The Mental Health Act and people with mild learning disabilities

Mrs N. G., aged 74, had mild learning disabilities and chronic schizophrenia. Concern had been present for months regarding the conditions in which she lived. She had refused access to professionals but, following environmen tal health concerns, a successful visit revealed her living in squalor. She was incontinent of faeces and urine which were passed through a hole in her mattress on to the floor boards. Faeces were smeared around the house. Psychotic symptoms were not evident but, in view of her physical condition, further assessment of her mental state was indicated. Informal admission was not agreed to, thus Section 2 of the Mental Health Act was implemented on the grounds of mental disorder that was placing her life at risk because of lack of self care. It was not felt appropriate to use the mental impairment category of the Act although it was questioned whether her behaviour could be construed as 'seriously irresponsible' and as a result of her learning

The Mental Health Act and people with mild learning disabilities DEARSIRS The paper by David James (Psychiatric Bulletin, June 1993, 17, 357-358) highlighted the difficulties faced when using the Mental Health Act for people with severe learning disabilities. These difficulties also apply to people with milder learning disabilities as highlighted by the following case.
Mrs N. G., aged 74, had mild learning disabilities and chronic schizophrenia.
Concern had been present for months regarding the conditions in which she lived. She had refused access to professionals but, following environmen tal health concerns, a successful visit revealed her living in squalor. She was incontinent of faeces and urine which were passed through a hole in her mattress on to the floor boards. Faeces were smeared around the house. Psychotic symptoms were not evident but, in view of her physical condition, further assessment of her mental state was indicated. Informal admission was not agreed to, thus Section 2 of the Mental Health Act was implemented on the grounds of mental disorder that was placing her life at risk because of lack of self care. It was not felt appropriate to use the mental impairment category of the Act although it was questioned whether her behaviour could be construed as 'seriously irresponsible' and as a result of her learning disability.
On admission to hospital no evidence of psychosis was revealed and she had insight into her situation. She was transferred to respite care. This case confirms a number of the points high lighted by James but illustrates other difficulties faced by implementation of the Mental Health Act for people with mild learning disability. It may be argued that the condition the patient was found in was not the result of her mental illness but lack of understanding resulting from her mild learning disability. Had her rights been abused by applying the Mental Health Act? Certainly her physical well-559 being was at risk and, as the psychiatrist involved in her care, I believe her life would have been in danger if she had remained in her home. A detailed assessment of her mental state was indicated to exclude an acute episode of a previously diagnosed schizophrenia.
It is to be hoped that further audit of the use of the Mental Health Act will assist in the management of these difficult cases but, as James commented, liberalism can lead to reluctance to use the Act which, apart from robbing a vulnerable group of people of proper legal safeguards, may also rob them of access to the professional help they need. SARAHBERNARD

Ravensbourne NHS Trust Bassetts Resource Centre Farnborough, Orpington KentBR67WF
Multidisciplinar)? approach in psychiatry DEARSIRS I read with interest the article by Green (Psychiatric Bulletin, June 1993, 17, 359-361) on the functioning of multidisciplinary teams and the problems of working between members from different orientations.
The power structure of psychiatry has undergone a transformation. This change may be a result of change in professional practice, or perhaps, in some sub-specialities, role diffusion or role confusion within the multidisciplinary team (Arya, 1993).
Green commented on the importance of boundaries within the team. In some areas of practice, as when the mainstay of treatment is psychopharmacological, the boundaries are relatively clear, but for treatments which do not require a pharmacological approach (e.g. managing a child with temper tantrums), we tend to accept the musical (revolving) chair game to elect a non-medical leader. I would suggest that treatment prescribed on that day is influenced by the chair.
We need to define the boundaries of our speciality clearly and accept that there may be ailments which came under the remit of psychiatric practice in the past, but are now best catered for by other disci plines with psychiatrists providing specialist advice if requested. Clarification of such boundaries will refine our management. DINESHK. ARYA Queens Medical Centre Nottingham NG72UH