Psychiatric risk assessment and the use of section 5/2

MHADr Tony Lewis

Specialty registrar

Objectives • To help FY1 doctors in risk assessing

patients.• To help identify when you can use the

MHA 1983 to detain at risk patients• To learn how and when to get psychiatric

assistance.• Learn what to do when your patient is very

agitated/aggressive.• Learn about the emergency psychiatric

drugs used to sedate or calm violent or severely agitated patients.

Content

• Section 5/2 Mental Health Act 1983– What is it?– When can I use it?

• Risk assessment and emergency detention– What is a psychiatric risk assessment?– Capacity assessment– Scenarios– Emergency drugs

What is mental illness?

• ‘Mental illness’ is a general term that refers to a group of illnesses affecting the mind, in the same way that physical illness refers to illnesses which affect the body.

• Episodes of a mental illness can come and go through people's lives. Some people experience their illness only once and then fully recover. For others, it may recur throughout their lives.

Mental Health Statistics

• Around 300 people out of 1,000 will experience mental health problems every year in Britain

• 230 of these will visit a GP • 102 of these will be diagnosed as having a

mental health problem • 24 of these will be referred to a specialist

psychiatric service • 6 will become inpatients in psychiatric

hospitals

What is the purpose of mental health legislation?

• ‘To regulate the circumstances in which the liberty of persons who are mentally disordered may be restricted and, where there is conflict, balance their interests against those of public policy’

MHA definitions

• Under the latest revision of the MHA Act, there is a single definition of mental disorder:

‘any disorder or disability of the mind’

• Exclusions:– Learning disability, unless ‘associated with’

abnormally aggressive or seriously irresponsible behaviour

– Dependence on alcohol and drugs

What are the most common elements of the Mental Health Act?

• Section 2 – admission for assessment (up to 28 days)

• Section 3 – admission for treatment (up to 6 months, may be renewed)

• Section 4 - Admission for assessment in cases of emergency

• Section 5(2) - Doctors and Approved Clinicians Holding Power (up to 72 Hours)

• Section 5(4) - Nurses Holding Power (up to 6 Hours)

• Part 3 – provision for mentally disordered offenders

• Section 117 Aftercare

Section 5/2 MHA

• Section 5(2) allows the compulsory detention of a patient already receiving inpatient treatment for a duration of up to 72 hours by the doctor in charge of the case.

• As for Section 2, the patient must be suffering from a mental disorder and be a potential danger to himself or to others.

• The detention is to allow time for an application for admission under Section 2 or 3 to be made

Duties and Responsibilities

Consultant Psychiatrists/Approved Clinician (AC)2: When available to personally assess in-patients for S.5(2). Alternatively when contactable but not able to attend the ward to nominate a deputy to implement S.5.2. Where the nominated deputy uses S.5(2) the Consultant/AC must attend the ward to assess whether an application is required under Section 2 or 3.

Nominated Deputy: To attend the ward as soon as possible. Where the Consultant Psychiatrist/AC is not contactable/available, the nominated deputy should exercise their own judgment when assessing the patient for a S.5(2)

Approved Mental Health Professional3 (AMHP): to coordinate an assessment of patient’s possible detention under S.2 or S.3.

Locality Mental Health Act Manager: To arrange for the medical/administrative scrutiny and recording of S.5(2). To provide advice to staff and others about the power.

Psychiatric vs. Somatic illnessPsychiatric symptom Possible physical causes

Depression HypothyroidismCushing’s Syndrome (esp on endogenous steroids)Parkinson’s DiseaseStrokeAlcohol useCancer

Anxiety HyperthyroidismPhaeochromocytomaEpilepsyAlcohol use

Elation Frontal lobe tumoursMultiple SclerosisCushing’s syndrome

Psychosis EpilepsyStrokeAlcohol useHypothyroidismPorphyria

Small group work -Common presentations

Case 1“I want to die so F*!!k off!

Case 2“where am I? who are you?”

Case 3“no one cares about me…..I want to die”

Case 4“it’s the voices again……”

Case 5“I want to leave right now…. ”

Case 6“There is just something not quite right

about her….. ”

Case 7“the aggressive patient”

Case 8“Yes I am diabetic but I do not want any

insulin”

Case 9“ My insides are rotting and I am dead”

How do you risk assess?

• Is the patient a risk to….– Themselves?– Others?– Be exploited?– Self neglect?

• If any of the above is true, then you need to think hard about the management issues, and possible use of the Mental Health Act, depending on how serious the risk appears to be.

• IF IN SLIGHTEST DOUBT CONSULT WITH ONCALL PSYCHIATRIST!!

Focus on risk assessment, and management plan.

Referral

You are called to A&E to see a lady who is fantastically intoxicated. According to the staff she is distressed, difficult to control, displaying suicidal ideas, and needs to be seen urgentlyso that she can be moved away from A&E.

History and examination:

35-year old lady, dishevelled, smells strongly of alcohol, unwashed clothes and hair.Been out on a massive binge with her usual drinking friends.Expressing suicidal ideas ”I just want to die!”, however denies making any concrete plans or practical arrangements.Appears agitated, tearful at times, angry at times.No delusions or hallucinations.Her alcohol use seems to fall under the dependency category, with drinking every day, including in the morning to minimise the withdrawl symptoms. Her drinking pattern has been the same for the past 2 years.At the end of the conversation she is struggeling to keep awake, and she now says ”I just want to sleep…”

Focus on risk assessment, capacity assessment and the next step in his management

Referral

Called to see a gentleman who has recently been treated for pneumonia, who now appears more confused.

History and examination

Known to old age psychiatry, with a diagnosis of Lewy Body Dementia.On examination he appeared bright, cooperative, but confused and disorientated. He could not recall coming in to hospital and doesn’t appear to understand that he is talking to a doctor, despite repeated introductions and you wearing a stethoscope.Appears well kempt, in hospital gown. No sign of malnutrition, recent test shows that the infection has cleared.He has no close relatives, and has up until now lived on his own, independantly.There are no evidence of delusions, hallucinations or any thought disorder.

Focus on risk assessment, use of the Mental Health Act and the next step in her management

Referral

A&E referral to see 19-year old woman, following multiple lacerations to her forearms, and legs, and telling staff she wants to die.

History and examination

After spending an extensive period of time interviewing this lady, who was initially tearful and uncooperative, she discloses that her first long-term relationship ended some two weeks prior to her starting self-harming.There is no evidence of hallucinations, delusions, substance use or thought disorder.She has been seen in A&E with similar problems, 6 times in the past 2 weeks, with a total of 63 stitches to her forearms.She calmed down throughout the interview, and made repeated requests to go home.One hour in to the interview her mom and dad arrives, stating that they could ”look after their precious princess” and take her home.

Focus on risk assessment, use of the Mental Health Act and the next step in her

management

Referral

A&E referral to see a 33-year old woman who has presented with auditory hallucinations, and is visibly very distressed despite attempts to reassure and calm down.

History and examination

Well-known to psychiatric services, diagnosed with paranoid shizophrenia 20 years ago, although has been well managed in the community for the past 6 years.After contacting her CPN, you are informed that she has not attending her last two OP appointments, and not been compliant with her depot injections in the last two months.On examination she is clearly responding to auditory hallucinations, and is very distressed. The voices are telling her that she is worthless and that she would be better off dead. You observe her arguing with the voices (?) saying that ”I don’t want to die….”.She is actively asking for help and wants the voices to go away. However, when you talk about admission to an inpatient psychiatric unit, she becomes more agitated and she says ”the voices are telling me I shouldn’t go there because you will poison them.”

Focus on risk assessment, capacity assessment and the next step in his management

History and examination

65-year old man, being treated for CML. He is normally fully compliant with his treatment and ward instructions, and has never shown any signs of confusion.During the evening he has become more confused, and has shown signs of paranoia, telling the nurses he wants to leave, because the doctor will kill him ”as he did to the patient next to him”.When asking the patient about this, he tells you that the doctor killed his room mate, and he is now terrified that the ”asian doctor” will kill him as well and he needs to escape and notify the police.You notice that there is a note in the patients slippers, and when reading it is says ”It was the asian doctor who did it”.You discuss the case with the on call oncology consultant, who happens to know this patient, and get informtaion about the patients current high dose steroid treatment, his prognosis and normal mental state.

Referral

You are called to the oncology ward in the middle of your night shift. The nurses inform you that one of the patients wants to leave the ward, and has called the police from his bed-side phone ”because the doctor will kill him”.

Focus on risk assessment , use of the Mental Health Act and the next step in her management

History and examination

45-year old woman, known to psychiatric services, with a history of bipolar disorder. Managed by her GP for the past 5 years. Only repeat perscription is for Lithium, levothyroxine and bisoprolol.On examination she is clearly fixated on donating blood to Tiger Woods, and she informs you that she is worried he may get hurt if she is not allowed to donate her blood, which shares a unique blood group with Tiger Woods. She also disclose that her and Tiger Woods are planning to get secretly married later this year, when he is finally divorced from ”the slutty Swedish tart” he is currently married to. She is dressed bizarrly (”Tiger really likes it”) in very colourful clothes, and with heavily applied make up.There is no evidence of hallucinations or thought disorder.She has not been taking her lithium, because she believes that her blood will be contaminated and will therefore affect Tiger Woods’ as well.

Referral

A&E referral to see a 45-year old lady, who will not leave the department until she is allowed to donate her blood to Tiger Woods.The nurses tell you that ”there is just something not quite right about this one….”

Focus on risk assessment , use of the Mental Health Act and the next step in his management

History and examination

45-year old man who was brought in by his wife with increasing agitation.You are unable to obtain any information from the very uncooperative patient, but luckily you are able to talk to the wife and get a collateral history.The wife tells you that he during the last year has become more and more focused on body building, and she has noticed him taking pills every day. He says it is supplements to help his muscle growth, however the wife thinks that it might be steroids.When asked, she tells you he has been getting increasingly moody, and unpredictable and at times he has been hitting both her and the kids.She also reveals that he has been ”talking to someone who isn’t there”.You are urgently called back to see the patient who has now punched both a security guard and the staff nurse, and is saying that he is The Devil.

Referral

You are called to A&E to assist the medical staff in dealing with a very aggressive and agitated 45-year old gentleman, not previously know to psychiatric or medical services.

Rapid tranquilisation algorithm

Focus on risk assessment , use of the Mental Health Act and the next step in his management

History and examination

It is a 60-year old gentleman, who is 5 days post-op of dilation of a colon stricture 2° to advanced colon cancer.This gentleman knows he is terminally ill, but has up until now been compliant with all medication and treatment.You assess this gentlemans capacity, and he clearly demonstrate that he has full capacity to make a decision about his insulin management.When interviewing the patient, it becomes clear that he is clinically depressed, with low mood, anhedonia and fleeting thoughts of suicide, although no fixed plans. He confides in you that he knows that not taking his insulin will be a ”less painful way to go”.

Referral

You are called to W23 by one of the senior surgery consultants, who is by now in a bit of a strop.”This patient is being stupid and uncooperative. This patient is mental – sort him out!”

Focus on risk assessment , use of the Mental Health Act and the next step in his management

History and examination

35-year-old man who has recently been seen for the first time in psychiatric OP after being referred by his GP with depressive symptoms, unmanageble with convential anti-depressants.He lives alone, is unemployed, and is showing signs of malnutrition and self neglect.He has a fixed delusion that his insides are rotting, that other people and himself can smell this, and the only explaination to this is that he is dead.He denies any suicidal ideation ”Well Doctor, I am already dead….”.There is no evidence of formal thought disorder.There is no history of drug or alcohol misuse.

ReferralA&E referral to see a 35-year-old gentleman, who presented to A&E saying he was dead.The nursing staff is getting increasingly frustrated with the man’s obvious delusion, and want you to deal with this urgently.