Advance choice documents could reduce numbers of people sectioned under Mental Health Act

Fewer people with mental illnesses would need to be sectioned if advance choice documents were included in the Mental Health Act reforms, according to a leading psychiatrist.

Lade Smith, the president of the Royal College of Psychiatrists, said that advance choice documents, which set out a desired treatment plan while the individual is well, are the only proven way to reduce the number of people detained under the Act.

Research shows that the use of these documents can reduce sectioning, in which an individual is compulsorily detained in a psychiatric unit, by 25%.

“It’s high time there was reform of the Mental Health Act because the rates of detention are increasing, especially for marginalised groups, those who are poor or from a minoritised ethnic community, especially black Caribbean,” Smith told the Guardian. “Advance choice docs were a recommendation of the review – I don’t know why they haven’t gone through,” she added.

Black people with mental illness are more likely to be sectioned under the Act than white people. Smith believes that advance choice documents could be particularly effective in reducing this differential, because they can help patients feel more autonomous and reduce unconscious bias.

The documents can also reduce the time spent in hospital, Smith said.

Takeup remains low

To create an advance choice document, patients work with a healthcare professional when they are well to outline the signs that they are experiencing a manic or psychotic episode. They also mention the effective treatments, and their personal preferences.

These preferences could include background information and trigger questions to help healthcare practitioners establish delusional thought patterns; medications and doses which have been effective previously; and requests to be put in hospital for their own safety, or that of others.

NHS guidance recommends the use of advanced choice documents, but takeup remains low, probably as a result of limited awareness, logistical challenges and a misconception amongst health professionals that patients might ask for ineffective treatments, such as Reiki healing, said Smith.

“Ideally, there should be a mandatory requirement of services to offer advance choice documents to anybody who’s ever been detained under the Mental Health Act – that’s what we’d like to see,” she said.

King’s College London is introducing a new site to improve awareness of the documents. The site will be used as a resource on the NHS to drive a culture shift towards shared decision-making.

Dr Tania Gergel, a researcher at UCL who is leading on the Advance Choice project, told the Guardian this would represent a move away from the “paternalistic” model of psychiatry, reflecting that “people have a very good understanding of their illness”.

Some clinicians have ignored documents

In interviews for the project, she said she had found examples where clinicians refused to follow the advance choice document. One patient had written that an antipsychotic worked for them at a lower dose, while the usual prescribed dose made them physically unwell. This was ignored, however, and the patient only recovered after going through a traumatic process of trial and error when they were sectioned.

Others said they hated being injected, which is common in forcible detentions. “People can feel that who they are as a person becomes completely erased,” Gergel said.

Gergel herself has bipolar disorder and believes that advance choice documents have saved her life, as she experiences severe psychotic episodes in which she becomes suicidal.

Her document contains trigger questions to help doctors reveal her delusions, and includes a “self-binding” agreement, meaning that when these symptoms are present she needs to be treated and supervised immediately for her own safety. It adds that conventional medications do not work for her and that she needs electroconvulsive therapy (ECT). “It has really worked, and has meant I’ve stayed safe although I’ve been deeply suicidal,” Gergel said.