Therapy and counselling, mood stabilisers, mental health law COPY Flashcards
(112 cards)
1
Q
Rationale behind CBT?
A
Treatment is based on the idea that the disorder is not caused by life events, but by
the way the patient views these events (Fig. 12.1.2). It is a short-term, collaborative therapy,
focused on the ‘here and now’, the goals of which are symptom relief and the development of
new skills to sustain recovery. Some people hold unhelpful core beliefs or ‘silent assumptions’
that they learn from early, traumatic life experiences. These people are more vulnerable to
depression. When exposed to stress at a later date, these core beliefs are activated and they
have negative automatic thoughts or cognitive distortions
2
Q
Example thought process of CBT
A
Friend didnt call when she said she would = CBT comes in =
Negative automatic thought: friend doesnt like me > Emotional response: sadness> Maladaptive behaviour: attempts to avoid friend > social isolation > worsening of mood
3
Q
Key features to look into with CBT?
A
Thoughts
Emotions
Behaviours
Bodily sensations
4
Q
What is selective abstraction
A
Focusing on one minor aspect rather than the bigger picture eg I failed an exam cuz I got 1 question wrong
5
Q
All or nothing thinking
A
Thinking of things in all or nothing terms eg If he doesnt see me today it means he hates me
6
Q
What is magnification/minimisation
A
Over-or under-estimating the importance of an event eg He didnt talk to at that meeting, so he must dislike me
7
Q
What is catastrophic thinking
A
Worst possible outcome of an event
8
Q
What is an overgeneralisation
A
If one thing is not going well, everything is going wrong
9
Q
What is arbitrary inference?
A
Coming to a conclusion in the absence of any evidence to support it eg No one likes me
10
Q
Aim of CBT
A
The aim of CBT is initially to help individuals to identify and challenge their automatic
negative thoughts and then to modify any abnormal underlying core beliefs. The latter is
important in reducing risk of relapse
11
Q
Modes of delivery of CBT
A
CBT can be delivered on an individual basis, in groups, or as self-help via
books or computer programmes (including online). It is usually fairly brief (6–20 sessions)
12
Q
What is relaxation training?
A
This is particularly useful for those with stress-related and anxiety disorders.
Here, the patient is asked to use techniques causing muscle relaxation during
times of stress or anxiety. The patient also learns to put themselves in
situations that they find relaxing, such as walking in the fields.
13
Q
What is systemic desensitisation?
A
This is often used for phobic anxiety disorders. In this therapy, an individual is
gradually exposed to a hierarchy of anxiety-producing situations (
14
Q
What is flooding>
A
Unlike systemic desensitization, flooding therapy involves the patient rapidly
being exposed to the phobic object without any attempt to reduce anxiety
beforehand. They are required to continue exposure until the associated
anxiety diminishes. It is not a technique commonly used.
15
Q
What is Exposure and
response
prevention
(ERP)?
A
This therapy can be used for a variety of anxiety disorders but is particularly
useful for OCD and phobias. Patients are repeatedly exposed to the situation
which causes them anxiety (e.g. exposure to dirt) and are prevented from
performing the compulsive actions which lessens that anxiety (e.g. washing
their hands). After initial anxiety on exposure, the levels of anxiety gradually
habituate and decline.
16
Q
What is behavioural action?
A
This therapy is used for depressive illness. The rationale behind it is that
patients avoid doing certain things as they feel they will not enjoy them or fear
failure in completing them. Behavioural activation involves making realistic and
achievable plans to carry out activities and then gradually increasing the
amount of activity.
17
Q
What are the features of psychodynamic therapy?
A
Freud’s original model focused on therapy as a process of uncovering past trauma to resolve present day symptoms (originally ‘hysterical’ symptoms, such as dissociative paralysis)
Modern day psychoanalytic approaches are still founded on Freud’s theory but the focus is more broadly on making connections between past and present
Helping the person to become more aware of the unconscious processes which are giving rise to symptoms or to difficult repeating patterns
Helping the person construct a narrative of their life and give meaning to symptoms
18
Q
What is important in psychodynamic therapy?
A
The therapeutic relationship with the therapist is seen as part of the focus of the work, with the idea that patterns of relating to others in everyday life will come up in therapy, where they are worked on safely
In the NHS psychodynamic therapy typically takes around a year (may be longer) and involves weekly sessions
NICE Guidelines – Depression in young people and adults
19
Q
Indications of psychodynamic therapy?
A
Dissociative disorders, somatoform disorders, psychosexual disorders, certain
personality disorders, chronic dysthymia, recurrent depression
20
Q
What is the rationale behind psychodynamic therapy?
A
It is based upon the idea that childhood experiences, past unresolved conflicts and
previous relationships significantly influence an individual’s current situation. It is based on
psychoanalytic principles
21
Q
What is the aim of psychodynamic therapy?
A
The unconscious is explored using free association (the client says whatever comes to their
mind) and the therapist then interprets these statements. Conflicts and defence mechanisms
220
(e.g. denial, projection) are explored and the client subsequently develops insight in order to
change their maladaptive behaviour.
There is much emphasis on the relationship between the therapist and patient. Therapies can be
offered on an individual, couples, group or residential community basis.
Key therapeutic tools:
1. Transference: The patient re-experiences the strong emotions from early important
relationships, in their relationship with the therapist. When the current emotions are positive
it is said to be positive transference and vice versa for negative emotions.
2. Counter-transference: The therapist is affected by powerful emotions felt by the patient
during therapy and reflects what the patient is feeling.
22
Q
What is the mode of delivery for psychodynamic therapy?
A
Psychoanalysis is an intense therapy that usually involves between one and
five 50-minute sessions per week, possibly for a number of years. This is a much longer duration
than in CBT.
23
Q
What is psychoeducation?
A
Psychoeducation (PE) is the delivery of information to people in order to help them understand
and cope with their mental illness.
It is usual to inform the patient of: 1) the name and nature of their illness; 2) likely causes of the
illness, in their particular case; 3) what the health services can do to help them; and 4) what they
can do to help themselves (self-help). PE may take place individually or in groups, and will
usually take the person’s own strengths and coping strategies into account.
24
Q
What is counselling?
A
Counselling is a form of relieving distress and is undertaken by means of active dialogue
between the counsellor and the client. It is less technically complicated than other forms of
psychotherapy and can range from sympathetic listening to active advice on problem solving
25
Indications of counselling?
Adjustment disorder; mild depressive illness; normal and pathological grief;
childhood sexual abuse; other forms of trauma (e.g. rape, postnatal depression, pregnancy loss
and stillbirth); substance misuse; chronic medical conditions; and prior to decision making, e.g.
genetic testing or HIV testing.
26
Rationale of counselling?
Behaviour and emotional life are shaped by previous experience, the current
environment, and the relationships that individuals have. People have the tendency towards
positive change and fulfilment which can be halted by ‘life problems’. A collaborative relationship
with a counsellor is one method of addressing these issues
27
Aim of counselling
To help the client or patient find their own solutions to problems, while being supported to
do so and being guided by appropriate advice.
28
What is supportive psychotherapy and what does it involve?
Is used to describe the psychological support given by mental health professionals to patients
with chronic and disabling mental illnesses.
It does not aim to produce change, but rather to help people cope with adversity or unsolved
problems over a sustained period.
Key elements include active listening, providing reassurance, providing explanation of the
patient’s illness, providing guidance and possible solutions to difficulties they are faced with, as
well as enabling the patient to express themselves in a safe environment.
29
What is problem-solving therapy and what does it involve
Consists of a structured combination of counselling and CBT. It facilitates individuals to learn to
deal actively with their life problems by selecting an option for tackling each one, trialling out
solutions and reviewing their effect.
Indications are mild anxiety and depressive disorders.
30
What is Interpersonal therapy (IPT)
IPT is used to treat depression and eating disorders.
The focus is on an interpersonal problem such as a complicated bereavement, relationship
difficulties or interpersonal deficit, adopting techniques from different psychotherapies. The
therapy focuses on the difficulties that arise in relationships and the impact on the individual.
It has some overlap with CBT and psychodynamic therapy and deals with four interpersonal
problems (grief at the loss of relationships, role disputes within relationships, managing changes
in relationships and interpersonal deficits) which may be causing difficulty in initiating or
maintaining relationships.
31
What is eye movement desensitisation and reprocessing (EMDR)
EMDR is a psychotherapy treatment that aims to help patients access and process traumatic
memories with the goal of emotionally resolving them.
It is an effective treatment for PTSD.
It involves the client recalling emotionally traumatic material while focusing on an external
stimulus. The stimulus usually involves the therapist directing the patient’s lateral eye
movements by asking them to look one way and then another or follow their finger.
32
Psychotherapy indications
Adverse life events PE, counselling, relaxation training.
Depression PE, counselling, CBT, psychodynamic therapy, IPT, behavioural
activation.
PTSD PE, CBT (trauma focused), EMDR.
Schizophrenia PE, CBT, family therapy.
Eating disorders PE, CBT, IPT, family therapy, CAT.
Anxiety disorders PE, CBT, behavioural therapies.
Substance misuse PE, CBT, motivational interviewing, group therapy.
Borderline personality
disorder
PE, DBT, psychodynamic therapy, CAT.
33
Features of Family/ systemic therapy
NICE guidance – Psychosis, Depression, Perinatal difficulties, substance use, eating disorders
Family attend together. Interactions are observed by other therapists to help therapists and family reflect.
Works with a family’s strengths to help family members think about (and try) different ways of behaving with each other.
34
What is Dialectical behavioural therapy? (DBT)
DBT is used for individuals with borderline PD.
The therapy adopts components of CBT and also provides group skills training to provide the
individual with alternative coping strategies (rather than deliberate self-harm) when faced with
emotional instability
35
Features of DBT
NICE Guidelines – Borderline Personality disorder, Self-harm & Suicidality
Emotion dysregulation, interpersonal difficulties, repeat self-harm / impulsivity
Intensive therapy
1-hour individual therapy weekly
2 hours group skills training weekly
12-18 months total
Learn and apply skills to understand and regulate emotions, manage interpersonal difficulties and tolerate distress.
36
What does DBT mean?
‘Dialectics’ means trying to balance seemingly contradictory positions
Balancing acceptance (yourself and your experiences as you are) and change (making positive changes in your life)
37
What is cognitive analytic therapy (CAT)
Combines cognitive theories and psychoanalytic approaches into an integrated therapy.
It is based on various areas of analysis including analysing problems and difficulties, how they
began and how they affect everyday life as well as analysing the reasons behind symptoms.
Can be used for a range of psychiatric problems such as eating and personality disorders.
38
What are mood stabilisers?
Mood stabilizers are drugs that are used to prevent depression and mania in bipolar affective
disorder and schizoaffective disorder.
39
Examples of mood stabilisers?
Lithium
Topiramate
Gabapentin
40
Treatment of acute mania
Stop antidepressant > Is patient taking antimanic medication >
No: Consider antipsychotic or mood stabiliser - consider short term benzodiazepine for all patients
Yes: If taking antipsycho check compliance and dose or add mood stabiliser - if taking mood stabiliser only check levels and consider antipsychotic - consider short term benzo
41
Indications of Lithium treatment
First-line prophylaxis in bipolar affective disorder. Also effective in an acute
manic episode (if an atypical antipsychotic is ineffective) and as an
adjunctive treatment for depression (to prevent antidepressant-induced
hypomania).
42
Mechanism of action of lithium
Lithium is an element in the body that is handled in a similar way to sodium.
There is some evidence that bipolar patients have an ↑ intracellular
concentration of sodium and calcium, and that lithium can ↓ these. With
lithium, a decreased activity of sodium-dependent intracellular secondary
messenger systems has been shown, as well as modulation of dopamine
and serotonin neurotransmitter pathways, ↓ activity of protein kinase C and ↓
turnover of arachidonic acid. Lithium may also have neuroprotective effects
mediated through its effects on N-methyl-D-aspartate (NMDA).
43
SE of lithium
GI & LITHIUM
Leucocytosis, Impaired renal function, Tremor
(fine)/Teratogenic, Thirst (polydipsia), Hypothyroidism/Hair loss, Increased
weight and fluid retention, Urine ↑ (polyuria), Metallic taste. In toxicity
(‘TOXIC’): Tremor (coarse), Oliguric renal failure, AtaXia, Increased reflexes,
Convulsions/Coma/Consciousness
44
Contraindications and cautions of lithium
Avoid in renal failure, pregnancy (teratogenic) and breast feeding. Caution
with QT prolongation (including concomitant use of drugs that ↑ QT interval),
epilepsy (↓ seizure threshold), diuretic therapy. Lithium is contraindicated in
untreated hypothyroidism, Addison’s disease and Brugada syndrome (heart
disease with ↑ risk of sudden cardiac death).
45
How do we monitor for lithium
Before lithium treatment is started U&Es and eGFR (lithium has renal
excretion and is nephrotoxic), TFTs, pregnancy status and baseline
ECG should be checked. Drug levels should be closely monitored and
patients should be informed of potential side effects and toxicity.
Lithium levels should be monitored 12 hours following the first dose,
then weekly until therapeutic level (0.4–1.0 mmol/L) has been stable for
4 weeks. Once stable check every 3 months.
U&Es should be checked every 6 months.
TFTs should be checked every 12 months.
46
Dosage of lithium
Usually given as lithium carbonate. Must be given for at least 18 months for
clear benefit. Starting dose 400 mg at night. Titrate dose (400–1200 mg/day)
to keep plasma levels between 0.5 and 1.0 mmol/L.
47
What do you do for lithium therapy?
Check lithium levels (12 hours post dose), at least every
three months and during any intercurrent illness (can ↑
causing toxicity).
At each consultation, ask about any signs of toxicity or
signs of hypothyroidism.
Check thyroid function, U&Es, calcium and creatinine
every 6–12 months.
Inform patients: of potential toxicity and symptoms of this;
the need for contraceptives in women of child bearing
age; the need for regular fluid intake; the need for
compliance in taking medication; of the dangers of crash
diets; to avoid NSAIDs; not to exceed more than 1–2 units
of alcohol per day; that it takes 3–6 months to be
established on lithium, and that lithium cards are available
from pharmacists.
48
What do you not do in Lithium therapy
Prescribe if you are not a
specialist.
Give lithium to women of
child bearing age. Lithium
is teratogenic and can
cause congenital heart
defects.
Give in severe renal
failure.
Prescribe NSAIDs,
diuretics (particularly
thiazides) or ACE
inhibitors without careful
thought.
Prescribe lithium if you
feel that adherence to
treatment will be a
problem.
Withdraw lithium abruptly.
Abrupt withdrawal (either
because of poor
compliance or rapid
change in dose) can
precipitate relapse.
Withdraw lithium slowly
over several weeks,
monitoring for signs of
relapse
49
How do we manage lithium toxicity>
Lithium toxicity is a medical emergency which can lead to seizures, coma and death.
Lithium toxicity is enhanced by the 4 D’s: Dehydration, Drugs (ACE inhibitors, NSAIDs),
Diuretics (thiazide), Depletion of sodium.
If signs of toxicity are identified, lithium should be stopped immediately.
A high intake of fluid should be provided including intravenous sodium chloride therapy, to
stimulate osmo tic diuresis. In the most severe cases, renal dialysis may be needed.
50
Indication of sodium valproate (valproic acid) treatment
Comparable efficacy to lithium as a mood stabilizer. If lithium (and an atypical
antipsychotic) is ineffective or unsuitable in acute mania. Used in
combination with lithium for rapid cycling bipolar affective disorder
51
Mechanism of action of sodium valproate
Valproate is a simple branched-chain fatty acid. It is thought to inhibit the
catabolism of GABA, ↓ turnover of arachidonic acid and activate extracellular
signal-regulated kinase. This alters synaptic plasticity, interferes with
intracellular signalling, promotes brain-derived neurotrophic factor (BDNF)
expression and ↓ levels of protein kinase C.
52
SEs of Sodium Valproate
GI and VALPROATE
GI disturbances, Very fat (↑ weight), Aggression, LFTs ↑, Platelets low
(thrombocytopenia), Reversible hair loss (in 10%), Oedema (peripheral),
Ataxia, Tremor/Tiredness/Teratogenic, Emesis.
53
Contraindications of sodium valproate
Avoid in pregnancy (can cause neural tube defects in the fetus and result in
spina bifida), hepatic dysfunction and porphyria.
54
Monitoring of sodium valproate
FBC (to check platelets) before therapy and before any surgery. Monitor
LFTs and prothrombin time (PT) before therapy and during first 6 months.
Pregnancy test and weight/BMI before commencing. Check LFTs, FBC and
weight again after 6 months then annually.
55
Dosage of sodium valproate
Dose started at 250–500 mg daily, and subsequently titrated upwards.
Oral. IV only used for epilepsy.
56
Indications for carbamazepine
Mania (not first-line), prophylaxis of bipolar affective disorder unresponsive to
lithium. Alcohol withdrawal.
57
Mechanism of action for carbamazepine
Carbamazepine blocks voltage-dependent sodium channels, and therefore
inhibits repetitive neuronal firing. It ↓ glutamate release and ↓ turnover of
dopamine and noradrenaline.
58
SE of Carbamazepine
GI disturbances, dermatitis, dizziness, hyponatraemia, blood disorders e.g.
leucopenia, thrombocytopenia.
59
Contraindications of carbamazepine
Caution in cardiac disease and blood disorders. Contraindicated in AV
conduction abnormalities and acute porphyria. Avoid in pregnancy (can
cause neural tube defects in the fetus).
NOTE: Is a potent enzyme inducer so drugs such as COCPs will be
metabolized faster. If the COCP is being used as a contraceptive, other
methods should be considered.
60
Monitoring of carbamazepine
Check WCC after a week. Measure plasma carbamazepine levels if signs of
toxicity. LFTs and U&Es (hyponatraemia). Baseline measure of weight is
desirable
61
Dosage of carbamazepine
Start at 400 mg daily in divided doses. Build up (max 1.6 g/day).
Oral.
62
Indications of lamotrigine
Used to treat bipolar depression. It is less teratogenic than the other mood
stabilizers and therefore usually the drug of choice in women of child bearing
age. Lamotrigine does not treat or prevent manic episodes.
63
Mechanism of action of lamotrigine
Lamotrigine is thought to work by inhibition of sodium and calcium channels
in presynaptic neurons and subsequent stabilization of the neuronal
membrane.
64
SEs of lamotrigine
GI disturbances, rash (in around 5% of patients), headache and tremor
65
Contraindications of lamotrigine
A combination of lamotrigine and carbamazepine may cause neurotoxicity
66
Monitoring of lamotrigine
LFTs, FBC and U&Es prior to starting. Do not routinely measure plasma
lamotrigine levels unless there is evidence of ineffectiveness, poor
adherence or toxicity.
NOTE: Inform patients to see doctor if signs of hypersensitivity e.g. severe
rash, fever, lymphadenopathy (antiepileptic hypersensitivity syndrome)
67
Dosage of lamotrigine
Must be initiated very gradually beginning at 25 mg daily.
NOTE: Avoid abrupt withdrawal (unless serious Stevens–Johnson rash).
Oral.
68
What is a fundamental principle of medical care
for treatment to be given to the patient, consent
should be gained, i.e. the patient has a right to decide for themselves which treatment to undergo
and which treatments to refuse.
69
What is mental capacity defined by?
one’s ability to make decisions. Capacity can involve consent about
personal welfare, healthcare and financial decisions.
70
What is time specific mental capacity?
Person may lack capacity at one point in time but may have capacity at
another point in time. If the lack of capacity is likely to be temporary, e.g. delirium, it may be
possible to delay the decision until the person has recovered.
71
What is decision specific mental capacity?
May have capacity to consent for one decision but not for another (e.g.
may have capacity to consent for a simple endoscopy but not for a more complex surgical
procedure which poses greater risks, such as a hemicolectomy).
72
What are the situations where treatment can take place without consent?
1. Treatment under the Mental Capacity Act.
2. Treatment under the Mental Health Act.
3. Treatment authorized by a court.
73
What is common law
Common law is the law based on previous court rulings, which differ from laws that are created
by acts of parliament such as the Mental Health Act and the Mental Capacity Act.
74
What is the mental capacity act (2005)
A person may lack capacity to make a decision for a variety of reasons, e.g. dementia, delirium,
intellectual disability, neurological disorder.
The Mental Capacity Act (MCA) aims to identify those people who may lack capacity to consent
to or refuse treatment (see OSCE tips 1 and Fig. 12.7.1) and to protect them. The MCA applies
to England and Wales only and failures to comply with the Act are potentially criminal offences.
75
What is the mental capacity assessment
Look at page 252 of susmit das book
76
When do we suspect a lack of capacity?
CARD
Cognitive impairment, e.g. dementia.
Abnormal behaviour.
Refusing treatment.
Delirium.
77
What are the 5 key principles of the Mental Capacity Act (2005)
1. Best Interests: Decisions made on behalf of the patient must be in their best interests.
2. Help to make decisions: People must be given all appropriate help before anyone concludes
that they cannot make their own decisions, e.g. use of interpreters and multiple times (as
capacity may fluctuate).
3. Eccentric or unwise decisions are allowed: Capacity is determined by the way in which a
decision is made and not the decision itself. Therefore, it does not matter how unwise the
decision is.
4. Least restrictive intervention: Decisions made on the patient’s behalf should be the least
restrictive option.
5. Presumption of capacity: Capacity is assumed to be present until proven otherwise
78
What is a lasting power of attorney?
This allows a person with capacity to appoint an attorney (usually a relative or close friend) to
make future decisions on their behalf if they lose capacity.
There are two types of lasting power of attorney:
1. Property and affairs deals with property and financial affairs.
2. Personal welfare deals with decisions about healthcare, living conditions and location.
79
What is advance care planning?
process that allows patients to make decisions about their future
care. It takes the form of making an advance statement or an advance decision to refuse
treatment, or appointing a lasting power of attorney.
80
What is an advance decision or advance directive?
legal document with a specific refusal of treatment
in a predefined future situation (where the person would have lost capacity) that is signed by the
patient and witnessed. Advance decisions permit a person to refuse treatment but not demand it.
They do not allow patients to refuse basic care needs such as food and drink by mouth or basic
hygiene. Persons writing an advance decision should have capacity at the point of writing it
advance decision only concerns refusing certain treatments. An advance statement can
also be used to express other wishes and preferences not directly related to care, e.g. stating food
preferences. Advance statements are not legally binding like advance decisions
81
What is an advance statement?
(made verbally or written) allows the patients to make general statements
about their wishes and preferences for the future, if they were to lose capacity.
82
What is the Deprivation of Liberty Safeguard (DoLS)
The aim of DoLS is to make sure that people in care homes, hospitals and supported living, who
lack capacity, are looked after in a way that does not inappropriately restrict their freedom.
When a hospital or care home identifies that a person who lacks capacity is being, or risks being
deprived of their liberty, they must apply for an authorization of deprivation of liberty
83
What is Independent Mental Capacity Advocate (IMCA)
An IMCA is someone appointed to support a person who lacks capacity but has no one to speak
on their behalf (i.e. no next of kin or lasting power of attorney).
The IMCA makes representations about the person’s wishes, feelings, beliefs and values, while
bringing to the attention of the decision maker all factors that are relevant to the decision.
84
What is the Mental Health Act 1983 Amended in 2007
The Mental Health Act (MHA) (1983, amended in 2007) is the law in England and Wales that
allows people with a ‘mental disorder’ (see Key facts 2 for definition) to be sectioned, i.e.
admitted to hospital, detained and treated without their consent – either for their own health and
safety, or for the protection of other people.
This is used for individuals who will not consent to be admitted voluntarily, or who lack capacity to
consent to admission and treatment.
Patients who are only under the influence of alcohol or drugs are specifically excluded.
85
When do we decide when to use the MHA 1983
Page 255 Susmit Das book
86
Common abbreviations related to the Mental Health Act (MHA)
MHAC: Mental Health Act Commission (MHA is supervised by this commission).
AMHP: Approved mental health professional (they make an application for the patient to be
sectioned. They may be social workers, nurses, psychologists or OTs, but not doctors).
AC: Approved clinician (almost always doctors but can be other professionals. If they are
section 12, it means they are approved by the Secretary of State as having expertise in the
assessment and treatment of mental disorders as described in Section 12 of the MHA).
NR: Nearest relative.
CTO: Community treatment order
87
What is the definition of a mental disorder?
A mental disorder is defined as any disorder or disability of the mind. It includes mental illness,
personality disorder, learning disability and disorders of sexual preference (e.g. paedophilia), but
NOT dependence on alcohol or drugs.
88
When to use Mental Health Act 1983/2007
Revise Our Mental Health Act
Refusal of voluntary treatment.
Other options have been considered but are not appropriate.
Mental disorder: The behaviour must be the result of a known or suspected mental disorder.
Harm (risk of): The person must be at significant risk of self-harm, self-neglect or harm to
others.
Appropriate treatment: There must be an appropriate treatment option available to the patient.
89
Purpose and recommendations for Section 2 and 3 under MHA
Purpose: Section 2 (s2) allows for an admission, for assessment and response to treatment. It
lasts up to 28 days. The purpose of section 3 (s3) is for the treatment of a mental disorder.
Patients can be detained under s3 if they are well known to mental health services or following
an admission under s2. For s3, patients can be detained for up to 6 months, but may be
discharged before this. Detention under s3 can be renewed for a further 6 months. After that,
detention can be renewed for further periods of one year at a time.
Recommendations: For s2 and 3, an AMHP or rarely the NR makes the application on the
90
Patients rights in section 2 and 3 under MHA
A patient under s2 can appeal against the section to a tribunal during the first 14 days and to
hospital managers at any time.
For s3, patients have the right to appeal against detention to a tribunal (only one time)
during the first 6 months of detention. If the s3 is renewed, an appeal can be made once
during the second 6 months. Then an appeal can be made once during each one-year
period.
Patients have the right to apply for discharge to the Mental Health Act managers at any time
whilst they are detained and an Independent Mental Health Advocate can be sought to raise
any issues patients have with their care and treatment.
Under s2 and s3, patients can’t refuse treatment. Under s3, patients can be treated against
their will for 3 months, but after this time they are seen by a second opinion appointed
doctor (SOAD) if they lack capacity to consent or are refusing treatment. A SOAD carries
out an assessment to see if they think that the treatment is needed.
Some treatments can’t be given without consent unless certain criteria are met. These
treatments include ECT.
91
After care for section 2 and 3 under MHA?
Free aftercare is provided for patients when discharged from s3. This is known as
section 117 aftercare.
92
What are the emergency sections
Section 4
Section 5(2)
Section 5(4)
Section 135
Section 136
All last up to 72 hours apart from section 5(4) which is up to 6 hours
93
What is section 4
Used as an emergency, when s2 would involve an unacceptable delay. Often
changed to a section 2 upon arrival at hospital. It can be done by one doctor with an AMHP or
nearest relative (NR). There is no right to appeal.
94
What is section 5(2)
Is the urgent detention of inpatients on any ward excluding A&E, by an AC.
Patients on s5(2) must then be assessed for s2 or s3 or discharge from s5(2) to become an
informal patient. There is no right to appeal.
95
What is section 5(4)
Allows urgent detention for up to 6 hours of an inpatient already receiving
treatment for a mental disorder in hospital. It is carried out by a registered mental health nurse
when a doctor is unable to attend immediately. There is no right to appeal.
96
What is section 135
Allows a police officer or authorized person with a magistrate’s warrant to enter a
person’s premises, who is suspected of suffering from a mental disorder, and remove them to a
place of safety.
97
What is section 136
Allows a police officer to remove an individual, who appears to suffer from a mental
disorder, from a public place to a place of safety for assessment.
98
What is a community treatment order
A community treatment order (CTO) allows patients on s3 who are well enough, to leave the
hospital for treatment in the community.
The decision is made by the responsible clinician (RC) with the agreement of the AMHP.
The patient can be recalled to hospital if they do not comply with treatment or attend
appointments. Once recalled they may be detained for up to 72 hours for assessment.
99
Other notable sections
Section 117: Deals with aftercare responsibilities after a patient has been detained under s3.
Sections 35–38: Used by a court to send offenders to hospital for psychiatric assessment.
Section 7 (guardianship): Gives power to specify where the patient lives and requires them to
give professionals involved in their care, access to their home.
Sections 58 and 59: Deal with treatments requiring consent or second opinion and consent and
second opinion, respectively.
Section 62: Concerns urgent treatments such as ECT for life-threatening depression.
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Section 2
Admission for assessment
– not renewable.
Assessment
An AMHP or rarely the NR
makes the application on the
recommendation of two doctors.
One of the doctors should be
‘approved’ under Section 12 of
the MHA (usually a consultant
psychiatrist).
28 days
Duration: 28 days
Renewal: No
Purpose: Assessment +/- treatment (with or without consent)
Professionals involved: 2 doctors (one S12 approved), 1 AMHP
Evidence required:
The patient is suffering from a mental disorder that is…
Of a nature or degree that warrants detention in hospital for assessment; and
The patient ought to be detained for his or her own health or safety, or the protection of others
Tribunal: Yes
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Section 3
Admission for treatment –
renewable.
Treatment Same as section 2.
6 month
Duration: 6 months
Renewal: Yes, each renewal then lasts 12 months
Purpose: Treatment
Professionals involved: 2 doctors (one S12 approved); 1 AMHP; Nearest Relative
Evidence required:
The patient is suffering from mental disorder that is…
of a nature or degree which makes it appropriate for the patient to receive medical treatment in a hospital; and
The treatment is in the interests of his or her health and safety and the protection of others; and
Appropriate treatment must be available for the patient
Tribunal: Yes; also, more significant role of Nearest Relative
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Section 4
Used as an emergency,
when a section 2 would
involve an unacceptable
delay. Often changed to a
section 2 upon arrival at
hospital.
Emergency GP and AMHP or NR. 72
hours
Duration: 72 hrs
Purposes: Admission for assessment when there is an “urgent necessity” in which waiting for a second doctor would lead to “undesirable delay”
Professionals required: 1 doctor; 1 AMHP or Nearest Relative
Evidence required:
The patient is suffering from a mental disorder that is…
of a nature or degree that warrants detention in hospital for assessment; and
The patient ought to be detained for his or her own health or safety, or the protection of others; and
There is not enough time for 2nd doctor to attend (risk)
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Section 5(2)
A patient who is a voluntary
patient in hospital can be
legally detained by a doctor.
Holding Doctor. 72
hours
For a patient already admitted (can be psychiatric or general hospital) but wanting to leave
Duration: 72 hours
Renewal: No
Purpose: Allows time to convene MHA assessment
Treatment: Cannot be coercively treated
Evidence required:
It appears to the registered medical practitioner that an application ought to be made [under the Act] for the admission of the patient to hospital
Tribunal: No
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Section 5(4)
Similar to section 5(2) but
completed by nursing staff.
Holding Nurse. 6 hours
For a patient already admitted to hospital (psychiatric or general) but wanting to leave
Duration: 6 hours
Renewal: No
Purpose: Allows time for MHA assessment
Treatment: Cannot be coercively treated
Evidence required:
It appears that the patient is suffering from mental disorder…
to such a degree that it is
necessary for his health or safety or for the protection of others for him to be immediately restrained from leaving the hospital
Tribunal: No
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Section 135
A court order can be
obtained to allow the police
to break into a property to
remove a person to a place
of safety.
Police Magistrate/Police officer. 72
hours
Allows police to legally enter a private dwelling and remove someone to a place of safety
Duration: 24 hours
Professionals involved: AMHP
Needs a court order (Magistrate)
Renewal: No
Evidence Required:
Reasonable cause to suspect that a person believed to be suffering from mental disorder; and
Is being ill-treated; or
Is living alone and is unable to care for themselves
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What is a private dwelling??
What is a private dwelling?
Any house, flat or room where that person, or any other person, is living; or
Any yard, garden, garage or outhouse that is used in connection with the house, flat or room, other than one that is also used in connection with one or more other houses, flats or rooms.
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Section 136
Allows police to legally detain (not arrest) someone in a public place without a warrant and remove them to a place of safety
Duration: 24 hours
Professionals involved: Police
Renewal: No
Evidence Required:
A person appears to a constable to be suffering from mental disorder and to be in immediate need of care or control
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What is needed for someone to have a mental disorder?
Mental Disorder
What’s included? What’s excluded?
Nature / Degree
Section 12 Approved Doctor
“Special experience in the diagnosis or treatment of mental disorder”
Approved Mental Health Professional (AMHP)
Social worker, Psychiatric Nurse, OT, Psychologist
Nearest Relative
Section 26 MHA
Listed in terms of priorities
Has certain powers and responsibilities
Place of Safety
ED
Police Cell
Psychiatric Hospital (‘136 Suite’)
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Who does the mental health disorder exclude?
Disorder:
“Any disorder or disability of the mind” – Ch 1, MHA
Excludes
Acute intoxication
Autism / ID alone unless accompanied by “abnormally aggressive or seriously irresponsible conduct” (MHA CoP 2.15)
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What are the guiding principles of the mental health law?
Least Restrictive Option
Empowerment and Involvement
Respect and Dignity
Purpose and Effectiveness
Efficiency and Equality
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What are the guiding principles of the mental health law? (2)
Respect for patients' past and present wishes and feelings
Respect for diversity
Avoidance of unlawful discrimination
Involvement of patients, carers, and other interested parties in planning, developing, and delivering care and treatment appropriate to them
Effectiveness of treatment
Patient wellbeing and safety
Public safety
Minimising restrictions on liberty
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