Ethical conflicts in mental health law

Psychiatry is not exclusively the only medical specialty conflicting with legislation on capacity, although within public health medicine this occurs rarely ([Lepping, 2008][1]). Individuals with capacity can be legally detained, if they have an infectious disease placing the public at risk (Public

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Ethical conflicts in mental health law
Psychiatry is not exclusively the only medical specialty conflicting with legislation on capacity, although within public health medicine this occurs rarely (Lepping, 2008). Individuals with capacity can be legally detained, if they have an infectious disease placing the public at risk (Public Health Act 1984, s38/39).
The ability to legally detain individuals under this Act and the Mental Health Act 1983/2007 is derived from the European Convention of Human Rights, article 5(1)(e). This states that, 'everyone has the right to liberty except in the lawful detention of persons for the prevention of the spreading of infectious diseases, of persons of unsound mind . . .'. This legislation and its interpretations made by courts make no consideration of capacity [Winterwerp v. Netherlands, 1979] and take a utilitarian approach to the treatment of the mentally ill.
The Human Rights Act 1998 demands that British legislation is read in a compliant manner with the European Convention of Human Rights, but as the Convention takes a utilitarian approach to mental illness we would argue the Human Rights Act in this context is not a rightsbased legislation as suggested. We agree with Lepping that the Mental Capacity Act 2005, a primarily rights-based legislation, is in ethical conflict with the utilitarian approach of the Mental Health Act 1983/ 2007, but it equally conflicts with the European Convention of Human Rights. Winterwerp v. Netherlands [1979]  PRN sedative prescribing in the elderly Doctors admitting elderly patients to hospital frequently prescribe sedation as required or pro re nata (prn). They may do this for a variety of reasons, including inexperience, habit and to avoid disturbing a medical colleague at night.
Here we report the results of an audit to determine the frequency of prn sedative prescribing in the elderly.
A prospective and retrospective case note and drug chart analysis of all patients admitted to the old age psychiatry wards during 3 months (1 November 2007-31 January 2008) was completed at the Highgate Mental Health Centre in North London. A total of 35 patients were admitted during this period; of these, 31 notes and drug charts (89%) were available and analysed. As many as 45% of patients were prescribed prn sedation on admission, of which only 16% (n=5) had a clear indication for sedation documented. One patient who should have been prescribed sedation, was not.
The majority of sedative prescriptions appeared to be made routinely and, therefore, inappropriately.
Further training and support for doctors, nurses and other clinical staff on wards should be encouraged to raise awareness of inappropriate prescribing of sedatives in the elderly.

Attendance at psychiatric clinics
We conducted a 1-year retrospective study of attendance at a general National Health Service psychiatric clinic in London between 2005 and 2006. We aimed to compare attendance rates between grades of doctors and identify demographic and organisational factors affecting attendance. Previous publications on the subject had identified relatively poor attendance in psychiatric clinics compared with other medical specialties (Killaspy, 2006) and variation between different grades (McIvor et al, 2004). Little improvement had been noticed between 1969 (Nehama) and 2004 (McIvor et al), taking into account the variation in settings and significant changes to the structure of mental healthcare in the UK. In our study, we looked at the clinics covered by 13 doctors with various degrees of seniority and experience. Appointments were set for 30 min on average at a community hospital in a suburban area with good transport links. The overall attendance rate was 72.4%, ranging between 79.1% for consultant psychiatrists and 63.8% for associate specialists, with intermediate figures for specialist registrars (72.3%) and senior house officers (66.3%). We also found significantly better attendance for morning clinics and on Wednesdays. There was no significant difference between male and female service users or between new and follow-up appointments. Most missed appointments were an isolated event but a small number of service users (n=61) were responsible for 38% of overall non-attendance, having missed between 3 and 12 appointments in that year.
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