Psychiatric risk assessment
and the use of section 5/2
MHA
Dr 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 illness
Psychiatric symptom
Possible physical causes
Depression
Hypothyroidism
Cushing’s Syndrome (esp on endogenous steroids)
Parkinson’s Disease
Stroke
Alcohol use
Cancer
Anxiety
Hyperthyroidism
Phaeochromocytoma
Epilepsy
Alcohol use
Elation
Frontal lobe tumours
Multiple Sclerosis
Cushing’s syndrome
Psychosis
Epilepsy
Stroke
Alcohol use
Hypothyroidism
Porphyria
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.
History and examination:
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 urgently
so that she can be moved away from
A&E.
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
History and examination
Referral
Called to see a gentleman
who has recently been
treated for pneumonia,
who now appears more
confused.
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
History and examination
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.
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
History and examination
Referral
A&E referral to see a 33year old woman who has
presented with auditory
hallucinations, and is
visibly very distressed
despite attempts to
reassure and calm down.
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
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”.
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.
Focus on risk assessment , use of the Mental
Health Act and the next step in her management
History and examination
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….”
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.
Focus on risk assessment , use of the Mental
Health Act and the next step in his management
History and examination
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.
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.
Rapid tranquilisation algorithm
Focus on risk assessment , use of the Mental
Health Act and the next step in his management
History and examination
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!”
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”.
Focus on risk assessment , use of the Mental
Health Act and the next step in his management
History and examination
Referral
A&E referral to see a 35-yearold 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.
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.