Least restrictive alternative - advance statements and the new mental health legislation

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Prevalence and experience of harassment of people with mental health problems living in the community

<i>Declaration</i> <i>of</i> <i>interest</i>: This study was funded by the Communities Fund and was the result of a partnership between the Nuffield Centre for Community Care Studies, University of Glasgow, the National Schizophrenia Fellowship (Scotland) and the Scottish users' network. <i>Background</i>: The levels and experiences of harassment of people with mental health problems in the community compared with those of the general population have not been explored. <i>Aims</i>: To measure the levels and experience of harassment experienced by people with mental health problems in the community in Scotland and compare them with the general population. <i>Method</i>: Experiences of harassment were collected by interviewing 165 individuals with mental health problems and a control group of 165 people from the general population. <i>Results</i>: Harassment in the community was found to be twice as common for individuals with mental health problems (41%) than for those in the general population (15%). The harassment commonly involved verbal abuse referring to the individual's mental health problems and was committed primarily by teenagers and neighbours. <i>Conclusions</i>: Harassment has a significantly higher prevalence among individuals with mental health problems living in the community and is believed to have a detrimental effect on mental health

Models of advance directives in mental health care: stakeholder views

<i>Objective</i>: The aim of this study was to examine perceptions of the place of advance directives in mental health care. <i>Methods</i>: Postal survey of stakeholders was carried out to assess their views on different models of advance directives in mental health care. A total of 473 responded. <i>Results</i>: In all, 28% of psychiatrists thought advance directives were needed compared to 89% of voluntary organisations and above two–thirds of the other stakeholder groups. There were clear tensions between patient autonomy and right to treatment which underpin many of the concerns raised. Autonomy provided by advance directive can be contrasted with a co–operative partnership approach to advance planning. The legal status of advance directives is important for some people in relation to treatment refusal. There was general concern about the practical issues surrounding their implementation. <i>Conclusion</i>: There is a wide range of views in all stakeholder groups about the possible form advance directives should take. Although there is a widespread desire to increase patient involvement in treatment decisions, which advance directives could possibly help to realise, they may also have unwanted consequences for mental health services and individuals

The introduction and evaluation of Community Care Orders following the Mental Health (Patients in the Community) Act 1995

Community Care Orders (CCOs) were introduced in Scotland in the Mental Health (Patients in the Community) Act 1995, which also saw the reduction of leave of absence. The aim of the study was to evaluate the use of CCOs in the first 33 months of their availability and to assess psychiatrists' and patients' views on their usefulness. Three data sources were used: (1) Mental Welfare Commission; (2) a named patient survey to consultant psychiatrists; (3) interviews with patients. Forty-five CCOs were used between 1 April 1996 and 31 December 1998. Half of these were judged successful by consultants. Conditions were varied and the impact on patients' lives could be extensive. There is confusion over the ability of CCOs to enforce medication but 77% implicitly or explicitly mentioned medication. CCO use has been low but set against the negative expectations of psychiatrists might be judged more successful than expected

Changes to leave of absence in Scotland: the views of patients

Sixty-four patients were interviewed about changes to leave of absence brought about by the Mental Health (Patients in the Community) Act 1995 in the context of their views about services and medication. Few patients were clear about the change in the law,which suggests that more has to be done to inform patients of their rights and legal status. A number of patients reported difficulty in negotiating preferred medication with their psychiatrists and felt compelled to take medication that resulted in debilitating side-effects. A third of patients eligible to be interviewed agreed to an interview and ethical and practical difficulties in accessing patients for this type of research are discussed

Issues in the development of advance directives in mental health care

<i>Background</i>: Interest in advance directives in mental health care is growing internationally. There is no clear universal agreement as to what such an advance directive is or how it should function. <i>Aim</i>: To describe the range of issues embodied in the development of advance directives in mental health care. <i>Method</i>: The literature on advance directives is examined to highlight the pros and cons of different versions of advance directive. <i>Results</i>: Themes emerged around issues of terminology, competency and consent, the legal status of advance directives independent or collaborative directives and their content. Opinions vary between a unilateral legally enforceable instrument to a care plan agreed between patient and clinician. <i>Conclusion</i>: There is immediate appeal in a liberal democracy that values individual freedom and autonomy in giving weight to advance directives in mental health care. They do not, however, solve all the problems of enforced treatment and early access to treatment. They also raise new issues and highlight persistent problems. <i>Declaration</i> <i>of</i> <i>interest</i>: The research was funded by the Nuffield Foundation grant number MNH/00015G

The end of indefinitely renewable leave of absence in Scotland: the impact of the Mental Health (Patients in the Community) Act 1995

The Mental Health (Patients in the Community) Act 1995 restricted leave of absence (LOA) for detained patients in Scotland to 12 months. This study looked at the impact on patients who were affected by this restriction. A total of 266 patients were identified from Mental Welfare Commission records: 194 reached the new maximum, 47 were 'transitional', 16 were on improperly long LOA and 9 were on community care orders (CCOs) following LOA but not maximum LOA. Of this 194, 12 were transferred to guardianship and the remainder became voluntary patients. The responsible medical officers (RMOs) would have liked to renew LOA for 71% of patients. In 90% of cases RMOs renewed LOA to ensure compliance with medication. Patients were significantly more likely to be compliant with medication while on LOA than post-LOA. A minority (28%) were recorded as being involved in 'incidents' post-LOA. There were 37% who were known to have a substance use problem in their management. The results suggest that RMOs may have been conservative in using LOA

Grounded theory research: literature reviewing and reflexivity

<i>Aim</i>: This paper is a report of a discussion of the arguments surrounding the role of the initial literature review in grounded theory. <i>Background</i>: Researchers new to grounded theory may find themselves confused about the literature review, something we ourselves experienced, pointing to the need for clarity about use of the literature in grounded theory to help guide others about to embark on similar research journeys. <i>Discussion</i>: The arguments for and against the use of a substantial topic-related initial literature review in a grounded theory study are discussed, giving examples from our own studies. The use of theoretically sampled literature and the necessity for reflexivity are also discussed. Reflexivity is viewed as the explicit quest to limit researcher effects on the data by awareness of self, something seen as integral both to the process of data collection and the constant comparison method essential to grounded theory. <i>Conclusion</i>: A researcher who is close to the field may already be theoretically sensitized and familiar with the literature on the study topic. Use of literature or any other preknowledge should not prevent a grounded theory arising from the inductive–deductive interplay which is at the heart of this method. Reflexivity is needed to prevent prior knowledge distorting the researcher’s perceptions of the data