Mental Health Review Tribunal Research Articles

Amend the Mental Health Care Act 2017: A Survey of Indian psychiatrists (Part 2)

Background: Information about the experience of practicing psychiatrists with the use of the Mental Health Care Act (MHCA), 2017, India, after 5 years of its promulgation has not been available. Aim: The present study was carried out to understand the experience of the practicing psychiatrists in using and complying with the MHCA 2017 and to bring out the problems and suggested reforms, if any, in various provisions of the MHCA 2017. Methods: An online survey by practicing psychiatrists of Indian Psychiatric Society on the various sections and provisions of the MHCA 17 was carried out through structured and open-ended responses. This paper presents the qualitative analysis of the open-ended responses. Results: There were 600 respondents, who gave a total of 1239 (range 116–154) responses to eight open-ended questions about various provisions of the MHCA. Qualitative analysis revealed that most respondents opined for keeping the General Hospital Psychiatry units exempted from inclusion as the mental health establishment, thus treating physical illness at par with the mental illness; a separate stand-alone law for mental illness perpetuates stigma, asked for a larger representation of psychiatrists in the State Mental Health Authority and Mental Health Review Boards. Most respondents opined that the provisions of capacity assessment, nominated representative, and advance directive are a hinderance in treatment and should be amended; treating psychiatrists and family/caregiver’s consent should suffice for supported admission, just like in other disciplines of medicine; and MHCA 2017 needs major amendments/repeal to make it convenient for patient care. Any unauthorized places/centers where persons with mental illness are kept should come under regulatory control of the state mental health authorities. Conclusion The survey has highlighted several deficiencies and operational difficulties in the current Act that hinder the delivery of mental health care to patients with mental illness in the country and need amendments.

Factors Considered for the Assessment of Risk in Administrative Review Boards of Canada: A Scoping Review

Background: This scoping review examines the risk factors considered in assessing the dangerousness of individuals found Not Criminally Responsible on Account of Mental Disorder (NCRMD) in Canadian administrative courts. This review aims to identify the factors used by mental health review boards during annual case reviews to guide decisions on detention or release. Methods: Using a scoping review approach following PRISMA guidelines, this study analyzed research across multiple databases to identify relevant studies focusing on risk assessment for NCRMD cases. Results: The findings indicate that five primary categories of risk factors—historical, clinical, behavioral, legal, and miscellaneous—are influential in the decision-making process. Historical factors, such as past violence and early psychiatric contacts, are critical in predicting future risk. Clinical factors, including psychiatric diagnosis and treatment adherence, are key to evaluating current and potential future risks. This study reveals variability in the application of standardized risk assessment tools, highlighting a need for more consistent practices across Canadian jurisdictions. Conclusion: This review concludes that, while a multifaceted approach to risk assessment is essential for balancing public safety with individual rehabilitation, further research is needed to refine these processes and establish more uniform standards for managing NCRMD cases in forensic psychiatry.

The reform of Irish mental health law: Aligning with human rights obligations?

This article critically examines the proposed reforms to Irish mental health law the Mental Health Act 2001 (2001 Act). The article will provide background to the 2001 Act and the lengthy law reform process, which has resulted in the publication of the Heads of Bill that propose significant amendments. The article assesses the suggested reforms, considering Ireland's 2018 ratification of the UN Convention on the Rights of Persons with Disabilities (CRPD), which provides important context to the law reform process. The 2001 Act is the primary piece of legislation regulating mental health services and safeguarding the rights of persons subject to the legislation in Ireland. While passed in 2001, the legislation did not come into effect until 2006. The 2001 Act was seen as bringing Irish mental health law into compliance with international human rights law, in particular the European Convention on Human Rights (ECHR). However, Ireland's ratification of the CRPD has necessitated closer scrutiny of the legislation. This review has culminated in the publication of a Heads of Bill in July 2021 and pre-legislative scrutiny by the responsible parliamentary committee in 2022. The long title of the Heads of Bill explicitly states its goal of safeguarding individual autonomy and underscores its commitment to upholding and advancing the rights of people subject to the legislation. The analysis of the Heads of Bill addresses several key areas. These areas include a background to the long process of review, new guiding principles, the category of persons under the mental health legislation, mental health tribunals, consent to treatment, advance healthcare directives, provisions relating to children and young people, and independent advocacy. Based on this analysis of the Heads of Bill, recommendations are suggested which would strengthen respect for the human rights of persons subject to the legislation.

Narrative Review of Learning Methods for Junior Doctors Around Presenting Evidence at Mental Health Review Tribunals

Narrative Review of Learning Methods for Junior Doctors Around Presenting Evidence at Mental Health Review Tribunals

Improving reasonable adjustments for people with learning disabilities in mental health tribunals

Improving reasonable adjustments for people with learning disabilities in mental health tribunals

Tribunal therapy: using the mental health tribunal to instil optimism

SUMMARYThe role of mental health review tribunals is to oversee that standards of care and treatment are maintained for involuntary patients and for those on community treatment orders. This article considers some ways in which the basic principles of psychotherapy can be applied by tribunal members to offer patients a sense of hope, encouragement and optimism and reduce the emotional challenge of the tribunal review.

Professional Values and Mental Health Tribunals: How Healthcare Professionals’ and Lawyers’ Views Are Shaped by Values, and How This Might Impede Reform

Most countries that provide for compulsory treatment for mental illness have a system by which this treatment is subject to independent legal oversight. Many countries use a special type of legal body for this purpose, called a mental health tribunal. Mental health tribunals have been subject to criticism from the points of view of both legal professionals and mental healthcare practitioners. Similar themes have manifested in these criticisms and have been consistent across several decades; legal professionals tend to focus on the tribunals being biased toward the medical opinion, and acting as a ‘rubber stamp’, whereas healthcare practitioners tend to focus on the adversarial nature of the trial, and the adverse effect that this can have on clients. However, empirical studies of the tribunals have not separated and directly compared these perspectives. This study aimed to explore this dynamic between lawyers’ views and healthcare practitioners’ views of mental health tribunals. We used thematic analysis to re-analyse data from two previous research studies, one which looked at lawyers’ views of the tribunals, and one which looked at healthcare practitioners’ views. Our results are divided into three themes: views of the problems with tribunals, professional roles in relationship to the tribunals and professional values demonstrated through these views and roles. We then consider if the ‘clash of values’ represented by these findings, and found in the literature, may pose an impediment to tribunal reform. Identifying and exploring this barrier is an important step to moving beyond critique to reform.

Giving evidence before the First-tier Tribunal (Mental Health): the role of inpatient mental health nurses

The First-tier Tribunal (Mental Health) is a legal body that reviews the rights of detained patients in hospital and whether continued detention under the Mental Health Act 1983 remains in the best interests of the patient. To undertake this work, the Tribunal examines evidence presented in clinical reports and oral evidence by mental health staff, including psychiatrists, community mental health nurses and/or social workers, and inpatient mental health nurses. This article discusses best practice concerning preparation required by inpatient mental health nurses attending the Mental Health Tribunal as expert witnesses to give evidence.

Exploring Psychiatrists' Experiences During Transition from Mental Health Act, 1987 to Mental Healthcare Act, 2017 in Goa, India.

Mental Healthcare Act 2017 (MHCA) came into force on 29 May 2018. Goa State Mental Health Authority (GSMHA) notified the Mental Health Review Board on 8 February 2022, completing the important process of implementation of the act. The transition comes with challenges. A qualitative study was conducted with 18 practicing psychiatrists who had worked under Mental Health Act 1987 as well as MHCA 2017 through purposive sampling across Goa. Data was collected through individual interviews; analysis was done by Braune and Clarke's framework of Thematic Analysis. Eighteen psychiatrists participated: 4 private, 3 secondary and 11 from tertiary levels. The themes extracted were work during MHA 1987, transition, and after the implementation of MHCA 2017. Some participants reported difficulties, felt an increase in workload, and had negative emotions, while a few were neutral, indicating mixed perceptions. This study highlights the administrative struggles and moral dilemmas faced by psychiatrists in handling the new legislation. It's imperative that the implementation of new act should be carried out with sufficient resource allocation and monitoring mechanisms.

What Does "Least Restrictive" or "Less Restrictive" Mean in Mental Health Law? Contradictions and Confusion in the Case of Queensland, Australia.

Most legal systems in the West allow for involuntary treatment of mental illness, usually on the basis that without such treatment the person would be a danger to themselves or others. While historically the mental health law jurisdiction has been a protective one, it has become increasingly influenced by civil rights and international human rights law, which privilege the value of autonomy and the right to personal liberty.In this regard, an important principle that has developed is that decisions about treatment for mental illness must be the "least restrictive alternative" available. This may mean, for example, that a person is supported to make a decision on treatment for their mental illness, according to evolving practices of "supported decision-making," so that their legal capacity is still recognized. If involuntary treatment is required, the "least restrictive" approach demands that the liberty and integrity of the person be respected to the greatest extent possible.The Mental Health Act 2016 (Qld) ("MHAQ") prescribes that decision-making on non-consensual treatment should preferably be done according to what it calls the "less restrictive way." However, the "less restrictive way" is defined as decision-making by patients under advance directives, and also by substitute decision-makers, including by attorneys or guardians not appointed by the patient, usually a family member. The MHAQ states that these arrangements are distinguished from and prioritized over what it calls "involuntary treatment and care," where the decision for non-consensual treatment is made by the treating team.However, we argue that these arrangements are not in fact "less restrictive" of the person's autonomy, but are less accountable forms of decision-making. Decision-making by treating teams under involuntary treatment provisions is subject to higher levels of transparency and accountability. In Australian states these decisions are reviewed regularly by a specially constituted, independent mental health tribunal. By contrast, treatment decisions made under the "less restrictive way" are not even defined as constituting involuntary treatment, and are outside the scope of the tribunal's review.In the case of decision-making by advance directive, we acknowledge that this is widely considered to be "less restrictive" of a person's right to legal capacity and autonomy. However, in these cases, the patient may actually be refusing treatment at the time the advance directive is relied upon. This raises serious questions as to whether such "voluntary" admissions and treatment should not be subject to the same oversight and accountability as involuntary ones. Patients have a right to less restrictive forms of decision-making, but when deprived of their liberty, they also have a right to adequate safeguards established by law.The term "less restrictive" in the MHAQ is largely misplaced and misleading. In the case of advance directives, it deflects attention from the potentially restrictive nature of the treatment and the lack of accountability. Even more problematically, the privileging of private substitute decision-making under the less restrictive way ignores the real risk of abuse and undue influence within the personal and family sphere. We argue that the "less restrictive way" under the MHAQ is a step backwards for the rights of patients, in that it shifts power to family on the risky assumption that decision-making by these less supervised individuals is more likely to uphold human rights. We believe that this reflects a pre-feminist assumption that the informal, family, private sphere is nearly always safe. This is a contentious assumption, which nevertheless underpins much unproblematized thinking and advocacy on supported decision-making. This issue also highlights the need for further elucidation and discussion on what least restrictive means in the context of involuntary treatment for mental illness.

Psychiatric rehabilitation in secure forensic settings in NSW: Measuring outcomes.

To quantify outcomes for patients of forensic psychiatric rehabilitation in NSW. Data on 245 conditionally released forensic patients was extracted from the Mental Health Review Tribunal (MHRT) files and matched to several state-wide datasets. Descriptive statistics were generated to establish the cohort characteristics, rates of reoffending and social and clinical outcomes. At conditional release, social circumstances for the majority of patients were improved. Clinically, the cohort was more stable, though many did not remain stable over time. Only one-fifth of the sample received a further criminal charge. Preliminary evidence suggests that forensic rehabilitation services in NSW are effective.

A voice of experience: Positive and negative experiences of mental health from a service user's/lived experience perspective.

WHAT IS KNOWN ON THE SUBJECT?: People with mental health problems are often left behind, forgotten and excludedLittle is known or written from a service user perspective about experiences of psychiatry, mental health nursing, Mental Health Tribunals and alternative approaches (such as counselling, peer support, psychological and recovery approaches, cognitive behavioural therapy-CBT and creative/art/music/drama/horticultural/dance therapies). WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This paper aims to remedy this gap in knowledgeIt focuses on positive and negative experiences of psychiatry, Mental Health Tribunals and alternative treatments from a service user's perspective. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The paper makes several recommendations. In brief, (1) psychiatrists need to listen more attentively rather than being focused on signs of psychosis; (2) de-escalation techniques (for example, talking calmly with the patient) should be used by nurses before physical restraint; (3) psychiatry should be less biomedical. Nurses and social care professionals deserve better training, time for and practice in alternative and more therapeutic forms of care; (4) carers need to be more involved; (5) there need to be better, more democratic, more open processes of law; (6) voluntary work and supported employment schemes should be run by health and social services for people who want to work and want to have a vocational life. This paper aims to describe the lived experience of mental illness, coercive treatment by psychiatry and mental health nursing, and the problematic case and bias of Mental Health Tribunals. It then looks at more positive experiences of alternative approaches and makes recommendations for improving mental health services and people's experiences of them.

First Nations Peoples in the forensic mental health system in New South Wales: Characteristics and rates of criminal charges post-release.

It is well established that First Nations Peoples in Australia are overrepresented within the criminal justice system. However, First Nations Peoples appear to be comparatively underrepresented in the forensic mental health system, and little is known about their outcomes once released from secure care. To compare the characteristics and rates of repeat criminal justice contact for a criminal charge of First Nations and non-First Nations forensic patients in New South Wales. Data on the sample were extracted from the New South Wales Mental Health Review Tribunal paper and electronic files matched to the Bureau of Crime Statistics and Research Reoffending Database. Characteristics of First Nations and non-First Nations patients were compared using univariate logistic regression analysis. Univariate and multivariate Cox proportional hazard regression was used to determine predictors of post-release criminal charges. Key differences in the sociodemographic, clinical and forensic characteristics of First Nations compared with non-First Nations forensic patients were identified. The time to first criminal justice contact following release was significantly shorter for First Nations forensic patients (p < 0.01). The findings of this study confirm that First Nations forensic patients have distinct and complex needs that are apparent at entry to the forensic mental health system and that their poorer criminal justice contact rates following release from secure care indicate that these needs are not being adequately met either during treatment or once in the community. Responses to these study findings must consider the complex and continuing impact of colonisation on First Nations Peoples, as well as the need for solutions to be culturally safe.

Caveats of mental healthcare act-2017: Recommendation for amendments.

Dear Sir, The rights-based framework in the current Mental Healthcare Act 2017 (MHA-2017) has received a wider acceptance in the minds of policymakers, patients, caregivers, judicial officers, and mental health professionals.[1,2] However, there appears to be a huge gap between acceptance in our minds and implementation at the ground level. Theoretical knowledge of MHA-2017 and the inability to translate it into practice in most of the general hospitals in the country due to systemic issues has created a dilemma in the minds of psychiatry residents. Therefore, it is necessary to have periodic sensitization programs for psychiatry trainees as well as psychiatrists to learn about changing scenarios in mental health legislation in the past five years.[3] The only discipline of Medicine that carries special significance beyond ethical practice involving beneficence, autonomy, non-maleficence, and justice is psychiatry. This practice and the respect for the rights of a person to bring about optimum mental health outcomes have been legally guided. Forensic psychiatry has started to evolve as a subspecialty of psychiatry.[4] However, are psychiatrists in the country confident in dealing with legal issues evolving in the aftermath of MHA-2017 and imparting this practice to postgraduate trainees? Is clinical practice synchronizing with the legal framework? Are we dealing with the paradox of MHA-2017? Are budding psychiatrists across the country in dilemma with regard to MHA-2017? The response of different states is varied in terms of readiness of infrastructure, the constitution of the State Mental Health Authority (SMHA), the functioning of Mental Health Review Boards (MHRB), and overall dismal application of MHA-2017. Are there hasty translations of Western World rules on the infertile grounds of India? More than four years after passing the act, the current level of functional implementation does not appear to be a healthy indicator for the growth of mental health services in the country. This could provoke lawmakers to bring out the amendments to MHA-2017 to best suit the mental health services and practices of the country. In the absence of functional MHRBs, the practical caveats that may require amendments may include providing electroconvulsive therapy (ECT) to children and use of hospital beds for day-care procedures in psychiatry that include but are not limited to the somatic therapies in psychiatry such as administration of electroconvulsive therapy and repetitive transcranial magnetic stimulation (rTMS). It also includes short-term observation for a few hours in a general hospital following administration of long-acting injectables (LAI) antipsychotics and assessment for the appearance of acute side effects such as post-injection delirium sedation syndrome, and acute dystonia and oculogyric crisis. The other concerns requiring immediate attention for the functioning of MHRB include notifying advance directives, continuing admission under special circumstances, and provision of separate wards for children and women under psychiatry in a general hospital. These amendments could also add the role of MHRBs for adolescents involved in juvenile delinquency, child custody, termination of parental rights, and other related issues.[5] The protection of the rights of a person with mental illness should not be viewed as safeguarding oneself from the practice of psychiatry in the absence of full-fledged implementation of MHA-2017. This could be important for making a provision for the psychiatrist witnessing nonsexual or sexual boundary violation to notify the MHRB in advance, a point not placed in MHA-2017. The spirit of the MHA-2017 also does not clarify the role of the Consultation Liaison Psychiatrist and its effective practice in different departments under general hospital units. Further, the role of the psychiatrist in cases requiring cognizance of other specified acts such as the Prevention of Child Sexual Offense (POCSO) Act, Narcotics and Psychoactive Substances (NDPS) Act, The Rights of Persons with Disabilities (RPwD) Act, Right To Information (RTI) Act, etc. should also be viewed in parallel with MHA-2017. Authors emphasize the opportunity of teaching programs to highlight the gaps in training and implementation of MHA-2017.[6] The absence of functional implementation of MHA-2017 requires the churning of thoughts of stakeholders to amend a few provisions such as the formation of the transitional local hospital review board till formal MHRBs are functional.[7] This letter encourages clinicians and researchers to assess the compliance status of Indian states with MHA-2017 and to provide feasible solutions through systematic scientific research. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Clinical Practice Guidelines for the Use of Electroconvulsive Therapy.

Clinical Practice Guidelines for the Use of Electroconvulsive Therapy.

Nurses and the Discursive Construction of Procedural Justice in Review Board Hearings

There has been growing interest about procedural justice in mental health tribunals. A process considered procedurally just increases adherence to treatment, increases compliance with judicial decisions and allows efficient community reintegration. Yet, little is known about how procedural justice is carried out and the role of professionals in its implementation. Stemming from the results of a critical ethnography of the Ontario Review Board, in this article we examine how procedural justice materializes during Review Board hearings and the role of nurses in this materialization. We do so by leveraging Goffman’s work on total institutions and institutional ceremonies. Our findings suggest that nurses participate in activities that provide a perception of procedural justice, rather than serve their patients’ right to true procedural justice. We conclude by recommending that nurses engage in reflections about the distal effects of their clinical practice to broaden the possibilities for resistance within the forensic psychiatric system.

Nigeria's mental health and substance abuse bill 2019: Analysis of its compliance with the United Nations convention on the rights of persons with disabilities

Countries are struggling with reconciling their national mental health legislation with the CRPD approach, which stresses equality as the focal point of legislation, policies, and practices that affect people with disabilities. Several failed attempts have been made over the last two decades to update Nigeria's obsolete mental health legislation. The most recent attempt is the Mental Health and Substance abuse Bill 2019, which aims to protect the rights of people with mental health needs. It addresses many areas neglected by previous bills, such as non-discrimination of people with mental and substance use problems in the exercise of their civil, political, economic, social, full employment, religious, educational, and cultural rights. It categorically prohibits the use of seclusion in the treatment of people with mental health problems, makes provision for service users to be members of the Mental health review tribunal and allows for the protection of privacy and confidentiality of information about people with mental health problems. While keeping to most of WHO's recommendations for mental health legislation, the bill diverges from the CRPD's recommendations by allowing forced admission and treatment based on mental capacity, substitute decision-making by legal representatives or closest relatives, and non-prohibition of coercive practices. The bill does not make provisions for advance directives and is silent on informed consent to participate in research. Despite the bill's deficiencies, it would be a significant step forward for the country, whose current mental health legislation is the Lunacy Act of 1958. Although the CRPD has left it unclear how countries, especially low resource countries, should go about creating a workable legal framework, it is clear that all countries are expected to join the current global effort to eliminate, or at least reduce to the barest minimum, the use of coercion in mental health care. We expect that future revisions of this bill will examine its limitations in light of Nigeria's socio-cultural context.

The Urgent Need to Review the use of CTOs and Compliance with the UNCRPD Across Australian Jurisdictions

In every Australian jurisdiction, legislation permits mental health service providers and/or mental health tribunals to force people with mental illness to engage in treatment, under Community Treatment Orders (CTOs). Despite considerable efforts made by every Australian state and territory to meet human rights obligations under the United Nations Convention on the Rights of Persons with Disabilities (CRPD) (2008; Maylea &amp; Hirsch, 2017), Australia has rates of CTO usage that are very high by world standards (Light, 2019). Even within Australia, rates of CTO usage vary considerably between and within jurisdictions in spite of the legislation being very similar (Light, 2019; Adult mental health quarterly KPI report, 2019). This occurs in the context of mixed evidence about the efficacy of CTOs and a lack of clear understanding of their purpose (Segal et al., 2017; Kisely et al., 2017). The use of CTOs remains one of the most contentious issues in mental health service delivery. Not only is their efficacy unresolved, they also raise serious ethical and human rights concerns. The current debates, and attempts at reform, must be informed by valid and reliable data. This brief commentary will make the case for a research agenda that addresses the minimal research that has been undertaken to address the variations of CTO use across Australian jurisdictions.

Improving human rights in mental health takes more than just changing the law: An audit of medical assessments in regional community patients in Queensland

To evaluate the medical assessments of involuntary community patients in a regional mental health service, determine the compliance with requirements under Queensland's Mental Health Act 2016 (the Act) to regularly review orders and assess patients' mental capacity. We audited 183 patient records on community treatment authorities (CTAs) to determine whether medical assessments undertaken under the Act included consideration of the person's capacity, and regular reviews by an authorised doctor as required1s205. The audit revealed that 51% of the CTA patients did not comply with legal requirements either to complete a capacity assessment and/or be medically assessed within three months of the last review. Over 50% of medical assessments did not comply with the legislative requirements to record capacity assessments and review involuntary treatment on at least a three-month basis. However, when the treatment criteria were met, it did not appear to be a basis for CTA revocation. Further research may help determine whether the Mental Health Review Tribunal (Tribunal) could play a greater role in overseeing compliance with the new legislative requirements or if other clinical oversight mechanisms would be appropriate to improve the assessment process.

Implementation of MHCA 2017 and Formation of Mental Health Review Boards: Current Status of IPS South Zone Territory.

Implementation of MHCA 2017 and Formation of Mental Health Review Boards: Current Status of IPS South Zone Territory.