Emergency psychiatric detentions in a Scottish health region--the use of Sections 24 and 25 of the Mental Health (Scotland) Act 1984

Civil detentions of older adults under successive Scottish mental health legislation: a comparative analysis

BACKGROUND

Many countries have adopted new mental health legislation, with the detention of adults for treatment of mental disorders remaining an integral part of such policies. However, there are relatively few publications on the use of mental health legislation in the detention of older adults. This paper examines the civil detention of older adults in one Scottish region under successive mental health legislation.

METHOD

This prospective study collected data primarily by clinician-based interviews on all emergency detentions under the Mental Health (Scotland) Act 1984 of older adults in 1994 and compared these with all emergency and initial short-term detentions under the Mental Health (Care and Treatment) (Scotland) Act 2003 of older adults during 2008 in the same Scottish region.

RESULTS

There were a total of 124 detentions, with an initial rate of 68 increasing to 141 detentions per 100,000 of the respective over-65 year age populations, a two-fold increase. Compared to the 1994 patient cohort, the 2008 cohort had higher rates of over 85-year-olds (18.4% v 5.4%) and organic mental disorders (74.7% v 56.8%) and were significantly more likely to be detained by consultant psychiatrists (73.6% v 18.9%) during working hours (87.4% v 48.6%) and proceed to six-month detention orders (31% v 10.8%).

CONCLUSION

The observed higher rates and longer periods of detention in the 2008 cohort may reflect changes in clinical attitudes and legal requirements from a previous reliance on the common law doctrine of necessity to the requirements of a more legalistic framework, and may signal future clinical requirements, given the aging population, pointing towards the need for earlier recognition and management of clinical issues in an attempt to minimize the "necessity" of clinico-legal intervention.

Detentions of older adults under the Mental Health (Care and Treatment) (Scotland) Act 2003

This study prospectively examined all initial emergency and short-term detention orders of older adults under the Mental Health (Care and Treatment) (Scotland) Act 2003 in a Scottish health region in 2008 to determine differences in characteristics and outcomes by patients' age, gender and those detained by consultant compared with non-consultant clinicians. Detention order papers were scrutinized, the detaining practitioners were interviewed and case records were examined. Appropriate statistical analyses were performed. For the 87 detentions, subjects were Caucasian, male (54%) and 45% were aged 80 years or older. Ninety-four percent of detentions occurred on a weekday, during working hours (87%), in hospital (67%) with consultants initiating 74% of orders. Detention rates ranged from 66 to 171 per 100,000 over-65s. Seventy-five percent of patients had an organic disorder, 46% exhibiting psychotic symptoms. The older group had higher rates of confusion, organic diagnoses, but lower levels of previous psychiatric admissions. Consultants were more likely to detain patients with a wider variety of disorders, with more admissions to and detentions in psychiatric hospital care. Final detention outcomes were significantly different between the consultant and non-consultant groups. The results indicated few differences between the genders, but differences were more significant between the age cohorts and were further influenced by the grade of the detaining clinician. Further research is required to examine the influence that community mental health teams, advance statements and the use of guardianship and incapacity legislation have on the increasing rates of mental health detentions in the aging population.

Social exclusion and risk of emergency compulsory admission. A case-control study

BACKGROUND

Emergency detentions under section 4 of the Mental Health Act 1983 are more frequent in socially deprived areas of England and Wales. However, it is not clear whether individual socio-economic disadvantage increases likelihood of emergency detention. Therefore, this study tests the hypothesis that a higher proportion of people who are socially excluded will be admitted to hospital under section 4 than those who are not.

METHODS

A total of 300 mental health act assessments in two London boroughs with different rates of section 4 admissions were studied by retrospective case note review in a case-control design. An index of social exclusion was created and piloted for this study.

RESULTS

The logistic regression analysis discovered four risk factors for section 4 admissions: presenting with a risk to self or others at the mental health act assessment, bi-polar affective disorder, non-White British ethnicity and low social support. There were no significant differences between the two boroughs on these variables. Risk factors for any compulsory admission were: presenting with a risk, psychosis and non-White British ethnicity.

CONCLUSION

This study found low social support to be the only social exclusion indicator that increases likelihood of admission under section 4. While individual-level variables explain some of the variation in section 4 rates, it is likely that, as indicated by other studies, different configurations of mental health services affect rates to a greater degree.