The use of the Mental Health Act in elderly patients in one health district

There has been little published on the application of the Mental Health Act (1983) in the elderly. We therefore surveyed its use in a district old age psychiatry service covering a mixed rural and urban population with about 60,000 people over 65 years. The MHA was applied 36 times to 32 patients over a two year period. The primary diagnosis was a functional psychiatric illness in 64% patients (usually depression) and dementia in 36%. Functionally ill patients were most frequently detained on a treatment section (S3) and demented patients on an assessment section (52). Only one patient with dementia was placed on a guardianship order. The outcome of treatment is described. a review of referrals to community in one antidepressants therapeutic the of have identified problems relating to GP prescribing of antidepressants.

The use of the Mental Health Act in elderly patients in one health district

C. Morris and I.M. Anderson
There has been little published on the application of the Mental Health Act (1983) in the elderly. We therefore surveyed its use in a district old age psychiatry service covering a mixed rural and urban population with about 60,000 people over 65 years. The MHA was applied 36 times to 32 patients over a two year period. The primary diagnosis was a functional psychiatric illness in 64% patients (usually depression) and dementia in 36%. Functionally ill patients were most frequently detained on a treatment section (S3) and demented patients on an assessment section (52). Only one patient with dementia was placed on a guardianship order. The outcome of treatment is described.
The Mental Health Act (1983) (MHA) is a neces sary part of treating older people with psychiatric problems but despite this, little has been written about specific difficulties in applying the MHA to the elderly. It would be a mistake to suggest that this is the result of uniformity in practice, indeed there seems little consensus across the country (or even within districts) about how the powers should be used.
Another legal power, section 47 of the National Assistance Act (1948), is not primarily concerned with mental health problems although studies indicate a high incidence of major psychiatric disorder (predominantly organic mental illness) in its recipients (Forster & Tiplady, 1980;Wolfson et al, 1990). There are several difficulties in its use, including lack of legal protection for the subjects except through the courts and the vague wording of the Act itself. Most subjects appear to live alone and are removed from their own homes with little hope of return and the mortality is high (Forster & Tiplady, 1980;Wolfson et al, 1990). It is possible therefore that the MHA may often be a more appropriate power to use, providing more protection of civil liberties and perhaps improving outcome.
We were therefore interested in the application of the MHA to the elderly. It has been reported that most of those subject to a guardianship order live alone and suffer from a chronic organic brain syndrome and that its use tends to be to facilitate transfer to, or continuation of, residen tial care. While the outcome of its application is usually favourable (e.g. Wattis et al, 1990), it is not used frequently and one criticism of guard ianship is the doubt over whether a 'power to convey' is included. As part of an audit pro gramme, we carried out a retrospective survey of how the MHA was used in a district old age psychiatry service covering a mixed urban and rural population with approximately 60,000 people over 65 years.

The study
Patients placed under a section of the MHA by one of the three consultants in old age psychiatry or the senior registrar from January 1991 to December 1992 were identified, and their casenotes examined. Although some degree of func tional and organic illness frequently coexisted, for the purpose of this survey patients were assigned exclusively to having a functional or organic illness depending on which was pre dominant. Outcome was assessed from casenote review and discussion with the clinician involved. A four-point clinical global impression of outcome was made: marked improvement (re covery or sufficient improvement to allow attain ment of premorbid level of functioning), moderate improvement (significant alleviation of present ing condition sufficient to allow supported living in the community), mild improvement (somealleviation of presenting condition but continu ing to need intensive nursing care in hospital or nursing home), no improvement/worsening (in cluding death). The survey is descriptive but x2 tests are applied sparingly where they enhance interpretation of the findings.

Patients and length of admission
Thirty-two patients were admitted on section during the study period, 24 female and eight male. The mean age was 80 years (range 70-96). The median length of admission was ten weeks; this was the same in the group of patients with functional illness (median ten weeks, range 2-47) and dementia (median 9.5 weeks, range 3-18).

Sections
There were 33 admissions on section involving 32 patients. Of the 36 times the MHA was used, section 5(2) was used twice (6%, both for organic illness), section 2 on 15 occasions (42%, five for functional and ten for organic illness) and sec tion 3 on 18 occasions (50%, all but one for functional illness). One guardianship order was completed (3%). Demented patients were most frequently detained under a section 2 and func tionally ill patients under a section 3 (P<0.001). On three occasions patients were transferred from one section to another (section 5[2] to 2, section 2 to 3 and section 3 to guardianship order).
The majority of episodes were admissions as the result of worsening of the mental state (18 out of 33; 55%), while in five cases (15%) physical decline resulting from a mental disorder was the major concern. In nine cases (28%), the patient was placed on section 3 before requesting a second opinion from the Mental Health Act Com mission for ECT. In all cases the Commissioner agreed to the proposed treatment plan. The guardianship order was completed to facili tate transfer of a patient with dementia to a residential home.

Diagnoses
The majority of patients (21 out of 33; 64%) had a primary functional illness (five had a paranoid psychosis, 13 a severe depressive illness, two mania and one a severe hypochondriacal dis order) with 12 patients (36%) suffering primarily from dementia.
Admission and discharge Eight-two per cent of patients (9 demented, 18 functionally ill) were living at home at the time of admission (17 alone, ten with a career of whom three were dementing), and in five cases (15%) the patient was in residential care. One patient with a severe hypochondriacal disorder was admitted directly from a district general hospital.
Thirteen patients (39%) returned home, 12 (36%) moved into residential care for the first time and five (15%) returned to residential care from where they had been admitted. Three patients (9%) died, one with dementia and two functionally ill patients.
Ten of the 11 patients (91%) with dementia who left hospital were discharged to residential care compared with seven of the 19 discharged patients (37%) with functional disorders (P<0.01). Of those entering care, the proportion who did so for the first time was comparable in the two groups (7 out of 10 demented patients v. 5 out of 7 functionally ill patients).

Outcome
Five patients (15%) made a marked improve ment, 17 (52%) a moderate improvement, five (15%) a mild improvement, three (9%) no im provement and three patients (9%) died. Of the functionally ill patients, five (24%) made a marked, and eight (38%) a moderate improve ment. No demented patients made a marked improvement but nine (75%) had sufficiently improved behaviour or physical state, or both, to be considered as moderately improved and able to return to supported community living. Of the nine patients prescribed ECT under section 3 with a second opinion, five (55%) had moderate or marked improvement, two (22%) showed only mild improvement and two (22%) died after transfer to the district general hospital for physical illness; one before starting ECT due to severe dehydration, the second as a conse quence of a severe chest infection developing early in the course of treatment.

Comment
This survey describes the use of the MHA In a district service. There is little dispute over the need for the MHA in some patients with func tional disorders. While our measure of outcome was retrospective and limited and must therefore be treated with caution, it is noteworthy that while 62% of functionally ill patients made a moderate improvement or better, only 24% could be considered as recovered.
The place of the MHA in the management of patients with dementia is less clear. It has been said that sections 2 and 3 of the Mental Health Act are of little help in the elderly with dementia who are unable to live safely at home (Manger & Oppenheimer, 1989). However our survey shows that it is possible to use section 2 of the MHA to facilitate transfer from home to residential care. Once the patient is in hospital it has been our experience that a firm wish to return home is usually not expressed (contrary to the refusal to leave home voluntarily before admission) and, once the patient has been transferred to residen tial care, he or she has settled without major problems. The use of the MHA for this group of patients does depend on the psychiatrist, general practitioner and social worker working together in an agreed and flexible manner. Our findings do not, of course, preclude other ways of achiev ing the same clinical end without invoking the MHA, although the statutory safeguards of civil liberties embodied in the MHA arguably make its use preferable to the National Assistance Act (1948), and to 'persuasion' or even deception that undoubtably does occur In this difficult clinical situation.
However, it was not the intention for the as sessment and treatment sections of the MHA to be used to facilitate residential care for patients with dementia, and controversy over the use of section 47 of the National Assistance Act (1948) and guardianship orders indicates that none of the available legislation adequately provides for this group. The recent Royal College of Psychiatrists' proposals for a community super vision order and the Department of Health's re sponse (supporting greater use of guardianship orders, extended leave of absence on a section 3 and a new form of supervised discharge) is con cerned primarily with ensuring the continuing psychiatric treatment of patients with recurrent psychotic illness following discharge from hospi tal (Bluglass, 1993). None of these proposals addresses the need of demented patients which is usually 24-hour social care rather than psy chiatric treatment. One option would be a new 'care order' which would enable demented patients to be looked after more satisfactorily while still providing protection of civil liberties, but we suggest that it would be preferable for the role of the existing guardianship order to be extended and made more explicit. We believe this would lead to a greater consensus over the application of legal powers to this very needy and extremely vulnerable group of patients. Antidepressant prescribing among referrals to a community mental health unit in New Zealand

Robert J. Thomson
This study involved a case-note review of referrals to community psychiatric services in a university town in New Zealand. About one third of all 163 patients referred were taking antidepressants for depression; of these one third were taking therapeutic doses, with the remainder taking inadequate doses. This tends to confirm the findings of other studies that have identified problems relating to GP prescribing of antidepressants.
In the UK, increased interest in depression in the setting of general practice has led to the recent Defeat Depression campaign.
As long ago as 1973, the correct prescribing of antidepressants by general practitioners (GPs) was questioned with inadequate doses being one of the main problems. Johnson (1973) recommended that more active super vision of treatment was needed by GPs and a