Medication for side-effects under the Mental Health Act

The need to authorise the use of hyoscine to counter hypersalivation caused by antipsychotics has been recently debated by Woochit & Husain ([2008][1]). They question the logic of the Mental Health Act Commission in suggesting that authorisation needs to be sought on Forms 38 or 39 for detained


Medication for side-effects under the Mental Health Act
The need to authorise the use of hyoscine to counter hypersalivation caused by antipsychotics has been recently debated by Woochit & Husain (2008). They question the logic of the Mental Health Act Commission in suggesting that authorisation needs to be sought on Forms 38 or 39 for detained individuals to receive such medication. They propose a corollary of the Commission's position that all medication used for possible side-effects should similarly be specified, such as senna for constipation and metformin for diabetes.
The Mental Health Act 1983 nowhere defines 'medication for mental disorder' in relation to its consent to treatment powers and the courts have never ruled on the question, although the case of B v. Croydon Health Authority [1995] is often cited as a precedent for the contention that a treatment ancillary to the administration of medication for mental disorder can fall within section 58 of the Act (Jones, 2006) and therefore requires certification. It is a long accepted practice, for example, that antimuscarinic drugs should be named on the legal forms. Of course this approach could be taken to absurd lengths, meaning that a statutory second opinion might be required to administer a laxative or an indigestion tablet to an incapacitated detained individual.
The Mental Health Act Commission seeks to ensure that forms should provide a clear indication of the limits of any authorisation, both for clinical teams and for the service user, while remaining practical. We therefore seek to distinguish between ancillary treatments that are an essential adjunct to the core treatment, without which the latter could not be reasonably given, and treatments of more widespread physical complaints that may or may not be related to the core treatment.
Hyoscine is a good example of how this distinction should work in practice. Idiopathic sialorrhoea is exceptionally rare. Where it occurs with antipsychotics, in particular but not exclusively with clozapine, it can be said to be almost certainly one of the side-effects of that drug and nothing else. Contrast this with, for example, constipation or indigestion: both are known to be side-effects of psychotropic medication, but are also common intermittent or chronic problems in the general population, often with no exact known cause. From such pragmatic distinctions we have drawn up a list of ancillary treatments requiring certification including, for example, antimuscarinics used in parkinsonism and other motor effects of antipsychotics and hyoscine used for hypersalivation but excluding laxatives, indigestion remedies, or antidiabetics (Mental Health Act Commission, 2002 Depot risperidone, hyperprolactinaemia and prolactin-associated side-effects Hyperprolactinaemia is a significant adverse effect of antipsychotic treatment and is particularly associated with dopamine-blocking agents like risperidone. Hyperprolactinaemia may cause menstrual disturbance, galactorrhoea, impotence and reduced libido. These problems impair the quality of life and contribute to non-adherence to medication (Maguire, 2002). Chronic hyperprolactinaemia has been associated with osteoporosis (Naidoo et al, 2003).
Depot risperidone is an injectable, slow-release formulation whose prolactininducing properties may differ from oral risperidone. Only one previous trial assessed hyperprolactinaemia associated with the use of depot risperidone in routine clinical care (Bushe & Shaw, 2007).
In a pilot study in Renfrewshire, Scotland, we identified 37 individuals who were taking depot risperidone. Twelve individuals had medical conditions or took other drugs that may have influenced the level of prolactin and thus were excluded from our study. The remaining 25 individuals had the level of prolactin measured and they completed a questionnaire about prolactin-related side-effects. Ten individuals refused to take part in the study and it was completed by 15 participants (9 men and 6 women, mean age 48 years, mean duration of treatment with depot risperidone 15.4 months).
In 12 participants the level of prolactin has risen, with 3 individuals having levels more than four times the upper limit of columns Columns Correspondence normal. Only 4 participants with hyperprolactinaemia complained of any prolactin-related symptoms. One person complained of prolactin-related symptoms despite having a normal prolactin level.
The prevalence of hyperprolactinaemia in this study was 80% compared with 53% reported by Bushe & Shaw (2007).
Most individuals taking depot risperidone will have hyperprolactinaemia and reported symptoms are an unreliable guide to prolactin levels. Further study is required to inform decisions about the clinical management of this patient group. 'I wish to speak to a psychiatrist, please': psychiatric vocabulary in phrase books Phrase books play an important role for many tourists and travellers in helping to manage everyday situations. Whether or not individuals with mental health problems can express their needs in local languages using the vocabulary found in commonly available phrase books has not been assessed.

Declaration of interest
We wished to ascertain whether the expression of basic psychological distress was possible using widely available phrase books and whether vocabulary requesting access to psychiatric services was covered. Seven publishers of phrase books were identified: Teach Yourself, Dorling Kindersley Eyewitness, Lonely Planet, Berlitz, Rough Guide, Collins and BBC Active. For each publisher we aimed to assess phrase books in Spanish, Portuguese, Mandarin Chinese and Polish. All seven publishers produced phrase books for Spanish and Portuguese, two did not publish a Mandarin Chinese phrase book and one did not publish a Polish one. We assessed whether a particular phrase book contained a section on health and vocabulary regarding symptoms of depression, anxiety, psychosis, suicidal ideation, asking to see a psychiatrist, requiring psychotropic medication, specifically explaining that one is taking psychotropic medication, explaining that one is taking lithium. We obtained a total of 25 phrase books from the seven identified publishers.
All the books had sections on health: 12% (n=3) had vocabulary for depression and 40% (n=10) had vocabulary for anxiety disorders. Two of the publishers had produced phrase books which contained a word for 'anxious' in the general dictionary, without any cultural context, 16% (n=4) had a (context-free) expression for 'I feel strange,' but none had a word for 'psychosis' or stated how to say 'I have a diagnosis of schizophrenia.' None had any of the other vocabulary elements surveyed.
Publishers of phrase books were contacted for their comments and advice before the survey. The one representative of a publishing house who responded informed the authors that phrase books follow a set template closely (personal communication with Anna Stevenson, Harrap Publishing Manager, Chambers Harrap Publishers, 26 October 2007). It would be irresponsible to suggest that anything more than very basic expression of psychological distress and relevant needs would be possible using a phrase book. Cultural sensitivity would be required to help facilitate effective communication of the most immediate needs. However, as phrase books are prepared according to a template, it would seem a straightforward matter for psychiatrists to approach the publishers of phrase books with a few suggested phrases. Perhaps this is an opportunity to the specialty to work with the publishers to help, in a small way, make the lives of our patients easier.