When you're asked to assess if a patient should be sectioned
Adrian is a chronic schizophrenic you have seen in surgery twice. He is on the psychiatric ward where you are being asked to assess for Section 3 of the Mental Health Act. He is a bit fed up, is able to tell you the circumstances of his admission but displays no obvious psychotic symptoms and tells you he is willing to stay in hospital and
co-operate with the consultant. Dr Richard Stokell advises.
What are you being asked to do here?
Your are seeing this patient in the capacity of 'doctor with prior knowledge of the patient'. To recommend the section you must be happy there is mental illness, that it poses a risk to the patient or other people and that the patient won't stay unless he is forced.
What kind of a consultation can I expect?
The patient is entitled to know why you are there and this may generate some hostility. Personal safety is definitely an issue with this unpredictable patient, who you're seeing in unfamiliar surroundings. You must not be afraid to insist on being accompanied during the interview. But this is less of an issue than when seeing a similar patient in his or her own home.
Start with 'do you know why I am here?' followed by 'how did you end up in hospital?'. Then let him talk, if he will, in the usual GP manner.
Save any closed questions about voices and so on until the end as he is more likely to demonstrate paranoid ideation if allowed to ramble about the conflicts prior to admission than volunteer a 'yes' to a direct question.
Because he is aware of what is being proposed and is on treatment already, it would not be unusual for him to be very guarded, showing few signs of the acute psychotic symptoms that he may have displayed on admission. The difficulty is deciding if they are still there.
What other information can be gathered to assist in your assessment?
lHis medical record
lDetails supplied by carers for the patient: CPN, social worker, relatives
lHospital records and information from the consultant and nurses.
Both the GP record and the hospital records could be expected to confirm the presence of significant mental illness in this patient. A history of violent, unpredictable behaviour over time, taken in conjunction with the circumstances leading to his present admission,
will help establish the presence of risk.
The question of the need for compulsory admission can be difficult. Any past behaviour in terms of absconding from the ward during treatment will give clues, but you have to be satisfied the risk is significant.
Who can help?
Discussion with the approved social worker is compulsory and he or she will have looked for all this information. They will often know a lot more about home circumstances leading to admission and impediments to community treatment. The psychiatrist will usually have filled in their recommendation. You are allowed to look at what they've said and discuss the case with them, especially if you have doubts.
What if I still don't feel happy?
If you don't feel there is a good case for recommending a section you are entitled
not to. This would usually come out in discussion with the approved social worker and result in an attempt to treat the patient on a voluntary basis.
How will all this affect our relationship?
Banging someone up on a psychiatric ward against their will might be expected to have a fairly negative effect on future relations, but this tends not to be the case if the action was justified and as the patient gets better they are able to gain insight into their problems.
Conducting a fair assessment, listening to what they have to say and offering continuing support at the time seem to help when the patient is subsequently discharged.
lApproach an assessment for sectioning as if it was a normal consultation
lMake full use of the other professionals involved,
especially the approved social worker
lTry not to spoil the continuing relationship you have with your patient