Evolving judicial approaches to longstanding anorexia nervosa

Interface of Law and Psychiatric Problems in the Elderly.

Treatment of Eating Disorders in Children, Adolescents, and Young Adults

Trends in international human rights law have challenged States globally to rethink involuntary mental health interventions from a non-discrimination perspective. The United Nations Convention on the Rights of Persons with Disabilities (CRPD) in particular prohibits laws that discriminate on the basis of disability. However, a key criterion for compulsory mental health treatment under typical mental health legislation is a psychiatric diagnosis (in conjunction with risk of harm and other criteria). Hence, for people with mental health disabilities, rights to liberty and consent in healthcare are held to a different standard compared to other citizens. A prominent law reform option being explored by some governments and commentators for achieving non-discrimination is to replace the diagnostic criterion for triggering involuntary intervention with an assessment of mental capacity. After all, every citizen is subject to restrictions on autonomy where they are deemed to lack mental capacity, such as where concussion necessitates emergency service. However, the use of mental capacity “testing” is seen by diverse commentators as wanting in key respects. A prominent criticism comes from the United Nations Committee on the Rights of Persons with Disabilities, which considers mental capacity assessments a form of disability-based discrimination. This article queries the call to replace the diagnostic criterion in mental health law with an assessment of mental capacity in the light of jurisprudence on equality and non-discrimination in international human rights law. Instead, we examine the doctrine of necessity as an area of law, which might help identify specific thresholds for overriding autonomy in emergency circumstances that can be codified in a non-discriminatory way. We also consider the need for deliberative law reform processes to identify such measures, and we suggest interim, short-term measures for creating a “supported decision-making regime” in the mental health context. The article focuses in particular on the Australian context of mental health law reform, though the analysis can be generalised to international trends in mental health law.

Healthcare professionals without specialist training in communication disorders may not know how to identify and support patients with communication disabilities during mental capacity assessments. To meet this need, a novel communication screening tool was developed and tested as part of a mental capacity assessment support toolkit. To provide an initial evaluation of the communication screening tool's usability, interrater reliability and criterion validity. A prototype communication screening tool was developed iteratively using co-production and user-centred design principles. A mixed-methods case series design was used to explore how multidisciplinary healthcare professionals used the tool to test patients in acute hospital and intermediate care settings. Usability data were collected in an electronic survey and from a documentary analysis. Screening test outcomes obtained by pairs of professionals were compared to measure the tool's interrater reliability. Outcomes obtained by professionals were compared with the outcomes of a speech and language therapist's communication assessment to measure criterion validity. Quantitative data were analysed using frequency counts and inferential statistics. Qualitative data were analysed using framework analysis. A total of 21 professionals, including physicians, nurses, occupational therapists, physiotherapists, and speech and language therapists, and 17 patients with diagnoses of stroke or cognitive impairment took part. Professionals reported they found the tool easy to use, useful and that its use increased their understanding of communication support methods and the speech and language therapist role in relation to mental capacity assessment. However, not all used it consistently or accurately. Professionals reported they chose not to use the tool when they perceived patients' communication to be intact. Four of eight patients with a diagnosis of dementia or memory impairment, who professionals elected not to screen, were found to have significant communication needs. Screening outcome data for nine patients suggest the tool's interrater reliability is currently moderate, whilst its criterion validity is poor. This study highlights that non-speech and language therapist health professionals have difficulty identifying and screening for communication difficulties. This confirms existing evidence that people with communication disabilities may not receive the decision-making support they require during mental capacity assessments when speech and language therapists are not involved. Greater understanding of health professionals' thought processes regarding communication is required to further develop this unique communication screening tool so that it can effectively enable healthcare professionals to identify and use communicative adaptations to support decision-making. What this paper adds What is already known on this subject Limited previous research suggests that assessing the mental capacity of people with communication disabilities is complex. Practice needs to be improved to ensure this group is adequately supported to make decisions, in line with legal requirements. What this paper adds to existing knowledge This paper describes the development and testing of a novel communication screening tool for use by healthcare professionals preparing to undertake mental capacity assessments. It increases our understanding of how healthcare professionals without specialist training understand communication disability and the role of the speech and language therapist in relation to mental capacity assessment. What are the potential or actual clinical implications of this work? Healthcare professionals without specialist training require support to understand and respond to the needs of people with communication disabilities during mental capacity assessments. With further development and testing, in response to initial evaluation, this novel communication screening tool may be able to provide this support.

The effectiveness of compulsory drug treatment: A systematic review

BackgroundThe compulsory treatment of anorexia nervosa is a contentious issue. Research suggests that psychiatrists have a range of attitudes towards patients suffering from anorexia nervosa, and towards the use of compulsory treatment for the disorder.MethodsA postal self-completed attitudinal questionnaire was sent to senior psychiatrists in the United Kingdom who were mostly general adult psychiatrists, child and adolescent psychiatrists, or psychiatrists with an interest in eating disorders.ResultsRespondents generally supported a role for compulsory measures under mental health legislation in the treatment of patients with anorexia nervosa. Compared to 'mild' anorexia nervosa, respondents generally were less likely to feel that patients with 'severe' anorexia nervosa were intentionally engaging in weight loss behaviours, were able to control their behaviours, wanted to get better, or were able to reason properly. However, eating disorder specialists were less likely than other psychiatrists to think that patients with 'mild' anorexia nervosa were choosing to engage in their behaviours or able to control their behaviours. Child and adolescent psychiatrists were more likely to have a positive view of the use of parental consent and compulsory treatment for an adolescent with anorexia nervosa. Three factors emerged from factor analysis of the responses named: 'Support for the powers of the Mental Health Act to protect from harm'; 'Primacy of best interests'; and 'Autonomy viewed as being preserved in anorexia nervosa'. Different scores on these factor scales were given in terms of type of specialist and gender.ConclusionIn general, senior psychiatrists tend to support the use of compulsory treatment to protect the health of patients at risk and also to protect the welfare of patients in their best interests. In particular, eating disorder specialists tend to support the compulsory treatment of patients with anorexia nervosa independently of views about their decision-making capacity, while child and adolescent psychiatrists tend to support the treatment of patients with anorexia nervosa in their best interests where decision-making is impaired.

Background: The assessment of mental capacity in patients who have self harmed is often difficult. Contextual factors may influence judgements on mental capacity.Aims: To determine the proportion of consultant psychiatrists who judge a self harming patient described in a vignette likely to have mental capacity, and to test the hypothesis that judgements are influenced by contextual factors which should not necessarily influence mental capacity.Method: Four hundred and four consultant psychiatrists were randomized to receive one of four vignettes describing a woman who took a serious paracetamol overdose and required liver transplantation.Results: Seventy percent of questionnaires were returned. Forty-nine percent of participants thought that the patient lacked mental capacity. There was no statistically significant effect of vignette on judgement of mental capacity (p = .4). Psychiatric speciality of the participants influenced capacity judgements (p = .06), with old age psychiatrists being least likely to judge her as lacking capacity (36%) and psychotherapists being most likely to do so (80%).Conclusions: This study suggests that clinicians' assessments of capacity are not greatly influenced by context, but that psychiatric speciality has some impact.Declaration of interest: None.

BackgroundThe Mental Capacity Act requires staff to consider a patient’s ability to make major decisions, including decisions about their property and affairs, health care treatments, where a person lives, and...

Up to 75% of UK care home residents may lack the mental capacity to make certain decisions (Wade, Clinical Rehabilitation, 2019, 33, 1561-1570). Care home staff need evidence-based tools to help them assess residents' mental capacity and provide decision-making support (NICE, Decision-making and mental capacity NICE guideline NG108, 2018). The Mental Capacity Assessment Support Toolkit (MCAST) was designed to support multidisciplinary healthcare staff to prepare, complete and document legally compliant mental capacity assessments. MCAST has not yet been trialled in care homes. This study used a descriptive qualitative design to: (a) understand the current challenges faced by care home staff when supporting residents to make decisions and participate in mental capacity assessments; (b) explore staff members' support needs in this context and (c) to identify if and how the toolkit could be adapted for use in care homes. A purposive sample of 29 staff working as managers (n=18), nurses (n=7) and care assistants (n=4) across five care homes in North West England participated in five semi-structured focus groups between May and July 2019. Data from the focus group transcripts were analysed thematically (Braun & Clarke, Qualitative Research in Psychology, 2006, 3, 77-101). Five main themes were identified: (a) involvement of residents in decision-making; (b) approaches to mental capacity assessment; (c) working with residents with communication difficulties; (d) feelings about practice and (e) responses to MCAST. Participants appeared competent and confident about supporting decision-making and assessing capacity, but recognised the complexity of this area of practice, and identified a need for further support. They reported a range of challenges, including accessing support from speech and language therapists for residents with communication needs. They responded positively to the toolkit and were keen to use it in practice. This study suggests that care home staff would benefit from, and welcome, support to develop their practice. Furthermore, MCAST appears usable in this context and formal feasibility testing is justified.

ObjectiveCognitive disorders can impair decision-making ability in older adults. In patients with cognitive disorders, including cognitive impairment, dementia and delirium, a mental capacity assessment (MCA) should be undertaken to assess whether a patient can consent to inpatient treatment. If a patient is found not to have capacity, a Deprivation of Liberty Safeguards (DoLS) should be authorised. This audit evaluates whether MCA and DoLS are used appropriately across the four Complex Medical Units (CMUs), which treat multimorbid patients, at the John Radcliffe Hospital.MethodsThe first and second rounds of assessment were completed on September 26, 2022 (n=65) and December 13, 2022 (n=66), respectively. Inpatients in CMUs aged ≥70 years were assessed for records of Abbreviated Mental Test Score (AMTS) <8, or diagnosis of delirium or cognitive impairment, which may indicate a lack of capacity to consent to inpatient admission. Where these criteria were met, it was assessed whether patients had a mental capacity assessment regarding hospital admission and a DoLS application if found to lack capacity.ResultsPatient characteristics were similar across the two cycles. In the first cycle, 66.2% (n=43) had AMTS assessment completed. Of the 62 eligible patients, 27.4% had a mental capacity assessment and 17.7% had DoLS in place. Interventions included MCA-DoLS teaching to CMU doctors and a week-long pilot measure in CMU-B to discuss MCA-DoLS during daily board rounds. In the second cycle, 72.7% (n=48) had AMTS assessment completed. Of the 58 eligible patients, 25.9% had a mental capacity assessment and 12.1% had DoLS in place.ConclusionMCA and DoLS protect patient’s rights while delivering quality care. Our audit has identified gaps in the current practice. Though educating doctors is effective, further work, including educating the multidisciplinary team, could help achieve higher rates of MCA-DoLS completion.

The introduction of the Mental Capacity Act in Singapore represents a step forward in affirming individual autonomy. However, gaps remain in assessing mental capacity, which is needed for legal documentations such as Lasting Power of Attorney and deputyship applications. The present paper explores, through hypothetical case illustrations, contributions of community psychology in mental capacity assessments by incorporating the community psychology ecological framework and considering unique strengths pertaining to skills and training of community psychologists. Specifically, community psychologists may assist with mental capacity assessments within downstream community settings, leveraging on rapport building skills and interdisciplinary collaboration to enhance existing medicolegal processes. Overall, the expertise, experience and orientation of community psychologists underpins their ability to provide competent mental capacity assessments in accordance with guidelines set out by the statutory principles and guidelines. Finally, challenges regarding the involvement of community psychologists in mental capacity assessment, particularly within Singapore, are highlighted.

Aims: To evaluate the level of documentation and quality of mental capacity assessments (MCA) in the Emergency Department (ED), specifically examining the frequency, documentation methods, and outcomes of capacity assessments for patients presenting with mental health complaints. We hypothesize that most patients who attend with mental health presentations and leave before treatment is completed do not receive formal capacity assessments.Methods: A retrospective audit was conducted of all patients attending ED triaged under the “Mental Health” category during October 2024 (n=81). Data was collected on demographics, presenting complaints, rates of re-attendance, whether formal and informal capacity assessments were carried out, involvement of Liaison Psychiatry and patient outcomes. Formal capacity assessments were defined as those using the MCA form or explicitly documenting the decision in question, reason for doubt, and assessment of the four key criteria (understanding, retaining, weighing, and communicating information).Results: Of 81 patients (49% female, median age 29, range 13–77), the predominant presenting complaints were suicidal ideation (n=33, 41%), overdose (n=9, 11%), and depressed mood (n=8, 10%). 75 patients (92.6%) left before treatment was completed. 16 (21.3%) of those who left before treatment was completed returned within 24 hours.Only 7.4% (n=6) had formal capacity assessments documented, with 42% (n=34) having informal assessments noted elsewhere. 5 of 6 formal assessments were done by ED staff and one was conducted by Liaison Psychiatry staff. Of all assessments conducted (n=40), 8 patients (20%) lacked of capacity at the time. The majority of patients (92.6%) left before treatment completion. Liaison Psychiatry was involved in 34.6% (n=28) of cases.Conclusion: This audit highlights significant gaps in the formal documentation of capacity assessments in the ED, with few mental health presentations receiving fully documented assessments despite RCEM and MCA guidance. The high rate of patients leaving before treatment completion underscores the need for further investigation into possible reasons, a standardized assessment approach to capacity assessment and focused training for ED staff. Informal assessments may be more common due to time pressures, limited knowledge of the MCA process, or difficulty accessing forms.

Purpose To evaluate the usability and acceptability of the Mental Capacity Assessment Support Toolkit (MCAST) in healthcare settings and whether its use was associated with increased legal compliance and assessor confidence. Materials and methods A mixed methods convergence triangulation model was used. Multidisciplinary professionals used the MCAST during mental capacity assessments for UK hospital patients with diagnoses of stroke or acute or chronic cognitive impairment. Changes in legal compliance were investigated by comparing scores on case note audits before and after implementation of the MCAST. Changes in assessor confidence and professionals’ perceptions of the MCAST’s usability and acceptability were explored using surveys. Patients’ and family members’ views on acceptability were determined using semi-structured interviews. Data were integrated using triangulation. Results Twenty-one professionals, 17 patients and two family members participated. Use of the MCAST was associated with significant increases in legal compliance and assessor confidence. Most professionals found the MCAST easy to use and beneficial to their practice and patients. Patients and family members found the MCAST materials acceptable. Conclusions The MCAST is the first toolkit to support the needs of individuals with communication disabilities during mental capacity assessments. It enables assessors to deliver high quality, legally compliant and confident practice. IMPLICATIONS FOR REHABILITATION Mental capacity assessment practice needs to be improved to maximise patient autonomy, safety and well-being. The MCAST is a paper-based toolkit designed to facilitate and improve mental capacity practice in England and Wales. This study suggests the MCAST would be easy and acceptable to use in healthcare settings and could lead to improvements in assessment quality and assessor confidence.

This guideline watch reviews new evidence and highlights salient developments since the 2006 publication of APA’s Practice Guideline for the Treatment of Patients With Eating Disorders, 3rd Edition. The authors of this watch constituted the work group that developed the 2006 guideline. We find the guideline to remain substantially correct and current in its recommendations. The sole exception is a recommendation (with moderate-level confidence) for sibutramine for binge-eating disorder. In 2010, the U.S. Food and Drug Administration (FDA) withdrew approval for sibutramine because clinical trials showed increased risk of heart attack and stroke, and the manufacturer, Abbott Laboratories, subsequently withdrew this medication from the U.S. market. Noteworthy recent publications about the treatment of eating disorders include systematic reviews by the Agency for Healthcare Research and Quality (Berkman et al. 2006; Bulik et al. 2007); practice guidelines from international groups, including the Catalan Agency for Health Information, Assessment and Quality (Working Group of the Clinical Practice Guideline for Eating Disorders 2009), the World Federation of Societies of Biological Psychiatry (Aigner et al. 2011), and the German Society of Psychosomatic Medicine and Psychotherapy and the German College for Psychosomatic Medicine (Herpertz et al. 2011); and a 2011 guidance statement by the Academy for Eating Disorders, which was written by some of the authors of this

After completing this activity, practitioners will be better able to:• Discuss the growing body literature emphasizing moderation and harm-reduction in patients with severe and enduring anorexia nervosa (SE-AN)• Outline and discuss the legal, ethical, and medical challenges inpatient providers face when treating patients with SE-AN. Patients with severe and enduring anorexia nervosa (SE-AN) present numerous clinical and ethical challenges for the hospital psychiatrist. Patients typically come to the hospital in a state of severe medical compromise. Common difficulties in the period of acute medical stabilization include assessment of decision-making capacity and the right to decline treatment, as well as legally complex decisions pertaining to administering artificial nutrition over the patient's objection. Following acute medical stabilization, the psychiatric consultant must decide whether psychiatric hospitalization for continued treatment is indicated, and if so, whether involuntary hospitalization is indicated. The standard of care in these situations is unclear. Pragmatic issues such as lack of appropriate facilities for specialized treatment are common. If involuntary hospitalization is not approved or not pursued, there may be difficulty in determining whether, when, and how to involve palliative care consultants to guide further management. These cases are complex and largely reside in a medico-legal and ethical gray area. This article discusses the difficulties associated with these cases and supports a growing body of literature emphasizing moderation and harm-reduction in patients with SE-AN. Physician-assisted dying (PAD) is also discussed.