Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Authors' Response
- Rajan Darjee, John Crichton (14 April 2007)
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An overemphasis on public safety can be counterproductive
- D B Double (16 April 2007)
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Mental Health Law: many psychiatrists support the new Bill
- Anthony Maden (17 April 2007)
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Supervised Community Treatment Orders
- Mark Agius, Catherine Louise Murphy PRHO Psychiatry Bedford Hospital. (18 April 2007)
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New Mental Health Bill
- J S Bamrah, Julian Sheather, Barbara Wood (23 April 2007)
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New Mental Health Bill
- Hugh W Griffiths (28 April 2007)
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Mental Health Law: Many psychiatrists support the Bill but Maden does not represent the Royal College of Psychiatrists
- Anthony Maden (29 April 2007)
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Respose to Professor Maden
- John C O'Grady (30 April 2007)
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Rajan Darjee, Consultant Forensic Psychiatrist The Orchard Clinic, Royal Edinburgh Hospital, EH10 5HF, John Crichton
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Sir We agree with Professor Appleby that there should be no discrimination between potentially violent and potentially suicidal patients. Providing high quality care and treatment for people with mental disorders will prevent some, but not all, violence and suicide in these individuals. But he would seem to be an isolated professional voice in claiming that the Mental Health Bill is sufficiently concerned with, or likely to improve, the care and treatment of patients. We are not aware of any other psychiatrist who whole-heartedly welcomes the new bill, and know of many colleagues from south of the border who have serious concerns. This bill has not, as far as we are aware split the profession, but has united psychiatrists, and many others, in opposition. Even forensic psychiatrists with opposing views about the role of psychiatry in public protection find major faults with the bill. We do not oppose compulsory treatment in the community, but the evidence for its benefits remains elusive (1). In Scotland compulsory treatment in the community has been introduced with the safeguards of principles and a decision-making-ability test. Where compulsion has resulted from criminal proceedings the latter does not apply. Our view is that psychiatry should have a significant but cricumscribed role in public protection (2). Where patients have mental illness or learning disability then mental health services clearly have to take a lead role, and mental health legislation should be used where necessary to ensure appropriate treatment to reduce risk. However where serious risk to others is posed by offenders with sexual deviation and/or personality disorder, then incapacitating individuals to protect the public is the role of the criminal law. In such cases psychiatry should play a supporting role. If the bill is about the care and treatment of people with mental health problems, why is sexual deviation not excluded, and why is paedophilia explicitly mentioned, in the bill’s supporting documents, as a condition for which compulsory measures would be appropriate? We are not aware of any legal jurisdiction that includes sexual deviation under the remit of mental health law. Controversial sexual predator laws in the USA allow the civil commitment of such individuals, but at least they are explicit about what they do. At a time when we are meant to be striving to reduce the stigmatisation of people with mental health problems, does the Mental Health Tsar endorse the detention of paedophiles under mental health legislation? Dr Rajan Darjee Consultant Forensic Psychiatrist Dr John Crichton Consultant Forensic Psychiatrist References 1. Kisely S, Campbell LA, Preston N. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Art. No.: CD004408. DOI: 10.1002/14651858.CD004408.pub2. http://www.cochrane.org/reviews/en/ab004408.html 2. Coid J, Maden T. Should psychiatrists protect the public? BMJ 2003;326:406-7. Competing interests: See original article |
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D B Double, Consultant Psychiatrist Norfolk & Waveney Mental Health Partnership NHS Trust, Norwich NR6 5BE
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Louis Appleby suggests that the fact that some suicides and homicides by mentally ill people are preceded by refusal to take medication is evidence for the introduction of supervised community treatment.1 His position as national clinical director for mental health makes clear the political nature of this statement and we need to be cautious about interpreting it as a rational statement about risk.2 Risk factors do not necessarily provide information about prevention.3 Coercing people to take medication may not save lives. Reports from the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness have been used by Government to give scientific respectability to estimates of the number of people that will be saved by introducing supervised community treatment. However, these estimates have been calculated assuming without evidence that supervised community treatment will be of benefit. Louis Appleby does not appreciate that an overemphasis on public safety can be counterproductive. Some survivors of mental health services, however, are clear that the psychiatric treatment they have received has precipitated them into attempting suicide or behaving aggressively.
Competing interests: Member of Critical Psychiatry Network which was an original but is not currently a member of the Mental Health Alliance |
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Anthony Maden, Professor of Forensic Psychiatry Imperial College London, Claybrook Centre, London W6 8RP
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It is wrong for Rajan Darjee to suggest that Louis Appleby is alone in his support for the new Bill. The forensic executive of the Royal College of Psychiatrists strongly supports the main planks of the Bill, namely the Community Treatment Order (CTO) and current, risk-based (rather than judgment or capacity-based) criteria for compulsion. Many psychiatrists believe the Bill does not go far enough, and that it should allow the use of a CTO in certain cases without the need for a period of detention in hospital first. Psychiatrists know too well the destruction wrought by a single psychotic relapse; why should they want to put their patients throught that experience several times before, as "revolving-door" patients, they would qualify for the Lords' emasculated version of a CTO? Although other parts of the Bill are more contentious, the divisions have been exaggerated. For example on treatability there is a wide consensus that compulsory treatment ought to be likely to benefit the patient whilst we can never guarantee success in a particular case. The argument boils down to whether the wording around availability of appropriate treatment is satisfactory. Incidentally, the current financial crisis in the NHS ought to reassure anybody who seriously fears the Department of Health is going to create hundreds of new beds to warehouse untreatable criminals; this is a paranoid fantasy. The debate over paedophilia is more complicated than Darjee suggests. Society's first response to sexual offending against children is and always will be the criminal law, followed by family law, with mental health law a long way down the list. However, the exclusion of sexual deviation from the 1983 Act had the unfortunate and unintended effect of allowing mental health services to virtually ignore the problem, so that all our services for the treatment of sex offenders are poorly developed by international standards. Doctors have more or less abandonded the field, so pharmacological treatment is less common than it was 25 years ago, despite improvements in efficacy. The value of removing the exclusion would be that it would put paedophilia back in the medical mainstream. The understandable fear of most psychiatrists is that there would be pressure on mental health services to detain large numbers of paedophiles. My personal view is that the fears are exaggerated because detention in hospital would rarely be the appropriate treatment for paedophilia. On the other hand, predatory paedophilia would be a more honest criterion for detaining a handful of patients in high security hospitals who are currently held under the label of psychopathic disorder. We need to keep the numbers in perspective, and we need to acknowledge that there are no easy answers. In a perfect world all the sadistic, predatory paedophiles would be safely under the care and control of the criminal justice system, with the support of mental health services as appropriate. In our imperfect world I cannot envisage a forensic mental health system entirely free of such patients, and a good mental health law would include them. Any clinician familiar with sex offenders will also be familiar with their ambivalence towards offending, and will understand the the extent to which helping the patient and protecting the public are intextricably linked. Competing interests: None declared |
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Mark Agius, Associate Specialist Weller Wing Bedford Hospital, Catherine Louise Murphy PRHO Psychiatry Bedford Hospital.
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Despite their present apparent unpopularity, it seems important to write in favour of Supervised Community Treatment Orders. It is of concern that these orders are likely to be introduced by the new mental health bill, but in only a very limited manner, and actually only after a section three treatment order has been applied. It is of further concern that Professor Appleby [1] states that according to an amendment recently introduced, Supervised Community Treatment Orders will not be used for patients at risk of committing suicide. Our present system for treating mental health issues, in particular patients with psychosis, is now very dependent on treatment in the community. Thus, many persons who would heretofore have been treated in hospital are now treated in the community by a number of community teams including Home Treatment teams, Early Intervention teams, Assertive Outreach teams, and Community mental health teams. Only the most severely ill are now treated in hospital. It is true that admission to many acute psychiatric wards is traumatic in itself, and indeed, may even lead to post-traumatic stress disorder. [2] It is also true that it is essential that young persons with psychosis should be treated in the least restrictive manner possible, and so home treatment is often preferable to hospital. [3] Treatment in acute psychiatric wards is often frightening and often stigmatising.[3] All of the above facts have made many health care professionals loathe to use their powers under present legislation to admit young persons with psychotic illness to hospital when it is evidently necessary. We have recently in our own team experienced two cases where primary care professionals have delayed using powers under the mental health act to admit young psychotic patients who were evidently not engaging with treatment or accepting medication, when they were clearly entitled to do so, and this to the clear detriment of both the patients and their families. It is now clear that prolonged duration of untreated psychosis does tend to lead to a poorer prognosis in psychotic illness [4], but on the other hand, many young people with psychotic illness do not wish to engage with treatment, even despite the best efforts of our community teams, either because they are in denial or because they lack insight. All that Supervised Community Treatment Orders as presently proposed can offer in order to remedy this situation is to begin with an admission under Section 3 of the Mental Health Act, which will then be substituted with a Supervised Community Treatment Order once the patient improves. This, in effect means using the very powers under the act which are recognised as being traumatic and stigmatising at the present time. Under these circumstances, our community treatment teams will not receive any support in performing their functions from the new powers, and equally the new powers will not help improve the mental health of our patients. We need to reflect, while drafting legislation, that the most important human right which any of us possesses is that of being of sound mind and able to control our own lives, rather than a somewhat spurious ‘right to choose’. We need to ensure that those of our patients who are at risk of suffering permanent damage to their mental state as a result of not accepting treatment which is in their best interest are given every possibility of receiving treatment. We need to ensure that treatment is delivered in a non-stigmatising manner and in the least restrictive way possible. Although risk of violence or suicide are important factors in assessing the severity of mental illness, our primary focus should be on improving the mental state of our patients, which is what we are most able to do with our available treatments. Once patient’s mental state improves, we can expect risks of violence, suicide, and non-compliance with treatment will improve also. Therefore, we need to take the present opportunity to develop a new form of Supervised Community Treatment Order, which can be applied directly within the patient’s home, without the patient suffering the trauma and stigma of a hospital admission. Such an order could be designed so that it can be administered by the treatment team, in the most discreet way possible. It would then be an added power in the armamentarium of our community teams and would be effective in enabling patients to become well and to stay out of hospital. References. [1] Appelby L. 2007. Bill aims to protect people at times of high risk. BMJ 334; 761 [2] McGorry PD et al 1991 Post-traumatic stress disorder following recent onset psychosis. An unrecognised postpsychotic syndrome . Journal of Nervous and Mental Disease 179, 253-258. [3] IRIS Guidelines 1999 North Birmingham Mental Health Trust [4] Marshall M , Lewis S, Lockwood A, Drake R, Jones P, Croudace T Association Between Duration of Untreated Psychosis and Outcome in Cohorts of First-Episode Patients’ 2005 Archives of General Psychiatry 62 975-983. Competing interests: None declared |
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J S Bamrah, Chair of the BMA's Psychiatric subcommittee British Medical Association, BMA House, Tavistock Square, London WC1H 9JP, Julian Sheather, Barbara Wood
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We disagree with Louis Appleby (1) in his assertion that the new mental health Bill for England and Wales will bring additional benefits to detained patients. The Bill broadens the criteria for mental disorder, dispenses with vital exclusions and permits detention on the basis of 'appropriate treatment'. The definition of ‘appropriate treatment’ has been extended to include 'nursing, psychological intervention, and specialist mental health habilitation, rehabilitation, and care'. This vague categorisation of treatment dramatically increases the scope of compulsory powers. It now becomes possible to detain individuals with psychopathic disorders where no therapeutic benefit can be offered. Not only does this turn health legislation into an instrument for social control, it also draws scarce resources away from those who can actually benefit. Professor Appleby's contention that suicides and homicides would be reduced due to better compliance with medication is also questionable. Despite our broad support for supervised community treatment, we believe that it is spurious to suggest that any changes to the definition of medical treatment will help in this regard. The real motivation behind the proposals is to remove the restrictions on treating individuals with personality disorders. This misplaced objective ignores the positive health benefit for the larger number of mentally ill patients who require detention, in favour of enforcing psychological interventions in a much smaller number of individuals with dangerous and severe personality disorders. The British Medical Association (BMA) is also concerned about the dilution of the role of psychiatrists under this new Bill. The idea that medical expertise can be offered by professionals other than registered medical practitioners runs against the spirit of the landmark judgement of the European Court of Human Rights in Winterwerp. Of course we recognise the invaluable skills that nurses, psychologists, occupational therapists and social workers offer to mentally ill patients, but in the spheres of diagnosis, investigation, initiating and supervising complex drug regimes, surely the profession with the highest level of expertise should remain at the centre of the treatment of these vulnerable patients. Patients do not like to be sectioned by psychiatrists, but the risks to them are far greater if there isn't a psychiatrist actively involved during their period of detention. Scotland may not have the perfect mental health laws but we agree with the Scottish authors Crichton and Darjee (2) that ours falls well short of the mark. JS Bamrah, Chair of the BMA's Psychiatric subcommittee
1 Appleby L. Bill aims to protect people at times of high risk. BMJ 2007;334:761. 2 Crichton J, Darjee R. New mental health legislation. BMJ 2007;334:596-7. Competing interests: JS Bamrah is Chair of the BMA's Psychiatric Subcommittee and gave evidence against the 2004 Mental Health Bill at the Parliamentary Scrutiny Committee on behalf of the BMA. Julian Sheather is a senior ethics adviser at the BMA. Barbara Wood is Chair of the BMA's Patient Liaison Group |
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Hugh W Griffiths, Consultant Psychiatrist and Deputy National Clinical Director for Mental Health Department of Health, Richmond House, Whitehall
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The new Mental Health Bill for England and Wales is rightly generating debate within professional groups including psychiatrists. However it does seem unfortunate that some of it seems to be based more on supposition and anxiety than on fact. J S Bamrah and his colleagues from the BMA assert that the Bill broadens the definition of mental disorder; in truth it simplifies it by condensing several definitions into one. It does remove the exclusion for sexual deviancy but this is in ICD-10 and if the strict criteria for detention are met, why should appropriate treatment (if available) be denied? They also say that the definition of appropriate treatment has been extended and describe it as a “vague categorisation”. Their quote is accurate but under the current Act it is defined as “nursing, and also includes care, habilitation and rehabilitation under medical supervision”. Given the obvious similarities and that the only “extending” is the inclusion of psychological therapies, their criticism appears somewhat misleading. They go on to say that they are concerned about the “dilution of the role of psychiatrists under this new Bill”. In truth psychiatrists will retain their responsibilities for assessment prior to detention. The intention is to enable other mental health professionals to take responsibility for some detained patients if they have the relevant competencies and if it is clinically appropriate. This is entirely in keeping with the evolution of professional roles and Winterwerp aside (which should be satisfied by the Bill’s proposals), it is difficult to believe that the role of psychiatrists is enhanced by restricting the progress of others. If a mental health professional has the right competencies and is most appropriately placed to take responsibility for a patient (for example a clinical psychologist where the need is predominantly for psychological therapy) then the service and the law should enable it. To argue otherwise might be construed as professional protectionism. Competing interests: Dr Griffiths works as Deputy National Clinical Director for Mental Health at the DH. |
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Anthony Maden, Professor of Forensic Psychiatry Imperial College London, Claybrook Centre, London W6 8RP
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My rapid response of 17th April has offended some people within the Royal College and, particularly, within the Forensic Executive. I am happy to correct any misunderstanding and to confirm that I am not a spokesperson for the Royal College or for any part of it. I should have written "most forensic psychiatrists" rather than "The forensic executive of the Royal College of Psychiatrists". With that substitution, I stand by my comments. Competing interests: None declared |
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John C O'Grady, Chair Forensic Faculty, Royal College of Psychiatrists Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG
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I am grateful to Professor Maden for clarifying that he is not a spokesperson for the Forensic Faculty of the Royal College of Psychiatrists but is writing as an individual. That clarification is most helpful. It may help readers to know that the Forensic Faculty is an elected body which has in addition co-opted members drawn from the body of Forensic Psychiatrists. The Executive is able to consult a network of Regional Representatives in Forensic Psychiatry who in turn are in touch with colleagues local to them. In this way the Forensic Faculty is able to rapidly consult on important matters. Professor Maden suggests that most Forensic psychiatrists support the main planks of the Government’s proposals on the Mental Health Bill. The Forensic Executive does not agree with that statement. The Forensic Faculty disagrees with some but not all "planks" of the Mental Health Bill. In particular we fully support the inclusion of principles on the face of the Bill which is contrary to the Government's position. We support the Lord's amendment on Therapeutic Benefit to require it to be necessary to justify detention, again contrary to the Government's position. We do not agree with the Government's position on the extension of the RMO role to other disciplines and are in support of the BMA statements on this issue. We have argued, contrary to the Government's position, that Sexual Deviancy should, like substance dependence, be an exclusion criterion for detention. The Forensic Faculty has not been supportive of Capacity based legislation but accepts that Impaired Decision Making, as one of the criteria for detention, is more acceptable than a pure capacity based bill. We have fully accepted that we are a minority within the Royal College of Psychiatrists on this and therefore bow to the majority will of the elected College. We did request, and the Central Executive Committee of the Royal College accepted, that the College should argue that Impaired Decision Making not apply to part three of the act. This is the current advice from the Royal College of Psychiatrists. We do agree with the Government on Community Treatment Orders (CTOs). We believe they are a proportionate and reasonable response to the management of those who may pose a significant risk to others. We have acknowledged that our colleagues in General and Rehabilitation Faculties have legitimate and reasoned arguments against them including the fear of driving away those who most in need of contact with mental health services, the likely impact on services to Black and Ethnic minorities and the concerns from our colleagues over "numbers needed to treat" if CTOs are introduced. Nevertheless having carefully considered the arguments concerning CTOs, the Forensic Faculty of the College believes the College should support the Government's position on Community Treatment Orders. Dr John C O’Grady
Competing interests: Dr O'Grady is a member of the Implementation Group for the Code of Practice for the proposed Mental Health Bill |
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