Friday, October 21, 2022

Preventing people becoming reliant on antidepressants

The Economist has an editorial ‘Most people on antidepressants don’t need them: Time to wean them off’. It helpfully focuses on the need for de-prescribing. As I said in a previous post for example, doctors have made too many people dependent on antidepressants. 

It’s not just deprescribing that’s needed. More people need to be managed without antidepressants. There may be a sense in which it’s misleading to say that most people on antidepressants don’t need them. It may be underestimating how much they have become habituated to taking them. People who want to stop antidepressants do need help but it is also important to prevent so many people becoming reliant on them.

Tuesday, October 11, 2022

Evidence to the Joint Committee on the draft Mental Health bill

My submission to the Joint Committee on the Draft Mental Health Bill has been published, together with four pages of other submissions. As far as I am concerned, the draft Mental Health bill does not go far enough to reverse the re-institutionalisation of services that has taken place over recent years, particularly reflected in the increase in secure psychiatric provision (see eletter). Those secure services (and other inpatient services) are repeating the worst aspects of the asylums even in the NHS (see last post). There needs to be a refocus on developing community care and inpatient services need to become more open and therapeutic.

As I say in my submission, what's needed in legislative changes are: (1) no further community treatment orders (CTOs) (2) prohibiting civil detentions to secure facilities (3) improving advocacy to create an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts and (4) extending the role and powers of the Mental Health Tribunal (MHT) to treatment as well as detention decisions (thereby making the role of Second Opinion Approved Doctors (SOADs) redundant). A central feature of these changes would be creating a right to a second opinion for detained patients on both treatment and detention, as is being strengthened elsewhere in the world, such as in Victoria, Australia (see previous post). 

Both the National Survivor User Network (NSUN) (see submission) and Mind and ROTA (see submission) agree with me about CTOs. Dr Gareth Owen, in his submission, summarises the lack of evidence for the effectiveness of CTOs. As he says, the amendments proposed in the draft bill are unlikely to reduce CTOs and make their purpose even less clear.

As NSUN say, the revised legislation has not been sufficiently grounded in a rights-based understanding of mental health (see eg. previous post). NSUN and Mind mention the overlap with Seni's law (see previous post), as I did in my submission. Mind make the helpful suggestion of extending the role of the responsible person in each hospital, created by Seni's law, to oversee the promotion of race equity. As I said in my submission, appointment of a responsible person to reduce detention and coercion in each hospital with wider powers than provided by Seni’s law, and not just for racial issues, who could liaise closely with the MHA monitoring division of the Care Quality Commission (CQC), would help to produce a national focus on improving the rights of people with mental health problems delivered through each hospital.

Voiceability (see submission) helpfully endorse the recommendation of the Law Commission that only the Mental Health Act (MHA) should be used to deprive people of their liberty in psychiatric settings. Making this clear in the bill should deal with the fear expressed by several contributors (eg. submission by Lucy Series) that limiting the scope of detention of people with learning disabilities and/or autism under the MHA will not prevent those same people being detained under the Mental Capacity Act. As Voiceability note, however, there are a few examples where the Court of Protection has helped to secure better outcomes for people with a learning disability and autistic people in long-term detention.

Voiceability has also proposed that a national specialist advocacy service for people with a learning disability and autistic people should be commissioned in mental health settings (see paper). Similarly, I am keen to see consideration given to creating a national advocacy service, not only for people with a learning disability and autism, but also for those with mental illness, rather than relying on piecemeal commissioning arrangements. This would be an integrated service of Independent Mental Health Advocates (IMHAs), mental health lawyers and independent experts.

Voiceability also usefully highlight that the primary focus of the Wessely review and White paper was not on Part III patients. I have argued that no further detentions of Part II patients should be made to secure facilities. This will allow secure services to develop their proper function of being an alternative to prison. There may well need to be a national review of forensic/secure services.

The scrutiny committee starts hearing oral evidence this afternoon (see meeting details).

The need for institutional change in mental health services

Another television programme, this time from Channel 4's Dispatches: Hospital undercover are they safe?underlines how current inpatient psychiatric services are not fit for purpose (see last post). The comment by the retired policewoman who worked as an undercover Health Care Assistant at the acute unit at the Linden Centre in Chelmsford for two months is pertinent:-

I found it tiring, mentally exhausting … and sad. Mentally exhausting because I’ve wanted to do the best I can while I’ve been on there. Sad because I personally think if that was any of my friends or family on one of these wards, I would not want them to be there. And that’s not a reflection on anybody in particular but just the whole set-up.

She’s right to emphasise institutional aspects about “the whole set-up”. The Essex Mental Health Independent inquiry needs to make recommendations for a complete overhaul of inpatient psychiatric services to make them more open and therapeutic. In fact, the whole of mental health services needs better direction.

Sunday, October 02, 2022

Psychiatric services have not really progressed since the worst days of the asylums

The scandal at the Edenfield Centre exposed by the BBC Panorama programme is reminiscent of scandals in the asylums from the 1960s. Services haven’t really progressed from the worst aspects of the asylums (see Mail on Sunday article).

The asylum scandals came to light from whistleblowers going to the papers rather than BBC television as in the Edenfield case. Panorama used similar undercover reporting to expose the same sort of abuse of people with learning disability at Winterbourne View and Whorlton Hall (see eg. previous post). The subsequent focus on reviewing the care plans of learning disabled people through independent Care Education and Treatment Reviews (CETRs) has not really reduced segregation, mistreatment and inappropriate provision (see another previous post). 

The phase of public inquiries into the asylums was launched by the Ely Hospital inquiry. In 1967 a nursing assistant at Ely Hospital in Cardiff made a series of allegations about the treatment of patients and the pilfering of property by staff. These allegations were published in the News of the World. The inquiry found examples of callous, ‘old fashioned and unsophisticated’ techniques of nursing control. Although in most instances this practice was not seen as ‘wilful or malicious’, nursing standards were low, supervision weak, reporting of incidents inadequate, and training of nursing assistants virtually non-existent. Staff were found to have pilfered supplies of food. There were determined and vindictive attempts to silence complainants. It also transpired that members of the Nursing Division of the Ministry had visited Ely some years before and had reported ‘scandalous conditions, bad nursing’, and yet nothing had been done about it. In essence the inquiry report confirmed the basis of all the News of the World revelations. 

Another influential inquiry was the Whittingham Hospital inquiry. In 1969 two senior members of the staff at Whittingham Hospital near Preston, Lancashire, made allegations of ill-treatment of patients, fraud and maladministration, including suppression of complaints from student nurses. Two male nurses were convicted of theft. Shortly after the police investigation a male nurse assaulted two male patients, one of whom died. The nurse was convicted of manslaughter and imprisoned. An inquiry was set up after the trial was over. What was significant about the report was that it placed the responsibility on the management for the institutional conditions that led to callous and incompetent nursing and some deliberate cruelty. The inquiry also uncovered suppression and denial of student nurses’ complaints about ill-treatment. 

The political response to this series of inquiries was to set up the Hospital Advisory Service (HAS), which, independent of the normal departmental machinery, provided visiting teams for inspecting hospitals. The Care Quality Commission (CQC) now provides a similar function, although using different methods. Arguably it has more powers than HAS, but it did rate the Edenfield Centre as good. CQC can close private providers but NHS services such as Edenfield can only be put into special administration with its services being taken over by other providers. 

The other main political consequence of the asylum inquiries was the government’s renewal of its promotion of the policy of community care. The view was strengthened that society should not reject its mentally ill and learning disabled people. No longer was it appropriate to consign these people to distant institutions where they lived their lives out of sight and mind of the rest of society, with the potential for them being abused. The white papers Better services for the mentally handicapped (1971) and Better services for the mentally ill (1975) were published. Mental illness hospitals were to be replaced by a local and better range of facilities. On the other hand, the government also wanted to correct the misapprehension that it was actively encouraging a precipitate rundown of psychiatric hospitals.

Louise Hide (2022) provides an overview of the asylum inquiries in her book chapter. This historical perspective is relevant for current problems with services. As I said in my eletter,  open-door policies in traditional psychiatric hospitals led to England reducing its number of inpatients from 1954 before other European countries. The 1959 MHA made informal admission rather than detention the usual method of admission. By 1963, 80% of English psychiatric patients were in open wards. The advantages were striking: tension reduced, violence declined, ‘escapes’ were no longer a problem and staff were able to give their attention more to therapy rather than custody. This therapeutic trend was reinforced by improving patients’ rights in the 1983 MHA. Many old long-stay patients grew old and died in hospital, and the number of new long-stay patients to replace them became much less. With the reduction in hospital bed space, there was a reduction in the average length of stay, although actual numbers of acute admissions increased, including so-called ‘revolving door’ patients. The traditional asylums went into decline and became increasingly irrelevant to the bulk of mental health problems.

There was resistance to the rundown of the psychiatric hospital, not least because it was seen as a challenge to the authority of psychiatrists. Attitudes to community care were polarised and only ended after the traditional hospitals were eventually closed. Fears about public safety due to homicide by psychiatric patients led to the new Labour government’s controversial conclusion that community care had failed. Even if this was true, which I do not think was the case, community care has clearly not developed sufficiently to prevent continuing abuse in hospital. 

The harm caused by inappropriate detention in psychiatric hospital must be acknowledged. Services again need to focus on the development of community care, not that inpatient care may not be needed at times, which, whenever possible, should be truly informal rather than formal under detention. The current draft Mental Health bill being considered by a parliamentary scrutiny committee does not go far enough (see eg. previous post). 

What made progress with the asylum inquiries was the Whittingham hospital inquiry, which saw the problems as institutional rather than only blaming individuals. I think Edenfield needs a similar independent inquiry. It's no good relying on the CQC and NHSE, from which there is a need for independence. Psychiatric services need to become more open and therapeutic. We need government to produce a new mental health strategy (which is currently going through a refresh - see webpage) that makes services more integrated and less dysfunctional.