EMERGENCY DEPARTMENT ASSESSMENTS FOR INVOLUNTARY ADMISSION TO AN APPROVED CENTRE, AFTER IMPLEMENTATION OF MENTAL HEALTH ACT (2001): RETROSPECTIVE CASE REPORT STUDY FOR THE FIRST SIX MONTHS SOMERS CJ & McKAY AP, PSYCHOLOGICAL MEDICINE SERVICE, ADELAIDE & MEATH HOSPITAL, INCORPORATING NATIONAL CHILDREN’S HOSPITAL, TALLAGHT, DUBLIN 24. psychmed@amnch.ie INTRODUCTION A new Mental Health Act – MHA, 20011- passed by Dáil Eireann in July 2001 to update Irish legislation, in keeping with international standards, was implemented fully in November 2006. The principal objective of the present study was to determine, for the first six months of implementation of the new legislation, outcomes of Emergency Department (adult) assessments for possible involuntary admission to MHA, 2001, Approved Centre in Adelaide & Meath Hospital. Secondary objectives were to analyse sociodemographic and clinical factors; and to compare the number of involuntary hospital admissions in the first six months of the new legislation with the same time period, three years later. METHOD Approved Centre for admission under MHA, 2001, in Dublin West/South West Mental Health Service (St Loman’s) is in Adelaide & Meath Hospital, a University Teaching Hospital. The study was carried out in adult services Emergency Department (ED), for the time period 1 November 2006 to 30 May 2007. Data on number of involuntary admissions for the same time period in 2010 was also obtained. All cases aged 16 years or older i. presenting to ED for possible involuntary admission; and/or ii. where MHA, 2001, application for involuntary admission was made during the patient’s time in ED, were included. Sociodemographic and clinical features, with ICD-10 diagnosis2, as well as outcome of presentation, were determined by retrospective chart study. Results analysed using Excel.3 RESULTS Over the first six months of the new legislation, 22 subjects (13m, 9f) were included. Source of referral to ED was GP (8), Garda (6), self (4), community mental health team (2), family member (1). Ten cases were brought to ED by Garda, with Garda involvement in transfer to ED for another 4. 14 subjects were single or separated and 5 were married; 11 resided with family members, 2 lived alone and 2 were homeless; 12 subjects were unemployed or in receipt of disability benefit, and 5 were employed. All were from the local psychiatry catchment area. Outcome of assessment was involuntary admission for 9 subjects, 5 were admitted voluntarily, 5 were referred to community mental health service, 1 was referred to community alcohol service, and 1 refused follow-up. Involuntary admission from ED in these 9 subjects represented 15% of the total number of patients (n=58) admitted involuntarily to Approved Centre in this time period, via all care pathways. CONCLUSIONS Results may indicate that, over this time period, additional development in the local community psychiatry service may have led to fewer patients with schizophrenia being admitted involuntarily via ED. Length of hospital stay appears to have been lower in the later study period, for patients admitted involuntarily via ED, although this did not reach statistical significance. This requires further study but may possibly be associated with additional development and care options in the local community psychiatry service. Numbers included in the study are too small to allow further statistical analysis. RESULTS In the first six months of the new legislation, median length of stay for patients admitted involuntarily via ED was 67 days (2-300), compared to 8 days (6-14) for those admitted voluntarily via ED (p=0.10, ns). For the same calendar period three years later, a total of 45 patients had been admitted involuntarily, via all care pathways, of whom 6 had been admitted from ED. Of these 6 patients, all presented with symptoms of psychosis. Two had a history of paranoid schizophrenia and 2 of depression. Five were brought to ED by Garda. For these 6 patients in the later study period, mean length of stay was 26 days (3-36, p=0.13, ns). Where outcome was involuntary admission, 6 patients had presented with aggressive behaviour, 6 with features of psychosis and 1 with self-harm. For those with other outcomes, 8 patients had presented with aggressive behaviour, 4 with self-harm, 4 with intoxication and 2 with features of psychosis. Current or previous diagnoses (ICD-10): schizophrenia or delusional disorder in 6 patients admitted involuntarily and 2 with other outcomes; mood disorder in 2 patients admitted involuntarily and 5 with other outcomes; learning disability in 1 patient admitted involuntarily and 2 with other outcomes; mental and behavioural disorder due to alcohol use (F10-19) in 1 patient admitted involuntarily and 6 with other outcomes; personality disorder in no patient admitted involuntarily and 2 with other outcomes. REFERENCES 1. Mental Health Act, 2001. Irish Statute Book, No 25/2001. 2. The ICD -10 Classification of Mental and Behavioural Disorders. World Health Organisation, Geneva. 1992. 3. Microsoft Office Excel 2007. PRINTED BY THE DEPT. OF MEDICAL PHOTOGRAPHY AND ILLUSTRATION A.M.N.C.H.

CONCLUSIONS: Results may indicate that, over this time period, additional development in the local community psychiatry service may have led to fewer patients with schizophrenia being admitted involuntarily via ED. Length of hospital stay appears to have been lower in the later study period, for patients admitted involuntarily via ED, although this did not reach statistical significance. This requires further study but may possibly be associated with additional development and care options in the local community psychiatry service. Numbers included in the study are too small to allow further statistical analysis.

EMERGENCY DEPARTMENT ASSESSMENTS FOR INVOLUNTARY ADMISSION TO AN APPROVED CENTRE, AFTER IMPLEMENTATION OF MENTAL HEALTH ACT (2001): RETROSPECTIVE CASE REPORT STUDY FOR FIRST SIX MONTHS 3

PSYCHOLOGICAL MEDICINE SERVICE, ADELAIDE & MEATH HOSPITAL, SOMERS CJ & McKAY AP, PSYCHOLOGICAL MEDICINE SERVICE, ADELAIDE & MEATH HOSPITAL, INCORPORATING NATIONAL CHILDREN’S HOSPITAL, TALLAGHT, DUBLIN 24. psychmed@amnch.ie 4

INTRODUCTION A new Mental Health Act – MHA, 20011- passed by Dáil Eireann in July 2001 to update Irish legislation, in keeping with international standards, was implemented fully in November 2006. The principal objective of the present study was to determine, for the first six months of implementation of the new legislation, outcomes of Emergency Department (adult) assessments for possible involuntary admission to MHA, 2001, Approved Centre in Adelaide & Meath Hospital. Secondary objectives were to analyse sociodemographic and clinical factors; and to compare the number of involuntary hospital admissions in the first six months of the new legislation with the same time period, three years later. 5

METHOD Approved Centre for admission under MHA, 2001, in Dublin West/South West Mental Health Service (St Loman’s) is in Adelaide & Meath Hospital, a University Teaching Hospital. The study was carried out in adult services Emergency Department (ED), for the time period 1 November 2006 to 30 May 2007. Data on number of involuntary admissions for the same time period in 2010 was also obtained. All cases aged 16 years or older i. presenting to ED for possible involuntary admission; and/or ii. where MHA, 2001, application for involuntary admission was made during the patient’s time in ED, were included. Sociodemographic and clinical features, with ICD-10 diagnosis2, as well as outcome of presentation, were determined by retrospective chart study. Results analysed using Excel.3 6

RESULTS: first six months Over the first six months of the new legislation, 22 subjects (13m, 9f) were included. Source of referral to ED was GP (8), Garda (6), self (4), community mental health team (2), family member (1). 10 cases were brought to ED by Garda, with Garda involvement in transfer to ED for another 4. 14 subjects were single or separated and 5 were married; 11 resided with family members, 2 lived alone and 2 were homeless; 12 subjects were unemployed or in receipt of disability benefit, and 5 were employed. All were from the local psychiatry catchment area. Outcome of assessment was involuntary admission for 9 subjects, 5 were admitted voluntarily, 5 were referred to community mental health service, 1 was referred to community alcohol service, and 1 refused follow-up. Involuntary admission from ED in these 9 subjects represented 15% of the total number of patients (n=58) admitted involuntarily to Approved Centre in this time period, via all care pathways. 7

RESULTS: first six months Where outcome was involuntary admission, 6 patients had presented with aggressive behaviour, 6 with features of psychosis and 1 with self-harm. For those with other outcomes, 8 patients had presented with aggressive behaviour, 4 with self-harm, 4 with intoxication and 2 with features of psychosis. Current or previous diagnoses (ICD-10): schizophrenia or delusional disorder in 6 patients admitted involuntarily and 2 with other outcomes; mood disorder in 2 patients admitted involuntarity and 5 with other outcomes; learning disability in 1 patient admitted involuntarily and 2 with other outcomes; mental and behavioural disorder due to alcohol use (F10-19) in 1 patient admitted involuntarily and 6 with other outcomes; personality disorder in no patient admitted involuntarily and 2 with other outcomes. 8

RESULTS In the first six months of the new legislation, median length of stay for patients admitted involuntarily via ED was 67 days (2-300), compared to 8 days (6-14) for those admitted voluntarily via ED (p=0.10, ns). For the same calendar period three years later, a total of 45 patients had been admitted involuntarily, via all care pathways, of whom 6 had been admitted from ED. Of these 6 patients, all presented with symptoms of psychosis. Two had a history of paranoid schizophrenia and 2 of depression. Five were brought to ED by Garda. For these 6 patients in the later study period, mean length of stay was 26 days (3-36, p=0.13, ns). 9

10

11

12

13

14

CONCLUSIONS: Comparing months 1-6 and months 37-42 of MHA, 2001, operation: there was a slight reduction in total number of involuntary admissions (58 in first six months and 45 in later period, ns). in the first six months, some 15% of patients admitted involuntarily to Approved Centre were admitted from Emergency Department, and there was little change in this proportion (13%), 3 years later. in the first six months, 66% (n=6) of those admitted involuntarily from ED were diagnosed with schizophrenia / psychotic disorder, as compared to 15% (n=2) of those with other outcomes. three years later, 2 (33%) of 6 patients admitted involuntarily from ED had a history of schizophrenia and 2 of depression. 15

CONCLUSIONS: Results may indicate that, over this time period, additional development in the local community psychiatry service may have led to fewer patients with schizophrenia being admitted involuntarily via ED. Length of hospital stay appears to have been lower in the later study period, for patients admitted involuntarily via ED, although this did not reach statistical significance. This requires further study but may possibly be associated with additional development and care options in the local community psychiatry service. Numbers included in the study are too small to allow further statistical analysis.

REFERENCES 1. Mental Health Act, 2001. Irish Statute Book, No 25/2001. 17 1. Mental Health Act, 2001. Irish Statute Book, No 25/2001. 2. The ICD -10 Classification of Mental and Behavioural Disorders. World Health Organisation, Geneva. 1992. 3. Microsoft Office Excel 2007.