Involuntary admission procedures for psychiatric hospitals poorly understood
Opinion: Minister for Health should have been clear that a suicidal pregnant woman cannot be summarily committed
On May 1st, Pat Kenny interviewed Minister for Health James Reilly on RTÉ Radio 1 about the abortion legislation currently going through the Oireachtas. Kenny asked the Minister about a hypothetical scenario in which a woman requested a termination on the grounds of suicide risk, was refused a termination but was still suicidal.
He asked: “[Could it] be a result that someone is deemed to need psychiatric care, has been turned down for a termination and they could end up being committed for the duration of their pregnancy?” James Reilly responded: “Well, that could happen at the moment anyway, Pat, if someone is psychotically depressed or has another psychosis.”
What the Minister should have said was: “No.”
This exchange was part of an ongoing public discussion that indicates the process of involuntary admission to psychiatric hospital is poorly understood.
The law governing involuntary admissions in Ireland is the Mental Health Act, 2001, which was implemented in 2006. For an involuntary admission to be lawful, the person being admitted must meet criteria for a “mental disorder” as defined in section 3 of the Act.
Section 3 (a), the relevant subsection, states that mental disorder means mental illness, severe dementia or intellectual disability where “because of the illness, dementia or disability, there is a serious likelihood of the person concerned causing immediate and serious harm to himself or herself or to other persons”.
As such, a diagnosis of a mental illness is necessary for a person to have a mental disorder under Section 3 (a) but it’s not enough. There must be risk, which must be serious and immediate, and the risk must arise as a result of mental illness.
A pregnant woman with no mental illness cannot be admitted as an involuntary patient; by definition she does not have a “mental disorder”. Being pregnant does not change the criteria for involuntary admission. A woman denied a termination may be in crisis but a crisis is not an illness.
One question here is whether a person reporting suicidal thoughts is by definition mentally ill. The answer is no. Suicidality and mental illness are not synonymous.
Suicidality is one feature of major depression and other diagnoses but is not itself diagnostic of anything. A diagnosis of a mental illness such as depression depends on the presence of multiple symptoms for a specified period of time, alongside “clinically significant distress or impairment” caused by those symptoms. No single symptom is diagnostic, not even suicidality.
Suicidal thoughts are common
Moreover, while suicidal thoughts are always to be taken seriously and evaluated with the utmost caution, they are common in the general population. A 2006 Europe- wide survey of suicidal ideation published by Prof Patricia Casey and colleagues showed that 15 per cent of Irish respondents reported suicidal ideation in the previous two weeks.
When that study was published, no one suggested that all those people were mentally ill, and no one suggested detaining 15 per cent of the Irish population.
So suicidality can exist without mental illness, and involuntary admission of a pregnant woman without “mental disorder” is not lawful.
Still, let’s imagine that a psychiatrist wished to detain a woman denied a termination. A psychiatrist cannot detain anyone alone.
There are two avenues to involuntary admission, which is a strictly regulated process.
If the person is outside the psychiatric unit when the admission process begins, then the process has three stages: an application, usually made by a family member; a recommendation, made by a doctor, usually a GP; and the admission order, signed by the consultant psychiatrist. The psychiatrist is not in charge. Unless all parties agree with a decision to admit involuntarily, it will not happen.
If a person is already a voluntary patient in a psychiatric unit, and expresses a wish to leave, the treating psychiatrist must seek a second consultant opinion regarding detention. If the second opinion states that the person does not have a mental disorder, the person must be discharged.
Psychiatrists cannot always be certain, at the time that a decision about admission must be made, whether a person in crisis has a mental disorder or not. Clinical information in an emergency is often inadequate. Cases can arise in which there is substantial but inconclusive evidence of mental disorder and a serious and immediate risk of harm, and the only safe course of action available is to admit under the Act for further assessment.
But in the event that evidence of mental disorder fails to emerge, prolonged admission is not a possibility. It soon becomes clear whether there is a diagnosis to be made and, if not, there is a clear onus on the treating psychiatrist to discharge the patient.
Independent review of diagnosis
Additionally, the 2001 Mental Health Act provides for and mandates an independent, regular review of diagnosis and need for treatment. Each admission is automatically reviewed by a three-person tribunal within 21 days. The tribunal is appointed by the Mental Health Commission. Tribunals are chaired by a solicitor or barrister, and otherwise composed of one consultant psychiatrist and one “lay person” (neither a lawyer nor a doctor).
The tribunal takes evidence from another independent consultant psychiatrist as well as the treating consultant, so that at least three consultants have been involved in the admission process by the time it gets to the tribunal. Every patient is assigned a solicitor to argue his or her case.
If an admission order is upheld at tribunal there is another tribunal within the next 21 days, and more as necessary. It is a stringent system.
Pregnant women are not immune from serious mental illness; and they are not exempted from involuntary admission in very particular circumstances. No one is. But the notion that a woman seeking a termination on grounds of suicidality has to fear that she will be summarily detained for the duration of her pregnancy is wrong.
Dr Niall Crumlish is a consultant psychiatrist at St James’s Hospital in Dublin