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Schizophrenia and capacity

Discussion

Schizophrenia is a mental illness characterised by a range of symptoms related to thinking, perceiving, emotion, behaviour and judgement. Symptoms can include delusions (irrational beliefs that persist despite evidence to the contrary), hallucinations (perceptions without an appropriate external stimulus, such as ‘hearing voices’), and a range of other disturbances of psychological and physical function.

The two main diagnostic systems used for the diagnosis of mental illness are the International Classification of Diseases (ICD-10, World Health Organisation, 1992) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, American Psychiatric Association, 2013). For schizophrenia, these sets of diagnostic criteria include phenomena such as delusions, hallucinations and disturbances of thought and speech. Other diagnostic criteria include negative symptoms, catatonic symptoms and reduced social function or reduced overall quality of life. Catatonic behaviour refers to specific disorders of physical function such as excitement, posturing or stupor. Negative symptoms include paucity of speech, social withdrawal and blunting of emotional responses.

In practice, clinical presentations with schizophrenia vary widely, ranging from the loud, acutely-disturbed individual who may volunteer delusional beliefs spontaneously, to the quiet, withdrawn individual who may refuse to speak to their family or friends due to paranoid or persecutory beliefs.

Mental Health Act 2001

Most treatment of schizophrenia takes place on a voluntary, outpatient basis. Schizophrenia is, however, the single most common diagnosis among persons admitted as involuntary patients, accounting for 44 per cent of involuntary admissions in Ireland in 2013 (Daly and Walsh, 2014).

Involuntary psychiatric treatment in Ireland is governed by the Mental Health Act 2001. Involuntary admission involves a three-step process:

  • An application is made by a spouse, relative, health service officer, Garda or other person, who must have observed the patient within the previous 48 hours;
  • The person is examined by a doctor (eg, GP) within 24 hours of the doctor receiving the completed application; the doctor may then complete a recommendation for involuntary admission and this remains valid for seven days;
  • The person is brought to a psychiatric inpatient facility and, within 24 hours of arrival, a consultant psychiatrist examines the person and either a) agrees that involuntary admission is appropriate and completes an admission order; or b) does not agree that involuntary admission is appropriate and does not complete such an order.

The admission order, if completed, permits involuntary detention and treatment for up to 21 days, during which time the matter will be reviewed by a mental health tribunal. If the admission order is affirmed by the mental health tribunal, renewal orders are possible for periods of three, six or 12 months.

Expert Group Review of the Mental Health Act 2001

The case report featured on this page outlines involuntary admission and treatment under the Mental Health Act 2001, which is the legislation currently in force in Ireland. This legislation may, however, be revised significantly in the relatively near future.

On 5 March of this year, Kathleen Lynch, Minister for Primary Care, Social Care (Disabilities and Older People) and Mental Health, published the Expert Group Review of the Mental Health Act 2001. This detailed report presents 165 recommendations which, if implemented, would bring radical changes to psychiatric care in Ireland.

The past five decades have already seen enormous changes in Irish mental health services. In 1963, there were 19,801 people in Irish psychiatric hospitals. By 2013, this had fallen to 2,401, a decrease of 88 per cent.

In 2013, there were 18,457 psychiatric admissions in Ireland, of which the vast majority (89 per cent) were voluntary. Far greater numbers were treated on an outpatient basis in primary care or by community mental health teams.

The Mental Health Act 2001, fully enacted in 2006, introduced important protections of human rights for that minority of patients who experience involuntary treatment. It introduced mental health tribunals to review all detention orders within 21 days, and created the Mental Health Commission to oversee standards of care.

The 2001 Act brought Ireland into much greater compliance with international human rights standards.

The human rights landscape has, however, developed significantly since 2001, owing not least to the Convention on the Rights of Persons with Disabilities (United Nations, 2006) (see text box), which is likely to apply to some, but not all, persons with schizophrenia (Kelly, 2014).

Proposed changes

Against this background, the recent Report of the Expert Group on the Review of the Mental Health Act 2001 proposes a further series of reforms to Ireland’s mental health legislation. One of the key proposals is the replacement of the principle of ‘best interests’ with a new set of guiding principles to govern decisions made under the Act.

The proposed new principles are: “a) The enjoyment of the highest attainable standard of mental health, with the person’s own understanding of his or her mental health being given due respect; b) Autonomy and self-determination; c) Dignity (there should be a presumption that the patient is the person best placed to determine what promotes or compromises his or her own dignity); d) Bodily integrity; and e) Least restrictive care.”

The principles of the legislation are important, not only for the guidance they give to mental health professionals, but also because they are commonly relevant to the decisions of mental health tribunals, which face the complex task of weighing-up rights to liberty and treatment in individual cases.

Further revisions: Definitions, capacity and consent

The Expert Group report proposes several other substantial changes, including re-definitions of ‘mental illness’, ‘treatment’ and ‘voluntary patient’ (now to require mental capacity); a requirement that, for all detained patients, admission and treatment “would be likely to benefit the condition of that person to a material extent”; additional protections for patients who are not detained but lack mental capacity; reduced burden on families and clearer access to medical care during the involuntary admission process; mandatory, multidisciplinary input into detention and treatment decisions; earlier tribunals (to be renamed ‘mental health review boards’); shorter renewal detention orders; various measures relating to children; inspection of community facilities; better access to information; and provisions to ensure that any detained patient who has capacity to refuse electroconvulsive therapy (ECT), and is unwilling to receive it, has that decision respected.

This deletion of ‘unwilling’ from the ECT provisions is an important step forward, even though it will affect only a very small number of patients. In 2012, there were 1,921 involuntary admissions and the ‘unwilling’ criterion in the ECT provisions was relevant to just four of these, three of whom were also documented as lacking mental capacity to decide about treatment (Mental Health Commission, 2014). As a result, ECT without consent was administered to just one patient, solely on the basis of the ‘unwilling’ criterion.

Despite these small numbers, it is still clearly essential to revise this provision, as the Expert Group duly recommends. On 25 April, addressing a mental health conference in University College Cork, Minister Lynch confirmed that she would shortly seek approval from Government to give legislative effect to the recommendations of the Expert Group Report, and will also separately bring forward proposals to change the legislation governing ECT.

It is, however, very interesting that this ECT recommendation dominated media coverage of the Expert Group Report, which contains many other measures which are far more radical and will affect much greater numbers of patients and families.

For example, the report recommends deleting the word ‘unwilling’, not just in relation to ECT but also in relation to continued administration of medication to detained patients. This means that no person, detained or otherwise, can receive medication against his or her wishes, once he or she has the mental capacity to make this decision.

For detained patients who lack capacity but still need treatment, the report recommends additional protections in addition to those already in place (eg, tribunals), ranging from an external review of medication after 21 days (as opposed to the current three months) and a legislative requirement for multidisciplinary input into decisions about involuntary treatment.

The next steps

The College of Psychiatrists of Ireland (of which I am a member) warmly welcomed the publication of the Expert Group report, noting that it “will advance the rights of those patients with mental illness who are involuntarily detained” and “recommends changes to protect those who lack capacity but who do not fulfil criteria for involuntary detention”. The College also, however, saw this as “a missed opportunity to improve appropriate access to multi-faceted assessment and intervention for the majority of people with mental health problems”.

Notwithstanding these matters, it is clear that the Expert Group Report is a significant step in the continuous reform process that saw the number of psychiatry inpatients decline from the high levels of the 1960s to the relatively low levels today. Improving mental health law is, however, insufficient on its own. These proposed reforms need to be accompanied by continued improvement of mental health services in line with national mental health policies in A Vision for Change (Expert Group on Mental Health Policy, 2006).

Many people with mental illness still face profound social and economic discrimination. The mentally ill are over-represented in prisons and among homeless populations.

They and their families experience stigma, underemployment and social exclusion. These adverse social, economic and societal factors greatly impair access to psychiatric and social services, and hugely amplify the effects of mental illness in people’s lives.

The solutions to these problems lie not only in mental health law and policy, but in policies relating to housing, employment, justice and social welfare. Mental illness is an all-of-society issue requiring an all-of-society response.

Reforming and reframing mental health law is certainly a good beginning, but there is much, much more to be done.

References on request

General principles of the United Nations Convention on the Rights of Persons with Disabilities

  • Respect for dignity, autonomy (including the freedom to make one’s own choices) and independence;
  • Non-discrimination;
  • Full and effective inclusion and participation in society;
  • Respect for difference and acceptance of persons with disabilities as part of humanity and human diversity;
  • Equality of opportunity for all;
  • Accessibility;
  • Equality between women and men; and
  • Respect for the right of children with disabilities to preserve their identities and respect for the evolving capacities of children with disabilities.

Adapted from Article 3 of the United Nations, Convention on the Rights of Persons with Disabilities, Geneva: United Nations, 2006.

 

Case report

Richard was a 20-year-old university student living with his family in Dublin. He was an excellent student and a keen runner. Over a period of three months, Richard’s mother noticed that Richard was not attending classes as much as he used to and had virtually stopped running. Richard had also become suspicious and withdrawn and rarely spoke with her or, it seemed, his friends.

Richard’s mother suggested that he attend their GP, but Richard refused. Soon, he took to going out all night and wandering around the streets, returning at breakfast time, saying that the house “wasn’t safe” at night. He soon added that he believed the food was poisoned and that he could no longer go on living whilst under such threat. He started to refuse all food and did not leave his bedroom for over a week.

Most concerned, Richard’s mother consulted her GP, who came to see Richard at home, but Richard shut his bedroom door in the GP’s face, insisting he was not ill. The GP advised Richard’s mother about the involuntary admission procedure in the Mental Health Act 2001 and they downloaded the relevant forms from the website of the Mental Health Commission (www.mhcirl.ie).

Richard’s mother completed the application form and the GP went back to see Richard again. Again, Richard opened his bedroom door to the GP only let the GP know that he did not regard himself as ill; the real problem was the poison in the food and the threats to his wellbeing, he said, and that he did not want treatment of any sort.

The GP explained to Richard that the GP was examining Richard with a view to involuntary admission to a psychiatric unit for treatment. Richard said that he fundamentally disagreed with the need for treatment but that, if compelled, he would go to the psychiatric unit in order to explain that the threats to his wellbeing were valid.

The GP faxed the completed application and recommendation forms to the psychiatric unit, where the team examined them, discussed the case with the GP by telephone, and confirmed that a bed was available. Richard’s parents brought Richard to the unit, where he first saw a junior doctor and then a consultant psychiatrist, who agreed with Richard’s mother and GP and completed the admission order.

In the unit, Richard received multidisciplinary care, as well as antipsychotic medication. After seven days, his thinking was much more reality-based. Ten days after admission, he was well enough to engage with the clinical psychologist and go out of the unit with his parents for periods of time. After 15 days, he was much improved and agreed with the need for treatment. The admission order was soon revoked, prior to the scheduled mental health tribunal, and Richard remained as a voluntary patient for a further week.

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