Artificial intelligence and mental capacity legislation: Opening Pandora's modem.

People with impaired decision-making capacity enjoy the same rights to access technology as people with full capacity. Our paper looks at realising this right in the specific contexts of artificial intelligence (AI) and mental capacity legislation. Ireland's Assisted Decision-Making (Capacity) Act, 2015 commenced in April 2023 and refers to 'assistive technology' within its 'communication' criterion for capacity. We explore the potential benefits and risks of AI in assisting communication under this legislation and seek to identify principles or lessons which might be applicable in other jurisdictions. We focus especially on Ireland's provisions for advance healthcare directives because previous research demonstrates that common barriers to advance care planning include (i) lack of knowledge and skills, (ii) fear of starting conversations about advance care planning, and (iii) lack of time. We hypothesise that these barriers might be overcome, at least in part, by using generative AI which is already freely available worldwide. Bodies such as the United Nations have produced guidance about ethical use of AI and these guide our analysis. One of the ethical risks in the current context is that AI would reach beyond communication and start to influence the content of decisions, especially among people with impaired decision-making capacity. For example, when we asked one AI model to 'Make me an advance healthcare directive', its initial response did not explicitly suggest content for the directive, but it did suggest topics that might be included, which could be seen as setting an agenda. One possibility for circumventing this and other shortcomings, such as concerns around accuracy of information, is to look to foundational models of AI. With their capabilities to be trained and fine-tuned to downstream tasks, purpose-designed AI models could be adapted to provide education about capacity legislation, facilitate patient and staff interaction, and allow interactive updates by healthcare professionals. These measures could optimise the benefits of AI and minimise risks. Similar efforts have been made to use AI more responsibly in healthcare by training large language models to answer healthcare questions more safely and accurately. We highlight the need for open discussion about optimising the potential of AI while minimising risks in this population.

Should Dignity Preservation Be a Precondition for Safety and a Design Priority for Healing in Inpatient Psychiatry Spaces?

Therapeutic security in inpatient psychiatric settings requires careful planning and implementation if it is to support patients' safety and dignity. This commentary on a case considers patients' dignity experiences when restrictions on their freedom are used to keep them safe.

New technology, psychiatry, and the law: Panic, prudence, possibility.

Throughout human history, all new technology has been met with surprise, anxiety, panic, and - eventually - prudent adoption of certain aspects of specific technological advances. This pattern is evident in the histories of most technologies, ranging from steam power in the nineteenth century, to television in the twentieth century, and - now - 'artificial intelligence' (AI) in the twenty-first century. Each generation believes that the technological advances of its era are quantitatively and qualitatively different to those of previous generations, but the underlying phenomenon is the same: the shock of the new, followed by more gradual adjustment to (and of) new technology. These concerns are apparent today in relation to AI, which reflects interesting but incremental advances on existing technologies, rather than stand-alone developments. The usual concerns with all technologies (e.g., that they will replace certain aspects of human function) are, perhaps, more concerning in fields such as mental capacity law, which often applies to people with impaired decision-making capacity who might be especially vulnerable to technologies which appear capable of encroaching disproportionately on decision-making or other areas of core human function. This paper approaches this topic from an historical standpoint, noting both previous technological panics in the past and the possibilities offered by AI today, provided it is approached in a proportionate, prudent, and person-centered way, underpinned by appropriate ethical guidance and active ethical awareness in clinical and legal practice.

Comparing mental health and mental capacity law data across borders: Challenges and opportunities.

The island of Ireland is partitioned into Northern Ireland and the Republic of Ireland. In both jurisdictions, there have been important developments in mental health and mental capacity law, and associated policies and services. This includes an emphasis on developing more comprehensive approaches to collecting data on outcomes and so there is an opportunity to align these processes to enable comparison and shared learning across the border. This article explores: legal and policy developments; international approaches to mental health outcomes; and the type of data that would be helpful to collect to better understand the use of mental health and mental capacity laws. It is argued that an inclusive strategy to developing a comprehensive, integrated and aligned approach to collecting and analysing data would benefit citizens, policy makers and professionals.

Medicine in history and history in medicine: the inaugural Davis Coakley Memorial Lecture.

Professor Davis Coakley (1946-2022) was an outstanding physician, historian, and leader of reform in medical services and education. This inaugural Davis Coakley Memorial Lecture, delivered in The Edward Worth Library at Dr Steevens' Hospital, Dublin, Ireland, on 28 September 2023, focuses on 'Medicine in History & History in Medicine'. It explores the position of the physician-historian in medical historiography, discusses Coakley's extensive historical work (especially his many books about the history of medicine), and concludes with comments about one of Coakley's great interests: the work of Sir William Wilde (1815-1876). Sir William was a prominent Victorian doctor, father of playwright Oscar, and remarkably prescient commentator on public health in Ireland. Sir William's comments about patterns of epidemics are especially arresting and relevant today in the immediate wake of COVID-19. Coakley's interest in Sir William echoed Coakley's broader commitment to medical care, progressive education, and genuine scholarship that shed light on suffering, illness, healing, and recovery. The fields of both medicine and history are greatly enriched by Coakley's life and work.

Multi-level protection of rights: India's Mental Healthcare Act, 2017 and the United Nations' Convention on the Rights of Persons with Disabilities (Articles 12 and 14).

Mental health law is a feature of mental health systems around the world, so legislative reform is an important way to advance compliance with the United Nations' Convention on the Rights of Persons with Disabilities (CRPD). This paper provides an overview of India's Mental Healthcare Act, 2017 in the context of Articles 12 ('Equal recognition before the law') and 14 ('Liberty and security of person'). Notwithstanding the potential of law to produce change, exclusive or disproportionate emphasis on law draws attention from other areas in need of equal if not greater reform, such as public education, mental health services, physical healthcare, social care networks, criminal justice systems, and gathering political backing for the profound reforms needed to transform the socio-economic landscapes in which mental illness develops, diagnoses are made, treatment is provided (or not provided), recovery occurs (or does not occur), and social citizenship is protected and promoted (or eroded and obstructed). There is a particular issue with misunderstandings of psychiatry in academic discussions of mental health legislation which appears to stem from lack of engagement with the full diversity of service-user views and the evidence base for psychiatric care. Greater recognition of upstream factors that shape both suffering and services would acknowledge that the decisions of politicians and service managers have a much greater impact on rights, especially the right to treatment and support, than the decisions of individual clinicians whose options are often very limited at the level of individual care. India's legislation seeks to address not only individual-level care, but also this higher level of reform through its articulation of an explicit 'right to access mental healthcare and treatment'. Similar multi-level legislative reform elsewhere would increase cooperation from all stakeholders, improve compliance with the CRPD, and help move towards zero coercion in mental health services.

What is the role of gender in perceived coercion during psychiatric admission?

OBJECTIVES: This paper explores factors linking gender with increased perceived coercion, perceived negative pressures and procedural injustice during psychiatric admission. METHODS: We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry admission units at two general hospitals in Dublin, Ireland, between September 2017 and February 2020. RESULTS: Among female inpatients (n = 48), perceived coercion on admission was associated with younger age and involuntary status; perceived negative pressures were associated with younger age, involuntary status, seclusion, and positive symptoms of schizophrenia; and procedural injustice was associated with younger age, involuntary status, fewer negative symptoms of schizophrenia, and cognitive impairment. Among females, restraint was not associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation; seclusion was associated with negative pressures only. Among male inpatients (n = 59), not being born in Ireland appeared more relevant than age, and neither restraint nor seclusion were associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation. CONCLUSIONS: Factors other than formal coercive practices are primarily linked with perceived coercion. Among female inpatients, these include younger age, involuntary status, and positive symptoms. Among males, not being born in Ireland appears more relevant than age. Further research is needed on these correlations, along with gender-aware interventions to minimise coercive practices and their consequences among all patients.

The changing face of Capacity legislation in Ireland: algorithms for clinicians.

Capacity legislation in Ireland is evolving. The Assisted Decision-Making (Capacity) Act 2015 has been passed into law, but its main provisions are yet to be commenced. This paper compares the law and its practical implications currently and under the new legislation. Quick reference algorithms for frontline clinicians are proposed.

Psychiatrists and homicidal threats: a cross-sectional study.

OBJECTIVES: To investigate the frequency, characteristics and impact of death threats by patients towards psychiatrists. METHODS: A cross-sectional survey of psychiatrists (n = 60) was undertaken to investigate the frequency, characteristics and impact of death threats by patients in one Irish healthcare region serving a mixed urban-rural population of 470,000. RESULTS: Forty-nine responses (82%) were received. Thirty-one per cent of respondents experienced death threats by patients during their careers. Victims were more likely to be male and in a consultant role. Patients making the threats were more likely to be males aged 30-60 with a history of violence and diagnosis of personality disorder and/or substance misuse. A majority of threats occurred in outpatient settings and identified a specific method of killing, usually by stabbing. Prosecution of the perpetrator was uncommon. Of the victimised psychiatrists, 53% reported that such threats affected their personal lives, and 67% believed their professional lives were impacted. In half of the incidents, there were adverse incidents subsequent to the threats, involving either the patient or the clinician. CONCLUSIONS: Death threats by patients have significant psychological and professional impacts on psychiatrists. Early liaison with employers and police and transferring the care of the patient to another clinician may be useful measures.

Enhancing GP care of mental health disorders post-COVID-19: a scoping review of interventions and outcomes.

OBJECTIVES: Considerable literature has examined the COVID-19 pandemic's negative mental health sequelae. It is recognised that most people experiencing mental health problems present to primary care and the development of interventions to support GPs in the care of patients with mental health problems is a priority. This review examines interventions to enhance GP care of mental health disorders, with a view to reviewing how mental health needs might be addressed in the post-COVID-19 era. METHODS: Five electronic databases (PubMed, PsycINFO, Cochrane Library, Google Scholar and WHO 'Global Research on COVID-19') were searched from May - July 2021 for papers published in English following Arksey and O'Malley's six-stage scoping review process. RESULTS: The initial search identified 148 articles and a total of 29 were included in the review. These studies adopted a range of methodologies, most commonly randomised control trials, qualitative interviews and surveys. Results from included studies were divided into themes: Interventions to improve identification of mental health disorders, Interventions to support GPs, Therapeutic interventions, Telemedicine Interventions and Barriers and Facilitators to Intervention Implementation. Outcome measures reported included the Seven-item Generalised Anxiety Disorder Scale (GAD-7), the Nine-item Patient Health Questionnaire (PHQ-9) and the 'The Patient Global Impression of Change Scale'. CONCLUSION: With increasing recognition of the mental health sequelae of COVID-19, there is a lack of large scale trials researching the acceptability or effectiveness of general practice interventions. Furthermore there is a lack of research regarding possible biological interventions (psychiatric medications) for mental health problems arising from the pandemic.

Asclepiades of Bithynia: Greek physician and medical reformer.

Asclepiades of Bithynia (124-40 BC) was a Greek physician who practised and taught Greek medicine in Rome. Among his many contributions, Asclepiades challenged the long-standing Hippocratic doctrine of the four humours. Influenced by Epicurean philosophy, he sought to construct a new theory of human disease, derived in part from atomic theories of chance and evolution earlier described by Democritus and Epicurus. In clinical practice, Asclepiades's approach to physical and mental illnesses was reasoned, humane, and, in many ways, ahead of its time. As a result of his many contributions and his overall approach to care, Asclepiades is now considered a pioneer of modern physical therapy, the progenitor of a more humane approach to mental illness, and, as highlighted by Yapijakis, the father of modern molecular medicine.

Seclusion, Restraint, Therapeutic Alliance, and Legal Admission Status: What Really Matters?

OBJECTIVE: To determine the relationships, if any, between use of seclusion and restraint and factors such as demographic parameters, diagnosis, legal admission status (voluntary or involuntary), symptoms, cognitive function, global functioning, therapeutic alliance, attitudes toward medication, and insight, among psychiatry inpatients in Ireland. METHODS: We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry units at 2 general hospitals in Dublin, Ireland over a 30-month period, between September 2017 and February 2020. RESULTS: The most common diagnoses in our sample were affective disorders (46.7%), schizophrenia and related disorders (27.1%), and personality and behavioral disorders (11.2%). Over a quarter (n=29, 27.1%) of the participating patients had involuntary legal status. Of the 107 patients, 11 patients (10.3%) experienced sedation and/or physical restraint, with 9 patients (8.4%) experiencing at least 1 episode of seclusion and 10 patients (9.3%) experiencing at least 1 episode of physical restraint. On the basis of multivariable analyses, seclusion was associated with younger age and involuntary status, while physical restraint was associated with involuntary status. Each multivariable model explained just over one third of the variance in the distribution of these seclusion and restraint practices. CONCLUSIONS: Use of seclusion and restraint was most strongly associated with involuntary admission status and, in the case of seclusion, younger age, rather than sex, diagnosis, symptoms, cognitive function, global functioning, therapeutic alliance, attitudes toward medication, or insight. The network of interactions between involuntary status and use of seclusion and restraint merits much closer attention, especially as use of seclusion and physical restraint appears to be associated with involuntary legal status independent of level of symptoms, therapeutic alliance, or insight.

The collaborative development through multidisciplinary and advocate consensus of an accessible notice of rights for people with intellectual disabilities in police custody.

Background People with intellectual disabilities are over-represented in the criminal justice system. The United Nations' Convention on the Rights of Persons with Disabilities (UNCRPD) enshrines a right to equal access to justice for persons with disabilities (Article 13, UNCRPD). Accessible information is a key aspect of exercising this right. Yet, many jurisdictions, including Ireland, are yet to develop accessible information for disabled people who may be arrested. Aims This paper describes the collaborative development through multidisciplinary and advocate consensus of an accessible (Easy -to- Read) Notice of Rights (ERNR) for people with intellectual disabilities in police custody in Ireland. Methods Guidelines developed by Ireland's representative organisation for people with intellectual disabilities and examples of international practice were used to develop a draft ERNR by the primary researcher in partnership with an expert from a representative organisation for people with intellectual disabilities. The ERNR was developed thereafter through two focus groups with a view to achieving consensus with a focus on accessibility, accuracy and layout. This included a multidisciplinary focus group with participants from a representative organisation for people with intellectual disabilities, psychology, speech and language therapy, the police force, public health, forensic psychiatry, mental health, law and, subsequently, a focus group of people with lived experience of intellectual disability. Results Progressive development of the ERNR resulted in incremental improvements in textual accuracy as well as the inclusion of more accessible language and imagery. Originality/value This is the first attempt at developing an easy-to-read document relating to the legal rights of suspects in police custody in Ireland and, accordingly, this procedural innovation promises to assist, not just persons with intellectual disabilities, but also those with limited literacy at the point of arrest. The methodology used in the preparation of the document, employing a focus group to achieve consensus with participation from both multiple disciplines and persons with an intellectual disability, is in harmony with the ethos of the UNCPRD. This methodology may usefully be employed by other member states that have ratified the Convention but have yet to develop accessible version of the legal rights and entitlements that extend to arrested persons under their domestic law.

The association between objective necessity for involuntary treatment as measured during admission, legal admission status and clinical factors in an inpatient psychiatry setting.

Involuntary psychiatric admission is a common feature of mental health services around the world, but there is limited research about tools to support clinical assessment of objective necessity for compulsory care. Our study aimed to determine the relationships between objective necessity for involuntary treatment as measured by the Compulsory Treatment Checklist (CTC), legal admission status (voluntary or involuntary) and various clinical parameters (e.g. symptoms, insight) in an Irish inpatient psychiatry setting. The CTC is relatively new tool, developed and described by Brissos et al. (2017) in Portugal and designed to evaluate the necessity for compulsory treatment; its total score ranges from 0 to 50 (with higher scores indicating greater need for involuntary care). In our study, we used validated tools, including the CTC, to perform detailed assessments of 107 adult patients admitted to the acute psychiatry inpatient units of two general hospitals in Dublin, Ireland over a 30-month period. The most common diagnoses were affective disorders (46.7%), schizophrenia and related disorders (27.1%), and personality and behavioural disorders (11.2%). Over a quarter (27.1%) of patients had involuntary legal status. Higher CTC scores were significantly and independently associated with involuntary status (p < 0.001), more positive symptoms of schizophrenia (p < 0.001), and younger age (p = 0.031). The original Portuguese study of the CTC identified an optimal cut-off score of 23.5, which detected compulsory treatment with a sensitivity of 75% and specificity of 93.6% in that sample. In our sample, the optimal cut-off score was 16.5, which detected compulsory treatment with a sensitivity of 82.8% and specificity of 69.2%. We conclude that the CTC is a useful tool not only in Portugal but in other countries too, and that its performance will likely vary across jurisdictions, resulting in different optimal cut-off scores in different countries.

Homelessness amongst psychiatric Inpatients: a cross-sectional study in the mid-west of Ireland.

BACKGROUND: This cross-sectional study sought to establish the prevalence of homelessness amongst inpatients in two psychiatric units in Ireland and explore the perceived relationship between psychiatric illness and homelessness. METHODS: The study employed a semi-structured interview format utilising a specifically designed questionnaire which received ethical approval from the Limerick University Hospitals Group ethics committee. RESULTS: Fifty psychiatric inpatients were interviewed. Fifteen were either "currently" homeless (n = 8) or had experienced "past" homelessness (n = 7). Those who had experienced homelessness were more likely to have a psychotic illness. A majority of those who had experienced homelessness believed that psychiatric illness contributed to their homelessness. Involuntary admission rates were more than double for patients in the homeless group. A number of participants also reported that a lack of accommodation was preventing their discharge. CONCLUSION: Homelessness affects a significant number of psychiatric patients and can be both a contributory factor to, and consequence of, mental illness. With homelessness at unprecedented levels, there is a need for the development of tailored programmes aimed at supporting these vulnerable groups.

England's rate of involuntary psychiatric admission is double that of the Republic of Ireland: Why? A consideration of some possible causes.

Involuntary psychiatric admission or 'sectioning' is a serious event with clear implications for the right to liberty, among other rights. Rates of involuntary admission vary considerably across jurisdictions. The rate of involuntary admission in England is approximately double that in the Republic of Ireland. Why? This paper examines potential explanations for this difference, including the prevalence of mental disorder in the two jurisdictions, factors relating to mental health legislation, differing levels of police involvement in care-pathways, funding and resources, and attitudes to risk among the public and professionals. Overall, it appears that the relatively high rate of involuntary admission in England might be attributable to the role of perceived risk in shaping mental health law in England but not Ireland, the broader definition of 'mental disorder' in the Mental Health Act, 1983 in England, broader legal criteria for involuntary admission in the 1983 Act, differences in the operational definitions of 'voluntary patient' between the two jurisdictions and, possibly, increased involvement of police in pathways to care in England and differences in relation to different ethnic groups. The relatively higher number of inpatient beds in England could be a cause or a consequence of higher rates of involuntary admission. Future research could usefully focus on other factors that are also likely relevant: issues relating to social care, substance misuse, availability of alternative treatment options in the community and various other factors that are, as yet, unknown. The potential impact of risk aversion among mental health professionals and others merits particular attention.