In Practise Flashcards
Mental Health Act Assessments, The Law and Pathways
What are the components of the MSE?
- Appearance and Behaviour
- Speech
- Mood
- Thought
- Perception
- Cognition
- Insight
How would you comment on the patient’s appearance and behaviour?
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General appearance starting with age, sex and ethnicity. Note makeup, clothing, scars, piercings, tattoos, and self care (I.e. well kempt or neglected).
- When presenting, start with the most striking thing.
- Body language including facial expression, eye contact, posture, activity level.
- Describe what they where doing: e.g. pacing around the room
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Other movements such as:
- Extrapyramidal side effects
- Repeated movements such as mannerisms (goal-oriented movements such as sweeping hair from face), stereotypies (not goal-oriented such as flicking fingers in the air), tics (involuntary movements involving groups of muscles) and compulsions (rituals the patient feels compelled to undertake).
- Catatonic symptoms which are very rare - such as waxy flexibility.
- Rapport - are they withdrawn and cold; polite and friendly; rude or guarded?
- Smells
How would you comment on the patient’s speech?
- Rate - fast, slow or normal.
- Volume - loud, soft or normal, e.g. shouting or whispering
- Tone - the emotional quality of speech, e.g. sarcastic, angry, glum, calm, neutral.
- Flow - speech may be spontaneous, or only when prompted; hesitant, or with long pauses before answers.
- Speech can be pressured, there can be poverty of speech, though block, loosening of associations/knight’s move thinking.
How would you comment on the patient’s mood?
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Mood is the pervasive experience of the patient, while affect is the momentary changing state we observe from the outside. Mood can be euthymic, hypothymic, hyperthymic:
- Subjective - how the patient says they are feeling - recorded in their own words
- Objective - what you think about the patient’s emotional state. As well as naming the mood, you can comment on its variability: It can be labile or flat/blunted.
Affect can be reactive/unreactive and comment on whether it was congruent/incongruent
How would you comment on the patient’s thoughts?
- Preoccupations and worries
- Delusions
- Overvalued ideas - reasonable ideas pursued beyond the bounds of reason.
- Obsessions
- Thoughts or harm
How would you comment on the patient’s cognition?
Cognition is the umbrella term covering thinking and remembering. It includes orientation, attention, concentration, and memory, all of which are affected by the patient’s level of consciousness.
What are the key mental health laws in England and Wales?
- Mental Health Act 1983, amended by the Mental Health Act 2007 - with supporting Regulations and Codes of Practice (further amendment in 2012)
- Mental Capacity Act 2005
- European Convention on Human Rights (ECtHR)
- Human Rights Act (HRA) 1998
Laws for children:
- Children Act 1989
- Children Act 2004
- Family Law Reform Act 1969
What are the ways patients are admitted to mental health wards since 2005?
If the patient does not have capacity and requires detention for assessment/treatment:
- And is refusing- requires MHAA (Mental Health Act Assessment)
- And is accepting admission - requires DoLS (Deprivation of Liberty Safeguards). For example if an elderly patient accepts admission but it is known she wonders off at night, she can be detained (may be in a great nursing home) under SoLS
If the patient does have capacity and requires detention for assessment/treatment:
- And is refusing- requires MHAA
- And is accepting admission - this is called informal admission
Describe the details of the sections which allow patients to be detained into hopsital from the community.
The MHA provides powers to admit people living in the community to hospital by force. Legal criteria must be met when a person with a mental health condition needs hospital admission for assessment and treatment of their condition.
Police Sections:
- Section 135 - Warrant to search and remove. AMHP (Allied Mental Health Professional) applies to Magistrates Court for warrant to gain access to property to look for and remove an ill patient to a place of safety (usually a hospital). This is executed by the police who must be accompanied by AMHP and a doctor. This can result in 72 hour admission for assessment.
- Section 136 -Police power of arrest.Police power to remove mentally ill person from a public place to a place of safety. This can result in 24 hour admission for assessment.
Who are the people involved in a mental health act assessment?
There are five people involved in section 2 and section 3 assessments:
- The patient
- Approved Mental Health Professional (AMHP)
- Medical Recommendation (1) - a S12 Approved Doctor
- Medical Reccomendation (2) - any fully registered practitioner, preferably the patient’s GP
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The nearest relative - should be consulted (and for section 3 must agree).
- Spouse > Eldest Parent > Eldest Sibling
After the MHAA the patient is either detained under section 2 or 3, or not detained.
What are the features of a section 2 detention?
Section 2 of the MHA grants power to detain and treat a person in hospital for up to 28 days. This can be used to:
- Admit patient from community
- Prevent a voluntary patient from leaving hospital
- Following a short-term section (135, 136, 5(2), 4)
The patient can appeal to the MH review tribunal and the right to independent MH advocate.
Patients are allowed to leave the ward temporarily under section 17.
Patients can be discharged from section 2, by RC, tribunal, manager’s hearing.
How long does a section 3 detainment last for?
Section 3 allows detention for up to 6 months. However, no treatment is allowed after 3 months without patient consent or with SOAD(second opinion) review.
The section can be renewed for 6 months and then 1 year.
What are the features of a section 4 detainment?
Section 4 is used in an emergency when a second doctor is not available. It allows admission for assessment in cases of emergency where waiting for a second doctor would cause undesirable delay. It requires one doctor and an AMHP. It is rarely used in London as a second doctor is nearly always available.
- Lasts up to 72 hours.
What are the features of a section 5(2)?
Section 5(2) is the Doctor’s holding power. A consultant psychiatrists or nominated deputy (with full GMC registration i.e. FY2+). It is used when the inpatient (not A&E or outpatients) is suspected to be suffering from a mental disorder. The purpose is to allow time for a MHA assessment.
- Allows detention for up to 72 hours
- Does not authorise treatment for a mental disorder. However, if you need to treat without consent, either perform a MHA assessment to section them under another section, or use the MCA (Mental Capacity Act) to make a decision in the patient’s best interest.
Often used in general wards but can be done in the psychiatric ward in emergency situations when other less restrictive measures have been tried, or if it is not possible/safe to wait for section 2/3 complete assessment.
- All doctors need to see the patient
- A form must be given to the nurse in charge and site-lead
- Section 132 rights read
- AMHP informedwho’ll arrange a formal MHAA
How long does a section 5(4) last?
Section 5(4) is the nurse’s holding power that lasts up to 6 hours.
