Australasian Psychiatry 2014, Vol 22(1) 93–94 © The Royal Australian and New Zealand College of Psychiatrists 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav apy.sagepub.com
Time to consider the principles of reciprocity and treatability in our Mental Health Acts? Dear Sir, Reciprocity is derived from the Latin phrase quid pro quo, or ‘this for that’. In mental health, if one is detained for reasons of mental illness, a treatment should be offered.1 A related issue is treatability. In the current era where treatment is available for most psychiatric conditions, treatment is expected in involuntary admission to a mental health ward – not only containment.2 There is no provision for reciprocity or treatability in Australian and New Zealand mental health acts (MHAs). However, the question remains, should people with untreatable conditions be housed in mental health facilities? And, is it a breach of human rights to detain people when inadequate resources are available to properly treat a condition? Wand and Wand suggest that, though provisions for reciprocity and treatability are not within the MHAs, they should be considered in cases of involuntary detention.2 We present a case of prolonged admission to an acute adult mental health inpatient unit in regional New South Wales. This is not an isolated case. It begs the question: should there be provisions for these principles in the mental health legislation to protect the human rights of similar individuals? A 32-year-old male with a 10-year history of treatment-resistant schizophrenia and polysubstance use was admitted to the acute inpatient ward. He resided in a rented caravan after the
closure of the last remaining grouphome in the area. His history included multiple involuntary admissions, a prolonged rehabilitation admission, trials of almost every antipsychotic available on the Pharmaceutical Benefits Scheme and clozapineinduced myocarditis several years prior. He was admitted to hospital on this occasion with deterioration in his mental state in the context of increasing cannabis use and poor adherence to long-acting depot medication. Neighbours raised concerns about his behaviour, including threatening gestures to children. He also sent threatening text messages to his mother during this period. On review he was guarded and irritable. Psychotic symptoms included grandiose delusions, paranoid delusions and thought disorder. He denied threatening others, though repeatedly made threatening gestures towards staff. He was also responding to non-existent stimuli. There was poor insight into his illness and judgement was impaired. Oral antipsychotic medication was added to the depot preparation. Drug tests were repeatedly negative. Medication adherence strategies were implemented and closely monitored. Alternative medication strategies were trialled without improvement in mental state. Similar behaviour was noted on previous admissions, including a prolonged rehabilitation admission, which resulted in discharge after several months of relapsing–remitting psychosis and threatening behaviour. A further rehabilitation admission was sought. Due to overt psychotic symptoms and poor response to
previous rehabilitation admission, the request was declined. A recommendation was made for our patient to closely engage with a psychologist to teach cognitive behavioural strategies to manage his psychotic symptoms and explore his behavioural outbursts. Unfortunately, there was no psychologist available to see our patient on the ward. The attending psychiatrists were ‘fly-in fly-out’ and their limited time prioritised to seeing emergency room patients, inpatient assessments and community outpatients. Of further concern, there was no occupational therapist available on most days. An alternative option for our patient was to recognise the institutional requirement of a patient that has exhausted treatment options. Unfortunately, there were no boarding houses or group homes available in the area near his family and no highsupport community supervision packages available. At the time of writing, the patient was involuntarily detained under the state MHA for 6 months. The lack of resources in this regional area limited appropriate psychology intervention, occupational therapy, boarding houses, group homes and community high-support packages. This may be endemic to rural areas. However, it raises the issue of protecting the human rights of patients with mental illness. If we are involuntarily detaining people based on their propensity to harm, with inadequate resources to treat, in possibly untreatable conditions, how does this differ from pre-emptive incarceration? This is not permitted for any citizen in Australia or New Zealand under normal circumstances. 93
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The government priority of protection of patient and others from harm is thus apparent. Here, risk minimisation outweighs self-determination. The judge presiding over the Tarasoff case famously wrote, “The protective privilege ends where the public peril begins”.3 Perhaps protective privilege ends even when the personal peril begins. Unfortunately, detriment to the patient from the trauma of repeated involuntary containment is often not considered.
treatment of opioid use disorders by psychiatrists warrants consideration.
In summary, readers are alerted to the ongoing problem of under resourcing, particularly in regional and rural areas and their implications for the rights of mental health patients. Following, we wonder if reciprocity and treatability should be included in Australian and New Zealand MHAs, to protect against human rights violations.
Sixteen psychiatrists and 20 psychiatric trainees and medical officers employed in a large Victorian adult mental health service undertook the training in early 2012. A brief survey prior to the training, and 2 weeks later, was used to evaluate effectiveness of the training session in increasing confidence in the assessment of opioid dependence, initiating and continuing OMT, and knowledge of related regulatory frameworks. In total, 36 questionnaires were returned prior to the training session, with 15 postsession questionnaires completed.
References 1. Welsh S and Deahl M. Modern psychiatric ethics. Lancet 2002; 359: 253–255. 2. Wand A and Wand T. ‘Admit voluntary, schedule if tries to leave’: Placing Mental Health Acts in the context of mental health law and human rights. Australas Psychiatry 2013; 21: 137–140. 3. Buchner F and Firestone M. (2000). Where the public peril begins: 25 years after Tarasoff. J Legal Med 2000; 21: 187–222.
Brendan Daugherty and Daud Saeed Sydney, NSW DOI: 10.1177/1039856213510578
An audit examining the impact of a training session on interest in prescribing opioid maintenance treatment among psychiatrists and trainees Dear Sir, Opioid use disorders are often comorbid with other Axis I disorders, including post-traumatic stress disorder,1 depression,2 and Axis II disorders such as antisocial and borderline personality disorder.3 The Australian Pharmaceutical Benefits Scheme and other data sources suggest that prescription opioid misuse has increased over the last decade.4 This has implications for psychiatrists, who are often involved in managing their patients’ chronic pain conditions. Hence the 94
Our health network’s alcohol and drug service recently provided a 2.5hour training session on Opioid Maintenance Therapy (OMT). The programme was adapted from modules used by Australian jurisdictions to train community doctors as authorised prescribers of methadone solution and sublingual buprenorphine for opioid addiction.
Prior to the training session, 70% of those surveyed felt that they were confident in assessing opioid addiction, although only 25% felt confident or very confident to initiate either methadone or buprenorphine. Although only 30% felt confident making adjustments to methadone maintenance treatment, over half (51%) felt confident minimising the potential for diversion of prescribed psychotropic medications. Approximately 42% reported an understanding of the regulatory frameworks relating to OMT. Two weeks following the training session, there was no change in the percentage of those surveyed who felt confident in assessing for opioid addiction. However, 35% now felt confident or very confident in initiating either methadone or buprenorphine, whereas 47% reported an understanding of the jurisdictional regulations relating to OMT. Fortyseven per cent now felt confident in making adjustments to methadone maintenance treatment, with 72% confident in minimising the potential for diversion of prescribed psychotropic medications.
Despite the majority of respondents feeling confident in assessing for opioid dependence, only 46% were ‘interested or very interested’ in prescribing opiate substitution treatment prior to the training session, and surprisingly, this dropped to 33% following the training. Although our survey uses a small sample, has high attrition rates and focuses on only one mental health service, it indicates continued reluctance amongst psychiatrists and trainees in delivering OMT. Contri butory factors to clinicians being less willing to prescribe after training may include increased concern about the complexity of OMT regulatory requirements and a perception that OMT patients are overly complex and difficult to manage. A lack of opportunities for structured clinical training and a dearth of addiction placements across most psychiatry teaching programmes in Australia is likely to exacerbate a culture of ambivalence in trainee psychiatrists. Our audit demonstrates that relying solely on workshops focused on managing opioid addiction may not increase interest by psychiatrists in prescribing opioid pharmacotherapies. Other strategies, such as embedding principles of prescribing OMT within the core competencies of the psychiatric training programme, and increasing trainee opportunities for addiction medicine placements need to be considered. References 1. Mills KL, Lynskey M, Teesson M, et al. Post-traumatic stress disorder among people with heroin dependence in the Australian treatment outcome study (ATOS): prevalence and correlates, Drug and Alcohol Dependence 2005; 77: 243–249. 2. Teeson M, Havard A, Fairbairn S, et al. Depression among entrants to treatment for heroin dependence in the Australian Treatment Outcome Study (ATOS): prevalence, correlates and treatment seeking, Drug and Alcohol Dependence 2005;78: 309–315. 3. Darke S, Williamson A, Ross J, et al. Borderline personality disorder, antisocial personality disorder and risktaking among heroin users: findings from the Australian Treatment Outcome Study (ATOS), Drug and Alcohol Dependence 2004; 74: 77–83. 4. Nicholas R, Lee N and Roche A. Pharmaceutical Drug Misuse in Australia: Complex Problems, Balanced Responses, Flinders University, Adelaide: National Centre for Education and Training on Addiction (NCETA), 2011, pp. 2-5.
Lea Foo, Dan Lubman, Matthew Frei and Shalini Arunogiri, Melbourne, VIC DOI: 10.1177/1039856213510751
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