Psychiatry: Psychiatric Management

Psychological Therapies

How therapies work

  • Psychological therapies work by helping people understand why they feel as they do. They can do this by:
    • reflecting with clients about how past and present life events have affected their relationship styles and patterns of thinking, and how these might affect their current mental state;
    • using the client–therapist relationship as a tool (e.g. modeling good communication, exploring how emotions felt towards the therapist might reflect those in other relationships);
    • teaching skills (e.g. problem-solving, communication).
  • The therapist can support the clients to change the way they interact and perceive the world, to come to terms with past stresses and cope more effectively with current and future stresses.

Types of therapy (see Figure 33.1)

  • There are three broad categories of psychological therapy:
    • supportive therapies
    • cognitive and behavioural therapies
    • psychodynamic psychotherapies.
  • More recently designed therapies have been based on the principles of these therapies.
  • Choice of therapy will be guided by patient preference, illness characteristics and cost-effectiveness. Treatments may involve individual, group, couple or family interventions.
  • Group therapy emphasises interrelationships within the group where problems are shared.
  • Family therapy may be systemic or behavioural. Systemic theory assumes that problems have arisen with the ‘system’ of family functioning, not just the individual. It is used predominantly in child and adolescent psychiatry. The expectation is that improved family functioning will result in improvement in the patient.

Cognitive behavioural therapy (CBT)

  • Some people hold unhelpful core beliefs or ‘silent assumptions’ that they learn from early, traumatic life experiences.
  • These people are more vulnerable to depression. When exposed to stress at a later date, these core beliefs are activated and they have negative automatic thoughts.
  • These negatively biased thoughts play a role in the persistence of depression because they sustain the underlying negative beliefs in the face of contrary evidence.
  • The aim of CBT is initially to help individuals to identify and challenge these automatic negative thoughts and then to modify any abnormal underlying core beliefs. The latter is important in reducing the risk of relapse.
  • CBT is used to treat depression, anxiety, eating disorders and some personality disorders. It can also be used to treat psychosis.

Behavioural therapies

  • These are based on learning theory. Operant conditioning encourages desirable behaviours by positive reinforcement and discourages undesirable behaviours by withholding reinforcement (negative reinforcement).
  • Avoiding feared items, places or actions increases the anxiety associated with them. If people challenge their avoidance, their anxiety will rise but then eventually decrease (habituation). Techniques include graded exposure to a hierarchy of anxiety-producing situations (systematic desensitisation) – for example, to a spider in a glass box, then one on the other side of the room, finally on the patient’s hand. In flooding, the patient is rapidly exposed to an anxiety-producing stimulus. Reciprocal inhibition couples the desensitisation with a response incompatible with the symptom.
    For example, habit reversal training, used in Tourette’s syndrome, aims to increase awareness of tics, training to develop a competing response and social support from an identified person (example partner, parent). A competing response involves selection and implementation of a physically incompatible behaviour to prevent tics or make them more difficult: for example for a lateral head jerking tic could be to tense the neck muscles (thus preventing the tic).
  • Behavioural activation focuses on activity scheduling to encourage patients to approach activities that they are avoiding.
  • Behavioural management therapy uses the ‘ABC’ approach, where observations are made on Antecedents to target behaviour, the Behaviour itself and its Consequences. The antecedents and consequences can then be manipulated to increase or decrease the target behaviour as required. An example target behaviour may be aggression or wandering in dementia. Behavioural techniques are included in interpersonal psychotherapy, CBT and dialectical behaviour therapy.
  • Behavioural couples therapy is recommended for treatment of depression and anxiety in people who have a regular partner and where the relationship may contribute to the development or maintenance of depression.

Psychodynamic therapies

  • Psychodynamic therapy is unstructured. It helps many who have longstanding personality disorders or undiffererentiated psychological problems or for whom anxiety and/or depression are ingrained within a person’s personality. It is based on psychoanalytic principles.
  • Psychoanalysis stems from the work of Sigmund Freud. It views human behaviour as determined by unconscious forces derived from primitive emotional needs. Therapy aims to resolve longstanding underlying conflicts and unconscious defence mechanisms (e.g. denial, repression).
  • Psychoanalysis explores the unconscious using free association (the patient saying whatever enters their mind) and the therapist interprets these statements. These interpretations make links between events in the patient’s past experiences, current life and relationship with the therapist.
  • Key therapeutic tools are:
    • transference: the patient re-experiences strong emotions from early important relationships in their relationship with the therapist;
    • counter-transference: the therapist experiences strong emotions towards the patient.
  • In psychoanalysis, sessions are four to five times a week for 50 minutes for two to five years. Psychodynamic psychotherapy has the same theoretical basis as psychoanalysis but treatment sessions are less frequent (one to two times a week).
  • Therapeutic communities are inpatient facilities run along psychodynamic lines and most frequently used to treat severe borderline personality disorder that has not responded to other therapies. Treatment involves group and individual sessions.

Newer therapies

  • Interpersonal psychotherapy (IPT) is used to treat depression and eating disorders. It focuses on interpersonal aspects of the illness. All close relationships are carefully discussed, and any problems are conceptualised as difficulties in role transitions (e.g. promotion, loss of job, becoming a parent), interpersonal disputes, deficits in the number or quality of relationships, or grief. This formulation is the focus of discussion in subsequent sessions.
  • Dialectical behaviour therapy (DBT) is designed for individuals with borderline personality disorder and is particularly intended to address their repeated self-harm behaviours. The therapy incorporates some components similar to CBT and also provides group skills training to equip the individual with alternative coping strategies (rather than deliberate self-harm) when faced with difficult problems or emotional instability. The skills taught include mindfulness (bringing one’s attention back to the present moment), which is derived from Buddhist meditation.
  • Mentalisation-based treatments, developed for people with borderline personality disorder, are based on psychodynamic principles and promote understanding in personal relationships by improving patients’ ability to deduce the mental states that lie behind their own and other people’s behaviour.
  • Eye movement desensitisation and reprocessing (EMDR) is a psychotherapy treatment that aims to help patients access and process traumatic memories with the goal of emotionally resolving them. Clients recall emotionally disturbing material while simultaneously focusing on an external stimulus. This stimulus usually involves the therapist directing the patients’ lateral eye movements by asking them to look first one way then the other (saccadic eye movements). It is an effective treatment for posttraumatic stress disorder (PTSD).

Improving access to psychological therapies (IAPT)

  • Since 2006, the NHS IAPT programme has increased availability of brief psychological therapies for depression and anxiety in primary care in the UK.
  • IAPT provides treatments recommended by NICE (National Institute for Health and Clinical Excellence). These are:
    • CBT for depression and anxiety disorders, including obsessive–compulsive disorder and PTSD
    • IPT, behavioural activation, counselling or couples therapy for depression
    • EMDR for PTSD.

Antipsychotics

Types of antipsychotic

  • The first antipsychotic, chlorpromazine, was introduced in 1951 for anaesthetic (antiemetic) premedication. It was noted to reduce delusions and hallucinations in schizophrenia without causing excessive sedation.
  • Antipsychotics are divided into typical (first-generation) and atypical (second-generation) drugs (see Table 34.1).
    • Typical antipsychotics are more likely to cause extrapyramidal side effects (EPSE), hyperprolactinaemia and tardive dyskinesia.
    • Atypical antipsychotics may be slightly better at treating negative symptoms of schizophrenia.
  • Atypical antipsychotics are now recommended for first-line treatment of new onset psychosis, but typical antipsychotics are still used.

Clozapine

  • Only clozapine has demonstrated superior efficacy to other antipsychotics. It substantially reduces overall mortality from schizophrenia because of a reduction in the rate of suicide.
  • Because of potentially dangerous side effects, it is only prescribed if two different antipsychotics have failed to control symptoms.
  • It may cause potentially fatal agranulocytosis (risk of death 1:10 000 exposed), and requires regular haematological monitoring (full blood count (FBC) once a week for 18 weeks, then fortnightly for a year, then monthly).
  • There is also a risk of seizures.
  • The most common side effects are listed in Figure 34.2. Associations with venous thromboembolism, myocarditis and cardiomyopathy have also been suggested.

How do antipsychotics work?

  • Figure 34.1 shows the action of antipsychotics on brain neuroreceptors:
  • We do not know exactly how these actions treat psychosis.
  • Abnormal dopamine transmission can result in a false sense of having seen or heard something before, or of not having done so, leading to the experience of psychosis. It is thought that antipsychotics improve psychosis by diminishing this abnormal transmission by blocking the dopamine D2/3 receptors. Several brain regions may be involved, but the ventral striatum may have a critical role.

Mode of administration

  • This is usually by mouth, sometimes with extensive ‘first-pass’ metabolism in the liver.
  • Many can also be given by short-acting intramuscular (IM) or (very rarely) intravenous injection.
  • Some (such as flupenthixol (Depixol), fluphenazine (Modecate) and risperidone (Risperdal)) can be given by depot injection every one to four weeks. This bypasses first-pass metabolism; it may improve adherence or at least allow closer monitoring.

Indications

  • Treatment and relapse prevention in schizophrenia and other psychoses (e.g. mania, psychotic depression); they are most effective in alleviating positive symptoms such as delusions, hallucinations and thought disorder.
  • Some atypical antipsychotics (risperidone, olanzapine and quetiapine) are licensed for treatment of acute mania.
  • They are also used for treatment of violent or agitated behaviour (usually on inpatient wards) that does not respond to deescalation.
    Haloperidol is most commonly used in this context, usually with a benzodiazepine.
  • They are no longer recommended for treatment of behavioural disturbance in older people with dementia because of increased risk of stroke and impairment of glycaemic control, with the exception that risperidone is licensed for short-term use (up to six weeks) in this context.
  • Antipsychotics are also used to treat Tourette’s syndrome but generally in much lower doses than for the psychoses (e.g. haloperidol up to 5 mg/day); aripiprazole usually maximum 5–10 mgm/day.

Side effects

  • Patients report that movement disorders, sedation, weight gain and sexual dysfunction are the most troublesome side-effects.
  • Because of their more potent dopaminergic effects, typical antipsychotics are more likely than atypical antipsychotics to cause:
    • extrapyramidal movement disorders (due to dopamine blockade in the nigrostriatal pathways):
      – Acute dystonia and Parkinsonism reflect drug-induced dopamine/acetylcholine imbalance and respond to anticholinergic drugs such as procyclidine.
      – Akathisia (psychomotor restlessness) is less responsive to anticholinergics; beta-blockers or benzodiazepines may be helpful.
      –Tardive dyskinesia is usually caused by long-term antipsychotics, thought to be because of dopamine-receptor supersensitivity and characterised by abnormal buccolingual masticatory movements and, in severe cases, choreiform trunk and limb movements, especially in older people.
      Reduction or cessation of anticholinergics (which do not help and may make it worse) and typical antipsychotics where possible and substitution of an atypical antipsychotic are recommended, although the condition is irreversible in 50% of cases. Clozapine may treat the tardive dyskinesia as well as psychosis.
    • raised prolactin leading to endocrine effects (due to tuberoinfundibular pathway dopamine blockade).
  • Atypical antipsychotics cause more metabolic side effects.
    Increased insulin resistance is the most likely cause.

Stopping antipsychotics

  • It is generally recommended that antipsychotics should be continued for at least one to two years after a first episode of psychosis. As 98% of those discontinuing medication after two years relapse, many recommend that they are continued for five years.
  • In practice, patients often discontinue antipsychotic medication long before this, with a quarter non-adherent 10 days post-discharge in one study.
  • Patients should be advised to taper their medication over at least three weeks if they decide to stop because stopping suddenly doubles the risk of relapse.

Physical health monitoring

  • Prior to commencing antipsychotics (and yearly thereafter), the following monitoring is recommended:
    • Body Mass Index and waist circumference;
    • ECG;
    • Blood tests: FBC, urea and electrolytes, blood lipids, liver function tests, glucose and HBA1C, prolactin.

Antidepressants

  • Selective serotonin reuptake inhibitors (SSRIs) (citalopram, fluvoxamine, fluoxetine, sertraline and paroxetine) were introduced in the 1980s and are now the most commonly prescribed class of antidepressants in the developed world.
  • Venlafaxine and duloxetine are selective serotonin and noradrenaline reuptake inhibitors (SNRIs]).
  • Mirtazapine and mianserin have a noradrenergic and selective serotonergic action.
  • Reboxetine is a noradrenaline selective reuptake inhibitor.
  • Moclobemide is a reversible inhibitor of MAO-A.
  • Agomelatine is a melatonergic agonist and 5-HT antagonist.
  • Vortioxetine has recently been licensed and affects serotonergic neurotransmission through multiple mechanisms.
  • Other antidepressants available include trazodone, maprotiline, and nefazodone.
  • The herbal preparation hypericum (St John’s Wort), whose active ingredient is thought to be hypericin, is widely used and may be effective in mild to moderate depression. Its action is similar to that of monoamine oxidase inhibitors (MAOIs) and it may interact adversely with many other drugs.
  • Antidepressants available prior to 1980 were divided into the tricyclics (such as imipramine, amitriptyline, dothiepin and lofepramine) and the MAOIs such as phenelzine and tranylcypromine. Tricyclic antidepressants are still in regular use, while MAOIs are occasionally prescribed.

How they work (see Figure 35.1)

  • The common mechanism of action of antidepressants involves increasing neural transmission of monoamines (serotonin, noradrenaline and in some cases dopamine).
    • The SSRIs and SNRIs do this by inhibiting their reuptake from the synaptic cleft.
    • MAOIs inhibit the breakdown of serotonin (and to a lesser extent noradrenaline) at the synapse by inhibition of MAO-A.
    • Mianserin and mirtazapine block presynaptic α2-receptors. These are autoreceptors that usually inhibit neurotransmission as a negative feedback mechanism. Blocking α2-receptors increases monamine output.
  • When the monoamines bind to post-synaptic receptors, second messengers are released that result in increased production of transcription factors that control gene expression.
  • These appear to increase production of Brain Derived Neurotrophic Factors (BDNF). The transcription factors are downregulated by increased levels of cortisol (produced at times of stress).
  • While the increase in monoamine availability in the synaptic cleft occurs within hours of taking antidepressants, antidepressants take around four weeks to show most of their effects clinically.
    The reasons for this are not certain: explanations include.
    • Four weeks may be the time it takes BDNF to increase neuroplasticity and neurogenesis in the hippocampus, reversing the atrophy of hippocampal neurons that results from depression.
    • The receptor sensitivity hypothesis has also been suggested to explain the delayed action of antidepressants. This proposes that depression results from supersensitivity and up-regulation of post-synaptic receptors that have too little stimulation. Increased availability of these neurotransmitters results in desensitisation and possibly a decrease in the number of receptors, and according to this theory it is this that lifts the patient’s mood.

Indications

  • The main indication for antidepressants is a moderate or severe depressive episode. They are not generally recommended for mild depression, for which active monitoring, problem-solving and exercise are preferred.
  • They should be taken for at least four to six months after resolution of symptoms. Studies suggest a response rate of 60–70% (compared with 30% with placebo).
  • Antidepressants are also useful in phobic anxiety, panic disorder, post-traumatic stress disorder (PTSD), general anxiety disorder (GAD), bulimia nervosa and obsessive–compulsive disorder (OCD) and in preventing depressive relapse. Bulimia and OCD often require higher doses (e.g. 60 mg fluoxetine).
  • Buproprion is a dopamine and noradrenaline reuptake inhibitor that is commonly prescribed as an antidepressant in the USA. In the UK it is only licensed as a smoking cessation drug.

Mode of administration

  • Antidepressants are taken orally. Most can be given once daily and are extensively and variably metabolised by first pass in the liver.
  • The antidepressant response seldom occurs in less than two weeks and often not for four weeks, though early partial response is predictive of remission. Patients not warned of the delayed therapeutic action are likely to be less treatment adherent.

Side effects

  • The main side effects of the most commonly prescribed antidepressants are listed in the table (see Figure 35.1).
  • Tricyclic antidepressants may increase mortality from cardiovascular disease and are often fatally toxic in overdose. SSRIs display minimal cardiotoxicity even in overdose.
  • SSRIs inhibit platelet aggregation and have been associated with an increased risk of gastrointestinal bleeding especially in older people, so should be avoided if possible in patients aged over 80 years, those with prior upper GI bleeding, or in those also taking aspirin or a non-steroidal anti-inflammatory drug.
  • SSRIs may cause hyponatraemia in older people.
  • There is evidence that SSRIs and SNRIs may increase agitation during the first one to two weeks of use. There have been some reports that SSRIs and venlafaxine may be associated with increased suicidal ideation and aggression, and because of these concerns all except fluoxetine are contraindicated in children under 18.
  • Venlafaxine may cause hypertension (or hypotension).
  • MAOIs can cause an occasionally fatal syndrome of hypertension and throbbing headache if foods containing large quantities of tyramine (e.g. cheese, red wine) are eaten.

Stopping antidepressants

  • All antidepressants have the potential to cause withdrawal phenomena. They should not be stopped abruptly unless a serious adverse event has occurred. Gradual tapering over two to four weeks is recommended.
  • Discontinuation symptoms include electric shock sensations, dizziness, increased mood change, restlessness, difficulty sleeping, unsteadiness, sweating, abdominal symptoms and altered sensations.

Serotonin syndrome

  • Drugs that increase serotonin availability may cause serotonin syndrome. This is more likely where two such drugs are given in combination. Features of serotonin syndrome include confusion, delirium, shivering, sweating, changes in blood pressure and myoclonus.

Other Psychotropic Drugs

Antimanic drugs (mood stabilisers)

Lithium

  • Lithium is used for:
    • prophylaxis in recurrent affective disorder (unipolar and bipolar),
    • acute treatment of mania,
    • augmentation of antidepressants in resistant depression,
    • schizoaffective illness,
    • the control of aggression.
  • We do not know the exact mechanism of action. We do know that:
    • lithium interacts with all biological systems where sodium, potassium, calcium or magnesium are involved;
    • at therapeutic blood levels it probably has effects on neurotransmission including 5HT, noradrenaline, dopamine and acetylcholine;
    • its interference with cyclic adenosine monophosphate (cAMP)-linked receptors explains its action on the thyroid and kidney.
  • It is taken orally and excreted by the kidneys. It has a narrow therapeutic range (0.4–1.0 mmol/L). Monitoring should include:
    • thyroid and renal function prior to starting lithium and every six months while taking it;
    • serum lithium levels (initially weekly, thereafter every 12 weeks), blood being taken around 12 hours after the last dose.
  • Treatment of toxicity or overdose involves cessation of lithium and fluid therapy to restore glomerular filtration rate (GFR), normalise urine output, and enhance lithium clearance.
  • Contraindications: lithium should be avoided in renal, cardiac, thyroid and Addison’s disease.
  • Dehydration and diuretics can lead to lithium toxicity.
  • Adverse interactions can also occur between lithium and nonsteroidal anti-inflammatory drugs, calcium channel blockers and some antibiotics.

Other antimanic drugs

  • Valproic acid (sodium valproate) and carbemazepine are also used for prophylaxis in bipolar disorder. Lamotrigine may be particularly effective in preventing depressive episodes. Here are their main side effects.

Lithium, lamotrigine and valproic acid are teratogenic and should be avoided during pregnancy (especially first trimester) and lactation.

Hypnotics and anxiolytics

  • The most commonly used are the benzodiazepines and zopiclone and related compounds.
  • Benzodiazepines are anxiolytic, sleep inducing, anticonvulsant and muscle relaxant. Their indications include:
    • insomnia,
    • short-term (two to four weeks) use in generalised anxiety (but not phobia or panic disorder),
    • alcohol withdrawal states,
    • the control of violent behaviour.
  • Underlying conditions (such as depression) should always be excluded and behavioural alternative treatments considered.
    Benzodiazepines are also used as ‘second-line’ drugs in refractory epilepsy.
  • Zopiclone and zolpidem are commonly used hypnotics without anticonvulsant or muscle-relaxing properties.
  • Antihistamines such as promethazine are available over the counter in Britain.
  • Buspirone is licensed for short-term treatment of anxiety.

Mode of administration

  • Usually administered orally.
  • Intramuscular, intravenous and rectal benzodiazepines preparations are available and may be required in status epilepticus and violent patients.

Pharmacokinetics

  • Most have active metabolites, some with half-lives of several days.
  • The long-acting benzodiazepines include diazepam, chlordiazepoxide and nitrazepam.
  • Lorazepam, oxazepam and temazepam are shorter acting benzodiazepines.

Mechanism of action

  • Benzodiazepines, zopiclone and zolpidem potentiate the inhibitory effects of γ-aminobutyric acid (GABA).
  • Buspirone is a 5HT1a partial agonist.

Side effects

  • These include:
    • drowsiness and lightheadedness the next day,
    • ataxia (risk of falls in older people),
    • amnesia,
    • dependence,
    • disinhibition, which may lead (paradoxically) to aggression.
  • Benzodiazepines potentiate alcohol and other sedatives; the combination is dangerous in overdose.

Tolerance and withdrawal

  • Tolerance to benzodiazepines frequently occurs, and there is a prolonged withdrawal syndrome, with:
    • marked anxiety
    • shakiness
    • abdominal cramps
    • perceptual disturbances
    • persecutory delusions
    • seizures.
  • They should therefore usually only be prescribed for no more than a couple of weeks. Weaning patients off benzodiazepines to which they have (iatrogenically) become dependent may take months or even years.
  • Benzodiazepines inhibit REM sleep and so there is a rebound experienced as increased dreaming when they are stopped.
  • Zopiclone and related compounds may also cause dependency and so long-term use should be avoided.

Stimulants

  • Methylphenidate is used to treat attention-deficit hyperactivity disorder (ADHD) and, more rarely, narcolepsy.
  • Atomoxetine is a newer medication used for treating ADHD.
  • Side effects of stimulants are:
    • decreased appetite and weight loss
    • anxiety
    • agitation
    • insomnia.

Antidementia drugs

  • Drugs currently available to treat the symptoms of Alzheimer’s disease (and Lewy body and Parkinson’s disease dementia) are:
    • cholinesterase inhibitors (donepezil, rivastigmine and galantamine);
    • memantine (an glutamate receptor antagonist).
    • All are given orally. Rivastigmine is also available as a transdermal patch, applied every 24 hours.
  • The most common side effects of cholinesterase inhibitors are:
    • gastrointestinal (nausea, diarrhoea, anorexia)
    • dizziness, syncope, bradycardia
    • rash
    • muscle cramps
    • urinary incontinence (and potentially retention).
  • The most common side effects of memantine are:
    • constipation
    • hypertension
    • dyspnoea
    • headache
    • dizziness
    • drowsiness.

Electroconvulsive Therapy and Other Physical Treatments

Electroconvulsive therapy (ECT)

Mechanism of action

  • ECT involves the induction of a modified cerebral seizure. A series of such treatments induces complex effects including:

Legal aspects

  • Figure 37.2 shows when ECT may be given in England and Wales.

Indications

  • The UK National Institute for Health and Clinical Excellence (NICE) recommends that ECT be used for the treatment of:
    • severe depressive illness (the main indication);
    • a prolonged or severe episode of mania that has not responded to treatment;
    • catatonia;
    • moderate depression that has not responded to multiple drug treatments and psychological treatment.
  • ECT should be used to induce fast and short-term improvement of severe symptoms after all other treatment options have failed, or when the situation is thought to be life-threatening (because of high risk of suicide or not eating and drinking).
  • Patients with depressive delusions and/or psychomotor retardation are most likely to respond.
  • Response rates may be as high as 90%. Speed of response may be faster than that of antidepressants.
  • Patients having ECT would nearly always need subsequent treatment for their depression in order to prevent early relapse. This is usually antidepressants and talk therapy.

How is ECT given?

Contraindications

  • There are no absolute contraindications to ECT.
  • Important relative contraindications are:
    • raised intracranial pressure
    • recent stroke
    • recent myocardial infarction
    • crescendo angina.

Side effects

  • Patients have reported that ECT causes cognitive impairment.
    Therefore cognitive function should be assessed prior to, during and after a course of treatment. Assessment should include:
    • orientation and time to reorientation after each treatment,
    • new learning,
    • retrograde amnesia,
    • subjective memory impairment.
  • If there is evidence of significant cognitive impairment at any stage, consider:
    • changing from bilateral to unilateral electrode placement; memory problems are reduced by unilateral electrode placement, though this may be slightly less effective;
    • reducing the stimulus dose;
    • stopping treatment.
  • Other side effects include:
    • anaesthetic complications,
    • dysrhythmias due to vagal stimulation,
    • postictal headache,
    • confusion,
    • retrograde and anterograde amnesia with difficulties in registration and recall that may persist for several weeks.

New methods of brain stimulation

Transcranial magnetic stimulation

  • The prefrontal cortex is stimulated by the application of a strong magnetic field.
  • Treatment usually involves a daily 30-minute session for two to four weeks.
  • It does not require a general anaesthetic or analgesia.
  • It has shown promise in the treatment of severe depression, although it is still primarily given in a research context.

Vagal nerve stimulation

  • This is used in epilepsy and has been employed to treat refractory depression.
  • A generator implanted under the skin in the chest area is used to provide electrical stimulation to the nerve.

Deep brain stimulation

  • A thin electrode is inserted directly into the brain and currents applied.
  • It is used in Parkinson’s disease.
  • In the USA, it has been used experimentally for obsessive–compulsive disorder (OCD) and Tourette’s syndrome.

Neurosurgery for mental disorder

  • This is now extremely rare (less than 10 operations a year in the UK). Bilateral anterior capsulotomy or anterior cingulotomy are the only two procedures currently performed.
  • Indications are severe treatment-resistant depression and OCD. Success rates of 40–60% are reported.
  • There are strict legal constraints to its use in the UK.

Psychiatry in the Community

Most people with mental illness are managed in primary care (if their illness is detected at all). Only those with severe and enduring mental illness are treated by psychiatric services, usually in the community rather than in hospital.

Psychiatry in primary care

  • Psychiatric morbidity doubles the likelihood of primary care consultation, and one in four of these consultations relates to mental health.
  • About 30% of significant psychiatric illness is not detected by primary care. Illness is less likely to be detected (and therefore treated) in patients who do not accept that their illness is psychiatric or treatable. Detection may be facilitated in primary care by GPs and other practice staff who:
    • are empathic and understanding;
    • are knowledgeable about mental health;
    • have more time available for consultation;
    • have good communication skills, including appropriate use of eye contact and sensitivity to non-verbal cues;
    • avoid exclusive concentration on the presenting complaint at the expense of any ‘hidden agenda’.
  • The most common psychiatric illnesses among people attending primary care are depression, anxiety and somatisation disorder.
  • Only about one-eighth of cases detected will be referred to psychiatrists. The decision to refer may reflect the GP’s confidence in managing psychiatric illness, the patient’s wishes, the accessibility of the psychiatric service and the severity and duration of the illness.
  • The challenge of primary care psychiatry is to ensure recognition and optimal care for the submerged iceberg of psychiatric morbidity.
    The NHS Improving Access to Psychological Therapies (IAPT) programme was introduced to increase the availability of evidence-based psychological treatments for depression and anxiety diagnosed in primary care. Patients are usually offered computer-aided CBT or guided self-help, and ‘stepped up’ to CBT or other evidence-based psychological treatments with a psychological therapist if this does not help. (See http://www.iapt.
    nhs.uk/services for more information on treatments offered.)

Community care of severe psychiatric illness

  • Between 1980 and 1995, large psychiatric hospitals (asylums) closed, and most psychiatric care shifted to the community, supported by fewer, smaller inpatient units. This major change was enabled by:
    • the effectiveness of psychotropic drugs,
    • an ideological commitment to the closure of asylums,
    • the greater cost-effectiveness of community care.
  • Since 2000, the number of inpatient beds has declined further as Crisis Resolution Teams have been set up to manage severely unwell people at home. Now only those with the most severe illness or highest risk are treated on inpatient wards.
  • Most secondary psychiatric care is now delivered by Community Mental Health Teams (CMHTs) consisting of psychiatrists, community psychiatric nurses (CPNs), social workers, occupational therapists (OTs) and psychologists.

Specialist psychiatric teams

Many CMHTs are currently undergoing reconfiguration to focus on specific disorders (e.g. psychosis, people with borderline personality disorder). Table 38.1 shows some that are already common in the UK.

Care Programme Approach

  • Psychiatric care is managed through the Care Programme Approach (CPA) in England, Wales and Scotland (introduced by the 1991 Community Care Act). In Northern Ireland, care plans are reviewed on a regular basis in a similar system.
  • CPA meetings take place at least every six months to devise a care plan, documenting:
    • all those involved in a patient’s care,
    • the treatment plan,
    • early relapse indicators,
    • a crisis plan should the patient’s mental health deteriorate.
  • The patient, usually their family and all relevant professionals and services (primarily the health and social services but also housing, GP) are invited.
  • Each patient has a nominated care coordinator (who may be any member of a CMHT), who arranges the CPA and is responsible for the care plan, seeing the patient regularly (usually monthly). The care coordinator also monitors the patient’s mental state and medication adherence, detecting any relapses at an early stage, providing emotional and practical support and promoting the patient’s mental well-being (e.g. by avoiding stress, excessive alcohol and drug use).

Patient-centred care

  • Services aim to provide patient-centred collaborative care, involving patients and their families in treatment decisions, reflecting a shift from previous ‘paternalistic’ services.
  • Many patients find self-help groups beneficial.
  • Service users (patients) are increasingly involved in the management of services, training professionals, and advising current patients through advocacy services.

Accommodation

  • Patients unable to live independently are usually cared for by family or friends (who may themselves need support from services to provide this care).
  • There are three main types of supported accommodation:
    • residential/nursing care homes,
    • supported housing (individual or shared accommodation with staff on-site),
    • floating outreach (support of a specified number of hours per week not tied to accommodation).
  • These services are usually run by social services, voluntary and independent sector organisations.
  • The amount of professional support varies from 24-hour nursed care (residential/nursing homes) to mental health workers visiting two or three times per week (floating outreach services).
  • Most aim to provide rehabilitation so that people can return to independent living or less supported settings.
  • The assessment of people’s ability to care for themselves (e.g. personal hygiene, shopping, budgeting, cooking, cleaning) and the nature of their illness is important in deciding what level of support they will need to live successfully in the community and avoid relapse and return to hospital.

Daytime activity

  • Employment is important for mental health, as it brings:
    • income
    • purpose
    • daytime structure
    • social networks.
  • Barriers to accessing employment are anxiety, a lack of motivation, concerns about losing state benefits and discrimination.
  • Discrimination is an important barrier, even though the Disability Discrimination Act 1995 prohibits employers from treating people with chronic (including mental) illness differently.
  • Most services now focus on supporting people with mental health problems to obtain employment, attend college courses or train for work.
  • Support, Time and Recovery (STaR) workers help service users to access a range of daytime activities. Many STaR workers are ex-service users and provide expertise through their experience of mental health problems to give service users peer support as well as helping them access daytime activities.

Forensic Psychiatry

Forensic psychiatry concerns the legal aspects of mental disorders. The forensic psychiatrist is primarily concerned with the assessment, treatment and rehabilitation of mentally disordered offenders.

Crime and mental disorder

  • Most mentally ill people are never dangerous. They are far more likely to be victims than perpetrators of crime.
  • People with mental illness commit proportionately fewer violent crimes than those without such illness.
  • Mental disorder may increase the likelihood of arrest because of decreased ability to avoid detection or to negotiate an alternative outcome.

Schizophrenia

  • There is an association with violent crime, which is mostly accounted for by a higher frequency of substance misuse in people with schizophrenia than in the general population.
  • Up to 10% of homicide offenders may have schizophrenia, but, as violent crime is rare, the annual risk that a person with schizophrenia will commit a homicide is low (about 1 in 10 000).
  • The rate of homicide in 15 times higher in psychosis if the illness is untreated.
  • Arson is much more commonly perpetrated by people with schizophrenia than by members of the general population.

Affective disorder

  • Severe depression can lead to hopelessness and a view that death is the only solution.
  • Depression-related homicide is rare, usually domestic (often infanticide), in response to delusions (e.g. believing that the victim is fatally ill and suffering) and often followed by suicide.
  • Offences linked to mania may reflect financial irresponsibility (fraud, defaulted debt) or impulsivity (shoplifting, occasionally violence).

Alcohol and substance misuse

  • These are strongly associated with violent crime and driving offences.
  • Theft, robbery and shoplifting may be motivated by a lack of funds to buy illicit drugs.
  • Alcohol is often implicated in morbid or pathological jealousy, which may culminate in spousal homicide.

Cognitive disorders

  • Dementia is occasionally associated with shoplifting (forgetting to pay) and sexual offences (usually reflecting frontal disinhibition).
  • Subjects with learning disability may commit sexual offences or arson.

Personality disorders

  • There is a strong association between crime and antisocial personality disorder, although this assertion is somewhat circular since offending may be integral to the diagnosis.
  • Individuals with severe emotionally unstable, impulsive, paranoid and histrionic personality traits are more likely than others to offend.
  • Shoplifting has been associated with poor impulse control (e.g. in antisocial personality disorder).

Managing violence

Assessing risk of violence

  • This is important when assessing for compulsory detention, transferring patients between different levels of security and planning aftercare.
  • Pay attention to the forensic history and distinguish:
    • crimes against property and violence against the person,
    • crimes occurring during periods of illness and during remissions,
    • precursors to past violence and their risk of recurrence.
  • While a history of violence is a strong predictor of risk subsequently, a first episode of violence can occur in the context of severe stress or a psychotic disorder.
  • Risk may have to be managed by compulsory detention, sometimes long term. Resource issues should not be allowed to cloud judgements about the management of violence.

Managing mental illness in the criminal justice system

  • Psychiatric illnesses, particularly psychoses and drug- or alcohol-related disorders, are overrepresented in prisoners. This partly reflects a group of urban, homeless, psychiatrically ill, multiple reoffenders.
  • Half to two-thirds of prisoners have a personality disorder.
  • Most prisoners with mental illness are managed by prison-based primary and mental health services.
  • The forensic sections of the Mental Health Act are used where prisoners are judged to require transfer to psychiatric hospital.

Managing offenders and potentially violent patients in the psychiatric services

  • Court diversion schemes seek to ensure that mentally ill people who are brought before the courts obtain appropriate care from health and social services.
  • Psychiatric inpatients judged to be too high a risk for general psychiatric or psychiatric intensive care units (PICUs) are managed in:
    • medium (or regional) secure units, or (where the risk is greatest)
    • high secure hospitals (Broadmoor, Ashworth, Rampton and Carstairs in the UK).
  • Some UK prisons (and Broadmoor and Rampton high secure hospitals) have specialist units for the treatment of people with dangerous severe personality disorders. These are for prisoners who present a serious risk to others as a result of a personality disorder.

Prostitution

  • Prostitution is not in itself illegal, but it is illegal to loiter or solicit sex on the street.
  • Women who work as prostitutes are at high risk of mental illness.

Mental Capacity

  • In health and social care, as in other areas of life, people are generally presumed to have capacity to make their own decisions unless there is reason to believe they do not. Capacity should be assessed carefully so that patients who are able to make their own decisions are not denied their right to do so, and those without capacity receive good health and social care.
  • In some countries, a legal framework governs the process by which carers and professionals make welfare, health care and financial decisions on behalf of people who lack capacity. These laws seek to protect vulnerable people from harm, neglect and exploitation. In other countries there is no specific legislation, and decisions are made under common law.

Assessing capacity

  • A person may lack capacity to make a decision as a result of any cause that impairs reasoning ability, be it temporary or permanent (e.g. dementia, intellectual disability, acute confusional state).
  • A person lacks capacity to make a decision if he or she is unable to:
    • understand information relevant to the decision;
    • retain, use and weigh that information to come to a decision;
    • communicate that decision (by talking, sign language or other means).
  • If a lack of capacity is likely to be temporary, it may be possible to delay the decision until the person can make it themselves.
  • People should always be helped to make decisions for themselves where they have the capacity to do so, and to give their views where possible if they do not.
  • Assessment of capacity should be repeated because a person’s capacity to make a decision can change with time.

The Mental Capacity Act (England and Wales)

If a person lacks capacity, professionals must make decisions in their best interests.

  • Professionals have a duty to consult carers and family. If the person has no one to speak for them, an independent mental capacity advocate (IMCA) is appointed to represent their wishes on important issues of welfare and health.

Lasting Power of Attorney (LPA)

  • This allows a person with capacity to appoint an attorney to make these decisions on their behalf if they lose capacity.
  • The attorney (usually a relative or friend) can be directed by the person appointing them to make decisions about their property and financial affairs and their personal welfare, which includes health care and where they live.

Advance decisions

  • Anyone with capacity can make an advance decision (also sometimes called an ‘advance directive’) about treatment they do not want to receive in the future if they lose capacity to make treatment decisions.
  • This can include life-saving treatment so long as this is specified by the person making the advance decision.
  • Advance decisions permit a person to refuse treatment but not to demand it.

Deprivation of liberty safeguards (DoLS)

  • These apply to people in hospitals and care homes who:
    • are deprived of their liberty (not allowed to come and go as they please),
    • lack capacity to consent to the confinement,
    • are not sectioned under the Mental Health Act (MHA).
  • When a hospital or care home identifies that a person who lacks capacity is being, or risks being, deprived of their liberty, they must apply for an authorisation of deprivation of liberty. Authorisation is only granted if two assessors agree that:
    • the person is aged 18 or over;
    • it would not conflict with a valid decision by a donee of Lasting Power of Attorney, a deputy appointed by the Court of Protection, or an advance decision;
    • the person lacks capacity to decide whether to be admitted to, or remain in, the hospital or care home;
    • the person is suffering from a mental disorder;
    • the person is not detained under the MHA;
    • the application is not to enable mental health treatment in hospital of someone who objects to being in hospital or to the treatment (in which case the MHA should be considered);
    • it is in the person’s best interests, and necessary and proportionate to prevent harm to them.
  • Authorisations must be renewed at least annually.
  • The patient (or their representative) may appeal; the Court of Protection has the powers to terminate the order or vary the conditions.

Legal competence

Most mentally ill people retain responsibility for their actions and the capacity to manage their affairs. However, careful assessment of capacity is crucial to the criminal justice system.

Fitness to plead

  • This is for a jury to decide.
  • It refers to a defendant’s competence to mount a defence against charges.
  • People are deemed fit to plead if they have the capacity to:
    • understand the charge
    • distinguish between guilty and not guilty pleas
    • instruct lawyers
    • follow court evidence
    • challenge jurors.
  • If a person is found unfit to plead, a trial of the facts may still take place, and the defendant would be acquitted if the facts were not established. If the facts are proven, there may be flexibility in the sentence imposed.

Mens rea

  • For guilt (of most crimes) to be established, it is necessary to demonstrate that the defendant was ‘criminally responsible’, possessing the mens rea (guilty mind) to commit the offence.
  • Mens rea may be absent by virtue of:
    • age – children under 10 years cannot be criminally responsible, and for those aged 10–14 years the prosecution must prove mens rea;
    • lack of criminal intent (e.g. accidents);
    • automatism – this refers to dissociation between mind and action (e.g. epilepsy, sleepwalking, concussion);
  • mental disorder – this is rarely invoked to deny mens rea; it must be established that the defendant was mentally ill at the time of the offence, resulting in a ‘defect of reason or disease of the mind’, and that consequently he/she could not tell what he/she was doing or know that it was wrong. If successful, the verdict is ‘not guilty by reason of insanity’. This theoretically allows some flexibility of sentence, although it usually results in hospital detention.

Diminished responsibility

  • In murder, conviction may be modified to manslaughter on grounds of diminished responsibility on the basis of specific ‘abnormality of mind’ substantially impairing mental responsibility.
    This is defined as ‘arising from a condition of arrested or retarded development of mind or any inherent causes or induced by disease or injury’.

Testamentary capacity

  • Testamentary capacity (capacity/competence to make a will) must be present for a will to be valid.
  • It requires a person to:
    • understand the act of making a will,
    • appreciate the extent of his/her property and assets,
    • be aware of who might have a reasonable claim on their estate.
  • If the person is mentally ill, testamentary capacity implies that his/her judgement should not be clouded regarding the will itself. Delusions or hallucinations only impair testamentary capacity where they are directly relevant to the will (e.g. delusions of poverty).

Mental Health Legislation in England and Wales

  • The Mental Health Act (MHA) 1983 (amended by the MHA 2007) is concerned with the care and treatment of patients compulsorily detained in hospital and those under community treatment orders.
  • It is supervised by the Mental Health Act Commission (MHAC).

Sectioning (compulsory admission)

  • Compulsory admission (‘sectioning’) requires that:
    • a patient is judged to have a mental disorder sufficiently severe to need detention in hospital in the interests of his/her own health/safety, or for the protection of others;
    • for patients to be detained under the longer lasting sections (e.g. Sections 3, 37) appropriate medical treatment must be available to them;
    • people cannot be detained because of learning disability alone unless it is associated with abnormally aggressive or seriously irresponsible conduct.

      Mental disorder is defined as any disorder or disability of the mind. It includes mental illness, personality disorder, learning disability and disorders of sexual preference (e.g. paedophilia), but NOT dependence on alcohol or drugs.

How ‘sectioning’ is carried out

  • Most hospital detentions are under Sections 2 or 3:
    • Section 2: admission for assessment (or assessment followed by treatment), lasts up to 28 days.
    • Section 3: admission for treatment, lasts up to six months (renewable).
  • Application for these sections is made by an Approved Mental Health Professional (AMHP). AMHPs may be social workers, nurses, psychologists or occupational therapists (not doctors). Rarely, the nearest relative may make the application.
  • Application is made on the recommendations of two medical practitioners, one of whom should be ‘approved’ under Section 12 (for which specialist experience and completion of a training course is required) and one of whom should have ‘previous knowledge/acquaintance’ of/with the patient (e.g. the patient’s GP). Doctors with ‘previous knowledge/acquaintance’ may also complete the recommendations even if they are not Section 12 approved.
  • For Section 3, the AMHP has a duty to consult the nearest relative if possible, and, if they object, the section cannot proceed unless the responsible clinician (RC: person responsible for care under section, generally consultant psychiatrist) takes legal action to displace the nearest relative.
  • MHA assessments are convened by the AMHP, usually at the patient’s home or in hospital. Two ACs and the AMHP assess the patient; if they decide that the patient should be in hospital and the patient refuses informal admission, they arrange admission under section.
  • Police may attend assessments if there are concerns that the patient will be violent or physically resist coming to hospital if detained.
  • Where a patient lacks capacity to agree to an informal admission (e.g. because of dementia), the patient may still be admitted informally so long as she/he appears to assent and does not object. Such admission would be subject to the provisions of Deprivation of Liberty Safeguards (DoLS).

Emergency sections

These last for up to 72 hours, except Section 5(4) which lasts six hours:

  • Section 4 is used when admission (otherwise fulfilling Section 2 requirements) is more urgent than Section 2 procedures would allow.
  • Section 136 empowers a police officer who finds a person in a public place appearing to suffer from a mental disorder to remove him/her to a ‘place of safety’ for assessment.
  • Section 135 empowers a police officer or other authorised person acting on a magistrate’s warrant to enter premises and remove to a place of safety a person who is believed to be suffering from a mental disorder.
  • Section 5(2), for patients already in hospital (any ward but not A&E), is on the recommendation of the RC or his/her nominated deputy. Patients placed on Section 5(2) must subsequently be assessed for Sections 2 or 3 or discharged from Section 5(2) to become an informal patient.
  • Section 5(4) allows urgent detention for <6 hours of a patient already receiving treatment for mental disorder in hospital, on the recommendation of a registered mental nurse when a doctor is not able to attend immediately.

Community treatment

  • Community Treatment Order (CTO): patients may be placed on a CTO following detention in hospital under Sections 3 or 37, by application of the RC with agreement of the AMHP. CTOs require that patients make themselves available for medical examination.
    Patients may be recalled to hospital if they require treatment on grounds of their health or safety that can only be given in hospital; refuse to make themselves available for examination by the RC or do not comply with conditions of the CTO. Once recalled they may be detained for up to 72 hours for assessment. During that time, the RC must either revoke the CTO (the patient returns to being detained under Sections 3 or 37) or release the patient. Alternatively the patient may agree to an informal admission.
  • Guardianship (Sections 7 and 8): a guardian (usually an AMHP), nominated by the local authority, is empowered to ensure that an individual resides at a specified place, attends specified places and times for treatment, education, training or occupation and allows specified people (e.g. AMHPs, doctors) access to their residence.

Leave and discharge from section

  • Section 17 requires that patients on Sections 2 or 3 can only have leave subject to the RC’s specific instructions.
  • Patients may be discharged from a section before it expires by:
  • the RC;
  • a Mental Health Review Tribunal (MHRT), to whom patients may appeal, within 14 days for Section 2 or at any time within the first six months and once during each subsequent period of renewal for Section 3 (MHRTs consist of a lawyer (president), psychiatrist and a lay member (for Section 41 patients the president is a judge or Queen’s Counsel)); patients may be granted legal aid and obtain an independent medical opinion;
  • the Mental Health Act managers (community members who act as non-executive directors of a hospital) for discharge, if patients appeal to them;
  • the nearest relative, although they must give 72 hours’ notice and can be barred in some circumstances by the RC.

Forensic sections

  • Here are the main sections of the MHA relating to those charged with or convicted of crimes.

Treatment without consent

  • Except in emergencies, patients detained under the emergency sections (e.g. 5(2), 135, 136, 4) may not be treated without their consent.
  • Here are the sections that allow treatment without consent and what they say:

Mental Health Legislation in Scotland

  • The Mental Health (Care and Treatment) (Scotland) Act 2003 concerns the compulsory treatment of people with mental disorders living in Scotland. It amends the Criminal Procedure (Scotland) Act 1995 regarding the treatment of mentally disordered offenders.
  • The Mental Welfare Commission is an independent body that monitors the operation of the Act and promotes best practice. It appoints designated medical practitioners when circumstances require a second medical opinion on compulsory treatment.
  • The 2003 Act gives people with a mental disorder a right to independent advocacy. Additionally, any adult can appoint a named person (if this is agreed in writing and witnessed) who has a right to be consulted and to appeal against the detention of the person they support.
  • The Act also allows people to make advance statements about how they would wish to be treated if they became unable to express their views as a result of becoming mentally unwell. The Mental Health Tribunal and doctors treating the person must take notice of an advance statement and inform the patient, the patient’s named person and the Mental Welfare Commission in writing of the reasons if they do not follow it.

Compulsory orders

  • To be detained:
    • a person must be suffering from a mental disorder (mental illness (including dementia), personality disorder or learning disability) that:
      – significantly impairs their decision making with respect to medical treatment of the disorder, and
      – would put their health, safety or welfare, or the safety of another, at significant risk if they were not detained.
    • detention must be deemed necessary.
  • Significantly impaired decision-making ability is not the same as ‘incapacity’ under the Adults with Incapacity (Scotland) Act 2000, but it is a related concept. It refers to the specific capacity of an individual to make decisions about medical treatment for mental disorder, whereas the Adults with Incapacity (Scotland) Act 2000 covers a range of different capacities.
    Here are the main compulsory orders.
  • a Mental Health Officer (MHO) (a social worker with additional training),
  • an Approved Medical Practitioner (AMP) (a doctor with mental health expertise, usually a psychiatrist).

Compulsory Treatment Orders

  • Compulsory Treatment Orders (CTOs) require that medical treatment is available that may prevent deterioration, or help treat any symptoms or effects of the mental disorder, and without which there would be a significant risk to the person or others.
    Medical treatment may include nursing care, psychological intervention, education and training in living skills. It lasts up to six months initially, can be extended for a further six months, and subsequently for 12 months at a time. It may be based in hospital or the community. A community order may require the patient to receive medical treatment (but not by force), live at a certain address and attend certain services for treatment.
  • The decision on whether to grant a CTO is made by the Mental Health Tribunal. Tribunals have three panel members: a lawyer, a doctor with experience in mental health and a third person with other skills and experience. An MHO makes an application to the Tribunal, including two medical recommendations and a proposed care plan. Patients are given the opportunity to express their views at the Tribunal, if they wish to.
  • If the Tribunal needs further information before making a final decision, or the patient or their solicitor needs more time to prepare their case, the Tribunal may make an interim (temporary) CTO (<28 days), which can be renewed once only.

How orders are ended

  • If the person no longer fulfils the criteria, short-term detention and CTOs can be cancelled by:
    • the Responsible Medical Officer (a medical practitioner, usually a consultant psychiatrist and AMP),
    • the Mental Welfare Commission, or
    • the Mental Health Review Tribunal. The patient or their named person has the right to appeal against decisions made by the Tribunal.

Other short-term holding powers

  • Nurses’ holding power – an appropriately qualified nurse can hold a hospital patient who has been receiving treatment on a voluntary basis for up to two hours to allow a doctor to assess the patient. This can be extended by another one hour once the doctor arrives.
  • Removal to place of safety – the police can take a person from a public place to a place of safety for <24 hours for assessment if the person appears to have a mental disorder and to be in need of care and treatment.

Mental health law relating to prisoners

  • The court can make assessment and treatment orders at any stage of the criminal justice process prior to sentencing. Here are the main orders:
  • The court may detain a person who has been acquitted of an offence but who may require admission to hospital for treatment of a mental disorder in a place of safety for <6 hours so a medical examination can be carried out.

Medical treatment

  • Urgent treatment that is not associated with significant risks or irreversible consequences may be given without consent to save a patient’s life, to alleviate serious suffering on the part of the patient or to prevent violent or dangerous behaviour. Where a detained patient does not or cannot consent to drug treatment, it must be authorised by an independent medical practitioner to continue beyond two months.
  • Electroconvulsive therapy (ECT) may only be given to a patient if he or she can and does consent, or is incapable of consenting and the treatment is authorised by an independent medical practitioner.
    ECT cannot be given to a patient who has capacity and refuses the treatment, even in an emergency.
  • Neurosurgery for mental disorder can only be carried out after an independent medical practitioner gives an opinion that it will be beneficial to the patient, and two lay people appointed by the Commission have certified that the person consents, or does not object if they are incapable of giving consent. Where the person is incapable of consenting, the Court of Session must also give approval.

Mental Health Legislation in Northern Ireland

  • The 1986 Mental Health (Northern Ireland) Order makes provision for the detention, guardianship, care and treatment of patients. Its use is monitored by the Mental Health Commission of Northern Ireland.
  • The Mental Capacity (Health, Welfare and Finance) Bill, which it is hoped will be enacted in 2015 will replace the 1986 Mental Health Order. It will reform mental health legislation and develop new capacity legislation. At the time of writing, the 1986 Mental Health (Northern Ireland) Order remains in force.

Criteria for detention

  • The definition of mental disorder comprises mental illness, mental handicap, severe mental handicap and severe mental impairment. Mental illness is defined as a ‘state of mind which affects a person’s thinking, perceiving, emotion or judgement to the extent that he requires care or medical treatment in his own interests or the interests of other persons’. The order cannot be used for the compulsory treatment of addictions, personality disorders (unlike the legislation in England, Wales or Scotland) or sexual deviancy, unless the above criteria are also met.
  • People may be detained only if:
    • they are suffering from a mental disorder of a nature or degree that warrants detention in hospital for assessment (or for assessment followed by medical treatment),
    • failure to detain the patient would create a substantial likelihood of serious physical harm to the patient or to others.
  • Criteria for likelihood of serious physical harm are that the patient has inflicted, or threatened or attempted to inflict, serious physical harm on themselves; the patient’s judgement is so affected that they are, or would soon be, unable to protect themselves against serious physical harm, and that reasonable provision for their protection is not available in the community; or that other persons have reasonable fear they may suffer serious physical harm owing to violent or other behaviour of the person.

Compulsory admission to hospital

  • Article 4 permits a patient to be compulsorily admitted and detained in hospital for assessment on the application of the nearest relative or an approved social worker (ASW).
  • This application must be supported by the recommendation of one doctor (who completes a Form 3) and the doctor and ASW must have seen the patient in the two days preceding the application.
  • The doctor should (if possible) know the patient and (except in cases of urgent necessity) not be on the staff of the receiving hospital. In practice, the doctor is usually the patient’s GP.
  • All detained patients are initially admitted for a period of assessment of up to 14 days.
  • A doctor must assess the patient immediately after admission to hospital (and complete a Form 7).
  • If the admitting doctor is not a consultant, the patient must be seen by a consultant within 48 hours of admission.
  • If the patient is further detained, he or she will be seen again by a consultant within the first and second seven-day periods of the admission (the consultant will complete a Form 8 and a Form 9 for these respective time periods).
  • The consultant may then complete a Form 10, which allows detention for treatment (six months in the first instance). This may be extended for a second six-month period (Form 11), and thereafter for periods of one year (for which a Form 12 must be signed by two consultants).

Police powers

  • A police officer may remove from a public place an individual who appears to be suffering from a mental disorder and in need of immediate care and control and take the person to a place of safety (usually a police station), where he or she must be seen by a doctor and ASW.
  • If the person is not in a public place and access to the property is denied, a warrant to enter the premises may be obtained (Article 129) by an ASW, another officer of the Health and Social Services Trust or a police officer from a Justice of the Peace.
  • If the police officer has to enter the premises, by force or otherwise, he or she must be accompanied by a medical practitioner (usually a GP) who will administer medical treatment if required. The person may then be transferred to a place of safety.

Informal hospital patients

  • A patient who has been admitted informally and subsequently wants to leave or refuse treatment may be detained if appropriate by completion of a Form 5 or 5a (for psychiatric and general hospital patients respectively), usually by a junior doctor.
  • The patient’s own GP (or another practitioner who has previous knowledge of the patient) must then attend the hospital to complete a medical recommendation (Form 3), and an ASW or nearest relative must make an application, after which matters proceed as for other detained patients.
  • A doctor on the staff of the hospital in which it is intended that the assessment should be carried out cannot give the recommendation except in a case of urgent necessity.

Guardianship

  • A guardianship order may require the patient to:
    • reside at a certain place;
    • attend at specified places and times for the purpose of medical treatment, occupation, education or training;
    • allow any specified doctor, ASW or other person access to their residence.
  • The order lasts for six months initially, and may then be renewed for a further six months and yearly thereafter.
  • Persons aged 16 or over may be subject to a guardianship order if they are found to be suffering from mental illness or severe mental handicap and it is deemed necessary in the interests of their welfare.
  • The application may be made by an ASW or a patient’s nearest relative, who must have personally seen the patient within 14 days of the application, and be supported by two medical recommendations.
  • The ASW should consult the nearest relative if possible. If the nearest relative objects, involvement of a second ASW is required.
  • The nominated guardian is normally a social worker.

Patients involved in criminal proceedings

  • Courts may remand an unsentenced prisoner to hospital for two weeks for the preparation of reports (Article 42) or for treatment (Article 43).
  • A remand under Article 42 can be made on the basis of one medical opinion – the oral evidence of a Part II-approved doctor (in practice, a consultant). Article 42 does not allow treatment without the patient’s consent, or granting of temporary leave from the hospital.
  • The court may make a hospital or guardianship order or hospital order with restriction when sentencing a prisoner (Article 44) on receipt of evidence from two medical practitioners, one of whom must be Part II-approved and give oral evidence.
    An interim hospital order allows admission to hospital before the court makes a hospital order.
  • A person serving a sentence of imprisonment may be transferred to hospital for treatment after two written reports have been provided to the Secretary of State (Article 53). Article 53 requires ‘that the person is suffering from mental illness or severe mental impairment’.

Appeal

  • The Mental Health Review Tribunal hears appeals against detention in hospital or guardianship orders. It consists of a legal member who is the president, a medical member and a lay member.
  • Referral to the Tribunal may be by the patient or nearest relative and the hospital trust must refer any patient who has been detained for two years without a tribunal hearing.
  • Under the 1986 Order, the patient needed to prove that he or she should be released. This was found to be incompatible with the European Convention on Human Rights. The Mental Health (Amendment) (Northern Ireland) Order 2004 has therefore amended the 1986 Order to shift the burden of proof to the health and social services trust to demonstrate that a patient should not be discharged.

Consent to treatment

  • This legislation is similar to the 1983 Mental Health Act (England and Wales) provision.
  • Article 63 states that patients may not receive neurosurgery for mental disorder unless they consent and the treatment is recommended in a second opinion from an independent doctor.
    These safeguards apply to both detained patients and voluntary patients.
  • Article 64 covers other serious forms of treatment and requires either the patient’s consent or a second medical opinion (e.g. for electroconvulsive therapy (ECT)). These requirements apply only to detained patients.
  • Article 68 deals with cases requiring urgent treatment necessary for certain specified emergencies (e.g. ECT) which may be given without the patient’s consent or a second medical opinion.

Mental Health Legislation in Australia and New Zealand

Each Australian state and territory as well as New Zealand has its own Mental Health Act (MHA), upholding the rights and interests of people with mental illness. Definitions of mental illness, disorder and distress vary between jurisdictions but each act sets a standard that must be met for detention and considers risk to self or others, and the need to provide the least restrictive form of care.

Requirements for detention

Table 44.1 lists the sections relevant to the assessment and detention of a person under the MHA, in each of the Australian States and Territories and in New Zealand.

A medical practitioner (MP)’s ability to provide treatment without consent

In each jurisdiction there is statutory provision for authorised MPs or other persons or bodies (e.g. Guardianship Board (TAS), responsible clinician (NZ)) to give treatment to involuntary patients, usually in approved mental health facilities. The treatment may be for mental illness or disorder (all jurisdictions) and, in some jurisdictions (e.g. NSW, SA), for any other illness.

Community treatment orders (CTOs) and the role of medical practitioners

Community treatment or community care orders impose varying requirements on mental health patients to accept medication and therapy, counselling, management, rehabilitation and other services while living in the community.
New South Wales (NSW): A CTO may be made by the Mental Health Review Tribunal (MHRT) or a magistrate and is valid for up to one year. The director of community treatment (who may be an MP) may initiate breach proceedings.
South Australia (SA): A Level 1 CTO may be made by an MP if the patient meets the requirements of the MHA. It is valid for 28 days if made by a psychiatrist or an authorised MP. An application for a Level 2 CTO may be made by an MP to the Guardianship Tribunal and is valid for up to one year.

Western Australia (WA): A psychiatrist may make a CTO. A CTO is valid for up to three months if within 72 hours it is confirmed by another psychiatrist or authorised MP. The supervising psychiatrist can revoke a CTO.
Northern Territories (NT): A community management plan authorises the involuntary treatment or care of a person in the community. An authorised psychiatric practitioner may make an interim community management order (valid up to 14 days).
The MHRT must review the interim order within 14 days. An authorised psychiatric practitioner may suspend a community management order.
Tasmania (TAS): A CTO may be made by two approved MPs who have each separately and within the previous seven days examined the patient. A CTO is valid for up to one year. The MHRT must review a CTO within 28 days.
Australian Capital Territory (ACT): Community care orders are made by the ACT Civil and Administrative Tribunal. A community care order is a form of mental health order and valid for up to six months; it is not age limited.
Victoria (VIC): An authorised psychiatrist may make a CTO. A CTO is valid for up to one year. The authorised psychiatrist may revoke a CTO.
New Zealand (NZ): Wherever possible a CTO is heard and determined by a Family Court judge after examination by a number of MPs who formed the opinion that the person met the criteria set out in the MHA for compulsory treatment. The patient is required to attend and ‘accept’ treatment in the first month of the CTO and thereafter if a psychiatrist appointed by the MHRT considers that the treatment is in their best interests.
The CTO must be reviewed at least every six months.

Forensic sections

NSW: A magistrate, if of the view that a defendant is (or was at the time of the alleged offence) ‘developmentally disabled’ (not defined) or is suffering from a ‘mental illness’ (see MHA) or a ‘mental condition’ (not defined) for which treatment is available in a mental health facility, but is not a ‘mentally ill person’ within the MHA, can make various procedural or final orders. A final order means that the charge is dismissed and the defendant discharged unconditionally or on condition for assessment and/or treatment.
QLD: A ‘forensic order’ made by a judge of the Mental Health Court in respect of a forensic patient remains in force until revoked by the MHRT. The MHRT must not revoke a forensic order unless satisfied that the patient does not represent an unacceptable risk to self or others.
SA: ‘Supervision orders’ include a ‘limiting term’ cap and can be revoked by the Supreme Court, whereupon the person can be released after taking into account, among other matters, the nature of the person’s mental impairment, whether the person is, or would if released be, likely to endanger others, and whether there are adequate resources available for their care in the community.
WA: The Governor may order the release of a person from custody if the Minister, based on a recommendation by the
Mental Health Review Board, advises the Governor to do so. However, if a trial judge determines that an accused is unfit and will not become fit within six months, the judge may quash the indictment (or dismiss the case if there is no indictment) without deciding the guilt or otherwise of the accused and may either release the accused or make a ‘custody order’ in respect of the accused.
NT: A ‘supervision order’ (potentially for an indefinite term) must be reviewed every year by the Supreme Court which must vary it to a non-custodial supervision order unless satisfied that this would put the safety of the supervised person or the public seriously at risk. The court must consider an appropriate medical report and treatment plan.
TAS: If a person is found unfit for trial and not likely to become fit in 12 months, the court must hold a special hearing. If the person is not found not guilty, or is found not guilty on the grounds of insanity, then the court may make a custodial ‘restriction order’, a continuing care order or a community treatment order, or the court may release the person conditionally or unconditionally. The patient must be reviewed every 12 months by the Forensic Tribunal, and if determined that the order is no longer necessary, the Supreme Court may discharge or revoke the order.
ACT: The tribunal reviewing an ‘order for detention’ must take into account: dangerousness/public safety, the nature and extent of the person’s mental dysfunction and its likely effect on their future behaviour, and the likely sentence of imprisonment had the person been found guilty.
VIC: A ‘custodial supervision order’ is reviewed by the court and must ordinarily be confirmed or varied to a ‘non-custodial supervision order’ (which is for an indefinite period). The court must take into account similar matters to those that must be considered in SA.
NZ: The Family Court has principal jurisdiction in mental health matters and oversees offenders who have entered the system of ‘compulsory care’ but has no jurisdiction in criminal matters affecting patients.

Guardianship

Where a person has a disability that affects their capacity to make informed decisions (e.g. intellectual impairment, mental disorder, brain injury, physical disability or dementia) all jurisdictions allow a legal guardian to be appointed (by a court, board or tribunal).
Relevant legislation is:
NSW: Guardianship Act 1987; QLD: Guardianship and Administration Act 2000; SA: Guardianship and Administration Act 1993; WA: Guardianship and Administration Act 1990; NT: Adult Guardianship Act 1988; TAS: Guardianship and Administration Act 1995; ACT: Guardianship and Management of Property Act 1991; VIC: Guardianship and Administration Board Act 1986; NZ: Protection of Personal and Property Rights Act 1988.

Mental Health Review Tribunals

MHRTs conduct mental health inquiries, make and review orders including CTOs, hear appeals and make other decisions about the treatment and care of people with mental illness. They are usually composed of three members: a lawyer (chair), a psychiatrist and another suitably qualified member.

Preparing for Clinical Examinations in Psychiatry

Introduction

Objective structured clinical examinations (OSCEs) are now used in most UK medical schools to assess clinical specialities, including psychiatry. An OSCE examination consists of several (usually 16–20) stations with a standard and relatively short time (5–15 minutes) spent on each.

  • Sticking to task and time is therefore vital.
  • Remember that the marking system is standardised and that stations are distributed across the main topic areas that you should cover.
  • A good revision technique is to write some OSCE stations yourselves, preferably in a revision group, and devise your own marking sheet (see our examples in the self-assessment section of this book).
  • It is good to practise OSCE scenarios in groups of three, so that one can be the patient, one the candidate and one can assess and give feedback as the examiner.
    In this chapter we outline different types of OSCE station and give some practice tips.

During the OSCE

  • Start with open questions (to which a longer descriptive answer is expected) and move towards closed questions (yes/no answers) as the consultation progresses.
  • Don’t waste time discussing things that are not relevant to the task. If the question says ‘Assess this man’s current risk of suicide’, you will get marks for asking about his current thoughts, plans and intentions, so refocus and signpost the conversation if it drifts away from the task: ‘That sounds like something we certainly need to discuss, but I really want to understand how you feel about x before we move on.’
  • Listen to the patient and ask follow-up questions to clarify any points that are not clear. For example, if they mention that things have been difficult at work or home recently, perhaps the disorder has had an important impact on their work or relationship.
    If you say, ‘I’m sorry to hear that. How have things been difficult?’ you will find out.
  • Use language that is understandable to people without a medical degree.
  • Acknowledge any distress a patient shows (e.g. ‘I’m sorry this is upsetting’).
  • Always leave time to summarise back to the patient what has been said. This allows for clarification and a chance for the patient to mention anything important they may have forgotten.
    Here are some typical tasks requested in OSCE stations and tips
    on how to address them.

Interview stations

Giving information to a patient or relative, about a diagnosis, treatment or prognosis

  • You will not be expected to take a history unless the question specifically tells you so to do.
  • Practise succinctly explaining the main psychiatric diagnoses (e.g. schizophrenia, bipolar affective disorder, depression, dementia); try to avoid technical language, or explain any terms you use (e.g. ‘tests of kidney function’, not ‘U&Es’).
  • Ensure that you first check what the patient/carer knows and a little bit about their particular condition. They want to know about their own illness, not about the condition generally. But don’t delay answering their question. So, if they ask, ‘What is dementia?’ you can give a general answer and then say that it varies a lot between people, and ask if that sound like the types of difficulty their mother has been having?
  • Ask if there are things they particularly want to know, ensure all information is given in small chunks and, after giving each explanation, check if that answers their questions.
  • Ensure the actor has a chance to speak; it is not a mini-lecture and people can only take a few pieces of information on board at a time.
  • At the end, explain how they can get in touch with someone (care coordinator, GP etc.) in the future and offer to send them leaflets or refer them to appropriate Internet sites (e.g. MIND, Alzheimer’s Society) to show you know that they will not remember everything.

Assessing suicide risk

  • This is a very common station, so well worth practising.
  • If you are asked to assess someone’s level of suicide risk after a recent attempt, make sure you elicit:
    • the key details of the attempt (Were they alone? Was it planned? How were they discovered? Perceived lethality etc.);
    • how they feel about it now (thoughts, plans, intent, mood).
  • If asked to assess suicide risk, the number of past attempts and family history are relevant, but don’t get bogged down in the past history at the expense of current mental state and the recent attempt.
  • Assess the risk factors for suicide, such as sex, age, depression, alcohol/drug abuse, social support, employment and chronic illness.

Eliciting an aspect of the psychiatric history

  • This will be in a very focused area, such as taking an alcohol or illicit substance use history.

Depression

  • This will be a station focused on taking a depression history. You will need to cover all the core, cognitive and biological symptoms as well as suicidal intention and a brief past psychiatric history.
  • The examiner will be looking for you to exclude differential diagnoses such as bipolar disorder and psychosis.

Eliciting an aspect of the mental state

  • Again this will be in a focused area.
  • Make sure you do not drift into taking a history. For example, if asked to elicit symptoms of depression, ask about current mood, ability to enjoy life, energy levels, negative cognitions (guilt, hopelessness), biological symptoms etc. Don’t ask when they first became depressed.

Video stations

  • You may be asked to assess a mental state from a video.
  • A good way to practise this is to try to write a mental state for a patient you have seen in a ward round and ask for feedback.
  • Make sure you write something for every section, even if there is no abnormality you can see – for example, ‘cognition grossly normal’ or ‘no perceptual abnormality detected’.
  • Watch for physical signs (e.g. tremor or other extrapyramidal signs, tics, exophthalmos, evidence of liver disease, tattoos, scars, needle marks, obviously over-/underweight, clothes too big) and abnormal or indicative behaviours, such as crying or poor eye contact.

Pencil and paper stations

  • You may be asked to discuss a drug chart or section paper (so make sure you have seen and discussed some during your clinical attachment).