Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
New Mental Health Legislation - Do no harm
- Tejpal Singh, Ramandeep Singh, Specialist Registrar- Learning Disability Psychiatry, Hertfordshire Partnership NHS Trust (26 March 2007)
-
Making sense of the government's motivation for reform of the Mental Health Act
- D B Double (27 March 2007)
-
New mental health legislation
- Louis Appleby (31 March 2007)
-
New Mental Health Legislation and Public Protection
- Tom Farmer (2 April 2007)
-
Mental Health Law: real doctors should not become spin doctors
- Anthony Maden (17 April 2007)
-
Double standards at the Department of Health
- Jonathan Waite (17 April 2007)
-
Authors' Response to Maden: Bill offers no advantages over the Scottish approach in contributing to the role of psychiatry in public protection
- Rajan Darjee, John Crichton (25 April 2007)
|
|
|||
|
Tejpal Singh, Specialist Registrar- Forensic Psychiatry Wessex Forensic Psychiatry service, Ravenswood House, Knowle, Fareham, Hampshire. PO17 5NA, Ramandeep Singh, Specialist Registrar- Learning Disability Psychiatry, Hertfordshire Partnership NHS Trust
Send response to journal:
|
Crichton and Darjee's article highlights a stark challenge to the moral legitimacy of psychiatrists in general, and forensic psychiatrists in particular.(1) The moral rule, primum non nocere- first do no harm, may be a moral rule for all people, but for physicians, especially for psychiatrists (psychiatrists are physicians) it achieves elevated status. However the assumption that all activities of physicians must be governed by the same ethical principles is clearly falacious. If forensic psychiatrists were to be charged only with pursuing their patients best interests and avoiding harm - as are their clinical colleagues - their evaluations would be worthless. Inherent in the value of a forensic psychiatric evaluation is the idea that information adverse to the subject's interest might well be derived from the evaluation and that the forensic expert will truthfully present such data where it is relevant to the issue at hand. There is no shame in this reality. What we need (and what is lacking) is, a set of guiding principles that will help us fulfill the duties of beneficience without interfering with our forensic functions.(2) (1) Crichton J, Darjee R: New Mental Health Legislation. BMJ 2007; 334:596-7 (2) Applebaum PS : Theory of Ethics for Forensic Psychiatry. J Am Acad Psychiatry Law, vol 25, no 3, 1997. Competing interests: None declared |
|||
|
|
|||
|
D B Double, Consultant Psychiatrist Norfolk & Waveney Mental Health Partnership NHS Trust, Norwich NR6 5BE
Send response to journal:
|
Crichton & Darjee are correct to point out the confusion of purpose in new mental health legislation in England and Wales.1 Although the Government ordered a root and branch review of the law, it gave the Richardson Committee no option about introducing supervised community treatment. The Expert Committee consequently avoided the issue by making little differentiation between hospital and community treatment in its proposals. The government's decision to introduce supervised community treatment was, therefore, made without evidence. In fact, a recent review of mental health legislation overseas has concluded that it is not possible to state whether supervised community treatment is beneficial or harmful to patients.2 The impetus for reform also comes from the notion that mental health services are not doing enough to prevent homicide by psychiatric patients.3 However, homicide inquiries in mental health services have too often become destructive.4 Systematic review of these inquiries is required, taking into account the complexity of mental healthcare systems and avoiding stigmatisation of the mentally ill. Legislation should not proceed without making sense of these inquiries.
Competing interests: None declared |
|||
|
|
|||
|
Louis Appleby, National Clinical Director for Mental Health Department of Health
Send response to journal:
|
Sir, Crichton and Darjee misrepresent the Mental Health Bill that is currently going through Parliament, claiming that it is insufficiently concerned with care and treatment. The aim of the Bill is to ensure that people with mental disorder receive the treatment they need at times of high risk. This will have benefits to patient and public safety - 14 per cent of the 1300 patient suicides that occur annually in England and Wales, and 25 per cent of the 52 patient homicides, are preceded by refusal to take medication - but the starting point will be better care. The Bill introduces supervised community treatment (SCT) - a similar power exists in many countries including Scotland (where the authors work). Patients will be eligible for SCT only if they are already detained in hospital for treatment - a safeguard that goes beyond what is in the Scottish legislation. The Bill also removes the "treatability test" that currently acts as an impediment to care for some people with personality disorder. Crichton and Darjee claim, without evidence, that an over-emphasis on public safety will be counter-productive. But whose over-emphasis are they referring to? It is the House of Lords that has amended the Bill so that SCT can not be used for the suicidal patient, and the Mental Health Alliance, described by the authors as a "remarkable coalition" that has asked the Government not to reverse this change. Protection for the violent but not the suicidal patient? Remarkable indeed. Professor Louis Appleby National Director for Mental Health Competing interests: The author advises the Government on mental health policy |
|||
|
|
|||
|
Tom Farmer, 3rd year medical student & Bio-ethics BSc, Bristol University, Faculty of Medicine, BS2 8DZ
Send response to journal:
|
Sir, John Crichton is right to say that the ‘fundamental flaw’ in the government’s new mental health bill is the ‘belief that mental health law is a worthy vehicle to enhance public protection’(1) . At the very core of the new bill’s changes to the treatability test is the utilitarian notion that it is morally justifiable to reduce the freedom of a minority of individuals who may be potentially dangerous due to mental disorder with the aim of protecting the majority of society, regardless of whether those detained individuals’ conditions will be effectively treated. This sort of reasoning is seriously flawed. Given the considerable uncertainty concerning the exact number of new patients who would qualify for detainment under the proposed legislation, it is reasonable to question whether there would be enough psychiatric ward space and mental health professionals to cope with the influx. The mental health service is stretched financially as it is, and the Royal College of Psychiatrists has stated throughout the government’s attempts to reform the mental health act that the blurring of the treatability test would represent a drain on money that would be better spent on other mental health services (2). The changes are also likely to have a significant negative impact on psychiatry for other reasons. As well as the resentment many mental health workers have towards the bill, new patients may well become more apprehensive in seeking help from mental health services. The use of psychiatry as a ‘vehicle to enhance public protection’ is dependent on reliable means of predicting which mentally disordered individuals will actually commit violent crime if left un-detained. An editorial in the Psychiatric Bulletin in 2001 reported that eighty two percent of psychiatrists believed that available risk assessment procedures were inadequate to identify potentially dangerous individuals (3). It is doubtful that confidence has increased dramatically in the proceeding years. Over-prediction is a real possibility, as a psychiatrist failing to detain a patient who then goes on to commit violent crime is likely to be heavily criticised by the press and may potentially face litigation. A belief that the overall welfare of society will be increased by the changes to the treatability test set out in the new bill is far too simplistic and fails to consider all the possible consequences. 1) Crichton J, Darjee R: New Mental Health Legislation. BMJ 2007; 334:596-7 2) Forrester A. Preventative detention, public protection and mental health. Journal of Forensic Psychiatry 2002;13:329-44. 3) Haddock A, Snowden P, Dolan M, Parker J, Rees H. Managing dangerous people with severe personality disorder: a survey of forensic psychiatrists’ opinions. Psychiatric Bulletin 2001;25:293-6. Competing interests: None declared |
|||
|
|
|||
|
Anthony Maden, Professor of Forensic Psychiatry Imperial College London, Claybrook Centre, London W6 8RP
Send response to journal:
|
Whatever the final shape of our new mental health law, the lasting damage will be to the psychiatric profession which has thrown away any claim to objectivity or scientific integrity by joining the Mental Health Alliance of pressure groups. Crichton and Darjee's editorial reads more like a campaign leaflet for the Alliance than a dispassionate overview. First, they claim that "an overemphasis on public safety in mental health law increases risk to the public" without producing any of the supporting evidence usually required of medical experts. Their next dubious claim is that "The problem of violence in the mentally disordered is much more about how society manages violence generically than how it manages mental disorder", which is simply not true when applied to violence in schizophrenia. Some homicide inquiries show that the killing was coincidental to the illness but the vast majority find that the killing resulted directly from delusions, hallucinations or other symptoms. In these cases good treatment, good risk management and good public protection are virtually identical. They go on to complain that "Politicians and the media may highlight that one homicide a week is perpetrated by someone with a mental illness...", but their numbers are wrong: the one-a-week figure refers to mentally ill patients with recent service contact, whereas the overall number of mentally ill homicides is about 100 per annum in England and Wales. The implication is that the media and politicians are making too much fuss - but let us put the figures in context. That death rate of one a week is higher than the rate at which British soldiers have been killed in Iraq. It is far above the level of deaths associated with any other form of medical treatment - because a medical treatment associated with one unnecessary death a week would be banned without a second thought. The real scandal here is professional complacency - the media are having to ask the difficult questions because psychiatrists are too busy patting themselves on the back and blaming scarce resources for all the profession's failings. Crichton and Darjee go on to quote selectively from the findings of the Confidential Inquiry, omitting to mention its main finding - that in 59% of cases the psychiatrist looking after the perpetrator thought the chances of the killing could have been reduced, most commonly through better compliance with medication. Presumably this fact was considered inconvenient, as it supports the Government's intention to introduce provisions for compulsory community treatment. The authors worry instead that the Inquiry found "only 12 cases, 6% of a sample, where respondents involved in the care of a mentally ill perpetrator believed different legal powers may have made a homicide less likely"; but since when were doctors so casual about unnecessary deaths? Having had some involvement with the relatives of victims, I would consider a change in the law justified if it prevented one homicide. The authors also make selective use of the Barrett report, and ought to explain why they did not quote p211: "In our view, the only means of securing John Barrett's compliance with treatment as an out-patient would have been a community treatment order, which is not available under the Mental Health Act". The statement relates to Barrett's care before he almost killed his first victim. There are numerous homicide inquiry reports that have suggested a community treatment order may have made a difference, and poor compliance with treatment features in most inquiries. These comments may seem harsh, but my target is the extent to which psychiatry has become part of a pressure group when it ought to be dealing more effectively with the problem of violence risk. The latest manifestation of this fact is that the Royal College of Psychiatrists has employed a PR firm to put across its case over violence risk management. The simple fact is that our services are much less safe than they could be. The profession ought to put its energies into improving them, rather than spending money on explaining away their deficiencies. Good violence risk management in mental illness is usually synonymous with good treatment, and the profession should be taking a lead. Competing interests: None declared |
|||
|
|
|||
|
Jonathan Waite, Consultant in the Psychiatry of Old Age Nottinghamshire Healthcare NHS Trust, Queen's Medical Centre Nottingham NG7 2UH
Send response to journal:
|
It is sad to see the enthusiasm of the National Director for Mental Health to deprive people with mental disorder of their fundamental human rights. The Department of Health have been eager to promote the Mental Capacity Act which explicitly codifies the rights of people with capacity to refuse medical treatment and to make advance refusals of treatment, even if this may result in their death. Despite this, Professor Appleby wishes the just and reasonable amendments made to the current Mental Health Bill by the House of Lords to restrict the forcible imposition of medical treatment for mental disorder to those who have impaired decision making to be reversed. I look forward to reading his proposals for the compulsory transfusion of Jehovah's Witnesses. Jonathan Waite Consultant in the Psychiatry of Old Age, Nottinghamshire Healthcare NHS Trust Competing interests: None declared |
|||
|
|
|||
|
Rajan Darjee, Consultant Forensic Psychiatrist The Orchard Clinic, Royal Edinburgh Hospital EH10 5HF, John Crichton
Send response to journal:
|
We agree with Tony Maden that compulsory treatment in the community should be available to prevent patients with psychosis from relapsing where there may be a potential risk to others (and also where there may be a potential risk to the patient). We also agree that forensic psychiatrists should be more involved in the treatment of paraphilias and other conditions of relevance to sexual offending. Never-the-less Tony Maden is highly critical of our allegedly non-evidence based editorial (1) which he feels is no more than propaganda for the Mental Health Alliance (2), an organisation with which we have no formal or informal ties and which provided no input to the editorial. He also criticises our response to Louis Appleby's comments (3, 4). We are both psychiatrists working in the forensic service serving Edinburgh and South-East Scotland. We each have a case load of psychotic and personality disordered patients, with histories of serious violence, currently being managed in the community. Some of them are subject to compulsory community treatment. The current Scottish legislation supports us in assertively, and sometimes coercively, managing such cases where necessary. As is the case with most forensic psychiatrists, we are all too aware of the cases where things go wrong. Many of our patients have offended whilst under the care of mental health services. Retrospectively one can identify the factors that could perhaps have been addressed to perhaps prevent the violent outcome: misdiagnosis, rejection of difficult patients, a piece of information ignored, a piece of information not shared, lack of beds, lack of assertive management of non-compliance, lack of an objective structured approach to risk assessment, not heeding a relative's concerns etc. None of these issues would be preferentially addressed by the approach set out in the Mental Health Bill as compared with current Scottish legislation. We are not complacent or tempted to pat psychiatrists on the back. In Scotland we have not traditionally been subject to the level of scrutiny seen in England where a psychiatric patient commits homicide. However, following a recent case (5), we were invited to join a working group to produce new Scottish Executive guidance on improving the management of restricted patients in the community (6). Our approach in this has been to assert, as Tony Maden does, that properly conducted structured risk assessment and management is central to the treatment of potentially violent individuals with mental disorders, and the provision of high quality care and treatment is the best way to improve public safety. In his recent book he has branded forensic psychiatrists who do not believe that public protection is our business as 'ludites' (7); we do not feel that our views and approaches would lead him to place us in this group. In relation to Tony Maden's comments on the contribution of mental illness and its treatment to homicide, there are a number of medical treatments that produce far more deaths. Hospital acquired infections cause thousands of deaths in the UK annually (8). This clearly needs to be dealt with at a number of different levels, but surely hospital treatment for very ill people should not be banned, and draconian legislation is not required. We are also involved in trying to establish a liaison service for criminal justice agencies in the management of sex offenders. As Tony Maden mentions knowledge and expertise in assessing and managing sex offenders amongst forensic psychiatrists in the UK is generally pretty lamentable, and in Scotland it is particularly poor. Within the context of new (in Scotland) Multi-Agency Public Protection Arrangements (9) we want to offer appropriate clinical input (including consideration of pharmacological treatment in some cases) to help police and criminal justice social workers reduce further victimisation by sex offenders in the community. Again the Mental Health Bill's potential inclusion of sexual deviation would not help us in our task. Rather than focussing what we do on clinical assessment and treatment, we would potentially be forced into debates on whether or not we should section offenders with paedophilia or sadism. The appropriate means to detention in such cases is through imprisonment, and although many psychiatrists do not agree, we believe clinical assessment for the courts has a role to play in these sentencing decisions. How far will the Mental Health Bill improve the treatment of potentially violent patients with psychosis in the community, or psychiatry’s involvement in the management of sex offenders? We believe the potential benefits will be, at best, minimal, at an overwhelming cost to the proper role of mental health services and the correct balance between freedom and restriction. Beyond these important forensic issues, it is also difficult to see why the approach in England and Wales cannot be more similar to that in Scotland. Certainly the Mental Health Bill would seem to offer no particular advantages over the Mental Health (Care and Treatment) (Scotland) Act 2003 in improving the care of patients with mental disorders. We have a number of criticisms of the Scottish legislation, but know of no psychiatrist in Scotland, forensic or otherwise, who would rather have any of the three incarnations of the Mental Health Bill south of the border. We are accused of being spin doctors rather than real doctors. Hopefully the above has given some indication that we practice in the real world of forensic mental health, and although we have both worked with the Scottish Executive, we have not felt the need to promote the government position. But we are not reliant on direct government funding for our jobs, our services or our research. Not to comment on legislation we believe will be detrimental would be wrong. If the Mental Health Bill (un-'emasculated' by the House of Lord's amendments) does become law, then at least there will be the potential for a natural experiment comparing the impact on, amongst other outcomes, homicides and suicides of new but very different legislation either side of the border. The likely outcome of this study, we predict, would be that neither piece of legislation will produce significant differences in homicide or suicide rates. As Grounds (10) stated, when referring to Appelbaum's authoritative review of cycles of mental health reform in America (11), both pessimists and optimists are usually wrong, which is both 'reassuring and depressing'. Rajan Darjee Consultant Forensic Psychiatrist The Orchard Clinic, Royal Edinburgh Hospital John Crichton Consultant Forensic Psychiatrist The Orchard Clinic, Royal Edinburgh Hospital REFERENCES 1. Crichton J, Darjee R: New Mental Health Legislation. BMJ 2007; 334:596-7 [Full text] 2. Maden, A. Mental Health Law: real doctors should not become spin doctors. BMJ Rapid Response. http://www.bmj.com/cgi/eletters/334/7594/596 3. Appleby, L. . Bill aims to protect people at times of high risk. BMJ 2007; 334: 761-761 [Full text] 4. Maden, A. Mental Health Law: many psychiatrists support the new Bill. BMJ Rapid Response. http://www.bmj.com/cgi/eletters/334/7597/761- b#163985 5. Mental Welfare Commission for Scotland. Report of Inquiry into the care and treatment of Mr L and Mr M. Edinburgh: Mental Welfare Commission for Scotland, 2006. http://www.mwcscot.org.uk/web/FILES/Publications/Mental_Welfare_Inquiry.pdf 6. Forensic Mental Health Services Managed Care Network (2006) Review of Care Programme Approach Guidance for Restricted Patients in Scotland (Draft Guidance for Consultation) http://www.forensicnetwork.scot.nhs.uk/documents/reports/CPA%20Consultation/Draft%20for%20Consultation%20_inc%20appendices_.pdf 7.Maden, A. Treating Violence: A Guide to Risk Management in Mental Health. Oxford University Press, 2007. 8. National Audit Office. The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England. London: National Audit Office, 2000. http://www.nao.org.uk/publications/nao_reports/9900230.pdf 9. Scottish Executive (2007) Implementation of the Multi Agency Public Protection Arrangements (MAPPA) in Scotland. Circular No JD/15/2006. Edinburgh: Scottish Executive http://www.scotland.gov.uk/Publications/2007/03/circjd1506updmar07 10. Grounds, A. Reforming the Mental Health Act British Journal of Psychiatry 2001; 179: 387-389 11. Appelbaum PS. Almost a revolution. Mental health law and the limits of change. New York: Oxford University Press, 1994. Competing interests: See original article. |
|||