Mental Health Review Tribunal Research Articles

The Mental Health Care Bill 2013: A step leading to exclusion of psychiatry from the mainstream medicine?

Byline: Choudhary. Narayan, Deep. Shikha, Mridula. Narayan After India signed and ratified the United Nations' Convention on Rights of Persons with Disability, 2006 (UNCRPD), Ministry of Health and Family Welfare (MOHFW) initiated the exercise of revising the Mental Health Act - 1987 (MHA-1987) to bring it in harmony with the UNCRPD in 2010. After about 31/2 years long drafting and consultation process, the proposed legislation named Mental Health Care Bill, 2013 (MHCB) was introduced in the Rajya Sabha in August 2013. The Parliamentary Standing Committee on Health Related Matters submitted its report with suggestions of some minor changes in November 2013. [sup][1] Though invited to the consultation process at different stages, Indian Psychiatry Society (IPS) was not assigned any role in drafting of the current Bill. IPS and other professional bodies of psychiatrists have expressed apprehensions about a number of provisions in the Bill, which are not considered to be in the interest of persons with mental illness (PMI). IPS has submitted its representations at various stages expressing these concerns. Antony (2014) said that the Bill has an over-inclusive definition for mental illness, which will hurt a huge number of victims of even minor mental illnesses and their families, because of the wide prevalence of stigma. [sup][2] Though there are provisions of emergency admission on any bed anywhere in the country for a maximum period of 72 h (96 h in NE states), all the hospitals or nursing homes who admit PMI have been brought under the purview of the Bill and are required to be registered as mental health establishments (MHEs). All involuntary admissions in MHE even for a day may be subject to review by Mental Health Review Board to be established throughout the country by the Mental Health Review Commission. Kala (2013) said that the provision is undoubtedly progressive, but expressed his doubt that whether we as a society, are ready for this large scale countrywide post-admission review in almost all cases of involuntary admissions. [sup][3] Unmodified electroconvulsive therapy (ECT) has been totally banned, and ECT to minors can be given only after approval from the board. Many other provisions like those of nominated representative, advance directive etc., are supposed to create an obstacle in the treatment of PMI. The Bill has many positive features as well which, if properly and genuinely implemented, are set to revolutionize mental health care services in our country. The Bill ensures the right of every person to access affordable and good quality mental health services funded by the government. All PMI have the right to equality of treatment, protection from inhuman and degrading treatment, free legal services, right to access their medical records, and right to complain regarding deficiencies in provisions of mental health care. [sup][4] Special emphasis has been given to human rights of PMI, and there is a separate chapter in the Bill for this purpose. The government is mandated to establish good quality mental health services at all levels so as to ensure everyone to have access to mental health care services. Decriminalizing suicide is another welcome feature of the Bill. The single provision, which is supposed to inflict greatest damage to the system of mental health care delivery, is that of bringing all the general hospital psychiatry unit (GHPU) within the ambit of definition of MHE. It will result in moving the clock backwards, so far as the development of psychiatry and mental health care in our country is concerned. In Indian Lunacy Act, 1912, there was no mention of the GHPU. In MHA-1987, "any general hospital or general nursing home established or maintained by the government and which provides also for psychiatric services" were excluded from the ambit of definition "psychiatric hospital/ psychiatric nursing home". Thus, the GHPU established or maintained by the government were exempted from obtaining a "license" for running psychiatric inpatient services. …

A retrospective study of psychotropic drug use among individuals with mental illness issued a community treatment order

Community treatment orders (CTOs) are legal orders which require individuals with mental illness to accept treatment in the community. Previous studies report that long-acting injectable (LAI) antipsychotics are associated with CTOs, however, little is known about the specific treatment plans prescribed in CTOs. The objective of this study was to describe the patterns of psychotropic drugs prescribed to individuals issued a CTO, focusing on LAI antipsychotics, antipsychotic polypharmacy and high-dose antipsychotics. This was a retrospective cross-sectional study of 378 individuals randomly selected from a sample of 1317 individuals with a CTO expiry date up to and including 30 April 2010, taken from all 2856 individuals issued a CTO by the New South Wales Mental Health Review Tribunal, Australia, in 2009. De-identified information relating to individuals' treatment plans, demographic and clinical details were systematically extracted. A total of 377 (99.7%) individuals were prescribed at least one antipsychotic. Of these, 310 (82%) were prescribed a LAI antipsychotic, either alone (45%), or in combination with, an oral antipsychotic (37%). Risperidone was the most prevalent antipsychotic, prescribed to 164 (43%) individuals. Antipsychotic polypharmacy was prescribed to 121 (32%) individuals and between 20% and 27% of individuals were prescribed high-dose antipsychotics. Antipsychotic polypharmacy accounted for 74-80% of individuals prescribed high-dose antipsychotics. The results from this study confirm that LAI antipsychotics are commonly prescribed in CTOs. Antipsychotic polypharmacy was also common, and accounted for the majority of individuals prescribed high-dose antipsychotics. Further research is needed to determine the potential outcomes and implications of the patterns observed.

The Mental Health Act. vs the Mental Capacity Act. Is the MHA losing its edge?

Purpose – The purpose of this paper is to explore the clinical implications of the case of AM and the ruling that the Mental Health Act no longer has primacy over other legislation in certain treatment situations. Design/methodology/approach – Critical case analysis and discussion. Findings – The Mental Capacity Act Deprivation of Liberty Safeguards could be used more widely, and in preference to the Mental Health Act, but this may cause problems to clinicians and other decision makers such as Mental Health Tribunals. Originality/value – This case and its findings have not been widely discussed in academic or clinical practice literature.

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

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

Patients' awareness of the mental health tribunal and capacity to make requests

Aims and methodTo evaluate patient awareness of the mental health tribunal and identify any association between capacity to request a tribunal and frequency of completed hearings. A cohort of detained patients within a secure hospital were assessed and data for past tribunals evaluated by presence of capacity and mode of application.ResultsOf the 65 patients evaluated, 78% were aware of the tribunal's power to discharge, 14% were aware of its power to recommend leave and 4% were aware of its power to recommend transfer; 12% lacked capacity to request a tribunal. Patients with capacity received more completed hearings per year than those without, both overall (0.58 v. 0.29 per year, P = 0.04) and by patient application (0.45 v. 0.12 per year, P = 0.03).Clinical implicationsHospital managers should ensure that all detained patients have regular assessments of their capacity to request a tribunal and that those who lack capacity are referred to the Secretary of State when it is considered that a tribunal would be in their best interests. Hospital managers should consider referring such cases to the Secretary of State every 12 months.

A 21-year retrospective outcome study of New South Wales forensic patients granted conditional and unconditional release

To retrospectively examine the outcomes of forensic patients found not guilty by reason of mental illness (NGMI) in New South Wales (NSW) and subsequently released into the community, as measured by reoffending, conditional release revocation and psychiatric hospital readmission. Data were collected from the NSW Mental Health Review Tribunal (MHRT) files for all patients who received an NGMI verdict between January 1990 and December 2010, and who were released into the community during this period. The outcome measures of conditional release revocation and psychiatric hospital readmission were extracted from these files. Information about subsequent criminal charges, convictions and penalties were obtained from the Bureau of Crime Statistics and Research's reoffending database. During the 21-year period studied, 364 offenders received an NGMI verdict and were placed under the supervision of the MHRT. Of these, 197 were released into the community, including 85 who were granted unconditional release. Over a follow-up period averaging 8.4 years, 18% of conditionally released patients reoffended, 11.8% were convicted of a further offence, 8.7% were charged with a violent offence, 3.1% were convicted of a violent offence and 3.7% were sentenced to a term of imprisonment. Five (3.1%) conditionally released forensic patients received a further NGMI verdict. One-quarter of the conditionally released patients had their conditional release revoked and half were readmitted to hospital. Of the forensic patients granted unconditional release, 12.5% were charged with an offence, 9.4% received convictions for an offence, 6.3% were charged with a violent offence and 4.7% were convicted of a violent offence, in a mean follow-up period of 7.6 years. None committed a further serious offence resulting in a term of imprisonment, nor a second NGMI verdict. The results of this study suggest that the treatment and rehabilitation of forensic patients in NSW, together with the decision-making procedures of the MHRT, is effective in protecting the community from further offending by forensic patients.

Responsibilities in giving evidence to mental health tribunals

Responsibilities in giving evidence to mental health tribunals

Prospective study of factors influencing conditional discharge from a forensic hospital: the DUNDRUM-3 programme completion and DUNDRUM-4 recovery structured professional judgement instruments and risk

BackgroundWe set out to examine whether structured professional judgement instruments DUNDRUM-3 programme completion (D-3) and DUNDRUM-4 recovery (D-4) scales along with measures of risk, mental state and global function could distinguish between those forensic patients detained in a secure forensic hospital (not guilty by reason of insanity or unfit to stand trial) who were subsequently discharged by a mental health review board. We also examined the interaction between these measures and risk, need for therapeutic security and eventual conditional discharge.MethodsA naturalistic observational cohort study was carried out for 56 patients newly eligible for conditional discharge. Patients were rated using the D-3, D-4 and other scales including HCR-20, S-RAMM, START, SAPROF, PANSS and GAF and then observed over a period of twenty three months during which they were considered for conditional discharge by an independent Mental Health Review Board.ResultsThe D-3 distinguished which patients were subsequently discharged by the Mental Health Review board (AUC = 0.902, p < 0.001) as did the D-4 (AUC = 0.848, p < 0.001). Item to outcome analysis showed each item of the D-3 and D-4 scales performed significantly better than random. The HCR-20 also distinguished those later discharged (AUC = 0.838, p < 0.001) as did the S-RAMM, START, SAPROF, PANSS and GAF. The D-3 and D-4 scores remained significantly lower (better) for those discharged even when corrected for the HCR-20 total score. Item to outcome analyses and logistic regression analysis showed that the strongest antecedents of discharge were the GAF and the DUNDRUM-3 programme completion scores.ConclusionsStructured professional judgement instruments should improve the quality, consistency and transparency of clinical recommendations and decision making at mental health review boards. Further research is required to determine whether the DUNDRUM-3 programme completion and DUNDRUM-4 recovery instruments predict those who are or are not recalled or re-offend after conditional discharge.

Mental Health Review Tribunals in Action: A Systematic Review of the Empirical Literature

The effectiveness of Mental Health Review Tribunals in providing safeguards for patients to ensure their right to be free from unjustified detention or treatment has been subject to much criticism in the literature. This article systematically reviews studies on the decision-making of such tribunals in order to synthesize the literature thematically and subject it to an assessment of methodological rigour [Hawker, S., Payne, S., Kerr, C., Hardey, M., & Powell, J. (2002). Appraising the evidence: reviewing disparate data systematically. Qualitative Health Research, 12(9), 1284]. Of the 7,845 citations initially identified, 50 papers met the inclusion criteria. Although most studies were found to have “satisfactory” methodological rigour, our assessment revealed some issues related to ethics and bias, sampling procedures, and data collection and analysis processes. Eleven prevailing themes were identified that largely relate to the shortfalls of current tribunal systems. Suggested areas for practical improvement and further research were also given. The article concludes by suggesting how future studies could be developed to cover areas in need of further research and with greater methodological rigour.

The role of nurses in mental health review tribunals

The role of nurses in mental health review tribunals

Mental health tribunals in England and Wales: a representative's guide

SummaryConsultant psychiatrists are familiar with mental health tribunals, at which they appear as key witnesses giving both factual evidence and expert opinion. They also commonly act as the representative of the ‘responsible authority’. The implications of this in terms of roles and responsibilities, and in terms of training and continuing professional development, have received little attention. Psychiatrists should not accept a representative role unless they are sure that they have the necessary competencies and resources – competencies that are alien to most clinicians and resources that are not available in many services. This article outlines those requirements so that psychiatrists can make better-informed decisions about whether or not to undertake the role and provides practical guidance for those who choose to do so.

Time to face new realities; mental health care bill-2013

Byline: Anirudh. Kala A young man has been brought by the family and got admitted with history of marked insomnia, excitement, violence, being boisterous, and spending away to an impending ruin. He demands to be released since is fine and does not need any treatment. Familiar so far? If the Mental Health Care Bill, 2013, tabled in the Rajya Sabha on the 19 [sup]th August, 2013, is passed by the parliament,which is likely, following will be a routine continuum of the above scenario. The patient is offered a chair and explained about the concept of 'supported admission', which is the new and politically correct name for 'involuntary admission'. He is given a phone number to call if he has any objection to being admitted. The phone rings in the office of the district mental health review panel and somebody listens carefully, jots down details, and reassures the patient that a team will visit shortly and look into this matter. The team, which is actually a judicial body headed by a former district judge does visit the hospital, conducts a court hearing, and decides whether the patient needs to continue staying in the hospital or not. If the decision is in patient's favor, he will be allowed to go home. Welcome to the world of post admission judicial review. All involuntary admissions, in all Mental Health Establishments, which is the new name for any and all such places, wherever a person with mental illness is admitted even for a day, whenever challenged by the patient; will undergo a review by panels of Mental Health Review Commission, which will be located at district levels. Theoretically, family as well as the psychiatrist can appeal against the decision, but appeal against the panel lies with the high court, which would mean several visits to the state capital and whatever else is involved in going in an appeal to a high court including costly lawyers. Psychiatrists who have worked in the West will find some similarities in it to the system of Mental Health Tribunals. The provision in principle is undoubtedly progressive. After all we are talking about civil detention and curtailing patients' most basic right, that is, liberty; and so, a review if asked for by the patient, should be possible. It will also take care of an occasional complaint that patients file with the police, who having no sensitization about situations associated with severe mental illness, are sometimes a source of considerable trouble to mental health professionals. The mainstream judicial system is equally incapable of handling such complaints because of lack of sensitivity and also being clogged with a huge pendendency of mainstream cases. But are we, as a society ready for this large scale, countrywide post admission review in almost all cases of involuntary admissions? Because let us face it, all patients who are admitted involuntarily believe that they do not need admission; that is why, it is involuntary admission in the first place? A cynic would say that it would officialize, bureaucratize, and stigmatize mental illness even more. Terms like 'feasibility', 'ground reality', and 'administrative bottle-necks blocking access'; reflexely come to mind. More importantly, in a country where families bear the total burden of mental illness, and constitute by far the largest manpower resource in treating mental illness in an otherwise resource strapped country, such a step would put families and patients on the opposite side of the legal fence, as adversaries and push a wedge between the two. It is argued that it will sabotage goodwill and bonding, and make families less willing to be as proactive in the treatment of their wards as at present, which will be an unmitigated disaster. In an ideal world, the state should be in a position to support treatment and rehabilitation of the mentally ill, so that dependence on families is minimized, but that does not seem to be happening very soon. …

The Mental Health Care Act No 17 – South Africa. Trials and triumphs: 2002-2012

The Mental Health Care Act 17 of 2002 (MHCA) was promulgated in 2004. It has been hailed as one of the most progressive pieces of mental health legislation. A true measure of its merit is the degree to which it has transformed mental health services and in particular improved the quality of care. This paper will describe the impact of the Act on mental health care service delivery in the country. Literature pertaining to the MHCA published from 2006-2012, a report compiled by the South African Society of Psychiatrists and the results of a national survey conducted among Heads of Departments of Psychiatry, Mental Health Review Boards and Provincial Directors of Mental Health was reviewed. The MHCA has been successful in shifting the emphasis of care from psychiatric institutions to general hospitals. However, the integration of services has been hampered by infrastructure constraints and shortages of mental health personnel. It has been less successful in integrating mental health care into primary health services where the focus remains largely on the pharmacological maintenance treatment of the chronically mentally ill. Little attention has been given to the health promotion, disease prevention and rehabilitation aspects of care. Mental health review boards contend with limited resources, administrative challenges and limited political support. Isolated pockets of success characterised the implementation of the MHCA across the country. Greater investment of resources is needed to ensure the comprehensive implementation of the Act.

Community treatment orders in Australia: rates and patterns of use

Community treatment orders (CTOs) allow clinicians to provide unconsented outpatient treatment to people living with mental illness. Though controversial and of uncertain efficacy, CTOs are used throughout Australia and internationally. We sought to determine the prevalence of CTO use in Australian states and territories, and to examine changes in the pattern of use over time. Australian state and territory mental health review tribunals and health departments were surveyed for the most recent annual data on the total number of CTOs made and the total number of individual people placed on a CTO. Rates of CTO use range from 30.2 per 100,000 population (in Tasmania) to 98.8 per 100,000 population (in Victoria). Use of CTOs in Australia is high by world standards, appears to be increasing over time, and varies significantly across jurisdictions. The high (by world standards), increasing and variable use of CTOs in Australia is concerning and raises important implications for mental health policymakers and legislators. Current mental health policy activity, particularly the new National Mental Health Commission, provides a unique opportunity to enhance transparency and accountability if regular and nationally uniform CTO data are collected and publically reported.

Exposing secrets: mental health tribunals held in public. An “ongoing media circus” or justified transparency?

PurposeThe purpose of this paper is to discuss and examine the implications of holding mental health tribunals in public.Design/methodology/approachThe paper discusses the functioning of tribunals, compares tribunals with other legal processes in the UK and elsewhere, and reviews the legal reasoning for holding tribunal hearings in public.FindingsThe first tribunal hearing has already been held in public and another public hearing is agreed. Public hearings should allow for greater transparency and scrutiny than has thus far been possible, and may change the behaviour of attendees.Originality/valuePublic tribunal hearings have not yet been widely discussed in the academic literature, yet are expected to have implications for all involved.

‘It doesn't have to be treatable’: Mental Health Review Tribunal (MHRT) members’ views about Dangerous and Severe Personality Disorder (DSPD)

The development of four high security Dangerous Severe Personality Disorder (DSPD) units in the prison service and mental health system has been controversial. Drawing from a case-note review of DSPD patients’ Mental Health Review Tribunal (MHRT) records and qualitative interviews with MHRT members and DSPD clinical staff, this article explores the outcomes of DSPD patients’ MHRTs and MHRT members’ views about DSPD. Mental Health Review Tribunal members most often identified the high security location of the DSPD units to be more relevant to their decision-making than the label of DSPD. Many made clear distinctions between patients with mental illness and those with personality disorder. However, while MHRT members held a range of views about DSPD and some notable doubt about the clinical treatability of DSPD patients, nearly all identified that this was a population who were legally treatable under the Mental Health Act (MHA) 1983 (prior to the MHA 2007 amendments).

Jurisdiction of Mental Health Tribunals to Provide Positive Remedies: Application, Challenges, and Prospects

Modern mental health legislation protects the civil rights of the mentally ill by limiting the scope of permissible state interference with an individual’s autonomy. It also generally sets up mental health tribunals in charge of reviewing compliance with parts of the legislation. However, the legislation does not generally address the right to adequate mental health care. The latter (or its lack thereof) has increasingly become a source of debate among scholars and policy makers. The right to adequate care is increasingly being seen as the sine qua non of the civil rights of the mentally ill. This article explores recent Canadian jurisprudence dealing with the power of administrative tribunals to address constitutional and quasi-constitutional claims, and questions whether such power could give rise to a claim for adequate health care before mental health tribunals. It argues that, subject to some limited circumstances where mental tribunals have been given certain discretion to factor adequate care into their decisions, the recent Canadian jurisprudence does not significantly modify the limited remedies available before mental health tribunals.

Dismal use of legal safety net for mental health patients

It’s been eight years since South Africa’s ailing Mental Health Care Act was completely revised to better protect the human rights of patients with mental illnesses, thus revealing some horrific systemic and social abuses, but a dim ray of hope is that the safety net can be made to work. One rare example is the Western Cape where, according to Dr Tom Sutcliffe, former provincial Director-General of Health (1993 - 2002) and now chairperson of the trend-setting (Western Cape) Mental Health Review Board, ‘I’d be hard pressed to name a single hospital that doesn’t manage its mental health care patients at district and hospital level adequately’. He says the country’s multiple boards are statutorily obliged to review all case histories of institutionalised patients at least annually. This was not the case before the new (2004) promulgation. In terms of the revised Act, boards were set up incrementally across provinces from April 2005 onwards (Gauteng and the Free State have three each to cover their more numerous health districts, while many provinces have two).

P-889 - A study of 300 mental health tribunals in the United Kingdom

Introduction In the United Kingdom, a Mental Health Tribunal has legal powers to discharge or uphold detention of patients who have been detained under the Mental Health Act. Detained patients cost a great deal of money for hospitals and tribunal services. Aims The purpose of the study was to identify whether patients were detained as per mental health legal criteria or not. We also considered the economic impact of these tribunals. Methods We collected and analyzed data from 300 tribunals held between 2006 and 2011.The most commonly used sections were - Sections 2, 3, 37 and 37/41. Results, analysis and discussion Our analysis showed that: - Majority of patients detained under Section 2 were not discharged. - Very few patients detained under Section 37/41 were discharged. Blumenthal and Wessley (1994) reported that the total cost of holding Mental Health Review Tribunals was £12,274,380. In Scotland, the total costs for all Tribunal related activity in 2006–07 was £12,784,909. In the current economic scenario it is worth investigating cost effective alternatives to Tribunals - especially in cases of Section 2 and Section 37/41 - where the data indicates that tribunals do not change the original recommendation. Viable alternative would include locally conducted Managers Hearings; However it is of paramount importance to ensure patients’ rights and the presence of independent panel members in such hearings. Conclusion We propose that more analysis, on a national level would be needed to determine the current cost of Mental Health Tribunals and to consider cost effective alternatives.

Australian mental health tribunals—‘Space’ for rights, protection, treatment and governance?

This paper draws on a multi-year Australian collaborative study of mental health review tribunals (‘MHTs’) in three jurisdictions (Victoria, New South Wales and the Australian Capital Territory) undertaken in conjunction with the NSW Law and Justice Foundation, using qualitative and quantitative methods to examine the role of MHTs in advancing goals such as fairness, legality and access to treatment. Study findings regarding stakeholder and client concerns – about access to quality treatment and associated support services, review of treatment adequacy and drug regimes, and their ‘participation’ or dignity of engagement in review processes – are presented as variants of the need for adequate hearing ‘space’: temporal, jurisdictional, cognate/relational, physical and symbolic, and ‘connective’. Building on earlier arguments for MHTs to engage not only legal, but also clinical and social domains, and for adopting some processes more characteristic of case-conferencing, this paper examines the implications of tribunal ‘flexibility’ and a wider overall ‘governance’ jurisdiction in mental health.