the population will at some point in their lives experience mental illness, but so few reach Secondary Care services let alone in-patient admission).

Hands up who thinks detaining people is just about hospitals? A not uncommon scenario for me is of someone with dementia who's been diagnosed and treatment's been optomised but they can't manage in the community despite having lots of support. One elderly lady this Summer became more confused at night, thinking since it was light that 9.00pm was 9.00am. She was helped to bed at 8.00pm by home care and would then rise to wander around the street through the night - living on a busy main road made this particularly unsafe. She'd been active at night for many months, it got worse, what were we to do? She was adamant that she wanted to stay at home.

Section 7 of the MHA 1983 lets the local Social Services authority force someone to reside at a specific address (e.g. you now live at Care Home X). As this is then the law, if they leave police are obliged to return them to this property. They're also compelled to attend out-patient clinics, any medical reviews and even non-medical meetings such as job centre attendance, going to a specific place of work, or having to attend specific evening classes as well as having no choice where they live.

All this seems pretty heavy, doesn't it? What I find more perturbing is that the protection patients have within the MHA 1983 are pretty good. The Mental Capacity Act 2005 is far more widely reaching (e.g. allowing community treatment orders against the patient's wishes) but has none of the scrutiny, no need for 2 doctors/doctors with specialist training and experience, no rights of appeal to hospital managers and a Mental Health Review Tribunal and no review dates. Scary.