The World Health Organization's QualityRights materials for training, guidance and transformation: preventing coercion but marginalising psychiatry.

The World Health Organization has developed training material to support its QualityRights Initiative. These documents offer excellent strategies to limit coercion. However, the negative portrayal of psychiatry, the absolute prohibition on involuntary treatment and the apparent acceptance of the criminalisation of individuals with mental illness are causes for concern.

The right to mental healthcare: India moves forward.

In 2018, India's Mental Healthcare Act 2017 granted a legally binding right to mental healthcare to 1.3 billion people, in compliance with the Convention on the Rights of Persons with Disabilities. Many countries, including the UK, ratified the Convention but only India has stepped up to the mark so dramatically.Declaration of interestNone.

Convergence or Divergence? Comparing Mental Capacity Assessments Based on Legal and Clinical Criteria in Medical and Surgical Inpatients.

Despite the high prevalence of mental incapacity for treatment decisions in hospitals (27.7%), there is little information about the relationship, if any, between mental capacity assessments based on clinical and legal criteria. We performed a cross-sectional study of mental incapacity for treatment decisions in 300 hospital inpatients in two hospitals in Ireland, using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) and the legal definition of mental incapacity in Ireland's incoming Assisted Decision-Making (Capacity) Act 2015. We found that patients who lacked mental capacity according to the legal criteria scored significantly lower on all four subscales of the MacCAT-T (Understanding, Appreciation, Reasoning, and Communication) compared to those who had mental capacity according to the legal criteria. In light of the similarity between Ireland's legal definition of mental incapacity and legislative definitions in other jurisdictions (e.g. England and Wales), we conclude that legal assessments of mental incapacity in these countries accord closely with clinical assessments (as reflected in the MacCAT-T). Ireland's new mental capacity legislation should be implemented promptly in order to further operationalize Ireland's new legal definition of mental incapacity and provide patients with the supports they need to optimize their mental capacity for treatment decisions in hospitals.

Experiences of Using Prezi in Psychiatry Teaching.

OBJECTIVE: Prezi is a presentation software allowing lecturers to develop ideas and produce mind maps as they might do on an old-style blackboard. This study examines students' experience of lectures presented using Prezi to identify the strengths and weaknesses of this new teaching medium. METHODS: Prezi was used to present mental health lectures to final-year medical and physiotherapy students. These lectures were also available online. This cross-sectional study used a questionnaire to assess students' experience of the software. RESULTS: Of students approached, 75.5 % (74/98) took part in the study. A majority, 98.6 % (73/74), found Prezi to be a more engaging experience than other styles of lecture delivery. The overview or "mind map" provided by Prezi was found to be helpful by 89.2 % (66/74). Problems arose when students used Prezi in their personal study, with 31.1 % (23/74) reporting some difficulties, mostly of a technical nature. CONCLUSION: This study highlights the potential of Prezi for providing students with an engaging and stimulating educational experience. For Prezi to be effective, however, the lecturer has to understand and be familiar with the software and its appropriate use.

A survey of perceived traumatic birth experiences in an Irish maternity sample - prevalence, risk factors and follow up.

OBJECTIVES: To establish the prevalence and correlates of a subjectively traumatic birth experience in an Irish maternity sample. DESIGN: A questionnaire routinely provided to all women prior to hospital discharge post-birth was amended for data collection for this study. Two additional questions seeking information about women's perceptions of their birth were added and analysed. Women who described their birth as traumatic and agreed to follow-up, received a City Birth Trauma Scale (Ayers et al., 2018) at subsequent follow-up (6 to 12 weeks postpartum). Demographic, obstetric, neonatal variables and factors associated with birth trauma were collected from electronic maternity records retrospectively. SETTING: A postnatal ward in an Irish maternity hospital which provides postnatal care for public maternity patients. PARTICIPANTS: Postpartum women (N=1154) between 1 and 5 days postpartum. MEASUREMENTS & FINDINGS: Participants completed the Edinburgh Postnatal Depression Scale (EPDS) (Cox et al., 1987) with two additional questions about birth trauma. Eighteen percent (n=209) of women reported their birth as traumatic. Factors associated with reporting birth as traumatic included a history of depression, raised EPDS scores (>12), induction of labour, combined ventouse/forceps birth, and postpartum haemorrhage. Of these 209 women, 134 went on to complete the City Birth Trauma Scale (Ayers et al., 2018). The average score was 3.84 and 6 of this sample (4%) reached the threshold for postpartum post-traumatic stress disorder (PTSD). KEY CONCLUSIONS: This study identified a prevalence of 18% of women experiencing birth as traumatic and the potentially important role of a current and past history of depression, postpartum haemorrhage, induction of labour and operative vaginal birth in defining a traumatic birth experience. The majority of women were resilient to birth trauma, few developed PTSD , but a larger cohort had significant functional impairment associated with sub-clinical postpartum PTSD symptoms. IMPLICATIONS FOR PRACTICE: Maternity care providers should be aware of the risk factors for traumatic birth. Introducing a trauma-informed approach amongst midwives and maternity care providers in the postnatal period may help to detect emerging or established persisting trauma-related symptoms. For women with sub-clinical postpartum PTSD symptoms a detailed enquiry may be more effective in identifying postpartum PTSD at a later postnatal stage e.g., at six weeks postpartum. Maternity services should provide ongoing supports for women who have experienced birth trauma.

Health-related quality of life and quality of care in pregnant and postnatal women during the coronavirus disease 2019 pandemic: A cohort study.

OBJECTIVE: Health-related quality of life (HRQoL) and the delivery of high-quality care are ongoing concerns when caring for pregnant women during the coronavirus disease 2019 (COVID-19) pandemic. We compared self-reported HRQoL and hospital quality of care among perinatal women with and without COVID-19. METHODS: This is a prospective cohort study of perinatal women attending a tertiary maternity unit during the pandemic. Eighteen women who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and 20 SARS-CoV-2-negative women were recruited. Participants completed the Short Form Health Survey (SF-12), Clinical Outcomes in Routine Evaluation-Outcome Measure, and Quality from the Patient's Perspective questionnaires. Mean scores were compared. RESULTS: Of the Non-COVID-19 cohort, 95% (n = 19) were Caucasian, whereas 67% (n = 12) of the COVID-19 cohort were not Caucasian (χ2  = 16.01, P < 0.001). The mean SF-12 for physical health in the COVID-19 cohort had significantly lower scores (P < 0.002). There was no difference in mental health and well-being between cohorts. The quality of care experienced was notably similar and very positive. CONCLUSION: There was a significantly greater burden on physical health among pregnant women with COVID-19. Mental health and psychological status were similar in both groups. High quality of care during a pandemic is possible to deliver in a maternity setting, irrespective of COVID-19 status.

India's Mental Healthcare Act, 2017: Content, context, controversy.

India's new mental health legislation, the Mental Healthcare Act, 2017, was commenced on 29 May 2018 and seeks explicitly to comply with the United Nations Convention on the Rights of Persons with Disabilities. It grants a legally binding right to mental healthcare to over 1.3 billion people, one sixth of the planet's population. Key measures include (a) new definitions of 'mental illness' and 'mental health establishment'; (b) revised consideration of 'capacity' in relation to mental healthcare (c) 'advance directives' to permit persons with mental illness to direct future care; (d) 'nominated representatives', who need not be family members; (e) the right to mental healthcare and broad social rights for the mentally ill; (f) establishment of governmental authorities to oversee services; (g) Mental Health Review Boards to review admissions and other matters; (h) revised procedures for 'independent admission' (voluntary admission), 'supported admission' (admission and treatment without patient consent), and 'admission of minor'; (i) revised rules governing treatment, restraint and research; and (j) de facto decriminalization of suicide. Key challenges relate to resourcing both mental health services and the new structures proposed in the legislation, the appropriateness of apparently increasingly legalized approaches to care (especially the implications of potentially lengthy judicial proceedings), and possible paradoxical effects resulting in barriers to care (e.g. revised licensing requirements for general hospital psychiatry units). There is ongoing controversy about specific measures (e.g. the ban on electro-convulsive therapy without muscle relaxants and anaesthesia), reflecting a need for continued engagement with stakeholders including patients, families, the Indian Psychiatric Society and non-governmental organisations. Despite these challenges, the new legislation offers substantial potential benefits not only to India but, by example, to other countries that seek to align their laws with the United Nations' Convention on the Rights of Persons with Disabilities and improve the position of the mentally ill.

A Focus Group Study of Indian Psychiatrists' Views on Electroconvulsive Therapy under India's Mental Healthcare Act 2017: 'The Ground Reality is Different'.

BACKGROUND: India's Mental Healthcare Act, 2017 (MHCA) greatly restricts the use of electroconvulsive therapy (ECT) in minors and bans unmodified ECT. Indian psychiatrists have raised concerns that these measures may deprive certain patients of life-saving treatment. This study describes the perspectives of Indian psychiatrists on how ECT is dealt with in the legislation. METHODS: We conducted nine focus groups in three Indian states. We explored the positive and negative implications of the MHCA and discussed its implementation, especially in relation to ECT. RESULTS: Many of the themes and concerns commonly discussed in relation to ECT in other jurisdictions are readily apparent among Indian psychiatrists, although perspectives on specific issues remain heterogeneous. The one area of near-universal agreement is Indian psychiatrists' affirmation of the effectiveness of ECT. We identified three main areas of current concern: the MHCA's ban on unmodified ECT, ECT in minors, and ECT in the acute phase. Two broad additional themes also emerged: resource limitations and the impact of nonmedical models of mental health. We identified a need for greater education about the MHCA among all stakeholders. CONCLUSION: Core concerns about ECT in India's new legislation relate, in part, to medical decisions apparently being taken out of the hands of psychiatrists and change being driven by theoretical perspectives that do not reflect "ground realities." Although the MHCA offers significant opportunities, failure to resource its ambitious changes will greatly limit the use of ECT in India.

Which involuntary admissions are revoked by mental health tribunals? A report from the Dublin Involuntary Admission Study (DIAS).

Little is known about which involuntary psychiatry patients are likely to have their involuntary admission orders revoked by mental health tribunals or review boards and which are not. We studied 2940 admissions, of which 423 (14.4%) were involuntary, at three adult psychiatry units covering a population of 552,019 people in Dublin. A majority of involuntary admission orders were revoked by psychiatrists (94.6%) rather than tribunals (3.0%). Revocation by tribunal was associated with older age and a diagnosis of schizophrenia. More detailed information about the conduct and outcome of tribunals is needed to better protect the rights of the mentally ill.

New legislation, new frontiers: Indian psychiatrists' perspective of the mental healthcare act 2017 prior to implementation.

CONTEXT: The mental healthcare act 2017 represents a complete overhaul of Indian mental health legislation. AIMS: The aim of this study was to establish the opinions of Indian psychiatrists regarding the new act. SETTINGS: Mental health professionals in Bihar and Jharkhand were interviewed. DESIGN: A focus group design was utilized. MATERIALS AND METHODS: Key questions explored the positive and negative aspects of the act and the management of the transitional phase. All focus groups were recorded and transcribed. ANALYSIS: Data were coded and analyzed using an inductive approach. RESULTS: Many positive aspects of the new legislation were identified especially relating to rights, autonomy, and the decriminalization of suicide. However, psychiatrists have significant concerns that the new legislation may negatively impact patients and increase stigma. Psychiatrists held varying views on the proposed licensing and inspection of general hospital psychiatric units. CONCLUSIONS: Careful evaluation of the new legislation is needed as the concerns raised warrant ongoing monitoring.

Variations in involuntary admission rates at three psychiatry centres in the Dublin Involuntary Admission Study (DIAS): Can the differences be explained?

Involuntary psychiatric admission is an established practice for patients who are acutely or severely mentally ill but the factors contributing to involuntary (as opposed to voluntary) admission are not fully clear. Nor is it clear why rates of involuntary admission often vary between hospitals within the same jurisdiction. We studied all admissions, voluntary and involuntary, in three inpatient psychiatry units in Dublin, Ireland, which cover a population of 552,019 people, over a one-year period (1 July 2014 until 30 June 2015, inclusive), as part of the Dublin Involuntary Admission Study (DIAS). During the study period, there was a total of 1136 admissions to these three units, of which 17% were involuntary for all or part of their admission. The overall admission rate (205.8 admissions per 100,000 population per year) was lower than the national rate (387.9) but this varied substantially across the three units studied. On multi-variable analysis, involuntary admission status was associated with male gender, being unmarried, and a diagnosis of schizophrenia, and was not significantly associated with age, occupation or which inpatient unit the person was admitted to. We conclude that variations in involuntary admission rates between different psychiatry admission units in Dublin are significantly explained by patient-level variables (such as gender, marital status and diagnosis) rather than centre-level variables, but that much of the variation in admission status between patients remains unexplained. Future, multi-level research could usefully focus on other patient-level factors of possible relevance (e.g. symptom severity), centre-level factors (e.g. local mental health service resourcing) and community-level factors (e.g. socio-economic circumstances in different areas) in order to further elucidate unexplained variance in admission status between patients.

Does Involuntary Admission With Bipolar Disorder Differ From Involuntary Admission With Schizophrenia and Related Disorders? A Report From the Dublin Involuntary Admission Study (DIAS).

BACKGROUND: While involuntary psychiatric admission and treatment are common, little is known about what impact different diagnoses have on specific features of involuntary admission and on how involuntary status is terminated (eg, by psychiatrists or tribunals, which are independent, court-like bodies reviewing involuntary admissions). METHODS: We studied 2940 admissions, 423 (14.4%) of which were involuntary, at 3 psychiatry units covering a population of 552,019 individuals in Dublin, Ireland. RESULTS: Involuntary patients were more likely than voluntary patients to be male and unmarried. The median length of stay for involuntary patients was 27 days compared with 10 days for voluntary patients (P<0.001). Schizophrenia (and related disorders, including schizoaffective disorder) and bipolar disorder accounted for 58.6% and 17.3% of involuntary admissions, respectively, compared with 20.1% and 12.4% of voluntary admissions (P<0.001). Psychiatrists revoked the majority of involuntary orders for both patients with bipolar disorder (85.3%) and those with schizophrenia (and related disorders) (86.6%); in contrast, tribunals did not revoke any involuntary admission orders for patients with bipolar disorder and revoked orders for 3.8% of patients with schizophrenia (and related disorders) (P=0.034). On the basis of multivariable testing, increased age among patients with bipolar disorder was the only characteristic among those studied (sex, age, marital status, occupation, involuntary admission criteria, length of stay, method of involuntary order revocation, location) that independently distinguished involuntary patients with bipolar disorder from those with schizophrenia (and related disorders) (P=0.028). CONCLUSIONS: Involuntary admission of patients with bipolar disorder is similar in most respects to that of patients with schizophrenia (and related disorders). Consequently, it is important that measures aimed at reducing the need for involuntary admission (eg, patient advance statements/advance directives) are implemented equally across all diagnostic groups associated with involuntary care.

Concordance of the Indian Mental Healthcare Act 2017 with the World Health Organization's Checklist on Mental Health Legislation.

BACKGROUND: India is revising its mental health legislation with the Indian Mental Healthcare Act 2017 (IMHA). When implemented, this legislation will apply to over 1.25 billion people. In 2005, the World Health Organization (WHO) published a Resource Book (WHO-RB) on mental health, human rights and legislation, including a checklist of 175 specific items to be addressed in mental health legislation or policy in individual countries. Even following the publication of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) (2006), the WHO-RB remains the most comprehensive checklist for mental health legislation available, rooted in UN and WHO documents and providing the most systematic, detailed framework for human rights analysis of mental health legislation. We sought to determine the extent to which the IMHA will bring Indian legislation in line with the WHO-RB. METHODS: The IMHA and other relevant pieces of Indian legislation are compared to each of the items in the WHO-RB. We classify each item in a binary manner, as either concordant or not, and provide more nuanced detail in the text. RESULTS: The IMHA addresses 96/175 (55.4%) of the WHO-RB standards examined. When other relevant Indian legislation is taken into account, 118/175 (68.0%) of the standards are addressed in Indian law. Important areas of low concordance include the rights of families and carers, competence and guardianship, non-protesting patients and involuntary community treatment. The important legal constructs of advance directives, supported decision-making and nominated representatives are articulated in the Indian legislation and explored in this paper. CONCLUSIONS: In theory, the IMHA is a highly progressive piece of legislation, especially when compared to legislation in other jurisdictions subject to similar analysis. Along with the Indian Rights of Persons with Disabilities Act 2016, it will bring Indian law closely in line with the WHO-RB. Vague, opaque language is however, used in certain contentious areas; this may represent arrangement-focused rather than realisation-focused legislation, and lead to inadvertent limitation of certain rights. Finally, the WHO-RB checklist is an extremely useful tool for this kind of analysis; we recommend it is updated to reflect the CRPD and other relevant developments.

Rights, laws and tensions: A comparative analysis of the Convention on the Rights of Persons with Disabilities and the WHO Resource Book on Mental Health, Human Rights and Legislation.

BACKGROUND: Good mental health legislation is essential for ensuring high quality mental health care and protecting human rights. Many countries are attempting to bring mental health legislation in line with the UN - Convention on the Rights of Persons with Disability (UN-CRPD). The UN-CRPD requires policy-makers to rethink the 'medical model' of mental illness and existing laws. It also challenges WHO guidelines on drafting mental health law, described in the WHO Resource Book on Mental Health, Human Rights and Legislation (WHO-RB). AIMS: This study examines the relationship between the UN-CRPD and the WHO-RB. METHODS: It compares the documents, highlighting similarities and identifying areas of disagreement. The WHO-RB contains a checklist of human rights standards it recommends are met at national level. This study analyses each component on this checklist and identifies the relevant sections in the UN-CRPD that pertain to each. RESULTS: Both the UN-CRPD and WHO-RB address more than just acute exacerbations of illness, providing guidelines on, inter alia, treatment, education, occupation and housing. They are patient-centred and strongly influenced by social rights. The UN-CRPD, however, gives just superficial consideration to the management of acute illness, forensic and risk issues, and does little to identify the role of family and carers. CONCLUSION: The UN-CRPD has evolved from disability research and strong advocacy organisations. Careful consideration is needed to enable it to address the specific needs encountered in mental illness. Both the UN-CRPD and WHO-RB highlight common tensions that must be resolved by clinicians, and provide some guidance for stakeholders who commonly need to observe one principle at the expense of another.