The Mental Health Act Review

[Project Status - Completed]

In 2017, the United Kingdom government announced an Independent Review of the Mental Health Act for England and Wales.  The aim was to understand the rapid rise in detentions, particularly among people from Black, Asian and Minority Ethnic (BAME) groups, to clarify the interface between the Mental Health Act and the Mental Capacity Act (2005), and to review recent developments in human rights. The Mental Health Act Review working group commissioned projects that were performed by the Mental Health Policy Research Unit.

The MHPRU held a dissemination event to discuss the results of our work.

Dr. Lloyd-Evans, deputy director of the MHPRU, was a panellist in a Mental Health Question Time event about compulsory admissions and the Mental Health Act (MHA).

Social and Clinical Correlates of Involuntary Psychiatric Detention: A Systematic Review and Meta-Analysis

Euan Mackay, Susan Walker, Monica Leverton, Christian Dalton-Locke, Brynmor Lloyd-Evans and Sonia Johnson

A systematic review was carried out to explore the social and clinical determinants of involuntary psychiatric detention both in the UK and internationally. 69 studies were included in the review. The results highlighted an increased risk of involuntary care for the following groups: males, people with a diagnosis of a psychiatric or bipolar disease, those in receipt of social benefits, people living with friends or relatives rather than their partner/children, non-home owners, single people, people who were previously married or in a long-term relationship and people who have had a previous involuntary detention. Overall, we found that those without long-term partners and who are reliant on social benefits are more likely to be detained under the MHA. This highlights the importance of the role of social support and the link between social support and an increased risk of severe mental illness for vulnerable people. 

PPI commentary: Members of the MHPRU Lived Experience Working Group (LEWG) wrote a commentary on the results of the study. They highlight the clinical risk factors identified in the study measure clinical opinion, which may be a poor proxy for actual need and experience. For example, individuals who were judged to have more severe symptoms were more likely to be detained but measures on the Brief Psychiatric Rating Scale would worsen by detention.

Patients' Experiences of Asessment and Detention Under Mental Health Legislation: Systematic Review and Qualitative Meta-synthesis

Syeda Ferhana Akther, Emma Molyneaux, Ruth Stuart, Sonia Johnson, Alan Simpson and Sian Oram

A systematic review and meta-synthesis of patients’ experiences of being formally assessed for involuntary admission and the experience of detention in a psychiatric hospital. The study included 56 papers. Five themes were identified: 1) information and involvement in care; 2) quality of the environment; 3) quality of relationships; 4) impact on self-worth and 5) emotional impact of detention. The themes were consistent across the studies with involuntary admission being recognised as a negative experience despite keeping them safe at that current time.

PPI commentary: Members of the MHPRU Lived Experience Working Group (LEWG) wrote a commentary on the results of the study. Both members were aware of the traumatic process being detained under the Mental Health Act can be and recommended service providers should focus on ameliorating patient experience. For example, the standards set by independent regulators such as the Care Quality Commission could be increased.

Crisis-planning Interventions For People with Psychotic Illness or Bipolar Disorder: Systematic Review and Meta-analyses 

Emma Molyneaux, Amelia Turner, Bridget Candy, Sabine Landau, Sonia Johnson and Brynmor Lloyd-Evans

A systematic review and meta-analysis of the effectiveness of crisis-planning interventions in reducing rates of compulsory hospital admissions for people with psychotic illness or bipolar disorder. Crises plans, in advance, describe a person’s preference for treatment during a future mental health crisis and can come in different forms such as Advance Decisions and Advance Statements. 1428 studies and 5 randomised-controlled trials were included. The results found that crisis-planning interventions reduce the risk of hospital admissions among individuals with psychotic illness or bipolar disorder compared with usual care, although the interventions varied in content and intensity despite having common underpinnings.

PPI commentary: Members of the MHPRU Lived Experience Working Group (LEWG) wrote a commentary on the results of the study. They highlight the need to consider overall and voluntary admissions as although there has been a 25% decrease in compulsory admissions, voluntary admissions are “de facto”, which lacks legal safeguards.

Compulsory Community Treatment To Reduce Readmission To Hospital and Increase Engagement With Community Care In People With Mental Illness: A Systematic Review and Meta-analyses

Phoebe Barnett, Hannah Matthews, Brynmor Lloyd-Evans, Euan Mackay, Stephen Pilling and Sonia Johnson

A systematic review and meta-analysis of the effectiveness of compulsory community treatment (CCT) in reducing readmission, length of stay in hospital and increasing community service use and treatment adherence. Compulsory Community Treatment (CCT) legally requires people with mental illness living in the community to receive treatment and was introduced in England in 2008, following the Mental Health Act in 2007 in the form of Community Treatment Orders. 41 studies were included, including randomised controlled trials, contemporaneous comparison studies and pre-post studies. Analysis found no consistent evidence that compulsory community treatment reduces readmission or length of inpatient stay but can have some benefit to increasing service provision and enforcing use of outpatient treatment.

PPI commentary: Members of the MHPRU Lived Experience Working Group (LEWG) wrote a commentary on the results of the study. They pointed out the need to know what difference interventions make to the quality of people’s lives and wellbeing, rather than simply measures of readmissions and inpatient bed-days. Although, further research needs to see who is subject to CCT and the fuller picture of experiences of specific groups e.g. women labelled with Personality Disorder.

Psychosocial Interventions To Reduce Compulsory Psychiatric Admissions: A Rapid Evidence Synthesis

Jessica K. Bone, Tayla McCloud, Hannah R. Scott, Karen Machin, Sarah Markham, Karen Persaud, Sonia Johnson and Brynmor Lloyd-Evans

A systematic review and narrative synthesis of interventions for reducing compulsory admissions. Studies that examined one of 15 interventions were included, such as acute day units, adherence therapy, crisis houses and open dialogue. The results found no eligible RCT’s reporting compulsory admissions on some interventions such as acute day units and so interventions could not be sufficiently evaluated. Although, 19 RCT’s were identified including compulsory admissions as an outcome and so, crisis planning interventions showed promising effectiveness and particularly self-management programmes with a crisis planning element. Interventions such as adherence therapy were found to not reduce subsequent compulsory admissions.  

PPI commentary: Members of the MHPRU Lived Experience Working Group (LEWG) wrote a commentary on the results of the study. They highlight the difficulty for someone in crisis to access the support and that topics such as peer support and career involvement were outside the scope of the review. Additionally, the clinical trials reviewed didn’t consider the impact of individual participant variables, such as ethnicity and religion, which effect use of mental health services and may mirror research participation.

Patterns of The Use of The Mental Health Act 1983, from 2007-2008 to 2016-2017, in Two Major London Secondary Mental Healthcare Providers 

Sian Oram, Craig Colling, Megan Pritchard, Mizanur Khondoker, Daniela Fonseca de Freitas, Lucile Ter-Minassian, Johnny Downs, Brynmor Lloyd-Evans, Sarah Markham, Ceri Owen, Nomi Werbeloff, Chin-Kuo Chang, Sonia Johnson, Matthew Hotopf and Richard D Hayes

This study explored how rates of detention have changed in a mental health trust in London (Camden and Islington NHS Foundation Trust). In particular, the study examined if there was an increase in the percentage of patients who were detained at least once, an increase in the number of detention episodes initiated comparing each financial year, or both. Clinical data from electronic mental health records as part of Case Register Interactive System (CRIS) was analysed on working age adults between the ages of 18-65. Analysis found an increase in the number of patients who had at least one detention episode per financial year observed and this finding was due to an increase in the total number of patients being seen with a small decline in the proportion of patients undergoing compulsory admission between 2009-10 and 2015-16.

PPI commentary: Members of the MHPRU Lived Experience Working Group (LEWG) wrote a commentary on the results of the study. They highlight the experience of detention under The Mental Health Act can be both traumatising and damaging to one’s confidence in mental health services. Although, it is positive that the overall number of detentions per individual did not increase over time, it is unfortunate that at both sites, detentions per year increased and at one site, the mean length of detention per active patient detained also increased.

Variations In Patterns of Involuntary Hospitalisation and In Legal Frameworks: An International Comparative Study

Luke Sheridan Rains, Tatiana Zenina, Marisa Casanova Dias, Rebecca Jones, Stephen Jeffreys, Stella Branthonne-Foster, Brynmor Lloyd-Evans and Sonia Johnson

An International Comparative Study was carried out to describe the extent of variations in involuntary annual hospitalisation rates between countries, to compare trends over time, and to explore whether variations in legislation, demographics, economics, and health-care provision might be associated with variations in involuntary hospitalisation rates. There have been rising rates of involuntary hospitalisation in England and other higher-income countries but the reason for this is unclear. Annual incidence of involuntary hospitalisation was compared between 2008 and 2017 for 22 countries across Europe, Australia and New Zealand. Results found variations between countries were large and mostly, unexplained. Although, a higher annual incidence of involuntary hospitalisation is associated with a lower rate of absolute poverty, higher gross domestic product (GDP), higher proportion of foreign-born individuals and larger numbers of inpatient beds; although the associations were weak. Future research could include a more fine-grained analysis of the relationship between involuntary hospitalisation and social context and clinical practice.

Understanding Increasing Rates of Detention in Psychiatric Hospitals In England: Development and Preliminary Testing of An Explanatory Model

Luke Sheridan Rains, Scott Weich, Clem Maddock, Shubulade Smith, Natasha Lyons, Lottie Millett, Sonia Johnson and Brynmor Lloyd-Evans (on behalf of the “Understanding the Rising Rates of Detention Topic Group” for the Independent Review of the Mental Health Act).

A study was carried out to understand the causes of the increase in detentions under the Mental Health Act and explore the plausibility of proposed explanations for their rising rate. The methodology of this study was based on four stages: hypothesis generation, hypothesis testing, assessing the plausibility of hypothesis and developing an explanatory model.

This study is currently under review and the results will be reported in due course.  

Carers' Experiences of Involuntary Admission Under Mental Health Legislation: Systematic Review and Qualitative Meta-synthesis

Ruth Stuart, Syeda Akther, Karen Machin, Karen Persaud, Alan Simpson, Sonia Johnson and Sian Oram

A systematic review and meta-synthesis of the carers’ experiences of the assessment and detention of patients under mental health legislation was carried out including 23. Themes identified in the literature often related to the emotional impact of detention, the impact of detention on carers’ relationships with those who they cared for, the extent to which carers felt involved in decision-making and the provision of care, the availability of support for carers and the quality of care for patients both before and during detention. The themes found were consistent across time and setting.

PPI commentary: Members of the MHPRU Lived Experience Working Group (LEWG) wrote a commentary on the results of the study. They reinforced the need for further research to be carried out to explore how to support carers. For instance, they rarely talk about their own needs and discussions of support for carers tends to focus on supporting carers to support someone else, rather than support for themselves.