General practitioners' referrals for compulsory admission under the Mental Health Act, I: comparison with other GP mental health referrals

Although the work of general practitioners (GPs) with mental illness generally, particularly in relation to minor mental illness, has been extensively exam ined, there has been practically no work devoted to the role of GPs in assessment for compulsory admission, either under the 1959 or 1983 Acts. The notable exception is the work of Bean ( 1980),who is, in some respects, highly critical, accusing them of showing little interest in patients, referring at times inappropriately, committed to the rhetoric rather than reality of care and of knowing little or nothing of the law they were supposed to be using. Bean's

Although the work of general practitioners (GPs) with mental illness generally, particularly in relation to minor mental illness, has been extensively exam ined, there has been practically no work devoted to the role of GPs in assessment for compulsory admission, either under the 1959 or 1983 Acts. The notable exception is the work of Bean ( 1980),who is, in some respects, highly critical, accusing them of showing little interest in patients, referring at times inappropriately, committed to the rhetoric rather than reality of care and of knowing little or nothing of the law they were supposed to be using. Bean's work is, however, a study of the 1959 Act, and no research exists on the 1983 Act which now governs section assessments. This neglect of GPs is surpris ing, in view of the severe consequences of compulsory admissions (sections) and research on the use of the 1983Act already available on other participating pro fessionals (Sheppard, 1990;Rogers, 1989). GPs are likely to be professional instigators of section assess ments as well as involved in the assessment itself.

The study
These two articles report studies of referrals from GPs to a community mental health centre in a city of about 240,000 over one year from December 1987to November 1988. This article compares GP referrals for section assessments (totalling 40) with other referrals from GPs to the centre (totalling 91). The centre received practically all working hours requests for approved social worker (ASW) assessment, referrals therefore reflecting the rate and nature of referrals for the whole city, this rate being well within the range evident from referrals over a wide number of areas in England and Wales (Barnes et al, 1990). Because of its extensive use, the centre provided a central focus for monitoring referrals from an other wise disparate group of practices. The articles, there fore, will give some insight into the behaviour of GPs in relation to compulsory admission, and the conse quences of this both for those referred and the specialist psychiatric services.
The methods used are discussed in great detail elsewhere (Sheppard, 1991). The results are based on well established instruments (see Sheppard, 1991). Our instrument contained fourmajorelements: social and demographic characteristics, mental health state, social problems, and intervention undertaken. Assessment of mental health state was guided by ICD-9 classification (WHO, 1977). The instrument was designed to reflect, cumulatively, the 'in practice' judgements of the practitioners, helping us under stand what those actually carrying out the work perceived themselves to be doing. The research instrument was completed by the practitioner responsible for the case: psychiatrist, social worker or community psychiatric nurse (CPN). Section referral questionnaires were filled in by the ASW after consultation with medical personnel.

Findings
Forty referrals for compulsory admission were made by GPs. The comparison group involved 91 referrals. The majority of section referrals (80%) were women, compared with only 45% of other referrals (/)=0.02). Under half of both groups were married. Over 40% of both groups were unemployed.
Significantly more section (87%) than other referrals (42%) were previously known to the psychiatric services (P< 0.0001). Ninety-three per cent of section referrals and 80% of other referrals were considered to be definite or borderline mentally ill. Only 36% of 'other' referrals were considered 'definite' cases compared with 85% of section referrals (P<0.0001), while 77% of section and 17% of other referrals were considered psychotic (/><0.0001). More section referrals (38%) than other referrals (6%) suffered affective psychosis (P< 0.0001), and more section referrals were con sidered schizophrenic (23%) than other referrals (7%) (P=0.02). Examination of social and physical ill health problems showed that markedly fewer section (23% compared with 45%) referrals had practical (P = 0.02) or physical ill health (10% compared with 25%) problems (/>=().07). Analysis of detailed problems shows significantly more social relations problems among section referrals (65%) than other referrals (41%) (/>= 0.02). The prac titioners were asked to indicate which from the range of psychiatric and social problems they considered to be primary. Section referrals showed greater emphasis on mental health and psychosis: 60% were considered to be primarily psychotic, 15% neurotic and 18% emotional or relationship. Other referrals were considered primarily psychotic in 11% of cases, and neurotic and to have emotional or relationship primary problems in, respectively, 34% and 41% of referrals (/>< 0.0001).
Intervention was quite different for the two groups. Those not referred for section assessment received significantly more information and advice, psychodynamic therapy and discussion of future options. Very few were subject to section assessment, and always after the initial referral. Non section referrals were also subject to significantly longer intervention: one was seen for more than a week, compared with 32% of other referrals (P< 0.005). Only 12% of section referrals compared with 34% of other referrals were subject to more than two interviews (/><0.0004). A high proportion of other referrals nonetheless received brief intervention, reflecting the gatekeeping role of the service, whereby patients were referred for assessment or advice by other professionals, or where they were subsequently referred on to other agencies considered appropriate for their needs.

Comment
Although the number of section referrals studied here was relatively small, these data are nonetheless useful. There is generally a lack of information on GP section referrals, as there is great difficulty collecting data from a profession in such diverse bases, and referrals were over one year in a medium sized city (and hence not insignificant).
Bean's (1980) research criticised GPs for inappro priate referrals and a failure even to be minimally 139 aware of the law. This study indicates that GPs, overall, distinguished between those referred for compulsory admission and those for other specialist help, indicating a number of factors triggering sec tion referrals. The two groups differed markedly in the severity of their condition. A greater proportion of section referrals were considered by specialist practitioners to be definite cases, there was greater emphasis on psychotic conditions, primarily schizo phrenia and affective psychosis, while the majority of referrals were previously known to the psychiatric services. This suggests that a history of psychiatric disorder may have played a part in the decision to refer for compulsory admission. Together these indi cate three key characteristics acting as a trigger for GP referral for section assessment: definite disorder, psychotic condition, and previous contact with psychiatric services. The emphasis, therefore, tends not to be on acute conditions of recent onset, and it may be that previous specialist diagnosis, together with a previous willingness by specialists to see the patient, encourages GPs to make a section referral. While the predominance of psychotic primary problems demonstrates their centrality, significantly more relationship problems were evident in section referrals. These are likely to reflect problematic behaviour by individuals referred. Psychotic con dition on its own was often insufficient to trigger referral. A fourth trigger was frequently when prob lematic behaviour occurred in a familial or wider social context. A final trigger appears to be the sex of the individual. This is of some concern. GPs may be more willing to use the compulsory route for women than for men. Finally, the brevity of inter vention with section referrals, whether or not they were compulsorily admitted, indicates a 'mental set' on the part of specialist practitioners, which involves seeing the task simply as one of section assessment separate from other forms of help. This suggests that if GPs wish to keep their options open, incorporating the possibility both of hospital admission and other intervention, it may be better not to refer for a section.

References (See end of paper II.)
Psychiatric Bulletin (m2),16,[139][140][141] General practitioners' referrals for compulsory admission under the Mental Health Act, II: the process of assessment MICHAEL SHEPPARD This is the second of two articles on GP referrals for compulsory admission, and seeks to examine the process and outcome of assessment by (a) comparing GP with other section assessment referrals and (b) comparing GP referrals who were compulsorily admitted to hospital with those not compulsorily