THE LAWS OF the Mental Health Act (MHA) are concerned with the admission, treatment and rights of people in in-patient facilities for mental health care.
At present, a range of proposed amendments to the MHA is being scrutinised by the Oireachtas. As trainee psychiatrists and future consultants, we have grave concerns about our ability to provide the right treatment and care for our patients if these proposed amendments are signed into law.
Those concerns are shared by our colleagues. According to a recent sample survey of 63 psychiatry trainees conducted by the College of Psychiatrists of Ireland, 77% believe the revised MHA will impact their ability to treat patients effectively.
Changes
The proposed amendment to the MHA that has generated the fiercest debate surrounds a person’s need for treatment versus their right to autonomy.
At present, if someone is suffering from a mental illness, is at risk of deterioration and is too unwell to voluntarily give their consent for treatment, they can be admitted involuntarily for urgent, life-saving treatment. But the proposed revisions of the MHA would mean the bar for admission for people who do not have the capacity to understand that they need treatment would be raised significantly to protect their right to autonomy.
It would mean admission is only “immediately necessary for the protection of life of the person, for protection from a serious and imminent threat to the health of the person, or for the protection of other persons”.
Essentially, this means that someone’s life would have to be under serious and imminent threat before they have a right to treatment under the proposed MHA. There is no other medical condition where this is the case.
Care in practical terms
We are at the coalface of supporting those with mental ill health and mental illness and we see first-hand the heartbreak of families who seek admission for their loved ones in often very troubling circumstances.
Take an example of an older person suffering from a severe depressive episode who is living alone and socially isolated. Some of the symptoms of depression include reduced appetite, feelings of guilt and, in severe depression, they may harbour delusional beliefs.
We have both treated patients who have unfortunately become so unwell in these situations that their thought processes and decision making abilities are altered. Some stopped eating and drinking and others believed they were already dead. Treatment in the community is often not possible if this person does not have the insight to understand that this is part of an illness.
While such a patient clearly is deserving of access to treatment, they are not experiencing active suicidal thoughts or thoughts of harming others, so they would not meet this new threshold for treatment.
The thought that we may not have any means to treat what is a very serious condition does not bear thinking about. The fact that we may be in a position where we have to watch patients deteriorate to dangerous levels when we know we have effective treatments available goes against all of the moral values that led us into a career in medicine.
Imagine a cardiologist watching their patient having a heart attack and being fully aware that they can treat this but being unable to and watching a patient die. This is the reality of the proposed amendments to the MHA.
Thankfully, not everyone will experience such severe levels of mental illness, but fair access to timely intervention is crucial to help our most vulnerable patients get their lives back on track.
Authorised personnel
Another proposed amendment to the MHA is that involuntary admission could only be commenced by Authorised Officers (AOs), who are often social workers, psychiatric nurses or other multidisciplinary team members.
The role of the AO is a critically important one; they provide an assessment and apply to a GP for a further assessment before a person goes to the hospital to be assessed by a psychiatrist.
In the currently used MHA, the AO is only one of several options to begin the pathway to treatment. This presently includes the patient’s family members, the Gardai, or another medical practitioner. If involuntary admission can only be carried out by an AO, this is highly likely to delay much-needed treatment in many cases.
For example, we have both seen many cases where a patient is brought to an emergency department supported by Gardai for assessment, often due to behavioural changes, self-harm or attempted suicide. We assess patients experiencing these crises 24/7.
If a patient is found to be suffering from a mental disorder and fulfils the criteria for detention, it is critical that this process occurs quickly as people in these situations are understandably frightened, distressed and may be struggling to trust those around them.
We are worried about a situation where patients are waiting for hours for an AO to start the process of treatment when this could be more quickly facilitated by a family member or a Guard.
Our goal is to uphold the right to care for our patients and to work in a system which supports us to expertly care for our most vulnerable patients, without delay and without having to wait for them to become a risk to themselves or others. If we are waiting until this critical point the balance will not always be struck. Patients will suffer unnecessarily and experience negative outcomes.
As future consultant psychiatrists, we are in favour of improved governance of our practice in all settings and welcome any support in the delivery of patient care to the highest standard.
However, the proposed amendments to the MHA would benefit neither patients nor medical practitioners, and if introduced, would have a hugely negative effect on mental health services in Ireland.
Dr Sarah Casey and Dr Aoife O’Callaghan are Senior Psychiatry Registrars and Co-Chairs of the Trainee Committee of the College of Psychiatrists of Ireland
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