Evidence-Based Mental Health Law: The Case for Legislative Change to Allow Earlier Intervention in Psychotic Illness
Hayes, Robert, Nielssen, Olav, Sullivan, Daniel, Large, Matthew, Bayliff, Kristie, Psychiatry, Psychology and Law
Psychosis is a relatively common and severe mental disorder that results in impaired judgment and reasoning and is associated with an increased incidence of violence in the period before the initiation of treatment. Studies published since the Mental Health Act 1990 (New South Wales) was enacted have shown that the period before the emergence of acute symptoms (the prodrome) and first episode of illness carries a greatly increased risk of violence. It is also established that the longer-term prognosis is improved by early initiation of treatment. We believe the New South Wales Mental Health Act should be amended to reflect the scientific evidence of an increased risk of violence in the early stage of illness and the harm arising from delaying treatment. Emerging psychosis should be regarded as a medical emergency and the threshold for compulsory treatment for people in the early phase of psychotic illness should be lower.
Psychotic illness, including schizophrenia, delusional disorders, bipolar mood disorder and psychosis arising from drug abuse, is a major cause of disability and cost to the community, both in providing care and in the lost output of those afflicted. (1) Psychosis is a relatively common condition, with between 20 and 30 new cases per 100,000 population per year (2) and a prevalence of chronic psychosis in our community of around 0.5%. (3) In recognition of past neglect of this common and disabling condition, federal and state governments have recently announced increased funding for mental health, particularly for early intervention programs and community treatment. (4)
There are many reasons for emotional and behavioural disturbances in young people for which medical assessment and intervention becomes necessary, of which the emergence of psychotic illness is one of the most serious. The much higher risk of suicide and violence associated with acute episodes of psychotic illness during the early phase of illness is the reason why most young people who are acutely psychotic are admitted to psychiatric hospitals for treatment, usually as involuntary patients. (5)
Current mental health legislation in New South Wales only allows for intervention when the person meets the legal definition of a 'mentally ill person' within the meaning of the Mental Health Act (MHA), even though an experienced clinician may be able to determine with reasonable certainty that the deterioration in a person's behaviour is due to the prodromal phase of psychotic illness, (6) and that the person is thereby at increased risk of causing or sustaining serious harm. (7)
While prediction of schizophrenia on the basis of prodromal symptoms, and the prediction of violence arising from abnormal mental states pose particular difficulties, the current MHA requires treating doctors and magistrates to make a judgment about risk if particular signs and symptoms of psychosis are present. In practice, the MHA is frequently given a narrow interpretation, requiring that the patient have fairly overt signs of psychosis before they are deemed able to be detained for treatment against their will.
A recent study of homicides by mentally ill people in New South Wales between 1992 and 2003 (8) shows that there is a greatly increased risk of a homicide during the early phase of psychotic illness. The study shows that, in retrospect, changes in behaviour and beliefs associated with a risk of violence were usually evident before the homicide took place. Other studies confirm the risk of violence (9,10,11) and suicide (12) during the early phase of mental illness.
The published studies showing a greatly increased risk of homicide and other violence during the first episode of psychotic illness establish the need for early intervention to prevent these catastrophic events. We argue that psychosis, or the likelihood that a person is becoming psychotic, is an inherently dangerous condition for which intervention and treatment is required. …