Saturday, 23 March 2013

When Do You Stop Extending a Community Treatment Order?

Patients subject to CTOs at 31 March 2012, by gender and by year

Community Treatment Orders were introduced into the MHA 1983 by the 2007 amendments. The Code of Practice (25.2) states that: “The purpose of SCT is to allow suitable patients to be safely treated in the community rather than under detention in hospital, and to provide a way to help prevent relapse and any harm – to the patient or to others – that this might cause. It is intended to help patients to maintain stable mental health outside hospital and to promote recovery.”

The intention of Parliament was for CTO’s (or Supervised Community Treatment) to prevent “revolving door” patients – that is, people with severe and enduring mental illness such as schizophrenia or bipolar affective disorder who would tend to become unwell, require hospital admission , recover and be discharged on medication, which they would then stop taking, leading to relapse and further acute admission.

Since this part of the Act came into force in 2008, CTO’s have become increasingly popular. The report on use of the MHA for 2010-11 reported: “The number of people on CTOs at the end of the year rose, even though the number of new CTOs made during the year reduced. This was due to the number of new orders made being greater than the number of orders from which people were discharged: 3,834 new CTOs were made in 2010/11 and 2,185 orders were closed.”

The data for 2011-12 shows that “there were a total of 4,220 uses of community treatment orders (CTOs) across the NHS and independent sector. This represents a 10 per cent increase from 3,834 in 2010/11.” The latest report said that the statistic suggest “that there were 6,964 CTOs in place at the end of the 2011/12”.

The main reason for this would appear to be that people on CTO’s frequently get them extended.

Typically, what happens is this: a patient is detained in hospital under Sec.3 MHA for treatment. When they are ready for discharge, consideration is given for them to be discharged under Supervised Community Treatment (SCT) and they would then be on a CTO. Although the patient’s psychiatrist is responsible for making an Order, an AMHP has to endorse this.

The first period of SCT lasts for 6 months. Towards the end of this period, the patient’s psychiatrist reviews the effectiveness of the CTO in keeping the patient well and out of hospital, and considers the need to extend it. An AMHP also has to endorse any extension. The first period of extension lasts for another 6 months. If the CTO is extended again, the period lasts for 1 year, and each subsequent extension will be for 1 year.

Patients on CTO’s rarely appeal against either the initial CTO, or subsequent extensions. In fact, in my experience, they often want nothing to do with the Tribunal or Manager’s Hearing which can be automatically triggered by a discharge of a CTO or an extension. Some of them have even told me that they feel safer knowing that they are on a CTO. I guess they feel that they are less likely to be abandoned by mental health services.

This often leads to strange Tribunals, where only the Community Responsible Clinician and an AMHP or care coordinator are present.

The difficulty with this system is that it is much easier to make a decision to extend the CTO, than to discharge it or let it lapse. After all, if the patient has complied with the conditions of the CTO, which are generally that they should see their care coordinator and community responsible clinician and that they should take their prescribed medication, and they have remained out of hospital, then that is surely evidence that the CTO is working, and therefore should continue. Isn’t it?

Andy is a man with bipolar affective disorder. I have been his care coordinator for over 4 years. Andy does not like taking medication, and has little insight into his mental illness. His view is that if he is well, then he obviously does not need to take medication, as that is only for people who are unwell. Consequently, when he is discharged from hospital well, he will very quickly stop taking his medication. He then becomes acutely unwell, and is soon detained under Sec.3 MHA again.

Not only does he become acutely and distressingly unwell, but his behaviour becomes very reckless and dangerous, and he invariably comes to the attention of the police. In the past, he has hijacked vehicles, threatened people with knives, and damaged property.

In the year prior to his being placed on a CTO, Andy had three acute hospital admissions, all via the police, and all under the MHA. His behaviour was often so unmanageable on an acute ward that he would need a period of time in a Psychiatric Intensive Care Unit (PICU). His wife was at the end of her tether and was considering leaving him. It was decided that he would be given depot medication by injection once a fortnight and was discharged under a CTO.

Towards the end of the first 6 months we reviewed him. During that time, Andy had complied with all the conditions of the CTO, especially the condition that he attended for his fortnightly injection. During that time, he had committed no offences and had not had any relapses. His wife said that she was pleased with his stability overall, but expressed concern about his sedation. However, Andy said he was completely satisfied with the medication regime and did not want any changes. Nevertheless, in view of the serious consequences not treating his mental illness in the past, we decided that it was appropriate to extend his CTO for a further 6 months.

We reviewed the CTO again a few weeks before it was due to lapse. There had been no problems or any evidence of relapse during that period, and Andy again said he was happy with his medication. However, his wife said that she was still concerned by his lack of motivation, complaining that he spent most of the day in bad and was reluctant to leave the house or socialize.

It was decided to change his depot medication to see if that improved these side effects. In view of this change, it was also decided to extend the CTO again, this time for 12 months.

We reviewed Alan a few days ago. Things were much the same – he was still happily attending for his injection, he had not been in any trouble, and he appeared to be free of the grandiose and aggressive symptoms that had troubled him in the past. However, his wife was still complaining about his lethargy and complete lack of any motivation.

I was concerned about this situation. What was the best thing to do? Should we stop his medication altogether? Should we stop the injection, but try him on oral medication, which could not be given by injection? By now, he had been out of hospital and mentally stable for 2 years. Should we discharge the CTO? Should we allow the risk of relapse, on the basis that his quality of life appeared to be seriously impaired?

We knew that he would still be unlikely to take oral medication, and if it was his sole medication, he would be at almost inevitable risk of relapse. In the end, it was decided that he would be prescribed an oral mood stabiliser in addition to the injection to see if that had an effect on his overall presentation.

Because of this further change in medication, it was also decided to extend the CTO, the consequence of which was that by the time of the next review, he would have been on a CTO continually for 3 years. I didn’t feel very comfortable about this decision, but was reluctant to disagree with the recommendation of his psychiatrist, and equally reluctant to risk a repetition of his behaviour when unwell.

The question remains: when could it be considered worth risking the relapse of a patient who has remained stable on a CTO?

I don’t have an answer to that.

Friday, 8 March 2013

Should People with Personality Disorders Ever Be Sectioned?

The DSMV (yes, I am that up-to-date), when discussing the diagnostic criteria for personality disorder, states:
“The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:
  • Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.
  • One or more pathological personality trait domains or trait facets.
  • The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.
  • The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual’s developmental stage or socio-cultural environment.
  • The impairments in personality functioning and the individual’s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).”
I have to say that this definition is rather harder to understand than the DSMIV criteria, which talks much more clearly about personality disorder as being “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture”. It goes on to talk about how the development of a personality disorder can be traced back at least to adolescence or early adulthood.
Personality disorder essentially comes about as a result of abusive or aversive early life experiences. An event, such as sexual abuse, interferes with the normal development of personality. In an effort to cope with such extreme and difficult life experiences, the child or young person can develop coping strategies which can be perceived as “abnormal”, but which within the context of that person’s experiences may be the only way they can survive. A typical example of this is deliberate self harming through cutting or other means, as a way of relieving the individual of emotional distress.
While a formal diagnosis of personality disorder may not be given too commonly, I would estimate that at least 50% of patients of a typical Community Mental Health Team could be identified as having at least some of the diagnostic features outlined in the DSMV manual. It’s certainly the case in the Charwood CMHT.
Traditionally, and unfortunately too often in the present, the term “personality disorder” has often been used negatively to describe people whose behaviour others find “difficult” or hard to understand. Because personality disorders can be difficult and unrewarding to treat, it has often been the case that doctors make a statement along the lines of: “This person has a personality disorder. They are therefore not mentally ill, are untreatable, and should not therefore receive services.”
Unfortunately, one still hears this sentiment, despite the publication in 2003 of Personality disorder: No longer adiagnosis of exclusion. Published by NIMHE, it remains the principal guidance for the development of services for people with personality disorder in this country.
The introduction is immediately encouraging:
“Personality disorders are common and often disabling conditions. Many people with personality disorder are able to negotiate the tasks of daily living without too much distress or difficulty, but there are others who, because of the severity of their condition, suffer a great deal of distress, and can place a heavy burden on family, friends and those who provide care for them.
As with all forms of mental disorder, the majority of people with a personality disorder who require treatment will be cared for within primary care. Only those who suffer the most significant distress or difficulty will be referred to secondary services. This guidance is designed to ensure that once referred, they receive access to appropriate care.”
The publication states:
“The current 1983 Act is often interpreted as excluding those with personality disorder from compulsory detention because of the requirement that the mental disorder be “treatable”. (i.e. treatment is likely to alleviate or prevent a deterioration in the patient’s condition). Many clinicians have not seen personality disorder as a mental disorder that is treatable. This will change with the new mental health legislation … which removes the treatability clause, and provides a generic description of mental disorder.”
The report makes frequent reference to the appropriateness of use of the MHA for the treatment of people with personality disorder, especially in the forensic area. It has been estimated that up to 80% of prisoners have some form of personality disorder.
Of course, this was written some years before the 2007 Act amendments to the 1983 Act were finalised. So what does the final Act say?
Well, the old definition of “mental disorder” was as follows: “mental illness, arrested or incomplete development of mind, psychopathic disorder and any other disorder or disability of mind and “mentally disordered” shall be construed accordingly”. The Act also included “mental impairment” and “severe mental impairment”.
The new definition is short and concise, being merely “any disorder or disability of the mind”.
The revised Act did not in fact remove the concept of treatability, and in fact detention under Sec.3 requires that “appropriate medical treatment is available for him
In an attempt to be helpful Sec.3(4) adds: “references to appropriate medical treatment, in relation to a person suffering from mental disorder, are references to medical treatment which is appropriate in his case, taking into account the nature and degree of the mental disorder and all other circumstances of his case.”
The Reference Guide (Para 1.16) adds that “medical treatment” “includes nursing, psychological intervention and specialist mental health habilitation, rehabilitation and care (as well as medication and other forms of treatment which might more normally be regarded as being “medical”)”. It goes on to say that this medical treatment is “for the purpose of alleviating, or preventing a worsening of, the disorder or one or more of its symptoms or manifestations”.
So where have I got with answering the question posed in this post?
I think I’ve established that detention under the MHA is possible, since a personality disorder is certainly a mental disorder under the MHA.
I’ve also established that personality disorder can be regarded as treatable, and that the legal guidance covers the main sorts of treatment that might be used with personality disorder.
There is therefore no legal reason why someone with a personality disorder cannot be detained under a section of the MHA.
But this is not the same as saying that formal detention should be a routine consideration when an AMHP is presented with someone with a personality disorder.
At least half of my caseload as a CMHT worker are people with personality disorders, in particular, emotionally unstable or borderline personality disorder. I’ve written about some of them on the blog. I even detained one under Sec.2 on one occasion. (although didn’t actually admit her).
Some of the people I work with will spend periods as an inpatient if their emotional instability becomes so severe that they become dangerous to themselves, although the primary thrust of care planning is always to keep them out of hospital.
The care plan of one woman I work with, who frequently engages in self harming and other challenging behaviour, specifically includes a passage stating that, in a crisis, it is unlikely that hospital admission would be helpful.
Hospital, and compulsion under the MHA, does certainly have a place in the treatment of severe personality disorder, especially in the forensic sphere, but the NIMHE guidance encourages the use of specialist resources within the community for most people. It is certainly my experience that it is better to work as much as possible with the wishes of the person, and to respect any advance decisions they may make about the use of hospital and compulsion.
But that does not mean that the MHA should never be used, or only used with forensic cases. I have discussed this issue at length in my post about the Kerrie Wooltorton case, where a patient with a personality disorder was allowed to die after drinking antifreeze, on the basis that that was what she wanted.
In the end, if the requirements for detention are met, then the MHA should be used, if all alternatives, including informal admission, have been exhausted. As well as the basic criteria relating to mental disorder of a nature or degree, for Sec.2, that would be “he ought to be so detained in the interests of his own health or safety or with a view to the protection of other persons”, and for Sec.3 “it is necessary for the health or safety of the patient or for the protection of other persons that he should receive such treatment and it cannot be provided unless he is detained under this section and appropriate medical treatment is available for him”.