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      Advance decision-making in mental health – Suggestions for legal reform in England and Wales

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          Abstract

          This paper argues that existing English and Welsh mental health legislation (The Mental Health Act 1983 (MHA)) should be changed to make provision for advance decision-making (ADM) within statute and makes detailed recommendations as to what should constitute this statutory provision. The recommendations seek to enable a culture change in relation to written statements made with capacity such that they are developed within mental health services and involve joint working on mental health requests as well as potential refusals. In formulating our recommendations, we consider the historical background of ADM, similarities and differences between physical and mental health, a taxonomy of ADM, the evidence base for mental health ADM, the ethics of ADM, the necessity for statutory ADM and the possibility of capacity based ‘fusion’ law on ADM. It is argued that the introduction of mental health ADM into the MHA will provide clarity within what has become a confusing area and will enable and promote the development and realisation of ADM as a form of self-determination. The paper originated as a report commissioned by, and submitted to, the UK Government's 2018 Independent Review of the Mental Health Act 1983.

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          Effect of joint crisis plans on use of compulsory treatment in psychiatry: single blind randomised controlled trial.

          To investigate whether a form of advance agreement for people with severe mental illness can reduce the use of inpatient services and compulsory admission or treatment. Single blind randomised controlled trial, with randomisation of individual patients. The investigator was blind to allocation. Eight community mental health teams in southern England. 160 people with an operational diagnosis of psychotic illness or non-psychotic bipolar disorder who had experienced a hospital admission within the previous two years. The joint crisis plan was formulated by the patient, care coordinator, psychiatrist, and project worker and contained contact information, details of mental and physical illnesses, treatments, indicators for relapse, and advance statements of preferences for care in the event of future relapse. Admission to hospital, bed days, and use of the Mental Health Act over 15 month follow up. Use of the Mental Health Act was significantly reduced for the intervention group, 13% (10/80) of whom experienced compulsory admission or treatment compared with 27% (21/80) of the control group (risk ratio 0.48, 95% confidence interval 0.24 to 0.95, P = 0.028). As a consequence, the mean number of days of detention (days spent as an inpatient while under a section of the Mental Health Act) for the whole intervention group was 14 compared with 31 for the control group (difference 16, 0 to 36, P = 0.04). For those admitted under a section of the Mental Health Act, the number of days of detention was similar in the two groups (means 114 and 117, difference 3, -61 to 67, P = 0.98). The intervention group had fewer admissions (risk ratio 0.69, 0.45 to 1.04, P = 0.07). There was no evidence for differences in bed days (total number of days spent as an inpatient) (means 32 and 36, difference 4, -18 to 26, P = 0.15 for the whole sample; means 107 and 83, difference -24, -72 to 24, P = 0.39 for those admitted). Use of joint crisis plans reduced compulsory admissions and treatment in patients with severe mental illness. The reduction in overall admission was less. This is the first structured clinical intervention that seems to reduce compulsory admission and treatment in mental health services.
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            Clinical outcomes of Joint Crisis Plans to reduce compulsory treatment for people with psychosis: a randomised controlled trial.

            The CRIMSON (CRisis plan IMpact: Subjective and Objective coercion and eNgagement) study is an individual level, randomised controlled trial that compared the effectiveness of Joint Crisis Plans (JCPs) with treatment as usual for people with severe mental illness. The JCP is a negotiated statement by a patient of treatment preferences for any future psychiatric emergency, when he or she might be unable to express clear views. We assessed whether the additional use of JCPs improved patient outcomes compared with treatment as usual. Patients were eligible if they had at least one psychiatric admission in the previous 2 years and were on the Enhanced Care Programme Approach register. The study was done with 64 generic and specialist community mental health teams in four English mental health care provider organisations (trusts). Hypotheses tested were that, compared with the control group, the intervention group would experience: fewer compulsory admissions (primary outcome); fewer psychiatric admissions; shorter psychiatric stays; lower perceived coercion; improved therapeutic relationships; and improved engagement. We stratified participants by centre. The research team but not participants nor clinical staff were masked to allocation. This study is registered with ClinicalTrials.gov, number ISRCTN11501328. 569 participants were randomly assigned (285 to the intervention group and 284 to the control group). No significant treatment effect was seen for the primary outcome (56 [20%] sectioned in the control group and 49 [18%] in the JCP group; odds ratio 0·90 [95% CI 0·58-1·39, p=0·63]) or any secondary outcomes, with the exception of an improved secondary outcome of therapeutic relationships (17·3 [7·6] vs 16·0 [7·1]; adjusted difference -1·28 [95% CI -2·56 to -0·01, p=0·049]). Qualitative data supported this finding. Our findings are inconsistent with two earlier JCP studies, and show that the JCP is not significantly more effective than treatment as usual. There is evidence to suggest the JCPs were not fully implemented in all study sites, and were combined with routine clinical review meetings which did not actively incorporate patients' preferences. The study therefore raises important questions about implementing new interventions in routine clinical practice. Medical Research Council UK and the National Institute for Health Research. Copyright © 2013 Elsevier Ltd. All rights reserved.
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              Interventions to Reduce Compulsory Psychiatric Admissions: A Systematic Review and Meta-analysis.

              Compulsory admissions, defined as admissions against the will of the patient (according to local judicial procedures), have a strong effect on psychiatric patients. In several Western countries, the rate of such admissions is tending to rise. Its reduction is urgently needed.
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                Author and article information

                Contributors
                Journal
                Int J Law Psychiatry
                Int J Law Psychiatry
                International Journal of Law and Psychiatry
                Elsevier
                0160-2527
                1873-6386
                1 May 2019
                May-Jun 2019
                : 64
                : 162-177
                Affiliations
                [a ]Reader and lead, Mental Health, Ethics and Law Research Group, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London SE5 8AF
                [b ]Wellcome Senior Research Fellow, Mental Health, Ethics and Law Research Group, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London SE5 8AF
                [c ]Clinical Research Associate, Mental Health, Ethics and Law Research Group, ST6 General Adult Psychiatry and Medical Psychotherapy., Institute of Psychiatry, Psychology and Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, London SE5 8AF
                [d ]ST4 in Forensic Psychiatry, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ
                [e ]Consultant Psychiatrist, Lambeth Home Treatment Team, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ, Visiting senior lecturer, Institute of Psychiatry, Psychology and Neuroscience, King’s College London 16 De Crespigny Park, London SE5 8AF
                [f ]Barrister, Wellcome Research Fellow, Visiting Lecturer at the Dickson Poon School of Law, Kings College London, Somerset House, East Wing WC2R 2LS, Visiting senior lecturer, Institute of Psychiatry, Psychology and Neuroscience, King’s College London 16 De Crespigny Park, London SE5 8AF
                Author notes
                [* ]Corresponding author. gareth.1.owen@ 123456kcl.ac.uk
                Article
                S0160-2527(19)30027-5
                10.1016/j.ijlp.2019.02.002
                6544565
                31122626
                8a7831ae-6445-4438-b8b4-accd99f16e0e
                © 2019 The Author(s)

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                Categories
                Article

                Law
                mental health act,mental capacity act,crpd,advance decision making,advance choice,advance directive,competence,mental capacity

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