Trends in referrals to liaison psychiatry teams from UK emergency departments for patients over 65.

INTRODUCTION: The number of people over the age of 65 attending Emergency Departments (ED) in the United Kingdom (UK) is increasing. Those who attend with a mental health related problem may be referred to liaison psychiatry for assessment. Improving responsiveness and integration of liaison psychiatry in general hospital settings is a national priority. To do this psychiatry teams must be adequately resourced and organised. However, it is unknown how trends in the number and type referrals of older people to liaison psychiatry teams by EDs are changing, making this difficult. METHODS: We performed a national multi-centre retrospective service evaluation, analysing existing psychiatry referral data from EDs of people over 65. We described trends in the number, rate, age, mental health presentation, and time taken to assessment over a 7 years period. RESULTS: Referral data from 28 EDs across England and Scotland were analysed (n = 18,828 referrals). There was a general trend towards increasing numbers of people referred to liaison psychiatry year on year. Variability in referral numbers between different departments, ranged from 0.1 to 24.3 per 1000 ED attendances. The most common reasons for referral were mood disorders, self-harm and suicidal ideas. The majority of referrals were assessed within 60 min, however there is variability between departments, some recording waits over 11 h. DISCUSSION: The data suggests great inter-departmental variability in referral numbers. Is not possible to establish the cause of variability. However, the data highlights the importance of asking further questions about why the differences exist, and the impact that has on patient care.

Interconnected or disconnected? Promotion of mental health and prevention of mental disorder in the digital age.

To date there have been few peer-reviewed studies on the feasibility, acceptability and effectiveness of digital technologies for mental health promotion and disorder prevention. Any evaluation of these evolving technologies is complicated by a lack of understanding about the specific risks and possible benefits of the many forms of internet use on mental health. To adequately meet the mental health needs of today's society, psychiatry must engage in rigorous assessment of the impact of digital technologies.

Mired in confusion: making sense of the Deprivation of Liberty Safeguards.

INTRODUCTION: There is uncertainty about how to identify deprivation of liberty and the interface of the Mental Health Act and Mental Capacity Act Safeguards. OBJECTIVE To increase current understanding by exploring how an expert legal panel interpret existing case law relating to deprivation of liberty in the clinical setting. Design Clinical vignettes of real patients were used to explore lawyers' thinking about important factors that: (1) distinguish lawful restriction from deprivation of liberty and (2) govern the choice between safeguard regimes when there is deprivation of liberty. The relative importance of such factors was discussed in a consensus meeting using a modified nominal group approach. Participants and setting Six eminent barristers and solicitors with expertise in mental health law attended a consensus meeting after making individual judgements about vignettes describing the situations of 28 incapacitated patients who had been admitted informally to a range of psychiatric inpatient units in South East London. RESULTS: Lawyers attributed key importance to a patient's 'freedom to leave' and suggested that patients' subjective experiences should be considered when identifying deprivation of liberty. CONCLUSIONS Clarification of deprivation of liberty and its safeguards will develop with future case law. Based on current available case law, the lawyers' expert views represented a divergence from Code of Practice guidance. We suggest that clinicians give consideration to this.

Mental capacity of those in immigration detention in the UK.

Asylum seekers and migrants can be detained in immigration removal centres (IRCs) or, post sentence, in prison while the Home Office makes decisions on their immigration status and/or arrangements for their removal or deportation. Currently, there is no process for identifying detainees who lack the mental capacity to participate in decision making relating to their immigration situation. Mental illness and distress are common among detainees. There are often cultural and language barriers; there is no consistent system of advocates, and many detainees are without legal representation. Mental capacity is decision specific. Clinicians in IRCs have a duty to consider detainees' capacity for health-care decisions, but are not expected to carry out any assessment in the broader context of immigration decision making, and there is no set procedure for notifying immigration decision makers with any concerns about a detainee's capacity. The Home Office focusses on safeguarding vulnerable people in detention, but not on whether such detention should happen or whether individuals identified as especially vulnerable have the necessary capacity for immigration-related decisions. In the community, asylum seekers and migrants can be supported in their engagement with immigration officials by family and friends and other advocates of their choice. This is not the case for immigration detainees. The current arrangements carry a significant risk of unfair decisions being made on the most vulnerable detainees without their capacitous participation. Recommendations for changes are made, including the need for a high threshold to be applied to justify any detention of people who lack immigration-related decision-making capacity.