What happens to patients discharged by Mental Health Review Tribunals?

Under the Mental Health Act (1983)Mental Hospital Review Tribunals act as a safeguard against un warranted detention of patients in psychiatric hospi tals. Detention, other than in special hospitals, is most commonly under section 2 (assessment order) or section 3 (treatment order) of the 1983 Act. Patients thus detained have the right to appeal to a Review Tribunal, which has the power to order their discharge. Tribunals work by holding formal hearings at the hospital where the patient is detained. They com prise legal, psychiatric and lay members. As well as interviewing the patient they hear reports from the Responsible Medical Officer, psychiatric social worker and independent legal representative (if appointed). Despite this careful process of review, psychiatrists and general practitioners often express concern about the welfare of patients discharged by Tribunals. Surprisingly no systematic information if collected concerning the outcome of patients discharged in this way. We report a retrospective case-note review of the six month outcome of patients discharged by Tribunals from Sections 2 and 3 of the 1983 Mental Health Act.

Under the Mental Health Act (1983)Mental Hospital Review Tribunals act as a safeguard against un warranted detention of patients in psychiatric hospi tals. Detention, other than in special hospitals, is most commonly under section 2 (assessment order) or section 3 (treatment order) of the 1983 Act. Patients thus detained have the right to appeal to a Review Tribunal, which has the power to order their discharge.
Tribunals work by holding formal hearings at the hospital where the patient is detained. They com prise legal, psychiatric and lay members. As well as interviewing the patient they hear reports from the Responsible Medical Officer, psychiatric social worker and independent legal representative (if appointed). Despite this careful process of review, psychiatrists and general practitioners often express concern about the welfare of patients discharged by Tribunals. Surprisingly no systematic information if collected concerning the outcome of patients discharged in this way.
We report a retrospective case-note review of the six month outcome of patients discharged by Tribunals from Sections 2 and 3 of the 1983 Mental Health Act.

The study
The study was limited to discharges from the Oxford hospitals over the four years up to April 1991. Casenotes of discharged patients were retrievable for the period from October 1989 at Warneford Hospital and from April 1987at Littlemore Hospital. Patient age, sex, diagnosis, the Section of the Act under which the patient was detained, and compliance with psychiatric after-care were recorded from the casenotes. General practitioners were contacted for additional information about outcome. No compari son group was included in the study. Because the Review Tribunal represented an intervention into the Responsible Medical Officer's management plans, we considered it reasonable to determine whether such patients enjoyed a medically satisfactory out come. Outcome was judged unsatisfactory if there was either non-compliance with medication or planned follow-up by psychiatric services and GP, or if there was a clinically untoward event that significantly affected outcome during the six months after discharge. The study was approved by the local Psychiatric Ethics Committee.

Findings
During the study period 12 patients had been dis charged by Tribunals from Section 2 or 3. Details of the cases are shown in Table I. These discharges were a result of 70 appeals from a total of 810 detentions (appeal rate 9%). The majority of patients had a satisfactory outcome. A significant minority (5/12; 42%) did not however. Of these five patients, four had failed to comply with planned after-care and medication, and three suffered clinically untoward events.
The untoward events comprised two readmissions and one suicide. A further patient left Oxford pre cipitously after discharge but subsequently complied with local after-care and was judged to have a clini cally satisfactory outcome. All untoward events occurred to patients with a principal diagnosis of mania.

Comment
The overall rate of appeal and of discharge recorded in this sample is similar to that reported from other hospitals (Spencer, 1989;O'Dwyer & Neville, 1991). While only preliminary conclusions can be drawn from such a small study, we consider several findings worthy of comment. First, while the majority of patients comply fully with after-care plans, noncompliance occurs in a substantial minority and may have clinically significant consequences. We cannot say from this study whether outcome would be differ ent if the patients had not been discharged. We do, however, believe that these findings give some cause for concern. Second, it is apparent that the postdischarge course of in-patients with a diagnosis of mania is particularly difficult to predict. This observation is consistent with our knowledge of the changeable nature of the mental state of patients with this disorder, and is particularly important as it has been observed that such patients may be more likely to be discharged by tribunals than those with other diagnoses (Spencer, 1989). Finally, the observation that most patients remained in contact with their general practitioners, even if they defaulted from psychiatric follow up, underscores the role of the general practitioner in the after-care of patients discharged from psychiatric hospitals. We would like to suggest that further systematic research into the outcome for patients discharged from psychiatric hospitals by review Tribunals is warranted. Until this is done particular care should be taken in planning after care for patients dis charged by Tribunals from Sections of the Mental Health Act, especially when the diagnosis is mania.