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AN expert in psychiatric ethics says doctors’ low compliance rates with legal requirements for involuntary mental health admissions reflects long-term underfunding of mental health services and an erosion of judicial oversight.
Associate Professor Michael Robertson, clinical associate professor of mental health ethics at the University of Sydney’s Centre for Values, Ethics and Law in Medicine, was commenting on research published in the MJA, which found that medical practitioners addressed all necessary criteria in only 40% of admission forms providing written grounds for the detention and involuntary treatment of their patients with mental illness. (1)
Professor Robertson said the findings, based on forms authorising the initial detention of involuntary patients in South Australia between 2008 and 2009, were “alarming, but not surprising”.
“It certainly is disturbing that there is a very minimal burden of proof to detain someone with a mental illness”, Dr Robertson said.
The SA study found that of the 2491 consecutive forms authorising detention of involuntary patients only 985 addressed all the legal requirements for detention, with 59% (1471 forms) failing to include a comment on the need for immediate treatment, 22% (540 forms) not stating the presence of a mental illness, and 14% (359 forms) not discussing risk to self or others.
“We view this very low completion rate as a significant problem in documenting evidence of compliance with the law and protecting the rights of the affected patient”, the researchers wrote.
Dr Robertson told MJA InSight there had to be evidentiary justification for detaining someone and enforcing treatment, and yet the burden of proof was “pretty flimsy”.
These failings reflected “generations of underfunding” of health services for the mentally ill and the consequent erosion of judicial oversight, he said.
“There needs to be the same level of judicial oversight to coercive treatment and involuntary detention that there is in a criminal matter”, said Dr Robertson, calling for a more rigorous system for involuntary detention.
Dr Christopher Ryan, psychiatrist with the Centre for Values, Ethics and the Law in Medicine at the University of Sydney, agreed that the findings were cause for concern, but emphasised that the documentation failures did not necessarily mean that patients were being detained unlawfully.
“The most important thing is that the person is detained lawfully and that they understand — or have the opportunity to understand — why they have been detained”, Dr Ryan told MJA InSight.
“We have to find some way of making sure both of those things happen.”
However, Dr Ryan said the findings did highlight the problem of “how do we know that people are being detained lawfully”.
The MJA authors said that in 2014 a review of the operation of the SA Mental Health Act recommended that reasons for detention not be included in written forms. The review is currently with the SA Government.
They wrote that requirements to complete forms and notify involuntary patients of the reasons for detention varied across jurisdictions.
“We suggest not only that the recording of reasons be required, but also, given the concerns discussed in this article, that the reasoning on the forms be regularly monitored for quality assurance and that clinicians be supported to improve their performance”, the authors wrote. They also suggested that mental health tribunals regularly review forms.
Christopher Povey, manager of mental health and disability at Victoria Legal Aid (VLA), said complying with the information requirements under the Mental Health Act was fundamental to a system in which human rights were being curtailed.
However, Mr Povey said variable compliance with these requirements was a feature in many of the 1100 cases the VLA represented before the state’s Mental Health Tribunal (formerly the Mental Health Review Board) last financial year.
(Photo: Monkey Business Images / shutterstock)
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It seems like the mental health assessment process is subjective and flawed. Yes, I agree with one comment that at times mental health professionals use an AO to teach patients a lesson for not conforming to their rules and judgements. Where is the standard for distinctions of rational emotional outburst and mental illness, and tagging normal behaviour with some jargon, and who decides? These normal emotions are then treated with medicine and disaster ensues. How psychiatric medicine is prescribed wrongly due to the subjective nature of judgements needs investigation and how we teach our medical students to tag patients with medical jargon. At this rate the whole of society’s emotion will be blunted so that only psychiatrists are left to shape society. Often real physical problem are overlooked for “so called tagged with mental problems” as a mental problem . It is a shame on phychiatry indeed.
How has physiatry infiltrated our society to shape our vocabulary even?
1. Now Apple apps can detect depression!
2. Use of “NO STRESS” instead of usual “No problem”!
There are many more.
It is time that speciality psychiatry is analysed and perhaps combined with neurology. That way many real diseases will be solved rather than all this expenditure on “Mental health awareness day/week/month/year” without resolving the real causes.
The documentation on MHA forms is indeed variable and would be a significant problem if it were the only information considered. Usually there is additional documentation with assessment by mental health staff involved in many referrals, with usually a much higher standard of care. In my clinical experience the actual appropriateness of referrals is usually reasonable and should be judged in context of the information involved at context and time of decision making with the practitioner at a disadvantage of having limited or ambiguous information and being required to make the best decision they can while balancing competing demands, safety and ethical consideration. A tough task at the best of times. I find feedback to practitioners who make errors in this regard is often useful.
“She pissed me off”, was the reason a patient was scheduled by a country GP. I was at the receiving facility and the doctor confessed this on the telephone. It was unfortunate because the patient had calmed down, become cooperative and the effects of alcohol had substantially worn off when I examined them. But they still had to be involuntarily detained until formal psychiatric reveiw could take place. It wasn’t just unnecessary paperwork, it was inappropriate use of the Mental Health Act, even at that time.
Attention must be drawn to the recent Guidelines on Article 14 of the Convention on the Rights of Persons with Disabilities – The right to liberty and security of persons with disabilities. These refer directly to the prohibition of involuntary or non-consensual commitment in mental health institutions:
Involuntary commitment of persons with disabilities on health care grounds contradicts the absolute ban on deprivation of liberty on the basis of impairments (article 14(1)(b)) and the principle of free and informed consent of the person concerned for health care (article 25). The Committee has repeatedly stated that States parties should repeal provisions which allow for involuntary commitment of persons with disabilities in mental health institutions based on actual or perceived impairments. Involuntary commitment in mental health facilities carries with it the denial of the person’s legal capacity to decide about care, treatment, and admission to a hospital or institution, and therefore violates article 12 in conjunction with article 14.
Since the civil and political rights contained within the CRPD have immediate effect upon ratification, and since the CRPD covers all levels of government, that means that involuntary commitment practices across the Australian jurisdictions are in breach of that Convention. Australia ratified the CRPD in Jul 08 and the Optional Protocol (that which allows for complaint to the United Nations) in Aug 09.
For a copy of the Guidelines on Article 14, please refer to this website, under ‘Recent Events and Developments’ http://www.ohchr.org/EN/HRBodies/CRPD/Pages/CRPDIndex.aspx
Just because thorough documentation has not occurred does not necessarily mean the patient has been incorrectly treated. this applies throughout the medical fields, as doctors often are under a lot of time pressure with heavy workloads, and time spent with the patient takes precedence over time spent as a pen-pusher. In general the amount of paperwork, clerical demands and bureaucracy in medicine has gotten way out of control. Little wonder patients wait hours to be seen in emergency departments. I could see far more patients each day if I didn’t have to spend half my day in front of computer screen and filling out forms.
“There needs to be the same level of judicial oversight to coercive treatment and involuntary detention that there is in a criminal matter”, said Dr Robertson, calling for a more rigorous system for involuntary detention.”
LOL. First, there is not evidence that not doing the paper work is resulting in any actual harm. Second, that would mean leaving them in the community while they had an opportunity to get a lawyer before the court date/date of admission. LOL.