The reform of Irish mental health law: Aligning with human rights obligations?

This article critically examines the proposed reforms to Irish mental health law the Mental Health Act 2001 (2001 Act). The article will provide background to the 2001 Act and the lengthy law reform process, which has resulted in the publication of the Heads of Bill that propose significant amendments. The article assesses the suggested reforms, considering Ireland's 2018 ratification of the UN Convention on the Rights of Persons with Disabilities (CRPD), which provides important context to the law reform process. The 2001 Act is the primary piece of legislation regulating mental health services and safeguarding the rights of persons subject to the legislation in Ireland. While passed in 2001, the legislation did not come into effect until 2006. The 2001 Act was seen as bringing Irish mental health law into compliance with international human rights law, in particular the European Convention on Human Rights (ECHR). However, Ireland's ratification of the CRPD has necessitated closer scrutiny of the legislation. This review has culminated in the publication of a Heads of Bill in July 2021 and pre-legislative scrutiny by the responsible parliamentary committee in 2022. The long title of the Heads of Bill explicitly states its goal of safeguarding individual autonomy and underscores its commitment to upholding and advancing the rights of people subject to the legislation. The analysis of the Heads of Bill addresses several key areas. These areas include a background to the long process of review, new guiding principles, the category of persons under the mental health legislation, mental health tribunals, consent to treatment, advance healthcare directives, provisions relating to children and young people, and independent advocacy. Based on this analysis of the Heads of Bill, recommendations are suggested which would strengthen respect for the human rights of persons subject to the legislation.

The association between the Police, Ambulance, Clinician Early Response model and involuntary detentions of people living with mental illness: A retrospective observational study.

WHAT IS KNOWN ON THE SUBJECT?: Involuntary detention is a legislative power that allows people to be taken against their will for a mandatory mental health assessment and is known to be a restrictive and traumatizing process for patients. While there is some literature examining police/ambulance and mental health worker co-response models, the conclusions are mixed as to whether they reduce rates of involuntary detentions in mentally ill people. The Police, Ambulance, Clinician Early Response (PACER) model is an example of a tri-response mental health crisis response team whose role is to respond and assess people thought to be experiencing a mental health crisis. There is little literature to determine whether PACER tri-response model reduces incidents of involuntary detention when compared with standard police and/or ambulance responses. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: This paper describes the outcomes of patients assessed by a PACER team, compared with patients who were assessed by police or ambulance. It demonstrates that PACER may reduce unnecessary involuntary detentions through expert mental health assessment for patients coming to emergency services for assistance. It is one of only two published studies examining a tri-response model. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The results of this study may support health and policing policymakers to implement PACER models as a means of reducing involuntary detentions, reducing demand for emergency departments, reducing time spent by emergency services responding to people experiencing mental health crisis and improving outcomes for people with mental illness. ABSTRACT: BACKGROUND: Involuntary detention is a common method of enforcing mental health assessment and treatment; however, it is associated with poor patient outcomes and high emergency service and hospital demand. AIM: To examine the association between (1) Police, Ambulance, Clinician, Early Response (PACER) model, (2) police or (3) ambulance response and rates of involuntary detention of mentally ill people. METHODS: A retrospective observational study using routine administrative data in an Australian City, over a 12-month period (2019-2020). RESULTS: Over a 12-month period, 8577 people received crisis mental health intervention in the study setting. We observed an 18% increase in the relative risk of being involuntarily detained by police, and a 640% increase in the relative risk of being detained by ambulance. The PACER team detained 10% of their total presentations, as compared with 12% by police and 74% by ambulance. Involuntary detentions enacted by PACER were more likely to convert to a post-detention hospitalization (72%), when compared with police (27%) and ambulance (17%). DISCUSSION: PACER was associated with lower rates of involuntary detention and higher rates of post-detention hospitalization when compared to police and ambulance response. IMPLICATIONS FOR PRACTICE: PACER cohort experience more positive outcomes than with police or ambulance cohorts.

The Association between the Police, Ambulance, Clinician Early Response (PACER) Model and Involuntary Detentions of People Living with Mental Illness: A Protocol for a Retrospective Observational Study.

Emergency services are frequently called to attend mental health incidents and are looking for innovative ways to improve their responses and reduce the burden on services. Involuntary detention of people living with mental illness is considered more frequent than necessary, leading to increased pressure on emergency departments, and is often a traumatic experience for patients. The Police, Ambulance, Clinician Early Response (PACER) model was developed in 2019 in Canberra, Australia, and seeks to reduce involuntary detentions by embedding a mental health clinician into emergency services as a mobile mental health crisis response intervention. This protocol details a retrospective cohort study that will examine the association between PACER and involuntary detentions using medical and police records and compare the results to standard ambulance and police responses. We will use relative risk and odds ratio calculations to determine the probability of being involuntarily detained or diverted from hospital; and we will describe the patient characteristics and outcomes in the PACER cohort. Results will be reported using the STROBE checklist for reporting cohort studies. This study was not registered on a publicly accessible registry.

Tri-Response Police, Ambulance, Mental Health Crisis Models in Reducing Involuntary Detentions of Mentally Ill People: A Systematic Review.

Police, ambulance, and mental health tri-response services are a relatively new model of responding to people experiencing mental health crisis in the community, though limited evidence exists examining their efficacy. Reducing unnecessary involuntary detentions and emergency department presentations is believed to be a benefit of this model. A systematic review was performed to review the evidence base around the relationship between the police, ambulance, mental health tri-response models in reducing involuntary detentions of people experiencing mental health crisis. We searched key health databases for clinical studies and grey literature as per a previously published protocol. Two researchers completed title and abstract screening and full text screening. Our search identified 239 citations. No studies or grey literature met the inclusion criteria. We report an empty review. It is recommended that further investigation of the tri-response mental health crisis model be undertaken to determine its effectiveness and value as a health and emergency service initiative.

Tri-Response Police, Ambulance, Mental Health Crisis Models in Reducing Involuntary Detentions of Mentally Ill People: Protocol for a Systematic Review.

Police, ambulance and mental health tri-response services are a relatively new model of responding to people experiencing mental health crisis in the community, but limited evidence exists examining their efficacy. To date there have been no systematic reviews that have examined the association between the tri-response model and rates of involuntary detentions. A systematic review examining co-response models demonstrated possible reduction in involuntary detention, however, recommended further research. The aim of this protocol is to describe how we will systematically review the evidence base around the relationship of the police, ambulance mental health tri-response models in reducing involuntary detentions. We will search health, policing and grey literature databases and include clinical evaluations of any design. Risk of bias will be determined using the Effective Public Health Practice Project Quality Assessment Tool and a narrative synthesis will be undertaken to synthesis key themes. Risk of bias and extracted data will be summarized in tables and results synthesis tabulated to identify patterns within the included studies. The findings will inform future research into the effectiveness of tri-response police, ambulance, and mental health models in reducing involuntary detentions.

The effect of changes to Australian Capital Territory mental health legislation on rates of emergency detention.

OBJECTIVES: The Australian Capital Territory (ACT) changed from the Mental Health (Treatment and Care) Act 1994 (ACT) to the Mental Health Act 2015 (ACT) on 1 March 2016. The objective was to find the association between legislative changes and detention rates. METHODS: A cross-sectional study of involuntary order rates in the period 3 years before the legislative change was undertaken. Chi-squared analysis was performed to compare proportions. RESULTS: There was a statistically significant decrease in the proportion of Psychiatric Treatment Orders (PTOs) over the two periods, which could be impacted by the change from a period of detention for 7 days to a period of detention of 11 days in Period 2. On the other hand, the total number of Emergency Actions (EAs) increased in Period 2, where ambulance officers could detain patients. CONCLUSION: The change in mental health legislation in the ACT was associated with a change in detention rates, in particular a decrease in the proportion of PTOs and an increase in EAs. Further study needs to be undertaken, given changes to frontline supports since the study period ended.

[Involuntary detention and seclusion measures in psychiatry: Where are we now? A regional Centre-Val de Loire 2012-2017 study]. / Soins sans consentement et mesures d'isolement en psychiatrie adulte : où en est-on ? L'exemple de la région Centre-Val de Loire via le Programme de médicalisation des systèmes d'information 2012­2017.

BACKGROUND: The French legal framework in psychiatry for involuntary detention (ID) and seclusion measures was modified in 2011 and 2016, respectively. This study aimed to describe the evolution of ID and seclusion measures in the Centre-Val de Loire region (CVL France) between 2012 and 2017, using the psychiatric hospital discharge database. METHODS: A cross-sectional study was conducted, including adult patients (≥ 18 years old) from CVL hospitalized in psychiatry or included in a care program (outpatient care) between 2012 and 2017. Hospital stays for each patient were identified by an anonymized number. RESULTS: In 2017 in CVL, 13,942 patients were hospitalised for psychiatric reasons, with 2378 in ID (17%), a proportion that has remained stable since 2012. Among them, 3% were in care due to imminent danger (+ 54% since 2013, stabilisation since 2016), and 11% were hospitalized following a third party request (-13%). However, regarding location results varied from one department to the next. Seclusion measures involved 10% of full-time patients (stable), 27% of ID patients and 3% of those under voluntary care (stable). One quarter of the secluded patients were in voluntary care. Mean seclusion duration was 12 days, consecutive or not, and somewhat less for patients in voluntary care alone (10 days). CONCLUSION: The region wide ID rate and average duration of seclusion were lower than the nationwide rate (24% in full-time ID in 2015; 15 days of seclusion/patient), whereas the number of imminent danger procedures increased, as did the persistence of seclusion measures for patients in voluntary care (recommended only as a last resort and/or for ID patients). These results should lead to renewed assessment of care center practices. The French psychiatric hospital discharge database has several limitations, including lack of financial incentive and highly complex structuration. However, since 2018 new data regarding seclusion and restraint measures have been added to the existing registry, and they should facilitate more accurate analyses, particularly as concerns restraint.

Mind the gaps: identifying opportunities in mental health assessment and mental health certificate completion in rural and remote NSW, Australia.

OBJECTIVE: This study aimed to examine the quality of mental health certificate (MHC) completion in rural and remote New South Wales, to include the determination of those identified as mentally ill or mentally disordered, and subsequent processes thereafter. METHODS: MHCs were collected from April 2016 to March 2017. A de-identified review was undertaken and audited for completion of mandatory criteria. Data were separated by three groups of completing health practitioners, and descriptive and inferential statistics calculated to assess for differences between groups. RESULTS: A total of 277 MHCs were included. Local medical officers were significantly more likely to: have longer assessment periods, indicate mentally disordered rather than mentally ill, and to have the mental health certificate revoked upon reassessment at a declared mental health facility, than their psychiatry or accredited person peers. They were also significantly less likely to complete documentation relating to behaviour personally assessed or observed by others. CONCLUSION: This study identified inconsistencies in documentation completion between groups, highlighting training opportunities for non-mental health specialists, particularly mental health assessment and lawful detention requirements. Attention to this is warranted within medical training syllabuses, post-graduate training and support programs.

Offenders with mental disorders in prison and the courts: links to rates of civil detentions and the number of psychiatric beds in England - longitudinal data from 1984 to 2016.

BACKGROUND: The Mental Health Act in England and Wales allows for two types of detention in hospital: civil and forensic detentions. An association between the closure of mental illness beds and a rise in civil detentions has been reported. AIMS: To examine changes in the rate of court orders and transfer from prison to hospital for treatment, and explore associations with civil involuntary detentions, psychiatric bed numbers and the prison population. METHOD: Secondary analysis of routinely collected data with lagged time series analysis. We focused on two main types of forensic detentions in National Health Service (NHS) hospitals and private units: prison transfers and court treatment orders in England from 1984 to 2016. NHS bed numbers only were available. RESULTS: There was an association between the number of psychiatric beds and the number of prison transfers. This was strongest at a time lag of 2 years with the change in psychiatric beds occurring first. There was an association between the rate of civil detentions and the rate of court orders. This was strongest at a time lag of 3 years. Linear regression indicated that 135 fewer psychiatric beds were associated with one additional transfer from prison to hospital; and as the rate of civil detentions increased by 72, the rate of court treatment orders fell by one. CONCLUSIONS: The closure of psychiatric beds was associated with an increase in transfers from prison to hospital for treatment. The increase in civil detentions was associated with a reduction in the rate of courts detaining to hospital individuals who had offended. DECLARATION OF INTEREST: None.

What are the critical incidents that affect how people cope with being detained under Section 136 of the Mental Health Act (1983, 2007)?

Purpose: Section 136 (S136) of the Mental Health Act (1983, 2007) provides legislative powers for police officers to detain those suspected of being 'mentally disordered' for a mental health assessment. Despite its increasing use, there is currently little qualitative research exploring detainee's experiences. Methodology: Participants recruited from NHS places of safety participated in a semi-structured interview. The novel application of Critical Incident Technique (CIT) within this study enabled the specific identification of critical incidents which mental health service users thought had either helped with, or worsened the S136 detention experience. A wish list of absent factors was also gathered. Findings: Six categories of helpful critical incidents, seven categories of unhelpful critical incidents and five categories of wish-list items were identified. The importance of authentic relationships underpinned many categories, as well as challenging stigma, considering previous detentions; and receiving practical support. Originality/value: The outlined study is the first of its kind to utilise CIT methodology to specifically identify critical incidents related to the process of S136 detention. These findings provide specific ways to improve the experience of detention informed directly by those who have been directly subjected to S136. Key points Take time to invest in meaningful relationships with those who are detained; asking about the individual's life experience and their perception of its relationship to their current presenting difficulties. Identify the service user's values -what's important to them, and what gives meaning to their life - and discuss this in relation to what their worries, concerns or wishes may be for treatment. Discuss previous experiences of involuntary admission- this can support all parties involved to consider the impact of detention upon the individual, and services. Use problem-free discussions to normalise and help de-stigmatise mental health difficulties and support rapport building. Provide practical support, such as food, drink and routinely allow those who are detained to gather personal belongings such as a change of clothes or a book. Ensure advocacy services are always available and accessible for those who are detained under S136. Where possible, avoid the use of restrictive or stigmatising practices in front of the public where possible (e.g. use of handcuffs, police vehicles as transport) to minimise risk of increasing mental health stigma.

Changes in the use of the Mental Health Act 1983 in England 1984/85 to 2015/16.

BACKGROUND: Concerns have been raised about the increase in the use of involuntary detentions under the Mental Health Act in England over a number of years, and whether this merits consideration of legislative change.AimsTo investigate changes in the rate of detentions under Part II (civil) and Part III (forensic) sections of the Mental Health Act in England between 1984 and 2016. METHOD: Retrospective analysis of data on involuntary detentions from the National Archives and NHS Digital. Rates per 100 000 population were calculated with percentage changes. The odds of being formally admitted to a National Health Service hospital compared with a private hospital were calculated for each year. RESULTS: Rates of detention have at least trebled since the 1980s and doubled since the 1990s. This has been because of a rise in Part II (civil) sections. Although the overall rate of detentions under Part III (forensic) sections did not rise, transfers from prison increased and detentions by the courts reduced. The odds of being detained in a private hospital increased fivefold. CONCLUSIONS: The move to community-based mental health services in England has paradoxically led to an increase in the number of people being detained in hospital each year, and in particular an inexorable rise in involuntary admissions. This is likely to be partly because of improved case finding with an increased focus on treatment and risk management, and partly because of changes in legislation. An increasing proportion of this government-funded care is being provided by private hospitals.Declaration of interestNone.

Qualitative exploration of stakeholders' perspectives of involuntary admission under the Mental Health Act 2001 in Ireland.

There is international interest in, and continued concern about, the potential long-term impact of involuntary admission to psychiatric institutions, and the effect this coercive action has on a person's well-being and human rights. Involuntary detention in hospital remains a controversial process that involves stakeholders with competing concerns and who often describe negative experiences of the process, which can have long-lasting effects on the therapeutic relationship with service users. The aim of the present study was to explore the perspectives of key stakeholders involved in the involuntary admission and detention of people under the Mental Health Act 2001 in Ireland. Focus groups were used to collect data. Stakeholders interviewed were service users, relatives, general practitioners, psychiatrists, mental health nurses, solicitors, tribunal members, and police. Data were analysed using a general inductive approach. Three key categories emerged: (i) getting help; (ii) detention under the Act; and (iii) experiences of the tribunal process. This research highlights gaps in information and uncertainty about the involuntary admission process for stakeholders, but particularly for service users who are most affected by inadequate processes and supports. Mental health law has traditionally focussed on narrower areas of detention and treatment, but human rights law requires a greater refocussing on supporting service users to ensure a truly voluntary approach to care. The recent human rights treaty, the UN Convention on the Rights of Persons with Disabilities, is to guarantee a broad range of fundamental rights, such as liberty and integrity, which can be affected by coercive processes of involuntary admission and treatment.

Clinical predictors of involuntary detention among voluntary inpatients in St Patrick's University Hospital (SPUH).

BACKGROUND: Few studies have described clinical characteristics of patients subject to an involuntary detention in an Irish context. The Irish Mental Health Act 2001 makes provision under Section 23(1), whereby a person who has voluntary admission status can be detained. Aims This study aimed to describe all involuntary admissions to St Patrick's University Hospital (SPUH) (2011-2013) and to evaluate clinical characteristics of voluntary patients who underwent Mental Health Act assessment during 2011 to determine differences in those who had involuntary admission orders completed and those who did not. METHODS: All uses of Mental Health Act 2001 within SPUH 2011-2013 were identified. All uses of Section 23(1) during 2011 were reviewed and relevant documents/case-notes examined using a pro forma covering clinical data, factors recognized to influence involuntary admissions and validated scales were used to determine diagnoses, insight, suicide and violence risk. RESULTS: Over 2011-2013, 2.5-3.8% of all admissions were involuntary with more detained after use of Section 23(1) than Section 14(2). The majority of initiations of Section 23(1) did not result in an involuntary admission (72%), occurred out of hours (52%) and many occurred early after admission (<1 week, 43%). Initiation of Section 23(1) by a consultant psychiatrist (p=0.001), suicide risk (p=0.03) and lack of patient insight into treatment (p=0.007) predicted conversion to involuntary admission. CONCLUSION: This study predicts a role for patient insight, suicide risk and consultant psychiatrist decision making in the initiation of Mental Health Act assessment of voluntary patients. Further data describing the involuntary admissions process in an Irish setting are needed.

Quis custodiet ipsos custodes? An audit of records of involuntary detention.

OBJECTIVES: To determine the appropriateness and utility of the certificates issued under the New South Wales Mental Health Act (MHA) and compliance with the requirements of the MHA. The analysis also compares MHA documentation by different groups of health professionals and police. METHODS: The MHA certificates associated with 100 consecutive involuntary Emergency Department presentations were audited. RESULTS: Considerable variability exists between professional groups in the level of detail, appropriateness, clinical utility and compliance of MHA certificates. Over 10% of Schedule 1s failed to meet the requirements of the MHA, potentially invalidating the involuntary detention of these patients. Information provided by police was typically superior in informing initial risk assessment and emergency management. CONCLUSIONS: A number of patients are presently being detained under incomplete MHA certificates. Educational initiatives that aim to improve awareness of the MHA's requirements, and the potential uses of the information contained in MHA certificates, could encourage professionals to complete these certificates in a more appropriate and clinically useful manner.

No duty owed to the relatives of a victim of a person with mental illness.

OBJECTIVE: To review the case of an acutely psychotic person who was discharged into the care of a friend whom he killed later the same day, and to consider the reasoning of the High Court in the subsequent negligence action of the victim's relatives. CONCLUSIONS: By a narrow interpretation, the High Court found that the exercise of the powers and duties in relation to the involuntary detention of a mentally ill person as prescribed by the Mental Health Act were inconsistent with a common law duty of care to another person or the relatives of another person.

Involuntary detention and treatment of the mentally ill: China's 2012 Mental Health Law.

The long-awaited Mental Health Law of China was passed on 26 October 2012 and took effect on 1 May 2013. Being the first national legislation on mental health, it establishes a basic legal framework to regulate mental health practice and recognizes the fundamental rights of persons with mental disorders. This article focuses on the system of involuntary detention and treatment of the mentally ill under the new law, which is expected to prevent the so-called "Being misidentified as mentally disordered" cases in China. A systematic examination of the new system demonstrates that the Mental Health Law of China implicitly holds two problematic assumptions and does not provide adequate protection of the fundamental rights of the involuntary patients. Administrative enactments and further national legislative efforts are needed to remedy these flaws in the new law.