UNPROSECUTED MENTALLY ABNORMAL OFFENDERS

Patients repeatedly admitted to psychiatric wards

Many admissions to general adult psychiatric beds occur as emergencies due to social crisis or relapse of psychiatric illness. Other admissions are planned to arrest or reverse deterioration. Length of stay varies depending on reason for admission and adequacy of support in the community. Rapid readmission or failed discharge, defined as readmission within three months, has been linked with multiple previous admissions and personality factors (Jones, 1991).

Psychiatric Referrals from the Police

Section 136 of the Mental Health Act (MHA) 1983 authorises the police to take a mentally disordered person from ‘a place to which the public have access’ to a place of safety in order to be assessed by a doctor and an approved social worker. The person may be detained in the place of safety for up to 72 hours. Despite increasing controversy, the provision survived a heated parliamentary debate virtually unchanged from the 1959 Act. During the passage of the Mental Health Bill through Parliament, concern was expressed about the considerable variation in its use. Psychiatric examination of the provision has often been in comparison to compulsory admission provisions and the research populations have generally been confined to persons admitted to one hospital only. Although some researchers have recognised the variations in the way the provision operates, there has been no systematic examination of these variations. An important question is whether these variations result in differences in patient care and this question is largely unexplored. In the first part of a three part study of s136∗ the researchers set out to examine this question.

Police referral of compulsory admissions — a comparison study

Objective: To determine the characteristics of compulsory admissions by the police and to compare them with compulsory admissions by other means. Method: A retrospective review over one year of the case records of 48 consecutive compulsory admissions after referral by the police was compared with 96 other randomly chosen compulsory referrals over the same period. Results: In both groups a majority had a chronic history of mental illness with frequent prior compulsory hospitalisation. Significant differences were found between the two groups with the police group more often younger, single, unemployed, males. They were also significantly more likely to suffer from schizophrenia and to have had their admission precipitated by behaviour of an assaultive nature, or by property offences, and on admission to spend a shorter period in hospital. Conclusions: It is suggested that at-risk case registers and the use of alternative emergency procedures will serve to lessen the need for police intervention with the mentally ill.

A prospective survey of section 136 in rural England (Devon and Cornwall)

The Mental Health Act 1983 gives the police the power to remove those persons who appear to be mentally disordered from a public place to a place of safety. Previous studies have shown conflicting results concerning its use and there have not been any previous studies in a rural area. This study is a prospective survey of the use of Section 136 in SW England and was carried out between October and December 2000 in six custody centres in SW England. Each detainee had a study form completed to examine how the section was being applied, specifically looking at the time taken for the assessment to be complete and the outcome. The results showed that there were 178 detentions under Section 136 over the three-month study period. It took 25 minutes for detainees to arrive at a police custody unit and the assessments took about 8 hours to complete. The longest delay was for the approved social worker to arrive at the custody centre, (3h 25m) which was significantly longer than the arrival time of the Section 12 doctor (2h 10m). After assessment 32% of Section 136 detainees were admitted to hospital. There were differences between the conversion rates between the six custody centres although these were not significant. This study's conclusions suggest that although rural areas meet the statutory maximum time limits for completing Section 136 assessments, greater distances than in inner city areas lead to substantial delays in completing assessments. Also this study found a much lower rate of hospital admission after assessment than has been found previously and this may reflect the differing needs and characteristics of a rural population compared with the inner city populations.

Section 136 use in the London borough of Haringey

A retrospective one-year study of the use of Section 136 of the Mental Health Act was undertaken in Haringey between 1995 and 1996 to ascertain behaviours resulting in detention, and their admission rate. Data were extracted from police Section 136 forms, Emergency Assessment Centre records and patient notes. Of 90 people assessed under Section 136, the majority were male and lived locally, with the largest ethnic group being Afro-Caribbean. Each category of presenting behaviour recorded by the police was a high predictor of admission, with an overall admission rate of 82%. Behavioural categories with an admission rate of less than 79% were threats or acts of deliberate self-harm and 'confusion' or disorientation (57% and 67% admission rates), which both warrant police referral for specialized assessment. The three most common presenting behaviours were violent threats/acts, abnormal form or stream of speech, and walking/lying/running in the road. The police did not appear to over use Section 136. Section 136 data were incomplete, in keeping with previous studies. This should be rectified by the introduction of both a national data collection standard and a requirement for a defined local data collection point for all instances of Section 136.

Are the newer antidepressant drugs as effective as established physical treatments? Results from an Australasian clinical panel review

OBJECTIVE

The aim of this study was to determine, in a clinical panel sample, the extent to which patients with depression (and melancholic and non-melancholic subtypes) judged the effectiveness of previously received antidepressant treatments, particularly the comparative effectiveness of the older and newer antidepressant drugs.

METHOD

Twenty-seven Australasian psychiatrists assessed 341 non-psychotic depressed patients and rated the extent to which previous antidepressant treatments had been effective. Patients were assigned to 'melancholic' and residual 'non-melancholic' categories by two processes (DSM-IV decision rules, and a cluster analysis-derived allocation) and treatment effectiveness examined within each category.

RESULTS

Electroconvulsive therapy (both bilateral and unilateral) was judged as highly effective by both melancholic and non-melancholic patients. Antipsychotic medication similarly rated highly (but was judged as more effective by the non-melancholic than melancholic patients). The tricyclics and irreversible monoamine oxidase inhibitors (MAOIs) were rated as more effective by the whole sample than several newer antidepressant classes (including the selective serotonin re-uptake inhibitors [SSRIs], venlafaxine, mianserin and moclobemide), whether effectiveness was examined dimensionally or categorically. Comparison of the overall tricyclic and SSRI classes indicated that any superior tricyclic effectiveness was specific to the melancholic subjects.

CONCLUSIONS

Despite methodological limitations intrinsic to such clinical panel data, the judged greater effectiveness of the older antidepressants (tricyclics and irreversible MAOIs) for melancholic depression is of importance. If valid, such data are of intrinsic clinical relevance but also have the potential to inform us about the neurobiological determinants of 'melancholia' and pharmacological actions which contribute to its effective treatment.

Personality disorder and police section 136 in Westminster: a retrospective analysis of 65 assessments over six months

Section 136 of the 1983 Mental Health Act empowers the police to detain those suspected of being mentally ill in public places. The current study is a retrospective analysis of those occurring within Westminster, London, over a six-month period. A high rate of referral was found. In those individuals assessed, schizophrenia was the commonest diagnosis, but personality disorder provided the largest number of assessments. This was due to the propensity of the latter individuals to present on multiple occasions. Those with personality disorders were significantly less likely to be placed under further sections of the Mental Health Act, less likely to be admitted to hospital and more likely to re-present under a further section 136. The inability of the current system to address these individuals' needs is a cause for concern.

Police may underuse Section 136

A one-year prospective study comparing Section 136 patients (39) and the severe Section 2 or 4 patients (29) of the Mental Health Act 1983 in a hospital with inner London catchment areas. The assessments were clinical, nurses' ratings and socio-demographic. The results showed that clinical and nursing ratings did not differentiate the two groups. Most social/demographic data showed similar trends with both groups being disadvantaged but Section 136 patients slightly more so. The differences were smaller than anticipated, suggesting a recent shift of patients admitted under Section 2 or 4 towards a more socially disadvantaged position. In conclusion, police did not overuse Section 136. Our comparison suggests: (a) police may underuse Section 136, and (b) Section 136 acts as a valuable 'back-up' for those patients who would otherwise fail to benefit from the Mental Health Act.

A comparison of voluntary with remanded schizophrenics

In this study two groups of schizophrenic patients are compared on a number of clinical and demographic variables. The first group consists of 52 consecutive admissions to a forensic assessment unit of patients with a diagnosis of schizophrenia. The second is a consecutive series of schizophrenic patients admitted to two open admission units. Significant differences were found between the two groups. Specifically the forensic patients were more often male, single and antisocial as assessed by previous convictions and more often transient or living semi-independently in sheltered accommodation. They were less compliant with treatment. The two groups did not differ with respect to clinical features such as duration of illness and number of hospitalizations. It is concluded that individual patient characteristics may contribute to an outcome of legal involvement among schizophrenics. The implications of this for service delivery and future research on criminalization are discussed.

Management of compulsorily admitted patients to a high security unit

The case-notes of all the 92 patients compulsorily detained under the Mental Health Act from 1st October 1982 - 31st December 1983 were examined retrospectively to deter mine the reasons for transfer to a high Security Unit. Young adult male schizophrenics who were unemployed predominated. Aggressive behaviour was associated with transfer but there was no such relationship with formal diagnosis. Lack of co-operation of the patient was seen more frequently in ethnic minority patients and may be a factor in influencing a trend towards ethnic minority patients being over populated on the unit. The reasons and implications of these findings are discussed.

Compulsory admissions in a London borough: I. Social and clinical features and a follow-up

This study examines the role that clinical and social factors play in compulsory admissions to hospital in a London borough. 150 patients compulsorily admitted under a section of the Mental Health Act 1959 were compared with 100 informally admitted patients. Significant differences in social-demographic and clinical characteristics are described as well as differences in outcome on follow-up. A long-term unwillingness on the part of the compulsory patients to engage in follow-up services was evident. These differences still held when the compulsory patients were compared with a group of informal patients matched for age, sex and diagnosis. Patients referred by the police and admitted under Section 136 of the Mental Health Act showed those features associated with compulsory admission in general to the most severe degree.

"No fixed abode": a survey of mental hospital admissions

Reorientation of the mental health services towards community care was one of the main recommendations contained in the report of the Royal Commission on Mental Health Law (1957) and accepted as Government policy. It was implied that there would be a considerable expansion in the services provided by local health and welfare authorities for the benefit of the mentally disordered, and local authorities were asked to draw up a proper order of priorities and plan their activities accordingly (Ministry of Health, 1959). The priorities depended upon an assessment of needs and time had to elapse before these became apparent. Since four complete years have passed since the coming into operation of the Mental Health Act, 1959, detailed assessment has become possible and this has revealed the difficulties experienced in the community by two special groups of patients, namely mentally abnormal offenders and patients of no fixed abode (N.F.A.s).